Original Study

Evaluation of an abdominal fluid scoring system

determined using abdominal focused assessment
with sonography for trauma in 101dogs with motor
vehicle trauma
Gregory R. Lisciandro, DVM, DABVP, DACVECC; Michael S. Lagutchik, DVM, MS, DACVECC;
Kelly A. Mann, DVM, MS, DACVR; Geoffrey T. Fosgate, DVM, PhD, DACVPM; Elizabeth G. Tiller,
DVM; Nicholas R. Cabano, DVM; Leslie D. Bauer, DVM; Bradley P. Book, DVM, DABVP and
Philip K. Howard, DVM
Abstract
Objective Evaluate an abdominal uid 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 uid-
positive quadrants identied using a 4-point scale: AFS 0 (negative for uid in all quadrants) to AFS 4
(positive for uid in all quadrants). Free abdominal uid was identied 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 uid. 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 uid 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): 426437) doi: 10.1111/j.1476-4431.2009.00459.x
Keywords: AFAST, FAST, hemoperitoneum, trauma, ultrasound
Introduction
Undiagnosed intra-abdominal injury
13
and uncon-
trolled hemorrhage
4,5
are leading causes of death in
human trauma patients, and ongoing hemorrhage is
responsible for 80% of early death in hospitalized hu-
mans.
3,610
Historically, occult hemorrhage in human
trauma patients has been problematic because aggres-
sive uid therapy in this subset of patients may exac-
erbate bleeding and increase patient morbidity and
mortality.
1115
Medical management of traumatized
Presented in part at the Resident Abstracts session at the International
Veterinary Emergency and Critical Care Society Symposium, San Antonio,
TX, September 2006.
The authors declare no conicts of interest.
Address correspondence and reprint requests to
Dr. Gregory R. Lisciandro, Emergency Pet Center Inc, 8503 Broadway, Ste
105, San Antonio, TX 78217, USA.
Email: woodydvm91@yahoo.com
From the Emergency Pet Center Inc, San Antonio, TX 78217 (Lisciandro,
Lagutchik, Mann, Tiller, Cabano, Bauer, Book, Howard); and the Depart-
ment of Veterinary Integrative Biosciences, College of Veterinary Medicine,
Texas A & M University, College Station, TX 77843, USA (Fosgate).
Journal of Veterinary Emergency and Critical Care 19(5) 2009, pp 426437
doi:10.1111/j.1476-4431.2009.00459.x
& Veterinary Emergency and Critical Care Society 2009 426
patients with known or occult intra-abdominal hemor-
rhage is complicated, because routine measures taken
to assess the presence of intra-abdominal hemorrhage
(eg, physical examination ndings, arterial and central
venous blood pressure, and abdominal radiographic
examination) have variable and poor reliability and
sensitivity for detecting the presence of hemo-
peritoneum.
5,13,1623,a
Recently, focused assessment with sonography
(FAST) in patients with abdominal trauma has been
shown to provide rapid and accurate information re-
garding the presence of hemoperitoneum in hu-
man
5,16,17,2232
and veterinary patients.
33,a
FAST is now
a favored diagnostic test for human trauma patients
because of its high specicity and sensitivity compared
with diagnostic peritoneal lavage (DPL) and computer-
ized tomography (CT).
2931,34
In fact, FAST has nearly
eliminated the use of DPL and markedly reduced CT
evaluations at some trauma centers.
22,25,2729,32,35,36
In contrast to FAST, DPL takes longer and is more in-
vasive. DPL lends itself to complications (eg, iatrogenic
puncture of intra-abdominal structures) and confounds
subsequent physical examinations and imaging because
of local and residual pain and the deposition of uid
into the abdominal cavity.
37
DPL gives no information
regarding the retroperitoneal space and is subject to
time-consuming laboratory interpretation. Although CT
is the gold standard for diagnosis of intra-abdominal
injury, CT requires equipment not universally available
and a hemodynamically stable patient for transport
to radiology. CT imaging also exposes the patient to
radiation.
22
There are sparse clinical veterinary data regarding
the utility of FAST in traumatized patients. In the only
reported veterinary study,
33
45 of 100 traumatized dogs
(45%) were positive for free abdominal uid, a marker
of intra-abdominal injury, with a sensitivity of 96% and
a specicity of 100%. Importantly, 39 of 45 (87%) FAST-
positive dogs were diagnosed with hemoperitoneum
by abdominocentesis and 9 of 45 (23%) required blood
transfusion. However, it should be noted that approx-
imately one-third of these dogs had been assessed by
another veterinarian and referred before abdominal fo-
cused assessment with sonography for trauma
(AFAST); many most likely received uid therapy
before their FAST examination, and 16 dogs had ab-
dominocentesis performed before abdominal FAST ex-
aminations, which may have skewed results and
interpretation.
Hemoperitoneum scoring systems using FAST are
utilized in human trauma patients to semiquantitative-
ly assess the degree of intra-abdominal hemor-
rhage.
16,17,20,38
Serial FAST examinations favorably
impact patient outcome by increasing sensitivity and
expediting the diagnosis of otherwise occult intra-ab-
dominal injury.
18,20,2426,38
Given that ultrasound (US) is
readily available in many veterinary practices and pro-
ciency using the FAST technique by non-radiologist
clinicians has been demonstrated in human and veter-
inary studies,
5,33,a
development of a veterinary uid
scoring system using FAST that would semiquantita-
tively assess the initial and progressive degree of intra
-abdominal injury would be helpful, as has been shown
in human FAST studies.
