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Meta-Analysis
. 2018 Dec 12;12(12):CD012669.
doi: 10.1002/14651858.CD012669.pub2.

Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma

Affiliations
Meta-Analysis

Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma

Dirk Stengel et al. Cochrane Database Syst Rev. .

Abstract

Background: Point-of-care sonography (POCS) has emerged as the screening modality of choice for suspected body trauma in many emergency departments worldwide. Its best known application is FAST (focused abdominal sonography for trauma). The technology is almost ubiquitously available, can be performed during resuscitation, and does not expose patients or staff to radiation. While many authors have stressed the high specificity of POCS, its sensitivity varied markedly across studies. This review aimed to compile the current best evidence about the diagnostic accuracy of POCS imaging protocols in the setting of blunt thoracoabdominal trauma.

Objectives: To determine the diagnostic accuracy of POCS for detecting and excluding free fluid, organ injuries, vascular lesions, and other injuries (e.g. pneumothorax) compared to a diagnostic reference standard (i.e. computed tomography (CT), magnetic resonance imaging (MRI), thoracoscopy or thoracotomy, laparoscopy or laparotomy, autopsy, or any combination of these) in patients with blunt trauma.

Search methods: We searched Ovid MEDLINE (1946 to July 2017) and Ovid Embase (1974 to July 2017), as well as PubMed (1947 to July 2017), employing a prospectively defined literature and data retrieval strategy. We also screened the Cochrane Library, Google Scholar, and BIOSIS for potentially relevant citations, and scanned the reference lists of full-text papers for articles missed by the electronic search. We performed a top-up search on 6 December 2018, and identified eight new studies which may be incorporated into the first update of this review.

Selection criteria: We assessed studies for eligibility using predefined inclusion and exclusion criteria. We included either prospective or retrospective diagnostic cohort studies that enrolled patients of any age and gender who sustained any type of blunt injury in a civilian scenario. Eligible studies had to provide sufficient information to construct a 2 x 2 table of diagnostic accuracy to allow for calculating sensitivity, specificity, and other indices of diagnostic test accuracy.

Data collection and analysis: Two review authors independently screened titles, abstracts, and full texts of reports using a prespecified data extraction form. Methodological quality of individual studies was rated by the QUADAS-2 instrument (the revised and updated version of the original Quality Assessment of Diagnostic Accuracy Studies list of items). We calculated sensitivity and specificity with 95% confidence intervals (CI), tabulated the pairs of sensitivity and specificity with CI, and depicted these estimates by coupled forest plots using Review Manager 5 (RevMan 5). For pooling summary estimates of sensitivity and specificity, and investigating heterogeneity across studies, we fitted a bivariate model using Stata 14.0.

Main results: We included 34 studies with 8635 participants in this review. Summary estimates of sensitivity and specificity were 0.74 (95% CI 0.65 to 0.81) and 0.96 (95% CI 0.94 to 0.98). Pooled positive and negative likelihood ratios were estimated at 18.5 (95% CI 10.8 to 40.5) and 0.27 (95% CI 0.19 to 0.37), respectively. There was substantial heterogeneity across studies, and the reported accuracy of POCS strongly depended on the population and affected body area. In children, pooled sensitivity of POCS was 0.63 (95% CI 0.46 to 0.77), as compared to 0.78 (95% CI 0.69 to 0.84) in an adult or mixed population. Associated specificity in children was 0.91 (95% CI 0.81 to 0.96) and in an adult or mixed population 0.97 (95% CI 0.96 to 0.99). For abdominal trauma, POCS had a sensitivity of 0.68 (95% CI 0.59 to 0.75) and a specificity of 0.95 (95% CI 0.92 to 0.97). For chest injuries, sensitivity and specificity were calculated at 0.96 (95% CI 0.88 to 0.99) and 0.99 (95% CI 0.97 to 1.00). If we consider the results of all 34 included studies in a virtual population of 1000 patients, based on the observed median prevalence (pretest probability) of thoracoabdominal trauma of 28%, POCS would miss 73 patients with injuries and falsely suggest the presence of injuries in another 29 patients. Furthermore, in a virtual population of 1000 children, based on the observed median prevalence (pretest probability) of thoracoabdominal trauma of 31%, POCS would miss 118 children with injuries and falsely suggest the presence of injuries in another 62 children.

