The diagnostic accuracy and clinical utility of fast ultrasound in adult abdominal trauma patients

Nº de DOI: 10.34896/RSI.2025.94.76.001

AUTHORS

1. Edwin Andrés Toapanta Chiluisa. General Practitioner and Master’s Degree in Health Institution Management. Attached to Health District 02D03 Chimbo San Miguel. Graduate of the Central University of Ecuador. (Latacunga-Ecuador). https://orcid.org/0000-0002-0426-5570 ciru gener udl
2. Stephania Abigail Duchi Parraga. General Practitioner. Attached to Guasmo Sur General Hospital. Graduate of the University of Guayaquil. (Guayaquil-Ecuador). https://orcid.org/0009-0003-4015-8814
3. Javier Andrés Martínez Calderón. General Practitioner. Attached to the Roberto Astudillo Health Center and Physician Supporting ENECSDI. Graduate of the University of Guayaquil. (Milagro-Ecuador). https://orcid.org/0009-0006-7007-0233
4. Jefferson Manuel Cevallos Gonzales. General Practitioner and Specialist in Occupational Health and Safety. Attached to the Esmeraldas Sur Delfina Torres de Concha Hospital. Graduate of the Technical University of Manabí. (Esmeraldas-Ecuador). https://orcid.org/0009-0002-0123-2316 cir gener
5. Jessenia de los Angeles Villena Tirado. General Practitioner and Master’s Degree in Occupational Health and Safety. Attached to Private Clinics in Ecuador. Graduate of the Autonomous University of the Andes. (Pelileo -Ecuador). https://orcid.org/0009-0007-2695-0601

ABSTRACT

This article aims to critically evaluate the diagnostic accuracy of eFAST in adult patients with abdominal trauma, compare its performance with other imaging modalities, and explore its clinical utility and inherent challenges in the emergency setting, thus providing a comprehensive overview of its role in trauma management and highlighting areas for improvement and research.

KEY WORDS

Efast, abdominal trauma, emergency ultrasound, diagnostic accuracy.

RESUMEN

Este artículo evalúa de manera crítica la precisión diagnóstica de la ecografía extendida enfocada en trauma (eFAST) en pacientes adultos con traumatismo abdominal. Compara el rendimiento de eFAST con otras modalidades de imagen y analiza su utilidad clínica y sus limitaciones en el entorno de urgencias. Al ofrecer una visión integral de su papel en el manejo del trauma, el artículo destaca los desafíos actuales e identifica áreas que requieren mejoras y mayor investigación.

PALABRAS CLAVE

eFAST, traumatismo abdominal, ecografía de urgencias, precisión diagnóstica.

INTRODUCTION

Trauma remains one of the leading causes of morbidity and mortality worldwide, and abdominal injuries account for a significant proportion of cases requiring rapid assessment and intervention in the emergency department. Timely and accurate diagnosis of intra-abdominal injuries is essential to prevent complications and improve patient outcomes. However, traditional imaging modalities, such as computed tomography (CT), while highly sensitive, are often limited by factors such as availability, time constraints, and the need for patient stability. In this context, Extended Focused Assessment with Sonography for Trauma (eFAST) has become a vital bedside diagnostic tool that provides rapid, noninvasive, and repeatable assessment of trauma patients. By using ultrasound windows to detect free fluid in the peritoneal, pleural, and pericardial spaces, eFAST facilitates the immediate identification of life-threatening conditions such as hemoperitoneum, hemothorax, and cardiac tamponade, thereby expediting clinical decision-making and intervention. Multiple studies have demonstrated that eFAST has high sensitivity and specificity for detecting blunt abdominal injuries, even when performed by non-radiologist personnel, underscoring its practicality in high-demand emergency settings. Furthermore, its ability to save valuable time and resources makes it an indispensable component of trauma protocols worldwide. Despite its numerous advantages, eFAST is not without limitations; its diagnostic accuracy can be influenced by operator experience, patient body constitution, and the nature of the injury, which can lead to false positives or negatives.

OBJECTIVE

Critically evaluate the diagnostic accuracy of eFAST in adult patients with abdominal trauma, compare its performance with other imaging modalities, and explore its clinical utility and inherent challenges in the emergency setting, thereby providing a comprehensive overview of its role in trauma management and highlighting areas for improvement and further research.

