On a FAST track to nowhere at St.Emlyn’s

wikipedia

wikipedia

This week a little attempt at #dogmalysis for USS education in the UK. I want this to make you think about the links between what we teach and learn vs patient outcomes. In an ideal world the two should be linked, but what happens when they start to diverge? Let’s take something (FAST scanning) that is held dear to many UK EPs.

We can sum this problem up in the two reasons why clinicians ‘like’ performing procedures. In an ideal world both reasons occur at the same time….., but not always.

[learn_more caption=”Reason number 1.”] The patient requires the procedure.[/learn_more] [learn_more caption=”Reason number 2.”] The clinician ‘wants’ to do it.[/learn_more]

The ever busy Natalie May recently cajoled me into a practical teaching session for our trainees on ED ultrasound. I spent a really great afternoon with colleagues to go through the basics. The session was focused around them gaining the skills needed for their level 1 accreditation in ultrasound. This is an important qualification in the UK as it is something they should really achieve before gaining their first consultant post. So, all well and good then…., but is it? Let’s just remind ourselves of what the level 1 competencies are for a UK EP to gain certification and thus the nod for independent practice. It comes down to 4 areas.

 

 

  • 1. Central vascular access. I have no problem with this as there is good evidence that USS aids the placement of central lines.
  • 2. Abdominal Aortic Aneurysm detection. Again, quite happy with this as it’s an easy diagnosis to miss without USS, and it’s a good time to remember Dr Osler’s thoughts in this area (pre USS) There is no disease more conducive to clinical humility than aneurysm of the aorta.
  • 3. ECHO in life support. The most recent addition to the quartet makes sense as there is evidence that ECHO during cardiac arrest can identify useful information.
  • 4. …..and then there is FAST scanning. Focused Abdominal Sonography in Trauma, a technique to detect the presence or absence of intraperitoneal fluid in trauma. It is only taught in the UK as a ‘rule in’ test. EPs are told that they cannot ‘rule out’ intra-abdominal injury and that further imaging will be required.  The idea behind the technique is that through the early detection of fluid in the peritoneal cavity the emergency physician will be able to influence the patient journey and thus improve outcome. In the days of old this was a laudable pursuit, a positive FAST scan would guarantee the interest of the surgeons and radiologists leading to an easy request for abdominal CT, but that was then, and this is now…  I was a vigorous enthusiast of FAST in the resus room during the early days. I really ‘liked’ doing it and felt that it did make a difference – I could get my patients to CT easily if there was a positive FAST – I felt good and clever 🙂 Time goes by though and whilst reflecting about the role of a trauma team leader in the resus room I’m less convinced of it’s role as a core skill for the emergency physician.

 

In recent years we have really been pushing to get our major trauma patients to the CT sanner as quickly as possible. There is good evidence for pan-scanning (known as the Afghani-scan here in Virchester) trauma patients to detect injuries early in the patient’s journey. The target in the UK is that patients get to the scanner within an hour of arrival. This can be tough and when introduced it certainly made us think hard about what is truly useful pre-CT. Here’s a list of things that we have changed (or are in the process of change) in order to streamline the arrival to CT time.

  • Stop doing Chest X-rays
  • Stop doing lateral C-spines
  • Stop doing Pelvic X-rays
  • Start using pelvic binders
  • Stop 90 degree log rolls
  • Stop catheterising
  • Stop putting a-lines in unless needed
  • Thoracostomy vs tube drainage in ventilated patients
  • Removal from spine boards onto vacuum mattress
  • Do they really need a PR???

So there is a balance of things we have started doing and things we have stopped doing. Remembering that we are against a time target then it is important that we only retain procedures that are going to contribute to patient outcome, and that’s got me thinking about FAST scanning. Perhaps we just need to stop and think about how FAST  ‘fits in’ to the the management of trauma in a UK trauma centre. Let’s just pause and not assume that everyone gets a FAST ‘because that’s we do’. Let us instead consider where it is ‘useful’ in a diagnostic strategy for abdominal trauma. Useful must mean that it makes a difference to patients, wither in terms of their disposition from the ED or in terms of identifying an injury that would not have been found otherwise. I’ve thought about this and in reality I think we can map out the process as follows for our major trauma patients…….

