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I would like to take this opportunity to thank the authors for their thorough analysis of the Cochrane database in regards to the review by Stengal et al entitled Emergency Ultrasound-Based Algorithms for Diagnosing Blunt Abdominal Trauma. Since receiving their letter, I have reviewed both the initial study by Boulanger et al, as well as the systematic review and indeed, the denominators were switched. In summarizing the review, I must admit that I did not detect this error. With this correction, the data does suggest a statistically significant decrease in computed tomographic usage. The statistically significant decrease in diagnostic peritoneal lavage is also noted, although somewhat expected, given the fact that the Focused Assessment with Sonography for Trauma (FAST) exam has largely replaced diagnostic peritoneal lavage in practice.

I would, however, like to reiterate my concern regarding decreased computed tomographic usage as a key outcome marker. Although many studies have reported this data, our clinical practice in the United States has been to use ultrasound as an adjunct to the primary trauma survey. Ideally, the FAST exam helps physicians to rapidly assess for the site of hemorrhage in a hemodynamically unstable patient and to expedite appropriate disposition based on the ultrasound findings. Clearly, the unstable patient with a positive FAST exam should go to laparotomy rather than to the computed tomography suite. However, the stable patient with blunt abdominal trauma and abdominal pain should not forego computed tomography based on a negative FAST exam. It is in these patients where isolated organ injuries are often found including contusions, low-grade liver and splenic lacerations without hemoperitoneum, and renal injuries. The FAST exam is an admittedly poor screening test in these types of injuries without intraabdominal free fluid. Therefore, it is not prudent to replace a highly sensitive diagnostic exam such as computed tomography with a much less sensitive FAST exam in this “low risk” population. This is precisely the “false sense of security” that Stengel et al were referring to in the Cochrane review.

I would like to again thank the authors for their careful review of the literature in this matter. I did correspond with Dr. Stengel regarding the authors’ points, and his response follows this letter. We should continue to study the performance of FAST exam in the acutely traumatized patient, focusing on patient morbidity, mortality, and time to appropriate disposition as key outcome variables. Although the data regarding decreased computed tomography usage is interesting, I would contend that attempts to replace computed tomographic scanning in the hemodynamically stable patient with serial FAST exams puts patients and physicians at risk of missing clinically significant injuries.