Potential Limitation of FAST
Reported Case
A 64 year old male pedestrian was struck by
a truck, sustaining blunt trauma to the right chest, abdomen and pelvis. In the
emergency department, he was conscious complaining of chest and back pain. The
patient had right flail chest and hemopneumothorax with abdominal
distention.
Chest thoracostomy was performed draining
400 mL blood in the first 60 minutes and another 500mL of blood over the next
30 minutes. Tachycardia and hypotension proved refractory to aggressive fluid
resuscitation. Serial focused assessment with sonography for trauma (FAST)
exams were performed on three occasions, proving negative. Chest thoracotomy
was performed revealing a large amount of blood draining from the abdomen into
the chest through a diaphragmatic laceration. Laparotomy was performed showing
a liver laceration with partial avulsion of the right lobe, the primary site of
hemorrhage. Repeat laparotomy was performed 3 days later due to ongoing
hemodynamic instability and worsening acidosis, revealing significant
hemoperitoneum related to the liver laceration - the patient developed
bradycardia during the procedure that progressed to asystole, no resuscitation
was attempted.
This case demonstrates a potential pitfall
in relying on the FAST exam for evaluation of unstable blunt abdominal trauma.
The potential hemoperitoneum was dissipated through the diaphragmatic
laceration and manifested as a hemothorax. Indications include the realization
that initial FAST examination on the arrival of a trauma patient may not allow
sufficient time for development of significant hemoperitoneum. It is suggested
that serial FAST examinations reduce the incidence of missed injuries with
ongoing hemorrhage. For more information, see:
Ryan, M., & Stella, J. (2004). Massive
hemorrhage from hepatic laceration with diaphragmatic laceration: A potential
limitation of the FAST examination: Case report. Journal of TRAUMA Injury,
Infection, and Critical Care, 57(3), 633-634. [review prepared by Andrew
Reimer BSN RN] |