 

 

 

 

In UK trauma centres we are encouraged (mandated almost) to CT all major trauma patients within the hour following arrival. If we are going to do this anyway then the role of FAST scanning must then be confined to those patients in whom an ultra-early diagnosis is needed, or in those too unstable to go to CT. With early access to CT I would suggest that both groups where FAST can make a contribution are rare.

An extension of resus?

An extension of resus?

When FAST scanning first came into my world there may have been reasonably good arguments for teaching everyone how to do it. However, as time goes on I’m not so sure that it is really functioning as a game-changer of an investigation in the ED. There are several reasons for this, here are just a few.

 

  • Regional trauma centre networks mean a greater understanding of trauma.
    We are much happier continuing resuscitation as we go to and through the CT scanner
    CT scanners are much faster and we are slicker at getting people into and out of them.
    The number of patients who are too unstable to go to the CT scanner, but are fit enough to go to theatre (it’s still a ride down the corridoor in most places) is tiny.
    I find less need to ‘convince’ my surgical colleagues of the need to actively manage abdo trauma. The surgical teams have done a lot of work in educating themselves and their teams in how to manage these injuries.
    We pan-scan pretty much anyone so the chances of missing an injury through not investigating is increasingly slim.

 

So, in the last 5 years I cannot personally recall a patient where an ED FAST scan has significantly changed a patient outcome. Sure, I’ve spotted some blood in a stable patient and sent them to CT, I’ve also spotted blood in the abdomen of someone with their guts hanging out….., but I cannot convince myself that such cases really made a difference to the patient, their destination out of the ED or to the surgical decision making. It may have given us a ‘heads-up’ about what we might find on the CT scan, but in all the time I’ve been doing it I can’t think of a single one.I know that the cases may be out there, perhaps it is just me and the quirks and chances inherent in our lives that means that the patients who really benefited just did not come to town on the days that I was around, but I suspect not.

Should we therefore abandon FAST scanning at level 1 training and change it to something more relevant to us as emergency physicians in the resus room? I think we might, and here are my suggestions for how we might better spend our time….

 

  • 1. Basics of Thoracic USS: Pneumothorax, effusion, consolidation and oedema
  • 2. Basic of CVS assessment: Long and short axis heart & IVC characteristics (a small extension from ECHO in life support IMHO).

 

Would we use these skills more often? Absolutely!

Would these be decision changing investigations for patient benefit? Of course!

So why are we not doing this? Well partly it is historical. FAST came to the fore at a time when we were not that good at getting sick patients through the CT scanner, it established itself in the curriculum and has remained there ever since. These days CT for trauma patients should be an extension of the resus room with active patient management continuing as investigations take place.

So should we abandon FAST at level 1?

All curricula suffer from middle age spread. As new and interesting techniques arrive we stuff ever more into a curriculum that gets larger and more unwieldy, so whilst I would really advocate the inclusion of thoracic and CVS USS we can only achieve this if we drop something that’s already there. It’s time for a new diet in my opinion. Let’s stop teaching FAST and instead teach techniques that will influence patient care in our resus rooms.

Should I stop doing FAST in the resus room?

It’s up to you really. I have stopped doing it in some patients if I don’t think it’s going to help. So long as it is not going to delay transfer then I allow it in resus, and I am still looking out for the patients where it’s going to make a massive difference. Similarly we need to ask ourselves whether we should keep teaching it. This is tricky. If we have lots of time and training then great. If time for this element of training then perhaps we need to think about whether this is the most helpful in terms of ‘time/effort’ vs. ‘usefulness’. In my practice we have a radiologist as part of the trauma team, so if I really need a scan……

What if I can’t get to CT in an hour?

OK. You’re Casey Parker in Broom WA. You’re nearest CT scanner is miles away. You need FAST, it’s all that you have, so clearly you should use it. Similarly, in the prehospital setting you might argue that FAST has a role and Cliff Reid has a great summary of the evidence around this. Should this have a role outside of trauma centres? Perhaps, though how often is a true game changer elsewhere? I’d love to hear.

 

For Nat, Dave, Katie, KP, and all my other colleagues I am still delighted to do more sessions on how to get through the level 1 assessments, but don’t be too surprised if we move through the FAST scanning quite quickly so that we can get onto the really valuable stuff 😉

Let’s abandon the abdomen for level 1 USS and move to teaching our trainees how to USS the chest and cardiovascular system. Who’s with me……?

