Journal of Veterinary Emergency and Critical Care () 2018, pp 1–7

Original Study doi: 10.1111/vec.12732

Evaluation of the agreement between focused

assessment with sonography for trauma
(AFAST/TFAST) and computed tomography
in dogs and cats with recent trauma
Andrea M. Walters, DVM, MS, DACVECC; Mauria A. O’Brien, DVM, DACVECC;
Laura E. Selmic, BVetMed (Hons), MRCVS, DACVS; Sue Hartman, RT(R)CT;
Maureen McMichael, DVM, DACVECC and Robert T. O’Brien, DVM, MS, DACVR

Abstract

Objective – To determine the agreement between focused assessment with sonography for trauma (FAST)
exams and computed tomography (CT) for the detection of pleural and peritoneal fluid and pneumothorax in
animals that have sustained recent trauma.
Design – Prospective study.
Setting – University Teaching Hospital.
Animals – Thirteen dogs and 2 cats were enrolled into the study, with 10 having sustained blunt force trauma
and 5 penetrating trauma.
Interventions – Abdominal FAST (AFAST) and thoracic FAST (TFAST) exams were performed by emergency
room (ER) clinician or house officers and radiology house officers (radiology). TFAST evaluated for the presence
of pneumothorax and pleural effusion, and AFAST evaluated for the presence of peritoneal effusion. A minimally
sedated, full-body CT exam was performed on each patient and interpreted by a board-certified radiologist.
The exams were performed in the same order for all patients: ER FAST, followed by radiology FAST, followed
by CT, and operators were blinded to the results of the other exams. A kappa statistic was calculated to assess
for agreement between the FAST exams and CT.
Measurements and Main Results – The median time to perform all 3 exams was 55 minutes (range 30–150 min).
There was moderate to excellent agreement between AFAST and CT for detection of free peritoneal fluid (ER
K = 0.82; radiology K = 0.53), fair to moderate agreement between TFAST and CT for detection of pleural
free fluid (ER K = 0.53; radiology K = 0.36), and poor agreement between TFAST and CT for detection of
pneumothorax (ER K = –0.06; radiology K = –0.12).
Conclusions – FAST exams reliably identify the presence of free fluid in the peritoneal and pleural cavities;
however, TFAST is not a reliable method to diagnose pneumothorax in dogs and cats following trauma.
(J Vet Emerg Crit Care 2018; (): 1–7) doi: 10.1111/vec.12732

Keywords: effusion, glide sign, multidetector, ultrasound

Abbreviations Introduction
AFAST abdominal focused assessment with sonogra- Severe trauma, caused by blunt force or penetrating in-
phy for trauma jury, is a common cause of morbidity in veterinary pa-
CT computed tomography tients and often results in life-threatening damage to
ER emergency room multiple body cavities or regions.1 In animals, blunt
TFAST thoracic focused assessment with sonography force trauma is associated with a 10% mortality rate, and
for trauma is most frequently caused by motor vehicular trauma
(MVT) or falls from a height.1–3 Penetrating trauma is
associated with a mortality rate of 13% and can be a
The authors report no conflicts of interest.
Address correspondence and reprint requests to
result of bite wounds, gunshot wounds, or penetrat-
Mauria A. O’Brien, Department of Veterinary Clinical Medicine, University ing objects.4 The body region most affected by trauma
of Illinois at Urbana-Champaign, 1008 West Hazelwood Dr, Urbana, IL 61802, is the thorax,1,5 resulting in pulmonary contusions,
USA.
Email: maobrien@illinois.edu pneumothorax, and hemothorax.3,6 Abdominal injury is
Submitted March 25, 2016; Accepted November 15, 2016. also common in veterinary patients following trauma,1


