FocUsEd assEssMEnt sonography For traUMa In "casa aUstrIa ...

Original articleS
FocUsEd assEssMEnt sonography For traUMa
In "casa aUstrIa" poLytraUMa cEntEr
- onE yEar FroM thE opEnIng
Sorin chiriac 1 , Mirela Danila 2 , cristian nica 3 , claudiu andrei 1 , Dorin claici 4 ,
Mircea Popescu 1
rEZUMat
Introducere: Ultrasonografia (US) este recunoscut\ ca metod\ de screening �n serviciile de urgen]\. Astfel, �n traumatologie, "Focused Assessment
Sonography for Trauma" (FAST) asigur\ �n principal o identificare rapid\ a colec]iilor lichidiene intraperitoneale, retroperitoneale, pleurale, pericardice, parietale,
etc. Material [i metod\: Studiul s-a efectuat la Compartimentul de Politraumatologie "Casa Austria" din cadrul Spitalului Clinic de Urgen]\ Jude]ean
Timi[oara, pe o perioad\ de un an (august 2003 - august 2004), pe un num\r de 130 pacien]i cu politraumatisme sub 24 ore. S-au �nregistrat 94 b\rba]i (72%),
36 femei (28%), cu v�rste �ntre 15 [i 79 ani (media 41 ani), prin accidente rutiere - 75 de cazuri (57,7%), prin c\dere de la �n\l]ime - 31 de cazuri (23,8%), prin
heteroagresiune - 16 cazuri (12,4%), prin strivire - 3 cazuri (2,3%), alte cauze - 5 cazuri (3,8%). S-au examinat: cavitatea peritoneal\, toracele (spa]iul pleural [i
pericardic) [i parietal la nivelul coapsei [i abdomenului. Rezultate: Rezultate pozitive s-au �nregistrat la 21 cazuri (16,15%) [i rezultate negative la 109 cazuri
(83,85%). Rezultate fals pozitive nu am �nregistrat, fals negative - un caz. Concluzii: Specificitatea a fost 100%, sensibilitatea 95,23% [i acurate]ea 99,23%.
Aceste rezultate, al\turi de durata scurt\ de examinare (2 min.), caracterul non-invaziv, repetitiv [i mobilitatea examin\rii au corespuns datelor din literatura de
specialitate.
Cuvinte cheie: ultrasonografie (US), traumatologie, FAST
abstract
Introduction: Ultrasound exploration (US) is a recognized screening method in the Emergency Room (ER). Focused Assessment Sonography for Trauma
(FAST) can be used to rapidly identify liquid collections in peritoneum, retroperitoneum, pleura and pericardium as well as intraparietal collections. Material
and method: The present study was performed in the "Casa Austria" Polytrauma Center of the Clinical Emergency County Hospital, Timisoara, over a one
year period (August 2003 - August 2004). During that period a number of 130 patients with acute (less than 24 hours) polytrauma were admitted. 94 of them
(72%) were males and 36 (28%) were females, with ages ranging from 15 to 79 years (median 41 years). 75 (57.7%) of cases were car accidents, 31 cases
(23.8%) falling from altitude, 16 (12.4%) cases of heteroagression, 3 (2.3%) cases resulting from crushes and 5 (3.8%) of other etiology. We have explored
the abdomen, thorax and the parietal aspects of the thigh and abdominal wall. Results: We have recorded a number of 21 (16.15%) positive cases and 109
(83.85%) negative cases. We have not recorded any false positive cases, and only a false negative one. Conclusions: The specificity was 100%, the sensibility
92.5%, and the accuracy 99.23%. These results, corroborated with the short time needed for the exploration (2 minutes), its multi-repetitive and non-invasive
aspects, correspond to the data found in the specialty literature.
Key Words: ultrasonography (US), trauma, FAST
IntrodUctIon
Ultrasonography (US) imposed itself as a screening
method in emergency rooms (ER) everywhere.
The term of “paraclinic exam” is thought to be less
appropriate, the US being considered “the stethoscope
of the 3 rd millennium”. 1
1 "Casa Austria"Polytrauma Center, 2 Clinic of Gastroenetrology, 3 3 rd Clinic of
Surgery, 4 Clinic of Urology, Clinical Emergency County Hospital, Timisoara
Correspondence to:
Sorin Chiriac, "Casa Austria"Polytrauma Center, Clinical Emergency County
Hospital, 156 Dr. I. Bulbuca Blvd., Timisoara, Romania, Tel: +40722657553
Email: s_chiriac@yahoo.com
Received for publication: Oct. 17, 2005. Revised: Mar. 13, 2006.