16,17,24,25,38,39
However, veteri-
nary data documenting the clinical utility of FAST in
identifying and quantifying hemoperitoneum is lack-
ing. A preliminary study
a
of 82 dogs with motor vehicle
trauma noted the reliability of FAST examination to
document intra-abdominal uid and was the rst to
document application of a veterinary abdominal uid
scoring (AFS) system. This study demonstrated that
higher-scoring FAST-positive dogs experienced more
marked anemia and need for blood transfusion than
lower-scoring and FAST-negative dogs. Evaluation of
an AFS system is warranted in traumatized veterinary
patients to help assess the degree of injury and guide
therapy.
The purpose of our study was to evaluate the appli-
cation of a novel AFS system for the semiquantication
of free abdominal uid using initial and serial abdom-
inal FAST examinations. Our hypothesis was that ear-
lier detection and estimation of the quantity of free
abdominal uid in trauma patients on presentation
would allow clinicians to better assess the types and
severity of internal abdominal injuries and the need for
clinical intervention (eg, advanced diagnostic testing,
blood transfusion, surgical exploration), and would
have greater clinical utility than conventional methods
of diagnosing intra-abdominal hemorrhage or urine or
bile leakage (eg, radiography). Furthermore, we hy-
pothesized that the serial use of AFASTand AFS would
allow trend analysis over time that would be useful to
direct clinical intervention or modify existing therapy.
Materials and Methods
Case enrollment and management
Dogs were eligible for study inclusion if they were
presented to the veterinary emergency center within 24
hours of motor vehicle trauma. AFAST was performed
before abdominocentesis and following a standardized
protocol as previously described.
33,a
Owner consent
was obtained before study enrollment for patients with
known owners.
Patient demographic and medical data were re-
corded in an electronic medical record as part of rou-
tine patient management. Outcome (long-term survival,
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
Fluid scoring with AFAST in traumatized dogs
was determined by telephone contact with owners a
minimum of 2 weeks after discharge from the center.
Diagnostic procedures
All clinicians participated in didactic US training by a
board-certied 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
with examination, resuscitative efforts, and point-of-
care testing, and before abdominocentesis. Every at-
tempt was made to perform AFAST within 15 minutes
of arrival. A 4-hour serial AFAST examination was per-
formed in all hospitalized patients. All dogs were eval-
uated with the same model of US machine
b
using a
7.5 MHz curvilinear probe. Imaging sites were not
clipped of fur, and alcohol was used instead of acoustic
gel for most patients, although some thick-coated
dogs had acoustic gel applied at the US probe-to-skin
interface.
A standardized AFS was assigned to all cases after
imaging 4 specic anatomic sites, as follows: AFS 0 was
assigned if no free abdominal uid was noted at any of
the 4 imaging sites, AFS 1 was assigned if free abdom-
inal uid was noted at only 1 of the 4 imaging sites,
AFS 2 was assigned if free abdominal uid was noted at
2 of the 4 imaging sites, AFS 3 was assigned if free
abdominal uid was noted at 3 of the 4 imaging sites,
and AFS 4 was assigned if free abdominal uid was
noted at all 4 imaging sites. Anatomic locations of pos-
itive sites were recorded. Although these sites were the
same as described previously,
33
we named each by their
associated targeted intra-abdominal structures, as fol-
lows: diaphragmatico-hepatic (DH) site, on the ventral
midline just caudal to the xiphoid; spleno-renal (SR)
site, on the left lateral abdominal wall; cysto-colic (CC)
site, on the ventral midline cranial to the pubis; and
hepato-renal (HR) site, on the right lateral abdominal
wall. This is similar to human studies.
22
The AFAST
sites and sequential order of imaging are illustrated in
Figure 1. In contrast to Boysen et al,
33
right lateral re-
cumbency was preferred because the gall bladder, left
kidney, and respective retroperitoneal space are more
readily imaged in this position, and iatrogenic puncture
of the spleen by abdominocentesis is less likely in the
authors experience. Additionally, with the recent ad-
vent of thoracic FAST (TFAST),
40,c
right lateral recum-
bency allows standard electrocardiogram measurement
and imaging of the left ventricle for assessment of pa-
tient cardiovascular volume status.
d
Thus, these diag-
nostic techniques may be advantageously applied at
one time in one patient position.
Preprinted, standardized data sheets were completed
by the attending veterinarian to record US ndings at
each imaging site, real time of study, examination du-
ration, patients clinical stability, and characterization of
abdominocentesis if performed. Hemoperitoneum was
diagnosed by abdominocentesis based on the failure of
the uid to clot, in addition to having a PCV and total
plasma protein (TPP) comparable to peripheral blood.
Abdominal radiographic serosal detail was assessed
by a board-certied veterinary radiologist blinded to
AFAST ndings and the study population. Only pos-
itive AFASTimages were printed for review by a board-
certied radiologist. All abdominal radiographs were
performed using traditional lm-screen radiography.
Other diagnostic procedures performed on all pa-
tients as part of the standardized protocol included
measurement of hemoglobin saturation by pulse oxi-
metry (SpO
2
); determination of PCV and TPP, concen-
trations of blood lactate (BL), serum alanine
aminotransferase (ALT), alkaline phosphatase, glucose,
lipase, urea nitrogen, and creatinine, and TFAST as de-
scribed previously.