C Veterinary Emergency and Critical Care Society 2018 1
A.M. Walters et al.
and can result in organ damage7 and intra-abdominal
hemorrhage.8,9
In human medicine, computed tomography (CT) is
the gold standard for diagnosis of trauma-related in-
juries and provides high spatial resolution, fast scan
times, and the ability to produce 3-dimensional image
reconstructions.10,11 Because CT scans are expensive and
expose the patient to high levels of radiation,12 increased
attention has been focused on the use of ultrasound in
the emergency room (ER) as the primary imaging modal-
ity for the assessment of human victims of trauma.11,13–15
The most common ultrasound protocol for assessment of
trauma victims is the focused assessment with sonogra-
phy for trauma (FAST) scan. FAST scan protocols have
been developed for evaluation of the thorax (which eval-
uate the pleural space for both pneumothorax and effu-
sion) and the abdomen (which evaluate for the pres-
ence of peritoneal effusion). In people, these techniques
are associated with a 90–98.1% sensitivity16,17 and 99%
specificity16 for diagnosing intracavitary free fluid and
a sensitivity of 92–100% and specificity of 94–99.4% for
the detection of pneumothorax.15,18
FAST scans have also been evaluated in small and
large animal veterinary patients following trauma.5,8,9,19
Boysen et al9 prospectively evaluated an abdomi-
nal FAST scan (AFAST) in traumatized patients and
Lisciandro et al8 evaluated a protocol and scoring system
to identify free fluid in the abdomen. Lisciandro et al5
also described the use of a thoracic FAST scan (TFAST)
to identify pneumothorax (sensitivity 78.1%, specificity
93.0% compared to thoracic radiographs) and pleural ef-
fusion.
Although the use of FAST scans in veterinary patients
following trauma is increasing, there have been no stud-
ies comparing the diagnostic performance of FAST scans
to full-body CT in dogs and cats having recently experi-
enced trauma. The goal of our study was to evaluate the
sensitivity and specificity of FAST scans as tools for the
diagnosis of pneumothorax, pleural effusion, and peri-
toneal effusion in the ER. Our hypothesis was that there
would be good agreement between FAST scans and CT
in the identification of fluid in the peritoneal cavity, and
fluid and air in the pleural space.
Materials and Methods
Patients that presented to the ER between April 1 and
August 31, 2014 and had undergone either blunt (eg,
motor vehicle trauma or falls) or penetrating trauma
(eg, bite wounds) were eligible for inclusion. Each pa-
tient underwent imaging in the following order: FAST
scans in ER, FAST scans in radiology, and full-body
CT scan. The study was approved by the Institutional
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C Veterinary Emergency and Critical Care Society 2018, doi: 10.1111/vec.12732
Animal Care and Use Committee and written owner con-
sent was provided for all animals before enrolled in the
study.
The following parameters were recorded for all pa-
tients upon admission to the ER: heart rate, respiratory
rate, rectal temperature, mucous membrane color and
capillary refill time, pulse quality, blood pressure, and
hemoglobin–oxygen saturation (via pulse oximetry). In
addition, a 3-minute ECG was evaluated. The primary
ER clinician was required to complete a separate check-
list, which included questions about history and physi-
cal examination. Additional monitoring, diagnostic, and
therapeutic procedures were performed at the discretion
of the ER clinician and in the order that was medically
appropriate for the clinical status of the patient.
Prior to initiation of the study, all ER clinicians (interns,
residents, and attending board-certified emergency and
critical care specialists) were required to complete a min-
imum of 1 hour of didactic training and a hands-session
on FAST scan procedures given by a board-certified vet-
erinary radiologist (RB). In addition to the didactic por-
tion, each ER clinician was required to complete a su-
pervised (by RB) AFAST and TFAST scan on a normal
dog. The FAST scans in the ER were performed using a
C611 micro convex 4–10 mHz probe.a The ER FAST scans
were performed by the primary receiving clinician, who
may have been an emergency/critical care resident (2),
medicine/surgery intern (2), emergency/critical care in-
tern (1), or a board-certified emergency and critical care
specialist (1). The radiology FAST scans were performed
by second or third year radiology residents (3), who were
blinded to the results of the initial FAST scan and under
direct supervision of a board-certified radiologist (while
the scans were occurring). Each patient had 1 ER clinician
who performed both the AFAST and TFAST scans, and
then 1 radiology resident performed both the AFAST and
TFAST scans. The scans performed by the radiology resi-
dents were performed using either an 11MC4 curvilinear
high frequency convex 4.2–10.2 mHz probeb or a CA123
micro convex 3–9 mHz probe.c All attempts to minimize
the time between the 2 FAST scans were taken, but the
clinical needs of the patient were the highest priority.
Patient stabilization was allowed at any point during
the imaging protocol, including, but not limited to, ad-
ministration of intravenous fluids and medications, tho-
racocentesis, and abdominocentesis. Any clinician per-
forming the scan was required to fill out a standardized
data sheet to record their FAST scan findings and give
information about the study (ie, time, date, and samples
taken).
FAST scan protocols for both the abdomen and tho-
rax were based on previously described patterns,5,8 and
patients were evaluated for the presence of pneumotho-
rax, pleural effusion, pericardial effusion, and peritoneal

