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A 70-year-old woman on warfarin was transported to the emergency department after a ground-level fall, injuring her left backside. Criteria for geriatric trauma activation was not met. An episode of haematuria created suspicion for an intra-abdominal injury, prompting a point-of-care ultrasound (POCUS) Focused Assessment with Sonography for Trauma scan, which was positive. Subsequent pan-scanning discovered a multitude of injuries, including low-grade left renal and splenic lacerations, multiple left rib fractures and a haemothorax. Patient also had a supratherapeutic International Normalized Ratio (INR), which was reversed with 4-factor Prothrombin Complex Concentrate (4F-PCC). She was admitted to the intensive care unit, underwent urgent thoracostomy and had a complicated hospital course. Moreover, an incidental large staghorn calculus in the left kidney might have contributed shearing forces. In summary, under triage of this patient emphasised the importance of performing detailed primary and secondary surveys, including POCUS, for all geriatric ground-level fall patients on anticoagulants to allow for rapid diagnosis and treatment of potential serious injuries.

Purpose The use of lung ultrasound for diagnosis of COVID-19 has emerged during the pandemic as a beneficial diagnostic modality due to its rapid availability, bedside use, and lack of radiation. This study aimed to determine if routine ultrasound (US) imaging of the lungs of trauma patients with COVID-19 infections who undergo extended focused assessment with sonography for trauma (EFAST) correlates with computed tomography (CT) imaging and X-ray findings, as previously reported in other populations. Methods This was a prospective, observational feasibility study performed at two level 1 trauma centers. US, CT, and X-ray imaging were retrospectively reviewed by a surgical trainee and a board-certified radiologist to determine any correlation of imaging findings in patients with active COVID-19 infection. Results There were 53 patients with lung US images from EFAST available for evaluation and COVID-19 testing. The overall COVID-19 positivity rate was 7.5%. COVID-19 infection was accurately identified by one patient on US by the trainee, but there was a 15.1% false-positive rate for infection based on the radiologist examination. Conclusions Evaluation of the lung during EFAST cannot be used in the trauma setting to identify patients with active COVID-19 infection or to stratify patients as high or low risk of infection. This is likely due to differences in lung imaging technique and the presence of concomitant thoracic injury.

Introduction Chest trauma is one of the most important and commonest injuries that require timely diagnosis, accounting for 25–50% of trauma related deaths globally. Although CT scan is the gold standard for detection of haemothorax, it is only useful in stable patients, and remains unavailable in most hospitals in low income countries. Where available, it is very expensive. Sonography has been reported to have high accuracy and sensitivity in trauma diagnosis but is rarely used in trauma patients in low income settings in part due to lack of the sonography machines and lack of expertise among trauma care providers. Chest X-ray is the most available investigation for chest injuries in low income countries. However it is not often safe to wheel seriously injured, unstable trauma patients to X-ray rooms. This study aimed at determining the efficacy of extended focused assessment with sonography for trauma (eFAST) in detection of haemothorax using thoracostomy findings as surrogate gold standard in a low resource setting. Methods This was an observational longitudinal study that enrolled 104 study participants with chest trauma. Informed consent was obtained from all participants. A questionnaire was administered and eFAST, chest X-ray and tube thoracotomy were done as indicated. Data were analysed using SPSS version 22. The sensitivity, specificity, predictive values, accuracy and area under the curve were determined using thoracostomy findings as the gold standard. Ethical approval for the study was obtained from the Research and Ethics Committee of Kampala International University Western Campus REC number KIU-2021-53. Results eFAST was found to be superior to chest X-ray with sensitivity of 96.1% versus 45.1% respectively. The accuracy was also higher for eFAST (96.4% versus 49.1%) but the specificity was the same at 100.0%. The area under the curve was higher for eFAST (0.980, P = 0.001 versus 0.725, P = 0.136). Combining eFAST and X-ray increased both sensitivity and accuracy. Conclusion This study revealed that eFAST was more sensitive at detecting haemothorax among chest trauma patients compared to chest X-ray. All patients presenting with chest trauma should have bedside eFAST for diagnosis of haemothorax.

BACKGROUND: Point of care ultrasound (POCUS) is required for use in many instances on a daily basis in the hospital, especially in the emergency department and other specialty treatment areas. While interns play a crucial role in running emergency services in Thailand, the POCUS usage of interns has not been well studied. METHODS: This was a retrospective observational study of the interns who worked at the Department of Emergency Medicine, a tertiary university hospital in Khon Kaen, Thailand between July 2020 and April 2021. The seven questions survey about participants’ experiences performing POCUS examinations was conceived and carried out by the research team. The primary aim of this study is to identify the frequency of POCUS examinations performed by interns in this or any other given rotation. RESULTS: The response rate was 81.25% with the frequency of POCUS examinations per physician coming in at 2.5 per shift. It should be noted that examinations occurred primarily during the morning shift (79%) and were for diagnostic purposes (100%). The highest POCUS use cases (80%) were found to take place for abdominal examinations and the most commonly used POCUS application was the FAST (Focused Assessment with Sonography for Trauma) examination (92%). The confidence level was rated as 3/5. The primary barrier to performing POCUS was lack of knowledge or ultrasound training (47%). CONCLUSIONS: POCUS is often used by interns though less than in some other specialties. The type of POCUS application employed was limited due to lack of training and the primary obstacle for POCUS use in the emergency department was patient overcrowding.