40,c
Routine measurements of patient
vital signs were recorded including heart rate, respira-
tory rate, rectal temperature, pulse quality, mucous
membrane color, capillary rell time, and body condi-
tion score. Serial measurements of SpO
2
, BL, PCV, TPP,
and TFAST were repeated approximately 4 hours after
Figure1: Depiction of the 4-point AFAST protocol beginning at
the diaphragmatic-hepatic (DH) view, followed by the spleno-
renal view (SR), the cysto-colic view (CC), and completed at the
hepato-renal view (HR). The HR view is called the Home Run
site because in high-scoring dogs this gravity-dependent site is
commonly positive for uid. Abdominocentesis can thus be
performed at the HR view for uid characterization at the ab-
dominal focused assessment with sonography for trauma
(AFAST) exams completion. Direction (arrows) and order of
AFAST exam (numbered ultrasound probes) are illustrated.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x 428
G.R. Lisciandro et al.
admission. Other diagnostic and monitoring proce-
dures were performed at the discretion of the attending
veterinarian.
Statistical analysis
Data were summarized for AFS-positive and AFS-neg-
ative dogs using descriptive statistics and 95% con-
dence intervals. Student t tests were used to compare
means for quantitative data between groups and cate-
gorical variables were compared using chi-square or
Fisher exact tests. The proportion of other traumatic
consequences (eg, fracture, coxofemoral luxation,
pneumothorax [PTX], diaphragmatic hernia) were com-
pared between AFS-positive and AFS-negative dogs by
the calculation of prevalence ratios, 95% condence in-
terval, and chi-square (or Fisher exact) tests. For AFS
positive dogs, data were compared for animals with
scores of AFS 1 and 2 versus AFS 3 and 4 on initial and
serial examinations. Mann-Whitney U tests were used
to compare medians of quantitative data between AFS
groups and categorical variables were compared using
Fisher exact tests. Initial PCV was compared between
dogs with positive and negative AFS examinations us-
ing a Student t test. All statistical analyses were per-
formed using available software.
e,f
Results with Po0.05
were considered significant.
Results
One hundred and one dogs with motor vehicle trauma
were enrolled in this study from April 2005 through
June 2006; 98% (98/101) were direct presentations to
our emergency center. There were 16 intact females, 31
spayed females, 30 intact males, and 24 neutered males,
with multiple breeds represented. Mean weight was
19.2 kg (SD, 13.1 kg) and mean age was 2.7 years (SD,
2.5 y). Injuries within our study population were var-
ied, but many dogs were presented with severe injuries
that included 22 dogs (22%) with PTX, 22 dogs (22%)
with pelvic fractures, 25 dogs (25%) with appendicular
fractures or luxations, and 2 dogs (2%) with diaphrag-
matic hernia (Table 1).
All enrolled dogs were imaged by AFAST within 24
hours of trauma. Every attempt was made to perform
AFAST within 15 minutes of arrival to our emergency
center. The majority of dogs (68%) were imaged using
AFAST within 2 hours of being traumatized; only 12%
dogs were initially imaged more than 3 hours after
trauma. Median time from presentation to AFAST imag-
ing was o5 minutes (range, 0, 420 min); from traumatic
injury to AFAST examination was 60 minutes (range, 15,
1440 min) and from initial to serial AFAST examination
was 4 hours (range, 3, 7 h). The median time to complete
the AFASTexamination was 3 minutes (range, 1, 30 min).
There were significant differences in the duration of
examination between AFS-positive and AFS-negative
dogs for both initial and serial examination (initial:
5.78 vs 3.59 min, P50.006; serial: 5.66 vs 3.59 min,
P50.006). However, there were no significant differ-
ences between AFAST-positive and AFAST-negative
dogs for time from admission to AFAST (38.9 vs
14.6 min, P50.08), time from trauma to AFAST (137.9
vs 102.7 min, P50.44), and time from initial to serial
AFAST (4.4 vs 4.2 h, P50.35). These data suggest there
was no clinician bias in the timing of AFAST examin-
ations in our study (Table 2).
All 101 enrolled dogs had an initial AFAST per-
formed, and 71 of these dogs had a serial AFAST per-
formed 4 hours after admission. Thirty dogs did not
have serial AFAST performed; 8 were euthanized, and
22 were discharged before serial AFAST. Overall, 27%
(27/101) of our study population was AFS-positive (ie,
free-abdominal uid identied by AFAST). Of these,
78% (21/27) were positive at admission and the re-
maining 6 dogs, initially AFS-negative, became AFS-
positive at the time of their serial AFAST examination.
Table1: Distribution of abdominal uid score and specic injuries in dogs with trauma
n
Trauma type
AFS-negative cases (n574) AFS-positive cases (n527)
Prevalence
ratio
95% condence
interval
P
value
Number of
cases
Percent of
cases
Number of
cases
Percent of
cases
Pelvic fractures 12 16 10 37 2.28 1.12, 4.67 0.03
Coxofemoral
luxations
5 7 2 7 1.1 0.23, 5.32 1
Pneumothorax 10 14 12 44 3.29 1.61, 6.72 o0.001
Diaphragmatic
hernia
2 3 0 0 NA NA 1
Appendicular
fractures
20 27 5 19 0.69 0.29, 1.64 0.38
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
Fluid scoring with AFAST in traumatized dogs
Fifteen of the 21 (71%) initially positive dogs had se-
rial AFAST examinations performed. Six AFS-positive
dogs did not have a serial AFAST examination; 4 were
euthanized for nancial reasons, 1 died within the ini-
tial 4-hour period from severe concurrent head trauma,
and the sixth dogs owner refused hospitalized care.