In traumatology, FAST ensures a quick detection
of liquid collections (fluids), usually blood, with a
sensitivity of 97-100%. 2,3 The pleurorrhea can be
noticed in a small quantity, as small as 20 ml. 4 In case
of parietal trauma, the US brings useful information
about hematoma, muscle tear, radio-transparent
foreign object etc. 4,5 It is also used for exploring the
retro-peritoneum, the urinary bladder and the scrotum,
in neonatology and neurosurgery. 6,7
Other advantages that impose this method are:
the economic aspect (including the possibility of
transferring the data into the computer), the portable
system that helps examining the patient in the ER,
while the patient is on the hospital bed or in the
operating room (OR) and also the lack or radiation,
which provides a risk free reexamination. 6
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Sorin Chiriac et al 59

The drawbacks are represented by the operator’s
experience, by the difficulty of the examination near
open wounds, dressed wounds and fractured ribs. 6
MatErIaL and MEthod
The study took place in “Casa Austria”, over a
period of one year, from the opening of the Polytrauma
Center, on 04.08.2003, until 04.08.2004. 130 patients
have been examined with the Voluson 530D portable
ultrasonograph. 101 patients have been examined by
two doctors with competence in Ultrasonography,
working in our department, the other cases being
examined by colleagues from other departments.
In the first 7 months we have examined the abdomen
(the peritoneal cavity and the retroperitoneum). Later
on, as we grew more accustomed with the technique,
we also scanned the posterior costodiaphragmatic
recesses, the pericardial cavity and parietal aspects, if
the symptoms suggested it.
We utilized bidimensional ultrasound (B mode)
with a convex transducer, the “abdomen 4-7 MHz”
program and the „HI Tissue” for superficial plans,
with the same existing transducer. In the abdomen we
looked for fluid in three spaces (perihepatic, perisplenic
and the Douglas’ space), retroperitoneal (kidneys,
perirenal and the wounded area) and the signs of ileus
(bowel loop distension and lack of peristalsis). 4,8,9 In
the thorax we have scanned the pleural cavity in its
lowest area, the posterior costodiaphragmatic recesses
bilateral through the subcostal window. 6 We used the
same window for the pericardial cavity, as well. 4 For
the abdominal wall and especially the lower extremities
we used the „HI Tissue” program, mainly with
“water pillows” (250 ml of distilled water in plastic
recipients). 4
For the FAST examination to run “fast” and
effective we examined all the patients in dorsal
decubitus, we used the same transducer and the same
abdominal window for abdomen, thorax and pericardial
cavity. The US alone never exceeded 2 minutes and
from the moment the doctor on duty received the call
until obtaining the result it took about 8 to 12 minutes.
Whenever necessary, FAST took place at the same time
while other therapeutic maneuvers where performed
(venous punctures, urinary probing, etc.).
FAST was applied in closed trauma, but also in
cases of nondominant cutaneous wounds. Trauma
cases older than 24 hours and repeats of US were not
included in the study. 10
The results were written in the patient’s charts,
presentation charts or the consultation registers for
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60 TMJ 2006, Vol. 56, No. 1
patients that were not admitted. Significant trauma
changes, in the clinical context, were printed on thermo
sensitive paper. 11
rEsULts
Between August 04, 2003 and August 04, 2004,
130 trauma patients were examined using the FAST
method. 94 men (72%) and 36 women (28%) with
ages between 15 and 79 years old have been registered.
There have been 75 cases of trauma from car accidents
(57.7%), 31 cases of trauma from altitude falling
(23.8%), 16 cases of heteroagression trauma (12.4%),
3 cases resulting of crushes (2.3%), 5 cases of trauma
with other causes (3.8%) (2 persons hit by a horse-shoe,
1 person hit by a cow-shoe, one industrial accident and
one injury resulting of an animal bite).
We have encountered FAST negative results in
109 cases (83.85%), out of which 14 were US positive
for other diseases (8 cases of asymptomatic and
symptomatic gall stones, 2 cases of hepatic cysts, one
case of hepatic cirrhosis, one case of renal cyst, one
cases of polycystic liver, one case of abdominal aortic
aneurism, one case of pregnancy in the 12th week and
one case of splenomegaly).
FAST positive results we have noted in 21 cases
(16.15%).