 

1. Huber-Wagner S, Lefering R, Qvick LM, et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009; 373: 1455-1461. Summary | Full Text | PDF(187KB) | CrossRef | PubMed

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28 Comments

  1. Andy Davies

    As always bang on the money with this one.

    Only role for me would be unstable patient IR vs OR decision. Blood in belly OR, no blood in belly CT.

    In trauma centres with a good pre-hospital service a system that delivers certain patients directly to CT has to be the way forward.

    Reply
  2. Andrew Ronald

    Seems eminently sensible. Big advantage of FAST was always the fact you could do it at the same time as someone else was doing something else and as a discriminator for CT. But if everyone you’d FAST scan previously is going for CT there is no point and you’d be much better training your juniors more useful skills. Personally I’d go for Focussed ED cardiac echo, and thoracic echo

    Reply
  3. Natalie May

    Cajoled… I prefer persuaded!
    I have to say my two most useful US experiences were:
    A) free fluid on a young woman in early pregnancy with hypotension – didn’t have to wait for her HCG to get her to theatre for her ruptured ectopic. Maybe processes would have worked without using the FAST protocol (not true FAST as not trauma) but the patient got ideal care – resus to theatre in under an hour.
    B) the accidental aortic dissection – wasn’t looking for it, wasn’t entirely sure what it was (was scanning for cardiac wall motion in pt wit chest pain and hypotension with ischaemic ECG) and didn’t think it would make much difference ultimately. Pt seen in clinic not so long ago after cardiothoracic repair and is “doing well”.

    So despite my considerable inadequacy, I am convinced of the utility of bedside US in ED – even if not employed exactly as it might have been intended. We had a lot of conversation at the PEM trainee conference this week about how to translate these skills into PEM practice fro the perspective of Paeds PEM trainees (AAA scanning is arguably not as useful) and I left feeling we hadn’t got the balance between competence and spectrum of practice. As a means to an end (basic US skills) the level one course serves a purpose but the real power of US comes from translating basic technique across patient groups. Well, that’s what I think. And I agree – FAST not really all that useful in trauma when the resistance to CT is diminishing.

    Reply
    1. Simon Carley (Post author)

      Sure, both your cases are non-trauma so would not be directly relevant to the post. As you know I am a big advocate of bedside USS. I just think the emphasis in training has not kept up with clinical practice and patient need.

      Great pick ups on those cases btw.

      S

      Reply
  4. Andrew Ronald

    Not sure what you mean by “inadequacy” Natalie. Two non-trauma patients. Two cases of exemplary care. Two excellent outcomes. You’re absolutely right though, learn the basis skills and apply them to patients across the spectrum. With competency-based training it’s now more often than not the speciality which “invented” a technique which advances it

    Reply
  5. Sean Scott

    Hey Simon,

    Great post as always. I’ve been teaching ultrasound for several years now and I couldn’t agree more. In my work in resource poor settings I think FAST is still a very useful tool but when I have rapid access to CT it rarely gives me useful information.

    By contrast lung ultrasound has completely changed my approach to patients with shortness of breath. It provides me with immediate bedside information to both rule in and rule out key differential diagnoses with significantly better sen and spec compared to CXR. More importantly it’s dead easy to learn. I use it on almost every shift. I think it is a basic skill that all EP’s should have and it’s utility is far superior to FAST

    Basic echo is also very useful but probably slightly more complex to teach an learn. I still think it is a core skill for EP’s but it requires more effort compared to the other skills you have mentioned.

    Overall I think the more ultrasound knowledge we have as EP’s the better and i would rather add lungs and hearts to the current curriculum. However, if we have to scrap something in order to introduce new material I would deffinately drop FAST in favor of lungs.

    Interested to hear what others think.

    Reply
  6. Jo Deverill

    Gosh – I regard eFAST as part of the primary survey. If performed properly it doesn’t impede definitive investigation or management – quite the opposite, the findings can expedite them. Both prehospital and in the department. Perhaps that’s a sign that the regional trauma service where I work can be sluggish to respond.

    Agreed, FAST no longer fulfils the role for which it was originally incepted (as a decision rule for unstable patients with combined abdominal and pelvic trauma). But that doesn’t mean it is redundant.

    These days 90% of my US work is placing difficult peripheral cannulae. Shouldn’t that be a core competency? Much trickier than CVL placement but more useful on the scale of things.