Euthanasia was not performed due to need for blood
transfusion or emergent laparotomy because of uncon-
trolled hemorrhage in any case. When the overall AFS
for each respective AFS-positive dog, either on their
initial or serial AFASTexam was determined, we found
33% (9/27) of AFS-positive dogs were scored as AFS 1,
15% (4/27) were scored as AFS 2, 15% (4/27) were
scored as AFS 3, and 37% (10/27) were scored as AFS 4.
When all 42 initial and serial AFS-positive exams
were combined, positive AFAST sites were plotted
(Figure 2) to illustrate locations and frequencies for
positive anatomic sites. We found that more often non-
gravity-dependent sites were positive in the lowest
scoring AFS 1 dogs. In AFS 2 dogs, we found the non-
gravity-dependent CC site equal in frequency to the
gravity-dependent (HR, SR) sites in right and left lateral
recumbency, respectively. No AFS 3 dogs were positive
at the non-gravity-dependent site. Because, by deni-
tion AFS 4 dogs were positive at all sites, they are ex-
cluded from Figure 2.
Overall, 12 of the 71 (17%) dogs with serial AFAST
exams (both AFS-positive and AFS-negative) were
noted to have a change in their AFS; none of these
dogs reverted to an AFS-negative score. All 6 of the
initially AFS-negative dogs that changed score became
AFS 1. Two of the initially AFS-positive dogs had an
increase by 1 in their AFS score, 1 dog had an increase
by 2 in its AFS score, and 3 dogs had a decrease by 1 in
their AFS score.
All initial AFAST examinations were performed be-
fore abdominocentesis. No dog had abdominocentesis
performed before becoming AFS positive, thus elimi-
nating any possibility of iatrogenic hemoperitoneum.
Abdominocentesis was performed in 18 of the 27 AFS-
positive dogs at the discretion of the attending veter-
inarian; 94% (17/18) had positive abdominocentesis re-
sults, with all cases diagnosed as hemoperitoneum. The
only AFS-positive dog with an unsuccessful abdomi-
nocentesis was AFS 1 on admission and serial exam-
ination. No dogs were diagnosed with uroperitoneum
or bile leakage based on abdominocentesis uid anal-
ysis or clinical course.
Abdominocentesis was performed on initial presen-
tation in 65% (11/17) of those dogs having this proce-
dure performed, and at the time of serial AFAST in the
remaining 35% (6/17) of dogs. No dog enrolled in this
study had abdominocentesis performed more than
once. AFS for dogs with positive abdominocentesis T
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& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x 430
G.R. Lisciandro et al.
varied: 3 dogs had AFS 1, 2 dogs had AFS 2, 4 dogs had
AFS 3, and 8 dogs had AFS 4. Of the dogs with positive
abdominocentesis on serial AFAST examination, 3 dogs
were initially AFS negative and 1 dog was initially AFS
1; the latter dog had progressed to AFS 3 and subse-
quently received a blood transfusion to manage anemia
from ongoing hemorrhage.
Abdominal radiographic examination was per-
formed on 97% (97/101) of dogs and reviewed by a
veterinary board-certied radiologist as described.
Comments regarding abdominal serosal detail were
extracted from the radiology reports. Abdominal ra-
diographic serosal detail was described as normal in
24% (6/25) of AFS-positive dogs and as abnormal in
34% (23/66) of the AFS-negative dogs.
Statistically significant differences were noted be-
tween AFS-negative and AFS-positive dogs (Table 3) in
several clinical parameters including: initial and serial
PCV, initial and serial TPP, initial BL concentration,
initial heart rate, initial serum ALT, initial SpO
2
, and
Figure2: Illustration showing the relationship between abdominal uid 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 AFASTsites. 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.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x 431
Fluid scoring with AFAST in traumatized dogs
initial rectal temperature. Additionally, there were sta-
tistically significant differences noted between AFS-
negative and AFS-positive dogs in the number of dogs
with pelvic fractures and PTX (see Table 1). Dogs with
truncal trauma (ie, PTX, pelvic fractures) were more
likely to be AFS positive than were dogs with append-
icular trauma (ie, appendicular fractures, luxations);
these individual comparisons were statistically signif-
icant (Po0.05).
The 27 AFS-positive dogs were divided into a lower
scoring group (AFS 1 and 2) consisting of 13 dogs (48%)
and a higher scoring group (AFS 3 and 4) consisting of
14 dogs (52%) for analysis. Statistically significant dif-
ferences were found for body weight, initial heart rate,
initial and serial ALT, and initial BL when compared to
serial AFS groups (Table 4).
Although not statistically significant, only the higher
scoring AFS-positive dogs (AFS 3 and 4) became ane-
mic (mean serial PCV of 34%; P50.15; reference inter-
val, 3652%). These dogs also had the greatest decrease
in PCV during the rst 4 hours of hospitalization, with
a mean decrease of 21%. Moreover, 31% (4/13) of dogs
in the higher scoring group developed a PCVof 25% or
less compared with the lower scoring group, in which
no dog developed a PCVo30% and only 1 dog became
anemic (PCVo36%). Only dogs in the higher scoring
group received blood transfusions.
