Hands-On Time in Simulation-Based Ultrasound Training - A Dose-Related Response Study.

Utilisation of Focused Assessment with Sonography for Trauma (FAST) in a referral hospital in an acute conflict zone

Point-of-care ultrasound (POCUS) has diverse applications across various clinical specialties, serving as an adjunct to clinical findings and as a tool for increasing the quality of patient care. Owing to its multifunctionality, a growing number of medical schools are increasingly incorporating POCUS training into their curriculum, some offering hands-on training during the first 2 years of didactics and others utilizing a longitudinal exposure model integrated into all 4 years of medical school education. Midwestern University Arizona College of Osteopathic Medicine (MWU-AZCOM) adopted a 4-year longitudinal approach to include POCUS education in 2017. There is a small body of published research supporting this educational model, but there is not much data regarding how this approach with ultrasound curriculum translates to real-world changes in POCUS use by graduate student clinicians having received this model of education. The objectives of this study are to determine the frequency of POCUS use by MWU-AZCOM graduates and to assess how a 4-year longitudinal ultrasound curriculum may enhance the abilities of MWU-AZCOM graduates to perform and interpret ultrasound imaging in specific residency programs. The study was approved by the MWU Institutional Review Board (#IRBAZ-5169, approval date October 3, 2022). An anonymous novel 12-question survey was conducted utilizing Research Electronic Data Capture (REDCap), a secure online platform, and distributed to MWU-AZCOM 2021 and 2022 graduates via email. Survey questions were aimed at assessing frequency of use, utilization of different imaging modalities, reasons for utilizing POCUS, barriers/enablers to utilizing POCUS, ultrasound training, and confidence in performing scans and interpreting POCUS imaging. All of the 104 surveys returned were included in the study. Statistical software R version 4.3 was utilized to conduct statistical analyses. Of the 484 surveys distributed, 104 were completed (21.5 % response rate). Responses came from residents working in 14 different specialties, 50 in primary care and 54 in nonprimary care. Of all respondents, 85.6 % currently utilize POCUS in their practice on at least a monthly basis and 77.0 % believe that their POCUS training in medical school enriches their current practice in residency. The top five modalities utilized by residents were procedures (89.9 %), cardiac (88.8 %), pulmonary (82.0 %), Focused Assessment with Sonography for Trauma (FAST, 73.0 %), and vascular (71.9 %). Respondents recognized POCUS as a beneficial diagnostic tool (97.8 %) and reported enhancements in physical examination skills (58.4 %) and professional growth (61.8 %). Facilitators for POCUS adoption included cost-effectiveness (82.0 %), diagnostic differentiation (78.7 %), and safety (79.8 %). Barriers included a lack of trained faculty (27.9 %), absence of necessary equipment (26.9 %), and cost of equipment (22.1 %). Participants demonstrated high confidence levels in performing (74.0 %) and interpreting (76.0 %) POCUS, with 43.3 % believing that their POCUS training enhanced their attractiveness as residency candidates. This study supports the positive impact of a 4-year longitudinal POCUS curriculum on graduates' practice. It emphasizes the link between MWU-AZCOM's curriculum and real-world clinical needs. Addressing identified barriers and advancing hands-on training can further enhance POCUS understanding, ensuring that future physicians are well-prepared to leverage its diagnostic potential across medical specialties.

Introduction:Focused assessment with sonography for trauma (FAST) has been shown to be useful to detect intraperitoneal free fluid in patients with blunt abdominal trauma (BAT). Objective:We compared the diagnostic accuracy of FAST performed by emergency medicine residents (EMRs) and radiology residents (RRs) in pediatric patients with BAT.Method:In this prospective study, pediatric patients with BAT and high energy trauma who were referred to the emergency department (ED) at Al-Zahra and Kashani hospitals in Isfahan, Iran, were evaluated using FAST, first by EMRs and subsequently by RRs. The reports provided by the two resident groups were compared with the final outcome based on the results of the abdominal computed tomography (CT), operative exploration, and clinical observation. Results:A total of 101 patients with a median age of 6.75 ± 3.2 years were enrolled in the study between January 2013 and May 2014. These patients were evaluated using FAST, first by EMRs and subsequently by RRs. A good diagnostic agreement was noted between the results of the FAST scans performed by EMRs and RRs (κ = 0.865, P < 0.001). The sensitivity, specificity, positive and negative predictive values, and accuracy in evaluating the intraperitoneal free fluid were 72.2%, 85.5%, 52%, 93.3%, and 83.2%, respectively, when FAST was performed by EMRs and 72.2%, 86.7%, 54.2%, 93.5%, and 84.2%, respectively, when FAST was performed by RRs. No significant differences were seen between the EMR- and RR-performed FAST. Conclusion:In this study, FAST performed by EMRs had acceptable diagnostic value, similar to that performed by RRs, in patients with BAT.

