ORIGINAL RESEARCH

International Journal of Surgery 10 (2012) 470e474

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International Journal of Surgery

journal homepage: www.theijs.com

Original research

Accuracy of FAST scan in blunt abdominal trauma in a major London

trauma centre
Simon Fleming a, Ruth Bird b, Kumaran Ratnasingham c, Shah-Jalal Sarker d, Mike Walsh e, Bijen Patel e, *
a
Barts and the London NHS Trust, Whitechapel, London E1 1BB, UK
b
Colchester NHS Trust, Turner Road, Colchester, Essex CO4 5JL, UK
c
Surgical Skills and Science, Barts Institute of Cancer, Old Anatomy Building, Charterhouse Square, London EC1M 6BQ, UK
d
Biostatistics, Centre for Experimental Cancer Medicine, Barts Cancer Institute, Barts and the London NHS Trust, Whitechapel, London E1 1BB, UK
e
Academic Department of Upper GI Surgery, Barts Institute of Cancer - a CR-UK Centre of Excellence, Queen Mary University of London, Old Anatomy Building,
Charterhouse Square, London EC1M 6BQ, UK

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Blunt abdominal trauma (BAT) is a leading cause of morbidity and mortality. Rapid diag-
Received 16 November 2011 nosis and treatment with the Advanced Trauma Life Support guidelines are vital, leading to the devel-
Received in revised form opment of Focused Assessment with Sonography in Trauma (FAST).
19 April 2012
Methods: A retrospective study carried out from January 2007e2008 on all patients who presented with
Accepted 22 May 2012
BAT and underwent FAST scan. All patients subsequently had a CT scan within 2 h of admission or
Available online 30 May 2012
a laparotomy within two days. The presence of intra-peritoneal free fluid was interpreted as positive.
Results: 100 patients with BAT presented; 71 had complete data. The accuracy of FAST in BAT was 59.2%;
Keywords:
Ultrasound
in these 31 (43.7%) were confirmed by CT and 11 (15%) by laparotomy. There were 29 (40.8%) inaccurate
Trauma FAST scans, all confirmed by CT. FAST had a specificity of 94.7% (95% CI: 0.75e0.99) and sensitivity of
Computerised tomography 46.2% (95% CI: 0.33e0.60). Positive Predictive Value of 0.96 (0.81e0.99) and Negative Predictive Value of
Abdominal injuries 0.39 (0.26e0.54). Fisher’s exact test shows positive FAST is significantly associated with Intra-abdominal
London pathology (p ¼ 0.001). Cohen’s chance corrected agreement was 0.3. 21 out of 28 who underwent
laparotomies had positive FAST results indicating accuracy of 75% (95% CI: 57%e87%).
Conclusion: Patients with false negative scans, requiring therapeutic laparotomy is concerning. In
unstable patients FAST may help in triaging and identifying those requiring laparotomy. Negative FAST
scans do not exclude abdominal injury. Further randomised control trials are recommended if the role of
FAST is to be better understood.
Ó 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction
Blunt abdominal trauma is a leading cause of both morbidity
and mortality in patients in the emergency department.1 Rapid
diagnosis and treatment are considered vital in the successful
management of the trauma patient, as missed injuries can lead to
preventable deaths.
All trauma patients are assessed and managed according to the
ATLS guidelines. Information from the primary survey combined
with examination of the abdomen is used to detect the likelihood of
possible injuries and tailor management plans. Abdominal pain/
tenderness together with observations such as blood pressure are
used in assessment to detect injury, however a limitation of this is
* Corresponding author. Tel.: þ44 7710678506; fax: þ44 2071016584.
E-mail address: b.patel@qmul.ac.uk (B. Patel).
that large amounts of blood can build up in the peritoneum before
such positive signs and symptoms can be detected on physical
examination alone. A retrospective study by Schurink et al in 1997
showed that abdominal examination produced equivocal results in
nearly half the patients with multiple injured trauma patients.2
This highlighted the need for further investigations in order to
aid better management.