Findings in the abdominal area: we have
scanned the 3 relevant abdominal regions (perihepatic,
perisplenic, and Douglas’ space), the kidneys and the
retro peritoneal space, the bowel loop (for distension
and peristalsis). We measured the quantity of peritoneal
liquid by the number of positive quadrants. 12
- Rupture of the spleen: 5 cases (3.8%) (Figures
1-3). Four of them had fluid in three quadrants, two
of them presenting positive images in the splenic
parenchyma - subcapsular or intraparenchymatous
hematoma; in one case an abdominal computer
tomography (CT) was taken and it came out positive;
one case had only intrasplenic hematoma and fluid in
only one abdominal quadrant; one case had a perirenal
hematoma, diagnosed US and during the operation. All
the cases had the preoperative diagnosis of rupture of
the spleen, based on FAST, clinical examination etc.,
integrating the ultrasonographical examination in the
clinical context. 11
- Rupture of ileum: 3 cases (2.3%) (Fig. 4). The
diagnosis of peritonitis was clinical (peritoneal
irritation syndrome) and ultrasonographical. One case
presented liquid in Douglas’ space and signs of ileus
and 2 cases presented liquid in all the 3 quadrants and
signs of ileus. 9,13

Figure 1. Splenic rupture, hemoperitoneum in Douglas' pouch.
Figure 2. Splenic rupture, perisplenic hematoma (the same case).
Figure 3. Fluid in the perihepatic space.
Figure 4. Ileus (case of ileum rupture).
- Right kidney explosion: 1 case, diagnosed by US
and confirmed by contrast CT (also for contralateral
kidney function).
- One case of pregnancy in 7 th month stopped in
evolution - US diagnosed and gynecological consult.
- One case of dynamic ileus – distended ansa and
lack of peristalsis.
- One case of intrarenal hematoma. (Fig 5)
Figure 5. Intrarenal hematoma.
All the abdominal cases, excepting the intrarenal
hematoma (urologically and urographically diagnosed)
were confirmed in the OR.
Findings in the thoracic segment: there were
3 cases of hemothorax, the FAST diagnosis being
confirmed radiographycally and also by pleural
drainage (minimal pleurostomia).(Fig. 6)
Figure 6. Left hemothorax.
There was no fluid in the pericardial cavity at the
FAST examination or the autopsy.
Parietal findings: we recorded two cases of
hematoma and edema in the thigh; one case of
hematoma and edema in the thigh and abdominal
wall, with Morel-Lavallée lesions; two cases of inguinal
hematoma. (Fig. 7) The case of hematoma and edema
in the thigh and abdominal wall with Morel-Lavallée
lesions and one case of inguinal hematoma were
confirmed in the OR. The other cases did not need
other investigations or surgical maneuvers.
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Sorin Chiriac et al 61

Figure 7. Calf concussion.
There were no false positive cases and only one
false negative case: a serious trauma by car accident: the
patient was unstable, the FAST exam was inconclusive
(negative), but the diagnostic peritoneal lavage (DPL)
was intensely positive, and the exploratory laparotomia
showed massive hemoperitoneum with coagulated
blood.
Regarding the fact that we had only one false
negative case and no false positive cases, FAST had
great specificity (100%), sensitivity (95.23%) and
accuracy (99.23%).
We had 6 special cases, worth mentioning:
- One case of trauma by falling from altitude,
thoracic concussion, multiple rib fractures, humeral
fractures, casts (Dessault immobilization). FAST
was difficult, the spleen and the right kidney being
impossible to examine;
- One case of severe trauma in an industrial
accident, serious head injury, 4 th degree coma (brought
in by helicopter) - positive abdominal puncture in left
low quadrant, but FAST and abdominal puncture US
guided showed retroperitoneal hematoma; the decision
was for conservative treatment. The autopsy found
infarction in the left sylvian territory and a medium
retroperitoneal hematoma.
- Three cases of ileum rupture, where ileus signs
and fluid in the peritoneal cavity were found.
- One case of intrasplenic hematoma and minimal
fluid in the Douglas’ space, where the therapeutical
decision was that of conservatory treatment with a
favorable evolution.
dIscUssIon
As mentioned before, in our service, FAST is
influenced by some managerial aspects. A US specialist
is not available at all time, patients are not brought up
constantly in our ER service and the examining of the
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62 TMJ 2006, Vol. 56, No. 1
pleural and pericardial cavities was made only in the
last 61 cases.
FAST took about 8 to 12 minutes from the moment
the doctor on duty received the call. Actually, from
the time the patient arrived in our trauma center we
managed to work within the 15 minutes of “abdominal
clearance with US”, considered optimal. 14
FAST took place at the same time with the
examination of the patient or some therapeutic
maneuvers (venous punctures, urinary probing etc.),
as recommended in emergencies. 4
It was a useful tool in finding intestinal lesions
(together with the clinical exam – peritoneal irritation
syndrome), even if it is thought to be less useful in
the detection of intestinal or mesenteric lesions, which
cannot be excluded by negative US. 3
Having mentioned the fact that we recorded
only one false negative result and no false positive
ones, FAST had very high specificity, sensitivity and
accuracy, comparable with the results in the literature,
i.e. sensibility of 92.5%, specificity of 97.2% and
accuracy of 95.5%. 15
concLUsIons
1. We mention the special qualities of FAST in
finding fluid in the peritoneal or thoracic cavities, the
possibility of repeating the exam, the accessibility in
the ER or at the bedside.