effusion. Because right lateral recumbency is routine for
the acquisition of ECG data and ideal for ultrasono-
graphic imaging of both the thorax5 and abdomen,8 dogs
were initially placed in right lateral recumbency unless
injuries prevented this positioning. Four points in the ab-
domen were examined for peritoneal effusion9 : (1) cau-
dal to the xyphoid to assess between the liver lobes and
diaphragm, (2) nondependent lateral flank, (3) caudally
on midline adjacent to the bladder, and (4) dependent
lateral flank. When scanning for effusion, the probe was
held parallel to the long-axis of the body (in a cranial-
caudal direction) and was fanned back and forth. The
probe was then rotated 90 degrees and the process was
repeated. Two points were evaluated on each side of
the thorax: (1) tallest nondependent chest wall bilater-
ally to identify pneumothorax, and (2) cranial pleural
space bilaterally to look for pleural and pericardial effu-
sion. For identification of pneumothorax, the probe was
held stationary parallel to the long-axis of the body (in a
cranial-caudal direction). Pneumothorax was defined by
the absence of the “slide” or “glide sign,” which is cre-
ated when the visceral and parietal pleura move against
each other. Effusion was defined by the identification
of hypo- to anechoic fluid in the pleural space or peri-
toneum. The AFAST scans and 3 out of 4 of the TFAST
scan sites (cranial pleural space bilaterally and the left
nondependent chest wall) were performed with the an-
imal lying in right lateral recumbency. Then, depending
on the comfort and stability of the patient, the animals
were shifted into sternal or left lateral recumbency and
the right hemithorax was imaged.
For each of the scans, the patients were sedated as
minimally as necessary with analgesics or small amounts
of injectable anesthetics. General anesthesia was not re-
quired for any patient and none of the patients were
intubated. Hair was not clipped for any of the FAST
scans, and 70% isopropyl alcohol was used to enhance
the probe contact surface for most cases instead of ul-
trasound gel, except where the use of alcohol would be
harmful or irritating to the patient (eg, extensive dermal
abrasions, need for defibrillation). Given that the pri-
mary goal of the study was to determine the presence
or absence of fluid and air, quantification of the size or
severity of effusion or pneumothorax and identification
of the type of effusion was not performed.
Following the FAST scans, survey and late venous
phase full body CT (from nose to tail) was performed
using a 16 multislice spiral CT.d Patients were mini-
mally manipulated from their preferred position of rest
to minimize pain and stress, resulting in variable po-
sitioning for the CT imaging. The CTs were performed
using a plexiglass positioning unite for small patients
or Velcro straps to restrain larger patients. The parame-
ters for the CT were as follows: 0.5 second tube rotation,