Authors' conclusions: In patients with suspected blunt thoracoabdominal trauma, positive POCS findings are helpful for guiding treatment decisions. However, with regard to abdominal trauma, a negative POCS exam does not rule out injuries and must be verified by a reference test such as CT. This is of particular importance in paediatric trauma, where the sensitivity of POCS is poor. Based on a small number of studies in a mixed population, POCS may have a higher sensitivity in chest injuries. This warrants larger, confirmatory trials to affirm the accuracy of POCS for diagnosing thoracic trauma.

PubMed Disclaimer

Conflict of interest statement

D Stengel: none known

J Leisterer: none known

P Ferrada: none known

A Ekkernkamp: none known

S Mutze: none known

A Hoenning: none known

Figures

1
1
Study flow diagram for the search conducted on 15 July 2017.
2
2
Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study
3
3
Risk of bias and applicability concerns graph: review authors' judgements about each domain presented as percentages across included studies
4
4
Coupled forest plots of sensitivity and specificity. TP = true positive; FP = false positive; FN = false negative; TN = true negative
5
5
Summary receiver operating characteristic (ROC) plot of sensitivity and specificity of all 34 included studies. The solid circle represents the summary estimate of sensitivity and specificity. The summary estimate is surrounded by a dotted line representing the 95% confidence region and a dashed lined representing the 95% prediction region.
6
6
Coupled forest plots of sensitivity and specificity for studies targeting only free fluid or free air (n = 22). TP = true positive; FP = false positive; FN = false negative; TN = true negative
7
7
Coupled forest plots of sensitivity and specificity for studies considering both surrogates and organ lacerations (n = 7). TP = true positive; FP = false positive; FN = false negative; TN = true negative
8
8
Summary receiver operating characteristic (ROC) plot of sensitivity and specificity: paediatric studies (n = 10; indicated in black) versus non‐paediatric studies (n = 24; indicated in red). The solid circles represent the summary estimates of sensitivity and specificity. The summary estimates are surrounded by a dotted line representing the 95% confidence region and a dashed lined representing the 95% prediction region.
9
9
Summary receiver operating characteristic (ROC) plot of sensitivity and specificity: abdominal studies (n = 27; indicated in black) versus thoracic studies (n = 4; indicated in red). The solid circles represent the summary estimates of sensitivity and specificity. The summary estimates are surrounded by a dotted line representing the 95% confidence region and a dashed lined representing the 95% prediction region.
1
1. Test
Main analysis set.
2
2. Test
Sensitivity analysis set with lower sensitivity/specificity values in two original studies.

Comment in

References

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Tajoddini 2013 {published data only}
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Tam 2005 {published data only}
    1. Tam M. Occult pneumothorax in trauma patients: should this be sought in the focused assessment with sonography for trauma examination?. Emergency Medicine Australasia 2005;17:488‐93. - PubMed
Tas 2004 {published data only}
    1. Tas F, Ceran C, Atalar MH, Bulut S, Selbes B, Isık AO. The efficacy of ultrasonography in hemodynamically stable children with blunt abdominal trauma: a prospective comparison with computed tomography. European Journal of Radiology 2004;51:91‐6. - PubMed
Tayal 2006 {published data only}
    1. Tayal V, Nielsen A, Jones A, Thomason M, Kellam J, Norton H. Accuracy of trauma ultrasound on major pelvic injury. Journal of Trauma and Acute Care Surgery 2006;61:1453‐7. - PubMed
Tummers 2016 {published data only}
    1. Tummers W, Schuppen J, Langeveld H, Wilde J, Banderker E, As A. Role of focused assessment with sonography for trauma as a screening tool for blunt abdominal trauma in young children after high energy trauma. South African Journal of Surgery 2016;54(2):28‐34. - PubMed
Tunuka 2014 {published data only}
    1. Tunuka C, Wangoda R, Bugeza S, Galukande M. Emergency sonography aids diagnostic accuracy of torso injuries: a study in a resource limited setting. Emergency Medicine International 2014;2014:978795. - PMC - PubMed
Valentino 2008 {published data only}
    1. Valentino M, Serra C, Pavlica P, Morselli Labate AM, Lima M, Baroncini S, et al. Blunt abdominal trauma: diagnostic performance of contrast enhanced US in children ‐ initial experience. Radiology 2008;246(3):903‐9. - PubMed
Van Diepen 2013 {published data only}
    1. Diepen K, Adams C, Harris M, Lin D. The sensitivity and specificity of the focused assessment with sonography for trauma in blunt abdominal injury in a level I trauma centre. Résumés Scientifique 2013;15(1):66.
Vassiliadis 2003 {published data only}
    1. Vassiliadis J, Edwards R, Larcos G, Hitos K. Focused assessment with sonography for trauma patients by clinicians: initial experience and results. Emergency Medicine 2003;15:42‐8. - PubMed

