{"id":568,"date":"2017-07-16T22:05:53","date_gmt":"2017-07-16T22:05:53","guid":{"rendered":"http:\/\/emultrasound.sdsc.edu\/?p=568"},"modified":"2020-07-22T00:12:21","modified_gmt":"2020-07-22T00:12:21","slug":"does-this-adult-patient-have-a-blunt-intra-abdominal-injury","status":"publish","type":"post","link":"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/07\/16\/does-this-adult-patient-have-a-blunt-intra-abdominal-injury\/","title":{"rendered":"Does This Adult Patient Have a Blunt Intra-abdominal Injury?"},"content":{"rendered":"<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-text-obj\">\n<h2 style=\"text-align: center;\">Background<\/h2>\n<p style=\"text-align: center;\"><span class=\"s1\">Trauma is the leading cause of death in those younger than 45 years in the United States. Around 80%\u00a0of injuries are due to blunt trauma with 20% involving penetrating trauma. It is blunt trauma, however, that carries substantial diagnostic challenges due to complex injury patterns and difficult management strategies. This paper sets out to review and summarize the comparisons of different techniques in diagnosis of intra-abdominal injury via physical exam findings, laboratory values, and imaging including bedside ultrasound.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<h4 style=\"text-align: center;\"><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/22496266\" target=\"_blank\" rel=\"noopener noreferrer\">Does This Adult Patient Have a Blunt Intra-abdominal Injury?\u00a0<\/a><\/h4>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-accordion-obj motopress-accordion motopress-accordion-dark\" data-atts=\"{&quot;active&quot;:&quot;false&quot;,&quot;collapsible&quot;:true,&quot;header&quot;:&quot;&gt; div &gt; h3&quot;,&quot;heightStyle&quot;:&quot;content&quot;}\">\n<div class=\"motopress-accordion-item\"><h3>Clinical Question<\/h3><div>\n<p>How accurate and reliable are existing symptoms, signs, laboratory tests and bedside imaging studies at\u00a0diagnosing intra-abdominal injury following blunt abdominal trauma?<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Methods &amp; Study Design <\/h3><div>\n<ul>\n<li class=\"li1\"><span class=\"s2\"><b>Population<\/b><\/span>\n<ul>\n<li class=\"li1\">The study analyzed 12 papers that assessed clinical examination and 22 papers to assess role of FAST in identifying intra-abdominal injury. Sample sizes ranged from 117 to 3435 patients. All studies defined inclusion criteria as adult patients with any blunt abdominal trauma except for 2 studies that included only adult patients in motor vehicle collisions.<\/li>\n<\/ul>\n<\/li>\n<li class=\"li1\"><span class=\"s2\"><b>Intervention<\/b><\/span>\n<ul>\n<li class=\"li1\">This particular paper focused on the likelihood ratios of various approaches in predicting intra-abdominal injury including: physical exam findings (i.e rebound tenderness, abdominal distention, guarding, seat belt sign, and hypotension), laboratory tests (i.e. \u00a0base deficit, hematuria, elevated transaminases and anemia), and FAST examination.<\/li>\n<\/ul>\n<\/li>\n<li class=\"li1\"><span class=\"s2\"><b>Outcomes<\/b><\/span>\n<ul>\n<li class=\"li1\">Researchers measured specificity, sensitivity, positive likelihood and negative likelihood of the various physical exam, laboratory, and imaging findings associated with blunt trauma.<\/li>\n<\/ul>\n<\/li>\n<li class=\"li1\"><span class=\"s2\"><b>Design<\/b><\/span>\n<ul>\n<li class=\"li1\">This is a meta-analysis of numerous\u00a0prospective studies looking at blunt abdominal trauma.<\/li>\n<\/ul>\n<\/li>\n<li class=\"li1\"><span class=\"s2\"><b>Excluded<\/b><\/span>\n<ul>\n<li class=\"li1\">The publishers chose to include studies that were prospective, with consecutive enrollment and blinding, and included a reference standard (i.e. \u00a0abdominal CT, DPL, laparotomy, autopsy, or clinical course to detect intra-abdominal injury or hemoperitoneum).<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Results<\/h3><div>\n<p><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-571 aligncenter\" src=\"https:\/\/i0.wp.com\/emultrasound.sdsc.edu\/wp-content\/uploads\/2017\/07\/Screen-Shot-2017-07-16-at-2.25.29-PM.png?resize=525%2C327\" alt=\"\" width=\"525\" height=\"327\" \/><\/p>\n<p><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-572\" src=\"https:\/\/i0.wp.com\/emultrasound.sdsc.edu\/wp-content\/uploads\/2017\/07\/Screen-Shot-2017-07-16-at-2.26.58-PM.png?resize=525%2C418\" alt=\"\" width=\"525\" height=\"418\" \/><\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Strengths &amp; Limitations<\/h3><div>\n<ul>\n<li class=\"li1\"><strong>Strengths<\/strong>\n<ul>\n<li class=\"li1\">Analyzed the biggest publications from top-trauma centers focusing on strength of statistical analysis.<\/li>\n<li class=\"li1\">Created subcategories of studies that focused on FAST in order to ascertain if any of the information was skewed.<\/li>\n<\/ul>\n<\/li>\n<li><strong>Limitations<\/strong>\n<ul>\n<li class=\"li1\">This is a 2012 study that only focused on papers older than 2007, excluding any new techniques and standards as well as imaging advancements of the last decade.