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The Utility of Focused Assessment With Sonography for Trauma Enhanced Physical Examination in Children With Blunt

Aaron E Kornblith¹, Jahanara Graf², Newton Addo³

¹From the, Department of Emergency Medicine and Pediatrics, University of California, San Francisco, CA.

Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine

|March 12, 2020

Insights

Focused assessment with sonography for trauma (FAST) and physical exams independently predict intraabdominal injury in children. Combining these (exFAST) improves accuracy, aiding decisions to forgo CT scans.

Area of Science:

Pediatric Emergency Medicine
Diagnostic Imaging
Trauma Surgery

Background:

Computed tomography (CT) is the standard for diagnosing intraabdominal injury (IAI) but involves radiation risks.
Existing CT-sparing rules for children often omit Focused Assessment with Sonography for Trauma (FAST), a widely adopted ultrasound technique.
The utility of FAST in conjunction with physical examination for IAI diagnosis in pediatric blunt torso trauma requires further evaluation.

Purpose of the Study:

To determine the independent associations of physical examination, laboratory studies, and FAST with IAI in children.
To compare the diagnostic test characteristics of these variables.
To assess if FAST enhances physical examination for identifying children who can avoid CT scans.

Main Methods:

Retrospective review of a pediatric trauma database (20-month period).
Inclusion criteria: children with blunt torso trauma.
Logistic regression analysis to evaluate associations and compare test characteristics of FAST, physical examination, and laboratory data.

Main Results:

Of 354 children, 50 (14%) had IAI.
Both positive FAST (OR=14.8) and positive physical examination (OR=15.2) were independent predictors of IAI.
FAST-enhanced physical examination (exFAST) demonstrated improved sensitivity (88%) and negative predictive value (97.3%) compared to either test alone (sensitivity 74%, NPV not specified).

Conclusions:

FAST and physical examination are both valuable predictors of IAI in children.
The combined approach (exFAST) offers superior sensitivity and negative predictive value for IAI detection.
exFAST can refine clinical decision rules for children with blunt torso trauma, potentially reducing unnecessary CT scans.

Read full analysis

Abstract

Objectives:

Computed tomography (CT), the reference standard for diagnosis of intraabdominal injury (IAI), carries risk including ionizing radiation. CT-sparing clinical decision rules for children have relied heavily on physical examination, but they did not include focused assessment with sonography for trauma (FAST), which has emerged into widespread use during the past decade. We sought to determine the independent associations of physical examination, laboratory studies, and FAST with identification of IAI in children and to compare the test characteristics of these diagnostic variables. We hypothesized that FAST may add incremental utility to a physical examination alone to more accurately identify children who could forgo CT scan.

Methods:

We reviewed a large trauma database of all children with blunt torso trauma presenting to a freestanding pediatric emergency department during a 20-month period. We used logistic regression to evaluate the association of FAST, physical examination, and selected laboratory data with IAI in children, and we compared the test characteristics of these variables.

Results:

Among 354 children, 50 (14%) had IAI. Positive FAST (odds ratio [OR] = 14.8, 95% confidence interval [CI] = 7.5 to 30.8) and positive physical examination (OR = 15.2, 95% CI = 7.7 to 31.7) were identified as independent predictors for IAI. Physical examination and FAST each had sensitivities of 74% (95% CI = 60% to 85%). Combining FAST and physical examination as FAST-enhanced physical examination (exFAST) improved sensitivity and negative predictive value (NPV) over either test alone (sensitivity = 88%, 95% CI = 76% to 96%) and NPV of 97.3% (95% CI = 94.5% to 98.7%).

Conclusions:

In children, FAST and physical examinations each predicted the identification of IAI. However, the combination of the two (exFAST) had greater sensitivity and NPV than either physical examination or FAST alone. This supports the use of exFAST in refining clinical predication rules in children with blunt torso trauma.

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