Prehospital Ultrasounds?

[Brandon O]

This can open doors to pericardiocentesis

This does interest me but would obviously add that much more of a skill requirement for safe execution in the field.

I guess that's the overall theme here -- to add a great deal, it seems like it'd need to come bundled with other tools, and it's already quite a mouthful to learn at our level of training. Merely inserting it into our current flow of care and decision-making seems like it would have limited utility. Not zero, but limited, so I don't know if the payoff is there.

 

[Veneficus]

Don't forget line placement also some strokes, dvt but I dunno the skill level required for these. I have begun a research project on this subject am collecting data. I will be on an atls course at the end of this month.
This can open doors to pericardiocentesis
Look up tranexamic acid for internal bleeding

And this is a must read for anyone trying to argue for or against
http://www.paramedicultrasound.com/

"Physiocontrol/Medtronic has announced a project with Sonosite to incorporate sales of:censored: ultrasound machines with future cardiac monitor/defibrillators.:censored:"

Ecgs were once too expensive and paramedics were too dumb to read them. we also didn't have much of a reason to get them because we don't treat much and the dr will just get on at the hospital... Serial ultrasounds?

Forget TXA, medical control of surgical bleeding doesn't hold a lot of promise, studies show it only helps in the most severe of patients. This is simply a subject that comes back every now and again.

 

[blindsideflank]

Well aren't you a party pooper.

I guess they used to to do pericardiocentesis here in the early 90's. My instructor said they quit because of too many accidental biopsies :S

Obstetrical patients would be another cool population to use this on.

Also, this can be used while en route to the hospital so scene time argument is less relevant. 3 mins can often be spared on a call ( or am I doing something wrong?)
":censored:The real value of Paramedic US may be similar to what we, as paramedics, do with the 12 lead ECG.:censored::censored: The 12 lead does not drastically change our field care but it sure does dramatically help the patient by ramping up the response at the hospital.:censored: The positive ultrasound may do the same thing by speeding the patient to the most appropriate location like ED/CT/OR or treatment such as having O- packed cells hanging upon arrival"

as stated before, I'm beginning (well I meet with my supervisor at the end of the summer) a research project on the feasibility of this in ems. Any links to training programs in Canada or northwest USA would be helpful as I am in the VERY preliminary phase of research

 

[medicsb]

Just came across this abstract, which is relevant to the (stalled) discussion:

J Emerg Med. 2012 May 15. [Epub ahead of print]
A Pilot Study Examining the Viability of a Prehospital Assessment with UltraSound for Emergencies (PAUSE) Protocol.
Chin EJ, Chan CH, Mortazavi R, Anderson CL, Kahn CA, Summers S, Fox JC.
Source

San Antonio Uniformed Services Health Education Consortium - San Antonio Military Medical Center, Ft. Sam Houston, Texas.
Abstract
BACKGROUND:

Prehospital ultrasound has been shown to aid in the diagnosis of multiple conditions that do not generally change prehospital management. On the other hand, the diagnoses of cardiac tamponade, tension pneumothorax, or cardiac standstill may directly impact patient resuscitation in the field.
STUDY OBJECTIVE:

To determine if prehospital care providers can learn to acquire and recognize ultrasound images for several life-threatening conditions using the Prehospital Assessment with UltraSound for Emergencies (PAUSE) protocol.
METHODS:

This is a prospective, educational intervention pilot study at an urban fire department with integrated emergency medical services (EMS). We enrolled 20 emergency medical technicians - paramedic with no prior ultrasonography training. Subjects underwent a 2-h training session on basic ultrasonography of the lungs and heart to evaluate for pneumothorax, pericardial effusion, and cardiac activity. Subjects were tested on image interpretation as well as image acquisition skills. Two bedside ultrasound-trained emergency physicians scored images for adequacy. Image interpretation testing was performed using pre-obtained ultrasound clips containing normal and abnormal images.
RESULTS:

All subjects appropriately identified the pleural line, and 19 of 20 paramedics achieved a Cardiac Ultrasound Structural Assessment Scale score of ≥4. For the image interpretation phase, the mean PAUSE protocol video test score was 9.1 out of a possible 10 (95% confidence interval 8.6-9.6).
CONCLUSION:

Paramedics were able to perform the PAUSE protocol and recognize the presence of pneumothorax, pericardial effusion, and cardiac standstill. The PAUSE protocol may potentially be useful in rapidly detecting specific life-threatening pathology in the prehospital environment, and warrants further study in existing EMS systems.

