Hrev_master [page 82] [Emergency Care Journal 2024; 20:12696] Emergency Care Journal 2024 volume 20:12696 Abstract The EFAST technique is a rapid ultrasound method introduced into ATLS guidelines since 2006 for the evaluation of trauma patients. It allows for the detection of free fluid in the abdomen, pericardial tamponade, and pneumothorax within 2 to 3 minutes without impacting management times in pre-hospital settings. Recently, the EFAST-PS protocol has been introduced, which includes an additional scan of the pubic symphysis to identify “open book” pelvic fractures. This mini review examines the effi- cacy of the EFAST-PS protocol in pre-hospital environments through a literature review and analysis of a clinical case. It is demonstrated that EFAST has high specificity and sensitivity in detecting free fluid in abdominal and thoracic recesses, improving the management of trauma patients and reducing time to definitive intervention. The addition of the pubic symphysis scan did not cause any issues but increased safety in managing patients with suspected fractures and hemodynamic instability. Emergency ultrasound assessment, including the EFAST-PS protocol, should be integrated into the overall clinical picture to provide useful data for the decision-making process. Correspondence: Moris Rosati Cardiology and Cardiac Intensive Care Unit, Azienda Ospedaliero Universitaria Senese, Siena, Italy. Tel.: +39.3474972040 E-mail: moris.rosati@unisi.it Key words: EFAST, FAST, EFAST-PS, trauma, pubic symphysis, pelvis, ultrasound, pelvic injuries, intra-abdominal bleeding, pelvic binder. Contributions: FP, editing the manuscript; GM, editing the manu- script; LB, editing the manuscript; MC, editing the manuscript; CB, editing the manuscript; LR, writing of the manuscript; MR, review- ing of the manuscript; SM, reviewing of the manuscript. Conflict of interest: the authors declare no potential conflict of inter- est, and all authors confirm accuracy. Ethics approval and consent to participate: no ethical committee approval was required for this case report. Informed consent was obtained from the patient included in this study. Patient consent for publication: the patient gave her written consent to use her personal data for the publication of this case report and any accompanying images. Availability of data and materials: all data underlying the findings are fully available. Received: 29 May 2024. Accepted: 29 September 2024. Early view: 11 October 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Emergency Care Journal 2024; 20:12696 doi:10.4081/ecj.2024.12696 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Efficacy of EFAST-PS in pelvic trauma for the assessment of the pubic symphysis in emergency settings: a mini review Federica Piazzai,1 Gilda Morelli,2 Lorenzo Barone,3 Manuel Carli,4 Chiara Borchi,5 Moris Rosati,6 Lorenzo Righi,1 Sara Montemerani7 1Emergency Department, Azienda USL Toscana Sud Est; 2Rehabilitation Facility, Istituto Anna Torrigiani; 3Intensive Care Unit, Azienda USL Toscana Centro, Ospedale Santa Maria Annunziata; 4Emergency Department, IRCCS Ospedale Sacro Cuore Don Calabria Negrar di Valpolicella; 5IRCCS Don Carlo Gnocchi, Firenze; 6Cardiology and Cardiac Intensive Care Unit, Azienda Ospedaliero Universitaria Senese, Siena; 7Acceptance and Emergency Medicine and Surgery Unit, San Donato Hospital in Arezzo - Pegaso 2 Helicopter Service, Emergency Department, Azienda USL Toscana Sud Est, Italy Highlights - The most widely used classification for pelvic fractures is the Young-Burgess classification, which categorizes pelvic injury based on the direction of impact in anteroposterior compression (APC), lateral compression (LC), vertical shear (VS), and combined mechanisms. - Pelvic fractures are frequently associated with high-energy traumatic mechanisms. The mortality rate for pelvic injuries is consistently high because of the potential rupture of major blood vessels in the pelvic region, resulting in hemorrhagic shock. - Pelvic circumferential compression device (PCCD) placement is indicated in two modalities: the compressive mode and the containment mode respectively in presence or absence of hemodynamic instability associated with anatomical and/or dynamic signs of pelvic injury. - Extended Focused Assessment Sonography for Trauma E- FAST can reduce the time required for surgical treatment, improve understanding of trauma severity, and