Consensus on sonogram use could help pediatric trauma patients

2021 11 29 01 31 6909 Child Hospital 400

Consensus definitions for assessing children with injury via sonography could help in the emergency department, according to research published March 18 in JAMA Network Open.

A team led by Dr. Aaron Kornblith from the University of California in San Francisco surveyed point-of-care ultrasonography (POCUS) experts and wrote a consensus statement on defining Focused Assessment with Sonography for Trauma (FAST) and extended FAST (E-FAST) studies. The recommendation includes ultrasonographic views, landmarks, and patient-specific factors that affect interpretation accuracy.

"Our definitions were developed using a rigorous methodology that included reviewing existing literature and expert consensus," Kornblith told AuntMinnie.com. "As a result, our definition is novel in that it captures the most critical views, landmarks, and accuracy consideration of experts for FAST in children."

FAST was introduced in the 1990s in the U.S. It uses ultrasonographic views to rapidly evaluate hemorrhaging in patients. In adults, this method decreases time to surgery, length of stay, complications, and CT scan rates. It does not require radiation. However, FAST has up and down reliability and accuracy compared with CT when identifying abdominal injuries in children. Additionally, there is no agreed-on standard for a complete protocol, image quality, and accurate interpretation for this method in pediatric patients.

"However, literature has shown that experts [instead of less experienced sonographers] perform the FAST more reliably and accurately than non-experts," Kornblith told AuntMinnie.com.

Kornblith and colleagues wanted to help with this by surveying ultrasonographers in defining a complete, high-quality, and accurate interpretation for FAST and E-FAST in children with injury using a modified Delphi technique.

Using data from 26 experts who completed the survey, including 24 who participated in online discussions, the team wrote that five anatomical views are important and appropriate for a complete FAST. These include the following:

  • Right upper-quadrant abdominal view
  • Left upper-quadrant abdominal view
  • Suprapubic views (transverse and sagittal)
  • Subxiphoid cardiac view

The same anatomic views can be used for E-FAST with the addition of the lung or pneumothorax view, the survey participants indicated.

Respondents also rated a total of 32 landmarks as important for assessing completeness and rated 14 statements on quality, as well as 20 statements on accurate interpretation as appropriate.

However, two statements divided experts though in two nearly equal groups. These include: "A FAST study can be considered a qualified negative if the operator does not adequately visualize one or more landmarks," and "Trace free fluid in the pelvis may be considered a negative study."

They also suggested that reporting FAST and E-FAST results should include any missing view or landmarks in interpretations as well as patient factors that could limit exams.

Kornblith and colleagues called for future studies to focus on whether certain landmarks are more critical to view than others for a complete FAST, as well as assess the accuracy and reliability of the FAST and E-FAST methods by defining trace-free fluid.

"The consensus statements may be used for future education, quality assurance, and research," they wrote. "An agreement was reached on the potential use of serial FAST studies; however, the panelists were unclear on how to clinically interpret trace volumes of abdominal free fluid, suggesting a direction for future research."

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