    Reply
  7. Adam Herbstritt (@apherbie)

    I second Jo Dervill – a FAST scan can be completed within 45seconds soon in the ‘patient journey’ & the discovery of free fluid at this stage, rather than at the 45-60minute mark with the CT, can expediting both the surgeons response and ownership of the patient. Whilst it is unlikely to change disposition or probably mortality for the reasons you’ve mentioned, I think it has other benefits that given its safety, ease of use & rapidity should continue to be used early in the resuscitation process.

    Reply
    1. Simon Carley (Post author)

      Thanks Jo and Adam. Let’s clarify this.. eFAST and FAST (simple detection of free fluid) are not the same. The blog advocates improved education and practice around CVS/Lung pathology. With the UK target to push patients to CT asap then there is little requirement for any further expedition of movement. That’s already in place within the trauma system.

      In the blog I talk about how things used to be where FAST did help galvanise the attention of surgeons and radiologists. Those days have increasingly passed and so it’s use a device to speed things up has diminished. It sounds as though this is not the case in your trauma systems and it is still functioning as a device to get others interested. If that’s the case and that’s your need then crack on.

      Again, as mentioned in the blog, the use of FAST prehospital is really a different question as there is a greater period of time that you have to detect and thus influence practice. If you haven’t already then you should visit Cliff’s site for a review of the evidence there.

      S

      Reply
      1. Jo Deverill

        Why would a FAST scan performed pre-hospital influence practice, and a FAST scan performed in ED not?

        Why would you not want immediate information on whether your trauma patient is bleeding into his peritoneum? Can you really get a CT instantly? Does your trauma system really have zero latency? If so – impressive, but it stretches credulity to argue that it’s like this across the UK. It’s certainly nothing like that here in Australia. And we don’t just train ED physicians to work in major trauma centres.

        If you apply the mandatory pan-scan in trauma argument (itself dogma – but we won’t go there for now) why bother asking about mechanism? Or examining the abdomen?

        Given that FAST is easily taught, learned and applied, and is a relatively cheap and simple binary test, is it really that much of a drag? Would you really US the lungs of a 12 year-old who has come off his skateboard and cracked his ribs on a ramp – but decline to US his abdomen? And are you seriously going to stick him through a pan-scan in a C-collar and pelvic binder too?

        Now I think you are just stirring the pot – and in the reply below this one you pretty much admit this. I wonder though, how uncritically some people might take your opinion and declare that FAST is dispensable. If so you might just be undoing years of hard work and advocacy (it was a bloody business here getting sonographers, radiologists and surgeons to accept the value of ED US).

        Still I would love it if somebody else properly taught registrars how to insert a PIVC under U/S. Would save me a lot of needlework. If you have to ration out U/S training go for that above the lung stuff please.

        Cheers.

      2. Simon Carley (Post author)

        Cheers. In the UK a level 1 USS competence for free fluid is indeed binary, but it’s not yes vs no!

        It’s ‘yes’ vs. ‘not positive-needs further imaging’ I suspect that this is not the dichotomy that you are referring to. Level 1 trainees are not permitted or trained to rule out free fluid.

        As for utility the blog does outline the patients in whom there is utility.

        As for relationships with colleagues then there is no change. I strongly advocate bedside USS. I use it all the time in fact In particular I want my colleagues to be using it daily on the many patients who would benefit from CVS/Thoracic assessment. Sadly, by only teaching FAST to trainees we end up in the situation where USS gets used rarely and not daily as colleagues associate USS use with a small group of trauma patients. The group of trauma patients where it can truly make a difference is arguably small. The group of medical/resus patients where it can make a difference is huge.

        My feeling is that if we change the emphasis at level 1 we will see far more USS by EPs, not less. I suspect that that’s what we both want to see 🙂

        Vb

        S

      3. Jo Deverill

        Thanks for clarifying. Whenever a FAST scan is negative it is followed by a CT – we don’t use it as a rule-out. I use it as part of the primary survey, and encourage registrars to do the same. This approach doesn’t discourage them from applying ultrasound in non-trauma cases – quite the reverse. I think that in a decade’s time, handheld U/S will be a routine part of bedside examination. And we’ll still be doing FAST.

        All the best.