C Veterinary Emergency and Critical Care Society 2018, doi: 10.1111/vec.12732
Trauma: FAST scan versus CT
0.9 pitch, 120 kvp, 250–320 mA (depending on patient
size), and a detailed algorithm. Transverse slices (2.5-
mm or 5-mm thick) were acquired and reconstructed into
0.625-mm slices for reformatted transverse, sagittal and
dorsal plane images, and 3-dimensional images. Intra-
venous contrast agentf was injected at a dose of 0.45
mL/kg and at a rate of 2 mL/sec. A maximum of 60 mL
of contrast agent was administered. The CT scans were
interpreted by a board-certified radiologist (RTO) who
was blinded to the results of the FAST scans.
Statistical Methods
Descriptive statistics were calculated for signalment and
presentation of variables. Categorical variables were
reported as frequency and percentages. Continuous
variables were tested for normality using histograms,
skewness, kurtosis, or the Shapiro–Wilk test. If normally
distributed, the mean and standard deviation (SD) was
reported or if nonnormally distributed the median and
range (minimum–maximum value) were reported. The
Kappa statistic was calculated to assess agreement be-
tween FAST scans and CT of each body part. A Kappa
statistic greater than or equal to 0.81 was deemed to have
excellent correlation, between 0.61 and 0.80 was charac-
terized as good correlation, between 0.41 and 0.60 was
moderate correlation, and < 0.20 was deemed to indicate
poor correlation.
Results
Thirteen dogs and 2 cats presenting to the ER follow-
ing trauma were enrolled. The dog breeds represented
in the study population consisted of mixed breed (n = 4),
Siberian Husky (n = 2), and 1 of each of Miniature Pin-
scher, Irish Setter, Labrador Retriever, Labradoodle, Rot-
tweiler, Shih Tzu, and Maltese dogs. Both cats were do-
mestic short hair cats. Combining both cats and dogs,
the population consisted of 8 males (4 neutered) and 7
females (4 neutered and 1 of unknown neuter status).
The mean (±SD) age of enrolled dogs and cats was 5.2 ±
4.2 years old, and the mean (±SD) weight was 18.8 ±
13.2 kg. Nine animals (60%) presented directly to the ER,
and 6 animals (40%) were referred to the ER after initial
assessment at their referring veterinarian. Nine animals
(60%) had injuries to ࣙ2 body cavities, and 6 animals
(40%) only had injury to 1 body cavity. There were 10
animals (67%) that had suffered blunt force trauma (9
motor vehicular trauma and 1 fall from a height) and 5
animals (33%) that had suffered penetrating trauma due
to bite wounds.
The time of trauma was known in 14 of the animals,
and the remaining 1 was estimated based on the owners
estimate as to the earliest possible time it could have
3
A.M. Walters et al.
Table 1: Summary of injuries detected by CT in 15 animals (13
dogs and 2 cats) following blunt or penetrating trauma
Musculoskeletal Vertebral fracture/luxation (n = 5; 31%)
(n = 12; 80%) Limb fractures (n = 3; 20%)
Sacral fracture (n = 2; 13%)
Subcutaneous emphysema (n = 2; 13%)
Soft tissue wounds (n = 1; 6%)
Thoracic (n = 8; 53%) Pneumothorax (n = 6; 38%)
Pleural effusion (n = 6; 38%)
Pulmonary contusions (n = 3; 19%)
Pneumomediastinum (n = 3; 19%)
Rib fractures (n = 2; 13%)
Traumatic bulla (n = 2; 13%)
Lung lobe herniation (n = 1; 6%)
Abdomen (n = 4; 27%) Peritoneal effusion (n = 4; 27%)
Hematoma within organs (n = 1; 7%)
Intestinal herniation (n = 1; 6%)
Head and neck Traumatic brain injury (n = 3; 20%)
(n = 3; 20%) Ruptured globe (n = 1; 6%)
Laryngeal tear (n = 1; 6%)
Nasal bone fracture (n = 1; 6%)
CT, computed tomography.
happened. The median (range) time from trauma to
presentation to the ER was 1.5 hours (0.3–72.0 h) and
the median time to perform all 3 scans (from ER FAST
through CT) was 55.0 minutes (30–150 min). The median
time from presentation to the hospital to the start of the
ER FAST scans was 54.0 minutes (0.0–80.0 min), from
the completion of the ER FAST scan to the start of the
radiology FAST scan was 30.0 minutes (10.0–130.0 min),
