34 year-old male self-presents to the Emergency Department after being hit in the abdomen with a baseball bat 3 hours before while walking too close to the on-deck circle at his son’s high school baseball game.
 

Figure 1: Parietal swelling with bruising after motor vehicle accident. courtesy of Agarwal N, Kumar S, Joshi MK, Sharma MS, via OPENi.

 

 
The patient is awake and talking, but clearly in pain. His past medical history is significant for treated Hepatitis C, and asthma. He has never had surgery before. He drinks daily, smokes half a pack of cigarettes daily.
 
Physical Exam:

    T 38C HR 108 BP 118/78 RR 22 O2 Sat 98% on RA
    Primary Survey: ABCs intact, GCS 15, and able to fully expose the patient.
    Secondary Survey:
    HEENT and neck: no trauma above the clavicles with midline trachea
    Chest: NTTP, equal breath sounds bilaterally, uniform bilateral chest wall excursion with inspiration though somewhat limited by abdominal pain
    Abd: large tender linear ecchymosis running transversely across the abdomen as in image above at the level of the umbilicus.
    Pelvis/GU:bony pelvis is stable, no blood at the meatus, no scrotal swelling, ecchymosis, or tenderness
    Extremities: intact distal pulses, no limitations of active ROM, no other signs of injury
    Neuro: moving all four extremities on command, A&Ox3, CN II- XII intact

 
According to ATLS what are the adjuncts to the primary survey?

    ECG monitoring
    Urinary catheter
    Gastric catheter
    ABG
    Vital sign monitoring including pulse oximetry and blood pressure
    X-ray examinations (mostly those that can be done portably)
    eFAST
    Other diagnostic studies
 
According to ATLS what are the adjuncts to the secondary survey?
    Additional x-ray studies (mostly those beyond a portable chest and/or pelvis)
    CT scans
    Contrast urography
    Angiography
    Transesophageal echocardiography
    Bronchoscopy
    Esophagoscopy
    Other Diagnostic procedures
 
 
What imaging is warranted for this patient?
 
Given his extensive abdominal bruising, tenderness, and tachycardia, ending up obtaining a CT scan of the abdomen and pelvis with IV contrast would provide the most diagnostic information about the extent of his possible injuries.
 
What a minute! This Morning Report has a bad pun about the eFAST exam in the title! Why aren't we putting the ultrasound probe on this man??!!?!
 
 
First, what does eFAST stand for?
 
Extended, Focused Assessment Sonography in Trauma
 
 
 
Second, what views are obtained as part of the eFAST exam?
    Morrison’s Pouch
    Splenorenal space
    Pelvic/Bladder view
    Subxiphoid View
    Thoracic views looking for a pneumothorax
 
 
Now, your answer.
 
The short answer is that no one stopping you so go right ahead. The longer answer is that you need to know the circumstances in which the eFAST has been studied to properly use this test.
 
In the case of the unstable or hypotensive trauma patient, a positive eFAST exam indicates that the patient’s next stop is the Operating Room.
 
However, in the stable and normotensive blunt abdominal trauma patient the paths are not all so clear. In the event that the fast is positive and the patient remains stable, evaluation with CT imaging allows for more precise localization of the injuries to determine the best course of management–operative or not.
 
 
In the event that the eFAST is negative in the blunt abdominal trauma patient, what next?
 
As the eFAST appears to be ~30% sensitive for intra-abdominal solid-organ injury and it provides no information about hollow-viscous injuries, the eFAST alone cannot rule out significant intra-abdominal pathology in the setting of blunt trauma. At this point, observation, serial exams, including serial eFASTs, might be warranted given your clinical suspicion. But again, eFAST is a test that provides limited information about solid-organ or hollow-viscous injuries. In short, you will likely end up obtaining CT imaging of the patient’s abdomen regardless.
 
All of this is not to say that the eFAST has no role in the evaluation of the normotensive trauma patient. Quite the opposite! The utility of the eFAST exam, and any other diagnostic tool for that matter, is maximized when it’s strengths and weaknesses are clearly known, so scan away if it’s clinically indicated.
 
 
Bibliography:
1. Initial Assessment and Management. In American College of Surgeons, Committee on Trauma (Ed.), Advanced Trauma Life Support for Doctors: Student Course Manual (8th ed., pp. 1-24).
 
Legome, E. L., & Freedman, J. P. Chapter 033. Blunt Abdominal Trauma. In A. B. Wolfson, R. L. Cloutier, G. W. Hendey, L. J. Ling, C. L. Rosen, & J. Schaider (Eds.), Harwood-Nuss’ Clinical Practice of Emergency
Medicine
(6th ed.). http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=booktext&D=books2&AN=01817268/6th_Edition/3&XPATH=/OVIDBOOK%5b1%5d/METADATA%5b1%5d/TBY%5b1%5d/EDITORS%5b1%5d.
 
Nishijima, D. K., Simel, D. L., Wisner, D. H., & Holmes, J. F. Does this adult patient have a blunt intra-abdominal injury. JAMA [serial online]. 2012; 307: (14), 1517-1527. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=22496266.
 
Panebianco, N. 24. Ultrasound in Acute Trauma. In K. A. Carmody, C. L. Moore, & D. Feller-Kopman (Eds.), Handbook of Critical Care and Emergency Ultrasound (pp. 303-306). New York: McGraw-Hill Medical.
 

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