Phudit Buaprasert,1 Jiraporn Sri-on,1 Jareeda Sukhuntee,2 Ranu Asawajaroenkul,2 Onchuda Buanhong,2 Trairat Khiaodee,2 Worrapat Keetawattananon,2 Gawin Tiyawat2 1Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand; 2Department of Disaster and Emergency Medical Operation, Faculty of Science and Health Technology, Navamindradhiraj University, Bangkok, ThailandCorrespondence: Gawin TiyawatDepartment of Disaster and Emergency Medical Operation, Faculty of Science and Health Technology, Navamindradhiraj University, 681 Samsen Road, Dusit District, Vajira Phayaban, Bangkok, 10300, ThailandTel +66 22443000Email gawin@nmu.ac.thBackground: Training on how to perform a prehospital extended focused assessment with sonography in trauma (EFAST) has resulted in improved outcomes for trauma patients in several countries. The result of previous studies showed good accuracy despite minimal training. However, data on the diagnostic accuracy among untrained paramedic students and the course length in middle-income countries is scarce. In Thailand, the current paramedic education does not include training on prehospital ultrasounds. In the present study, we aimed to investigate the diagnostic accuracy of EFAST among ultrasound-naïve paramedic students and factors that are associated with successful posttest training.Methods: Final-year paramedic students attending a 4-year university program were included in this study. A 2-h didactic training session and 1-h hands-on workshop were led by experienced emergency physicians. The diagnostic indices for EFAST interpretation were obtained pretraining and posttraining. The participants’ ultrasound image acquisition was also evaluated individually on a mannequin model using a standardized assessment tool.Results: In total, 47 paramedic students were voluntarily enrolled and underwent EFAST training. Of these participants, 31 (66%) reported having > 1 year of experience in the prehospital field. Four were advanced emergency medical technicians before becoming paramedic students. The sensitivity, specificity, positive predictive value, and negative predictive value after training were 85.7% (95% CI, 81.5– 89.3), 81.6% (95% CI, 74.2– 87.6), 91.6% (95% CI, 87.9– 94.4), and 71% (95% CI, 63.3– 77.8), respectively. Previous prehospital experience was not associated with accuracy.Conclusion: This study demonstrated that paramedic students in Thailand were able to achieve a competency comparable with that of other medical professionals in a simulated environment. The total 3 h training course was sufficient for them to acquire EFAST skills.Keywords: extended focused assessment with sonography in trauma, ultrasound, paramedic, training

It is generally recognized that lives are saved by administering high-quality cardiopulmonary resuscitation (CPR) to patients in cardiac arrest. A focused assessment with sonography for trauma (FAST) examination is an effective and non–invasive method for detecting rare complications of CPR, such as hemorrhage from abdominal visceral injury. We report the case of a 56-year-old female suffering from intra-abdominal hemorrhage caused by a liver laceration following CPR. The hemoperitoneum was diagnosed by a FAST examination. Although severe complications of CPR are rare, they can be easily detected with the use of a FAST examination. A FAST examination should be considered as a post-resuscitation approach to assess for life-threatening complications in all patients following cardiopulmonary resuscitation.

Imaging forms a crucial component in reducing mortality of polytraumatized patients by aiding appropriate diagnosis and guiding the emergency and definitive treatment. With the exponential expansion in the radiological armamentarium and introduction of protocols like Extended focused assessment with sonography for trauma (EFAST) and Whole body Computed tomography (WBCT), the role of imaging has considerably increased. Emergency imaging protocols should be done for rapid diagnosis of life-threatening injuries allowing simultaneous evaluation and resuscitation. Subsequent comprehensive imaging is essential to diagnose the often clinically missed injuries to reduce the overall morbidity. Imaging protocols must adapt to the patient’s clinical scenario, which can be dynamically changing. Each trauma team should devise clear guidelines, protocols, and algorithms suitable for their center depending on the local availability of types of equipment and expertise. Radiologists must efficiently communicate and adopt patient-centered approach to ensure early appropriate care to these severely injured patients. Future research should involve multicentre studies to formulate the most appropriate imaging protocol in polytrauma to increase diagnostic accuracy and thereby reduce patient mortality.

To perform a province-wide evaluation of adult major traumas and determine the proportion of patients who met clinical and/or anatomical criteria for resuscitative endovascular balloon occlusion of the aorta (REBOA). This is a retrospective analysis of all major trauma patients (age > 16) presenting to the sole adult level 1 trauma centre in Nova Scotia over a 5-year period (2012–2017). Data were collected from the Nova Scotia Trauma Registry and medical charts. We identified potential REBOA candidates using either: (1) clinical criteria (primary survey, Focused Assessment with Sonography for Trauma, pelvic/chest X-ray); or (2) anatomical criteria (ICD-10-CA codes). Potential candidates with persistent hypotension were considered true REBOA candidates. Overall 2885 patients were included in the analysis, of whom 248 (8.6%) patients were in shock (including 106 transfer patients) and had their charts reviewed. A total of 137 patients met clinical criteria for REBOA; 44 (1.5%) had persistent hypotension 10–20 min into resuscitation and were considered true REBOA candidates. There were 59 patients who met anatomical criteria for REBOA, of whom 15 (0.5%) patients had persistent hypotension and were true REBOA candidates. The 15 REBOA candidates based on anatomical criteria also met clinical criteria for REBOA. In this registry-based retrospective analysis, 1.5% of adult major trauma patients Nova Scotia were REBOA candidates based on resuscitative clinical presentation, while 0.5% were candidates based on post hoc anatomical injury patterns. Our findings suggest that using clinical findings and bedside imaging modalities as criteria may overestimate the number of candidates for REBOA.

The following recommendations are presented herein: All trauma patients admitted to the resuscitation room should be constantly (or periodically) monitored for parameters such as blood pressure, heart rate, respiratory rate, oxygen saturation, body temperature, electrocardiography, Glasgow Coma Scale, and pupil ref lex (1C). Chest AP and pelvic AP should be performed as the standard initial trauma series for severe trauma patients (1B). In patients with severe hemodynamically unstable trauma, it is recommended to perform extended focused assessment with sonography for trauma (eFAST) as an initial examination (1B). In hemodynamically stable trauma patients, eFAST can be considered as the initial examination (2B). For the diagnosis of suspected head trauma patients, brain computed tomography (CT) should be performed as an initial examination (1B). Cervical spine CT should be performed as an initial imaging test for patients with suspected cervical spine injury (1C). It is not necessary to perform chest CT as an initial examination in all patients with suspected chest injury, but in cases of suspected vascular injury in patients with thoracic or high-energy damage due to the mechanism of injury, chest CT can be considered for patients in a hemodynamically stable condition (2B). CT of the abdomen is recommended for patients suspected of abdominal trauma with stable vital signs (1B). CT of the abdomen should be considered for suspected pelvic trauma patients with stable vital signs (2B). Whole-body CT can be considered in patients with suspicion of severe trauma with stable vital signs (2B). Magnetic resonance imaging can be considered in hemodynamically stable trauma patients with suspected spinal cord injuries (2B).

