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FAST EXAM Positive Negative Stable Unstable Stable Unstable CT scan OR Seek extra-abdominal source, ?DPL, ?OR Observe, ?CT Figure 2.42 Consensus FAST protocol [ 27 ]. Diagnostic ultrasound 49 Focused assessment with sonography in trauma (FAST)
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Literature review Reference Methods Results Notes Melniker et al . 2006 [ 12 ] Randomized trauma patients to US-based pathway vs. trauma evaluations without FAST. FAST led to more rapid time to operating room (OR), fewer CT scans, fewer complications, reduced length of stay, and lower charges. Outcomes-based study on use of FAST exam. FAST improved outcomes in almost every clinical parameter evaluated. Plummer et al . 1992 [ 25 ] Penetrating trauma patients randomized to emergency department (ED) echo vs. “standard of care” evaluation (echo called in). Not only diagnosis and disposition expedited in ED echo group, but there was a survival benefit if patients had ED cardiac ultrasound. Mortality benefit of ED cardiac ultrasound in penetrating cardiac injury. Branney, et al . 1997 [ 11 ] Randomized trauma patients to US-based pathway vs. “standard of care” trauma evaluations (no FAST). In US-based pathway, DPL use decreased 13%, and CT use decreased 30%. No “significant” injuries missed. Cost savings estimated at $450 000. First study to note cost savings with implementation of FAST. Also first to document decrease in DPL and CT use. McKenney et al . 2001 [ 10 ] Developed and tested FAST score to help predict need for therapeutic laparotomy. Measured depth of fluid in deepest pocket, and 1 point was added for fluid in each of the other areas (4 maximum). 85% of patients with score > 3 required therapeutic laparotomy, whereas 15% of patients with a score ² 2 required surgery. Further defined characteristics of positive FAST that indicate need for therapeutic laparotomy. More evidence of US benefit over DPL because US predictive value more clinically useful. Moylan et al . 2007 [ 28 ] Looked at the rate of therapeutic laparotomy for normotensive blunt- trauma patients who have a positive FAST exam. Retrospective cohort study. Unadjusted odds ratio for a positive FAST and laparotomy was OR 116 (95% CI 49.5– 273). 37% of patients with a positive FAST required therapeutic laparotomy. Only 0.5% of patients with a negative FAST went to the OR. Even in normotensive patients, the FAST exam is highly predictive of the need for an operation and is very helpful in risk stratification and prioritization for CT scanning. 50 Diagnostic ultrasound Focused assessment with sonography in trauma (FAST)
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Detection of pneumothorax Traditionally, the standard test for the initial evaluation of the thorax in trauma patients is the supine chest x-ray. However, supine chest x-rays are notoriously inaccurate when looking for pneumothoraces because air layering anteriorly will be difficult to see. In this context, the sensitivity of ultrasound for diagnosing pneumothorax is an improvement on the current standard practice [ 24 ] and one of the most practice-changing diagnostic imaging developments to occur in medicine. This improvement is true not only for trauma but also for many critical care fields of medicine.
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