Donner Viviane, Thaler Julian, Hautz Wolf E, Sauter Thomas Christian, Ott Daniel, Klingberg Karsten, Exadaktylos Aristomenis K, Lehmann Beat
Department of Emergency Medicine Inselspital, University Hospital Bern Bern Switzerland.
Faculty of Medicine University of Bern Bern Switzerland.
J Am Coll Emerg Physicians Open. 2024 Apr 19;5(2):e13123. doi: 10.1002/emp2.13123. eCollection 2024 Apr.
Clinical examination alone cannot reliably rule out significant traumatic abdominal injury. Computed tomography (CT) has become the primary method for evaluating blunt abdominal trauma and clinicians rely heavily on it to rule out abdominal injury. Ultrasound examination may miss significant abdominal injury particularly in stable patients. The use of a contrast agent improves ultrasound sensitivity to visceral abdominal injuries. The objective of this diagnostic study is to compare bedside contrast enhanced ultrasound (CEUS) performed by emergency physicians to CT in hemodynamically stable adults for the assessment of blunt abdominal trauma and evaluate CEUS accuracy outcomes.
Hemodynamically stable patients with blunt trauma were prospectively enrolled in the trauma bay. After initial evaluation, we included patients at risk of abdominal injury and for whom an abdominal CT was planned by the trauma leader. Ultrasonography was performed prospectively and at the bedside by the emergency physician followed by abdominal CT used as a reference standard.
Thirty-three patients were enrolled in the study; among them, 52% showed positive traumatic findings in abdominal CT scans, and 42% were diagnosed with solid organ lesions. Compared to CT, a focused abdominal sonography (FOCUS) examination, looking for free fluid or perirenal hematoma, showed limited performance for traumatic findings with a sensitivity of 65% (95% confidence interval [CI]: 38%-86%), a specificity of 75% (95% CI: 48%-93%), a negative likelihood ratio (NLR) of 0.47 (95% CI: 0.23-0.95), and a positive likelihood ratio (PLR) of 2.59 (95% CI: 1.03-6.48). When combining FOCUS with CEUS, the sensitivity of the sonography increased to 94% (95% CI: 71%-100%) with a specificity of 75% (95% CI: 48%-93%). The PLR was 3.76 (95% CI: 1.6-8.87) and the NLR was 0.08 (95% CI: 0.01-0.54). In our population, abdominal sonography with contrast failed to identify a single positive abdominal CT with a grade 1 kidney injury.
A FOCUS examination shows limited sensitivity and specificity to detect positive abdominal CT in stable adults with abdominal trauma. With the addition of contrast and careful inspection of solid organs, abdominal sonography with contrast performed by the emergency physician improves the ability to rule out traumatic findings on abdominal CT. CEUS performed by emergency physicians may miss injuries, especially in the absence of free fluid, in cases of low-grade injuries, simultaneous injuries, or poor-quality examinations.
仅靠临床检查无法可靠地排除严重创伤性腹部损伤。计算机断层扫描（CT）已成为评估钝性腹部创伤的主要方法，临床医生严重依赖它来排除腹部损伤。超声检查可能会漏诊严重的腹部损伤，尤其是在病情稳定的患者中。使用造影剂可提高超声对腹部内脏损伤的敏感性。本诊断性研究的目的是比较急诊医生在血流动力学稳定的成年人中进行的床旁造影增强超声（CEUS）与CT在评估钝性腹部创伤方面的效果，并评估CEUS的准确性结果。
将血流动力学稳定的钝性创伤患者前瞻性纳入创伤室。初始评估后，我们纳入有腹部损伤风险且创伤负责人计划为其进行腹部CT检查的患者。超声检查由急诊医生前瞻性地在床旁进行，随后将腹部CT用作参考标准。
33例患者纳入研究；其中，52%在腹部CT扫描中显示有阳性创伤发现，42%被诊断为实体器官损伤。与CT相比，聚焦腹部超声（FOCUS）检查寻找游离液体或肾周血肿，对创伤发现的表现有限，敏感性为65%（95%置信区间[CI]：38%-86%），特异性为75%（95%CI：48%-93%），阴性似然比（NLR）为0.47（95%CI：0.23-0.95），阳性似然比（PLR）为2.59（95%CI：1.03-6.48）。当将FOCUS与CEUS结合时，超声的敏感性提高到94%（95%CI：71%-100%），特异性为75%（95%CI：48%-93%）。PLR为3.76（95%CI：1.6-8.87），NLR为0.08（95%CI：0.01-0.54）。在我们的研究人群中，造影剂增强腹部超声未能识别出一例腹部CT显示为1级肾损伤的阳性病例。
FOCUS检查在检测腹部创伤稳定成年人的腹部CT阳性结果方面敏感性和特异性有限。通过添加造影剂并仔细检查实体器官，急诊医生进行的造影剂增强腹部超声提高了排除腹部CT创伤发现的能力。急诊医生进行的CEUS可能会漏诊损伤，特别是在没有游离液体、低级别损伤、合并损伤或检查质量差的情况下。