METHODOLOGY

This narrative review was conducted to critically evaluate the diagnostic accuracy and clinical utility of the Extended Focused Assessment with Sonography for Trauma (eFAST) in adult patients with abdominal trauma. A structured search strategy was applied across PubMed, Scopus, Web of Science, and Google Scholar for studies published between 1990 and 2024. Search terms included: “eFAST,” “FAST exam,” “abdominal trauma,” “blunt trauma diagnosis,” “hemoperitoneum ultrasound,” “trauma imaging,” “emergency ultrasound accuracy,” “prehospital ultrasound,” and “CT vs ultrasound in trauma.”

Inclusion criteria encompassed:

1. Peer-reviewed studies evaluating eFAST performance in detecting abdominal, thoracic, or pericardial injuries.
2. Articles comparing eFAST with CT or other imaging modalities.
3. Studies involving adult or mixed-age trauma populations.
4. Research on operator-dependent factors, including training and interpretation accuracy.
5. English-language publications with explicit diagnostic outcome measures.

Exclusion criteria included:

1. Case reports and very small series.
2. Studies lacking diagnostic accuracy metrics.
3. Research unrelated to acute trauma or excluding abdominal assessment.
4. Non-clinical or experimental studies without human subjects.

Data extracted included sensitivity, specificity, positive and negative predictive values, time-to-diagnosis, operator variability, and identification of life-threatening conditions (hemoperitoneum, hemothorax, pneumothorax, and hemopericardium). Evidence was thematically synthesized across four domains: (1) diagnostic accuracy, (2) comparison with other imaging modalities, (3) clinical utility in emergency settings, and (4) limitations and operator-dependent challenges. Due to heterogeneity in methodologies and outcome variables, findings were analyzed descriptively without meta-analysis.

RESULTS

Diagnostic Accuracy of eFAST in Adult Abdominal Trauma:

How sensitive and specific is eFAST in detecting blunt abdominal injuries?

The extended Focused Assessment with Sonography for Trauma (eFAST) protocol has become an essential diagnostic tool for identifying closed abdominal injuries, with growing evidence supporting its reliability and accuracy in various clinical settings. It should be noted that eFAST maintains comparable sensitivities and specificities in both prehospital and hospital settings, underscoring its versatility and potential to streamline the diagnostic process and influence early management decisions for trauma patients¹ In pediatric populations, the FAST protocol—a fundamental component of eFAST—demonstrated 88% sensitivity in detecting intra-abdominal injuries requiring surgical intervention, highlighting its effectiveness in identifying clinically significant trauma cases in this vulnerable group². In addition, the specificity of the FAST protocol reached 97% in these pediatric evaluations, indicating a high capacity to correctly rule out intra-abdominal pathology and, therefore, minimize unnecessary interventions or delays in definitive care². The high sensitivity and specificity of eFAST not only facilitate rapid and accurate classification of trauma patients, but also reinforce the need for its integration into trauma assessment protocols, particularly in resource-limited or prehospital settings where rapid, noninvasive diagnostic methods are essential for optimizing patient outcomes^1,2.

What is the reliability of eFAST when performed by non-radiological personnel?

Although the FAST protocol has high sensitivity and specificity in detecting intra-abdominal injuries in pediatric trauma patients, its reliability may be compromised when eFAST scans are interpreted by non-radiologist personnel. The accuracy of these interpretations is closely related to the individual knowledge and accumulated experience of the operator, suggesting that variability in training and exposure may directly influence diagnostic outcomes³. In addition, patient-related factors such as body constitution, the presence of subcutaneous emphysema, or preexisting abdominal conditions can further complicate image acquisition and interpretation, affecting the diagnostic accuracy of non-specialist users³. It should be noted that the risk of false-negative results increases, especially in the context of subtle findings such as intestinal injury or pneumoperitoneum, conditions that may be overlooked by less experienced operators, potentially delaying critical interventions³. These interconnected challenges underscore the need for specific training programs, ongoing competency assessments, and the development of standardized protocols to ensure that eFAST performance by non-radiology personnel maintains a high degree of reliability and patient safety.

How does eFAST compare to other imaging modalities for abdominal trauma diagnosis?

