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J Vet Emergen Crit Care - 2009 - Lisciandro - Evaluation of An Abdominal Fluid Scoring System Determined Using Abdominal
J Vet Emergen Crit Care - 2009 - Lisciandro - Evaluation of An Abdominal Fluid Scoring System Determined Using Abdominal
Abstract
Objective – Evaluate an abdominal fluid scoring (AFS) system using an abdominal focused assessment with
sonography for trauma (AFAST) protocol.
Design – Prospective study.
Setting – Private veterinary emergency center.
Animals – One hundred and one client-owned dogs with motor vehicle trauma.
Interventions – AFAST performed on admission and 4 hours post-admission.
Measurements and Main Results – An AFS was assigned to each dog based on the number of AFAST fluid-
positive quadrants identified using a 4-point scale: AFS 0 (negative for fluid in all quadrants) to AFS 4
(positive for fluid in all quadrants). Free abdominal fluid was identified in 27 of 101 dogs (27%). Dogs with
AFS scores of 3 or 4 (14/27 [52%] AFS-positive dogs) experienced more marked decreases in packed cell
volume and total plasma protein, increases in alanine aminotransferase, and needed more blood transfusions
than dogs with lower AFS scores and AFS-negative dogs. Serial AFAST was performed in 71% of dogs (71/
101); 17% (12/71) of these cases changed AFS score, and 75% (9/12) of the changes were higher (worsened)
AFS, correlating with increasing amounts of free abdominal fluid. Ninety-eight percent of the study
population was a primary presentation. Overall, median time from trauma to initial AFAST was 60 minutes,
and median AFAST examination time was 3 minutes.
Conclusions – Initial and serial AFAST with applied AFS allowed rapid, semiquantitative measure of free
abdominal fluid in traumatized patients, was clinically associated with severity of injury, and reliably guided
clinical management. Where possible, AFAST and AFS should be applied to the management of blunt trauma
cases.
(J Vet Emerg Crit Care 2009; 19(5): 426–437) doi: 10.1111/j.1476-4431.2009.00459.x
From the Emergency Pet Center Inc, San Antonio, TX 78217 (Lisciandro, Introduction
Lagutchik, Mann, Tiller, Cabano, Bauer, Book, Howard); and the Depart-
ment of Veterinary Integrative Biosciences, College of Veterinary Medicine, Undiagnosed intra-abdominal injury1–3 and uncon-
Texas A & M University, College Station, TX 77843, USA (Fosgate).
trolled hemorrhage4,5 are leading causes of death in
Presented in part at the Resident Abstracts session at the International human trauma patients, and ongoing hemorrhage is
Veterinary Emergency and Critical Care Society Symposium, San Antonio,
TX, September 2006. responsible for 80% of early death in hospitalized hu-
mans.3,6–10 Historically, occult hemorrhage in human
The authors declare no conflicts of interest.
trauma patients has been problematic because aggres-
Address correspondence and reprint requests to sive fluid therapy in this subset of patients may exac-
Dr. Gregory R. Lisciandro, Emergency Pet Center Inc, 8503 Broadway, Ste
105, San Antonio, TX 78217, USA.
erbate bleeding and increase patient morbidity and
Email: woodydvm91@yahoo.com mortality.11–15 Medical management of traumatized
patients with known or occult intra-abdominal hemor- expediting the diagnosis of otherwise occult intra-ab-
rhage is complicated, because routine measures taken dominal injury.18,20,24–26,38 Given that ultrasound (US) is
to assess the presence of intra-abdominal hemorrhage readily available in many veterinary practices and pro-
(eg, physical examination findings, arterial and central ficiency using the FAST technique by non-radiologist
venous blood pressure, and abdominal radiographic clinicians has been demonstrated in human and veter-
examination) have variable and poor reliability and inary studies,5,33,a development of a veterinary fluid
sensitivity for detecting the presence of hemo- scoring system using FAST that would semiquantita-
peritoneum.5,13,16–23,a tively assess the initial and progressive degree of intra
Recently, focused assessment with sonography -abdominal injury would be helpful, as has been shown
(FAST) in patients with abdominal trauma has been in human FAST studies.16,17,24,25,38,39 However, veteri-
shown to provide rapid and accurate information re- nary data documenting the clinical utility of FAST in
garding the presence of hemoperitoneum in hu- identifying and quantifying hemoperitoneum is lack-
man5,16,17,22–32 and veterinary patients.33,a FAST is now ing. A preliminary studya of 82 dogs with motor vehicle
a favored diagnostic test for human trauma patients trauma noted the reliability of FAST examination to
because of its high specificity and sensitivity compared document intra-abdominal fluid and was the first to
with diagnostic peritoneal lavage (DPL) and computer- document application of a veterinary abdominal fluid
ized tomography (CT).29–31,34 In fact, FAST has nearly scoring (AFS) system. This study demonstrated that
eliminated the use of DPL and markedly reduced CT higher-scoring FAST-positive dogs experienced more
evaluations at some trauma centers.22,25,27–29,32,35,36 marked anemia and need for blood transfusion than
In contrast to FAST, DPL takes longer and is more in- lower-scoring and FAST-negative dogs. Evaluation of
vasive. DPL lends itself to complications (eg, iatrogenic an AFS system is warranted in traumatized veterinary
puncture of intra-abdominal structures) and confounds patients to help assess the degree of injury and guide
subsequent physical examinations and imaging because therapy.