Survival to discharge between AFS-positive and AFS-
negative dogs was statistically significant (P50.005).
Of the 64 AFS-negative dogs completing the study, 91%
(58/64) survived, 5% (3/64) died (1 during and 2 after
hospitalization), 5% (3/64) were euthanized, and 10
dogs were lost to follow-up. Survival for AFS-positive
dogs was lower; 63% (17/27) survived, 4% (1/27) died
during hospitalization, and 33% (9/27) were eutha-
nized; none were lost to follow-up. None of the AFS-
positive dogs were euthanized because of immediate
need for blood transfusion or exploratory laparotomy
due to uncontrolled hemorrhage.
Discussion
The results of our study demonstrate that an AFS sys-
tem used in conjunction with initial and serial AFAST
examinations in trauma patients consistently provided
a semiquantitative measure of free abdominal uid that
reliably estimated the degree of intra-abdominal hem-
orrhage and was related to actual decreases in PCVand
need for blood transfusion, and thus served as a marker
for the degree of intra-abdominal injury. Results also
demonstrated that dogs with higher AFS were more
likely to have more marked increases in ALT and BL
concentration and were more likely to have more severe
associated trauma, again supporting our hypoth-
esis that AFAST and AFS determination reliably esti-
mates severity of trauma. Our results additionally show
that an AFS used with AFAST improved clinical deci-
sion making and guided therapy during the initial
4 hours after admission. We found that initial PCV
values and radiographic abdominal serosal detail were
Table3: Patient characteristics, vital signs, and clinicopathologic data
Parameter
AFS-negative cases
(n574)
AFS-positive cases
(n527)
P value Mean SD Mean SD
Age (y) 3.0 2.7 (n 570) 1.8 1.9 0.05
Weight (kg) 18.7 13.9 20.8 10.9 0.46
Temperature (F) 101.7 1.4 (n 570) 101.0 1.8 (n 525) 0.05
Heart rate (beats/min) 133 28 (n 572) 154 34 (n 526) 0.002
Respiratory rate (breaths/min) 53 33 (n 559) 58 32 (n 523) 0.52
Lactate initial (mmol/L) 3.3 1.6 (n 559) 4.2 1.9 (n 524) 0.04
Lactate serial (mmol/L) 2.3 0.9 (n 545) 2.2 0.8 (n 518) 0.70
PCV initial (%) 48 6 (n 562) 43 9 (n 526) 0.004
PCV serial (%) 42 7 (n 545) 37 9 (n 521) 0.02
TPP initial (g/L) 61 10 (n 562) 55 9 (n 526) 0.01
TPP serial (g/L) 54 12 (n 545) 46 9 (n 521) 0.01
SpO
2
initial (%) 94 7 (n 542) 91 7 (n 518) 0.04
SpO
2
serial (%) 96 4 (n 533) 96 3 (n 515) 0.39
ALT (U/L) 479 586 (n 553) 1,067 1,011 (n 521) 0.003
PCV abdominocentesis (%) NA 46 0.1 (n 511) NA
TPP abdominocentesis (g/L) NA 59 11 (n 510) NA
Outcome (2 wk post discharge) (survived/died/euthanized) 58/3/3 (n 564) 17/9/1 (n 527) 0.005
AFS, abdominal uid score; kg, kilograms; F, degrees Fahrenheit; TPP, total plasma protein; SpO
2
, oxyhemoglobin saturation by pulse oximetry; ALT,
alanine transferase activity.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x 432
G.R. Lisciandro et al.
misleading not only for the presence of free abdominal
uid, but also the amount of free abdominal uid, thus
demonstrating further utility of AFAST and use of
an AFS.
In dogs in our study with hemoperitoneum, the de-
termination of the initial and serial AFS in traumatized
dogs allowed clinicians to semiquantitatively assess the
severity of injury (ie, dogs with AFS 1 were less severely
injured than AFS 4 dogs), as well as gauge the degree of
ongoing hemorrhage (ie, an increasing AFS on serial
examination was associated with progressive bleeding),
thus aiding evidence-based decisions regarding resus-
citative efforts, such as extent and type of uid resus-
citation and need for blood transfusion. Although not
statistically significant, marked decreases in serial PCV
were found in the higher scoring (AFS 3 and 4) dogs,
compared with the lower scoring (AFS 1 and 2) dogs. In
this study, only the high scoring dogs became anemic.
Historically, aggressive uid resuscitation in the
presence of occult hemorrhage has led to the deleteri-
ous exacerbation of intra-abdominal bleeding.
11,1315
Based on the results of this study, the use of initial and
serial AFAST examinations and the application of an
AFS can now be utilized to conrm intra-abdominal
uid and more reliably help to answer the pressing
question, is there ongoing hemorrhage? within veter-
inary resuscitation algorithms for bluntly traumatized
dogs.
13
Based on the results of this study, the use of
AFAST and the AFS should be considered one of the
rst tests in a diagnostic algorithm for traumatized
dogs and no longer considered an ancillary test,
13,41,42
similar to human standards of care. Although few pa-
tients in our study became anemic or required blood
transfusion, we are hopeful that further studies with
larger patient numbers will further conrm the utility
of AFAST and the AFS as a measure that can be used
with consistently reliable results to detect the degree
of intra-abdominal hemorrhage, and will improve pa-
tient management, as has denitively been shown in
humans.
