Introduction: Focused assessment with sonography for trauma (FAST) is a highly effective first screening tool for initial classification of abdominal trauma patients. The present study was designed to evaluate the outcome of patients with blunt abdominal trauma and positive FAST findings. Methods: The present prospective cross-sectional study was done on patients over 7 years old with normal abdominal examination, positive FAST findings, and available abdominopelvic computed tomography (CT) scan findings. The frequency of need for laparotomy as well as its probable risk factors were calculated. Results: 180 patients were enrolled (mean age: 28.0 ± 11.5 years; 76.7% male). FAST findings were confirmed by abdominopelvic CT scan in only 124 (68.9%) cases. Finally, 12 (6.6%) patients needed laparotomy. Mean age of those in need of laparotomy was significantly higher than others (36.75 ± 11.37 versus 27.34 ± 11.37, p = 0.006). Higher grading of spleen (p = 0.001) and hepatic (p = 0.038) ruptures increased the probability of need for laparotomy. Conclusion: 68.9% of the positive FAST findings in patients with blunt abdominal trauma and stable hemodynamics was confirmed by abdominopelvic CT scan and only 6.6% needed laparotomy. Simultaneous presence of free fluid and air in the abdominal area, old age, and higher grading o solid organ injuries were factors that had a significant correlation with need for laparotomy

Behboodi, Firooz

Masjedi, Navid

Mohtasham-Amiri, Zahra

Sadri, Peyma

Shojaie, Reza

English

PubMed

Firooz Behboodi

Zahra Mohtasham-Amiri

Navid Masjedi

Reza Shojaie

Peyma Sadri

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Outcome of Blunt Abdominal Traumas with Stable Hemodynamic and  Positive FAST Findings

