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Three Part Question

In [the stable adult, blunt abdominal trauma patients] is [Ultrasound as sensitive as computed tomography] in [diagnosing intra-abdominal organ injury?]

Clinical Scenario

In [the stable adult, blunt abdominal trauma patients] is [ultrasound as sensitive as computed tomography] in [diagnosing intra-abdominal organ injury?]

Search Strategy

PubMed on the worldwide web. 1950s - September 2005.
1. sonography[Title] AND (blunt[Title] AND abdominal[Title] AND trauma[Title]) AND English[Lang] AND "humans"[MeSH Terms] AND ("2004"[PDAT] : "2005"[PDAT]) - 3 citations - 1 deemd relevant: 'Sonography as the primary screening method in evaluating blunt abdominal trauma'. 104 related articles, 21 published in 2004-5. 6 relevant to study.
2. ultrasonography[Title] AND (blunt[Title] AND abdominal[Title] AND trauma[Title]) AND English[Lang] AND "humans"[MeSH Terms] AND ("2004"[PDAT] : "2005"[PDAT]): 4 citations: 2 relevant, 1 of which was listed in search 1.

Search Outcome

7 papers deemed relevant to BestBET question:
1. Bakker J, Genders R, Mali W, Leenen L. Sonography as the primary screening method in evaluating blunt abdominal trauma.
J Clin Ultrasound. 2005 May;33(4):155-63.
2.Stengel D, Bauwens K, Sehouli J, Rademacher G, Mutze S, Ekkernkamp A, Porzsolt F. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma.
Cochrane Database Syst Rev. 2005 Apr 18;(2):CD004446. Review.
3. Nural MS, Yardan T, Guven H, Baydin A, Bayrak IK, Kati C. Diagnostic value of ultrasonography in the evaluation of blunt abdominal trauma. Diagn Interv Radiol. 2005 Mar;11(1):41-4.
4. Poletti PA, Platon A, Becker CD, Mentha G, Vermeulen B, Buhler LH, Terrier F. Blunt abdominal trauma: does the use of a second-generation sonographic contrast agent help to detect solid organ injuries? AJR Am J Roentgenol. 2004 Nov;183(5):1293-301
5. Poletti PA, Mirvis SE, Shanmuganathan K, Takada T, Killeen KL, Perlmutter D, Hahn J, Mermillod B. Blunt abdominal trauma patients: can organ injury be excluded without performing computed tomography? J Trauma. 2004 Nov;57(5):1072-81.
6. Rhea JT, Garza DH, Novelline RA. Controversies in emergency radiology. CT versus ultrasound in the evaluation of blunt abdominal trauma. Emerg Radiol. 2004 Jul;10(6):289-95. Epub 2004 Mar 23. Review.
7. Sato M, Yoshii H. Reevaluation of ultrasonography for solid-organ injury in blunt abdominal trauma. J Ultrasound Med. 2004 Dec;23(12):1583-96.
After reading papers, 4 were deemed suitable for submission and review as part of BestBET.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Sato M, Yoshii H. 2004 Japan	604 patients with suspected blunt abdominal trauma, examined with both ultrasound and contrast-enhanced CT.	Retrospective cohort. Level 2b evidence. Ultrasound reports were compared to CT or surgical findings, as reference standards. Sonographers were divided into two groups on the basis of their experience: expert or limited.	Ultrasound sensitivity by organ	Hepatic trauma 87.5% > Splenic 85.4% > renal 77.6% > pancreatic 44.4%	Patients age 2-94. Male > female. 14 year study period. Severel different sonography systems used throughout study.
			Ultrasound sensitivity, expert sonographer versus limited experience	Hepatic trauma: Expert 87.5% versus liimited experience 46.2%
Nural MS, Yardan T, Guven H, Baydin A, Bayrak IK, Kati C. 2005 Turkey	454 patients with a history of blunt abdominal trauma who underwent ultrasound scanning.	Retrospective Cohort. Level 2b evidence. Ultrasound reports were compared with CT findings, diagnostic peritonel lavage, laparotomy and clinical course, as standard.	Ultrasound sensitivity in diagnosing intraabdominal organ injury	86.5%	Patients aged 1-88 years. Different controls: only 24 patients underwent CT. Different ultrasonographers.
			Ultrasound specificity	95.4%
Poletti PA, Platon A, Becker CD, Mentha G, Vermeulen B, Buhler LH, Terrier F. 2004 Switzerland	210 haemodynamically stable trauma patients undergoing ultrasound scanning and CT on admission.	Validating prospective cohort study. Level 1b evidence. Patients with false negative sonography findings for solid organ injuries, when compared to CT findings as standard, underwent control sonography. If solid organ injury was still undetectable, contrast enhanced sonography was performed.	Admission ultrasound sensitivity	40%	Variation in sonographers. Sonographers aware of CT results when control and contrast-enhanced sonography performed. Change in CT scanner half way through study. Male>female patients.
			Control ultrasound sensitivity	57%
			Contrast-enhanced ultrasound sensivity	80% - statistically significant (p=0.001) improvement in detection ratre between control and contrats enhanced sonography.
Stengel D, Bauwens K, SehouliJ, Rademacher G, Mutze S, Ekkernkamp A, Porzsolt F 2005 USA	1037 patients with blunt abdominal trauma undergoing investigation for abdominal organ injury.	Systematic review of randominsed control trials. Level 1a evidence. Diagnostic algorithms comprising emergency ultrasound versus diagnostic algorithms without e.g. CT or diagnostic peritoneal lavage (DPL)	Mortality	No evidence of a difference.	Children included in studies. Small sample of studies with significant heterogeneity.
			Surgical complications	Entero-enteral fistula and abscess
			Use of CT	Ultrasound algorithms reduced ordering of CT scans - statistically insignificant.
			Cost-effectiveness	2 studies showed contrary results
			Rates of missed abdominal injury	No data provided

Comment(s)

Ultrasound is specific in diagnosing abdominal organ injury. A positive sonogram (either free fluid or organ injury) proves the presence of intraabdominal damage. But, studies repeatedly show that ultrasound has a poor sensivity. It cannnot be used to rule abdominal injury out. Ultrasound-based algorithms are often assumed to have merits in sortening the primary trauma assessment, triaging patients more precisely, avoiding unnecessary interventional procedures, and reducing costs. These assumptions are NOT supported by the available scientific data.

Clinical Bottom Line

In the stable, adult, blunt abdominal trauma patient, ultrasound is NOT as sensitive as computed tomography in diagnosing intra-abdominal organ injury.

References

1. Sato M, Yoshii H. Reevaluation of Ultrasonography for solid-organ injury in lbunt abdominal trauma. The American Institute of Ultrasound in Medicine. 2004; 1583-96
2. Nural MS, Yardan T, Guven H, Baydin A, Bayrak IK, Kati C. Diagnostic value of ultrasonography in the evaluation of blunt abdominal trauma. Turkish Society of Radiology. 2005; 41-44.
3. Poletti PA, Platon A, Becker CD, Mentha G, Vermeulen B, Buhler LH, Terrier F. Blunt Abdominal Trauma: does the use of a second-generation sonographic contrast agent help to detect solid organ injuries? American Roentgen Ray Society 2004;1293-1301
4. Stengel D, Bauwens K, SehouliJ, Rademacher G, Mutze S, Ekkernkamp A, Porzsolt F Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma (Review). The Cochrane Library. WILEY. 2005; 1-20.