and from the completion of the radiology FAST scan to
start of CT scan was 15.0 minutes (5.0–85.0 min). Due
to injuries, pain, or stress, 5 patients only had 1 side
imaged to evaluate for the presence of pneumothorax,
2 patients only had 1 side imaged to detect the presence
of pleural effusion, and 1 patient did not have the
pleural space imaged at all (and was not included in the
statistical analysis for TFAST effusion).
A summary of the injuries identified by evaluation of
the CT scans is presented in Table 1. The results of the
Kappa analyses are summarized in Table 2. AFAST had
moderate (radiology) to excellent (ER) correlation to CT
for detection of peritoneal effusion. All 3 of the animals
with peritoneal effusion detected on ER AFAST scan also
had peritoneal effusion identified on the CT scan. The ra-
diology AFAST scan detected 5 patients with peritoneal
effusion, however only 3 of these had effusion identified
by analysis of the CT scan. In both cases, analysis of the
CT scan suggested the presence of peritoneal effusion
in 1 animal each in which the ER and radiology AFAST
exams had not detected fluid.
TFAST had fair (radiology) to moderate (ER) correla-
tion to CT for the detection of pleural effusion. Of the 3
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patients with pleural effusion identified by ER TFAST,
CT confirmed the presence of pleural effusion in all 3
patients, but 3 additional patients with pleural effusion
identified by CT scan did not have fluid identified on the
ER TFAST scan. Of the 2 patients with pleural effusion
detected by the radiology TFAST scan, CT confirmed
both cases, but found 4 additional patients with pleural
effusion.
TFAST had poor (radiology and ER) correlation to CT
for detection of pneumothorax. Of the 3 patients that had
a pneumothorax identified on the ER TFAST scan, only
1 was confirmed by CT, and CT identified 5 additional
patients with pneumothorax that was not detected by the
ER TFAST scan. Only 1 pneumothorax was identified on
radiology TFAST, and this was not identified by analysis
of the CT scan of that particular animal.
Thirteen animals received analgesic medications in the
ER prior to their FAST scans, all of which consisted of
intravenous intermittent boluses or constant rate infu-
sions of full opioid agonists. In addition, 1 animal was
given a bolus of lidocaine prior to the ER FAST scans, and
another animal required an IV bolus of propofol to pro-
vide sedation during the radiology FAST scans. All ani-
mals received sedation prior to the CT scan. Intravenous
sedative protocols included only full opioid agonistsg
(n = 8), full opioid agonist and a benzodiazepineh (n = 2),
full opioid agonist and an alpha-2 receptor agonist drugi
(n = 2), full opioid agonist and intermittent IV boluses
of propofolj (n = 2), and full opioid agonist, a benzodi-
azepine, and intermittent IV boluses of propofol (n = 1).
Additional IV medications provided in the ER prior to
imaging included lactated Ringer’s solutionk (n = 9),
mannitoll (n = 3), ampicillin and sublactamm (n = 2),
and VetStarchn (n = 1).
Of the cases assessed by ER clinicians, 3 were as-
sessed by a medicine/surgery intern, 1 by an emer-
gency/critical care specialty intern, 7 by an emer-
gency/critical care resident, and 4 by a board-certified
emergency/critical care specialist.
Discussion
AFAST had the highest agreement with CT for diagnosis
of peritoneal effusion, followed by TFAST to diagnose
pleural effusion. However, TFAST did not prove to be
a reliable diagnostic tool to identify pneumothorax in
trauma patients, when compared to CT.
AFAST performed in the ER had excellent agreement
with CT for diagnosis of free peritoneal fluid. AFAST
scans have been described as an accurate and easily
learned diagnostic technique for identification of peri-
toneal effusion in veterinary species caused by leakage
of urine or bile, vascular injury, or rupture of an abdom-
inal viscus.8,9,20 The presence of peritoneal effusion in

