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Three Part Question

In [children with blunt abdominal trauma] how [accurate is point of care ultrasound (POCUS)] compared to [computed tomography] in [diagnosing intra-abdominal injury]?

Clinical Scenario

Patient is a previously healthy 8-year-old male who presents to your emergency department as a level II trauma activation after being involved in a motor-vehicle collision. The patient was a restrained back-seat passenger when their vehicle was T-boned at a suspected speed of 45 mph. There was no loss of consciousness on scene. EMS report his vital signs have been stable enroute. The child has some moderate abdominal tenderness, and you consider whether to order computed tomography (CT) or perform point of care ultrasound (POCUS) to evaluate his abdomen.

Search Strategy

Medline 1966-07/21 using PubMed, Cochrane Library (2021), and Embase
[(exp abdominal injuries AND Focused Assessment with Sonography for Trauma)]. LIMIT to children (birth-18 years).

Search Outcome

37 studies were identified; four studies (including one meta-analysis) addressed the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bahrami-Motlagh H, et al. Oct 2020 Iran	129 pediatric patients who underwent FAST and CT imaging	Retrospective cohort	Diagnostic accuracy of FAST exam and clinical findings	Fast exam plus clinical findings had a sensitivity of 87%, specifity of 77%, PPV 70% and NPP 91% and accuracy of 81%	Retrospective, single center study. Majority (74%) of patients were male. Patients with unstable vital signs were excluded.
Stengel D, et al. Dec 2018 Germany/USA	34 studies with 8635 participants	Meta-analysis	Diagnostic accuracy of FAST exam in thorax-abdominal blunt trauma	Fast exam had a sensitivity of 63% and specificity 91% in children	Not specific to pediatric patients and significant heterogeneity across studies included
Kornblith AE, et al. Sept 2020 USA	354 pediatric patients from trauma data base	Retrospective cohort	To determine independent associations of physical exam, FAST, and laboratory data to identify children who could forgo CT imaging	Physical examination and FAST each had sensitivities of 74%	Retrospective, single center study. Only 14% (50/354) of patients had intraabdominal injury
				Combining FAST and physical examination improved sensitivity to 88%
Holmes JF, et al. Jun 2017 USA	975 pediatric patients randomized to standard trauma evaluation and fast exam vs standardized trauma evaluation alone	RCT	Diagnostic accuracy of FAST exam in thorax-abdominal blunt trauma compared to CT	No difference in rates of abdominal CT scans, missed intra-abdominal injuries, ED LOS, or hospital charges.	Single center study. Excluded high risk patients where FAST examination may have been beneficial

Comment(s)

In adults who have experienced blunt thoraco-abdominal trauma, focused assessment with sonography in trauma (commonly abbreviated as FAST or eFAST) has been utilized and standardized due to its sensitivity and specificity in identifying injuries. However, the utility of the FAST exam in pediatric patients has yet to be determined. The best evidence to address this concern was found in 4 articles, including a meta-analysis. All studies were limited by excluding patients with unstable vital signs. In comparison to adults, the pediatric fast exam was less sensitive and specific as demonstrated by the meta-analysis. However, two studies demonstrated that the FAST exam plus positive physical findings increased sensitivity and specificity for diagnosing intra-abdominal injuries in pediatric trauma patients. One study showed that there was no difference in rates of abdominal CT scans in standard trauma care versus standard care plus FAST exam. Further multi-center prospective studies are needed to determine the clinical utility of FAST exam in hemodynamically stable blunt abdominal trauma patients.

Clinical Bottom Line

In pediatric blunt abdominal trauma patients, point of care ultrasound plus positive physical exam finding increased sensitivity, specificity, and NPV for positive abdominal CT results and ultimately diagnosing intra-abdominal injuries.

References

1. Bahrami-Motlagh H, Hajijoo F, Mirghorbani M, SalevatiPour B, Haghighimorad M. Test characteristics of focused assessment with sonography for trauma (FAST), repeated FAST, and clinical exam in prediction of intra-abdominal injury in children with blunt trauma. Pediatr Surg Int 2020 Oct;36(10):1227-1234.
2. Stengel D, Leisterer J, Ferrada P, Ekkernkamp A, Mutze S, Hoenning A. Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma Cochrane Database Syst Rev 2018 Dec 12;12(12):CD012669
3. Kornblith AE, Graf J, Addo N, Newton C, Callcut R, Grupp-Phelan J, Jaffe DM. The Utility of Focused Assessment With Sonography for Trauma Enhanced Physical Examination in Children With Blunt Torso Trauma Acad Emerg Med 2020 Sep;27(9):866-875.
4. Holmes JF, Kelley KM, Wootton-Gorges SL, Utter GH, Abramson LP, Rose JS, Tancredi DJ, Kuppermann N. Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children with Blunt Torso Trauma: A Randomized Clinical Trial. JAMA 2017 Jun 13;317(22):2290-2296.