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        This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2016 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com   136 Emergency (2016); 4 (3): 136-139 ORIGINAL RESEARCH   Outcome of Blunt Abdominal Traumas with Stable Hemodynamic and  Positive FAST Findings    Firooz Behboodi1, Zahra Mohtasham-Amiri2, Navid Masjedi1*, Reza Shojaie1, Peyman Sadri3   1. Department of General Surgery, Guilan University of Medical Sciences, Rasht, IR Iran. 2. Department of Preventive & Social Medicine, Guilan University of Medical Science, Rasht, IR Iran. 3. Department of General Surgery, Zanjan University of Medical Science, Zanjan, IR Iran.  *Corresponding Author: Navid Masjedi. Department of General Surgery, Guilan University of Medical science, Tehran Road Km6, Rasht, Guilan; Iran;  E-mail: navid.masjedi1983@gmail.com; Tel: 00981333690884; Fax: 00981333690036 Received: June 2015; Accepted: September 2015  Abstract Introduction: Focused assessment with sonography for trauma (FAST) is a highly effective first screening tool for initial classification of abdominal trauma patients. The present study was designed to evaluate the outcome of pa-tients with blunt abdominal trauma and positive FAST findings. Methods: The present prospective cross-sectional study was done on patients over 7 years old with normal abdominal examination, positive FAST findings, and avail-able abdominopelvic computed tomography (CT) scan findings. The frequency of need for laparotomy as well as its probable risk factors were calculated. Results: 180 patients were enrolled (mean age: 28.0 ± 11.5 years; 76.7% male). FAST findings were confirmed by abdominopelvic CT scan in only 124 (68.9%) cases. Finally, 12 (6.6%) patients needed laparotomy. Mean age of those in need of laparotomy was significantly higher than others (36.75 ± 11.37 versus 27.34 ± 11.37, p = 0.006). Higher grading of spleen (p = 0.001) and hepatic (p = 0.038) ruptures increased the probability of need for laparotomy. Conclusion: 68.9% of the positive FAST findings in patients with blunt abdominal trauma and stable hemodynamics was confirmed by abdominopelvic CT scan and only 6.6% needed laparotomy. Simultaneous presence of free fluid and air in the abdominal area, old age, and higher grading o solid organ injuries were factors that had a significant correlation with need for laparotomy. Keywords: Abdominal injuries; wounds, nonpenetrating; patient outcome assessment; ultrasonography; tomog-raphy, X-ray computed  Cite this article as: Behboodi F, Mohtasham-Amiri Z, Masjedi N, Shojaie R, Sadri P. Outcome of blunt abdominal traumas with stable hemodynamic and positive fast findings. Emergency. 2016; 4(3):136-139.  Introduction: raumatic injuries are the major cause of mortality in the under 40 year old population and ab-dominal trauma is the third common trauma with a high rate of morbidity and mortality (1-3). Rapid diag-nosis and treatment can decrease the rate of abdominal trauma related mortality, up to 50% (4). Immediate re-ferral of the victim to a trauma center and timely diagno-sis and treatment play a key role in improvement of pa-tient outcome. When a patient with suspected blunt ab-dominal trauma is presented to emergency department (ED), the physicians look to determine the presence of intra-abdominal injuries and predict patient outcome (5). Focused assessment with sonography for trauma (FAST) is a highly effective first screening tool for initial classification of abdominal trauma patients (6). Yet, like all sonography techniques, its diagnostic value depends on the operator’s skill. Therefore, the findings of the studies are sometimes contradictory (7-9). The results of most existing studies show that FAST has average sensi-tivity and high specificity in detection of abdominal trau-matic injuries (8, 10, 11). The effect of using this diagnos-tic test on improvement of patient management is still a matter of debate. The present study was designed to evaluate the outcome of patients with blunt abdominal trauma and positive FAST findings.  Methods: The present prospective cross-sectional study was done with the aim of evaluating the outcome of patients with blunt abdominal trauma and positive FAST results. 180 patients presented to the ED of Poursina Hospital, Rasht, Iran, during 2013 and 2014 were enrolled using conven-ience sampling. The protocol of the present study was approved by the Ethics Committee of Guilan University of Medical Sciences. All the researchers adhered to the T        This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2016 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com  137 Emergency (2016); 4 (3): 136-139 principles of Helsinki Declaration. Inclusion criteria con-sisted of age over 7 years, normal abdominal examina-tion and positive FAST findings. Hemodynamic unstabil-ity, abnormal abdominal examination, pregnancy, lost to follow-up were among the exclusion criteria. The pa-tients underwent abdominal sonography by a trained (for 