  8. Andy Volans

    Challenging post but what for us in DGH land and less severe trauma. We see folk who have come off their mountain bikes and walk in to us looking a bit wan.
    A touch tender in the belly and lo and behold a haematoma around the spleen. This is a common occurance, should I be bullying my CT scanner (on call and 30 minute warm up time and 90+ minutes from the nearest TC?)
    It will be horses for courses. I can get CT’s when I need them, not always when I would like them, a hospital with limited resources is either going to be shut down! or will have to have a different skill set in it’s ED

    Reply
    1. Simon Carley (Post author)

      The post was really based on MTC practice to illustrate the point, but you’ve posed a really good question Andy. At level 1 training in UK we are told quite strongly that USS can only be used as a rule-in test. If that’s the case then you are going to have to proceed to further imaging in any case. If you are not proceeding then you are operating beyond UK level 1 competencies.

      So perhaps you are using USS as rule-out test & rule-in test, and that would be beyond level one competencies (and perhaps the data too). Or more likely you are using a useful tool in a pragmatic way rather than in the way it was originally sold to the speciality and to the trainers. I have great empathy with your approach as it would seem that you are operating in the way that we did a few years back where we were using USS to galvanise action amongst surgical and radiological colleagues. Those days have passed (for us) as a result of the changes around major trauma systems.

      Obviously I’m being a little cheeky to illustrate the point that are at a point in time where we might need to reappraise how and what we teach about USS at journal level.

      The real question is whether in a resource and time limited training program, would you put the need to do FAST ahead of CVS/thoracic assessment in the resus room?

      vb

      S

      Reply
  9. Stuart Nuttall (@StuartNuttall1)

    Hi Simon,

    I agree with your main point that FAST in isolation is of limited use as an investigation in major trauma especially if performing rapid CT. We’re an MTC, and have excellent access to CT yet I’m keen to include eFAST as part of the examination in the primary survey.

    As with other Ultrasound protocols such as ACES for shock there is little published evidence that it improves outcome, more that it is a viable protocol that can add further information to the clinical picture. I’m doing an MSc in point of care ultrasound and this is one of the common themes!

    This is where I see the role of eFAST as part of the primary survey in trauma. In the same way you would listen to the chest or feel the abdomen when examining, then USS should be part of the clinical examination rather than a stand alone investigation. Instead of saying there’s a tender LUQ ?splenic injury you may be able to say there is free fluid around the spleen or that it looks abnormal, get the TXA in and give the surgeons/IR a heads up as to what may be described in more detail on the CT. Alternatively advising the anaesthetist of the pneumothorax pre intubation and ventilation – can simultaneously prep for a drain too. If the machine is on and ready I don’t believe it causes any unnecessary delay.

    You may not need to action the findings pre CT but it makes me feel a little more confident in CT if I’ve got a better idea what’s going on under the surface prior to transfer. It may make responding to deterioration more focused too.

    That the College curriculum in ultrasound needs to catch up with the way it is being used by ED clinicians is probably true. I think there is reasonable overlap between eFAST and chest to teach together. I do keep suggesting to the Dean that he should put down his stethoscope and pick up a probe more…… 😉

    Reply
  10. Andy Volans

    Absolutely agree with Stuart, I see US as the equivalent of the stethescope. We can’t rule out with it but we can gain information and work out a “pre-test probability” using it. We should be doing the same for US, for those that are evidence based then someone cleverer than me should develop an “Ottowa” type study including US in a variety of scenarios to show the ROC etc. FOr me, it helps me in an environment where every investigation has a cost either in money or risk to the patient. I would hate the UK to have the iatrogenic cancer rate reported by the US from their multiple CT’s

    Reply
  11. Simon Carley (@EMManchester)

    Thanks for all the replies.

    I’m not hearing a whole bunch of reasons that the technique (detection of free fluid in abdomen for major trauma patients in an MTC) is a game changer in clinical practice. There are lots of people who want to keep doing it (reason 2 above), but not so much to defend reason 1 (because the patient needs it/it makes a difference to outcome).

    Most people are not using FAST as a rule out test – so therefore you are not ‘preventing’ further imaging and the truly difficult to diagnose patient who is too unstable for CT and who is also not obviously a IA catastrophe is rare. Rule in tests are great, but only if they are going to substantially change management.

