A Mysterious Stranger

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I'm seeing conflicting indications and recommendations. For the purposes of board exams, do we do a FAST exam when the patient is stable or unstable, or both in the setting of blunt abdominal trauma?
 

A Mysterious Stranger

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FAST is meant for the unstable patient, as a decision tool of who should bypass CT and go to the OR. It's just not used that way anymore. For the most part, all trauma activations get a FAST.
Thank you for the reply. This is what I'm seeing being reflected on board prep material. It looks like the age of when the algorithm questions were written are causing a variability in whether the correct answer is stable or unstable.
 
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gamerEMdoc

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It should be unstable because in a polytrauma patient who is unstable, you have no idea where they are bleeding. Taking them to the OR for a laparotomy when they could be bleeding to death from a pelvic fracture or femur fracture, or have spinal shock, makes little sense. So you FAST them to see if their cause of hypotension is from an abdominal bleed, and if so, take them to the OR. That was the intent of the FAST. FAST essentially replaced the DPL as a means of determining if the abd was the site of bleeding in a patient unstable for CT.

However, since its inception, it has become pretty standard to do a FAST on all trauma activations.

Here is a blurb from ATLS on FAST:

FAST, eFAST, and DPL are useful tools for quick
detection of intraabdominal blood, pneumothorax,
and hemothorax....The finding of intraabdominal blood indicates
the need for surgical intervention in hemodynamically
abnormal patients. The presence of blood on FAST or
DPL in the hemodynamically stable patient requires
the involvement of a surgeon as a change inpatient
stability may indicate the need for intervention.
 

thegenius

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FAST is meant for the unstable patient, as a decision tool of who should bypass CT and go to the OR. It's just not used that way anymore. For the most part, all trauma activations get a FAST.
I almost never do it, because it rarely changes mgmt of our trauma surgeons. If they want it then I will do it.
 
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Zebra Hunter

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Thank you for the reply. This is what I'm seeing being reflected on board prep material. It looks like the age of when the algorithm questions were written are causing a variability in whether the correct answer is stable or unstable.
There should be no variability for the correct answer, there is only one answer to this. The FAST exam is meant to only have clinical utility in the unstable blunt trauma patient. It has minimal utility in all other indications. You know what you do if you find intra-abdominal fluid on FAST in a stable blunt trauma patient? You get a CT. You know what you do if the FAST is negative? You get a CT. How about if they have a GSW to the abd and are unstable? They go to the OR. How about if they have a GSW to the abd and are stable? Still go to the OR. What board prep material is saying otherwise?

I used to annoy the heck out of Rosh Review customer service people by sending them corrections on their questions and explanations, like telling physicians to give diltiazem indiscriminately to weak old ladies in a-fib w/ a rate 120 without first providing evidence of thorough work up to attempt to explain the cause of the a-fib, given diltiazem could kill a weak old lady in new onset systolic heart failure or sepsis. I actually ended up writing a few questions for Rosh Review, but found that the effort was not worth the minimal pay received for each question.
 

Lexdiamondz

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The correct answer is in an unstable trauma patient.


That being said, in order to get good at both performing and interpreting an eFAST you need to do enough of them to do them quickly and recognise what a subtle, abnormal finding is. Because of that, most sites with EM residents or gen surg residents will perform an eFAST on basically every trauma activation.

I'm at a lvl 1 trauma center and if we only did FASTs on unstable trauma activations, we would do like 50 a year which, split among >30 residents is about 1.7 ultrasounds per resident annually - not nearly enough for anyone to be even remotely decent at it.
 

La Cumbre Lines

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Sorry OP, I don’t think many of us are able to answer your question well regarding what is the correct answer on the boards.

In theoretical practice a FAST is only clinically helpful in a hypotensive trauma patient to determine if they should go immediately to the OR for a laparotomy. In reality surgeons don’t trust FAST exams and usually want CTs. A FAST is basically worthless in a stable trauma patient. These patients get a CT.

I agree with the surgeons in that CTs are helpful in polyorgan system trauma even if borderline stability to determine order and type of operative intervention. An epidural or aortic dissection may kill the patient faster than a moderate grade splenic laceration.
 
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UKEMdoc

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The main indication for a FAST is that you’re a training institution and need to keep your numbers up.

ive never(in twenty years) seen FAST make a difference to themanagement of a trauma patient.
 

Fox800

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Unstable trauma patients get one to determine the need for laparotomy, thoracotomy, or a chest tube.

It's been expanded to be expected even in every trauma that gets called in as a "trauma activation", even though that's not the original intent.

If you think the patient needs a CT, get a CT. It was never designed to replace CT imaging, it was designed to tell you if the patient needs the OR now.
 