of local and residual pain and the deposition of fluid The purpose of our study was to evaluate the appli-
into the abdominal cavity.37 DPL gives no information cation of a novel AFS system for the semiquantification
regarding the retroperitoneal space and is subject to of free abdominal fluid using initial and serial abdom-
time-consuming laboratory interpretation. Although CT inal FAST examinations. Our hypothesis was that ear-
is the gold standard for diagnosis of intra-abdominal lier detection and estimation of the quantity of free
injury, CT requires equipment not universally available abdominal fluid in trauma patients on presentation
and a hemodynamically stable patient for transport would allow clinicians to better assess the types and
to radiology. CT imaging also exposes the patient to severity of internal abdominal injuries and the need for
radiation.22 clinical intervention (eg, advanced diagnostic testing,
There are sparse clinical veterinary data regarding blood transfusion, surgical exploration), and would
the utility of FAST in traumatized patients. In the only have greater clinical utility than conventional methods
reported veterinary study,33 45 of 100 traumatized dogs of diagnosing intra-abdominal hemorrhage or urine or
(45%) were positive for free abdominal fluid, a marker bile leakage (eg, radiography). Furthermore, we hy-
of intra-abdominal injury, with a sensitivity of 96% and pothesized that the serial use of AFAST and AFS would
a specificity of 100%. Importantly, 39 of 45 (87%) FAST- allow trend analysis over time that would be useful to
positive dogs were diagnosed with hemoperitoneum direct clinical intervention or modify existing therapy.
by abdominocentesis and 9 of 45 (23%) required blood
transfusion. However, it should be noted that approx-
Materials and Methods
imately one-third of these dogs had been assessed by
another veterinarian and referred before abdominal fo- Case enrollment and management
cused assessment with sonography for trauma Dogs were eligible for study inclusion if they were
(AFAST); many most likely received fluid therapy presented to the veterinary emergency center within 24
before their FAST examination, and 16 dogs had ab- hours of motor vehicle trauma. AFAST was performed
dominocentesis performed before abdominal FAST ex- before abdominocentesis and following a standardized
aminations, which may have skewed results and protocol as previously described.33,a Owner consent
interpretation. was obtained before study enrollment for patients with
Hemoperitoneum scoring systems using FAST are known owners.
utilized in human trauma patients to semiquantitative- Patient demographic and medical data were re-
ly assess the degree of intra-abdominal hemor- corded in an electronic medical record as part of rou-
rhage.16,17,20,38 Serial FAST examinations favorably tine patient management. Outcome (long-term survival,
impact patient outcome by increasing sensitivity and death, or euthanasia) was recorded. Long-term survival
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x 427
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G.R. Lisciandro et al.
Diagnostic procedures
All clinicians participated in didactic US training by a
board-certified radiologist (K.A.M.) that included a re-
view of the basic physics of US and hands-on AFAST
training conducted by several authors (K.A.M., G.R.L.,
M.S.L.). Clinicians completed periodic reviews of
AFAST imaging, including hands-on wet labs and ac-
cess to a slide presentation detailing the procedure and
that included normal and abnormal images.
AFAST was performed as soon as possible after ad-
mission in the emergency room, typically in concert Figure 1: Depiction of the 4-point AFAST protocol beginning at
with examination, resuscitative efforts, and point-of- the diaphragmatic-hepatic (DH) view, followed by the spleno-
care testing, and before abdominocentesis. Every at- renal view (SR), the cysto-colic view (CC), and completed at the
tempt was made to perform AFAST within 15 minutes hepato-renal view (HR). The HR view is called the Home Run
of arrival. A 4-hour serial AFAST examination was per- site because in high-scoring dogs this gravity-dependent site is
formed in all hospitalized patients. All dogs were eval- commonly positive for fluid. Abdominocentesis can thus be
uated with the same model of US machineb using a performed at the HR view for fluid characterization at the ab-
7.5 MHz curvilinear probe. Imaging sites were not dominal focused assessment with sonography for trauma
(AFAST) exam’s completion. Direction (arrows) and order of
clipped of fur, and alcohol was used instead of acoustic
AFAST exam (numbered ultrasound probes) are illustrated.
gel for most patients, although some thick-coated
dogs had acoustic gel applied at the US probe-to-skin
interface. tient cardiovascular volume status.d Thus, these diag-
A standardized AFS was assigned to all cases after nostic techniques may be advantageously applied at
imaging 4 specific anatomic sites, as follows: AFS 0 was one time in one patient position.
assigned if no free abdominal fluid was noted at any of Preprinted, standardized data sheets were completed
the 4 imaging sites, AFS 1 was assigned if free abdom- by the attending veterinarian to record US findings at
inal fluid was noted at only 1 of the 4 imaging sites, each imaging site, real time of study, examination du-
AFS 2 was assigned if free abdominal fluid was noted at ration, patient’s clinical stability, and characterization of
2 of the 4 imaging sites, AFS 3 was assigned if free abdominocentesis if performed. Hemoperitoneum was
abdominal fluid was noted at 3 of the 4 imaging sites, diagnosed by abdominocentesis based on the failure of
and AFS 4 was assigned if free abdominal fluid was the fluid to clot, in addition to having a PCV and total
noted at all 4 imaging sites. Anatomic locations of pos- plasma protein (TPP) comparable to peripheral blood.
itive sites were recorded. Although these sites were the Abdominal radiographic serosal detail was assessed
same as described previously,33 we named each by their by a board-certified veterinary radiologist blinded to
associated targeted intra-abdominal structures, as fol- AFAST findings and the study population. Only pos-
lows: diaphragmatico-hepatic (DH) site, on the ventral itive AFAST images were printed for review by a board-
midline just caudal to the xiphoid; spleno-renal (SR) certified radiologist. All abdominal radiographs were
site, on the left lateral abdominal wall; cysto-colic (CC) performed using traditional film-screen radiography.
