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Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma

  1. Dirk Stengel1,*,
  2. Kai Bauwens2,
  3. Grit Rademacher3,
  4. Axel Ekkernkamp4,
  5. Claas Güthoff1

Editorial Group: Cochrane Injuries Group

Published Online: 31 JUL 2013

Assessed as up-to-date: 4 FEB 2013

DOI: 10.1002/14651858.CD004446.pub3


How to Cite

Stengel D, Bauwens K, Rademacher G, Ekkernkamp A, Güthoff C. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD004446. DOI: 10.1002/14651858.CD004446.pub3.

Author Information

  1. 1

    Unfallkrankenhaus Berlin, Centre for Clinical Research, Department of Trauma and Orthopaedic Surgery, Berlin, Germany

  2. 2

    Unfallkrankenhaus Berlin, Department of Trauma, 12683 Berlin, Germany

  3. 3

    Unfallkrankenhaus Berlin, Institute of Diagnostic & Interventional Radiology, 12683 Berlin, Germany

  4. 4

    Ernst-Moritz-Arndt University Hospital, Department of Trauma Surgery, 17487 Greifswald, Germany

*Dirk Stengel, Centre for Clinical Research, Department of Trauma and Orthopaedic Surgery, Unfallkrankenhaus Berlin, Warener Str 7, Berlin, 12683, Germany. stengeldirk@aol.com. dirk.stengel@ukb.de.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 31 JUL 2013

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Characteristics of included studies [ordered by study ID]
Arrillaga 1999

MethodsQuasi-RCT (algorithm used was based on the daytime and weekday availability of ultrasound). Location: Community Hospital, Level-I-Trauma Center, South Carolina, USA. Recruitment period: 9 months.
Adequacy of concealment: 0.
Intent-to-treat: 0
Blinding: 0
Comparability of treatment groups at entry: 1
Comparability of care programmes: 0
Definition of inclusion and exclusion criteria: 1
Description of interventions: 1
Definition of outcomes: 2
Duration of surveillance: 0 (not defined)


ParticipantsInclusion criteria: consecutive patients with suspected blunt abdominal trauma (not specified). 331 enrolled (US 105, no US 226). US group: mean age 38.1 (SD 22.7) years, mean ISS 13.0 (SD 11.6), 62% males. No US group: mean age 33.6 (SD 18.6) years, mean ISS 13.4 (SD 9.7), 69% males.


Interventionsa. Clinical examination, focused ultrasound for free fluid, further management depended on sonograms and hemodynamical stability
b. Clinical examination, CT in stable and DPL in unstable subjects.


Outcomes1. Number of diagnostic tests (CT, DPL).
2. Mortality.
3. Morbidity (not specified).
4. Length of stay.
5. Diagnostic accuracy.
6. Total costs.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskNot used

Boulanger 1999

MethodsQuasi-RCT (algorithm used was determined by date of admission). Location: University Hospital, Kentucky, USA. Recruitment period: October 1995 to August 1997.
Adequacy of concealment: 0.
Intent-to-treat: 1.
Blinding: 0.
Comparability of treatment groups at entry: 2.
Comparability of care programmes: 0.
Definition of inclusion and exclusion criteria: 2.
Description of interventions: 2.
Definition of outcomes: 2.
Duration of surveillance: 1.


ParticipantsInclusion criteria: victims of blunt trauma, older than 16 years of age, resuscitated by trauma service, no clinical indication for laparotomy, unreliable or equivocal abdominal examination. 706 enrolled (US 460, no US 246).
US group: mean age 38.4 (SD 17.6) years, mean ISS 23.3 (SD 12.8), 73% males. No US group: mean age 40.2 (SD 18.2) years, mean ISS 22.8 (SD 11.3), 73% males.


Interventionsa. Clinical examination, focused ultrasound for free fluid, further management depended on sonograms and hemodynamical stability.
b. Clinical examination, CT in stable and DPL in unstable participants..


Outcomes1. Time from arrival to the completion of diagnostic algorithm.
2. Number of diagnostic tests (CT, DPL).
3. Mortality.
4. Laparotomy rates.
5. Diagnostic accuracy and number of significant injuries.
6. Total costs.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskNot used

Melniker 2006

MethodsRCT: Location - three level-1 trauma centers, New York Methodist Hospital, Maricopa Hospital, Phoenix, Jackson Memorial Hospital, Miami, USA.


