No improved care with ultrasound for paediatric blunt abdominal trauma
Use of focused assessment with sonography for trauma (FAST), or bedside ultrasound, among haemodynamically stable children and adolescents with blunt torso trauma in an emergency department (ED) did not appear to improve clinical care, including order for CT scans, ED stay duration, missed intra-abdominal injuries, and hospital charges compared with standard trauma evaluation alone, suggests a recent study.
“At least in the adult trauma population, there’s evidence that you can use ultrasound to safely decrease CT use. One of the big questions has been whether that holds true for children, too,” said lead author Professor James Holmes from University of California, Davis Medical Center in Sacramento, California, US.
Following a blunt torso trauma, 925 patients (mean age, 9.7 years, 62 percent males) who were randomized to undergo FAST examination during routine trauma evaluation in an ED had comparable rates of subsequent abdominal CT scans (52.4 percent vs 54.6 percent; p=0.50) and missed intra-abdominal injuries (0.2 percent vs 0 percent; p=0.50) as those who did not have FAST. [JAMA 2017;317:2290-2296]
Also, the average ED length of stay (6.03 vs 6.07 hours; p=0.88) and hospital charges (median, US$46,400 vs 47,800; p=0.67) did not differ significantly between the two groups.
“These findings do not support the routine use of FAST in this setting,” the researchers concluded.
In nonprespecified analyses whereby physician suspicions for intra-abdominal injury were recorded before and after a FAST examination, negative FAST results were associated with reduced physician concern for injury compared with that before FAST ─ 27 patients were downgraded to a <5 percent risk and 72 patients to a <1 percent risk for injury after a negative FAST result.
However, the reduced suspicion did not translate into fewer CT scans (n=49) although none of the 173 patients considered to have the lowest-risk after FAST (<1 percent) were diagnosed with intra-abdominal injury.
“This may represent a missed opportunity to reduce CT scans and raises important questions as to why physicians did not change their plans to order a CT,” wrote Dr David Kessler of Columbia University College of Physicians and Surgeons in New York City, New York, US, in an accompanying editorial. [JAMA 2017;317:2283-2285]
The discrepancy may reflect “the reluctance of physicians to definitely rule out intra-abdominal injury”, physician’s confidence with FAST in paediatric patients, or that decision for ordering CT lies beyond the sole purview of ED physicians (to paediatric and trauma surgeons), according to Kessler.
“Study protocol did not dictate what actions to take based on the interpretation of the FAST results … [which] may have reduced the potential influence of FAST examinations in this study,” he said. “An optimal algorithm would combine FAST interpretation with physical examination and laboratory findings.”
“Rather than removing FAST examinations from paediatric trauma algorithms, the results … should encourage the trauma, paediatric emergency medicine, and ultrasound communities to work together to further investigate the many unresolved questions about integrating FAST examinations into paediatric blunt abdominal trauma protocols,” said Kessler. “[F]uture implementation studies should focus on decision making in low-risk groups with negative FAST results.”
“This study excluded certain high-risk patients, such as those with hypotension, for whom the FAST examination may have the potential to be beneficial,” said Holmes and co-authors.
“[B]ecause this is a rare event in paediatric trauma, there may be important educational benefits to continued practice with … [routine] FAST examinations … [besides preparing] for disaster scenarios,” suggested Kessler.
“This is worth pursuing considering the potential to reduce exposure to ionizing radiation with point-of-care ultrasound.”