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. 2024 Apr 19;5(2):e13123.
doi: 10.1002/emp2.13123. eCollection 2024 Apr.

Contrast-enhanced point of care ultrasound for the evaluation of stable blunt abdominal trauma by the emergency physician: A prospective diagnostic study

Viviane Donner  1   2 , Julian Thaler  1 , Wolf E Hautz  1 , Thomas Christian Sauter  1 , Daniel Ott  3 , Karsten Klingberg  1 , Aristomenis K Exadaktylos  1   2 , Beat Lehmann  1
Affiliations

Contrast-enhanced point of care ultrasound for the evaluation of stable blunt abdominal trauma by the emergency physician: A prospective diagnostic study

Viviane Donner et al. J Am Coll Emerg Physicians Open. .

Abstract

Objectives: Clinical examination alone cannot reliably rule out significant traumatic abdominal injury. Computed tomography (CT) has become the primary method for evaluating blunt abdominal trauma and clinicians rely heavily on it to rule out abdominal injury. Ultrasound examination may miss significant abdominal injury particularly in stable patients. The use of a contrast agent improves ultrasound sensitivity to visceral abdominal injuries. The objective of this diagnostic study is to compare bedside contrast enhanced ultrasound (CEUS) performed by emergency physicians to CT in hemodynamically stable adults for the assessment of blunt abdominal trauma and evaluate CEUS accuracy outcomes.

Methods: Hemodynamically stable patients with blunt trauma were prospectively enrolled in the trauma bay. After initial evaluation, we included patients at risk of abdominal injury and for whom an abdominal CT was planned by the trauma leader. Ultrasonography was performed prospectively and at the bedside by the emergency physician followed by abdominal CT used as a reference standard.

Results: Thirty-three patients were enrolled in the study; among them, 52% showed positive traumatic findings in abdominal CT scans, and 42% were diagnosed with solid organ lesions. Compared to CT, a focused abdominal sonography (FOCUS) examination, looking for free fluid or perirenal hematoma, showed limited performance for traumatic findings with a sensitivity of 65% (95% confidence interval [CI]: 38%-86%), a specificity of 75% (95% CI: 48%-93%), a negative likelihood ratio (NLR) of 0.47 (95% CI: 0.23-0.95), and a positive likelihood ratio (PLR) of 2.59 (95% CI: 1.03-6.48). When combining FOCUS with CEUS, the sensitivity of the sonography increased to 94% (95% CI: 71%-100%) with a specificity of 75% (95% CI: 48%-93%). The PLR was 3.76 (95% CI: 1.6-8.87) and the NLR was 0.08 (95% CI: 0.01-0.54). In our population, abdominal sonography with contrast failed to identify a single positive abdominal CT with a grade 1 kidney injury.

Conclusions: A FOCUS examination shows limited sensitivity and specificity to detect positive abdominal CT in stable adults with abdominal trauma. With the addition of contrast and careful inspection of solid organs, abdominal sonography with contrast performed by the emergency physician improves the ability to rule out traumatic findings on abdominal CT. CEUS performed by emergency physicians may miss injuries, especially in the absence of free fluid, in cases of low-grade injuries, simultaneous injuries, or poor-quality examinations.

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Conflict of interest statement

The authors have no conflicts of interest to declare related to the present work. Bracco offered technical support and advice for the use of the contrast agent (Sonovue) and has provided educational grants to the Emergency Department of Inselspital since 2013. However, Bracco was not involved in any part of the study initiation, design, and conductance. No financial or material incentives were perceived by any of the authors. Wolf E. Hautz has received research funding from the European Union, the Swiss National Science foundation, the Zoll foundation, Dräger Medical Germany, Mundipharma Research UK, MDI International Australia, and Roche Diagnostics Germany. These are all outside the submitted work. He has provided paid consultancies to the AO Foundation Switzerland and MDI International Australia, all outside the submitted work. He has received financial support from the EBSCO for a congress he chaired Germany, Isabel Healthcare UK, Mundipharma Medical Switzerland, and VisualDx USA, all outside the submitted work.

Figures

FIGURE 1
FIGURE 1
CEUS, contrast enhanced ultrasound; CT, computed tomography; FOCUS, focused abdominal sonography; HD, hemodynamic;Study design; US, ultrasound.
FIGURE 2
FIGURE 2
(A) Stepwise approach for ruling out positive traumatic abdominal computed tomography (CT) by sonography. Focused abdominal sonography (FOCUS) looks for intraabdominal free fluid and perirenal hematoma, ultrasound (US) looks at solid organ parenchyma in B‐mode, and contrast enhanced ultrasound (CEUS) looks at solid organ parenchyma using contrast enhancement. (B) Posterior probability of positive abdominal CT according to FOCUS, US, and CEUS results in our population. BAT, blunt abdominal trauma; Pr, Probability.
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