<\/li>\n<li class=\"li1\">They did not review studies for clinical outcome, so cannot draw conclusions regarding how change in bedside exam and procedures impact patient care post diagnosis.<\/li>\n<li class=\"li1\">As with all large meta-analysis studies there is always risk of significant heterogeneity from varying study inclusion\/exclusion criteria making generalizability\u00a0complex.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Author's Conclusions <\/h3><div>\n<p>\u201cBedside ultrasonography has the highest accuracy of all individual findings, but a normal result does not rule out an intra-abdominal injury. Combinations of clinical findings may be most useful to determine which patients do not require further evaluation, but the ideal combination of variables for identifying patients without intra-abdominal injury requires further study.\u201d<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Our Conclusions<\/h3><div>\n<p>Overall, this paper reinforces the strength of bedside ultrasonography (adjusted positive LR of 30) as a diagnostic tool of intra-abdominal injury following\u00a0blunt trauma compared to physical exam and laboratory findings. This reinforces ultrasounds role as the best tool to \"rule-in\" an intra-abdominal injury. However, it also elucidates a relatively poor sensitivity of the FAST exam, making it a poor tool to \"rule-out.\" This is important as it urges physicians to not rely solely on a negative FAST exam when ruling out intra-abdominal injury but consider other factors including clinical gestalt, mechanism of injury, physical exam and laboratory work up.<\/p>\n<p>Additionally, to better understand the magnitude of this paper's findings it is important to known what a likelihood ratio really tells us. The following image is a quick way to think about likelihood ratios. A positive likelihood ratio of 2 should increase\u00a0your probability of disease ( resulting in your post test probability) by\u00a015%, 5 by\u00a030% and 10 by\u00a045%. Likewise a negative likelihood ratio of 0.5 should decrease your\u00a0probability of disease by 15%, 0.2 by 30% and 0.1 by 45%.<\/p>\n<p><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-573\" src=\"https:\/\/i0.wp.com\/emultrasound.sdsc.edu\/wp-content\/uploads\/2017\/07\/Screen-Shot-2017-07-16-at-2.50.50-PM.png?resize=525%2C235\" alt=\"\" width=\"525\" height=\"235\" \/><\/p>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-prvt-449-595bfa801309a mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-text-obj\">\n<h2 style=\"text-align: center;\">The Bottom Line<\/h2>\n<h3 style=\"text-align: center;\">Bedside ultrasonography is a highly specific diagnostic tool to rule in\u00a0 intra-abdominal injury following\u00a0blunt trauma but should be used in conjunction with clinical gestalt, physical exam findings and laboratory values when ruling out injury.<\/h3>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-accordion-obj motopress-accordion motopress-accordion-dark\" data-atts=\"{&quot;active&quot;:&quot;false&quot;,&quot;collapsible&quot;:true,&quot;header&quot;:&quot;&gt; div &gt; h3&quot;,&quot;heightStyle&quot;:&quot;content&quot;}\">\n<div class=\"motopress-accordion-item\"><h3>Authors<\/h3><div>\n<p>This post was written by Olga Miakicheve, MS4 at UCSD. It was edited by Michael Macias, MD.<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>References <\/h3><div>\n<ol class=\"ol1\">\n<li class=\"li1\" style=\"list-style-type: none;\">\n<ol>\n<li class=\"li1\">Simel, D. (2012). Does This Adult Patient Have a Blunt Intra-abdominal Injury?. JAMA, 307(14), 1517. doi:10.1001\/jama.2012.422<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"Background Trauma is the leading cause of death in those younger than 45 years in the United States. Around 80%\u00a0of injuries are due to blunt trauma with 20% involving penetrating trauma. It is blunt trauma, however, that carries substantial diagnostic challenges due to complex injury patterns and difficult management strategies. This paper sets out to &hellip; <p class=\"link-more\"><a href=\"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/07\/16\/does-this-adult-patient-have-a-blunt-intra-abdominal-injury\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> \"Does This Adult Patient Have a Blunt Intra-abdominal Injury?\"<\/span><\/a><\/p>","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_eb_attr":"","_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[5],"tags":[13,10,8],"class_list":["post-568","post","type-post","status-publish","format-standard","hentry","category-journal-club","tag-blunt-abdominal-trauma","tag-fast-examination","tag-trauma"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Does This Adult Patient Have a Blunt Intra-abdominal Injury? - UCSD Ultrasound<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/07\/16\/does-this-adult-patient-have-a-blunt-intra-abdominal-injury\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Does This Adult Patient Have a Blunt Intra-abdominal Injury? - UCSD Ultrasound\" \/>\n<meta property=\"og:description\" content=\"Background Trauma is the leading cause of death in those younger than 45 years in the United States. 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