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Emergency Ultrasound: The FAST Exam

Published in: Health & Medicine, Technology


  1. 1. FAST<br />Petra Duran-Gehring M.D.<br />Assistant Professor<br />Department of Emergency Medicine<br />University of Florida- Jacksonville<br />
  2. 2. Objectives<br />Evaluate the abdomen for free fluid, using the four ultrasonographic windows for FAST<br />Identify free peritoneal fluid, pericardial effusion and tamponade<br />Identify pneumothorax and hemothorax using extended FAST exam<br />
  3. 3. History<br />1970s: US first used to evaluate trauma patients in Europe<br />1980s: FAST replaces DPL in most trauma centers<br />1988: German Surgery Board requires US certification<br />1997: FAST included in ATLS course<br />2001: US training required in EM residencies<br />
  4. 4. Radiologic Evaluation in Trauma<br />CT: non-invasive, gives detail about organs<br />DPL: most sensitive, invasive<br />US: non-invasive, can detect 250cc of free fluid in Morrison’s Pouch<br />
  5. 5. What is FAST?<br />Focused Assessment with Sonography in Trauma<br />Objective:<br />Detection of intra-abdominal free fluid<br />Detection of pericardial fluid<br />E-FAST: detection of hemothorax and pneumothorax<br />
  6. 6. FAST<br />Benefits<br />Performed rapidly<br />Noninvasive<br />Inexpensive<br />Easily repeatable<br />Highly specific for therapeutic laparotomy<br />Limitations<br />Obesity<br />Subcutaneous emphysema<br />Non-specific<br />
  7. 7. Indications<br />Rapid detection of:<br />Hemoperitoneum<br />Pericardial Effusions<br />Pleural Effusions<br />Abdominal Trauma<br />Chest Trauma<br />
  8. 8. Abdominal Trauma<br />Blunt trauma<br />Most widely studied<br />Intraperitoneal bleeding due to splenic or liver injury<br />Penetrating trauma<br /> 50% sensitivity for determining the need for laparotomy<br />Doesn’t detect bowel injury<br />Can still determine hemoperitoneum<br />
  9. 9. Chest Trauma<br />Penetrating trauma <br />Pericardial Effusion<br />Pericardium seals self creating effusion leading to tamponade<br />US identifies prior to Beck’s triad<br />Screening exam for effusion<br />Hemothorax<br />US more sensitive than CXR (20ml vs. 200ml for detection)<br />Extended FAST for pneumothorax, sensitive for supine pts<br />Blunt trauma<br />May determine cardiac rupture<br />
  10. 10. Why FAST works<br />Fluid pools in predicable locations<br />Subhepatic<br />Perinephric<br />Perisplenic<br />Pelvic<br />Subpleural<br />Position patient to best locate fluid<br />Trendelenburg for upper quadrants<br />Reverse trendelenburg for pelvis<br />
  11. 11. FAST Anatomy<br />Transverse Colon Mesentery<br />Phrenicolic Ligament<br />Morrison’s Pouch<br />Pelvis<br />
  12. 12. Equipment<br />Probe<br />2-5 MHz<br />Curved array<br />Small footprint<br />Machine<br />Maneuverable<br />Color flow<br />Doppler<br />
  13. 13. FAST Components<br />Right Upper Quadrant<br />Left Upper Quadrant<br />Cardiac<br />Subxiphoid<br />Parasternal long axis<br />Suprapubic<br />Extended FAST<br />Lung fields<br />
  14. 14. Right Upper Quadrant<br />Position<br />Probe placed with indicator to pt’s head<br />Probe placed around 8-11th rib space, mid axillary line<br />May need to slide probe around rib shadow<br />Do not forget to interrogate inferior pole of kidney<br />
  15. 15. RUQ<br />Morrison’s Pouch<br />Liver<br />Kidney<br />Diaphragm<br />
