Advertisement

World Journal of Surgery

, Volume 42, Issue 1, pp 99–106 | Cite as

Double Jeopardy in Penetrating Trauma: Get FAST, Get It Right

  • Kazuhide MatsushimaEmail author
  • Desmond Khor
  • Kristin Berona
  • Derek Antoku
  • Ryan Dollbaum
  • Moazzam Khan
  • Demetrios Demetriades
Original Scientific Report

Abstract

Background

In hypotensive patients with thoracoabdominal penetrating injuries, trauma surgeons often face a considerable dilemma, which cavities and when to explore. We hypothesized that the Focused Assessment with Sonography for Trauma (FAST) would be accurate enough to determine the need and sequence of cavity exploration.

Methods

We conducted a 4-year retrospective study at a level 1 trauma center with high penetrating trauma volume. Patients with potential multi-cavity thoracoabdominal injuries were selected based on the location and number of external wounds. Findings in the operation or on computed tomography were used as references to evaluate the sensitivity, specificity, positive predictive value and negative predictive value of pericardial and abdominal FAST.

Results

A total of 2851 patients with penetrating injury were admitted from 2012 to 2015. Of those, 103 patients (3.6%) met our inclusion criteria (stab wounds 56.3%, gunshot wounds 43.7%). Median age: 32, male gender: 89.3%, median injury severity score: 17, in-hospital mortality rate: 11.7%. Thirty-seven patients (35.9%) required surgical exploration of more than one cavity. Although the pericardial FAST was falsely negative in only one case with large left hemothorax, all cardiac injuries were treated without delay (12/13, 92.3% sensitivity). Sensitivity and specificity of the abdominal FAST was 68.5 and 93.9%, respectively.

Conclusions

In hypotensive patients following penetrating thoracoabdominal injuries, the pericardial FAST was highly sensitive and could reliably determine the need to explore the pericardium. While positive findings of abdominal FAST warrant an exploratory laparotomy, negative abdominal FAST does not exclude the abdominal cavity as a bleeding source.

Notes

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

References

  1. 1.
    Hirshberg A, Wall MJ Jr, Allen MK et al (1995) Double jeopardy: thoracoabdominal injuries requiring surgical intervention in both chest and abdomen. J Trauma 39:225–229CrossRefPubMedGoogle Scholar
  2. 2.
    Asensio JA, Arroyo H Jr, Veloz W et al (2002) Penetrating thoracoabdominal injuries: ongoing dilemma-which cavity and when? World J Surg 26:539–543. doi: 10.1007/s00268-001-0147-8 CrossRefPubMedGoogle Scholar
  3. 3.
    Clarke DL, Gall TM, Thomson SR (2011) Double jeopardy revisited: clinical decision making in unstable patients with, thoraco-abdominal stab wounds and potential injuries in multiple body cavities. Injury 42:478–481CrossRefPubMedGoogle Scholar
  4. 4.
    Kimura A, Otsuka T (1991) Emergency center ultrasonography in the evaluation of hemoperitoneum: a prospective study. J Trauma 31:20–23CrossRefPubMedGoogle Scholar
  5. 5.
    Scalea TM, Rodriguez A, Chiu WC et al (1999) Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference. J Trauma 46:466–472CrossRefPubMedGoogle Scholar
  6. 6.
    The American College of Surgeons (2012) Advanced trauma life support student course manual, 9th editionGoogle Scholar
  7. 7.
    Rozycki GS, Feliciano DV, Schmidt JA et al (1996) The role of surgeon-performed ultrasound in patients with possible cardiac wounds. Ann Surg 223:737–746CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    McKenney MG, Martin L, Lentz K et al (1996) 1000 consecutive ultrasounds for blunt abdominal trauma. J Trauma 40:607–612CrossRefPubMedGoogle Scholar
  9. 9.
    Ma OJ, Mateer JR, Ogata M et al (1995) Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians. J Trauma 38:879–885CrossRefPubMedGoogle Scholar
  10. 10.
    Rozycki GS, Ochsner MG, Schmidt JA et al (1995) A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma 39:492–498CrossRefPubMedGoogle Scholar
  11. 11.
    Lee BC, Ormsby EL, McGahan JP et al (2007) The utility of sonography for the triage of blunt abdominal trauma patients to exploratory laparotomy. AJR Am J Roentgenol 188:415–421CrossRefPubMedGoogle Scholar
  12. 12.
    Rozycki GS, Ballard RB, Feliciano DV et al (1998) Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg 228:557–567CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Udobi KF, Rodriguez A, Chiu WC et al (2001) Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study. J Trauma 50:475–479CrossRefPubMedGoogle Scholar
  14. 14.
    Soffer D, McKenney MG, Cohn S et al (2004) A prospective evaluation of ultrasonography for the diagnosis of penetrating torso injury. J Trauma 56:953–957CrossRefPubMedGoogle Scholar
  15. 15.
    Boulanger BR, Kearney PA, Tsuei B et al (2001) The routine use of sonography in penetrating torso injury is beneficial. J Trauma 51:320–325CrossRefPubMedGoogle Scholar
  16. 16.
    Bank MA, Frankel HL, Tandon M et al (2004) Use of FAST to prioritize treatment of concomitant penetrating head, chest and torso wounds. Am J Emerg Med 22:491–492CrossRefPubMedGoogle Scholar
  17. 17.
    Berg RJ, Karamanos E, Inaba K et al (2014) The persistent diagnostic challenge of thoracoabdominal stab wounds. J Trauma Acute Care Surg 76:418–423CrossRefPubMedGoogle Scholar
  18. 18.
    Berg RJ, Inaba K, Okoye O, Karamanos E, Strumwasser A, Chouliaras K, Teixeira PG, Demetriades D (2014) The peril of thoracoabdominal firearm trauma: 984 civilian injuries reviewed. J Trauma Acute Care Surg 77:684–691CrossRefPubMedGoogle Scholar
  19. 19.
    Ball CG, Williams BH, Wyrzykowski AD et al (2009) A caveat to the performance of pericardial ultrasound in patients with penetrating cardiac wounds. J Trauma 67:1123–1124CrossRefPubMedGoogle Scholar
  20. 20.
    Biffl WL, Kaups KL, Cothren CC et al (2009) Management of patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial. J Trauma 66:1294–1301CrossRefPubMedGoogle Scholar
  21. 21.
    Brooks A, Davies B, Smethhurst M et al (2004) Prospective evaluation of non-radiologist performed emergency abdominal ultrasound for haemoperitoneum. Emerg Med J 21:e5CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Soto JA, Morales C, Múnera F et al (2001) Penetrating stab wounds to the abdomen: use of serial US and contrast-enhanced CT in stable patients. Radiology 220:365–371CrossRefPubMedGoogle Scholar
  23. 23.
    Blaivas M, Lyon M, Duggal S (2005) A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med 12:844–849CrossRefPubMedGoogle Scholar
  24. 24.
    Kirkpatrick AW, Sirois M, Laupland KB et al (2004) Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma 57:288–295CrossRefPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2017

Authors and Affiliations

  • Kazuhide Matsushima
    • 1
    • 3
    Email author
  • Desmond Khor
    • 1
  • Kristin Berona
    • 2
  • Derek Antoku
    • 1
  • Ryan Dollbaum
    • 1
  • Moazzam Khan
    • 1
  • Demetrios Demetriades
    • 1
  1. 1.Department of SurgeryUniversity of Southern CaliforniaLos AngelesUSA
  2. 2.Department of Emergency MedicineUniversity of Southern CaliforniaLos AngelesUSA
  3. 3.Los AngelesUSA

Personalised recommendations