site, on the ventral midline cranial to the pubis; and Other diagnostic procedures performed on all pa-
hepato-renal (HR) site, on the right lateral abdominal tients as part of the standardized protocol included
wall. This is similar to human studies.22 The AFAST measurement of hemoglobin saturation by pulse oxi-
sites and sequential order of imaging are illustrated in metry (SpO2); determination of PCV and TPP, concen-
Figure 1. In contrast to Boysen et al,33 right lateral re- trations of blood lactate (BL), serum alanine
cumbency was preferred because the gall bladder, left aminotransferase (ALT), alkaline phosphatase, glucose,
kidney, and respective retroperitoneal space are more lipase, urea nitrogen, and creatinine, and TFAST as de-
readily imaged in this position, and iatrogenic puncture scribed previously.40,c Routine measurements of patient
of the spleen by abdominocentesis is less likely in the vital signs were recorded including heart rate, respira-
authors’ experience. Additionally, with the recent ad- tory rate, rectal temperature, pulse quality, mucous
vent of thoracic FAST (TFAST),40,c right lateral recum- membrane color, capillary refill time, and body condi-
bency allows standard electrocardiogram measurement tion score. Serial measurements of SpO2, BL, PCV, TPP,
and imaging of the left ventricle for assessment of pa- and TFAST were repeated approximately 4 hours after
428 & Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x
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Fluid scoring with AFAST in traumatized dogs
admission. Other diagnostic and monitoring proce- that included 22 dogs (22%) with PTX, 22 dogs (22%)
dures were performed at the discretion of the attending with pelvic fractures, 25 dogs (25%) with appendicular
veterinarian. fractures or luxations, and 2 dogs (2%) with diaphrag-
matic hernia (Table 1).
Statistical analysis All enrolled dogs were imaged by AFAST within 24
Data were summarized for AFS-positive and AFS-neg- hours of trauma. Every attempt was made to perform
ative dogs using descriptive statistics and 95% confi- AFAST within 15 minutes of arrival to our emergency
dence intervals. Student t tests were used to compare center. The majority of dogs (68%) were imaged using
means for quantitative data between groups and cate- AFAST within 2 hours of being traumatized; only 12%
gorical variables were compared using chi-square or dogs were initially imaged more than 3 hours after
Fisher exact tests. The proportion of other traumatic trauma. Median time from presentation to AFAST imag-
consequences (eg, fracture, coxofemoral luxation, ing was o5 minutes (range, 0, 420 min); from traumatic
pneumothorax [PTX], diaphragmatic hernia) were com- injury to AFAST examination was 60 minutes (range, 15,
pared between AFS-positive and AFS-negative dogs by 1440 min) and from initial to serial AFAST examination
the calculation of prevalence ratios, 95% confidence in- was 4 hours (range, 3, 7 h). The median time to complete
terval, and chi-square (or Fisher exact) tests. For AFS the AFAST examination was 3 minutes (range, 1, 30 min).
positive dogs, data were compared for animals with There were significant differences in the duration of
scores of AFS 1 and 2 versus AFS 3 and 4 on initial and examination between AFS-positive and AFS-negative
serial examinations. Mann-Whitney U tests were used dogs for both initial and serial examination (initial:
to compare medians of quantitative data between AFS 5.78 vs 3.59 min, P 5 0.006; serial: 5.66 vs 3.59 min,
groups and categorical variables were compared using P 5 0.006). However, there were no significant differ-
Fisher exact tests. Initial PCV was compared between ences between AFAST-positive and AFAST-negative
dogs with positive and negative AFS examinations us- dogs for time from admission to AFAST (38.9 vs
ing a Student t test. All statistical analyses were per- 14.6 min, P 5 0.08), time from trauma to AFAST (137.9
formed using available software.e,f Results with Po0.05 vs 102.7 min, P 5 0.44), and time from initial to serial
were considered significant. AFAST (4.4 vs 4.2 h, P 5 0.35). These data suggest there
was no clinician bias in the timing of AFAST examin-
ations in our study (Table 2).
Results
All 101 enrolled dogs had an initial AFAST per-
One hundred and one dogs with motor vehicle trauma formed, and 71 of these dogs had a serial AFAST per-
were enrolled in this study from April 2005 through formed 4 hours after admission. Thirty dogs did not
June 2006; 98% (98/101) were direct presentations to have serial AFAST performed; 8 were euthanized, and
our emergency center. There were 16 intact females, 31 22 were discharged before serial AFAST. Overall, 27%
spayed females, 30 intact males, and 24 neutered males, (27/101) of our study population was AFS-positive (ie,
with multiple breeds represented. Mean weight was free-abdominal fluid identified by AFAST). Of these,
19.2 kg (SD, 13.1 kg) and mean age was 2.7 years (SD, 78% (21/27) were positive at admission and the re-
2.5 y). Injuries within our study population were var- maining 6 dogs, initially AFS-negative, became AFS-
ied, but many dogs were presented with severe injuries positive at the time of their serial AFAST examination.
Table 1: Distribution of abdominal fluid score and specific injuries in dogs with trauman
n
Note that some dogs had 41 type of associated trauma.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x 429
14764431, 2009, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1476-4431.2009.00459.x by UNLP - Univ Nacional de La Plata, Wiley Online Library on [22/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
G.R. Lisciandro et al.
value
Fifteen of the 21 (71%) initially positive dogs had se-
0.26
0.13
0.46
0.32
0.63
rial AFAST examinations performed. Six AFS-positive
P
dogs did not have a serial AFAST examination; 4 were
Range
15, 165
euthanized for financial reasons, 1 died within the ini-
o5 (n 5 9) 0, 45
2, 10
2, 9
4.8 (n 5 8) 3, 6
tial 4-hour period from severe concurrent head trauma,
and the sixth dog’s owner refused hospitalized care.