Targeted ultrasound examinations with portable ultrasound device (handheld ultrasound system [HHUS]) have been defined as "echoscopy" by the European Federation of Societies of Ultrasound in Medicine and Biology (EFSUMB). For abdominal diseases it has been shown that echoscopy is sensitive and specific. The aim of this study is to show that the use of HHUS for abdominal ultrasonography is possible under the conditions prevailing in emergency and intensive care medicine and that it is not inferior to high-end devices (high-end ultrasound systems [HEUS]). Examinations were carried out with afirst-generation Vscan™ (GE Medical Systems, Solingen, Germany) and HEUS device (Siemens Acuson X‑300 or X‑700, Siemens Healthcare, Erlangen, Germany). The HEUS device was seen as standard. The examinations were randomized and blinded and carried out by two examiners within 30 min in order to avoid falsifications due to time delay. They took place in the intensive care unit, the emergency room and the emergency medical service. The results had to be recorded in an examination sheet. In all, 86patients (54men and 32women, aged 73 ± 14.58 [28-95] years) were included. In 45.35% (39/86) of the ultrasound examinations using HEUS and in 41.86% (36/89) of the cases using HHUS the examination conditions were optimal. Furthermore, 76.19% of the examinations were carried out by both examiners in the same scanning position. For the detection of liver tumours, HHUS shows asensitivity of 70% and specificity of 100%. With regard to identifying signs of cholecystitis, i.e., evidence of surrounding inflammation(a) or hydrops(b), HHUS shows asensitivity of 66.67%(a) and 60%(b) and aspecificity of 97.06%(a) and 96.86%(b). The diagnosis of an ileus is successful with asensitivity of 87.5% and aspecificity of 60%. The respiratory variability of the inferior vena cava has asensitivity of 100% and aspecificity of 40% using HHUS. Ascites and pleural effusions can be diagnosed with asensitivity of 89% and aspecificity of 93.1%. When using the FAST (Focused Assessment with Sonography for Trauma) protocol, HHUS has asensitivity of 80% and aspecificity of 90.9%. With the exception of kidney cysts and inferior vena cava, the measurement of the diameter has apositive correlation. Echoscopy of the abdomen in emergency and intensive care medicine is possible despite restrictive circumstances. The inferior vena cava can only be assessed to alimited extent with the first generation of Vscan™. In order to use sonography in emergency and intensive care medicine, astandardized procedure is to be aimed for and training in emergency sonography is necessary.

To review the nonradiologist use of ultrasound (US) in the setting of emergency and critical care, the development, clinical applications, and standardization of veterinary abdominal and thoracic focused assessment with sonography for trauma (FAST) techniques. Since the 1990s, the 4-point FAST US technique has been used for injury surveillance in people with blunt and penetrating trauma. FAST screens for free fluid in the abdominal, pleural, and pericardial cavities with high sensitivity and specificity. More recently, an extended FAST scan was developed for the rapid detection of pneumothorax. These techniques and newly created scans have been applied to other critically ill, nontraumatized, subsets of human patients. As a result, the terminology related to this field, eg, extended FAST, HHFAST, FFAST, FAFF, BOAST, SLOH, bedside US, '$ Approach,' protocols, and objectives have become convoluted despite having similar goals. The importance of US in the setting of emergency medicine is highlighted by the fact that this diagnostic modality has become an integral part of the core curriculum for nonradiologists including the American College of Surgeons, American College of Emergency Physicians, American Board of Emergency Medicine, Society of Academic Emergency Medicine, and all United States Accreditation Council for Graduate Medical Education Emergency Medicine residency programs. Veterinary applications of FAST techniques include an abdominal FAST technique with an abdominal FAST applied fluid scoring system, and a thoracic FAST technique. In an attempt to avoid the creation of numerous acronyms, veterinarians would be well served by making the 'T' in 'FAST' stand for 'Trauma,''Triage,' and 'Tracking.' These veterinary FAST techniques provide an extension of the physical examination for the emergency and critical care veterinarian potentially expediting diagnosis, prompting life-saving maneuvers, and guiding patient management. Further clinical research to determine sensitivity, specificity, and accuracy for specific conditions is warranted.

