Extended FAST Exam

Goal of Trauma Care

Golden Hour of Trauma

eFAST

• Best INITIAL screening modality in trauma

2014 LLSA Article (ACEP Policy Statement)

• Level B Recommendation: In hemodynamically unstable patients (SBP ︎90 mmHg) with blunt abdominal trauma, bedside ultrasound, when available, should be the initial diagnostic modality performed to identify the need for emergent laparotomy

eFAST

Bedside

Non-invasive

Repeatable

Rapid

No Contraindications

Blunt or penetrating trauma to the abdomen or chest

Trauma in pregnancy

Unexplained hypotension

Indications

Thoraco-Abdominal Anatomy - between the ribs

Diaphragm

Liver

Kidneysuperior pole

Morison'spouch Kidney

(inferior pole)

Diaphragm

Need to move probe from diaphragm to lower pole of kidney

Right Upper Quadrant

If Eyes are the Window to the Soul, then Liver is the Window to the Heart

• Start at liver edge and follow the subcostal margin until heart is seen

• Aim beam at chin

• Never cross midline

Sub-Xiphoid Window

SubXiphoid View

Liver

ParaSternal Long

• 15% of the time unable to obtain sub-xiphoid

• Place the sound along the long axis of the heart

ParaSternal Long

• Point indicator towards the patient’s left elbow

ParaSternal Long

LALV

RV

Left Upper Quadrant

Left Upper Quadrant

Suprapubic View - Sagittal

Transducer just superior to the pubic symphysis

Fan side to side looking for anechoic wedges

Suprapubic view - SagittalBladder

Vesico-uterine space

Uterus

Recto-uterine space

Suprapubic Window

Suprapubic view - Transverse

Transducer just superior to pubic symphysis

Mirror Image Artifact• Sound glances off

diaphragm, returning to probe with a longer time of flight

• Machine misinterprets this as more liver tissue further afield

Mirror Image Artifact

Hemothorax

Normal

Pitfalls: Epicardial Fat

Gastric FluidSpleen

Stomach

Hemoperitoneum Fluid in Stomach

Blunt Trauma AlgorithmPositive FAST

Stable Unstable

ORCT

Negative FAST

UnstableStable

CT ??

Case 1: Blunt Traumatic Full Arrest

Case 2: Auto vs Peds

Case 3: Stab Wound to Left Upper Quadrant

Case 4: Fall from Ladder, on Coumadin

Case 5: Stab Wound to Right Upper Quadrant

Case 6: Fell off Motorcycle

Case 7: Auto vs Peds

Pneumothorax?

Pneumothorax?

Sensitivity of supine AP CXR is 47-75%

Compare AP chest x-ray with ultrasound for the diagnosis of pneumothorax

Pneumothorax - Methods

• English-language articles on the performance of chest x-ray and ultrasonography in the diagnosis of a pneumothorax were selected

• In eligible studies, data were recalculated, and the forest plots were analyzed

Chest. 2011 Oct;140(4):859-66

Ultrasound 88% Sensitive

Chest Xray 52% sensitive

Chest. 2011 Oct;140(4):859-66

Sensitiv

ity

Ultrasound 99% Specific

Chest Xray 100% Specific

Chest. 2011 Oct;140(4):859-66

Specific

ity

Sonographic Technique

High frequency linear probe

2nd intercostal space

Mid-clavicular line

4-5 respiratory cycles

B-Mode and M-mode

Pneumothorax Technique

Pleural interface

•Air in lung impairs transmission of sound

•Pleural interface is visible

•Visualize visceral & parietal pleura sliding on each other

Pneumothorax Technique

•With pneumothorax, lung falls away from chest wall

•Air separates the pleura

•Pleural interface is no longer “seen” by the probe

Pneumothorax?

Pneumothorax?

Pneumothorax?

Pneumothorax?

Pneumothorax?

Pneumothorax?

Sky-Ocean-Beach

• Depress M-mode key

• Place cursor line across pleural line

• Depress M-mode key again to generate an M-mode tracing

Sky-Ocean-Beach

SkyOcean

Beach

B-Mode

M-Mode

Sky-Ocean-Beach

SkyOceanNo Beach

B-Mode

M-Mode

Sky-Ocean-Beach

eFAST Summary

• Hepato-Renal • Cardiac • Spleno-Renal • Suprapubic

• 1. Pleural Line • 2. Lung Sliding • 3. M-mode (S-O-B)