Introduction. Severe trauma is one of the leading causes of disability and mortality in all age groups. Long bone fractures of lower extremities, in particular the femur, have increased risk of complications. The choice of surgical treatment tactic, timing and methods of fixing of long bone fractures of lower extremities in patients with severe associated trauma is relevant and controversial issue.Objective: to conduct a retrospective analysis of injury structure in polytrauma center and evaluate treatment outcomes in polytrauma patients with multiple long bone fractures of lower extremities, frequency of complications and mortality.Materials and methods: the retrospective study was conducted, included a group of patients had applied to the admission department of Kyiv City Clinical Hospital No17 during the period from January 2010 to December 2019.Results: the study included 54,613 patients at the first stage. 69.3% of patients were received outpatient care, 30.7% were hospitalized. Among all patients, 13.7% were diagnosed with polytrauma, of which 80.2% had chest injury, 78.4% had traumatic brain injury, and 71.1% had musculoskeletal injuries. In the structure of musculoskeletal system trauma the multiple bone fractures of lower extremities were in 16.7% of patients, among them long bone fractures were in 57.6%.The study included 220 patients at the second stage. The incidence of pulmonary embolism occurred in 4.1% of patients, fat embolism – 12.7%, nosocomial pneumonia was diagnosed in 38.2% of patients, acute respiratory distress syndrome (ARDS) – 16.8%. The incidence of sepsis, according to the criteria of definition «Sepsis II» was 30.9%, according to the criteria «Sepsis III» – 9.5%, multiple organ failure (MOF) – 18.6%.The duration of mechanical ventilation was 19.1±10.8 days. The length of stay in intensive care unit was 24.8±12.6 days and the hospital length of stay was 48.9±22.4 days. The mortality rate was 22.3%. Among the main causes of death – hemorrhagic shock (46.9%), MOF (34.7%), refractory septic shock 18.4%.Conclusions: the frequency of polytrauma was 13.7% in trauma structure and frequency of polytrauma with combined multiple long bone fractures of lower extremities – 0.5%. Most common localizations of injuries were chest trauma (78.6%), traumatic brain injury (73.6%), injuries of musculoskeletal system (71.1%). Multiple bone fractures of lower extremities were in 16.7% of patients in the structure of musculoskeletal system trauma, among them fractures of long bones were in 57.6% of patients.Ultrasound examination according to the protocol «Focused Assessment with Sonography for Trauma» (FAST) and whole body computed tomography were not performed after patient hospitalization in 100% of cases, as required by international protocols. The frequency of Early Total Care tactics application – 1.4% that was too low, the definitive osteosynthesis in some cases was performed unreasonably late, and 17.2% of primary and definitive cases and 23.9% of temporary stabilization of fractures were performed by conservative methods.The most common complications were pulmonary: nosocomial pneumonia, ARDS and fat embolism syndrome, and also sepsis and MOF.

Background Major pelvic fractures are often associated with intra-abdominal organ injuries. Considering patients’ hemodynamic status, Focused Assessment with Sonography for Trauma (FAST) can facilitate decision-making for abdominal exploration. Non-therapeutic exploratory laparotomy from pelvic fractures should be avoided. Aim of this study is to determine the accuracy of FAST in diagnosing significant intraabdominal hemorrhage that leads to determine whether or not to pursue therapeutic abdominal exploration in patients with major pelvic fractures. Material and methods We systematically reviewed the PubMed and SCOPUS databases from 2009 to 2019 and also using a retrospective review of patients admitted to the Acute Care Surgery service from 2016 to 2019. We performed a meta-analysis by using a random effects model. Results A total 677 patients were analyzed, 28 cases from our hospital. Mean patient age was 40.8 years. Leading mechanism of injury were motor vehicle collision (44.72%), fall from height (13.41%), and motorcycle collision (13.69%). Average injury severity score (ISS) was 32.5 (range: 24.1–50), and overall mortality rate was 11.65%. The pooled sensitivity, specificity, and accuracy of FAST to identify significant intra-abdominal hemorrhage was 79%,90%, and 93%, respectively (95% confidence interval: 89%–94%). Meta-regression revealed no significant correlation between injury severity score and the accuracy of FAST. Conclusion Our meta-analysis revealed that FAST in major pelvic fracture accurately detected significant intra-abdominal hemorrhage. Using FAST in the presence of unstable hemodynamics, we can decide to perform abdominal exploration with the expectation of finding significant intra-abdominal hemorrhage require surgically control., Highlights • Pelvic fractures is limiting the accuracy of FAST because free fluid from a major pelvic fracture could be retroperitoneal hematoma entering the transperitoneal plane into the peritoneal space or intraperitoneal free fluid (hemoperitoneum or uroperitoneum) caused by significant intra-abdominal organ injury. • Using FAST in the presence of unstable hemodynamics, we can decide to perform abdominal exploration with the expectation of finding significant intra-abdominal hemorrhage require surgically control. • Major pelvic fracture with initial FAST negative results, whole-abdomen CT still should be performed to detect occult injury, such as diaphragmatic injuries or hallow viscus organ injuries, which could be missed.

A seemingly healthy 84-year-old female pedestrian was mildly bumped by a car, and she hit her left shoulder, flank, and lower legs when she fell down on a street. She was conscious and stable when transferred to an emergency room. She had no sign of any major injuries except minor lacerations on her legs. Repeated evaluations including chest X-ray, ECG, and focused assessment with sonography for trauma did not reveal any abnormal findings. While waiting for discharge, she started having mild chest discomfort. Unexpectedly, the third echocardiogram showed mild pericardial effusion, and a CT with contrast showed aortic dissection in the ascending aorta and infra-left subclavian aortic dissection. She was immediately transferred by a helicopter to a tertiary trauma center for emergent repair surgery. Considering the site of dissections, progression of existing intrinsic intimal tear triggered by energy impact was suspected. However, traumatic causes could not be excluded. Extra caution and diligence should be exercised when examining elderly patients in blunt trauma.