ParticipantsInclusion criteria: patients presenting with any one of a mechanism of injury (energy reportedly delivered to the torso), symptomatology (complaint of chest, abdominal, or pelvic pain), or physical findings (chest, abdominal, or pelvic tenderness) suspicious of torso trauma
Exclusion criteria:
Patients or patient proxies who were unable to provide consent and those requiring immediate transfer to the operating suite were excluded


Interventionsa. Diagnostic interventions that the initial evaluating physician, under ordinary circumstances, would use to evaluate torso trauma patients plus 4-view FAST assessment
b. Ordinary diagnostic interventions to evaluate torso trauma


Outcomes1. Time from ED arrival to direct transfer to operative care in minutes (sample size calculations: 40% reduction, 90% power, alpha 5%).
2. Use of CT of the torso
3. Hospital length of stay in days
4. Composite complications (rate of hemorrhagic shock, septic shock, multisystem organ failure, or death) based on CPT or ICD codes found in the medical record
5. Total charges in 2003 US dollars


NotesOf 525 patients screened, 81 went directly to OR, 136 lacked consent, 262 were randomized, and 217 were analyzed


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Low riskAdequate

Rose 2001

MethodsRCT. Location: University Hospital, California, USA. Recruitment period: November 1997 to November 1998.
Adequacy of concealment: 1.
Intent-to-treat: 1.
Blinding: 0.
Comparability of treatment groups at entry: 2.
Comparability of care programmes: 1.
Definition of inclusion and exclusion criteria: 2.
Description of interventions: 2.
Definition of outcomes: 2.
Duration of surveillance: 1.


ParticipantsInclusion criteria: patients 18 to 75 years old meeting critical trauma triage criteria after blunt injury, defined by the American College of Surgeons Subcommittee of trauma. 212 randomised (US 105, no US 107), 208 analysed (4 dropped because of incomplete data). US group: mean age 40.0 (SD 19.5) years, mean ISS 9.9 (SD 12.4), 61% males. No US group: mean age 39.0 (SD 16.8) years, mean ISS 9.8 (SD 8.8), 63% males.


Interventionsa. Standard standard trauma management plus focused ultrasound for free fluid (none, small, moderate, large) with 15 minutes of arrival by experienced doctors.
b. Standard trauma management.


Outcomes1. Difference in abdominal CT scan use (sample size calculations: 20% difference, 80% power, two-tailed alpha 5%).
2. 30-minute difference in time to laparotomy.


NotesTrial was stopped at 215 participants because US was recognised as standard practice and did not allow for further patient recruitment.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskUnclear

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Branney 1997Comparison of prospectively collected ultrasound data (August 1995 to October 1995) with a historical cohort admitted before instituting ultrasound-based clinical pathways (August 1994 to October 1994).

Healey 1996Comparison of prospectively collected ultrasound data (May 1994 to August 1995) with a historical cohort admitted before instituting ultrasound-based clinical pathways.

Hesse 1999Comparison of prospectively collected ultrasound data (1990 to 1994) with a historical cohort admitted before instituting ultrasound-based clinical pathways (1986 to 1990).

Ma 2005Prospective study to evaluate the impact of the emergency physician's experience and skills with FAST to predict the need for a subsequent CT scan in case of a negative ultrasound exam.

McKenney 2001Comparison of prospectively collected ultrasound data (January 1995 to June 1995) with a historical cohort admitted before instituting ultrasound-based clinical pathways (January 1993 to June 1993).

Muniz 2003Diagnostic accuracy study which investigated the value of adding lab Information to FAST results to disclose abdominal trauma.

Navarrete-Nav. 1996Trial intended to prove the superiority of computed tomography over multiple diagnostic interventions including ultrasound.

 
Comparison 1. Mortality

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Relative risk of mortality31254Risk Ratio (M-H, Random, 95% CI)1.00 [0.50, 2.00]

 
Comparison 2. Use of computed tomography (CT)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Difference in CT frequency41462Risk Difference (M-H, Random, 95% CI)-0.52 [-0.83, -0.21]

 
Comparison 3. Use of diagnostic peritoneal lavage (DPL)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Difference in DPL frequency21016Risk Difference (M-H, Random, 95% CI)-0.06 [-0.11, -0.02]

 
Comparison 4. Cost-effectiveness

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Direct costs per patient (US$)1Mean Difference (IV, Random, 95% CI)Subtotals only

 
Comparison 5. Laparotomy

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Laparotomy rate31131Risk Difference (M-H, Fixed, 95% CI)-9.26 [-0.04, 0.04]

 
Comparison 6. Reduction in diagnostic time

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mean reduction in diagnostic time (minutes)1Mean Difference (IV, Fixed, 95% CI)Subtotals only

 
Comparison 7. Delayed diagnoses

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Risk of delayed diagnosis1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

 
Comparison 8. Non-therapeutic laparotomy

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Risk of non-therapeutic laparotomy1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

 
Comparison 9. Duration of hospital stay

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mean length of stay (days)1Mean Difference (IV, Fixed, 95% CI)Subtotals only

 
Comparison 10. Intensive care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mean ICU days1Mean Difference (IV, Fixed, 95% CI)Subtotals only