New FAST Definitions May Improve Trauma Assessment of Children

Newly developed consensus definitions for complete and accurate Focused Assessment With Sonography for Trauma (FAST) and extended FAST (E-FAST) evaluations may better guide clinical decision-making and assist future research in the rapid assessment of hemorrhage for children who have suffered a blunt abdominal trauma, new research suggests.

Dr Aaron Kornblith

“While our findings suggest that FAST in children is similar to that of adults, we were surprised to learn that there are several important age-related anatomic considerations, such as the importance of the suprapubic view in young children,” corresponding study author Aaron Kornblith, MD, University of California, San Francisco, told Medscape Medical News.

“Our team will be using the newly developed complete, high-quality, and accurate FAST definition to help nonexperts reach expert-level performance,” he added. “In addition, we are excited about bringing new education tools and technologies to assist clinicians in accurate and reliable FAST for injured children.”

The research findings were published online in JAMA Network Open.

FAST is a bedside, clinician-performed, ultrasonography examination used to assess injured patients in the first several minutes of presentation to the emergency department. “FAST is commonly used for injured adults but is not standardly used in children,” Kornblith noted. “This inconsistency is because FAST is less reliable and has variable accuracy for children.”

Dr Jennifer Marin

There are several reasons for that, according to Jennifer Marin, MD, University of Pittsburgh School of Medicine, when asked for comment on the study findings. These include “anatomical and intra-abdominal injury patterns in children which often do not result in free fluid, a variable which the FAST examination detects,” she explained to Medscape Medical News.

Marin, who wasn’t involved in the research, noted that other reasons for variable test characteristics of the FAST examination in children may depend on the operator performing the test as well as “variable protocols used to define an examination as positive or negative.”

She added, “It is for these reasons that in children, the sensitivity of the FAST examination has typically been quite low and therefore not an optimal screening tool for the evaluation of intra-abdominal injury.”

New Definitions for Pediatric Use

Kornblith and colleagues conducted an initial scoping literature review to help define a complete FAST protocol. A 26-member international team of pediatric emergency point-of-care ultrasonography experts underwent two rounds of online surveys and a webinar to establish consensus definitions of complete, accurate, and high-quality FAST and E-FAST studies for children following injury.

The panelists rated five anatomic views as the most important and appropriate for determining a complete FAST: right upper-quadrant abdominal view; left upper-quadrant abdominal view; suprapubic views (transverse and sagittal); and subxiphoid cardiac view. The same FAST anatomic views, in addition to the lung or pneumothorax view, were also considered “appropriate” and “important” for E-FAST.

Additionally, the expert team rated 32 landmarks as “important” for evaluating completeness of the studies. Also, the expert panelists rated 14 statements on quality as well as 20 statements on accurate interpretation of the FAST studies as “appropriate.”

The experts were divided with regard to the appropriateness or inappropriateness of two statements for a consensus definition of FAST in children: “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.”

According to the panel, reporting results of the FAST and E-FAST studies should therefore “include any missing view or landmarks in the interpretation as well as patient factors” ― such as stability, sex, and age ― that could potentially limit examinations.

The research team noted that in the training and practice settings of the members of their point-of-care ultrasonography expert panel, the clinical integration of FAST was not evaluated, nor were the psychomotor skills needed for obtaining imaging addressed.

“However, our definitions were created using a rigorous methodology that reviewed existing literature and expert consensus,” Kornblith said. “As a result, our intention is novel in that it captures the most critical views, landmarks, and accurate consideration of experts for FAST in children.”

“I think the true utility of the FAST in children is still unanswered and deserves further exploration,” Marin commented. “Perhaps if clinicians adopt the newly proposed standardized approach for performing the FAST and E-FAST examinations, the reliability of the examination will improve and allow for improved assessment of its use in children.”

While Marin believes that the new definitions represent “an important step in standardizing the approach to the FAST exam in children,” she added that it is important for clinicians who incorporate the definitions into their decision-making to also teach the exam to trainees. “There is a learning curve, and clinicians must be appropriately trained and competent to perform the examination before implementing it into their practice,” she stated.

JAMA Netw Open. Published online March 1, 2022. Full text

Kornblith and Marin have disclosed no relevant financial relationships.

Brandon May is a freelance medical journalist who has written more than 900 articles for medical publications in the United States and the United Kingdom. He resides in downtown Brooklyn, New York City. Twitter: @brandonmilesmay.

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