Table 2: Summary of agreement between FAST scans and CT performed in 15 animals (13 dogs and 2 cats) following blunt or
penetrating trauma. FAST scans were performed either by emergency room clinicians (ER department) or by radiology residents
(radiology department), and kappa scores were calculated assuming the results of the CT as a gold diagnostic standard
Imaging modality Department
AFAST (presence of peritoneal effusion) ER
Radiology
TFAST (presence of pleural effusion) ER
Radiology
TFAST (presence of pneumothorax) ER
Radiology
FAST, focused assessment with sonography for trauma; AFAST, abdominal focused assessment with sonography for trauma; TFAST, thoracic focused
assessment with sonography for trauma; CT, computed tomography; ER, emergency room.
dogs and cats following trauma has been linked to de-
creased survival and increased time to discharge from
the hospital.8 Progressive peritoneal effusion may indi-
cate ongoing hemorrhage.8,21 Early identification of free
abdominal fluid is imperative to determine the extent
of injuries, monitor the animal’s progression, and al-
low for initiation of specific treatment. Up to 20% of
dogs with hemoperitoneum require a blood transfusion9
and 5% will require emergency surgery to control
hemorrhage.1
The agreement between radiology AFAST scans and
CT was lower than that of the ER AFAST scans and CT.
Two animals had peritoneal effusion identified by radi-
ology AFAST only that was not seen on CT. Ultrasound
may be a more sensitive imaging modality than CT for
detection of small amounts of fluid, particularly in the
hands of skilled clinicians. Given the method by which
kappa is calculated, these cases were interpreted as “false
positives” and resulted in a decreased kappa value, al-
though they may have instead indicated a failure of the
CT scan to detect the presence of this fluid.
Our results showed fair to moderate agreement be-
tween TFAST and CT for the detection of pleural effu-
sion. Human studies have suggested that TFAST is an
easily learned, minimally user dependent,22 and accu-
rate diagnostic modality for the detection of hemothorax
after trauma, with a sensitivity of 92% and specificity of
100%.23 In our study, the difference between AFAST and
TFAST in the ability to identify fluid in the abdomen
or thorax may indicate that thoracic ultrasound is tech-
nically more challenging than abdominal ultrasound in
veterinary patients, or that the sites used may not be ideal
for fluid detection in all patients. The diaphragmatico-
hepatic (or subxyphoid) window is an additional view
that has been described for detection of pleural and peri-
cardial effusion in veterinary patients.24 Future prospec-
tive studies are needed to evaluate the utility of adding
this additional view to TFAST for identification of pleu-
ral effusion.