optimize patient management at the scene and during transport to the receiving hospital. - Implementing the E-FAST protocol with pubic symphysis scans (EFAST-PS) can significantly improve the prognosis of trauma patients by reducing therapeutic times, improving the placement of the PCCD and optimizing their care pathway. - The EFAST-PS exam is considered positive for an open book pelvic fracture if it detects a diastasis of more than 2.5 cm in transverse diameter between the two pubic tubercles. Non -co mmerc ial us e o nly Case Report A 40-year-old man was involved in a road accident following a fall from his motorcycle. The patient was found thrown against the guardrail. Upon the arrival of the emergency medical team, he was conscious but confused and agitated. The vital signs recorded by the first responders indicated a Blood Pressure (BP) of 70/40 mmHg, a Heart Rate (HR) of 42 bpm, and a peripheral oxygen sat- uration (SpO2) of 94% on room air. After removing the helmet, the medical personnel proceeded with cervical spine immobilization and clinical evaluation of the patient. The patient exhibited a suspected spinal cord injury, indi- cated by paraplegia and loss of sensation in the trunk and both lower limbs from the nipple line downward. During the assessment of neurological sensitivity, the medical team detected the presence of a scrotal hematoma. Given the con- text and dynamics of the incident, a pelvic trauma was also sus- pected in addition to the spinal injury. This prompted the team to perform an extended Focused Assessment with Sonography for Trauma (EFAST) that included an ultrasound evaluation of the pubic symphysis, referred to as the EFAST-PS protocol. While the abdominal and thoracic scans were negative for free fluid and signs of pneumothorax (PNX), the scan of the pubic symphysis revealed diastasis of the tubercles (Figure 1), suggesting a probable open book pelvic fracture. This made the placement of a pelvic cir- cumferential compression device a priority, in addition to complete spinal immobilization on a backboard. The patient received treatment with 1 g of tranexamic acid, fluid resuscitation with 250 ml boluses of saline solution, and an infusion of norepinephrine at 1 mcg/min to maintain a systolic blood pressure of at least 100 mmHg, considering the combination of spinal trauma and blunt trauma. The patient was then transferred to the designated trauma center. The whole-body CT scan per- formed upon arrival at the emergency department confirmed the presence of fractures involving the posterior wall of the thoracic vertebrae T3-T4 and an anteroposterior pelvic fracture with diasta- sis of the pubic symphysis, fracture of the right sacral wing, and diastasis of the anterior sacroiliac joints (Figure 2). Discussion A significant portion of trauma-related mortality is avoidable and often results from errors in the initial diagnosis and delays in emergency interventions.1 Approximately 30-40% of trauma mor- tality is caused by hemorrhages, with 33-56% occurring in the pre- hospital phase. In this clinical case, we went beyond the simple algorithmic execution of the EFAST and included the evaluation of the pubic symphysis in addition to the standard scans. The goal was to identify the possible presence of an Anteroposterior Compression (APC) type pelvic fracture within seconds. This tech- nique, developed in the early 2000s, involves using a high-fre- quency linear probe to scan the pubic symphysis. Cases reported in the literature2-4 define a maximum normal distance of 2.5 cm between the pubic tubercles. A diastasis of more than 2.5 cm in transverse diameter between the two pubic tubercles is considered positive for an open book pelvic fracture from anteroposterior compression (often associated with the rupture of the sacrospinous and sacroiliac ligaments and rupture of the pelvic vessels). The use of this new scan likely prevented a potential hemody- namic deterioration of the patient during mobilization in the absence of a Pelvic Circumferential Compression Device (PCCD). The ability to perform diagnostic screening for an APC fracture directly in the pre-hospital setting improved patient management, providing healthcare professionals with greater confidence in their assessment. Pelvic screening allowed recalibration of the reference blood pressure target and reconsideration of the patient’s clinical status, who, in addition to