1. FAST EXAM IN PEDIATRIC PATIENTS Evidence in the ED March 5, 2014 Sarah Cavallaro PGY-3

2. Introduction The role of the FAST exam in Pediatric Trauma is unclear Review 4 studies that set the stage for current thinking Share my thoughts on how I wish these were done A HUPISM for future practice

3. Paper #1 Jateen C. Patel and J.J. Tepas III. The Efficacy of Focused Abdominal Sonography for Trauma (FAST) as a Screening Tool in Assessment of Injured Children. Journal of Pediatric Surgery, Vol34,No 1 (January), 1999: pp 44-47 Study Type: Retrospective chart review Subjects: Children (11.3yo mean) with Suspected Blunt Torso Trauma who received FAST exam Hemodynamically unstable patients: Included (but limited n=2) N: 94 Ultrasonographer: Radiology Gold Standard: None

4. Results

5. Author's Conclusion Specificity 95%, Sensitivity 33% This “excellent specificity” combined with clinical examination allowed avoidance of “additional abdominal imaging”

6. Paper #2 Coley et al. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. J Trauma. 2000 May;48(5):902-6. Study Type: Prospective Study Subjects: Children (7.9yo mean) with Suspected Blunt Torso Trauma who were to receive CT Hemodynamically unstable patients: Excluded N: 107 Ultrasonographer: Radiology Gold Standard: CT

7. Results

8. Author's Conclusions Specificity 0.83, Sensitivity 0.55 Not an “appropriate” imaging study for hemodynamically stable children with concern for blunt abdominal injury Should not replace CT

9. Paper #3 Soudack et al. Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients. J Clin Ultrasound. 2004 Feb;32(2):53-61. Study Type: Retrospective Chart Review Subjects: Children (7.1yo mean) with Suspected Blunt Torso Trauma who had received FAST exam Hemodynamically unstable patients: Included N: 313 Ultrasonographer: Radiology *also evaluated for parenchymal injury or retroperitoneal fluid Gold Standard: None

10. Results

12. Author's Conclusions Specificity 97.2% Sensitivity 92.5% The clinical significance of blunt abdominal injuries with no FF must be established FAST Exam can be useful in patients with a normal physical exam to eliminate the need for CT A positive FAST exam should then go to CT if stable or the OR if unstable

13. Paper #4 Fox JC et al., Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med. 2011 May;18(5):477-82. Study Type: Prospective Subjects: All blunt abdominal trauma patients aged 0- 17yo (about ½ age 13-17) Hemodynamically unstable patients: Included (n=1) N: 357 Ultrasonographer: EM Residents, EM attendings, EM Ultrasound Fellows, surgeons Gold Standard: CT (with moderate or severe FF) or Laparotomy

14. Results

16. Author's Conclusion Sensitivity 52%, Specificity 95% for clinically significant FF Sensitivity 20%, Specificity 98% for any FF A positive FAST exam suggests hemoperitoneum while a negative FAST exam is not useful in the setting of a pediatric patient with blunt abdominal injury

17. My Thoughts Studying a very different use of the FAST exam Most studies do not examine our use of FAST in a pediatric population Need better reporting on the clinical significance of injury that presents with a negative FAST Use would require culture change Okay Byron, let’s hear your thoughts

18. HUPISM If positive, a FAST exam may still be helpful to locate the source of bleeding in blunt traumatic pediatric patients presenting with hemorrhagic shock. It is not however a study that can replace CT scan for diagnosis of all intra- abdominal injury in hemodynamically stable pediatric patients.

19. References Jateen C. Patel and J.J. Tepas III. The Efficacy of Focused Abdominal Sonography for Trauma (FAST) as a Screening Tool in Assessment of Injured Children. Journal of Pediatric Surgery, Vol34,No 1 (January), 1999: pp 44-47 Coley et al. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. J Trauma. 2000 May;48(5):902- 6. Soudack et al. Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients. J Clin Ultrasound. 2004 Feb;32(2):53-61. Fox JC et al., Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med. 2011 May;18(5):477-82.