Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma: A Randomized Clinical Trial

Abstract

Importance: The utility of the focused assessment with sonography for trauma (FAST) examination in children is unknown.

Objective: To determine if the FAST examination during initial evaluation of injured children improves clinical care.

Design, setting, and participants: A randomized clinical trial (April 2012-May 2015) that involved 975 hemodynamically stable children and adolescents younger than 18 years treated for blunt torso trauma at the University of California, Davis Medical Center, a level I trauma center.

Interventions: Patients were randomly assigned to a standard trauma evaluation with the FAST examination by the treating ED physician or a standard trauma evaluation alone.

Main outcomes and measures: Coprimary outcomes were rate of abdominal computed tomographic (CT) scans in the ED, missed intra-abdominal injuries, ED length of stay, and hospital charges.

Results: Among the 925 patients who were randomized (mean [SD] age, 9.7 [5.3] years; 575 males [62%]), all completed the study. A total of 50 patients (5.4%, 95% CI, 4.0% to 7.1%) were diagnosed with intra-abdominal injuries, including 40 (80%; 95% CI, 66% to 90%) who had intraperitoneal fluid found on an abdominal CT scan, and 9 patients (0.97%; 95% CI, 0.44% to 1.8%) underwent laparotomy. The proportion of patients with abdominal CT scans was 241 of 460 (52.4%) in the FAST group and 254 of 465 (54.6%) in the standard care-only group (difference, -2.2%; 95% CI, -8.7% to 4.2%). One case of missed intra-abdominal injury occurred in a patient in the FAST group and none in the control group (difference, 0.2%; 95% CI, -0.6% to 1.2%). The mean ED length of stay was 6.03 hours in the FAST group and 6.07 hours in the standard care-only group (difference, -0.04 hours; 95% CI, -0.47 to 0.40 hours). Median hospital charges were $46 415 in the FAST group and $47 759 in the standard care-only group (difference, -$1180; 95% CI, -$6651 to $4291).

Conclusions and relevance: Among hemodynamically stable children treated in an ED following blunt torso trauma, the use of FAST compared with standard care only did not improve clinical care, including use of resources; ED length of stay; missed intra-abdominal injuries; or hospital charges. These findings do not support the routine use of FAST in this setting.

Trial registration: clinicaltrials.gov Identifier: NCT01540318.

Figure 1.. Flow Diagram of Pediatric Patients With Blunt Torso Trauma

^aThe number of patients screened who met the exclusion criteria are not available. FAST indicates focused assessment with sonography for trauma.

Figure 2.. Clinician Suspicion of Intra-abdominal in the FAST Group Before and After the FAST Examination

Seven patients had missing data for clinician suspicion of intra-abdominal injury either before or after the focused assessment with sonography (FAST) examination and are not included in this figure. Rows represent clinician suspicion of intra-abdominal injury prior to performing the FAST examination. Columns represent clinician suspicion of intra-abdominal injury after performing the FAST examination; data represent No. (%) of patients. The dark blue cells (diagonal) represent no change in clinician suspicion of intra-abdominal injury after the FAST examination; light blue (above the diagonal), increased clinician suspicion of intra-abdominal injury after the FAST examination; and medium blue (below the diagonal), decreased clinician suspicion of intra-abdominal injury after the FAST examination.