 

[Melclin]

Forget TXA, medical control of surgical bleeding doesn't hold a lot of promise, studies show it only helps in the most severe of patients. This is simply a subject that comes back every now and again.

My understanding of CRASH-2 was that there were improvements across the board but that the biggest improvements were in the sickest pts.

Also, there was a reanalysis in the lancet talking about the necessity of giving it early. Within the first three hours or not at all. I don't know that anyone is suggesting this is superior to surgery for surgical bleeds, but not everyone can get on the angio/surgeons table quickly and not everyone has access to 1:1:1 transfusion products in time to resuscitate them. The numbers presented in this study are pretty good. I would think it is at least worth considering a trial of this drug on HEMS.

There was even a comment piece in the lancet last year suggesting its use in the prehospital environment, encouragingly, by the director of the National Trauma Research Institute here in Victoria.

 

[Veneficus]

My understanding of CRASH-2 was that there were improvements across the board but that the biggest improvements were in the sickest pts.

Also, there was a reanalysis in the lancet talking about the necessity of giving it early. Within the first three hours or not at all. I don't know that anyone is suggesting this is superior to surgery for surgical bleeds, but not everyone can get on the angio/surgeons table quickly and not everyone has access to 1:1:1 transfusion products in time to resuscitate them. The numbers presented in this study are pretty good. I would think it is at least worth considering a trial of this drug on HEMS.

There was even a comment piece in the lancet last year suggesting its use in the prehospital environment, encouragingly, by the director of the National Trauma Research Institute here in Victoria.

I encourage you to read the many studies on Txa and aprotinin from both surgery and anesthesia.

Overwhelmingly it gets a thumbs down.

I liken it to the prehospital use of factor VII.

 

[Melclin]

I encourage you to read the many studies on Txa and aprotinin from both surgery and anesthesia.

Overwhelmingly it gets a thumbs down.

I liken it to the prehospital use of factor VII.

Tranexamic acid is useful in a wide range of haemorrhagic conditions. The drug reduces postoperative blood losses and transfusion requirements in a number of types of surgery, with potential cost and tolerability advantages over aprotinin, and appears to reduce rates of mortality and urgent surgery in patients with upper gastrointestinal haemorrhage

http://www.ncbi.nlm.nih.gov/pubmed/10400410

Our data suggest that in valvular heart surgery, low-dose aprotinin is significantly better than tranexamic acid or a placebo for reduction of postoperative bleeding and allogenic transfusion, without increasing adverse outcomes.

http://www.ncbi.nlm.nih.gov/pubmed/10400410

Strong evidence that tranexamic acid reduces blood transfusion in surgery has been available for many years.

http://www.ncbi.nlm.nih.gov/pubmed/22611164



I haven't had a thorough look but I can't find a negative article about the stuff. The only articles I can find seem to arse over tit in love with it.

Also the guy who is suggesting it as a possibility in the prehospital environment is no slouch. Trauma surgery and surgical critical care training, Director of the National Trauma Research Institute and Professor of Surgery at Monash Uni. So again, I don't know that you can just write his opinion off just like that.

Especially when that opinion is informed by a multicentre RCT randomising over 20,000 people, that shows a clear benefit of early TXA.

 

[Veneficus]

All of the stuff I have, mostly PDFs that won't let me copy parts of it, demonstrate there is either non statistically significant survival in all groups except the most extreme, which show a minimal benefit.

It is not that I think anyone is a slouch, I think that it may fall under 2 issues.

1st, an assumed correlation of beneft. It is accepted that the amount of blood transfused is prognostic for outcome in many emergent surgeries.

Assuming that a reduction of transfused blood will improve survival to discharge. Which implies causation, which I do not think can be supported.

