Original ContributionsUtility of the Cardiac Component of FAST in Blunt Trauma
Introduction
Ultrasound was first used in the evaluation of trauma more than three decades ago (1). Focused assessment with sonography in trauma (FAST), a goal-directed examination for the diagnosis of blood in the peritoneal and pericardial spaces, has been shown to be accurate in the hands of trauma surgeons and emergency physicians 2, 3. FAST's routine coupling of abdominal and cardiac imaging has been widely taught and accepted almost universally as the standard approach for trauma sonography (4).
The echocardiographic portion of FAST is aimed at identifying pericardial fluid and cardiac activity. This examination has been shown to reduce time to operative care and improve survival for penetrating trauma (5). The utility of the cardiac portion of FAST is not well described for blunt trauma. A few dozen cases of hemopericardium due to blunt trauma diagnosed by echocardiography have been presented in the medical literature 6, 7, 8, 9, 10, 11, 12, 13, 14. These cases shed light on the fact that hemopericardium and cardiac rupture are diseases of severe trauma. However, FAST guidelines prescribe routinely coupling cardiac with abdominal sonography regardless of the severity of injury.
We aimed to investigate the prevalence of hemopericardium due to blunt trauma by retrospectively reviewing two institutional databases. We also aimed to determine the prevalence of incidental and insignificant pericardial fluid in these patients. Pre-existing effusions and false-positive findings may present serious diagnostic dilemmas in the management of critical trauma patients (7). We expected that cardiac ultrasound would be of most value in patients with the following high-risk features: a major mechanism of injury, hypotension, and emergent intubation. Therefore, we aimed to determine the sensitivity of these variables for hemopericardium and cardiac rupture. We believe understanding the prevalence of hemopericardium and incidental effusions and the sensitivity of high-risk variables will help establish indications for emergent echocardiography in trauma.
Section snippets
Study Design
We conducted a retrospective chart review of patients identified through two institutional databases. We identified patients with possible hemopericardium and then determined the prevalence of acute hemopericardium, cardiac rupture, incidental or insignificant effusions, and delayed hemopericardium. We reviewed the trauma registry for these patients from January 1, 2001 to June 6, 2007. We also queried the emergency ultrasound database to determine the prevalence of cardiac ultrasounds that
Results
The trauma registry contained 37,057 cases evaluated through the ED from January 1, 2000 to July 7, 2007, of which 29,236 were blunt trauma patients. Four hundred eighty of the 37,057 patients were identified as having one of our pre-specified ICD-9 codes. Of these, 401 patients were wounded by blunt mechanism, and 1 patient had an indeterminable mechanism of injury due to insufficient medical records. Eighteen blunt trauma patients were found to have our primary outcome of acute
Discussion
For almost two decades, FAST has served as the standard sonographic evaluation for trauma patients 2, 3, 4. FAST allows for the early detection of hemoperitoneum and hemopericardium and has revolutionized the initial management of trauma patients (4). Ultrasound is a rapid non-invasive test without the risks of radiation or contrast administration, and its use is steadily increasing. In 2008, the American College of Emergency Physicians and the American Institute of Ultrasound in Medicine
Conclusion
Patients rarely present to the ED with blunt hemopericardium. We found that in our sample, the absence of a major mechanism of injury, hypotension, or emergent intubation excluded this diagnosis. The routine performance of cardiac ultrasound in blunt trauma patients is likely unwarranted due to the very low prevalence of hemopericardium, the higher prevalence of incidental or insignificant effusions, and identifiable risk factors for the condition. Selective use of echocardiography guided by
References (22)
- et al.
Emergency department ultrasound in the evaluation of blunt abdominal trauma
Am J Emerg Med
(1993) - et al.
Emergency department echocardiography improves outcome in penetrating cardiac injury
Ann Emerg Med
(1992) Cardiac rupture secondary to blunt trauma: a rapidly diagnosable entity with two-dimensional echocardiography
Ann Emerg Med
(1991)- et al.
The use of echocardiography in the emergency management of nonpenetrating traumatic cardiac rupture
Ann Emerg Med
(1991) - et al.
Blunt cardiac rupture: the utility of emergency department ultrasound
Ann Thorac Surg
(1999) - et al.
Noninvasive estimation of right atrial pressures from the inspiratory collapse of the inferior vena cava
Am J Cardiol
(1990) - et al.
Echographic evaluation of splenic injury after blunt trauma
Radiology
(1976) - et al.
A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment
J Trauma
(1995) - et al.
Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference
J Trauma
(1999) - et al.
Blunt traumatic rupture of the heart: an experience in Tokyo
J Trauma
(1994)
“Incidental” pericardial effusion during surgeon performed ultrasonography in patients with blunt torso trauma
J Trauma
Cited by (21)
Focused Ultrasonography in Cardiac Arrest
2023, Emergency Medicine Clinics of North AmericaHelicopter Emergency Medical Services Performed Extended Focused Assessment With Sonography: Training, Workflow, and Sustainable Quality
2022, Air Medical JournalCitation Excerpt :This was not surprising because most of our trauma scene calls are blunt trauma. In 1 study of 29,000 blunt trauma patients, the prevalence of traumatic hemopericardium was 0.06%.44 More penetrating trauma would have likely increased the true-positive EFAST cardiac windows.45
Association of thoracic cage fractures and pericardial effusion in blunt trauma
2021, American Journal of Emergency MedicineCitation Excerpt :In addition, since clinically important pericardial effusions are so rare, many authors have questioned the utility of the cardiac view as a screening modality in blunt chest trauma [13,14]. While some authors have advocated for completely eliminating the cardiac view in this context, others have suggested that only patients with hypotension, in need of ventilatory support, or those with severe injuries would warrant routine use of the cardiac view [15]. Our findings, however, point to a potential benefit of the cardiac view to detect pericardial effusion even when all these findings are absent.
Hemopericardium and Cardiac Tamponade After Blunt Thoracic Trauma: A Case Series and the Essential Role of Cardiac Ultrasound
2021, Journal of Emergency MedicineCitation Excerpt :Although these pathologic findings and suspected pathophysiologic mechanisms are not described in detail, or considered as part of the primary analysis, there is evidence that several of these cases were not secondary to cardiac chamber rupture, but rather to penetrating trauma secondary to overlying boney injuries caused by the initial forces of the blunt trauma (6). Ultimately, Press and Miller focused on important clinical commonalities of the identified cases to help establish scenarios in which the cFAST was deemed to have a high degree of utility (6). They concluded that none of the patients identified with acute, blunt hemopericardium presented without a major mechanism of injury, hypotension, or emergent intubation.
Isolated right atrial appendage rupture following blunt chest trauma
2018, Trauma Case ReportsBlunt Cardiac Injury
2015, Emergency Medicine Clinics of North America