The focused assessment with sonography for trauma (FAST) is a screening ultrasound examination used to identify traumatic free fluid in the pericardium and peritoneum through four key windows: the subxiphoid, the hepatorenal recess, the splenorenal recess, and the suprapubic views. The primary role for the FAST examination is in the bedside evaluation of hemodynamically unstable blunt trauma patients to help direct operative management. The extended FAST (E-FAST) examination involves additional evaluation of the thorax and can reliably identify hemothorax and pneumothorax. The advantages of these modalities include rapid speed, low cost, and a lack of ionizing radiation. The limitations include operator dependence, although validated assessments hold promise in mitigating this issue, and poor sensitivity in identifying retroperitoneal hemorrhages, diaphragmatic injuries, and solid-organ injuries that do not produce significant intraperitoneal hemorrhage. In the future, contrast-enhanced ultrasonography may improve ultrasonographic evaluation of solid-organ injury. Nevertheless, significant concerns remain regarding the wide ranges of sensitivity reported for the FAST examination overall, and ongoing research may better identify its optimal role in evaluating trauma patients. This review contains 10 figures, 7 tables, 8 videos and 58 references Keywords: Blunt trauma; focused assessment with sonography for trauma (FAST); extended FAST (E-FAST); hemothorax; pneumothorax; ultrasonography

Introduction:Focused Assessment with Sonography for Trauma (FAST) has attracted attention for its use in the detection of intra-abdominal pathology for pediatric patients. However, computed tomography (CT) remains the gold standard for the assessment of blunt torso trauma. The study examines the effectiveness of FAST both in the detection of intra-abdominal pathology in pediatric patients (<19 years) with blunt torso trauma and in the determination of the need for CT for further examination.Methods:The study was designed as a retrospective observational investigation of diagnostic value. The pediatric patients who were admitted to the Emergency Department with blunt torso trauma between January 2013 and October 2016 were included in the study. The sample of the study comprised 255 patients who met the inclusion criteria. The primary outcome was the effectiveness of FAST in the detection of intra-abdominal pathology and the determination of the need for CT. The secondary outcome was to identify the agreement between CT and FAST for intra-abdominal injuries. The Chi-square test and Fisher's exact test were used for comparisons. A logistic regression model was developed to determine the variables that independently affect the agreement between FAST and CT.Results:FAST was determined to have low sensitivity (20.3%) despite its high specificity (87%). However; FAST had a good negative likelihood ratio. There was a poor agreement between CT and FAST in terms of the presence of both intra-abdominal and intrathoracic injuries in pediatric patients with blunt trunk trauma. The error rate of FAST increased by five-fold, especially in the presence of concomitant thorax trauma. However, FAST had a good negative likelihood ratio.Conclusion:FAST should not be regarded as an equivalent tool to CT for pediatric patients with blunt torso trauma. It is, instead, a noteworthy complementary tool that is a negative predictor.

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Point-of-care ultrasound (POCUS) plays a vital role in rapid diagnosis and management in emergency settings. We present a case of a 9-year-old male who presented after a high-speed motor vehicle collision with a negative focused assessment with sonography for trauma (FAST). However, the quality assurance (QA) review raised concerns for a splenic mass. Further imaging confirmed the finding, and the patient underwent elective splenectomy, revealing a rare benign littoral cell angioma. This case illustrates the importance of QA in identifying findings during POCUS exams, the limitations of POCUS compared with comprehensive imaging, and the value of a multidisciplinary approach to pediatric trauma care.

IntroductionPoint-of-care ultrasonography (POCUS) is increasingly utilized in emergency departments (EDs) throughout Thailand. Although emergency medicine (EM) residents are trained in POCUS, Thai medical students receive limited training. An introductory POCUS course was implemented for medical students to prepare them for internships.ObjectiveThis study described the perception and use of POCUS by graduates of an introductory POCUS course.Materials and MethodsMedical students who completed the POCUS course were surveyed during their intern year from 2012 to 2015. The survey collected demographic characteristics. The Likert Scale was used to assess POCUS practice patterns and perceptions of the course.ResultsThere were 230 respondents (98% response rate). All thought that POCUS was important. Furthermore, 96% of respondents felt that the POCUS course meaningfully impacted their ability to deliver care. POCUS use was greatest for obstetrics/gynecology and trauma cases. Over half of respondents (55.2%) felt very confident with using extended-Focused Assessment with Sonography in Trauma. Most respondents (81.8%) were positively impacted by the course, and 61.7% were satisfied with the scope of the course. Recommendations for improvement included increasing the course length, the content, and the hands-on time for POCUS practice.ConclusionGraduates positively perceived the course and felt it dramatically impacted their clinical practice as novice physicians. An introductory POCUS course should be incorporated into the medical school curriculum to prepare graduates for practice. Future goals include increasing the scope of POCUS practice to help guide interns and residents in emergency patient care such as lung ultrasound in COVID-19 or pneumonia patients and studying the impact this course has on patient outcomes.