2nd, in some of the TXA and apro studies I have read, I think I have seen one or 2 of the ones you mentioned as well, show exactly like I mentioned about factor VII, have a benefit is a very narrow range of extreme patients. Which means that it is a valid treatment for those patients, not all of them.

Which may not be conducive prehospital. In my experience and opinion, most prehospital providers don't really have a good handle on what a serious patient is and often overestimate patient severity.

Not something that is going to be acceptable when you are talking about playing with clotting agents.

Now I will point out that most of my research was focusing on ruptured aortic aneurysm, both in the thorax and abdomen, as blood loss doesn't usually get more rapid and significant or carry such a high mortality rate.

Having highly respected trauma surgeons making judgements of who will benefit from a given treatment is far different than a medic or emergency doc.

I am not sure there is going to be an easy way to make it user friendly for everyone.

In the first study, I will point out the benefit is specific to liver surgery, which can affect clotting factor produciton, and both upper GI and pregnancy related bleeding have long been known to respond to various non surgical therapy.

Which demonstrates a specific patient range.

for your enjoyment:

http://www.ncbi.nlm.nih.gov/pubmed/18931201

if you like a cochran review:

http://www.ncbi.nlm.nih.gov/pubmed/22161443

ruptured aneurysm:

http://www.ncbi.nlm.nih.gov/pubmed?...he use of aprotinin in the repair of ruptured

and a case report that is also bad (I can send the PDF if you need.

http://www.ncbi.nlm.nih.gov/pubmed/10193833
http://www.ncbi.nlm.nih.gov/pubmed/11209027

an interesting correlation with a specific patient group.

http://www.ncbi.nlm.nih.gov/pubmed/21716688

 

[Melclin]

I need to go to bed so I'll have to read them later but just two quick points.

In regards to 1). CRASH-2 showed mortality benefit. It wasn't based on an assumption about reduced transfusion. In fact, it didn't change the amount of blood transfused, so the mechanism involved in the increased survival is not clear. Something was suggested about short circuiting some part of the inflammatory process.

Now I might be wrong about this, I can't dig out the article right now but the inclusion criteria was basically anyone was likely to get transfused due to traumatic haemorrhage. Transfusion decisions are being made by our HEMS medics on the ground at the moment in regards to PRBCs. Perhaps a similar pt cohort would benefit from TXA.

In any case I'm almost always against the idea that certain treatment decisions are permanently beyond paramedics. If they are then we need to learn how to make them possible. We cant leave out a treatment that has shown good results and may even be restricted to the prehospital environment by virtue of the fact that its only affective when given early, just on the basis that paramedics are too stupid to apply it.

But thats just the thing. The respected trauma surgeon isn't saying it should only be his decision. The respected trauma surgeon is asking the question of whether or not we need to look at putting this drug in paramedic drug bags.

 

[Veneficus]

It is not about being stupidor not stupid, it is about precision.

If you have ever heard surgeons and intensivists go rounds over medical vs. surgical bleeding in patients, you understand how difficult the situation may be to determine.

That is in a hospital, with all kinds of gagets and toys.

The emergency setting uses and sometimes requires overtreatment.

When you have time, look at some of the risks of TXA administration. This is not a benign treatment.

It is the goal of trauma surgeons to save more people from trauma, over time, many extremely prestigious and respected trauma surgeons have suggested various additions to prehospital care.

But the nature of over triage and overtreatment has nullified ideas on multiple occasions.

Look at autotransfusion, in the OR, magnificent tool. In the ED, not so much, never seen it in the field, but i could only imagine how that would go down.

I am of the opinion that if there is such a need for massive hemorrhage control in the field, then medics need to be taught surgical skills, not try to back door surgical treatments by adding medicine.

As I have often heard it said, attempting to treat surgical pathology medically just delays the patient from the care they need.

When you talk about playing with clotting cascades, you are speaking of a precision game, and both the kininogen and inflammatory cascades are connected.

For the sake of academic discussion, how would you go about implementing TXA into prehospital treatment?

What would be the criteria?