Comparing eFAST with other imaging modalities for abdominal trauma reveals important interconnections between diagnostic accuracy, patient safety, and healthcare resource utilization. Although abdominal CT scans remain the gold standard due to their superior accuracy and ability to provide comprehensive visualization of abdominal injuries through detailed arterial, venous, and delayed phases, their use is limited by factors such as high cost, the need for patient transport, and exposure to ionizing radiation^4,5. In contrast, eFAST offers significant advantages for the initial assessment of trauma patients, especially in emergency and resource-limited settings; its portability, speed, and noninvasive nature make it particularly valuable for hemodynamically unstable patients who cannot be safely transported for CT imaging^4,5. In addition, eFAST does not emit radiation, reducing potential harm and allowing for repeated assessments without risk, while its rapid application at the patient’s bedside (often completed in 3-5 minutes) facilitates timely clinical decision-making in critical situations⁵. However, while eFAST excels as a triage tool for detecting free fluid and guiding early intervention, it is less comprehensive than CT, which remains necessary for definitive diagnosis and detailed evaluation of stable patients with blunt trauma⁵. Integrating both modalities—using eFAST for immediate triage and CT for comprehensive evaluation—can optimize patient outcomes and ensure a balanced approach to trauma management⁵. This underscores the need for customized imaging protocols that leverage the advantages of each modality, ensuring rapid evaluation and diagnostic accuracy in the care of patients with abdominal trauma.

Clinical Utility and Impact of eFAST in Emergency Settings

How does eFAST contribute to timely intervention and improved patient outcomes?

The integration of Extended Focused Assessment with Sonography for Trauma (eFAST) into trauma protocols has significantly improved the speed and accuracy of patient assessment, thereby facilitating timely interventions and better outcomes. Its simplicity and reliability allow clinicians to perform rapid assessments at the patient’s bedside, streamlining the diagnostic process and enabling faster decision-making in critical moments². The structured approach of the protocol allows emergency teams to identify life-threatening conditions such as hemothorax, pericardial effusion, or intra-abdominal hemorrhage, all of which require urgent action to mitigate the risk of morbidity and mortality^2,6. By providing a noninvasive and efficient method for evaluating patients with unstable trauma, eFAST shortens the gap between initial assessment and definitive care, ensuring that interventions such as tube thoracostomy, pericardial window, or laparotomy are performed without unnecessary delay^6,7. Furthermore, the high sensitivity and specificity of eFAST reduce the likelihood of undetected injuries, facilitating both immediate management and subsequent patient triage decisions⁷. The interconnection of these domains (diagnostic convenience, clinical decision-making, and procedural intervention) directly contributes to reducing complications and improving survival rates, emphasizing the need for widespread eFAST training, competency assessments, and ongoing validation studies to further optimize trauma care protocols.

In what ways does eFAST save time and resources in the emergency department?

Based on the high sensitivity and specificity demonstrated in pediatric abdominal trauma, the implementation of eFAST protocols in emergency departments offers significant savings in time and resources in multiple areas. By providing rapid diagnostic information at the bedside, eFAST allows clinicians to quickly identify life-threatening injuries such as hemoperitoneum, hemothorax, and pneumothorax, which is crucial for initiating timely interventions and improving patient outcomes^2,8. This immediacy not only speeds up the clinical decision-making process, but also streamlines trauma assessment by reducing reliance on more time-consuming imaging modalities, such as computed tomography or formal radiology, thereby saving personnel and equipment resources^8,9. The non-invasive nature of eFAST further facilitates resource optimization, as it can be performed by trained emergency personnel at the point of care, minimizing the need for specialized radiology personnel and facilitating repeat exams to monitor the patient’s condition without delaying care^8,10. Together, these efficiencies help prioritize care for the most critical patients, optimize workflow, and reduce wait times, while maintaining a high level of diagnostic accuracy. To maximize these benefits, emergency departments should ensure ongoing eFAST training for clinical staff and incorporate it into established trauma protocols, thereby reinforcing a culture of rapid and effective trauma management.

What are the main trauma conditions (e.g., haemoperitoneum, haemothorax, cardiac tamponade) identified using eFAST?

