Melniker LA, Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med. 2006 Sep;48(3):227-35. PMID: 16934640
Resident Reviewer: Courtney Cassella
What we already know about the topic
Trauma is an extremely common complaint in the emergency department with high potentional for morbidity and mortality. In trauma, Point-of-care limited ultrasonography (PLUS) examinations may supplement decision-making. PLUS exams are accurate to answer focused clinical questions in trauma, for example occult fluid in the peritoneal, pericardial, or pleural cavity. In the National Trauma Bank 45,365 patients with torso trauma who had PLUS exams had improved door to OR times, reduction in charges, and reduced length of stay.
Why this study is important
Prior to this study, retrospective data bank information indicated a benefit to PLUS. Additional studies indicated high accuracy of PLUS. However, until this study there was limited prospective evidence based data for the clinical or therapeutic utility of PLUS in trauma.
Brief overview of the study
This was a prospective, randomized, non-blinded, controlled clinical trial of all adult and pediatric trauma patients presenting to Level I trauma centers with suspected torso trauma. PLUS-arm patients were evaluated with the FAST by credentialed ED sonographers. 217 patients were included in the study, 111 PLUS vs. 106 controls. The primary outcome was time to operative care, the PLUS group had 64% less time compared to control. Of secondary outcomes, PLUS patients had fewer CT scans (OR 0.16, 95% CI 0.07 to 0.32), a 27% reduction in length of stay if non-operative, a reduction in total charges, and lower composite complications including hemorrhagic shock, septic shock, MOF, and death (OR 0.27, 95% CI 011 to 0.67).
One limitation is the primary outcome of time to operative care is based on the premise of the “golden hour” in trauma that earlier definitive management improves outcomes. However, the concept of the golden hours is not proven. In addition, 41% of eligible patients with slightly higher acuity compared to the study population were not enrolled secondary to lack of consent or attending refusal. Additional limitations include inability to blind and possible issues with screening as only 55% of the study population ended up having torso trauma as a final diagnosis.
Take home points
- Point of care ultrasound in trauma has many potential benefits including
- Decreased time to OR
- Lower utilization of CT scans
- Reduced total charges for the patient