Objective To investigate if patients with confirmed traumatic abdominal injury and a false-negative focused abdominal sonography for trauma (FAST) examination have a more favorable prognosis than those with a true-positive FAST. Methods This study included 97 consecutive patients with confirmed traumatic abdominal injury (based on computed tomography [CT] and/or surgical findings) who underwent FAST. Results FAST was false-negative in 40 patients (41.2%) and true-positive in 57 patients (58.8%). Twenty-two patients (22.7%) had an unfavorable outcome (defined as the need for an interventional radiologic procedure, laparotomy, or death due to abdominal injury). Univariately, a false-negative FAST (odds ratio [OR] 0.24; p = 0.017) and a higher systolic blood pressure (OR, 0.97 per mmHg increase; p = 0.034) were significantly associated with a favorable outcome, whereas contrast extravasation on CT (OR, 7.17; p = 0.001) and shock index classification (OR, 1.89 for each higher class; p = 0.046) were significantly associated with an unfavorable outcome. Multivariately, only contrast extravasation on CT remained significantly associated with an unfavorable outcome (OR, 4.64; p = 0.016). When excluding contrast extravasation on CT from multivariate analysis, only a false-negative FAST result was predictive of a favorable outcome (OR, 0.28; p = 0.038). Conclusion Trauma patients with confirmed abdominal injury and a false-negative FAST have a better outcome than those with a positive FAST. FAST may be valuable for risk stratification and prognostication in patients with a high suspicion of abdominal injury when CT has not been performed yet or when CT is not available.

Objective: Trauma is the significant non-obstetrical cause of maternal mortality in women aged 35 years or younger. It is expected to complicate around 1 in 12 pregnancies and accounts for 46% of such deaths. In this study, we present our experience of trauma during pregnancy at a tertiary care hospital in Karachi. Methods: A standardized form was used to extract data from online records for all pregnant women who presented with traumatic injuries to the Aga Khan University Hospital from 2014 to 2019. Analysis was performed using SPSS v. 21. Chi-squared tests were performed for comparison of categorical data. Results: A total of 48 pregnant females with a mean age of 28.80 ± 6.50 years were included in this study. Road traffic accidents (RTA) accounted for the commonest cause of injury in the first (66.7%) and second (65%) trimesters. However, fall (45.5%) followed by RTA (27.3%) was the most frequent mechanism of injury during the third trimester. Gunshot injuries were seen in 4 patients only. Overall, fetal ultrasound was the most commonly performed imaging (87.5%) followed by limb X-ray and focused abdominal sonography for trauma (FAST) ultrasound. Out of total, 52.1% of the patients were surgically managed. Fetal demise in utero and spontaneous abortion was reported in 2 patients only. Conclusion: Road traffic accidents and falls comprise a significant burden of maternal and fetal morbidity and mortality. In terms of prevention, several policies and interventions at the government level need to be introduced in order to reduce the incidence of traumatic events.

Importance: The wide variation in the accuracy and reliability of the Focused Assessment With Sonography for Trauma (FAST) and the extended FAST (E-FAST) for children after blunt abdominal trauma reflects user expertise. FAST and E-FAST that are performed by experts tend to be more complete, better quality, and more often clinically valuable. Objective: To develop definitions of a complete, high-quality, and accurate interpretation for the FAST and E-FAST in children with injury using an expert, consensus-based modified Delphi technique. Design, Setting, and Participants: This consensus-based qualitative study was conducted between May 1 to June 30, 2021. It used a scoping review and iterative Delphi technique and involved 2 rounds of online surveys and a live webinar to achieve consensus among a 26-member panel. This panel consisted of international experts in pediatric emergency point-of-care ultrasonography. Main Outcomes and Measures: Definitions of complete, high-quality, and accurate FAST and E-FAST studies for children after injury. Results: Of the 29 invited pediatric FAST experts, 26 (15 men [58%]) agreed to participate in the panel. All 26 panelists completed the 2 rounds of surveys, and 24 (92%) participated in the live and asynchronous online discussions. Consensus was reached on FAST and E-FAST study definitions, and the panelists rated these 5 anatomic views as important and appropriate for a complete FAST: right upper-quadrant abdominal view, left upper-quadrant abdominal view, suprapubic views (transverse and sagittal), and subxiphoid cardiac view. For E-FAST, the same FAST anatomic views with the addition of the lung or pneumothorax view were deemed appropriate and important. In addition, the panelists rated a total of 32 landmarks as important for assessing completeness. Similarly, the panelists rated 14 statements on quality and 20 statements on accurate interpretation as appropriate. Conclusions and Relevance: This qualitative study generated definitions for complete FAST and E-FAST studies with high image quality and accurate interpretation in children with injury. These definitions are similar to those in adults with injury and may be used for future education, quality assurance, and research. Future research may focus on interpretation of trace volumes of abdominal free fluid and the use of serial FAST.

This study reviewed the former studies conducted on the usefulness of accuracy of focused assessment with sonography for trauma (FAST) or any plain ultrasonography (US) scan in pediatric blunt abdominal trauma (BAT), to assess its accuracy, sensitivity, specificity, and positive and negative predictive values (PPV and NPV). Searches were conducted using the predefined keywords and Medical Subject Headings (MeSH) terms across MEDLINE (PubMed), Scopus, Web of Science, Cochrane Collaboration Library, Embase, ClinicalTrials.gov, Magiran and SID.ir databases. Duplicate publications were excluded; then the titles and abstracts of eligible studies were reviewed for how they report blunt trauma, pediatric patients, and ultrasound modality in their text. Cochrane RevMan version 5.3 was used for the results analysis and assessing the risk of bias in the studies. Out of 923 studies, 902 were excluded, and only 19 articles were included in this review, out of which one was a randomized clinical trial (RCT), three were cohort studies, two were contrast-enhanced US (CEUS) studies, and 13 were prospective or retrospective descriptive studies. The total population studied in the articles was 3454 patients. The results showed that the specificity of US in pediatric BAT was 93%, the sensitivity was 54%, and the PPV in comparison to clinical examination was 73% versus 37%. CEUS protocol achieved 100% in both sensitivity and specificity analysis. The only RCT study which included about 28% of the studies population also reached a sensitivity and specificity of 97% and 98%, respectively using a combinational protocol of clinical examination, laboratory investigation, and US assessment. Ultrasonography does not provide more results than clinical examination, though better PPV results. A combination of follow-up, US examination, and laboratory requests may also have more accurate results. Moreover, a CEUS protocol may reach that goal with an acceptable time-saving outcome, but it needs more studies to be confirmed.