The main trauma conditions identified using the eFAST protocol are hemopericardium, hemoperitoneum, hemothorax, and pneumothorax, each of which represents critical, life-threatening conditions that require rapid recognition and intervention¹¹. Detection of hemoperitoneum involves identifying free fluid within the abdominal cavity, which is strongly suggestive of intra-abdominal bleeding and often requires urgent surgical exploration in hemodynamically unstable trauma patients^11,12. Similarly, hemothorax, characterized by the accumulation of blood in the pleural space, is discerned through the visualization of intrathoracic fluid, a finding that guides the need for chest decompression or thoracostomy, while the identification of pneumothorax is based on the absence of lung sliding or the presence of a lung point, both of which have direct implications for respiratory management and can be quickly assessed at the patient’s bedside^11,12. Furthermore, detection of hemopericardium, which can progress to cardiac tamponade, is crucial, as it may explain signs of obstructive shock and warrants immediate pericardiocentesis or surgical intervention^11,13. These interconnected domains (abdominal, thoracic, and pericardial) emphasize the comprehensive utility of eFAST in trauma, as findings in one region often influence clinical suspicion and management strategies in others, particularly in the context of polytrauma and hemodynamic instability. Given the protocol’s limitations in distinguishing blood from other types of fluids and the potential for false positives and negatives, it is crucial to integrate eFAST results with the patient’s clinical condition and, when necessary, corroborate with additional imaging or surgical exploration to ensure that critical injuries are not overlooked or misinterpreted¹¹. This underscores the need for ongoing operator training, rigorous adherence to protocol, and multidisciplinary collaboration to maximize the diagnostic and therapeutic value of eFAST in acute trauma care.

Limitations and Challenges of eFAST in Trauma Assessment

What are the limitations of eFAST in different trauma scenarios?

One of the main limitations of the extended Focused Assessment with Sonography for Trauma (eFAST) examination is its inability to definitively rule out injuries in trauma patients, even with negative results. This limitation is particularly pronounced in cases of retroperitoneal hemorrhage, small-volume hemoperitoneum, or early-stage injuries, where the sensitivity of eFAST may be insufficient to detect subtle or evolving pathology, which could lead to misdiagnosis and delayed intervention. The clinical implication of this limitation is significant, as reliance on a negative eFAST result can give false assurance to clinicians, leading to premature discontinuation of diagnostic or surveillance studies¹⁴. Furthermore, given that trauma scenarios are dynamic and injury patterns can progress rapidly, the negative predictive value of eFAST is further compromised, making it imperative to integrate ultrasound findings with clinical assessment and consider other imaging modalities when suspicion persists. Therefore, while eFAST remains a valuable tool in the initial assessment of trauma, it should not be used in isolation for definitive decision-making, and protocols should emphasize the need for comprehensive assessment strategies to avoid adverse outcomes from undetected injuries¹⁴.

How does operator experience and training affect eFAST diagnostic performance?

The diagnostic performance of Extended Focused Assessment with Sonography in Trauma (eFAST) is not determined solely by the inherent capabilities of ultrasound technology, but is deeply influenced by the operator’s experience and the thoroughness of their training^15,16. Highly skilled and well-trained operators, whether physicians or nurses, are essential for consistent and accurate interpretation of eFAST findings, as their competence directly impacts overall diagnostic sensitivity, specificity, and accuracy^15,16. Research has shown that structured training programs, such as a 1-day lecture combined with practice and the performance of more than 25 supervised FAST exams, can rapidly elevate the diagnostic performance of non-physician providers to a level comparable to experienced professionals, producing high sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in trauma settings¹⁶. Specifically, FAST examinations performed by nurses have achieved an overall accuracy of up to 95% in detecting free intra-abdominal fluid, underscoring the importance of targeted educational interventions¹⁶. Furthermore, the integration of eFAST and other emergency ultrasound applications into basic emergency nursing training programs not only improves diagnostic capabilities but also increases the use of these crucial tools in acute care, ultimately improving patient outcomes and streamlining trauma management workflows¹⁶. These findings highlight the need for continued investment in practical, structured ultrasound training for all relevant healthcare professionals in order to optimize the utility of eFAST in both pediatric and adult trauma care.

What are the potential false positives or negatives associated with eFAST usage?

