Double Jeopardy in Penetrating Trauma: Get FAST, Get It Right

Kazuhide Matsushima, Desmond Khor, Kristin Berona, Derek Antoku, Ryan Dollbaum, Moazzam Khan, Demetrios Demetriades

In hypotensive patients with thoracoabdominal penetrating injuries, trauma surgeons often face a considerable dilemma, which cavities and when to explore. We hypothesized that the Focused Assessment with Sonography for Trauma (FAST) would be accurate enough to determine the need and sequence of cavity exploration. We conducted a 4-year retrospective study at a level 1 trauma center with high penetrating trauma volume. Patients with potential multi-cavity thoracoabdominal injuries were selected based on the location and number of external wounds. Findings in the operation or on computed tomography were used as references to evaluate the sensitivity, specificity, positive predictive value and negative predictive value of pericardial and abdominal FAST. A total of 2851 patients with penetrating injury were admitted from 2012 to 2015. Of those, 103 patients (3.6%) met our inclusion criteria (stab wounds 56.3%, gunshot wounds 43.7%). Median age: 32, male gender: 89.3%, median injury severity score: 17, in-hospital mortality rate: 11.7%. Thirty-seven patients (35.9%) required surgical exploration of more than one cavity. Although the pericardial FAST was falsely negative in only one case with large left hemothorax, all cardiac injuries were treated without delay (12/13, 92.3% sensitivity). Sensitivity and specificity of the abdominal FAST was 68.5 and 93.9%, respectively. In hypotensive patients following penetrating thoracoabdominal injuries, the pericardial FAST was highly sensitive and could reliably determine the need to explore the pericardium. While positive findings of abdominal FAST warrant an exploratory laparotomy, negative abdominal FAST does not exclude the abdominal cavity as a bleeding source.