Multi-slice CT scans can produce very detailed images, are non-
invasive and have become the gold standard investigation in
assessing blunt abdominal trauma. With the development of helical
CT, the scan time has been significantly reduced, improving its
usefulness with a sensitivity and specificity of over 95% in detecting
intra-abdominal injury and a high negative predictive value of
nearly 100%.3 It is also useful for localising, identifying and
assessing severity of solid organ injury helping guide the non-
operative management or surgical planning.4 The development
of contrast enhancement helical CT has enabled more accurate

1743-9191/$ e see front matter Ó 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijsu.2012.05.011
 ORIGINAL RESEARCH
S. Fleming et al. / International Journal of Surgery 10 (2012) 470e474
arterial/mesenteric injury detection and can be used to guide
surgical or angiographic intervention.5 It has also been shown to
improve bowel injury and retroperitoneal organ injury detection
rates.6
CT scans do however have their limitations and disadvantages.
The principal one being the need to transfer the patient to the
scanner from the emergency department, making it unsuitable in
unstable patients. Paediatric patients often require sedation, which,
means constant monitoring for risk of airway compromise. The
procedure also requires specialised radiographers to perform the
investigation and radiologists to interpret the images. Contrast
agents are known to cause allergic reactions in some patients. It
should also be noted that a conventional anterioreposterior
abdominal x-ray examination results in a dose to the stomach of
approximately 0.25 mGy, which is at least 50 times smaller than the
corresponding stomach dose from an abdominal CT scan.37 Also in
abdominal CT effective radiation dose is the equivalent of 400 chest
x-rays and the equivalent of 2.7 years worth of natural radiation
dose. This is, however, balanced out in terms of risk: benefit as
accurate diagnosis in these acute traumas far outweighs the
possible radiation risk.40
The need for a prompt diagnostic technique that could be used
in the emergency setting led to the introduction of focused
assessment with sonography in trauma (FAST) in emergency
departments in the 1990’s. It is undertaken after the primary survey
in order to identify the presence of free fluid in the peritoneal
cavity, which may represent haemoperitoneum, and thus enable
early referral for further imaging (CT), and/or surgery if necessary.1
Studies have shown that FAST can pick up as little as 100 ml of free
fluid, characterised by low echogenicity which appears black on
screen, or blood which is of increased echogenicity.7 There is some
evidence to suggest it can detect as little as 30 ml of free fluid, but
100 ml is generally considered to be the level at which FAST scan-
ning is accurate.8 Knowing that a patient has free fluid suggests the
possibility of severe intra-peritoneal haemorrhage and supports
the case for further management, such as an emergency CT and/or
surgery. Haemodynamically stable patients may be sent for CT
scanning in order to assess the origin and extent of injury so as to
achieve prompt and appropriate management, whilst haemody-
namically unstable patients may be taken directly to the operating
theatre for emergency laparotomy where a lack of formal,
comprehensive imaging could potentially lengthen the theatre
time as the site and extent of injury is unknown. Unlike FAST scan,
CT’s are able to detect solid organ injury, however a large study by
Fakhry et al in 2003 showed that nearly 15% of patients with
perforated small bowel injury had a normal pre-operative CT scan
so they are not without limitation.9 In unstable patients where time
is critical, ultrasound is quick and can be done at the bedside,
several observational studies have shown its utility as a screening
test in this setting.10e14 However, in stable patients the position of
FAST in the diagnostic algorithm has not been well established. It
has been shown to compare unfavorably with computerized
tomography (CT) when detecting injuries, so missed injuries are
a major concern.15e17
FAST’s ability to detect free fluid rapidly and in a non-invasive
manner has made it more attractive than other ‘in department’
tests such as diagnostic peritoneal lavage which carries risks of
perforation, infection and bleeding. Despite apparent ease of use
and accessibility, the accuracy of FAST scan is related to the
machine, the operator and the patient. Body shape, obesity and
surgical emphysema can make scans difficult to perform and
without a skilled operator, FAST has potential for misinterpretation
or, misdiagnosis.