2325,38
Table4: Comparison of patient characteristics, vital signs, and clinicopathologic data for dogs with positive abdominal uid scores
n
Parameter (median
values, ranges)
Initial AFS 1 and 2
positive dogs
(n510)
Initial AFS 3 and 4
positive dogs
(n511) P value
Serial AFS 1 and 2
positive dogs
(n512)
Serial AFS 3 and 4
positive dogs
(n59) 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)
(n 59)
0.24 101.4 (97.2, 103.0) 101.8 (99.9, 102.7)
(n 58)
0.57
Heart rate (beats/min) 150 (84, 190) 168 (128, 210)
(n 510)
0.04 153 (84, 190) 164 (120, 210) 0.31
Respiratory rate
(breaths/min)
55 (40, 164) (n 58) 60 (28, 11) (n 59) 1.00 50 (20, 164) (n 511) 60 (28, 110) (n 58) 0.66
Lactate initial
(mmol/L)
3.3 (1.3, 8.5) (n 59) 4.7 (2.6, 8.1) (n 510) 0.10 2.9 (1.3, 8.2) (n 511) 4.7 (2.6, 8.5) 0.04
Lactate serial
(mmol/L)
NA NA NA 2.0 (0.9, 3.7) (n 511) 2.5 (1.5, 3.5) (n 57) 0.43
PCV initial (%) 48.0 (38.0, 52.0)
(n 59)
44.0 (24.0, 55.0) 0.13 45.5 (25.0, 53.0) 44.0 (25.0, 55.0) 0.42
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 59) 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
SpO
2
initial (%) 94 (86, 98) (n 57) 87 (78, 97) (n 59) 0.17 94 (82, 98) (n 56) 96 (80, 98) (n 57) 0.84
SpO
2
serial (%) NA NA NA 97 (93, 100) (n 58) 95 (91, 100) (n 57) 0.69
ALT (U/L) 619 (38, 1,459) (n 58) 1,097 (784, 3,812)
(n 58)
0.04 365 (38, 1,741)
(n 511)
1,194 (448, 3,812) 0.02
PCV
abdominocentesis (%)
45.5 (45.0, 46.0)
(n 52)
48.0 (35.0, 60.0)
(n 59)
0.91 45.5 (45.0, 46.0)
(n 52)
49.5 (42.0, 60.0)
(n 56)
1.00
TPP
abdominocentesis (g/L)
56 (46, 66) (n 52) 58 (48, 76) (n 58) 0.53 56 (46, 66) (n 52) 68 (50, 76) (n 55) 0.38
Outcome (2 wk post
discharge) (survived/
died/euthanized)
7/2/1 (n 510) 7/1/3 (n 511) 1.00 8/2/2 (n 512) 8/1/0 (n 59) 0.34
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 uid score; kg, kilograms; F, degrees Fahrenheit; TPP, total plasma protein; SpO
2
, oxyhemoglobin saturation by pulse oximetry; ALT,
alanine transferase activity.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x 433
Fluid scoring with AFAST in traumatized dogs
The only previous veterinary study
33
evaluating US
use to detect hemoperitoneum reported that 45% of
dogs involved with automobile trauma had free ab-
dominal uid; 9 of these dogs required blood transfu-
sion but none required surgery. One unanswered
question raised by this study involved the signicance
of a positive result without an assessment or measure-
ment of severity of injury (ie, whats the clinical rele-
vance for patient management and prognosis for a dog
that has evidence of free abdominal uid, but without
any assessment of the volume of this uid?). Another
unanswered question raised by the previous study was
the actual prevalence of hemoperitoneum in dogs with
motor vehicle trauma presented directly to an emer-
gency facility (rather than a study population that con-
sisted of 35% referral cases). Previous studies
conducted before the widespread use of US reported
the prevalence of intra-abdominal hemorrhage to be
much lower than reported in this study, ranging from
6% to 13%.
4244
With the advent of US imaging and
FAST examinations, reported prevalence ranged from
27% to 45%.
33,a
The true prevalence of intra-abdominal
injury seems to be much higher than historically re-
ported before wider use of FAST and warrants further
study. To answer these critical questions, we developed
a simple, easy to remember scoring system with ana-
tomically named sites referring to target organs.
There are notable differences that warrant discussion
between this study and the only previous study
33
of
FAST in traumatized dogs, as the results of the previous
study cannot be universally applied to guide evaluation
or management of trauma patients based on the results
of this study. Ninety-eight percent of cases in this study
(vs 65% in the previous study) were primary presen-
tations, and patients in this study had a much shorter
median time from trauma to presentation (60 vs
240 min) and median time from presentation to initial
AFAST (o5 vs 60 min). Additionally, no dog in this
study (vs 16 dogs in the previous study) had abdom-
inocentesis performed before AFAST, and the majority
of dogs in this study were minimally uid resuscitated
before AFASTexamination. Thus, the higher prevalence
of uid-positive dogs in the previous study potentially
could reect iatrogenic hemoperitoneum or that re-
ferred cases tend to be the more severely affected and
thus more likely to have hemoperitoneum, but not re-
ect the true prevalence of hemoperitoneum in the
general population.
However, and much more clinically relevant, the dif-
ference in prevalence of hemoperitoneum may reect
differences in uid therapy during resuscitation. It is
known that aggressive uid therapy in occult hemor-
rhaging patients further contributes to blood loss and
increases morbidity and mortality.