False positives and negatives in the use of eFAST are influenced by a complex interaction of technical, procedural, and operator-dependent factors, with significant implications for both patient management and clinical workflow. A critical issue lies in the limitations of the eFAST exam itself, as it does not replace comprehensive imaging by a radiologist, which inherently carries the potential for overlooking injuries and overdiagnosis, especially in the early or incomplete phases of trauma assessment. Common sources of error, such as pelvic fluid, the double line sign, the pericardial fat pad, and chest findings, can result in both false positives and false negatives, as these anatomical features can mimic or obscure actual pathological findings, leading to diagnostic uncertainty in multiple organ systems¹⁷. In addition, procedural issues such as poor documentation, technically limited examinations, and incomplete studies further exacerbate the risk, as they can obscure subtle injuries or create artificial positive findings that mislead clinical decision-making¹⁷. These inaccuracies not only affect immediate trauma triage but also have subsequent repercussions on patient outcomes, resource utilization, and the need for additional imaging or interventions. Therefore, robust serial testing protocols, comprehensive documentation, and ongoing training are necessary to mitigate these risks and improve the reliability of eFAST in various clinical settings, while recognizing its role as a complementary and not definitive diagnostic tool².

DISCUSSION

The findings of this study underscore the fundamental role of eFAST as a rapid, reliable, and noninvasive diagnostic modality in the evaluation of abdominal trauma in adults, reaffirming its high sensitivity and specificity for detecting critical injuries such as hemoperitoneum, hemothorax, pneumothorax, and hemopericardium. Its proven effectiveness in both prehospital and hospital settings highlights its versatility and ability to facilitate early triage and immediate treatment, which are crucial for improving patient outcomes. The comparable diagnostic accuracy observed in pediatric populations reinforces its broad applicability across all age groups. However, the study also highlights important limitations, primarily the dependence on operator skill and experience, which can introduce variability in interpretation and potentially lead to false negatives or positives, especially in cases with subtle findings or complex injury patterns. Technical factors such as body constitution, preexisting conditions, and imaging artifacts can further compromise accuracy, underscoring the need for standardized training protocols and ongoing competency assessments. While eFAST offers significant advantages over other imaging modalities such as CT (particularly speed, portability, and safety), its inability to detect certain injuries, such as retroperitoneal hemorrhages or small hemorrhages, highlights the importance of complementary imaging techniques in comprehensive trauma assessment. The study results advocate for a balanced approach that integrates eFAST into clinical decision-making, with judicious use of additional diagnostics, especially in doubtful cases. Furthermore, the findings suggest that structured training programs can improve diagnostic reliability among non-radiologist clinical staff, thereby reducing the risk of misinterpretation. Future research should focus on developing standardized interpretation criteria, exploring advanced ultrasound technologies, and evaluating the impact of continuing education on diagnostic performance. Recognizing these limitations and avenues for improvement is essential to optimizing the clinical utility of eFAST, ensuring its effective integration into trauma protocols, and safeguarding patient safety through accurate and timely diagnosis.

CONCLUSIONS

1. The review demonstrates that eFAST is a highly valuable diagnostic tool in the initial assessment of adult abdominal trauma, offering rapid, noninvasive, and repeatable imaging that significantly accelerates clinical decision-making. Its high sensitivity and specificity for detecting free intraperitoneal and intrathoracic fluid make it indispensable in both prehospital and emergency department environments, particularly when time and patient stability limit the use of CT.
2. Despite these strengths, eFAST is not without limitations. Diagnostic accuracy is highly dependent on operator expertise, with less experienced clinicians showing greater variability and risk for false-positive and false-negative findings. Conditions such as retroperitoneal hemorrhage, early or low-volume hemoperitoneum, and subtle bowel injuries remain challenging for ultrasound detection, underscoring the need for complementary imaging—particularly CT—in hemodynamically stable patients or in cases of diagnostic uncertainty.
3. Comparative analysis confirms that CT remains the gold standard for comprehensive evaluation, but eFAST serves a critical role in triage, early stabilization, and ongoing monitoring. Its repeatability, lack of radiation exposure, and immediate bedside applicability make it especially advantageous in resource-limited settings.
4. Overall, integrating eFAST into trauma workflows enhances patient outcomes by improving efficiency, enabling timely interventions, and supporting informed clinical decision-making. However, systematic training, competency validation, and adherence to structured scanning protocols remain essential to optimize reliability and minimize diagnostic errors.

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