Despite the popularity of FAST, there remains a lack of clarity
and evidence around any actual contribution to patient survival.1
471
No prospective trials have been performed in relation to FAST
scanning and so it has been adopted into current practise with the
entire evidence base being retrospective. The implications of this
are that we are still learning how effective it is, both as a diagnostic
tool and in changing the management of patients.
There seems to be no consensus for training for FAST scanning,
with the variation being from 1hr practical session to over 200
supervised scans.18e20 A Study by Shackford et al22 has shown that
the learning curve plateaus if trained properly after 10 scans,
however others showed that it took approximately 50 scans for the
learning curve to plateau.23 There is no consensus on how people
should be trained and no consistency in their assessment. However,
in the UK it was recommended by the Royal College of Radiolo-
gists38 that all Emergency physicians undertake FAST scan training
and this has been adopted by the College of Emergency Medicine
training curriculum.39 It is also agreed that training should
comprise of both theoretical and practical components with
continuous review by a mentor.21 A study by McKenney has shown
that the quality of the scan is no different whether performed by
a radiologist, surgeon or emergency physician24 leading to the
training of all 3 specialties.
This pragmatic, retrospective observational study was under-
taken to determine how the results of FAST scans were used in
a routine inner city emergency department and whether they
influenced the subsequent treatment of adult, blunt trauma
patients.
2. Methods
This paper reports a retrospective study carried out at a leading trauma centre,
the Royal London Hospital, from Jan 2007eJan 2008. It included all patients aged
over 18 years who presented with blunt abdominal trauma and underwent a FAST
scan on arrival in the emergency department. Inclusion criteria required all patients
to then have had a CT scan within 2 h of admission or those who underwent
a laparotomy within the next two days. Patients with incomplete FAST, CT or clinical/
surgical notes were excluded. The FAST scans were performed by emergency
physicians ranging from 1st year SPR, to staff grades to consultants, depending on
their availability. These findings were documented in medical notes and along with
the assessment of solid organs. The presence of free fluid or intra-peritoneal fluid
was interpreted as a positive fast scan. Contrast CT images were obtained from the
xiphoid to the symphysis pubis. The scans were immediately viewed by an on call
radiologist ranging from 1st year SPR to consultant. However, a consultant reviewed
all images at a later date. PACS was used to retrieve these reports and data input from
medical notes collected on a standardised collection form.
3. Analysis
Fast reports were compared with CT scan reports if performed
within 2 h of the initial scan. If CT scans were not performed then
FAST scans were compared with laparotomy findings if present.
4. Results
100 patients with Blunt Abdominal Trauma were seen in the
Royal London Hospital emergency department between January
2007 to January 2008. A total of 80 medical notes were retrieved, 9
of these were unsuitable for the study as 6 were hospital transfers
and 3 had no FAST scan, therefore a total of 71 patients were
included.
62% of these were male patients. The mean age of participants
was 41 years with a standard deviation of 19 (range 18e83). Assault
was the most common cause (32%) followed by falls (28%) and
motor vehicle accident (14%).
5. Accuracy of FAST scan
The accuracy/inaccuracy of FAST scan was calculated. 84.5% of
cases were confirmed by CT and on 15.5% were confirmed by
 ORIGINAL RESEARCH
472 S. Fleming et al. / International Journal of Surgery 10 (2012) 470e474
laparotomy findings. The accuracy of FAST in BAT was 59.2%. Out of
the 42 accurate cases, 31 (43.7%) were confirmed on CT and 11 (15%)
were confirmed at laparotomy. There were a total of 29 (40.8)
inaccurate FAST scans, all of which were confirmed by CT.
All the FAST scans were divided into 4 groups;
1. positive scans with pathology present (on CT or laparotomy)
2. positive scan but without intra-abdominal pathology
3. negative scan but with intra-abdominal pathology actually
present
4. negative scan without pathology.