AFS 3, 4
55 (n 5 9)
positive
4 (n 5 9)
5 (n 5 8)
(n 5 9)
Euthanasia was not performed due to need for blood
Serial
dogs
1.5, 15
2.5, 5
15 (n 5 12) 0, 90
5 (n 5 11)
positive
(n 5 12)
Serial
dogs
4.3
0.35
0.1
NA
NA
4 (n 5 11) 2, 9
NA
NA
(n 5 11)
dogs
o5
NA
15 (n 5 10) 0, 90
2, 30
NA
AFAST, abdominal focused assessment with sonography in trauma; AFS, abdominal fluid score.
dogs
NA
NA
Table 2: Timing of abdominal ultrasonography related to adominal fluid scores
0.006
0.41
0.08
0.35
2, 30
2, 30
5 (n 5 19)
positive
(n 5 27)
0, 420
1, 13
2, 15
3 (n 5 72)
4 (n 5 48)
3 (n 5 47)
AFAST to serial
Serial AFAST
time (min)
430 & Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x
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Fluid scoring with AFAST in traumatized dogs
Figure 2: Illustration showing the relationship between abdominal fluid score (AFS) and the location(s) of the respective abdominal
focused assessment with sonography for trauma (AFAST)-positive site(s). By definition, the AFS is as follows: AFS 1, positive at one
site; AFS 2, positive at two sites; AFS 3, positive at 3 sites; AFS 4, positive at all 4 sites. Both right lateral recumbency, the preferred
AFAST positioning, and left lateral recumbency, and their respective frequency of positive sites are shown. We found that lower-
scoring AFS 1 and AFS 2 dogs were commonly positive at non-gravity-dependent AFAST sites. Note the highest scoring AFS 4 exams
are not shown because all sites are positive by our AFS scoring system. Number of exams in each subset is shown in parentheses.
varied: 3 dogs had AFS 1, 2 dogs had AFS 2, 4 dogs had Comments regarding abdominal serosal detail were
AFS 3, and 8 dogs had AFS 4. Of the dogs with positive extracted from the radiology reports. Abdominal ra-
abdominocentesis on serial AFAST examination, 3 dogs diographic serosal detail was described as normal in
were initially AFS negative and 1 dog was initially AFS 24% (6/25) of AFS-positive dogs and as abnormal in
1; the latter dog had progressed to AFS 3 and subse- 34% (23/66) of the AFS-negative dogs.
quently received a blood transfusion to manage anemia Statistically significant differences were noted be-
from ongoing hemorrhage. tween AFS-negative and AFS-positive dogs (Table 3) in
Abdominal radiographic examination was per- several clinical parameters including: initial and serial
formed on 97% (97/101) of dogs and reviewed by a PCV, initial and serial TPP, initial BL concentration,
veterinary board-certified radiologist as described. initial heart rate, initial serum ALT, initial SpO2, and
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x 431
14764431, 2009, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1476-4431.2009.00459.x by UNLP - Univ Nacional de La Plata, Wiley Online Library on [22/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
G.R. Lisciandro et al.
AFS, abdominal fluid score; kg, kilograms; F, degrees Fahrenheit; TPP, total plasma protein; SpO2, oxyhemoglobin saturation by pulse oximetry; ALT,
alanine transferase activity.
initial rectal temperature. Additionally, there were sta- (58/64) survived, 5% (3/64) died (1 during and 2 after
tistically significant differences noted between AFS- hospitalization), 5% (3/64) were euthanized, and 10
negative and AFS-positive dogs in the number of dogs dogs were lost to follow-up. Survival for AFS-positive
with pelvic fractures and PTX (see Table 1). Dogs with dogs was lower; 63% (17/27) survived, 4% (1/27) died
truncal trauma (ie, PTX, pelvic fractures) were more during hospitalization, and 33% (9/27) were eutha-
likely to be AFS positive than were dogs with append- nized; none were lost to follow-up. None of the AFS-
icular trauma (ie, appendicular fractures, luxations); positive dogs were euthanized because of immediate
these individual comparisons were statistically signif- need for blood transfusion or exploratory laparotomy
icant (Po0.05). due to uncontrolled hemorrhage.
The 27 AFS-positive dogs were divided into a lower
scoring group (AFS 1 and 2) consisting of 13 dogs (48%)
Discussion
and a higher scoring group (AFS 3 and 4) consisting of
14 dogs (52%) for analysis. Statistically significant dif- The results of our study demonstrate that an AFS sys-
ferences were found for body weight, initial heart rate, tem used in conjunction with initial and serial AFAST
initial and serial ALT, and initial BL when compared to examinations in trauma patients consistently provided
serial AFS groups (Table 4). a semiquantitative measure of free abdominal fluid that
Although not statistically significant, only the higher reliably estimated the degree of intra-abdominal hem-
scoring AFS-positive dogs (AFS 3 and 4) became ane- orrhage and was related to actual decreases in PCV and
mic (mean serial PCV of 34%; P 5 0.15; reference inter- need for blood transfusion, and thus served as a marker
val, 36–52%). These dogs also had the greatest decrease for the degree of intra-abdominal injury. Results also
in PCV during the first 4 hours of hospitalization, with demonstrated that dogs with higher AFS were more
a mean decrease of 21%. Moreover, 31% (4/13) of dogs likely to have more marked increases in ALT and BL
in the higher scoring group developed a PCV of 25% or concentration and were more likely to have more severe
less compared with the lower scoring group, in which associated trauma, again supporting our hypoth-