C Veterinary Emergency and Critical Care Society 2018, doi: 10.1111/vec.12732
Trauma: FAST scan versus CT
FAST negative FAST positive
CT positive CT negative Kappa
1 0 0.82
1 2 0.53
3 0 0.53
4 0 0.36
5 2 −0.06
6 1 −0.12
In contrast to a previous report,5 this study did not
find TFAST to be a reliable diagnostic tool for the iden-
tification of pneumothorax in veterinary patients. There
are several potential reasons for this discrepancy. This
study compared TFAST to CT, while the previous study
compared TFAST to thoracic radiographs. In human pa-
tients, radiographs have been reported to miss 11–64%
of pneumothorax diagnoses compared to CT.15,18,25,26 A
veterinary study has suggested that thoracic radiographs
obtained using horizontal beam views improved the sen-
sitivity of radiographs for detection of pneumothorax,27
and these views were not evaluated in the previous
TFAST study.5 The TFAST scan is also a more tech-
nically demanding procedure compared to AFAST in
both human13,28–31 and small and large animal veterinary
medicine,5,19 with a reported sensitivity of 45.4% for less
experienced users compared to 95.2% for an experienced
user in veterinary medicine.5 It is possible that the train-
ing program implemented for the current study was not
sufficient to provide enough clinical experience to result
in successful detection of all cases of pneumothorax.
Although it has been reported that TFAST has a high
sensitivity for detection of pneumothorax in human pa-
tients following blunt force trauma,32 a previous veteri-
nary report concluded that the accuracy of TFAST for the
diagnosis of pneumothorax was higher in patients with
penetrating trauma compared to blunt force trauma,
with sensitivities of 93.3% and 64.7%, respectively.5 It has
also been reported that a small pneumothorax may be
easily missed on ultrasound,33 although without quan-
tifying the size of pneumothorax, we are unable to say
if this played a role in our study. Although thoracic ul-
trasound is a sensitive and specific diagnostic modality
for pneumothorax in people,11 the results of the current
study may call into question the utility of TFAST for the
diagnosis of pneumothorax in veterinary patients.
Although FAST scans are arguably more sensitive for
detection of small amounts of intracavitary free fluid,
CT is more sensitive for diagnosis of pneumothorax. CT
5
A.M. Walters et al.
eliminates structural superimposition, is less dependent
on user experience and patient characteristics, and pro-
vides more complete images of all aspects of a partic-
ular body cavity. In addition, Hounsfield units can be
used to provide objective measurements to differentiate
fluid, air, bone, and a variety of soft tissues. In the hu-
man ER, full body CT scan results have been shown to
change treatment protocols in 19%34 and 32%35 of cases,
and are significantly associated with decreased mortal-
ity, as the CT is able to identify more occult injuries that
may require early interventions.12 New CT technology
has significantly decreased the time needed to perform
scans, and an average awake or minimally sedated full-
body CT in the authors’ hospital takes only minutes. It
is also important to emphasize that most of the animals
were adequately sedated during the CT scan with a neu-
roleptanalgesic protocol. None of the animals required
intubation or inhalant anesthesia, and no complications
from sedation were noted in any of the animals. There
are several other reports of the use of CT to produce good
quality images in awake or mildly sedated animals, with
minimal motion artifact.36–39
The limitations of this study pertain mostly to un-
certainties of clinical cases and small sample size. In
this study, the animals’ safety and treatment needs were
placed above strict adherence to the study protocol. For
a variety of reasons including stress, pain, vertebral frac-
tures, and respiratory distress, many of the patients re-
quired changes in position between the 2 fast scans, so
many were not in the same position for all of the scans.
Therefore, a comparison of the position of fluid within
the chest and abdomen between the different imaging
modalities could not be performed. Also, 2 therapeu-
tic thoracocentesis procedures (to treat pneumothorax)
were performed prior to the FAST scans, with one being
performed at the ER, and another at the referring veteri-
nary clinic prior to presentation to the ER. In addition,
1 animal had a diagnostic thoracocentesis performed af-
ter the ER FAST scan was completed to try and obtain
a sample of pleural effusion; however, no sample was
obtained by this procedure. Although this may have in-
troduced bias to the ER TFAST scans, this would not
have affected the blinded radiology TFAST scans as the
radiology residents were unaware of the prior thoraco-
centesis performed in ER. Also, adding to this bias is
the fact that radiographs were performed on 4 animals
(1 of which had a thoracocentesis described above) at
referring veterinary clinics prior to presentation to the
ER, which may have provided a suspected diagnosis
prior to FAST scans. However, only 2 of the cases had
2-view thoracic radiographs available for evaluation on
presentation. For 1 other dog, the ER clinician did not
have access to the thoracic radiographs and an addi-
tional dog only had a minimally collimated full body
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lateral radiograph available for evaluation, which was
difficult to interpret. The authors also attempted to min-
imize the amount of time between scans; however, given
the clinical nature of the study, patient needs occasion-
ally caused delays between scans. It is possible that air
or effusion may have accumulated during the time delay
that occurred between the imaging studies. However, the
authors feel that this methodology, albeit potentially bi-
ased, reflects real life interpretation and the conclusions
are relevant.
Due to external injuries, not all of the TFAST scans
were performed bilaterally. Of the unilateral scans for
pneumothorax, 4 out of 5 showed no signs of pneumoth-
orax on both TFAST and CT. One dog had a bilateral
pneumothorax identified on CT, so this should not have
affected the results, as a pneumothorax was present on
the one side that was imaged. Of the animals that under-
went unilateral TFAST scans, 1 did not have evidence
of pleural effusion on TFAST or CT. The other patient
did not have pleural effusion identified on TFAST but
did have effusion present on the CT exam, so the lack of
bilateral TFAST may have affected the ability to detect
fluid on the nonimaged side.
Human medicine dictates that appropriate treatment
be implemented immediately after trauma has occurred
to minimize patient mortality.12,40 The initiation of ap-
propriate treatment relies on both a timely and accurate
diagnosis of injuries. In veterinary patients, a full-body
CT scan allows for detection of pneumothorax, pleural,
and peritoneal effusion, and a complete evaluation of
trauma-based injuries. FAST ultrasound exams continue
to be a useful modality for rapid identification of free
peritoneal and pleural fluid, but TFAST appears to be an
inaccurate method for the diagnosis of pneumothorax.
More sensitive imaging diagnostics, such as horizontal
beam thoracic radiography or CT, should be considered
as a part of the initial imaging protocol for trauma pa-
tients with respiratory difficulty.
Footnotes
a
Sonoscape S8, Providian Medical Equipment LLC, Willowick, OH.
b
Aplio 300, Toshiba American Medical Systems Inc., Tustin, CA.
c
MyLab 70 XVG, Esaote, Indianapolis, IN.
d
Lightspeed 16, GE Healthcare, Waukesha, WI.
e
VetMouse Trap, Universal Medical Systems Inc., Solon, OH.
f
Omnipaque 300, GE Healthcare, Princeton, NJ.
g
Fentanyl Citrate, Hospira, Inc., Lake Forest, IL; Methadone hydrochloride,
Mylan Institutional LLC, Rockford, IL.
h
Diazepam, Hospira, Inc., Lake Forest, IL; Midazolam, Hospira, Inc., Lake
i
Forest, IL.
Dexmedetomidine hydrochloride, Zoetis, Inc., Parsippany, NJ.
j
PropoFlo, Zoetis, Inc., Parsippany, NJ.
k
Lactated Ringer’s Solution, ACE Surgical Supply Co. Inc., Brockton, MA.
l
25% Mannitol, Hospira, Inc., Lake Forest, IL.
m
Ampicillin and Sublactam, Pfizer, Inc., New York, NY.
n
VetStarch, 6% Hydroxyethyl Starch 130/0.4, Abbott Laboratories, North
Chicago, IL.

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