Opinion
EDITORIAL
Abdominal Ultrasound for Pediatric Blunt Trauma
FAST Is Not Always Better
David O. Kessler, MD, MSc
The focused assessment with sonography for trauma (FAST)
examination is conducted to rapidly identify bleeding within
the abdominal, pericardial, or intrathoracic spaces. The use of
the FAST examination is not
limited to trauma but is best
Related article page 2290
described in studies involv-
ing adults who sustained blunt or penetrating abdominal
trauma.1 Although no clear reduction in mortality has been re-
ported by incorporating the FAST examination into trauma pro-
tocols, the use of this bedside imaging modality has been as-
sociated with other improvements in outcomes among adult
patients including reductions in abdominal computed tomo-
graphic (CT) rates, decreased time to the operating room, and
decreased hospital length of stay.1-3
The imperative to reduce radiation exposure in children
makes ultrasound an ideal initial imaging modality for
diagnosis.4,5 The use of ultrasound in pediatric acute care set-
tings has increased substantially over the past decade. 6
Point-of-care ultrasound and specifically the FAST exam-
ination are now part of the core content specified by the
American Board of Pediatrics for pediatric emergency medi-
cine certification and maintenance of certification.7 Prior re-
search has demonstrated the willingness of surgeons to de-
crease ordering CTs after a reassuring physical and FAST
examination.8 Data from a secondary analysis of 6468 pa-
tients with blunt abdominal trauma revealed a decrease
in CTs ordered when physicians had a low suspicion for intra-
abdominal injury and a FAST examination was performed.9
Despite the increasing incorporation of the FAST examina-
tion into routine trauma care, relatively little is known about
the interpretation of how FAST examinations effect clinical out-
comes in children with blunt torso trauma.
In this issue of JAMA, Holmes and colleagues10 provide new
information about the effect of point-of-care sonography on
important outcomes in pediatric blunt trauma. In this clinical
trial involving 925 hemodynamically stable pediatric pa-
tients (<18 years old) with blunt torso trauma at a single cen-
ter, patients were randomized to undergo or not undergo
a FAST examination by the emergency department (ED) phy-
sician as part of the standard trauma evaluation. Outcomes
assessed included rates of abdominal CT scans, missed intra-
abdominal injuries, ED length of stay, and hospital charges.
Overall, a total of 50 patients (5.4%) were diagnosed with intra-
abdominal injuries, including 9 patients (0.97%) who under-
went laparotomy.
The authors found that the proportion of abdominal CT
scans performed were not significantly different between the
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groups (difference, −2.2%; 95% CI, −8.7% to 4.2%). In addi-
tion, there were no significant differences between groups in
rates of missed intra-abdominal injury (difference, 0.2%; 95%
CI, −0.6% to 1.2%), ED length of stay (difference, −0.04 hours;
95% CI, −0.47 to 0.40 hours), or hospital charges (difference,
$−1180; 95% CI, −$6651 to $4291). Although the desired im-
provements in efficiency and effectiveness of trauma care did
not appear to occur in this well-done single-center study, ques-
tions still remain regarding generalizability of these findings
given the variability in imaging technology, trauma proto-
cols, and decision making in different clinical settings that
provide emergency care to pediatric trauma patients.
In the study by Holmes et al, the use of negative FAST ex-
amination results successfully reduced physician concern for
intra-abdominal injury, yet this did not translate into lower CT
rates.10 When physicians were asked about their suspicions for
intra-abdominal injury before and after a negative FAST ex-
amination, they moved 27 patients (6%) to a less than 5% risk
and 72 patients (16%) to a less than 1% risk. Of note, none of
the patients who were considered to be in the lowest-risk
category (<1%) were diagnosed with intra-abdominal injury,
yet 49 (28%) still underwent an abdominal CT. This may rep-
resent a missed opportunity to reduce CT scans and raises im-
portant questions as to why physicians did not change their
plans to order a CT. Of 458 FAST examinations performed, only
25 led to a change in the physician’s decision to order a CT.
In 13 of those occurrences, the physician decided not to per-
form a CT and there were no subsequent missed intra-
abdominal injuries.
Study protocol did not dictate what actions to take based
on the interpretation of the FAST results. The discrepancy be-
tween physician suspicion and decision making may repre-
sent the fact that the decision to obtain a CT scan was not solely
in the purview of ED physicians but was influenced by pedi-
atric surgeons, trauma surgeons, or both. It may also reflect
the reluctance of physicians to definitely rule out intra-
abdominal injury. Single raters who enrolled multiple pa-
tients in the trial could have further magnified this effect.
The fact that decision-making guidelines were not incorpo-
rated into preexisting trauma algorithms may have reduced the
potential influence of FAST examinations in this study.
Implementing a new point-of-care ultrasound clinical
guideline, protocol, or pathway can be complex and involve
multiple stakeholders. The authors correctly point out that fu-
ture implementation studies should focus on decision mak-
ing in low-risk groups with negative FAST results. An optimal
algorithm would combine FAST interpretation with physical
(Reprinted) JAMA June 13, 2017 Volume 317, Number 22 2283
 Opinion Editorial