no dog developed a PCVo30% and only 1 dog became esis that AFAST and AFS determination reliably esti-
anemic (PCVo36%). Only dogs in the higher scoring mates severity of trauma. Our results additionally show
group received blood transfusions. that an AFS used with AFAST improved clinical deci-
Survival to discharge between AFS-positive and AFS- sion making and guided therapy during the initial
negative dogs was statistically significant (P 5 0.005). 4 hours after admission. We found that initial PCV
Of the 64 AFS-negative dogs completing the study, 91% values and radiographic abdominal serosal detail were
432 & Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x
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Fluid scoring with AFAST in traumatized dogs
Table 4: Comparison of patient characteristics, vital signs, and clinicopathologic data for dogs with positive abdominal fluid scoresn
Initial AFS 1 and 2 Initial AFS 3 and 4 Serial AFS 1 and 2 Serial AFS 3 and 4
Parameter (median positive dogs positive dogs positive dogs positive dogs
values, ranges) (n 5 10) (n 5 11) P value (n 5 12) (n 5 9) P value
Age (y) 2.0 (0.3, 8.0) 0.8 (0.3, 2.0) 0.07 1.0 (0.3, 8.0) 1.0 (0.3, 5.0) 0.75
Weight (kg) 19.1 (6.1, 44.5) 19.5 (6.8, 35.4) 0.92 18.4 (3.6, 31.4) 33.2 (6.8, 44.5) 0.04
Temperature (F) 102.2 (98.0, 103.0) 101.5 (99.9, 102.5) 0.24 101.4 (97.2, 103.0) 101.8 (99.9, 102.7) 0.57
(n 5 9) (n 5 8)
Heart rate (beats/min) 150 (84, 190) 168 (128, 210) 0.04 153 (84, 190) 164 (120, 210) 0.31
(n 5 10)
Respiratory rate 55 (40, 164) (n 5 8) 60 (28, 11) (n 5 9) 1.00 50 (20, 164) (n 5 11) 60 (28, 110) (n 5 8) 0.66
(breaths/min)
Lactate – initial 3.3 (1.3, 8.5) (n 5 9) 4.7 (2.6, 8.1) (n 5 10) 0.10 2.9 (1.3, 8.2) (n 5 11) 4.7 (2.6, 8.5) 0.04
(mmol/L)
Lactate – serial NA NA NA 2.0 (0.9, 3.7) (n 5 11) 2.5 (1.5, 3.5) (n 5 7) 0.43
(mmol/L)
PCV – initial (%) 48.0 (38.0, 52.0) 44.0 (24.0, 55.0) 0.13 45.5 (25.0, 53.0) 44.0 (25.0, 55.0) 0.42
(n 5 9)
PCV – serial (%) NA NA NA 39.5 (30.0, 46.0) 35.0 (10.0, 48.0) 0.35
TPP – initial (g/L) 58 (55, 68) (n 5 9) 50 (34, 74) 0.11 56 (39, 68) 55 (42, 64) 0.75
TPP – serial (g/L) NA NA NA 45 (38, 64) 50 (25, 54) 0.46
SpO2 – initial (%) 94 (86, 98) (n 5 7) 87 (78, 97) (n 5 9) 0.17 94 (82, 98) (n 5 6) 96 (80, 98) (n 5 7) 0.84
SpO2 – serial (%) NA NA NA 97 (93, 100) (n 5 8) 95 (91, 100) (n 5 7) 0.69
ALT (U/L) 619 (38, 1,459) (n 5 8) 1,097 (784, 3,812) 0.04 365 (38, 1,741) 1,194 (448, 3,812) 0.02
(n 5 8) (n 5 11)
PCV – 45.5 (45.0, 46.0) 48.0 (35.0, 60.0) 0.91 45.5 (45.0, 46.0) 49.5 (42.0, 60.0) 1.00
abdominocentesis (%) (n 5 2) (n 5 9) (n 5 2) (n 5 6)
TPP – 56 (46, 66) (n 5 2) 58 (48, 76) (n 5 8) 0.53 56 (46, 66) (n 5 2) 68 (50, 76) (n 5 5) 0.38
abdominocentesis (g/L)
Outcome (2 wk post 7/2/1 (n 5 10) 7/1/3 (n 5 11) 1.00 8/2/2 (n 5 12) 8/1/0 (n 5 9) 0.34
discharge) (survived/
died/euthanized)
n
Data are presented as median (range). Numbers of dogs in each subgroup vary due to changes in AFS in some dogs over time.
AFS, abdominal fluid score; kg, kilograms; F, degrees Fahrenheit; TPP, total plasma protein; SpO2, oxyhemoglobin saturation by pulse oximetry; ALT,
alanine transferase activity.
misleading not only for the presence of free abdominal ous exacerbation of intra-abdominal bleeding.11,13–15
fluid, but also the amount of free abdominal fluid, thus Based on the results of this study, the use of initial and
demonstrating further utility of AFAST and use of serial AFAST examinations and the application of an
an AFS. AFS can now be utilized to confirm intra-abdominal
In dogs in our study with hemoperitoneum, the de- fluid and more reliably help to answer the pressing
termination of the initial and serial AFS in traumatized question, ‘is there ongoing hemorrhage?’ within veter-
dogs allowed clinicians to semiquantitatively assess the inary resuscitation algorithms for bluntly traumatized
severity of injury (ie, dogs with AFS 1 were less severely dogs.13 Based on the results of this study, the use of
injured than AFS 4 dogs), as well as gauge the degree of AFAST and the AFS should be considered one of the
ongoing hemorrhage (ie, an increasing AFS on serial first tests in a diagnostic algorithm for traumatized
examination was associated with progressive bleeding), dogs and no longer considered an ancillary test,13,41,42
thus aiding evidence-based decisions regarding resus- similar to human standards of care. Although few pa-
citative efforts, such as extent and type of fluid resus- tients in our study became anemic or required blood
citation and need for blood transfusion. Although not transfusion, we are hopeful that further studies with
statistically significant, marked decreases in serial PCV larger patient numbers will further confirm the utility
were found in the higher scoring (AFS 3 and 4) dogs, of AFAST and the AFS as a measure that can be used
compared with the lower scoring (AFS 1 and 2) dogs. In with consistently reliable results to detect the degree
this study, only the high scoring dogs became anemic. of intra-abdominal hemorrhage, and will improve pa-
Historically, aggressive fluid resuscitation in the tient management, as has definitively been shown in
presence of occult hemorrhage has led to the deleteri- humans.23–25,38
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x 433
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G.R. Lisciandro et al.
