FAST and undertriage

Excerpt

We read with great interest the article by Giannakopoulos et al., studying the cancelations of mobile medical team (MMT) dispatches in the Netherlands [1]. Four hundred and sixty seven dispatches of the MMT were reviewed, and 92% of cases were trauma injuries (with 384 blunt trauma). Even if the rate of prehospital undertriage was said to be acceptable, to decrease this rate must be a priority. Hence, we want to highlight the role of the focused assessment with sonography in trauma (FAST), especially in blunt trauma (FAST is the gold standard early screening method for blunt abdominal trauma). FAST offers a reliable tool not only for trauma treatment but also during triage procedure, that can be used successfully even during the flight in a rotary wing aircraft, which is mainly used by MMT. Prehospital FAST has now become an extension of the physical examination. Within the “golden hour,” it helps to detect life-threatening injuries, and allows appropriate triage of the patients. In 1997, an international consensus conference committee defined the acronym FAST to describe the application of ultrasound in the initial evaluation of the trauma patients [2]. The development of hand-held ultrasound devices facilitated the introduction of FAST into prehospital trauma management, and caused significant changes in the triage of multiply injured patients. Of course, there are several factors that should be considered when using FAST. It should be used as an initial screening method to identify patients at risk. It does not provide a definitive diagnosis. We should not waste time by trying to identify organ lesions. Adequate training and experience is crucial for accurate ultrasound examination, as the quality of the evaluation is highly user dependent and must not delay patient management. Because of its moderate sensitivity, a negative FAST result with strong clinical suspicion demands further evaluation. Nevertheless, Walcher et al. showed that the average in the field FAST exam was complete in less than 3 min when the results were negative, whereas positive findings were detected within seconds [3]. FAST was found to be 93% sensitive and 99% specific compared with diagnoses made in the destination emergency department. Melniker et al. published the First Sonography Outcomes Assessment Program Trial, a randomized, controlled clinical investigation. The authors proved that ultrasound reduced the time from emergency department presentation to operative care (57 vs 166 min) [4]. Moreover, ultrasound completed in the austere environment of prehospital helicopter transport (and performed by an experienced physician) was 90% sensitive and 96% specific for detecting hemoperitoneum, pleural fluid, pneumothorax and pericardial fluid [5]. Based on their great experience, we would like to know the authors’ thoughts concerning the implementation of FAST to reduce undertriage. …