 

[zmedic]

Heres my take on prehospital ultrasound, as regards trauma. Tell me what you are going to do differently. If you have a negative FAST exam, with a serious mechanism, are you not going to go to the trauma center? No, you should still take the patient there. If you have a positive fast what are you going to do? Go to the same place. I don't see trusting my medics enough to take the patient directly to the operating room based on their FAST, especially since the patient is usually going to get a chest x-ray, get striped etc before going to the OR.

Furthermore, considering that there is a push to not start IVs on scene because they may increase scene time, I think ultrasound would be even worse in delaying transport, and distracting people from things they should be doing (splinting, controlling bleeding etc)

I'd also point out that some of the biggest cheerleaders of prehospital ultrasound are the companies that make the expensive machines, and those with an financial stake.

For me it comes down to NNT, or number needed to treat. How many patients do you have to ultrasound to save a life? In the ER I'd say it's less than 5% of my trauma patients who have a positive ultrasound finding, and even less than that who it changes management.

I'm pretty good at ultrasound, but I've had probably 60-70 hours of formal ultrasound training, in addition to the 500 or so ultrasounds I've done. I think if prehospital ultrasound gets rolled out a lot of places are going to have a 1 hour class and turn people loose. I think for certain groups, like critical care medics and flight nurses it may be useful. But I'm not sure it's ready for prime time.

 

[Veneficus]

Heres my take on prehospital ultrasound, as regards trauma. Tell me what you are going to do differently. If you have a negative FAST exam, with a serious mechanism, are you not going to go to the trauma center? No, you should still take the patient there. If you have a positive fast what are you going to do? Go to the same place. I don't see trusting my medics enough to take the patient directly to the operating room based on their FAST, especially since the patient is usually going to get a chest x-ray, get striped etc before going to the OR.

Furthermore, considering that there is a push to not start IVs on scene because they may increase scene time, I think ultrasound would be even worse in delaying transport, and distracting people from things they should be doing (splinting, controlling bleeding etc)

I'd also point out that some of the biggest cheerleaders of prehospital ultrasound are the companies that make the expensive machines, and those with an financial stake.

For me it comes down to NNT, or number needed to treat. How many patients do you have to ultrasound to save a life? In the ER I'd say it's less than 5% of my trauma patients who have a positive ultrasound finding, and even less than that who it changes management.

I'm pretty good at ultrasound, but I've had probably 60-70 hours of formal ultrasound training, in addition to the 500 or so ultrasounds I've done. I think if prehospital ultrasound gets rolled out a lot of places are going to have a 1 hour class and turn people loose. I think for certain groups, like critical care medics and flight nurses it may be useful. But I'm not sure it's ready for prime time.

While I agree with what you said, I would like to see it used to reduce more of the "what if" mentality as reason to call for airmed instead of transporting by ground.

I am of the mind that if the few minutes a fast takes will make a life or death difference, then the outcome is likely to be death anyway.

Rather than seeing it as life saving tool, I look at it as a way to reduce over-treatment by inititating needless flights.

Not to mention the lives that might be saved might be a flight crew.

Recently I was involved in researching the purchase of a portable ultrasound for an institution, and I can say with certainty, that the base diagnostic machine at a cost of 35K base and 50K for all you could want to do in an emergency, is a lot less costly than flights based on "what if" and mechanism.

From the EMS standpoint, you could probably get away with one of the $7800 handhelds.

Since you can buy at least 2 and possibly 3 for the cost of a flight, that might pay for itself rather quick.

 

[Fish]

I've been thinking about the utility of ultrasounds in the prehospital setting recently (and I'm sure there's been some discussion of it in the past).

After having a few patients who had triple-As (and one who had a thoracic aortic aneurysm), as well as a few who may have had intraperitoneal bleeding, I asked an ED doc what they did after we brought those folks in.

He indicated that one of the procedures he finds most useful (and, indeed, is required by ATLS) is the Focused Assessment with Sonography for Trauma.

For those who've done FAST exams, how complicated are they? Do you think it'd be realistic to add them to the EMT-P curriculum? How useful might it really be? Could it actually change prehospital management, or would it just be more info to give the receiving facility (or just useless, because the ED is going to do another ultrasound anyway)?