a spinal trauma with spinal shock, also had a probable hemorrhagic focus associated with the open book pelvic fracture. Pelvic fractures Pelvic fractures account for approximately 2%-8% of skeletal injuries,5 frequently associated with high-energy traumatic mecha- nisms. The primary risk factors include motor vehicle accidents and falls from significant heights. The mortality rate for pelvic injuries can reach up to 50% due to the potential rupture of major Mini review Figure 1. Pubic symphysis diastasis due to an open-book fracture. Figure 2. Axial CT images show a pubic diastasis >2.5 cm. [Emergency Care Journal 2024; 20:12696] [page 83] Non -co mmerc ial us e o nly blood vessels in the pelvic region, resulting in hemorrhagic shock.6,7 Indeed, the anatomical proximity of major vascular struc- tures to the pelvis, the concomitant visceral damage, and the high forces required to disrupt pelvic integrity predispose pelvic injuries to hemodynamic instability. The most widely used classification for pelvic fractures is the Young-Burgess classification, which cat- egorizes pelvic injury based on the direction of impact during the trauma and the degree of bone displacement, distinguishing among APC, Lateral Compression (LC), Vertical Shear (VS), and com- bined mechanisms. Type I-II-III APC fractures are associated with shock in 30- 67% of cases, with a mortality incidence of 15-37%; hence, timely recognition is essential.5,8 In the pre-hospital setting, pelvic assess- ment primarily relies on clinical examination, trauma dynamics, and the presence of pain or evident anatomical alterations. According to the study by Coulombe et al.,9 the “open book” type fracture benefits from the application of a Pelvic Circumferential Compression Device (PCCD). Indeed, in cases of significant pelvic ring injury, the PCCD can be used as a temporary measure to contain pelvic volume and thus reduce the anatomical space available for blood extravasation. According to the recommendations of the Istituto Superiore di Sanità (ISS) for the management of major trauma, PCCD place- ment is indicated in two modalities: the compressive mode in patients who are unstable or showing signs of hypoperfusion, asso- ciated with anatomical and/or dynamic signs of pelvic injury, and the containment mode in the absence of hemodynamic instability but with the presence of anatomical/dynamic criteria of pelvic trauma.10 The primary use of the PCCD is therefore in the tempo- rary management of suspected pelvic fractures and should be con- sidered a targeted provisional therapeutic measure rather than a routine immobilization device.11 EFAST-PS The Focused Assessment Sonography for Trauma (FAST) and its subsequent extended version (EFAST) have been integral to clinical practice in emergency medicine for many years. The acronym FAST was first introduced in the literature in 1996 to identify intra-abdominal hemorrhage in unstable abdominal trau- ma. In 2003, the American College of Emergency Physicians pub- lished “The EFAST Exam,” and approximately ten years after its inception, in 2006, the American College of Surgeons Committee on Trauma included it in the ATLS guidelines for managing thora- co-abdominal trauma.12,13 The term EFAST (Extended-FAST) appeared in 2004 following a proposal to extend the standard examination to include thoracic scans aimed at detecting pneu- mothorax. Today, EFAST is used in the “C” phase of the ABCDE assessment to identify causes of hemorrhagic shock, allowing for immediate resuscitative interventions. The exam should be com- pleted in 2-3 minutes and addresses specific questions: detecting intra-abdominal fluid, pericardial tamponade, and pneumothorax.14 EFAST can reduce the time required for surgical treatment, improve understanding of trauma severity, and optimize patient management at the scene and during transport to the receiving hos- pital.15,16 The proposal for further expansion of EFAST by adding ultra- sound evaluation of the pubic symphysis emerged in 2009 with Bauman et al., who first suggested the technique to early identify patients needing Pelvic Circumferential Compression Devices (PCCD).2 Subsequently, scans of the pubic symphysis are noted in the FAST-PLUS (FAST-PL pleural -US ultrasound of symphysis) protocol proposed by Ianniello et al. in 202017 and in the cohort study proposed by Planquart et al. in 2022.4 From the aforemen- tioned studies, it is evident