OBJECTIVE—: Pediatric focused assessment with sonography for trauma (FAST) is a sequence of ultrasound views rapidly performed by clinicians to diagnose hemorrhage. A technical limitation of FAST is the lack of expertise to consistently acquire all required views. We sought to develop an accurate deep learning view classifier using a large heterogeneous dataset of clinician-performed pediatric FAST. METHODS—: We developed and conducted a retrospective cohort analysis of a deep learning view classifier on real-world FAST studies performed on injured children less than 18 years old in two pediatric emergency departments by 30 different clinicians. FAST was randomly distributed to training, validation, and test datasets, 70:20:10; each child was represented in only one dataset. The primary outcome was view classifier accuracy for video clips and still frames. RESULTS—: There were 699 FAST studies, representing 4925 video clips and 1,062,612 still frames, performed by 30 different clinicians. The overall classification accuracy was 97.8% (95% confidence interval [CI]: 96.0–99.0) for video clips and 93.4% (95% CI: 93.3–93.6) for still frames. Per view still frames were classified with an accuracy: 96.0% (95% CI: 95.9–96.1) cardiac, 99.8% (95% CI: 99.8–99.8) pleural, 95.2% (95% CI: 95.0–95.3) abdominal upper quadrants, and 95.9% (95% CI: 95.8–96.0) suprapubic. CONCLUSION—: A deep learning classifier can accurately predict pediatric FAST views. Accurate view classification is important for quality assurance and feasibility of a multi-stage deep learning FAST model to enhance the evaluation of injured children.

A woman in her early 30s presented to a level 1 trauma center with a single through-and-through gunshot wound to the lower sternum and left posterior chest. She was hypotensive and tachycardic on arrival. Physical examination and chest X-ray suggested left hemothorax. An emergent left tube thoracostomy drained 200 mL of fresh blood. A focused assessment with sonography for trauma was equivocal for hemopericardium, while demonstrating a trace amount of fluid in the left upper abdomen. A massive transfusion protocol was initiated and she was taken to the operating room for an emergent median sternotomy due to a high suspicion for cardiac injury and an intra-abdominal involvement. Intraoperatively, a 3 cm right ventricle laceration was identified and a cardiorrhaphy was performed. Intrathoracic cardiac massages were necessitated due to asystole. The patient’s abdomen was noted more distended and firmer, and the bullet trajectory was identified coursing into the abdomen. A subsequent exploratory laparotomy revealed hemoperitoneum, liver laceration, and spleen laceration. These injuries required a splenectomy, liver packing, and negative-pressure abdominal packing. The patient received 47 units of packed red blood cells, rationed with fresh frozen plasma and platelets. She became coagulopathic, …

BACKGROUND This pilot assessed transfusion requirements during resuscitation with whole blood followed by standard component therapy (CT) versus CT alone, during a change in practice at a large urban Level I trauma center. METHODS This was a single-center prospective cohort pilot study. Male trauma patients received up to 4 units of cold-stored low anti-A, anti-B group O whole blood (LTOWB) as initial resuscitation followed by CT as needed (LTOWB + CT). A control group consisting of women and men who presented when LTOWB was unavailable, received CT only (CT group). Exclusion criteria included antiplatelet or anticoagulant medication and death within 24 hours. The primary outcome was total transfusion volume at 24 hours. Secondary outcomes were mortality, morbidity, and intensive care unit- and hospital-free days. RESULTS Thirty-eight patients received LTOWB, with a median of 2.0 (interquartile range [IQR] 1.0-3.0) units of LTOWB transfused. Thirty-two patients received CT only. At 24 hours after presentation, the LTOWB +CT group had received a median of 2,138 mL (IQR, 1,275-3,325 mL) of all blood products. The median for the CT group was 4,225 mL (IQR, 1,900-5,425 mL; p = 0.06) in unadjusted analysis. When adjusted for Injury Severity Score, sex, and positive Focused Assessment with Sonography for Trauma, LTOWB +CT group patients received 3307 mL of blood products, and CT group patients received 3,260 mL in the first 24 hours (p = 0.95). The adjusted median ratio of plasma to red cells transfused was higher in the LTOWB + CT group (0.85 vs. 0.63 at 24 hours after admission; p = 0.043. Adjusted mortality was 4.4% in the LTOWB + CT group, and 11.7% in the CT group (p = 0.19), with similar complications, intensive care unit-, and hospital-free days in both groups. CONCLUSION Beginning resuscitation with LTOWB results in equivalent outcomes compared with resuscitation with CT only. LEVEL OF EVIDENCE Therapeutic (Prospective study with 1 negative criterion, limited control of confounding factors), level III.

Saving children from motor vehicle collisions is a high priority because the injury rate among motor vehicle passengers has been increasing in Japan. This study aimed to examine the factors that influence death and serious injury in child motor vehicle passengers to establish effective preventive measures. To identify these factors, we performed a retrospective study using a nationwide medical database. The data of child motor vehicle passengers younger than 15 years (n = 1084) were obtained from the Japanese Trauma Data Bank, registered from 2004 to 2019. Physiological variables, outcomes, and injury severity were compared between fatal and non-fatal patients and between those with and without severe injuries. Multivariate logistic regression analysis was performed to determine factors affecting fatality and severe injury. The Glasgow Coma Scale score (odds ratio (OR): 1.964), body temperature (OR: 2.578), and the Abbreviated Injury Scale score of the head (OR: 0.287) were identified as independent predictors of a non-fatal outcome. Systolic blood pressure (OR: 1.012), the Glasgow Coma Scale score (OR: 0.705), and Focused Assessment with Sonography for Trauma positivity (OR: 3.236) were identified as independent predictors of having severe injury. Decreasing the severity of head injury is the highest priority for child motor vehicle passengers to prevent fatality and severe injury.