A few rural services find it useful, the difference beween ground and air transport can be decided when a Paramedic is concerned with ABD. bleeds. Negative fast, and no other reason to place the patient in a Critical Trauma Category(no other injuries or reason to suspect) then transport by ground, Postive Fast and The Helicopter can get there faster than you can drive them, then go by air.

I believe Midland or Odessa Fire Dept. added it to their scope. Which is interesting because they are not very Rural at all.

 

[Melclin]

On ultrasound. I think it could be a useful tool, especially rurally. I think its worth asking the question, especially as the units become cheaper.

I don't see it extending scene time. We tend to wait on scene or at a nearby landing site for quite a while with trauma pts for the chopper. We've often got no shortage of time to kill. Additionally, HEMS chaps will spend a bit of time resuscitating and assessing pts before they go up. RE pneumo, need for tubes, PRBCs etc. I don't think it would be that much of a stretch to include FAST type examinations. As far as trauma goes, once its a given that you're going to a trauma centre, I do think that reduces the need for US, meaning that US might actually be of more use on ground units rather than HEMS, which leads me to my next point.

Calling the chopper here is a big deal. We don't over triage, we more than likely under triage. I've been put in a few situations where I really would like to have had more information before calling a chopper. Every time, I've ended not calling and I happen to have be right each time, but its was only ever an educated guess. I agree that more POC tests in our hands can help make very relevant triage decisions.

It is not about being stupidor not stupid, it is about precision.

If you have ever heard surgeons and intensivists go rounds over medical vs. surgical bleeding in patients, you understand how difficult the situation may be to determine.

That is in a hospital, with all kinds of gagets and toys.

The emergency setting uses and sometimes requires overtreatment.

When you have time, look at some of the risks of TXA administration. This is not a benign treatment.

It is the goal of trauma surgeons to save more people from trauma, over time, many extremely prestigious and respected trauma surgeons have suggested various additions to prehospital care.

But the nature of over triage and overtreatment has nullified ideas on multiple occasions.

Look at autotransfusion, in the OR, magnificent tool. In the ED, not so much, never seen it in the field, but i could only imagine how that would go down.

I am of the opinion that if there is such a need for massive hemorrhage control in the field, then medics need to be taught surgical skills, not try to back door surgical treatments by adding medicine.

As I have often heard it said, attempting to treat surgical pathology medically just delays the patient from the care they need.

When you talk about playing with clotting cascades, you are speaking of a precision game, and both the kininogen and inflammatory cascades are connected.

For the sake of academic discussion, how would you go about implementing TXA into prehospital treatment?

What would be the criteria?

I'm not saying its right because a respected trauma surgeon said it, I'm saying its worth at least considering, especially when that opinion is informed by such a good trial. Your original post seemed to pretty much just write it off. Full stop. No questions asked.

I see the parallel you are drawing with factor VII and the delicate selection of groups of pts who will benefit.

I don't think its an accurate comparison. For starters its not a choice between medical vs sugical bleeding. TXA was given to everyone, not at all increasing the amount of time it takes to get to theatre/angio if thats whats required.

Factor VII is tremendously expensive. TXA isn't. The risks of factor VII and TXA aren't similar to my knowledge. I don't know a great deal about factor VII but I understand it is quite risky and often requires some fairly high level thought and approval before administration. In CRASH-2, rates of vascular occlusion were not statistically different (they were actually lower in the TXA group). There was no blood work required to inform the admin of TXA. It was given empirically, to hypotensive/tachy trauma pts at risk of haemorrhage, or to anyone generally thought to be at risk of haemorrhage. As for how it would be applied in the prehospital environment, I couldn't say. How it interacts with subsequent admin of blood products would have to be investigated. Many of the pts in CRASH-2 were not being resuscitated in the same way as they would be in modern western trauma centre. How TXA might fit into a such a system is not clear. I'm not suggesting it being introduced tomorrow with a list of indications, ready for paramedics everywhere. I'm saying that a study of this quality and size necessitates the asking of questions about its use in the prehospital environment given that 1) a large RCT has showed significant mortality benefit, with no apparent added risk, 2) A re-analysis has shown it may only be effective in the first three hours (which in many trauma pts will pass before they reach a trauma centre, and 3) It is cheap, does not extend scene times and does not really require any expansion of equipment, paramedic education or scope (at least here).