2. FAST was very useful in intestinal ruptures,
being an important factor in the terapeutic decision
- the very necessary surgical maneuvers.
3. Regarding the specificity, sensitivity and accuracy
of FAST, the results correspond to those in the
experienced trauma clinics.
4. The drawback given by the difficulty in examining
the open wounds, the dressed wounds, cases of rib
fractures, casts, were rarely present.
5. In our department it would be useful to improve
aspects like a permanent ultrasonograph in the ER,
the existence of a peripheral vascular transducer, so
valuable in evaluating the peripheral vascular lesions,
so that each patient can benefit from a complete FAST
examination.
acKnoWLEdgEMEnts
We are eternally grateful to Prof. Johannes
Poigenfűrst, M.D. Ph.D., who has conceived the “Casa
Austria” Polytrauma Center project for Timişoara 15
years ago and materialized it, the place where we work
now. We would also like to thank those who donated

the ultrasonograph that made this study possible and,
first of all, helped our patients receive the appropriate
medical care.
bIbLIography
1. Testa A, Mazzone M, Portale G, et al. Diagnostic power of ultrasonography.
XVI th European Congress of Ultrasound in Medicine
and Biology, Zagreb, Croatia, June 5-8, 2004, Abstract book
A303:110.
2. Hagiwara A, Murata A, Matsuda T, et al. Limitation of non-surgical
management in patients with severe hepatic injuries : the efficacy
of focused assessment with sonography for trauma (FAST). 6 th
European Trauma Congress, Prague, May 16-19 2004. A:360.
3. Abbasakoor F, Vaizey C. Pathophysiology and management of
bowel and mesenteric injuries due to blunt trauma. J Trauma
2003;(5):199-214.
4. Badea Gh, Badea R, Valeanu A, et al. Bazele ecografiei clinice, Ed.
Medicala: Bucureşti, 1994, p. 65-74.
5. Poposka A, Application of sonography diagnosis in soft tissue injuries.
XVI th European Congress of Ultrasound in Medicine and Biology,
Zagreb, Croatia, June 5-8, 2004, Abstract book A169:65.
6. Rosenberger A, Adler OB, Troupin R. Trauma imaging in the thorax and
abdomen. Year Book Medical Publishers, 1987, p. 139-48.
7. Platon A, Poletti P. Value of portable US device in an emergency
department in Romania. XVI th European Congress of Ultrasound
in Medicine and Biology, Zagreb, Croatia, June 5-8, 2004, Abstract
book A294:106.
8. Badea Gh, Badea R. Atlas comentat de ecografie abdominala, Ed.
Medicala: Bucureşti, 1990, p. 176.
9. Sporea I. Possibilities and scope of transabdominal ultrasound in
evaluation of the digestive tube. XVI th European Congress of
Ultrasound in Medicine and Biology, Zagreb, Croatia, June 5-8,
2004, Abstract book A065:23-25.
10. Habib F, Namias N, McKenney M, et al. Late (>24h) ultrasonography
is not useful in follow-up assessment of the abdomen
in the multiply injured critically ill blunt trauma patient. 6 th European
Trauma Congress, Prague, May 16-19, 2004, Abstract book A605.
11. Sporea I, Cijevschi, Prelipceanu C. Ecografia abdominala in practica
medicala. Mirton: Timisoara, 2001, p. 7.
12. Sirlin CB, Casolo G, Brown M, et al. Patterns of fluid accumulation on
screening ultrasonography for blunt abdominal trauma. Comparison
with site of injury. J Ultrasound Med. (USA) 2001;20:351-7.
13. Rebedea D, Dragoi A. Ecografia in patologia digestivă - ghid teoretic.
Excelsior: Bucuresti 1996, p. 62.
14. Balogh Z, Caldwell E, D’Amours S, et al. Practice guidelines for the
improvement of the outcome of hemodynamically unstable patients
with pelvic fractures. 6 th European Trauma Congress, Prague, May
16-19, 2004, Abstracts book A119.
15. Soudack M, Gaitini D. FAST in blunt abdominal trauma: our experience
with 313 children. XVI th European Congress of Ultrasound in
Medicine and Biology, Zagreb, Croatia, June 5-8, 2004, Abstract
book A297:108.
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Sorin Chiriac et al 63