Cecal perforation following blunt abdominal trauma is an uncommon and challenging injury. We report a 19-year-old HIV-positive woman who presented with abdominal pain after a high-speed motor vehicle crash. Abdominal exam revealed a seatbelt sign with evidence of peritonitis; Focused Assessment with Sonography for Trauma showed free intraperitoneal fluid. After fluid resuscitation and antibiotics, the patient was taken for urgent laparotomy. Intraoperatively, we discovered hemoperitoneum and an isolated rupture of the cecum. A right hemicolectomy with end-to-end ileo-transverse colon anastomosis was performed. Her only significant postoperative complication was a superficial wound infection. We review the epidemiology of hollow viscus injury in blunt trauma and discuss important considerations in diagnosis and treatment. Keywords: Blunt abdominal trauma, Cecal rupture, HIV positive, Hollow viscus

With continuing advancements in software, electronics, and miniaturization, ultrasound (US) is quickly becoming an everyday tool of numerous medical specialties. With the advent of new handheld and other small-scale units, physicians have a tool to obtain on demand imaging without exposing the patient to ionizing radiation in the pocket of their white coat. As such, the need for competency in US is increasing. Currently, US training primarily occurs in residency, with only a handful of institutions incorporating US into the undergraduate medical education (UME) curriculum. To date, no ideal method has been presented (Amini et al., Intern Emerg Med. 10(5):613-8, 2015; Wilson et al., J Ultrasound Med. 36(2):321-5, 2017). Presented herein is a method for the addition of US training into the undergraduate medical curriculum. Utilizing a co-enrolled course format, 6 medical students were given basic training in the history and physics of US, echocardiography (ECHO), right upper quadrant (RUQ) ultrasound, focused assessment with sonography for trauma (FAST), and extended (eFAST) exams, vascular access techniques, and MSK ultrasound over 17 sessions. Students theoretical knowledge was assessed during team-based learning (TBL) sessions in an individual and group readiness assurance test (IRAT/GRAT) format. Students' practical skill was assessed in an objective structured clinical examination (OSCE) format. Students demonstrated notable proficiency with the US unit and were able to conduct both US-guided peripheral and central vascular access techniques. Furthermore, students were able to identify 80% or more of the required structures for the RUQ, ECHO, and eFAST US exams.

Background Non-invasive, rapid, and precise assessment of injury in the military settings is extremely important, yet difficult. Focused assessment with sonography in trauma (FAST) is being increasingly employed for assessing the location and severity of injury and guiding further treatment strategy. However, the evidence regarding the utility of FAST in the military settings is scattered. Aims To evaluate the diagnostic performance of FAST in the assessment of injury in the military settings. Study design Meta-analysis. Methods We identified all relevant papers via the PubMed, EMBASE, and Cochrane Library databases. We evaluated the quality of included studies by the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We pooled the area under the curve (AUC), sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio as the effect sizes, followed by evaluating the heterogeneity among the studies by p value and I2. Results Among the 39 papers, a total of six papers were included. The sample size ranged from 15 to 396. The AUC of FAST for assessing the injury was 0.85. The pooled sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio were 0.66, 0.98, 33.1, 0.34, and 97, respectively. The heterogeneity among the studies was statistically significant (p=0.006, I2=78%). Conclusion FAST is potentially valuable for assessing injury in the military settings. Due to its high specificity, FAST may be appropriate to rule in significant injury. However, because of its poor sensitivity, the ability of FAST to rule out injury cannot be relied upon.

IntroductionThe management of a patient suffering from blunt abdominal trauma (BAT) remains a challenge for the emergency physician. Within the last few years, the standard therapy for hemodynamically stable patients with BAT has transitioned to a non-operative approach. The purpose of this study is to evaluate the outcome of patients with BAT and to determine the reasons for failure of non-operative management (NOM).Materials and methodsAnalysis of 176 consecutive patients treated for BAT was conducted in a German level 1 trauma center from 2004 to 2011. Abdominal injuries were classified according to the American Association for the Surgery of Trauma (AAST). Patients included were demonstrated to have objective abdominal trauma with either free fluid on focused assessment with sonography for trauma (FAST) or computed tomography (CT), or proven organ injury.ResultsPatients, 142 of 176 (80.7%), with BAT were initially managed non-operatively, with a success rate of 90%. The rates of NOM success were higher among those with less severe injuries; 100% with Abbreviated Injury Scale (AIS) of 1. In total, 125 patients (71.0%) were managed non-operatively, and 51 (29.0%) required surgical intervention. NOM failure occurred in 9.2% of the patients, the most common reason being initially undiagnosed intestinal perforation (46.2%). Positive correlation was identified (r = 0.512; p ConclusionNOM was successful for the vast majority of blunt abdominal trauma patients, especially those with less severe injuries. NOM failure and operative delay were most commonly due to occult hollow viscus injury (HVI), the detection of which was achieved by close clinical observation and abdominal ultrasound in conjunction with monitoring for rising markers of infection and by multidetector computed tomography (MDCT) if additionally indicated. Based on this concept, the delay in operation in patients with NOM failure was short. This study underscores the feasibility and benefit of NOM in BAT.