Table 1 shows that specificity of FAST scanning was high at 94.7%
(95% CI: 0.75e0.99), with a sensitivity of 46.2% (95% CI: 0.33e0.60).
It also shows a Positive Predictive Value of 0.96 (0.81e0.99) and
a Negative Predictive Value of 0.39 (0.26e0.54).Fisher’s exact test
shows that FAST result is significantly associated with the Intra-
abdominal pathology (p ¼ 0.001). Cohen’s chance corrected
agreement between the FAST scans and actual CT/Laparotomy was
0.3 which is fair41.
22 out of the 28 patients who had therapeutic laparotomies
were found to have positive FAST scan results. That is a 75% accu-
racy (95% CI: 57%e87%) of FAST in detecting intra-abdominal injury
that required therapeutic laparotomy. Indicating a 25% false nega-
tive in FAST scan.
5.1. Incidental solid organ analysis
FAST results were compared to CT or laparotomy findings for
detecting solid organ injury (Liver and/or spleen) and again for
retroperitoneal injury (renal or adrenal). Only one case of retro-
peritoneal injury was detected by FAST with 89% of injury to
kidneys or adrenal glands not being detected (1 case out of 11). Only
38.5% (10 cases out of 26 patients with injuries) of solid organ
injury (Liver or spleen) were detected by FAST.
6. Discussion
The high Positive Predictive Value of the FAST Scan combined
with its high specificity suggests that a positive result in FAST scan
should be identified and acted upon without delay. However, with
a sensitivity of 46.2% and a ¼ of results being false negative, it is also
prudent to consider carefully what that action should be.
Early detection of intra-abdominal injury is crucial in allowing
the clinician to optimise the treatment for patients with blunt
abdominal injury. CT remains the gold standard investigation for
assessing these patients, however it may not be possible to perform
at CT for numerous reasons, some of the most common being
haemodynamically instability or pregnancy. FAST scan has clear
potential advantages and disadvantages over CT scanning. It is
quick to perform, portable; allowing it to be performed at the
bedside and does not expose patients to radiation. Equally, it is user
dependant and, as this data suggests, a negative scan does not
always rule out an occult pathology, which may later require
further intervention.
Table 1
Comparative of FAST results with CT/laparotomy finding.
Positive pathology Negative pathology
Positive FAST 24 1 25
Negative FAST 28 18
Total 52 19
The historical data available from studies performed in the early
days of FAST scan usage in a trauma setting, primarily during the
1990s, put FAST scan in a positive light, which lead to the American
College of Surgeons recommending FAST as an alternative to
diagnostic peritoneal lavage or CT and was held in such high regard
that it was integrated into the Acute Trauma Life Support (ATLS)
program and in Germany was made a compulsory part of the
surgical residency training program.
With all of the successful studies being published in relation to
FAST scan, Chiu et al. raised valid concerns regarding the sensitivity
of FAST. Their study showed 50 out of 196 patients with free fluid on
CT did not have detectable fluid on FAST scan.25 This early work
correlates precisely with the real time experiences of this study
(Tables 1 and 2). Kathirkamanathen et al found that more than 25%
of patients with visceral injuries did not have free fluid on FAST scan
taken at admission, though the data from this study was insignif-
icant in terms of these findings. Therefore the reliance of detecting
free fluid by FAST does have its limitations and the clinicians are
clearly aware of this and must use it within the context of a full
clinical assessment. The data showed that the trauma teams are
aware of these limitations and the need for assessment and reas-
sessment as evidenced by the number of patients who went on to
further intervention, regardless of their FAST result.26
It has in fact been suggested that the true usefulness of FAST was
in the context of hypotensive patients and that it could instead be
used to ‘triage’, rather than diagnose, patients to laparotomy or
further clinical evaluation or investigation.27e29
In this study, the sensitivity of FAST scans in detecting free fluid
was 46.2% with 28/71 false negatives. 7 of these false negative
patients went on to require a therapeutic laparotomy. This does
strongly suggest that even at a Major Trauma Centre, FAST scan can
miss serious injury, if used in isolation.