11,1315
It seems plau-
sible that clinicians in this study may have been more
judicious with initial uid challenges, knowing on pre-
sentation whether the patient was AFS-positive or AFS-
negative. This conclusion is supported by the fact that
only 1 AFS-positive dog in our study received a shock
dose of greater than 90 mL/kg in the rst hour of treat-
ment, and only because of persistent hemodynamic in-
stability. All other dogs were initially resuscitated with
45 mL/kg or less of crystalloid boluses administered as
graduated uid challenges. Based on normalization of
serial BL levels and clinical improvement, we conclude
that our graduated uid challenges were adequate. In
fact, AFS-positive dogs had lower serial BL values than
AFS-negative dogs. Further study correlating initial
and serial AFAST and the application of patient AFS to
uid therapy may prove interesting. What is most rel-
evant regarding initial uid resuscitation of blunt
trauma patients is the apparent clinical benet of
knowing whether hemoperitoneum is present or not;
initial and serial AFAST and AFS thus proved invalu-
able in this regard.
Blood transfusions were administered to 10% of the
surviving dogs in this study versus 24% of dogs in the
previous study.
33
As previously mentioned, the appli-
cation of initial and serial AFAST with AFS application
may have provided significant preemptive knowledge
for resuscitative efforts in dogs with blunt trauma,
avoiding exacerbation of intra-abdominal hemorrhage,
as demonstrated in hemorrhaging humans.
16,24,25,39
This is yet another example of the clinical utility of
AFAST and AFS in positively directing therapy and af-
fecting outcome. There are other potential reasons for
the difference in blood transfusions, such as differences
in transfusion practices between centers, differences in
overall degree of trauma, or differences in primary
versus referred cases, as discussed previously. Of note,
3 dogs in this study with progressive anemia
(PCVo25%) did not receive blood transfusions because
they were hemodynamically stable; had these dogs
been transfused, the overall transfusion proportion
would have been similar to that reported previously.
33
Interestingly, the 2 studies had nearly identical num-
bers of PTX (22% vs 21%) and pelvic fractures (22% vs
20%), suggesting similar degrees of truncal trauma;
dogs in this study had more appendicular fractures
(25% vs 15%). In any event, correlating AFS with uid
therapy and need for blood transfusion warrants fur-
ther study.
We recorded not only AFS for each patient, but the
location of positive sites for each patient. Of clinical
interest in this study, we found that the lower scoring
(AFS 1 and 2) dogs were more frequently positive at
non-gravity-dependent sites (ie, HR view in right lat-
eral recumbency and SR view in left lateral recum-
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x 434
G.R. Lisciandro et al.
bency; Figure 2); this is in marked contrast to results
reported previously.
33
This nding suggests that in
early or mild stages of intra-abdominal hemorrhage,
dogs are positive for free abdominal uid in the ana-
tomical location of the injured organ and AFAST-pos-
itive ndings are much less affected by gravity. We
recommend that AFAST-positive sites (DH, SR, CC,
HR) be recorded for initial and serial AFAST examin-
ations in addition to the AFS because future studies
may show that positive sites correlate with location of
the injured organ and source of hemorrhage (eg, DH-
positive ndings may relate directly to hepatic injury;
SR-positive ndings may relate directly to splenic in-
jury), and may prove helpful to surgical teams by di-
recting efforts to specic anatomical locations during
emergency laparotomy in cases of uncontrollable hem-
orrhage when time is critical for patient survival.
Alternative explanations for the nding that AFS 1
and 2 dogs were positive more frequently at non-grav-
ity-dependent sites may be in the timing of AFAST
exam when comparing results to the Boysen and col-
leagues study, and in severity of intra-abdominal hem-
orrhage. In this study AFAST examinations were
performed much sooner relative to the time of trauma
(median: 60 min post trauma) compared with the pre-
vious study (median: 240 min post trauma).
33
It is plau-
sible that had dogs been imaged after a longer time
interval following trauma, as in the Boysen and col-
leagues study, the results may have been similar, in that
blood may have had time to distribute to gravity-
dependent sites. This is supported by the nding that of
the higher scoring (AFS 3 and 4) dogs, none were pos-
itive at non-gravity-dependent sites, which is similar to
ndings in the Boysen et al
33
report. Further study is
warranted.
Timely recording of initial and serial AFS and loca-
tions of positive ndings may prove the difference be-
tween survivors and nonsurvivors in not only
catastrophic hemorrhage, but as importantly, in cases
with occult, progressive, ongoing hemorrhage. In this
study, we found several lower-scoring AFS patients
progressed to higher-scoring AFS with changes in pos-
itive sites from non-gravity-dependent to gravity-
dependent sites, and a difference in severity of anemia
between lower AFS and higher AFS groups. Thus, we
recommend not only recording patient AFS in medical
records, but also the initial and serial AFAST-positive
site(s) because in cases with ongoing hemorrhage (in-
creasing AFS) we found that blood redistributes
throughout the abdomen from the initial non-gravity-
dependent sites (suggesting location of injury in AFS 1
and AFS 2 dogs) to gravity-dependent sites (injury now
can no longer be regionalized in AFS 3 and AFS 4 dogs)
as shown in Figure 2.