Objective. To determine the ways of improvement in results of delivery of surgical help to the wounded persons with the battle abdominal trauma (BAT) in conditions of military conflict on the east of Ukraine. Materials and methods. Delivery of surgical help was analyzed in 707 wounded persons with BAT on stages of medical evacuation (SME) Level III of the medical help delivery during conduction of Antiterrorist operation (ATO). Two groups of observation were implemented: GS–1 and GS–2. Into GS–1 were included 402 wounded persons, to whom surgical help was delivered in first two periods of ATO, when the military actions intensity was maximal; and into GS–2 – 305 wounded persons, in whom surgical help was delivered in third period, which was characterized by lowering of the battle intensity, optimization of system of treatment–evacuation support (TES), systematic application of the proposed scale for estimation of the trauma severity Admission trauma score (AdTS), Focused Assessment with Sonography for Trauma (FAST)–protocol and tactic of the Damage Control Surgery (DCS). Results. Reduction of the morbidities percentage was achieved: from 76.6% in the operated wounded persons GS–1 to 44.0% in the operated wounded persons GS–2, and lethality lowering by 2.7% for the wounded persons with severe and extremely severe BAT were achieved. Conclusion. Using surgical interventions in borders of the tactics DCS phases in all volume with further conduction of operations in accordance to the “Second look” program, relaparotomies and programmed relaparotomies on background of optimization of a TES system have improved the results of the surgical help delivery in the wounded persons with BAT on the SME level III of the medical help delivery while conduction of ATO.

Introduction: Access to high-quality emergency care in low- and middle-income countries (LMIC) is lacking. Many countries utilise a strategy known as “task-shifting” where skills and responsibilities are distributed in novel ways among healthcare personnel. Point-of-care ultrasound (POCUS) has the potential to significantly improve emergency care in LMICs. Methods: POCUS was incorporated into a training program for a ten-person cohort of non-physician Emergency Care Providers (ECPs) in rural Uganda. We performed a prospective observational evaluation on the impact of a remote, rapid review of POCUS studies on the primary objective of ECP ultrasound quality and secondary objective of ultrasound utilisation. The study was divided into four phases over 11 months: an initial in-person training month, two middle month blocks where ECPs performed ultrasounds independently without remote electronic feedback, and the final months when ECPs performed ultrasounds independently with remote electronic feedback. Quality was assessed on a previously published eight-point ordinal scale by a U.S.-based expert sonographer and rapid standardised feedback was given to ECPs by local staff. Sensitivity and specificity of ultrasound exam findings for the Focused Assessment with Sonography for Trauma (FAST) was calculated. Results: Over the study duration, 1153 ultrasound studies were reviewed. Average imaging frequency per ECP dropped 61% after the initial in-person training month (p = 0.01) when ECPs performed ultrasound independently, but rebounded once electronic feedback was initiated (p = 0.001), with an improvement in quality from 3.82 (95% CI, 3.32–4.32) to 4.68 (95% CI, 4.35–5.01) on an eight-point scale. The sensitivity and specificity of FAST exam during the initial training period was 77.8 (95% CI, 59.2–83.0) and 98.5 (95% CI, 93.3–99.9), respectively. Sensitivity improved 88% compared to independent, non-feedback months whereas specificity was unchanged. Conclusions: Remotely delivered quality assurance feedback is an effective educational tool to enhance provider skill and foster continued and sustainable use of ultrasound in LMICs. Keywords: ultrasound;non-physician, quality assurance, Hydroxyl radicals, remote feedback

Performing an extended Focused Assessment with Sonography in Trauma (eFAST) exam is common practice in the initial assessment of trauma patients. The objective of this study was to systematically review the published literature on diagnostic accuracy of all components of the eFAST exam.We searched Medline and Embase from inception through October 2018, for diagnostic studies examining the sensitivity and specificity of the eFAST exam. After removal of duplicates, 767 records remained for screening, of which 119 underwent full text review. Meta-DiSc™ software was used to create pooled sensitivities and specificities for included studies. Study quality was assessed using the Quality in Prognostic Studies (QUADAS-2) tool.Seventy-five studies representing 24,350 patients satisfied our selection criteria. Studies were published between 1989 and 2017. Pooled sensitivities and specificities were calculated for the detection of pneumothorax (69% and 99% respectively), pericardial effusion (91% and 94% respectively), and intra-abdominal free fluid (74% and 98% respectively). Sub-group analysis was completed for detection of intra-abdominal free fluid in hypotensive (sensitivity 74% and specificity 95%), adult normotensive (sensitivity 76% and specificity 98%) and pediatric patients (sensitivity 71% and specificity 95%).Our systematic review and meta-analysis suggests that e-FAST is a useful bedside tool for ruling in pneumothorax, pericardial effusion, and intra-abdominal free fluid in the trauma setting. Its usefulness as a rule-out tool is not supported by these results.Le recours à l’évaluation ciblée par échographie étendue en traumatologie (eFAST : sigle anglais) est pratique courante dans l’évaluation initiale des patients ayant subi un trauma. L’étude avait donc pour but une revue systématique de la documentation publiée sur l'exactitude du diagnostic reposant sur tous les éléments constitutifs de l'eFAST.Les chercheurs ont effectué une recherche d’études sur les examens de diagnostic ayant pour objets la sensibilité et la spécificité de l'eFAST, dans les bases de données Medline et Embase, depuis leur début respectif jusqu’à octobre 2018. Après le retrait des doubles, il restait 767 documents aux fins de sélection, dont 119 ont été soumis à un examen en texte intégral. Le logiciel Meta-DiScMC a servi à établir la sensibilité et la spécificité globales des études retenues. Quant à la qualité des études, elle a été évaluée à l'aide de l'instrument Quality in Prognostic Studies (QUADAS-2).Au total, 75 études totalisant 24 350 patients et publiées entre 1989 et 2017 répondaient aux critères de sélection. La sensibilité et la spécificité globales ont été calculées pour la détection des pneumothorax (69% et 99% respectivement), des épanchements péricardiques (91% et 94% respectivement) et de liquide libre intra-abdominal (74% et 98% respectivement). Il y a eu également analyse de sous-groupes en vue de la détection de liquide libre intra-abdominal chez les patients hypotendus (sensibilité : 74%; spécificité : 95%), les adultes normotendus (sensibilité : 76%; spécificité : 98%) et les enfants (sensibilité : 71%; spécificité : 95%).D'après les résultats de la revue systématique et de la méta-analyse, l'eFAST au chevet se montre utile pour confirmer la présence de pneumothorax, d’épanchement péricardique ou de liquide libre intra-abdominal en traumatologie, mais pas pour en écarter la présence.