    On twitter and on the blog site it has been interesting to review some comments as (esp on twitter) it would appear that opinions appeared to state that the blog said that we should stop using USS in resus, or even that not doing FAST scans might lead to the abandonment of USS by EPs!

    Gosh.

    I’m pretty sure that’s not what the blog post said at all. I’ve re-read it and to be honest some of the social media interpretations make me wonder whether people read the entire piece before comment. The post itself was a call for us to challenge our educational strategies and to build (not diminish) our training around developing USS for patients in whom we will use it daily rather than keeping it in reserve for the rare unstable, but not obvious, abdominal trauma patient.

    How then could the message have been misinterpreted?

    Was the blog badly written? I am not in a position to truly judge, but I don’t think so.

    Was the blog deliberately antagonistic? Perhaps a little, but that is a stylistic choice to encourage debate. I can therefore hardly complain, and I’m not. I’m just interested.

    Was the blog too parochial? Possibly as the problem illustrated is most applicable to an EP working in a major trauma centre rather than the sticks. If that was unclear it may well have led to different opinions, but arguably by bringing those in later it helped clarify the issue.

    Was the question lost via the debate? Almost certainly. What started out as simple question about FAST (as it is taught in the UK) ended up being perceived as an attack on extended FAST, ACES and CVS protocols (which was paradoxically what was suggested that we move towards in the blog). Concerns were raised about medical & obstetric patients (nothing to do with the original blog post). The porosity of the media and the Chinese whispers of conversation via twitter were truly fascinating.

    So, this has been really interesting for me. It’s been a great conversation and one which has helped clarify and improve the question.

    Thanks guys, particularly for allowing me to explore the process of post-publication error, anxiety and review.

    Cheers,

    S

    Reply
    1. Jo Deverill

      Nothing wrong with stimulating debate! It generated light not heat. And we’ve asked the same question here. Don’t know what went on in the Twittersphere. but this post clarified in my own mind why I do what I do where I am. And I reckon St Emlyns has a few hundred more fans which can only be good.

      Cheers

      Jo

      Reply
  12. Simon Carley (@EMManchester)

    Hi Jo,

    Cheers and hopefully I’ll get to meet you for real next year. Are you coming to SMACC GOLD?

    Reply
    1. Jo Deverill

      Absolutely. We’re training up a surfing SimWars team. In bikinis and budgie smugglers.

      Reply
  13. Gareth Hardy (@DrGDH)

    Provoking plenty of discussion as always Prof! For me as a trainee the issue is less the question of FAST’s usefulness, but whether it should be a ‘core’ skill for basic USS sign off.

    I totally agree that the role of FAST has declined with the push for CT’ing head to toe in major trauma, but as mentioned above, I still think it has a role if you are not in a smaller hospital, especially when discussing patients with the surgeon (those pesky handlebar/spleen injuries spring to mind).

    But…. Aren’t there USS skills that I use more frequently and would be of greater benefit to our patients? Thoracic USS is becoming a bigger part of my practice as time goes by (both for trauma and for medical patients), and assessing volume status and responsiveness is something we all do every day for sick patient. Teaching all junior ED docs basic CO measurement and IVC assessment would make a big difference here.

    Great post, and really interesting to see all the discussion above….. kind of what this whole FOAMed thing is all about!

    Gareth

    Reply
  14. Peter Cutting

    A FAST scan is a scan you perform to convince someone else to do the scan you needed to do in the first place

    #dogmalysis

    Reply
  15. Andy Webster

    Good article Simon. The only game changer for me, was a stab wound in a hypotension patient. Yes he would have gone to theatre, but the pericardial tamponade helped us decide quicker rather than later. We decided not to do tube thoracotomy and get him up there.

    Reply
    1. Simon Carley (Post author)

      Interesting. As I remember the heart is in the chest and so would be something we would pick up through cvs/redo exam. It’s still the abdominal component where I can’t recall a big game changed of a diagnosis that altered patient care/outcome.

      It must exist but it does seem unusual.

