11 - Operating Without Guidance: Pediatric EFAST Exams Highlight the Need for a Pediatric CPG

Introduction: Portable ultrasound is a critical tool used by SOF medics to identify life-threating injuries and make informed triage decisions far forward. The EFAST ultrasound exam is fundamental to this process, and it is routinely trained, sustained, and employed by SOF medics. However, the application of the EFAST exam in pediatric patients remains underexplored and faces obstacles in austere environments. As large-scale combat operations and irregular warfare escalate in urban environments, SOF medics are at increasing likelihood of having to provide far-forward care to children. Diagnostic inaccuracies using EFAST in this context may result in unnecessary evacuations or missed injuries, straining battlefield resources and operational priorities. We present the case of a six-month old with a false positive EFAST exam, along with the results of a literature review and analysis, and call for a clinical practice guideline to inform the use of the EFAST exam in pediatric trauma patients in the field.

Methods: Facts and Case Background
A six-month old female presented to a military treatment facility Emergency Department after a blunt trauma and received an EFAST that appeared positive to an experienced operator. Her alkaline phosphatase and ALT were within normal limits, but her AST was mildly elevated at 67. She received a CT scan of her abdomen that was negative for acute traumatic injury and was discharged.

Methods
We conducted a PubMed search using the following search terms, “pediatric EFAST trauma,” which yielded fourteen results, three of which were found to be relevant. A second PubMed search used the terms, “pediatric FAST ultrasound trauma,” which produced 171 results and 38 relevant articles. We included articles published in English in the preceding 25 years. Articles appearing in both searches were not counted twice.

Results: Not germane to this literature review

Discussion: Performing EFAST exams on children far forward raises challenges unique to the domain and which have not yet been considered in the literature. Although the EFAST exam is not intended to be used in isolation, SOF medics do not have access to ancillary testing that can inform interpretation of a pediatric EFAST exam. SOF medics are also less likely to be experienced operators in the interpretation of the pediatric EFAST exams, which heightens the risk of false positives and negatives. As demonstrated by the case presentation, even with ancillary testing and an experienced operator, the EFAST exam in pediatric patients can yield false positives with resultant radiation load to young patients. SOF medics, along with all medical providers, will benefit from parameters set forth in a clinical practice guideline for interpretation of the pediatric EFAST far forward.

Conclusion: Despite the great potential of ultrasound far forward, SOF medics at present lack an evidence-based framework to support their use of pediatric EFAST exams. This gap highlights the urgent need for further research and a clinical practice guideline directed to the pediatric EFAST exam.