that implementing the EFAST protocol with pubic symphysis scans (EFAST-PS) can significantly improve the prognosis of trauma patients by reducing therapeutic times and optimizing their care pathway. Conclusions As highlighted by the literature, current information on the EFAST-PS examination is scant and limited to three main studies. Therefore, despite recognizing the potential utility of applying this extended protocol in real-life scenarios, further studies are needed to validate its applicability and usefulness in the context of pre- hospital management of major trauma. It is also important to emphasize that emergency ultrasound assessment should always be integrated into the patient’s clinical context. Only when proper- ly integrated into a comprehensive evaluation that includes history, objective data, and dynamic assessments, can EFAST-PS provide valuable information to guide decision-making in polytrauma patients. References 1. Chaijareenont C, Krutsri C, Sumpritpradit P, et al. FAST accu- racy in major pelvic fractures for decision-making of abdomi- nal exploration: Systematic review and meta-analysis. Ann Med Surg (Lond) 2020;60:175-81. 2. Bauman M, Marinaro J, Tawil I, et al. Ultrasonographic deter- mination of pubic symphyseal widening in trauma: the FAST- PS study. J Emerg Med 2011;40:528-33. 3. Ianniello S, Conte P, Di Serafino M, et al. Diagnostic accuracy of pubic symphysis ultrasound in the detection of unstable pelvis in polytrauma patients during e-FAST: the value of FAST-PLUS protocol. A preliminary experience. J Ultrasound 2021;24:423-8. 4. Planquart F, Marcaggi E, Blondonnet R, et al. Appropriateness of initial course of action in the management of blunt trauma based on a diagnostic workup including an extended ultra- sonography scan. JAMA Netw Open 2022;5:e2245432. 5. Perumal R, S DCR, P SS, Jayaramaraju D, et al. Management of pelvic injuries in hemodynamically unstable polytrauma patients – Challenges and current updates. J Clin Orthop Trauma 2021;12:101-12. Erratum in: J Clin Orthop Trauma 2021;21:101558. 6. Mercer CB, Ball M, Cash RE, et al. Ultrasound use in the pre- hospital setting for trauma: a systematic review. Prehosp Emerg Care 2021;25:566-82. 7. Grotz MR, Allami MK, Harwood P, et al. Open pelvic frac- tures: epidemiology, current concepts of management and out- come. Injury 2005;36:1-13. 8. Melvin JS, Karunakar MA, Chapman JR. Pelvic fractures: epi- demiology, injury patterns, and associated injuries. Orthop Clin North Am 2007;38:193-203. 9. Coulombe P, Malo C, Robitaille-Fortin M, et al. Identification and Management of Pelvic Fractures in Prehospital and Emergency Department Settings. J Surg Res 2024; doi:10.1016/j.jss.2024.05.006 10. Sistema Nazionale linee guida, ISS. Gestione integrata del Trauma Maggiore dalla scena dell’evento alla cura definitiva - ISS. Updated on 19/06/2024. Accessed July 2024. Available Mini review [page 84] [Emergency Care Journal 2024; 20:12696] Non -co mmerc ial us e o nly from: https://www.iss.it/-/gestione-integrata-trauma-maggiore 11. Cano JR, Bogallo JM, Ramirez A, Guerado E. Immediate man- agement of a stable patient with unstable pelvis. EFORT Open Rev 2024;9:434-447. 12. American College of Surgeons. Committee on Trauma. ATLS, advanced trauma life support. Chicago, IL: American College of Surgeons; 1994. 13. Blackbourne LH, Soffer D, McKenney M, et al. Secondary ultrasound examination increases the sensitivity of the FAST exam in blunt trauma. J Trauma 2004;57:934-8. 14. Ketelaars R, Reijnders G, van Geffen GJ, et al. ABCDE of pre- hospital ultrasonography: a narrative review. Crit Ultrasound J 2018;10:17. 15. Magyar CTJ, Maeder F, Diepers M, et al. Detailed information gain and therapeutic impact of whole body computed tomogra- phy supplementary to conventional radiological diagnostics in blunt trauma emergency treatment: a consecutive trauma cen- tre evaluation. Eur J Trauma Emerg Surg 2022;48:921-31. 16. Demetriades D, Karaiskakis M, Toutouzas K, et al. Pelvic frac- tures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg 2002;195:1-10. 17. Ianniello S, Conte P, Di Serafino M, et al. Diagnostic accuracy of pubic symphysis ultrasound in the detection of unstable pelvis in polytrauma patients during e-FAST: the value of FAST-PLUS protocol. A preliminary experience. J Ultrasound 2021;24:423-8. Mini review [Emergency Care Journal 2024; 20:12696] [page 85] Non -co mmerc ial us e o nly