A radiologist’s perspective

Editorials / Commentaries

CJEM 1999;1(2):123-124

Focused abdominal sonography in trauma (FAST) has in many centres replaced the diagnostic peritoneal lavage (DPL) for the early assessment of acute blunt abdominal trauma. In many cases a negative FAST obviates the need for further imaging and intervention. In well-trained hands, it is a very specific and relatively sensitive test for the detection of hemoperitoneum and has the advantage over DPL of being noninvasive. However, the introduction of this exam has raised many contentious issues around indications for the study, as well as who should perform and interpret the study. Ironically, the question of who should perform the test has in many ways overshadowed the issue of whether it should be performed at all.

FAST ultrasound is clearly not appropriate for every patient suffering blunt trauma. It has the advantage of being able to rapidly confirm the presence of hemoperitoneum in the unstable patient, and, unlike computed tomography (CT), can be performed while other tests and interventions are being carried out. Asymptomatic patients who have suffered blunt trauma should be examined with FAST since a negative study precludes the need for CT. On the other hand, patients who are symptomatic should proceed directly to CT to determine the nature and severity of their injuries. The test should not be used to search for hollow or solid viscus injury since it is a relatively insensitive test and could delay proper diagnosis and treatment.

CT provides more specific anatomic injury data

The question remains as to who should perform and interpret the study. Radiologists, radiology residents and ultrasound technologists are well trained in the performance of U/S exams. Their level of training and experience far exceeds that available to other physicians wishing to perform FAST. For example, in many centres, ultrasound technologists now enroll in a 4-year university degree program. The Canadian Association of Radiologists (CAR) has suggested that a minimum of 6 months of training is required to perform and interpret ultrasound exams in daily radiology practice. While some surgeons and emergency physicians are using FAST, they do not have the training suggested by either the CAR, the American College of Radiology or the American Institute of Ultrasound in Medicine. Several studies, performed without the participation of radiologists, have claimed adequate ultrasound results in the emergency setting by physicians who have had only a few hours of training. However, the rates of detection in these studies would be deemed unacceptable by most sonologists.

If radiologists are going to provide quality care in the emergency realm, they must be available and included as part of the trauma team so they can perform and direct appropriate imaging and radiologic intervention and they must understand the needs of emergency physicians in this regard. Confrontation between radiology and emergency physicians can be avoided when appropriate exams are carried out in a timely and helpful manner.

Editors' note: We leave it to you to decide what is best for your patients in your setting. There are, however, creative solutions being developed across the country to similar interdisciplinary issues that arise. Please share your thoughts or experiences with your colleagues through CJEM. [J.R.]