A study by Moylan et al showed that 25 out of 33 (75.8%
sensitivity) therapeutic laparotomies had positive FAST scan.30
These findings are again, very similar to the data from the Royal
London (Table 2) and raise similar concerns regarding the possi-
bility of a potential quarter of patients who may have missed
diagnoses, if relying on FAST scan alone.
There was only one false positive, but in the context of this
patient, as they were haemodynamically stable, the patient went
onto have a CT scan which revealed no free fluid or intra-abdominal
injury, allowing the patient to be observed and discharge in due
course rather than going onto receive therapeutic laparotomy. This
further showed that within this research, there is an awareness of
FAST’s limitations and if the opportunity arises, more accurate
imagination is achieved. Due to the fact that small amounts of free
fluid are, even by experienced practitioners, difficult to detect, or
may not be detected by at all by FAST, it has been suggested that if
a patient is clinically stable on regular reassessment, a negative FAST
scan should be followed up by observation with at least a follow up
FAST scan. No trials have been performed regarding this matter.
Within the this study, FAST scanning missed 61.5% of solid organ
injury, again keeping in line with previous studies and experiences
elsewhere.31 The reason for such low detection rates is explained by
the fact that a significant proportion of these injuries do not
produce haemoperitoneum, or any free fluid in the abdomen and as
such highlight another weakness of FAST. Solid organ injury
Table 2
Shows the outcome of FAST scan in all the patients who had therapeutic laparotomy.
Therapeutic laparotomy
Total
Positive FAST scan Negative FAST scan
46 Number of patients 21 (75%) 7 (25%)
71 Total 28
 ORIGINAL RESEARCH
S. Fleming et al. / International Journal of Surgery 10 (2012) 470e474
accounts for a significant proportion of intra-abdominal injury in
blunt trauma and even though most are managed conservatively,
the detection of such injury is imperative in allowing the clinician
to make an informed decision as to whether to initiate conserva-
tive, medical or surgical management. The lack of vital information
in relation to an occult organ injury can be dangerous for the
patient especially if the injury is significant and causes rapid or
sudden deterioration, requiring rapid decisions to be made. This
research, in line with the work of Richard et al and McGahan et al,
experienced very low detection rates for renal/adrenal injury as
well as a lack of detection of bowel or mesentery injury. This all
gives ammunition to the argument that FAST has no major role in
identifying solid organ injury and as such has a major weakness as
a primary diagnostic choice.32,33 FAST scan is not designed to assess
solid organ injury and if such an injury is suspected, a formal
ultrasound or other imaging modality should be performed by an
appropriately trained clinician.
The difficulty in rationalising FAST for haemodynamically
unstable patients is that a negative FAST scan does not rule out
intra-abdominal injury. Therefore if the patient is unstable, with
a negative FAST scan, yet there is a high index of suspicion of intra-
abdominal pathology, whether this is based on history, examina-
tion or a combination of factors, the teams looked at during this
research would proceed to laparotomy regardless of FAST result.
The only proviso was that if it was felt that the patient could
tolerate it, there was the potential to proceed to CT to give a more
informed picture, not only for diagnostic purposes, but to inform
the surgeon of any relevant surgical anatomy. It must be added that
at this time there are no quantitative standards in use regarding
when a patient is ‘stable’ enough to have a CT scan. This again is
a clinical decision that was made, as a team, by the clinicians at the
Royal London.
There are, of course, limitations to this study of the experiences
at the Royal London. As with all retrospective studies, all data relied
on the written records found in patient notes and so there is the
possibility of recall bias, although there was none apparent within
this research. There was as with all retrospective studies no
blinding or randomisation, either in those performing or inter-
preting any of the imaging or further interventions.