Background Ventricular septal perforation (VSP) can be caused by a penetrating cardiac injury. Diagnosis of VSP tends to be delayed because a shunt might not be detected by color flow Doppler at an early stage following injury. Case presentation A 60-year-old man with depression was admitted to the emergency center after a knife injury in the chest. A focused assessment with sonography for trauma revealed cardiac tamponade. Shortly after an open cardiac massage and a pericardiotomy, his spontaneous circulation returned. At a later stage, follow-up computed tomography, echocardiography, and left ventriculography showed traumatic ventricular septal perforation. Conservative therapy was chosen because the pulmonary blood flow/systemic blood flow ratio was 1.42. Conclusion The initial contrast computed tomography shows a septal hematoma. Its presence could be perceived as a perforation site in the interventricular septum.

BAYDIN, AHMET/0000-0003-4987-0878 WOS: 000473282200007 PubMed: 31253211 Objective: To investigate the accuracy of focussed assessment sonography for trauma (FAST) bedside ultrasonography application in patients with blunt abdominal trauma and patient management, clinical outcome, and trauma severity scores. Study Design: Cross-sectional descriptive study. Place and Duration of Study: Department of Emergency Medicine, Ondokuz Mayis University, Faculty of Medicine, Samsun, Turkey, from April 2013 to June 2017. Methodology: The presence of intraperitoneal free fluid (FF) was investigated by FAST application by emergency physicians. Abdominal computed tomography (CT), which was considered the gold standard, was made use of for evaluating intraperitoneal FF presence. Patients were evaluated for urgent surgical intervention, requirement of blood transfusion, and mortality status. The relationship between the FF presence / absence in FAST practice and revised trauma score (RTS), injury severity score (ISS) and trauma injury severity score (TRISS) was statistically analysed. Results: All 28 FAST (+) patients also had intraperitoneal FF in gold standart CT. Although the gold standart CT detected intraperitoneal FF in 6 (4.2%) of 140 FAST (-) patients, the compatibility between FAST and CT in the detection of intraperitoneal FF in patients with blunt abdominal trauma was statistically significant (k: 0.882, p

Background: Formal ultrasonography has advanced to point-of-care ultrasound (POCUS) in the emergency department (ED) for the purpose of acute critical care. While POCUS application expands, little is known about POCUS utilisation in public hospital EDs. This study aimed to describe the use of POCUS in an ED in KwaZulu-Natal. Methods: A retrospective chart review study was conducted on all patients who had POCUS exams performed in the ED at the General Justice Gizenga Mpanza Regional Hospital from 01 September 2019 to 31 March 2020. A data collection tool was used to extract the required data from the Mindray M6 ultrasound machine. The data were processed using the Statistical Package for Social Sciences (SPSS version 26) and descriptive statistics were used to summarise the data. Results: A total of 978 POCUS were performed on 784 patients. Point-of-care ultrasound was utilised more often for focused emergency echocardiography in resuscitation ( n = 383) and extended focused assessment with sonography for trauma ( n = 319). The findings were normal in 17% of exams, 31% were positive, 9% were unspecified and 43% of POCUS exams were inconclusive. Seven percent of POCUS exams were performed by accredited level 1 emergency POCUS providers and ultrasounds occurred more frequently during day-shift hours than after-hours. Conclusion: Point-of-care ultrasound core applications were utilised by ED doctors for various emergency care scenarios, mainly for trauma and cardiac assessments.

We herein report a case of an 18-year-old female with Kawasaki disease who presented to the emergency department with epigastric abdominal pain and was subsequently found to have free fluid present in her abdomen visualized on bedside Focused Assessment with Sonography for Trauma (FAST) exam. Kawasaki disease is an acute vasculitis syndrome that primarily affects children and can have serious complications such as coronary artery aneurysms. The use of ultrasound in emergency departments is rapidly increasing, with the FAST being one of the most commonly performed bedside ultrasound examinations. FAST exams are most commonly performed in trauma patients as well as being part of the Advanced Trauma Life Support (ATLS) protocol. However, this case demonstrated that the FAST exam can also have application in other clinical scenarios and patient presentations where there is clinical suspicion of free intra-abdominal fluid.

A 33-year-old female presented to the trauma center with multiple gunshot wounds to her left posterior axilla, right of midline in the upper back, and left lateral thigh. She complained that she did not have sensation in or an ability to move her left upper extremity. The patient was screaming and uncooperative during the examination. Her systolic blood pressure was 110 mm Hg, heart rate was 138 beats per minute, and respiratory rate was 33 breaths per minute with audible breath sounds bilaterally. There was significant bleeding from her left posterior axillary wound, and this was packed with gauze. Her left upper extremity was cool with no palpable radial pulse nor Doppler signal, and she had no strength or sensation in this extremity. Palpable pulses were present in all other extremities. After blood was drawn for type and cross-match, two large bore intravenous catheters were inserted. Given her agitation and inability to cooperate with an examination, she was intubated using rapid sequence induction with 100 mg lidocaine, 150 mg propofol, and 100 mg rocuronium. With induction, she became hypotensive to a systolic blood pressure of 70 mm Hg. With the rapid decline in the patient’s systolic blood pressure, your choice for the next step in management would be: 1. Focused abdominal sonography for trauma (FAST) examination 2. Transfusion of blood products 3. Infusion of 1 liter lactated Ringer’s solution 4. Stat CT aortogram with contrast A Cordis central venous catheter was placed in her right femoral vein under ultrasound guidance, and she was transfused 1 unit of whole blood with a rise in her systolic blood pressure to 140 mm Hg. An extended FAST examination was performed and was negative for any blood in the pericardium, bilateral pleural spaces, or abdomen. An X-ray of her chest showed bullet fragments over her right clavicle and no evidence of an intrathoracic injury, …