8 hours) senior emergency medicine resident and in case of positive FAST findings, abdominopelvic com-puted tomography (CT) scan with intravenous (IV) con-trast was performed. Demographic data (age, sex) as well as sonography and CT scan findings, and need for laparotomy were recorded. Need for laparotomy was considered the final outcome of the present study. FAST was carried out using a SonoScape SSI-5500BW ultraso-nography machine with a 3.5 – 5 MHz probe. CT scan was done using a Toshiba Asteion 16 slice scanner and inter-preted by a radiologist blind to FAST and clinical find-ings. Positive FAST was defined as presence of solid or-gan injury or free abdominal fluid in at least one of the Morison's, spleno-renal or retro-vesical pouches. The sample size was calculated to be 170 cases, consid-ering the 20% prevalence of need for laparotomy in pos-itive FAST cases (12), α = 0.05, and d = 0.06. Data were analyzed using STATA 11.0. Quantitative data were re-ported as mean and standard deviation (SD) and qualita-tive ones as frequency and percentage. Independent t-test was used to compare the average age and hemoglo-bin level of operated and non-operated patients. In addi-tion, chi square or Fisher’s exact tests were used to com-pare frequency. In all analyses p < 0.05 was considered as significance level.  Results: 180 patients with blunt abdominal trauma, stable hemo-dynamic and positive FAST findings were enrolled (mean age: 28.0 ± 11.5 years; 76.7% male). Table 1 shows age and sex distribution of the participants. FAST findings were confirmed by abdominopelvic CT scan in only 124 (68.9%) cases (Figure 1). Hepatic (26.7%) and spleen (7.8%) ruptures, and presence of free fluid (12.8%) were the most common CT findings. Finally, 12 (6.6%) patients needed laparotomy, 7 (58.33%) of which had free abdominal fluid and air, 1 (8.33%) had ruptured liver, and 4 (33.34%) had ruptured spleen. Mean age of those in need of laparotomy was signifi-cantly higher than others (36.75 ± 11.37 versus 27.34 ± 11.37, p = 0.006). Higher grading of spleen (p = 0.001) and hepatic (p = 0.038) ruptures increased the probabil-ity of need for laparotomy (Table 2).  Discussion: Based on the results of the present study, only 68.9% of the positive FAST findings in patients with blunt ab-dominal trauma and stable hemodynamics was con-firmed by abdominopelvic CT scan. Finally, only 6.6% of these patients needed laparotomy. Simultaneous pres-ence of free fluid and air in the abdominal area, old age, and higher grading of solid intra-abdominal organ inju-ries were factors that had a significant correlation with need for laparotomy. Cunningham et al. express that all patients with evidence of free abdominal fluid in CT scan need laparotomy (13). In a study by Yanar et al. only 33% of the patients needed laparotomy. They believe that non-operative treatment will be efficient in 75% of cases. This study showed that solid viscus score, more than 20% decrease in hemato-crit, and level of serum lactate on admission are the most important predictive factors of non-operative manage-ment failure (14). The present study showed that simul-taneous presence of free abdominal fluid and air is di-rectly related to need for laparotomy. In addition, 93.3% of non-operative treatments were successful. This high rate might be due to the high percentage of solid organ injury cases, as a high percentage of solid organ injury Table 1: Age and sex distribution of the patients Variable  Frequency (%) Sex   Male  138 (76.7) Female  42 (23.3) Age (years)  < 10 13 (7.2) 11-20 42 (23.3) 21-30 49 (27.2) 31-40 54 (30.0) 41-50 15 (8.3) 51-60 7 (3.9)    Figure 1: Abdominopelvic computed tomography scan findings of FAST positive patients.  31.1126.6613.8912.787.783.893.890 20 40Normalhepatic ruptureRuptured spleenFree fluidKidney ruptureFree fluid and free airMulti-organ damagePercentage of patients  This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2016 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com  Behboodi et al 138 patients, even those with higher grading, are success-fully treated with non-operative treatments (15). The ex-isting studies show that FAST has low sensitivity and high specificity in identifying traumatic abdominal inju-ries. Fox et al. showed that the presence of positive FAST findings is a proper predictor for presence of intra-ab-dominal injury (16). Additionally, Kelley et al. showed a 73% sensitivity and 100% specificity for FAST in identi-fication of intra-abdominal traumatic injuries (17). In the present study, the number of false positive cases of FAST was high (31.1%). One of the reasons might be that accuracy of sonography has a significant correlation with the operator’s skill. Since in this study, FAST was per-formed by an emergency medicine resident, his skill and experience might have affected the interpretation of FAST data. One of the limitations of this study was its short follow-up duration. If long-term follow-up for 1, 6, or 12 months was done, factors affecting long-term outcome such as mortality or need for delayed surgery could be evalu-ated. Another limitation was performance of sonography by an emergency medicine resident. Although a sonogra-phy workshop was held for the resident, his lack of skill could affect the results. Conclusion: Based on the results of the present study, only 68.9% of the positive FAST findings in patients with blunt ab-dominal trauma and stable hemodynamics was con-firmed by abdominopelvic CT scan. Finally, only 6.6% of these patients needed laparotomy. Simultaneous pres-ence of free fluid and air in the abdominal area, old age, and higher grading o solid organ injuries were factors that had a significant correlation with need for laparot-omy.  