I'm not saying the kininogen and inflammatory cascades aren't connected, just making the point that its not correct to say that crash-2 was based at all on transfusion reduction being associated with reduced mortality, because it didn't reduce transfusion but it did improve mortality. So other mechanisms have been suggested.

What I'm saying is that results like this make more research imperative and that I don't agree that the whole idea can be written off quite as quickly as you originally seemed to want too.

 

[Veneficus]

What I'm saying is that results like this make more research imperative and that I don't agree that the whole idea can be written off quite as quickly as you originally seemed to want too.

I agree more studies are needed, particularly in trauma care, including prehospital.

I am quick to write it off because of a number of reasons. Not least of which is getting ethical approval for more studies.

I think you would have to compare number needed to treat and number needed to harm.

Are there specific populations that are predisposed to the potential complication of acute tubular necrosis?

What were the length of ICU stays and/or complications for both groups? (I don't have easy access to the study, if you have a PDF or free link that would be great )

Were the patients who were in the decreased mortlity group amiable to medical therapy of hemorrhage control based on specific injury?

Were they in a group (like low grade liver lacerations) that don't always require surgery or pharm therapy anyway?

How many of these patients went straight to OR vs. having some guy in A&E try to normalize vital signs first?

Another reason I am quick to write this off is the reason I compare in to Factor VII, all of these drugs are manipulating coagulation and degradation cascades and that is a bold move in the street.

You are a smart guy and I am sure you have looked at those cascades in a book somewhere and thought "Who the hell needs to remember that and why?" (I admit I have done that at one point too)

But then I learned why.

If you look at the definition of resuscitation, it is to restore homeostasis. Now even in medical texts, in order to make this very complex issue managable, it is often reduced to 4 or 5 (depending on the book) major components.

But it is just that, a simplification.

Now if a patient needs this and it works, that is great, and we should give it to those people without qualification.

However, how many people are you going to give it to that doesn't matter?
Or even harms?

In that population, how many is it going to add one more variable to test and balance in the ICU?

Sometime during my research and writing my dissertation, I realized that in resuscitation of shock, the most successful treatments are not the treatment itself, but the precision in which it is used. I coined the term "surgical resuscitation" to describe it.

Giving chrystaloid to everone was not a good idea. large amounts even worse.
Giving high flow oxygen to everyone is not a good idea. (just had an interesting discussion on that with a Specialist in pulmonary inflammatory disease today by the way)

I am extraordinarily skeptical regarding the administration of any treatment prophylactically because it is time sensitive in the population it works in, especially if it is a narrow population.

I am also more likely to consider the opinion of a respected practicioner than a study in this topic because I know first hand how watered down methodologies have to be to get ethical approval to deviate from the standards in a random population of shock patients. Which really reduces the power of any study regarding.

We know blood works in hemorrhaging patients. But modern methods and logistics make it impractical for prehospital care.

I submit for consideration: Rather than time, money, and effort looking for the magic therapy to circumvent blood, maybe we should look at improving the logistics and administration of its use prehospital?

I understand that somebody will feel compelled to talk about the dangers of paramedics initiating blood in the field, but honestly, we are talking about paramedics altering clotting cascades in the field.

Altering molecular cascades in a clinically apparent way?

In the ivory tower, ok. On the street?

I remain unconvinced.

 

[systemet]

Another one here, using EMT-I's, just popped up in my email pre-alerts.