There was exclusion of patients with incomplete data or
missing notes, though missing notes and incomplete data sets
were random and occurred in all groups and therefore not
believed to cause statistical bias. The quality of FAST scan will vary
from one operator to another as the emergency physicians per-
forming the scans at the time of this study will have had varied
amounts of training and experience and there is no data as to
whether every operator has been formally trained or has picked
up the skill “on the job”. The FAST scans in our study were per-
formed by emergency physicians ranging from 1st year Registrars
and went on to include staff grades and consultants (depending on
their availability). However a further limitation of the study is that
there is no documentation of the levels of training these doctors
received during their careers, prior to performing these scans.
However by ensuring that only senior Emergency doctors per-
formed the scans we guarantee an implicit level of experience and
from our data there was no apparent difference in false negatives
between operators of registrar level to consultant. Standardised
training that has now been introduced would improve the quality
of any further study.
The time taken between FAST scan and CT scan may also have
been another source of potential bias. FAST scan at the Royal Lon-
don was performed within half an hour of patients arriving in the
emergency department and whereas CT occurred at a later stage
(approximately 30e90 min later). There is suggestion that detect-
able quantities of free fluid may develop during the time between
473
initial assessment and later imaging and thus cause a bias towards
more false negatives. A similar bias may occur when comparing
FAST to laparotomy; free fluid may also have developed in the
interim period between admission and operation.
Another source of possible limitation is interpretation of
imaging (both FAST and CT) in that there was variability in expe-
rience at the initial reporting, however at the Royal London all CT
scans were later reviewed by a consultant, whereas by the very
nature FAST scans do not allow for a delayed review and therefore
not all of these were consultant scans.
The other aspect to this possible limitation was that the radi-
ologist performing both the initial and senior report of the CT
imaging was aware of the FAST results prior to reviewing the CT
(thus there was no blinding of the image interpreter), however
good clinical practise dictates the radiologist should have as much
information as possible, so this is difficult to avoid.
This study did not use serial FAST examinations. There is evidence
to suggest such practise increases the sensitivity of FAST34e36 The
exact time of injury was not always documented making it difficult
to estimate time between injury and imaging.
7. Conclusion and recommendations
This study casts more doubts regarding the usefulness of FAST
scan, within practise at the Royal London and thus more widely. The
high ratio of patients with false negative scans, requiring thera-
peutic laparotomy is a concern. In a trauma centre with an easily
accessible CT scanner, this should be the imaging of choice. In
unstable patients FAST may help in triaging and identifying
patients who need to go on to have a laparotomy but other clinical
considerations play a far more important role in the decision
making process and must be carefully examined. Negative FAST
scans do not exclude injury to the abdomen and further observa-
tions and imaging are needed to exclude this.
Patients with negative FASTs need further imaging/assessment,
however positive FAST scans tell us the patient most likely has
abdominal injuries which may potentially be time critical.
Regarding this study’s effect on the management of patients with
blunt abdominal trauma, because we know that a positive FAST
corresponds with intra-abdominal pathology from CT and lapa-
rotomy findings in 75% of cases, It may help in the triage of patients
to CT in the event of multiply injured patients, although hemody-
namic status and patient history are also going to guide our
decisions.
In UK trauma centres where CT scanning is available 24 h a day,
the use of FAST scan is limited. Further randomised control trials are
recommended if the role of FAST scanning is to be better under-
stood. In trauma units it will remain a weapon in their diagnostic
arsenal, but is not the only one at their disposal.
Ethical approval
None.
Funding
None.
Author contribution
Mr Simon Fleming e Writing the paper.
Dr Ruth Bird e Data analysis.
Dr Kumaran Ratnasingham e Data collections.
Mr Mike Walsh e Study design.
Mr Bijendra Patel e Critically revising the paper.
Conflicts of interest
None.
 ORIGINAL RESEARCH

474 S. Fleming et al. / International Journal of Surgery 10 (2012) 470e474

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