What is the first step in managing a hemodynamically stable patient with evidence of possible intraperitoneal bleed: Computed Tomography (CT) scan or Focused Assessment with Sonography for Trauma (FAST) exam?

From the Guidelines

For a hemodynamically stable patient with evidence of a possible intraperitoneal bleed, the first step in management should be a FAST (Focused Assessment with Sonography for Trauma) examination. This approach is supported by the most recent and highest quality study, which emphasizes the importance of determining the diagnostic method based on the patient's hemodynamic status 1. The FAST exam is preferred initially because it is rapid, non-invasive, can be performed at the bedside, and does not require moving the patient from the emergency department. It can quickly identify free fluid in the peritoneal cavity, which in the appropriate clinical context suggests hemorrhage.

Key Considerations

• The FAST exam serves as an excellent screening tool that helps determine whether immediate surgical intervention is needed or if there is time for further diagnostic evaluation with CT imaging 1.
• While CT scanning provides more detailed information about specific organ injuries and quantifies the amount of blood, it requires transporting the patient to the radiology department, which may delay care if the patient's condition deteriorates 1.
• CT involves radiation exposure and potentially nephrotoxic contrast, making FAST a safer initial choice for hemodynamically stable patients.
• If the FAST exam is negative but clinical suspicion remains high, proceeding to CT is appropriate as the next step, as CT scan with intravenous contrast is considered the gold standard in hemodynamically stable trauma patients 1.

Diagnostic Approach

• Extended-focused abdominal sonography for trauma (E-FAST) is rapid in detecting intra-abdominal free fluid 1.
• CT scan with intravenous contrast is the gold standard in hemodynamically stable trauma patients, with a sensitivity and specificity approaching 96–100% 1.
• The choice of diagnostic technique at admission must be based on the hemodynamic status of the patient 1.

From the Research

Initial Assessment of Hemodynamically Stable Patients with Possible Intraperitoneal Bleed

• The first step in managing a hemodynamically stable patient with evidence of possible intraperitoneal bleed is to perform a diagnostic imaging test to confirm the presence and extent of the bleed.
• According to the studies, both CT scan and FAST exam can be used for this purpose, but they have different advantages and limitations.

CT Scan vs. FAST Exam

• A CT scan is considered the most important imaging technique in detecting and characterizing spontaneous intraperitoneal bleeding 2.
• It can provide detailed information about the location and extent of the bleed, as well as the presence of any other injuries 3.
• However, a CT scan may not be necessary for all patients, especially those with low-risk profiles 3.
• A FAST exam, on the other hand, is a rapid and non-invasive test that can be used to detect intraabdominal fluid early in the unstable patient 4.
• However, its sensitivity and specificity may be limited, especially in skilled hands, and a negative result cannot reliably exclude intraabdominal bleeding 4.

Recommendations

• For hemodynamically stable patients with suspected abdominal injuries, a CT scan is recommended as the initial diagnostic test 5, 3.
• A FAST exam may be used as a screening test in patients who are potentially unstable or have a high risk of bleeding, but a negative result should be followed by additional diagnostic tests to exclude intraperitoneal hemorrhage 4.
• The choice of imaging test ultimately depends on the patient's clinical presentation, the availability of resources, and the physician's judgment.