Acknowledgments: Authors would like to thank all the staff of ED of Poursina Hospital, Rasht, Iran.   Conflict of interest: None  Funding support: None  Authors’ contributions: All authors passed four criteria for authorship contribu-tion based on recommendations of the International Committee of Medical Journal Editors.  References:  1. Miniño AM, Heron MP, Murphy SL, Kochanek KD. Deaths: final data for 2004. Natl Vital Stat Rep. 2007;55:1-119. 2. Hofman K, Primack A, Keusch G, Hrynkow S. Addressing the growing burden of trauma and injury in low-and middle-income countries. Am J Public Health. 2005;95(1):13-7. 3. Sabzghaba A, Shojaee M, Safari S, Hatamabadi HR, Shirvani R. The Accuracy of Urinalysis in Predicting Intra-Abdominal Injury Following Blunt Traumas. Emergency. 2015;3:[In press]. 4. Chardoli M, Rahimi-Movaghar V. Analysis of trauma outcome at a university hospital in Zahedan, Iran using the TRISS method. East Afr Med J. 2006;83(8):440-2. 5. Shojaee M, Faridaalaee G, Yousefifard M, et al. New scoring system for intra-abdominal injury diagnosis after blunt Table 2: The relationship of baseline characteristics and clinical findings with need for laparotomy Factors Laparotomy P Yes (n = 12) No (n = 168) Age 36.8±11.4 27.3±11.4 0.006 Sex    Male  10 (83.3) 128 (76.2) 0.57 Female 2 (16.7) 40 (23.8) Hemoglobin (mg/dl) 13.0±1.8 12.2±1.7 0.12 Grade of ruptured spleen    I 0 (0.0) 18 (64.3) 0.001 II 1 (25.0) 9 (32.1) III 1 (25.0) 1 (3.5) V 2 (50.0) 0 (0.0) Grade of hepatic rupture    I 0 (0.0) 7 (13.7) 0.038 II 0 (0.0) 32 (62.8) III 0 (0.0) 11 (21.6) IV 1 (100.0) 1 (2.0) Presence of air and fluid     No 5 (41.7) 168 (100.0) <0.001 Yes 7 (58.3) 0 (0.0)             This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2016 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com  139 Emergency (2016); 4 (3): 136-139 trauma. Chin J Traumatol. 2014;17(1):19-24. 6. Scalea TM, Rodriguez A, Chiu WC, et al. Focused assessment with sonography for trauma (FAST): results from an international consensus conference. J Trauma Acute Care Surg. 1999;46(3):466-72. 7. Soundappan S, Holland A, Cass D, Lam A. Diagnostic accuracy of surgeon-performed focused abdominal sonography (FAST) in blunt paediatric trauma. Injury. 2005;36(8):970-5. 8. Patel JC, Tepas J. The efficacy of focused abdominal sonography for trauma (FAST) as a screening tool in the assessment of injured children. J Pediatr Surg. 1999;34(1):44-7. 9. Chiu WC, Cushing BM, Rodriguez A, et al. Abdominal injuries without hemoperitoneum: a potential limitation of focused abdominal sonography for trauma (FAST). J Trauma Acute Care Surg. 1997;42(4):617-25. 10. Allen CJ, Tashiro J, Sola JE. Role of FAST or Abdominal Ultrasound to Limit CT Imaging in Evaluation of the Pediatric Abdominal Trauma Patient. Curr Surg Report. 2014;2(6):1-5. 11. Ben-Ishay O, Daoud M, Peled Z, Brauner E, Bahouth H, Kluger Y. Focused abdominal sonography for trauma in the clinical evaluation of children with blunt abdominal trauma. World J Emerg Surg. 2015;10(1):27. 12. Wu C-Y, Yang S-J, Fu C-Y, et al. The risk factors of concomitant intraperitoneal and retroperitoneal hemorrhage in the patients with blunt abdominal trauma. World J Emerg Surg. 2015;10(1):4. 13. Cunningham MA, Tyroch AH, Kaups KL, Davis JW. Does free fluid on abdominal computed tomographic scan after blunt trauma require laparotomy. J Trauma Acute Care Surg. 1998;44(4):599-603. 14. Yanar H, Ertekin C, Taviloglu K, Kabay B, Bakkaloglu H, Guloglu R. Nonoperative treatment of multiple intra-abdominal solid organ injury after blunt abdominal trauma. J Trauma Acute Care Surg. 2008;64(4):943-8. 15. Haan JM, Bochicchio GV, Kramer N, Scalea TM. Nonoperative Management of Blunt Splenic Injury: A 5-Year Experience. J Trauma Acute Care Surg. 2005;58(3):492-8. 16. Fox JC, Boysen M, Gharahbaghian L, 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;18(5):477-82. 17. Kelley SR, Tsuei BJ, Bernard AC, Boulanger BR, Kearney PA, Chang PK. The effectiveness of focused assessment with sonography for trauma in evaluating blunt abdominal trauma with a seatbelt mark sign. J Curr Surg. 2014;4(1):17-22.  

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Outcome of Blunt Abdominal Traumas with Stable Hemodynamic and Positive FAST Findings

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