References to studies awaiting assessment

Armstrong 2018 {published data only}
    1. Armstrong LB, Mooney DP, Paltiel H, Barnewolt C, Dionigi B, Arbuthnot M, et al. Contrast enhanced ultrasound for the evaluation of blunt pediatric abdominal trauma. Journal of Pediatric Surgery 2018;53(3):548‐52. - PubMed
Elbaih 2017 {published data only}
    1. Elbaih AH, Abu‐Elela ST. Predictive value of focused assessment with sonography for trauma (FAST) for laparotomy in unstable polytrauma Egyptians patients. Chinese Journal of Traumatology 2017;20(6):323‐8. - PMC - PubMed
Hsu 2017 {published data only}
    1. Hsu SD, Chen CJ, Chan DC, Yu JC. Senior general surgery residents can be trained to perform focused assessment with sonography for trauma patients accurately. Surgery Today 2017;47(12):1443‐9. - PubMed
Kozaci 2018 {published data only}
    1. Kozaci N, Avci M, Ararat E, Pinarbasili T, Ozkaya M, Etli I, et al. Comparison of ultrasonography and computed tomography in the determination of traumatic thoracic injuries. American Journal of Emergency Medicine 2018 Aug 3 [Epub ahead of print]. [DOI: 10.1016/j.ajem.2018.08.002] - DOI - PubMed
Maximus 2018 {published data only}
    1. Maximus S, Figueroa C, Whealon M, Pham J, Kuncir E, Barrios C. eFAST for pneumothorax: real‐life application in an urban level 1 center by trauma team members. American Surgeon 2018;84(2):220‐4. - PubMed
Mumtaz 2017 {published data only}
    1. Mumtaz U, Zahur Z, Raza MA, Mumtaz M. Ultrasound and supine chest radiograph In road traffic accident patients: a reliable and convenient way to diagnose pleural effusion. Journal of Ayub Medical College Abbottabad 2017;29(4):587‐90. - PubMed
Sauter 2017 {published data only}
    1. Sauter TC, Hoess S, Lehmann B, Exadaktylos AK, Haider DG. Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST. Emergency Medicine Journal 2017;34(9):568‐72. - PMC - PubMed
Waheed 2018 {published data only}
    1. Waheed KB, Baig AA, Raza A, Ul Hassan MZ, Khattab MA, Raza U. Diagnostic accuracy of focused assessment with sonography for trauma for blunt abdominal trauma in the Eastern Region of Saudi Arabia. Saudi Medical Journal 2018;39(6):598‐602. - PMC - PubMed
Zieleskiewicz 2018 {published data only}
    1. Zieleskiewicz L, Fresco R, Duclos G, Antonini F, Mathieu C, Medam S, et al. Integrating extended focused assessment with sonography for trauma (eFAST) in the initial assessment of severe trauma: Impact on the management of 756 patients. Injury 2018;49(10):1774‐80. - PubMed

Additional references

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