The purpose of this study was to evaluate the role of focused assessment with sonography for trauma (FAST) as a triage tool in multiple-casualty incidents (MCIs) for a single international conflict. The charts of 849 casualties that arrived at our level 1 trauma referral center were reviewed. Casualties were initially triaged according to the Injury Severity Score at the emergency department gate. Two-hundred eighty-one physically injured patients, 215 soldiers (76.5%) and 66 civilians (23.5%), were admitted. Focused assessment with sonography for trauma was performed in 102 casualties suspected to have an abdominal injury. Sixty-eight underwent computed tomography (CT); 12 underwent laparotomy; and 28 were kept under clinical observation alone. We compared FAST results against CT, laparotomy, and clinical observation records. Focused assessment with sonography for trauma results were positive in 17 casualties and negative in 85. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FAST were 75%, 97.6%, 88.2%, 94.1%, and 93.1%, respectively. A strong correlation between FAST and CT results, laparotomy, and clinical observation was obtained (P < .05). In a setting of a war conflict-related MCI, FAST enabled immediate triage of casualties to laparotomy, CT, or clinical observation. Because of its moderate sensitivity, a negative FAST result with strong clinical suspicion demands further evaluation, especially in an MCI.

Tele-Ultrasound in the Wilderness: A Tutorial Experience for Medical Students.

FAST Scan: Is it Worth Doing in Hemodynamically Stable Blunt Trauma Patients?

Although the routine use of FAST (focused assessment with sonography for trauma) in the evaluation of trauma victims is increasing, to our knowledge, a prospective comparison of contemporary adult trauma victims managed with and without FAST has not been reported in North America. Adult victims of blunt trauma for whom there was a suspicion of abdominal injury were managed with one of two diagnostic algorithms, FAST or no-FAST. The two algorithms were compared for diagnostic accuracy, cost, time, and delayed diagnoses. Among 706 patients (mean Injury Severity Score, 23), 460 were managed with FAST and 246 with no-FAST. The two groups were similar with respect to age, Injury Severity Score, prehospital time, and mortality (p = not significant). There were 3 of 460 (0.7%) delayed diagnoses in the FAST group and 4 of 246 (1.6%) in the no-FAST group (p = not significant). The diagnostic accuracy for the FAST and no-FAST algorithms was 99% and 98%, respectfully. The FAST and no-FAST algorithms led to similar rates of laparotomy, 13% and 14%, respectfully, but nonoperative management was more common in the no-FAST group (p < 0.01). The mean diagnostic cost for the FAST algorithm was $156, compared with $540 with the no-FAST algorithm (p < 0.0001) and the mean time required for diagnostic work-up was 53 minutes with the FAST algorithm, compared with 151 minutes with the no-FAST algorithm (p < 0.0001). This study has provided prospective evidence that a FAST-based algorithm for blunt abdominal injury was more rapid, less expensive, and as accurate as an algorithm that used computed tomography or diagnostic peritoneal lavage only. Trauma centers are encouraged to incorporate a FAST-based algorithm into their initial management of blunt trauma victims.

The use of ultrasound for the management of the injured patient has expanded dramatically in the last decade. The focused assessment with sonography for trauma (FAST) has become one of the fundamental skills incorporated into the initial evaluation of the trauma patient. However, there are significant limitations of this diagnostic modality as initially described. Novel ultrasound examinations of the injured patient, although useful, must also be considered carefully. Increasing evidence supports the high specificity of FAST for detecting a pericardial effusion and intra-abdominal free fluid (hemorrhage) in the patient with blunt injury. On the other hand, a so-called negative FAST result still requires further diagnostic work up given its low sensitivity. Similarly, the role of FAST in penetrating abdominal trauma appears to be limited because of lower sensitivity for visceral injury compared to other modalities. Extended FAST (EFAST), that adds a focused thoracic examination, has high accuracy for the detection of pneumothorax comparable to computed tomographic scan, the significance of which is not currently known. Finally, the utility of intensivist-performed ultrasound in the ICU is expanding to limited hemodynamic assessment and facilitation of central venous catheter placement. The indications for FAST and additional ultrasound studies in the injured patient continue to evolve. Application of sound clinical evidence will avoid unsubstantiated indications for ultrasound to creep into our clinical practice.