--------





DIAGNOSTIC ACCURACY OF FOCUSED ASSESSMENT WITH SONOGRAPHY
FOR TRAUMA (FAST) EXAMINATIONS PERFORMED BY EMERGENCY MEDICAL
TECHNICIANS
Chu Hyun Kim, MD, Sang Do Shin, MD, PhD, Kyoung Jun Song, MD, Chang Bae Park, MD
ABSTRACT
Objective. We aimed to assess the diagnostic accuracy of focused
assessment with sonography for trauma (FAST) examinations
when used by emergency medical technicians
(EMTs) to detect the presence of free abdominal fluid.
Methods. Six level 1 EMTs (similar to intermediate EMTs in
the United States) who worked at a tertiary emergency department
in Korea underwent an educational program consisting
of two one-hour didactic lectures that included the
principles of ultrasonography, the anatomy of the abdomen,
and two hours of hands-on practice. After this educational
session, the EMTs performed FAST examinations on a convenience
sample of patients from July 1 to October 5, 2009.
These patients also received an abdominal computed tomography
(CT) scan regardless of their chief complaints. The CT
findings served as the definitive standard and were interpreted
routinely and independently by emergency radiologists
whowere blinded to the study protocol. In addition, the
EMTs were blinded to the CT findings. A positive CT finding
was defined as the presence of free fluid, as interpreted by
the radiologist. The sensitivity, specificity, predictive values,
and their 95% confidence intervals (CIs) were calculated. Informed
consent was obtained from all participating patients.
Results. Among the 1,060 eligible patients with abdominal
CT scans, 403 patients were asked to participate in the study,
and 240 patients agreed. Of these 240 patients, 80 (33.3%) had
results showing the presence of free fluid. Fourteen patients
had a significant amount of peritoneal cavity fluid, 15 had
a moderate amount of peritoneal cavity fluid, and 51 had a
minimal amount of peritoneal cavity fluid. Compared with
the CT findings, the diagnostic performance of the FAST examination
had a sensitivity of 61.3% (95% CI, 50.3%–71.2%),
specificity of 96.3% (95% CI, 92.1%–98.3%), positive predic-
Received March 22, 2011, from the Department of Emergency
Medicine, Inje University College of Medicine (CHK), Seoul, Republic
of Korea; the Department of EmergencyMedicine, Seoul National
University College of Medicine (SDS, CBP), Seoul, Republic of Korea;
and the Department of Emergency Medicine, Seoul National
University Boramae Medical Center (KJS), Seoul, Republic of Korea.
Revision received November 18, 2011; accepted for publication December
9, 2011.
The authors report no conflicts of interest.
Address correspondence and reprint requests to: Sang Do Shin,MD,
PhD, Seoul National University College of Medicine, Emergency
Medicine, 101 Daehang-Ro, Chongno-Gu, Seoul, 110–744 Republic
of Korea. E-mail: shinsangdo@medimail.co.kr
doi: 10.3109/10903127.2012.664242
tive value of 89.1% (95% CI, 77.0%–95.4%), and negative predictive
value of 83.2% (95% CI, 76.9%–88.2%). For a significant
or moderate amount of peritoneal cavity fluid, the sensitivity
was considerably higher (86.2%). Conclusion. EMTs in
Korea showed a high diagnostic performance that was comparable
to that of surgeons and physicians when detecting
peritoneal cavity free fluid in a Korean emergency department
setting. The validity of FAST examinations in prehospital
care situations should be investigated further. Key words:
sonography; emergency medical technician; accuracy; FAST
PREHOSPITAL EMERGENCY CARE 2012;16:400–406

 

[systemet]

Heres my take on prehospital ultrasound, as regards trauma. Tell me what you are going to do differently.

For the obviously sick major trauma patient:

* It might result in an increase in the identification of pneumothoraces. This may or may not be a good thing.

* It might allow EMS to prenotify the hospital of a cardiac tamponade, or possibly perform pericardialcentesis in the field.

* It might put the ER slightly ahead of the game if there is intraabdominal hemorrhage.

If you have a negative FAST exam, with a serious mechanism, are you not going to go to the trauma center? No, you should still take the patient there. If you have a positive fast what are you going to do? Go to the same place.

Perhaps there's a cohort of patients that are alert, appear hemodynamically stable, but are FAST-positive? Maybe these patients would be able to get more timely care? Perhaps in a few atypical cases, a patient who might have been sent to a non-trauma center might be triaged "up"?

If your region has a cadillac trauma system, where anyone with the slightest hint of injury gets seen rapidly upon arrival by a trauma team, I would expect the incremental benefit to be small. But we probably won't know this until someone studies it, right?

I don't see trusting my medics enough to take the patient directly to the operating room based on their FAST, especially since the patient is usually going to get a chest x-ray, get striped etc before going to the OR.