examination and laboratory findings. For example, in a retro-
spective study involving 3171 trauma registry patients with
blunt abdominal trauma, the utility of combining FAST inter-
pretation with transaminase results was explored. These com-
bined data demonstrated improved screening test character-
istics for excluding intra-abdominal injury when compared
with FAST results alone, with increases in sensitivity and speci-
ficity from 50% and 91% to 88% and 98%, respectively
(P < .001).11
Performing serial ultrasounds can also improve the sensi-
tivity of the FAST examination to detect free fluid in intra-
abdominal injury but has not yet been adequately studied in
large-scale trials.12,13 Detection of solid organ injury (tradi-
tionally a weakness of the FAST examination) is also improv-
ing with better imaging technology and the method of
contrast-enhanced ultrasound, which may be an important
part of future algorithms.14-16 The FAST examinations in the
study by Holmes et al were performed using an older model
portable ultrasound scanner that is no longer manufactured
(Zonare Z One Ultra, Mindray).10 In addition, the authors
rightly point out that low-risk hemodynamically stable
patients are only one end of the spectrum for FAST examina-
tion use. It is fairly well established that a positive FAST
result in a hemodynamically unstable patient can be effective
in directing patients toward definitive care. 17 However,
because this is a rare event in pediatric trauma, there may be
important educational benefits to continued practice with
performing and interpreting FAST examinations routinely on
patients with abdominal or torso trauma, even if evidence
does not currently support decision making for those in the
low-risk strata. Preparedness for disaster scenarios is another
reason to consider routine FAST examinations despite the
results of this study demonstrating no significant benefits
with use of FAST examinations. Case studies have suggested
that ultrasound can be used as a trauma triage tool during
multicasualty incidents.18,19
In the study by Holmes et al, training level and comfort
with the FAST examination may have also played a role in
physicians not acting on negative FAST results to cancel
orders for abdominal CT scans.10 The sensitivity of FAST
examinations in this study (33%; 95% CI, 12% to 62%) was
lower than generally reported in the literature (66%), leading
to a high false-negative rate.20 Certification was required
for physicians performing FAST examinations according to
the American College of Emergency Physicians guidelines
that stipulate a minimum of 25 to 50 hands-on ultrasounds
along with didactic experiences and quality assurance feed-
back. Even though these criteria are necessary for certifica-
tion, they may not be sufficient for competency in FAST
examinations of pediatric patients.
Ultrasonography is a complex skill that requires coordi-
nated proficiency in cognitive (indications, limitations, docu-
mentation) visuospatial (image optimization, interpretation),
and psychomotor (image acquisition) skills for each unique
application.21 Blehar et al22 retrospectively examined 12 963
FAST scans from 99 emergency medicine residents and used
quality assurance data to construct learning curves with
expert interpretation as the gold standard. Of 9 core applica-
tions examined in the study, the FAST examination was the
most difficult skill for study participants to attain with learn-
ing curves plateauing at 57 image interpretations. The quality
of images was also assessed. It took an average of 183 scans
for novices to reach 90% of the image quality of an expert.
Other studies have also demonstrated that novices continue
to learn well beyond the 50-minimum scans recommended
for certification.23 In a joint practice parameter published by
the American College of Radiology, Society of Pediatric Radi-
ology, and the Radiologists in Ultrasound, a minimum of 500
scans was proposed as the number required for nonradiolo-
gist physicians as a prerequisite to supervising, performing,
and interpreting diagnostic ultrasound examinations.24 More
research is needed as to the optimal training and assessment
methods for physicians to feel comfortable and be competent
using FAST results to inform medical decision making.
Rather than removing FAST examinations from pediatric
trauma algorithms, the results of the clinical trial by Holmes
et al should encourage the trauma, pediatric emergency
medicine, and ultrasound communities to work together to
further investigate the many unresolved questions about
integrating FAST examinations into pediatric blunt abdomi-
nal trauma protocols. The use of the FAST examination in
pediatric trauma is increasing despite the lack of robust evi-
dence for best practice.6 Recent policy and consensus state-
ments have pushed for better standardization of training,
competency standards, and clinical practice of point-of-care
ultrasound.4,25 Propensity to order abdominal CT scanning is
a clear outcome to target for improvement. Still, there is hesi-
tancy to change clinical practice based on FAST examination
results without evidence for improvement provided by
strong implementation efforts. Quality improvement or
implementation studies may be better suited to studying the
desired behavior changes resulting from FAST algorithms.
This is worth pursuing considering the potential to reduce
exposure to ionizing radiation, the evolving technological
advances, and the minimal risks associated with point-
of-care ultrasound.

ARTICLE INFORMATION
Author Affiliation: Columbia University College of
Physicians and Surgeons, New York City, New York.
Corresponding Author: David O. Kessler, MD, MSc,
Columbia University College of Physicians and
Surgeons, 630 W 168th St, New York, NY 10032
(dk2592@cumc.columbia.edu).
Conflict of Interest Disclosures: The author has
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and no
disclosures were reported.
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 Editorial Opinion

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