The Diagnostic Accuracy of Point-of-care Ultrasonography in Children with Blunt Abdominal Trauma
Date First Published:
July 28, 2021
Last Updated:
July 28, 2021
Report by:
Alysa Butz MD, Mariah Barnes MD, EM Senior Resident, EM Faculty (Spectrum Health/Michigan State University Emergency Medicine Residency Program)
Search checked by:
Jeffrey Jones MD, Spectrum Health/Michigan State University Emergency Medicine Residency Program
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
Search Details:
[(exp abdominal injuries AND Focused Assessment with Sonography for Trauma)]. LIMIT to children (birth-18 years).
Outcome:
37 studies were identified; four studies (including one meta-analysis) addressed the clinical question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| 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. Bahrami-Motlagh H, Hajijoo F, Mirghorbani M, SalevatiPour B, Haghighimorad M. Oct-20 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. |
| Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma Stengel D, Leisterer J, Ferrada P, Ekkernkamp A, Mutze S, Hoenning A. Dec-18 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 |
| The Utility of Focused Assessment With Sonography for Trauma Enhanced Physical Examination in Children With Blunt Torso Trauma Kornblith AE, Graf J, Addo N, Newton C, Callcut R, Grupp-Phelan J, Jaffe DM. Sep-20 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% | |||||
| Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children with Blunt Torso Trauma: A Randomized Clinical Trial. Holmes JF, Kelley KM, Wootton-Gorges SL, Utter GH, Abramson LP, Rose JS, Tancredi DJ, Kuppermann N. Jun-17 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 |
Author Commentary:
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.
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:
- 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.
- 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
- 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
- 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.