      S

      Reply
  16. peterkthompson

    Interesting set of posts. The extended trauma scan is still ideal for level 1 as from that everything else falls into place. That is why it is there as the correct base on which to learn the other skills. Whether looking for free fluid in early pregnancy as picked up in one of the posts or haemothorax/ pleural effusions relevant across the spectrum. Imaging of the kidney should help colleagues pick up hydronephrosis which has relevance across all ages and is one way to early detect a risk to renal function in children. Essentially the basis of resus US is able to look at the four areas of FAST and add in the chest and better cardiac views as available.
    Certainly agree with Simon that Ultrasound in trauma only adds value. The extent of the value depends on how much CT one uses and how quickly it can be accessed. It would be interesting to see how many traumas do get to CT within the hour. Fantastic if it is happening consistently across the UK- it would be good to share that data.
    However, for most clinicians full CT with reporting is not available within the hour so Simon please keep on teaching the basic skill and demonstrate to your trainees how it can be applied to other areas of clinical practice.
    Also the spectrum of trauma needs to be considered- fortunately most is not Afghanistan like in intensity and if we do push ahead with a pan scanning model of care then we are moving to a worse place for clinical decision making.
    Game changes- for those not in trauma centre clinicians often still need to get surgeons on board for a laparotomy and the positive USS assists in this on numerous occasions that I can recall over the years for adults and children.
    And yes repeated ultrasound scans which are negative in the context of a patient remaining stable and symptoms settling/ controlled does not progress to further imaging/ CT. This in the context of observational ED units has been a good way of managing blunt trauma without all getting CTs.

    best wishes

    PKT

    Reply
  17. Mike

    Agree in general – it is the extended application of ultrasound that is of most use [i.e. thoracic: I imagine no readers here enjoy sending evolving (tensioning) pneumothoraces to CT to have their clinical acumen questioned 😉 ] rather than level I FAST.

    The 2009 paper referenced ( http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2961324-6/fulltext ) is pretty heterogeneous. Patient had ISS > 16. RISC has a better ROC AUC than TRISS and illustrated the least ‘benefit’ when applied. The SMR was a comparison of observed / estimated mortality in each limb using these (old) models (remember the trend is better outcome). Less than half of the included patients could have TRISS calculation: RISC was calculated on a greater proportion. It is unclear the actual contribution of whole-body CT itself compared to no / selected CT in these cases – you can’t help but wonder whether there is a trend in the selective CT group (i.e. a trend in specific omitted organ/system). Whole-body CT patients were more often managed in MTUs (this wasn’t considered an independant factor in analysis). Of course, non-management changing findings on whole body CT would elevate ISS and thus influence the difference between RISC / observed outcome in favour of whole-body CT group…

    In the face of creating decision-rules to exclude ‘all’ injuries, ‘pan-scan’ remains. The end-points of trauma imaging varies between studies. There remains reasonable literature to support that outside of head,spine/pelvis and traversing thoracic injuries, that ‘pan-scan’s doesn’t impact on management so much (although the variation here is pretty impressive: 5% – 34%) / the impact on mortality isn’t seen. Also, much like CTPAs for PEs, repeat scanning is often undertaken also – and the radiation risk is underestimated (the unit I work in hasn’t adopted a single-pass protocol yet – but this protocol improves things in htis regard). The greater issue is that ‘pan-scans’ are being requested for non-multiply injured patients (in actuality – often a retrospective conclusion much like ISS itself). We await the REACT-2 results…

    http://www.cmaj.ca/content/early/2012/03/05/cmaj.111420.abstract?sid=31419a47-a75f-409d-977e-bfaf6df4b7a7

    http://www.ncbi.nlm.nih.gov/pubmed/20659885
    http://www.ncbi.nlm.nih.gov/pubmed/19321199
    http://onlinelibrary.wiley.com/doi/10.1111/j.1742-6723.2011.01504.x/full
    http://onlinelibrary.wiley.com/doi/10.1111/j.1742-6723.2011.01526.x/full
    http://www.ncbi.nlm.nih.gov/pubmed/22152001
    http://www.ncbi.nlm.nih.gov/pubmed/22313570
    http://www.ncbi.nlm.nih.gov/pubmed/21817973
    http://www.ncbi.nlm.nih.gov/pubmed/21837260
    http://www.ncbi.nlm.nih.gov/pubmed/17414332

    Vomit Club: http://www.bmj.com//content/326/7401/1273.1?etoc=

    We don’t have multiple CT scanners in my unit. They do break down / can only scan 1 person at a time and trauma does like to come in batches 😉

    Keep up the good work all 🙂

    Reply
    1. Simon Carley (Post author)

      Cheers mike, really great helpful comments.

      S

      Reply
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