I'm not a physician, and you are, so let's start by accepting that you know a lot more about medicine than I do. While this might seem rude (it's not intended that way), the question that probably should be asked is "Why don't you trust them?". The specificity in some of these early studies seems pretty good, the PPV isn't terrible. Do you not trust them because you know from the data that there's going to be an unacceptable rate of false-activations? Or is this a nonscientific bias?

I've heard the opinion expressed before that the job of a good trauma team is to get the patient out of the ER as quickly as possible. If you have EMS arriving telling you the patient is FAST-positive, could this help you achieve that goal quicker? Is it going to improve patient care?

Furthermore, considering that there is a push to not start IVs on scene because they may increase scene time, I think ultrasound would be even worse in delaying transport, and distracting people from things they should be doing (splinting, controlling bleeding etc)

I agree that that's a risk, and would need to be prevented / mitigated by a decent educational and QI program.

Regarding IV initiation on scene on major trauma -- I would hope that it's been standard practice in most regions to do this en route for decades. There's obviously going to be a balance when you have an isolated extremity injury judged as low risk for major trauma that might benefit from IV analgesia.

I would hope that no one is silly enough to be ignoring external arterial hemorrhage to get a view of Morrison's pouch.

I'd also point out that some of the biggest cheerleaders of prehospital ultrasound are the companies that make the expensive machines, and those with an financial stake.

While we should view any product information with a healthy degree of suspicion, the fact that a product vendor is trying to sell a product aggressively isn't evidence against its potential usefulness, or lack thereof.

For me it comes down to NNT, or number needed to treat. How many patients do you have to ultrasound to save a life? In the ER I'd say it's less than 5% of my trauma patients who have a positive ultrasound finding, and even less than that who it changes management.

This is a reasonable point. But there's also a question here of whether we're doing healthcare economics, in which case we might conclude that the cost is excessive to catch a low-incidence condition, or whether there might be a tangible treatment benefit that outweighs any false-positives or potential problems that come with ultrasound.

I'm pretty good at ultrasound, but I've had probably 60-70 hours of formal ultrasound training, in addition to the 500 or so ultrasounds I've done. I think if prehospital ultrasound gets rolled out a lot of places are going to have a 1 hour class and turn people loose. I think for certain groups, like critical care medics and flight nurses it may be useful. But I'm not sure it's ready for prime time.

I think you're probably right, although the benefit of ultrasound might be greater if it was expanded to a nontrauma population. However, this might present additional problems.

It's hard with new technology because it's not possible to easily anticipate how it will develop in the future. Not so long ago, a 12-lead was luxury piece of equipment on most ALS rigs, hospitals rarely had the equipment to receive telemetry, often discarded paramedic ECGs, there was no such thing as prehospital fibrinolysis, ER bypass to PCI, and most paramedics couldn't read an ECG well. Over time it emerged that the technology could be used successfully to speed up reperfusion.

Only time will tell whether prehospital ultrasound is a useful tool or a frivolous novelty.

 

[the_negro_puppy]

We have several trauma Doctor here on fly cars that carry FAST scan equipment. The often respond to trauma calls and perform FAST scans in the field. If positive they relay to the receiving hospital. I have witnessed or heard about long scene delays waiting for the Doc to come FAST scan though :unsure:

 

[jjesusfreak01]

Furthermore, considering that there is a push to not start IVs on scene because they may increase scene time, I think ultrasound would be even worse in delaying transport, and distracting people from things they should be doing (splinting, controlling bleeding etc)

My system allows 10 minutes max onscene for traumas. You start your IVs in the truck, you complete the assessment in the truck, you haul *** to the hospital. Even if they introduced prehospital ultrasound here, there is no way its going to be done onscene or before stabilizing the patient.

 

[Dwindlin]

My system allows 10 minutes max onscene for traumas. You start your IVs in the truck, you complete the assessment in the truck, you haul *** to the hospital. Even if they introduced prehospital ultrasound here, there is no way its going to be done onscene or before stabilizing the patient.

Then don't bother (not saying I disagree with how you handle traumas btw). U/S is difficult with a completely still patient. Trying to get a clean picture bouncing down the road is a complete waste of time.