It seems logical that the need for emergency explor-
atory for uncontrolled hemorrhage may increase in the
future as more severely injured dogs will survive
shorter transit times to more prevalent veterinary emer-
gency facilities; AFAST will play a critical role in iden-
tifying these critically injured dogs within minutes of
arrival at emergency facilities. Performance of AFASTat
admission in trauma patients cannot be overempha-
sized, as this imaging modality can rapidly identify
life-threatening trauma and better direct resuscitative
efforts. For example, 21 dogs (15 AFS negative, 6 AFS
positive) in this study were presented within 30 min-
utes or less after motor vehicle trauma. The most se-
verely hemorrhaging AFS-positive dog in our study
presented within 15 minutes of being struck by an au-
tomobile and required multiple blood transfusions and
intense resuscitative efforts on presentation for its ul-
timate survival. This same dog may have died if transit
time was much longer; and may have not survived if
the degree of intra-abdominal hemorrhage (AFS 4) that
was not detected based on physical examination and
initial laboratory testing (PCVand TPP: 44% and 46 g/L
[4.6 g/dL]), had not been rapidly identied by AFAST
at admission.
In most AFS-positive cases, characterization of free
abdominal uid via abdominocentesis was performed
immediately following the initial AFAST exam for
timely characterization of the effusion. However, serial
AFAST exams with AFS application 4 hours after
admission allowed clinicians to assess not only the
development of intra-abdominal injury in previously
AFS-negative dogs, but also the progression of intra-
abdominal injury, reected by increasing AFS. Further-
more, the attending clinician was given a second
opportunity to perform abdominocentesis. The high
success of abdominocentesis in this study (94%) is
comparable to the previous FAST study.
33
Additionally,
AFAST markedly improved success of abdominocente-
sis from the 49% to 78% range reported in other stud-
ies,
43,45
presumably because clinicians could directly
access imaged uid pockets, compared with blind ab-
dominocentesis without US.
AFAST may help expediently diagnose other less
common types of intra-abdominal injury, such as
uroperitoneum, bile peritoneum, ruptured viscus
organ, and vascular injury, which may be missed by
physical examination, laboratory testing, and radiogra-
phy.
23,38,4656
Serial AFAST may prove helpful with re-
gards to early diagnosis of retroperitoneal injury
including not only uroretroperitoneum, but also other
causes of retroperitoneal uid accumulation such as
hemorrhage from aortic, vena caval, or renal vascular
injury or hemorrhage from vertebral and pelvic
fractures. AFAST incorporates left and right retroperi-
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00459.x 435
Fluid scoring with AFAST in traumatized dogs
toneal windows at the SR and HR sites, respectively.
FAST has shown clinical utility for retroperitoneal
injury in human trauma patients.
23,57
Future AFAST
studies may demonstrate the clinical utility of these
retroperitoneal window sites for early diagnosis of
such potentially life-threatening trauma-related injuries
that are rarely reported in the veterinary litera-
ture.
47,56,5861
Although clinicians in a previous report
33
preferred
performing AFASTwith dogs in left lateral recumbency,
we found that right lateral recumbency held several
advantages. Despite the absence of retroperitoneal uid
noted in any of our cases, the left kidney and its asso-
ciated retroperitoneal window were more reliably im-
aged at the SR site with the patient in right lateral
recumbency. With patients in left lateral recumbency,
the right kidney is often obscured beneath the rib cage
when imaging at the HR site. In this study, the gall
bladder was consistently found at the DH site. Its ab-
sence may lend clinical suspicion to either its rupture or
anatomic displacement, as with diaphragmatic hernia.
Because the spleen is anatomically more left sided, right
lateral recumbency makes iatrogenic puncture during
abdominocentesis less likely. Moreover, standard posi-
tioning for electrocardiogram analysis, left ventricular
short-axis view for patient volume status estimation,
d
and TFAST each utilize right lateral recumbency.
a
Thus,
the use of right lateral recumbency for these reasons
decrease patient stress by eliminating movement of the
traumatized patient to a second position.
In conclusion, the AFS system applied to initial and
serial AFASTexaminations provided a semiquantitative
measure of free abdominal uid, provided the clinician
with a powerful tool to aid assessment of severity of
injury, and guided clinical case management over the
initial 4 hours of emergency evaluation and care.
AFAST proved clinically more reliable than radio-
graphic assessment for abdominal trauma, and more
reliable than simply evaluating an admission PCV and
TPP conventional methods to detect hemoperitone-
um. AFAST and the AFS used in this study show clin-
ical relevance and should be used as a standard of care
in veterinary blunt trauma cases to evaluate for the
presence of free abdominal uid and to aid in the as-
sessment of trauma severity.
Acknowledgements
The authors thank Rebecca Ford for her medical illus-
trations; and Adrian Ford, LVT, VTS (ECC), Chief Op-
erational Ofcer, Emergency Pet Center Inc, San
Antonio, TX, for his technical support.
Footnotes
a
Lisciandro GR, Mann KA, Voges AK, et al. Evaluation of an abdominal
uid scoring system using focused assessment with sonography for
trauma (FAST) in 82 dogs involved in motor vehicle accidents. J Vet
Emerg Crit Care 2006;16:S12.
b
Alokat SSD-900V ultrasound machine, Aloka Company Limited,
Wallingford, CT.
c
Lisciandro GR, Mann KA, Voges AK, et al. Accuracy of focused
assessment for trauma (FAST) to detect pneumothorax in 134 dogs with
blunt and penetrating trauma. J Vet Emerg Crit Care 2006;16:S13.
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Fluid scoring with AFAST in traumatized dogs