The only previous veterinary study33 evaluating US sible that clinicians in this study may have been more
use to detect hemoperitoneum reported that 45% of judicious with initial fluid challenges, knowing on pre-
dogs involved with automobile trauma had free ab- sentation whether the patient was AFS-positive or AFS-
dominal fluid; 9 of these dogs required blood transfu- negative. This conclusion is supported by the fact that
sion but none required surgery. One unanswered only 1 AFS-positive dog in our study received a shock
question raised by this study involved the significance dose of greater than 90 mL/kg in the first hour of treat-
of a positive result without an assessment or measure- ment, and only because of persistent hemodynamic in-
ment of severity of injury (ie, what’s the clinical rele- stability. All other dogs were initially resuscitated with
vance for patient management and prognosis for a dog 45 mL/kg or less of crystalloid boluses administered as
that has evidence of free abdominal fluid, but without graduated fluid challenges. Based on normalization of
any assessment of the volume of this fluid?). Another serial BL levels and clinical improvement, we conclude
unanswered question raised by the previous study was that our graduated fluid challenges were adequate. In
the actual prevalence of hemoperitoneum in dogs with fact, AFS-positive dogs had lower serial BL values than
motor vehicle trauma presented directly to an emer- AFS-negative dogs. Further study correlating initial
gency facility (rather than a study population that con- and serial AFAST and the application of patient AFS to
sisted of 35% referral cases). Previous studies fluid therapy may prove interesting. What is most rel-
conducted before the widespread use of US reported evant regarding initial fluid resuscitation of blunt
the prevalence of intra-abdominal hemorrhage to be trauma patients is the apparent clinical benefit of
much lower than reported in this study, ranging from knowing whether hemoperitoneum is present or not;
6% to 13%.42–44 With the advent of US imaging and initial and serial AFAST and AFS thus proved invalu-
FAST examinations, reported prevalence ranged from able in this regard.
27% to 45%.33,a The true prevalence of intra-abdominal Blood transfusions were administered to 10% of the
injury seems to be much higher than historically re- surviving dogs in this study versus 24% of dogs in the
ported before wider use of FAST and warrants further previous study.33 As previously mentioned, the appli-
study. To answer these critical questions, we developed cation of initial and serial AFAST with AFS application
a simple, easy to remember scoring system with ana- may have provided significant preemptive knowledge
tomically named sites referring to target organs. for resuscitative efforts in dogs with blunt trauma,
There are notable differences that warrant discussion avoiding exacerbation of intra-abdominal hemorrhage,
between this study and the only previous study33 of as demonstrated in hemorrhaging humans.16,24,25,39
FAST in traumatized dogs, as the results of the previous This is yet another example of the clinical utility of
study cannot be universally applied to guide evaluation AFAST and AFS in positively directing therapy and af-
or management of trauma patients based on the results fecting outcome. There are other potential reasons for
of this study. Ninety-eight percent of cases in this study the difference in blood transfusions, such as differences
(vs 65% in the previous study) were primary presen- in transfusion practices between centers, differences in
tations, and patients in this study had a much shorter overall degree of trauma, or differences in primary
median time from trauma to presentation (60 vs versus referred cases, as discussed previously. Of note,
240 min) and median time from presentation to initial 3 dogs in this study with progressive anemia
AFAST (o5 vs 60 min). Additionally, no dog in this (PCVo25%) did not receive blood transfusions because
study (vs 16 dogs in the previous study) had abdom- they were hemodynamically stable; had these dogs
inocentesis performed before AFAST, and the majority been transfused, the overall transfusion proportion
of dogs in this study were minimally fluid resuscitated would have been similar to that reported previously.33
before AFAST examination. Thus, the higher prevalence Interestingly, the 2 studies had nearly identical num-
of fluid-positive dogs in the previous study potentially bers of PTX (22% vs 21%) and pelvic fractures (22% vs
could reflect iatrogenic hemoperitoneum or that re- 20%), suggesting similar degrees of truncal trauma;
ferred cases tend to be the more severely affected and dogs in this study had more appendicular fractures
thus more likely to have hemoperitoneum, but not re- (25% vs 15%). In any event, correlating AFS with fluid
flect the true prevalence of hemoperitoneum in the therapy and need for blood transfusion warrants fur-
general population. ther study.
However, and much more clinically relevant, the dif- We recorded not only AFS for each patient, but the
ference in prevalence of hemoperitoneum may reflect location of positive sites for each patient. Of clinical
differences in fluid therapy during resuscitation. It is interest in this study, we found that the lower scoring
known that aggressive fluid therapy in occult hemor- (AFS 1 and 2) dogs were more frequently positive at
rhaging patients further contributes to blood loss and non-gravity-dependent sites (ie, HR view in right lat-
increases morbidity and mortality.11,13–15 It seems plau- eral recumbency and SR view in left lateral recum-
434 & Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x
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Fluid scoring with AFAST in traumatized dogs
bency; Figure 2); this is in marked contrast to results It seems logical that the need for emergency explor-
reported previously.33 This finding suggests that in atory for uncontrolled hemorrhage may increase in the
early or mild stages of intra-abdominal hemorrhage, future as more severely injured dogs will survive
dogs are positive for free abdominal fluid in the ana- shorter transit times to more prevalent veterinary emer-
tomical location of the injured organ and AFAST-pos- gency facilities; AFAST will play a critical role in iden-
itive findings are much less affected by gravity. We tifying these critically injured dogs within minutes of
recommend that AFAST-positive sites (DH, SR, CC, arrival at emergency facilities. Performance of AFAST at
HR) be recorded for initial and serial AFAST examin- admission in trauma patients cannot be overempha-
ations in addition to the AFS because future studies sized, as this imaging modality can rapidly identify
may show that positive sites correlate with location of life-threatening trauma and better direct resuscitative
the injured organ and source of hemorrhage (eg, DH- efforts. For example, 21 dogs (15 AFS negative, 6 AFS
positive findings may relate directly to hepatic injury; positive) in this study were presented within 30 min-
SR-positive findings may relate directly to splenic in- utes or less after motor vehicle trauma. The most se-
jury), and may prove helpful to surgical teams by di- verely hemorrhaging AFS-positive dog in our study
recting efforts to specific anatomical locations during presented within 15 minutes of being struck by an au-
emergency laparotomy in cases of uncontrollable hem- tomobile and required multiple blood transfusions and
orrhage when time is critical for patient survival. intense resuscitative efforts on presentation for its ul-
Alternative explanations for the finding that AFS 1 timate survival. This same dog may have died if transit
and 2 dogs were positive more frequently at non-grav- time was much longer; and may have not survived if
ity-dependent sites may be in the timing of AFAST the degree of intra-abdominal hemorrhage (AFS 4) that
exam when comparing results to the Boysen and col- was not detected based on physical examination and
leagues study, and in severity of intra-abdominal hem- initial laboratory testing (PCV and TPP: 44% and 46 g/L
orrhage. In this study AFAST examinations were [4.6 g/dL]), had not been rapidly identified by AFAST
performed much sooner relative to the time of trauma at admission.