La Cumbre Lines

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Unstable trauma patients get one to determine the need for laparotomy, thoracotomy, or a chest tube.
How does a FAST determine the need for a thoracotomy or a chest tube? I feel like I usually perform these when indicated based off history/exam prior to ever picking up a probe.
If you think the patient needs a CT, get a CT. It was never designed to replace CT imaging, it was designed to tell you if the patient needs the OR now.
True. The reality is that CTs are usually performed pretty quickly and it rarely affects an outcome if there is a 5-10 minute delay prior to operative intervention. In our new ED remodel the CT is adjacent to the trauma rooms. I get equally frustrated when the patient doesn’t go immediately to the OR at times, but I’m also not the one operating. If a surgeon wants to know a little bit more before they cut other than that there is free fluid in the belly, then I’ll do my best to resuscitate them in the interim.
 

Zebra Hunter

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How does a FAST determine the need for a thoracotomy or a chest tube? I feel like I usually perform these when indicated based off history/exam prior to ever picking up a probe.

True. The reality is that CTs are usually performed pretty quickly and it rarely affects an outcome if there is a 5-10 minute delay prior to operative intervention. In our new ED remodel the CT is adjacent to the trauma rooms. I get equally frustrated when the patient doesn’t go immediately to the OR at times, but I’m also not the one operating. If a surgeon wants to know a little bit more before they cut other than that there is free fluid in the belly, then I’ll do my best to resuscitate them in the interim.
This reminded me of something I've been thinking about recently. Is the term "too unstable for CT", really even a thing anymore? Obviously patients who are coding, or are seconds from arresting (agonal breathing, hypoxia with progressively worsening bradycardia, etc.) are not going to scan, but I don't think anyone really cares about scanning those patients given that they are actively dying. I see this phrase thrown around all the time by colleagues or on EM:RAP where they are usually describing a run of the mill sick patient with soft BPs and maybe some respiratory distress. I can't think of a single time outside of trauma where I haven't gone to CT if I thought the patient really needed one regardless of stability. If I am really worried, I just start the patient on pressors and intubate them prior to going to the scanner, and then go with a crash cart and a nurse to watch them closely in CT.
 

Fox800

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How does a FAST determine the need for a thoracotomy or a chest tube? I feel like I usually perform these when indicated based off history/exam prior to ever picking up a probe.

True. The reality is that CTs are usually performed pretty quickly and it rarely affects an outcome if there is a 5-10 minute delay prior to operative intervention. In our new ED remodel the CT is adjacent to the trauma rooms. I get equally frustrated when the patient doesn’t go immediately to the OR at times, but I’m also not the one operating. If a surgeon wants to know a little bit more before they cut other than that there is free fluid in the belly, then I’ll do my best to resuscitate them in the interim.
I’m guessing your aren’t looking at thoracic windows. If you were you’d realize your decision to place a chest tube or not for a pneumothorax is fairly easy. You can exclude or diagnose a pneumothorax or hemothorax.

Same thing with looking for tamponade.
 

La Cumbre Lines

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I’m guessing your aren’t looking at thoracic windows. If you were you’d realize your decision to place a chest tube or not for a pneumothorax is fairly easy.

Same thing with looking for tamponade. I figured this would be clear.
A FAST only evaluates for intraabdominal fluid and pericardial effusion, not pneumothorax. We’ve been discussing FAST exams. Perhaps you meant an E-FAST exam. US doesn’t immediately determine chest tube placement or ED thoracotomy.

Hypotensive/tachycardic and no breath sounds unilaterally, then I sometimes perform needle thoracostomy while preparing for a chest tube, but almost always place a chest tube without using US to make that determination. If the patient is stable, then I get a CXR to determine need for a chest tube, which takes only a few minutes. No lung slide on US doesn’t change my management. I don’t put chest tubes in for stable trace to small pneumothoraces.

Also not sure if you are implying that tamponade in a non-arrested patient is an indication for an ED thoracotomy. Usually the indication for an ED thoracotomy by myself prior to surgery’s arrival is penetrating trauma arrest or more rarely blunt trauma arrest if the right rare situation. I work in a level 2 trauma center where surgery isn’t usually available at night for first 15 minutes. If I place a chest tube and the patient subsequently needs a thoracotomy based upon output then it is usually CT surgery while I resuscitate. I don’t think I have ever performed a thoracotomy in a trauma patient solely based upon tamponade alone.
 
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RoyBasch

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At academic centers it is used by protocol on EVERY trauma activation patient. In my community practice I only use it on unstable patients. Stable trauma patients just go to CT.
 
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