(median: 60 min post trauma) compared with the pre- In most AFS-positive cases, characterization of free
vious study (median: 240 min post trauma).33 It is plau- abdominal fluid via abdominocentesis was performed
sible that had dogs been imaged after a longer time immediately following the initial AFAST exam for
interval following trauma, as in the Boysen and col- timely characterization of the effusion. However, serial
leagues study, the results may have been similar, in that AFAST exams with AFS application 4 hours after
blood may have had time to distribute to gravity- admission allowed clinicians to assess not only the
dependent sites. This is supported by the finding that of development of intra-abdominal injury in previously
the higher scoring (AFS 3 and 4) dogs, none were pos- AFS-negative dogs, but also the progression of intra-
itive at non-gravity-dependent sites, which is similar to abdominal injury, reflected by increasing AFS. Further-
findings in the Boysen et al33 report. Further study is more, the attending clinician was given a second
warranted. opportunity to perform abdominocentesis. The high
Timely recording of initial and serial AFS and loca- success of abdominocentesis in this study (94%) is
tions of positive findings may prove the difference be- comparable to the previous FAST study.33 Additionally,
tween survivors and nonsurvivors in not only AFAST markedly improved success of abdominocente-
catastrophic hemorrhage, but as importantly, in cases sis from the 49% to 78% range reported in other stud-
with occult, progressive, ongoing hemorrhage. In this ies,43,45 presumably because clinicians could directly
study, we found several lower-scoring AFS patients access imaged fluid pockets, compared with blind ab-
progressed to higher-scoring AFS with changes in pos- dominocentesis without US.
itive sites from non-gravity-dependent to gravity- AFAST may help expediently diagnose other less
dependent sites, and a difference in severity of anemia common types of intra-abdominal injury, such as
between lower AFS and higher AFS groups. Thus, we uroperitoneum, bile peritoneum, ruptured viscus
recommend not only recording patient AFS in medical organ, and vascular injury, which may be missed by
records, but also the initial and serial AFAST-positive physical examination, laboratory testing, and radiogra-
site(s) because in cases with ongoing hemorrhage (in- phy.23,38,46–56 Serial AFAST may prove helpful with re-
creasing AFS) we found that blood redistributes gards to early diagnosis of retroperitoneal injury
throughout the abdomen from the initial non-gravity- including not only uroretroperitoneum, but also other
dependent sites (suggesting location of injury in AFS 1 causes of retroperitoneal fluid accumulation such as
and AFS 2 dogs) to gravity-dependent sites (injury now hemorrhage from aortic, vena caval, or renal vascular
can no longer be regionalized in AFS 3 and AFS 4 dogs) injury or hemorrhage from vertebral and pelvic
as shown in Figure 2. fractures. AFAST incorporates left and right retroperi-
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x 435
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G.R. Lisciandro et al.
436 & Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x
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Fluid scoring with AFAST in traumatized dogs
20. Cothren CC, Osborn PM, Moore EE, et al. Preperitoneal pelvic protocol to detect pneumothorax and concurrent thoracic injury
packing for hemodynamically unstable pelvic fractures: a para- in 145 traumatized dogs. J Vet Emerg Crit Care 2008; 18(3):
digm shift. J Trauma 2007; 62(4):834–842. 258–269.
21. Dechant JE, Nieto JE, Le Jeune SS. Hemoperitoneum in horses: 67 41. Herold LV, Devey JJ, Kirby R, et al. Clinical evaluation and man-
cases (1989–2004). J Am Vet Med Assoc 2006; 229(2):253–258. agement of hemoperitoneum in dogs. J Vet Emerg Crit Care 2008;
22. Dolich MO, McKenney MG, Varela JE, et al. 2,576 ultrasounds for 18(1):40–53.
blunt abdominal trauma. J Trauma 2001; 50(1):108–112. 42. Vinayak A, Krahwinkel DJ. Managing blunt trauma-induced
23. Korner M, Krotz MM, Degenhart C, et al. Current role of emer- hemoperitoneum in dogs and cats. Comp Cont Ed Pract Vet
gency ultrasound in patients with major trauma. Radiographics 2004; 26(4):276–290.
2008; 28(1):225–242. 43. Mongil CM, Drobatz KJ, Hendricks JC. Traumatic hemoperitone-
24. Ollerton JE, Sugrue M, Balogh Z, et al. Prospective study to eval- um in 28 cases: a retrospective review. J Am Anim Hosp Assoc
uate the influence of FAST on trauma patient management. 1995; 31:217–222.
J Trauma 2006; 60:785–791. 44. Kolata RJ, Dudley EJ. Motor vehicle accidents in urban dogs: a
25. Blackbourne LH, Soffer D, McKenney M, et al. Secondary ultra- study of 600 cases. J Am Vet Med Assoc 1975; 167:938–941.
sound examination increases the sensitivity of the FAST exam in 45. Crowe DT, Crane SW. Diagnostic abdominal paracentesis tech-
blunt trauma. J Trauma 2004; 57:934–938. niques: clinical evaluation in 129 dogs and cats. J Am Anim Hosp
26. McGahan JP, Richards J, Fogata MC. Emergency ultrasound in Assoc 1984; 20:223–230.
trauma patients. Radiol Clin N Am 2004; 42:417–425. 46. Lisciandro GL, Harvey HJ, Beck KA. Automobile-induced ob-
27. Rozycki GS. Surgeon performed US: its use in clinical practice. struction of the caudal vena cava in a dog. J Small Anim Pract
Ann Surg 1998; 228:16–28. 1995; 36(8):368–372.
28. McKenney M, Lentz K, Nunez D, et al. Can ultrasound replace 47. Weisse C, Aronson LR, Drobatz K. Traumatic rupture of the ure-
diagnostic peritoneal lavage in the assessment of blunt trauma? ters: 10 cases. J Anim Hosp Assoc 2002; 38(2):188–192.
J Trauma 1994; 37:439. 48. Cornelius L, Mahaffey M. Kinking of the intrathoracic caudal vena
29. Rozycki GS, Ochsner MG, Schmidt JA, et al. A prospective study cava in five dogs. J Small Anim Pract 1985; 26:67–80.
of surgeon performed ultrasound as the primary adjuvant mo- 49. Crowe DT, Lorenz MD, Hardie EM, et al. Chronic peritoneal ef-
dality for injured patient assessment. J Trauma 1995; 39:492–498. fusion due to partial obstruction caudal vena caval obstruction
30. Goletti O, Ghiselli G, Lippolis PV, et al. The role of ultrasono- following blunt abdominal trauma: diagnosis and successful sur-
graphy in blunt abdominal trauma: results in 250 consecutive gical management. J Am Anim Hosp Assoc 1984; 20:231–238.
cases. J Trauma 1994; 36(2):178–181. 50. Fine DM, Olivier NB, Walshaw R, et al. Surgical correction of late-
31. Boulanger BR, McLellan BA, Brenneman FD, et al. Emergent ab- onset Budd-Chiari-like syndrome in a dog. J Am Vet Med Assoc
dominal sonography as a screening test in a new diagnostic al- 1998; 212(6):835–837.
gorithm for blunt abdominal trauma. J Trauma 1996; 40:867–874. 51. Kolata RJ, Cornelius LM, Bjorling DE, et al. Correction of an ob-
32. Boulanger BR, McLellan, Brenneman FD, et al. Prospective evi- structive lesion of the caudal vena cava in a dog using a temporary
dence of the superiority of a sonography-based algorithm in the intraluminal shunt. Vet Surg 1982; 11:100–104.
assessment of blunt abdominal injury. J Trauma 1999; 47:632–637. 52. Parchman MB, Flanders JA. Extraheptic biliary tract rupture: eval-
33. Boysen SR, Rozanski EA, Tidwell AS, et al. Evaluation of focused uation of the relationship between the site of rupture and the cause
assessment with sonography for trauma protocol to detect free of rupture in 15 dogs. Cornell Vet 1990; 80(3):267–272.
abdominal fluid in dogs involved in motor vehicle accidents. J Am 53. Ludwig LL, McLoughlin MA, Graves TK, et al. Surgical treatment
Vet Med Assoc 2004; 225:1198–1204. of bile peritonitis in 24 dogs and 2 cats: a retrospective study
34. Healey MA, Simons RK, Winchell RJ, et al. A prospective eval- (1987–1994). Vet Surg 1997; 26(2):90–98.
uation of abdominal ultrasound in blunt trauma: is it useful? J 54. Mehler SJ, Mayhew PD, Drobatz KJ, et al. Variables associated
Trauma 1996; 40:875–883. with outcome in dogs undergoing extrahepatic biliary surgery: 60
35. Branney SW, Moore EE, Cantrill SV, et al. Ultrasound based key cases (1988–2002). Vet Surg 2004; 33(6):644–649.
clinical pathway reduces the use of hospital resources for the 55. Amsellum PM, Seim HB, MacPhail CM, et al. Long-term survival
evaluation of blunt abdominal trauma. J Trauma 1997; 42:1086– and risk factors associated with biliary surgery in dogs: 34 cases
1090. (1994–2004). J Am Vet Med Assoc 2006; 229(9):1451–1457.
36. Boulanger BR, Kearney PA, Brenneman FD, et al. FAST utilization 56. Worth AJ, Tomlin SC. Post-traumatic paraureteral urinoma in a
in 1999: results of a survey of North American trauma centers. Am cat. J Small Anim Pract 2004; 45(8):413–416.
Surg 2000; 66:1049–1055. 57. Tayal VS, Nielsen A, Jones AE, et al. Accuracy of trauma
37. Soderstrom CA, DuPriest RW, Crowley RA. Pitfalls of peritoneal ultrasound in major pelvic injury. J Trauma 2006; 61(6):
lavage in blunt abdominal trauma. Surg Gynecol Obstet 1980; 1453–1457.
151:513–518. 58. Moores AP, Bell AMD, Costello M. Urinoma (para-ureteral pseu-
38. Rozycki GS, Knudson MM, Shackford SR, Dicker R. Surgeon-per- docyst) as a consequence of trauma in a cat. J Small Anim Prac
formed organ assessment with surgery after trauma (BOAST): a 2002; 43(5):213–216.
pilot study from the WTA Multicenter Group. J Trauma 2005; 59. Bacon NJ, Anderson DM, Barnes EA, et al. Post-traumatic para-
59(6):1356–1364. ureteral urinoma (uriniferous pseudocyst) in a cat. Vet Comp Ort-
39. Ona AW, McKenney MG, McKenney KA, et al. Predicting the need hop Traumatol 2002; 15(2):123–126.
for laparotomy in pediatric trauma patients on the basis of the 60. McLoughlin MA. Surgical emergencies of the urinary tract. Vet
ultrasound score. J Trauma 2003; 54(3):503–508. Clin North Am Small Anim Pract 2000; 30(3):581–601.
40. Lisciandro GR, Lagutchik MS, Mann KA, et al. Evaluation of a 61. Aumann M, Worth LT, Drobatz KJ. Uroperitoneum in cats: 26
thoracic focused assessment with sonography for trauma (TFAST) cases (1986–1995). J Am Anim Hosp Assoc 1998; 34(4):315–324.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x 437