  16. 16. RUQ<br />Includes<br />Liver<br />Kidney<br />Morrison’s pouch<br />Diaphragm (E-FAST)<br />Look for: <br />Fluid in Morrison’s pouch<br />Lack of mirror artifact<br />Normally diaphragm acts as mirror, liver appears to be on either side<br />Indicates pleural fluid<br />
  17. 17. RUQ Free Fluid<br />Intraperitoneal fluid<br />Morrison’s Pouch<br />Along the lower edge of the liver<br />Superior to liver<br />Pleural fluid<br />Lack of mirror artifact<br />Lung appears to float with inhalation<br />
  18. 18. RUQ Free Fluid<br />
  19. 19. RUQ Free Fluid<br />
  20. 20. Left Upper Quadrant<br />Position<br />Probe placed with indicator to pt’s head<br />Probe placed around 6-9th rib space, mid axillary line<br />May be difficult to achieve due to rib shadow<br />Ask pt to inhale deeply to displace anatomy inferiorly<br />
  21. 21. LUQ<br />Spleen<br />Kidney<br />Diaphragm<br />
  22. 22. LUQ<br />Includes<br />Spleen<br />Kidney<br />Diaphragm (E-FAST)<br />Look for: <br />Fluid in spleenorenal fossa<br />Fluid inferior to spleen<br />Lack of mirror artifact<br />
  23. 23. LUQ Free Fluid<br />Intraperitoneal Fluid<br />Splenorenalfossa<br />Inferior to inferior pole of spleen<br />Superior to spleen<br />Pleural Fluid<br />Lack of mirror artifact<br />Lung floating with inspiration<br />
  24. 24. Cardiac View<br />May use either:<br />Subxiphoid<br />Parasternal long axis<br />Look for<br />Cardiac activity<br />Pericardial effusion<br />RV collapse<br />
  25. 25. Cardiac Limitations<br />View dependant on patient habitus and condition<br />Subxiphoid better<br />COPD <br />Parasternal better<br />Pregnancy<br />Obesity<br />Abdominal pain<br />
  26. 26. Subxiphoid View<br />Position<br />Probe placed in epigastrium<br />Probe indicator to patient’s right<br />Probe tip pointing to pt’s left shoulder<br />Increase depth<br />
  27. 27. Subxiphoid View<br />Four chamber view<br />Apex to right of screen<br />Left side at bottom of screen<br />Liver<br />RV<br />RA<br />LV<br />Mitral Valve<br />LA<br />Bicuspid Valve<br />
  28. 28. Subxiphoid View<br />Liver<br />Apex<br />RV<br />LV<br />RA<br />LA<br />
  29. 29. Subxiphoid View<br />
  30. 30. Parasternal View<br />Probe placed to the left of the sternum at 2-4th intercostal space<br />Long Axis<br />Probe indicator to patient’s right shoulder<br />Sagital plane<br />
  31. 31. Parasternal Long Axis View<br />Three chambers in view<br />LV<br />LA<br />RV<br />Aortic Root<br />Valves<br />Mitral<br />Aortic<br />Aortic Outflow Tract<br />Aortic Valve<br />RV<br />LA<br />LV<br />Mitral Valve<br />
  32. 32. Parasternal Long Axis View<br />RV<br />Aortic root<br />LV<br />LA<br />
  33. 33. Parasternal Long Axis View<br />
  34. 34. Pericardial Effusion<br />
  35. 35. Pericardial Tamponade<br />RV collapse<br />
  36. 36. Pericardial Tamponade<br />RV collapse<br />
  37. 37. Suprapubic<br />Position<br />Transverse<br />Probe in the midline just cephalad to the pubic bone<br />Probe indicator pointed to pt’s right<br />Longitudinal<br />Probe in the midline just cephalad to the pubic bone<br />Probe indicator pointed to pt’s head<br />
  38. 38. Suprapubic<br />Identify<br />Bladder<br />Uterus in women<br />Pouch of Douglas<br />Look for Fluid:<br />Men: posterior to bladder<br />Women<br />Vesicouterine space<br />Posterior to uterus (Pouch of Douglas)<br />Sharp edges indicate fluid outside of bladder<br />
  39. 39. Suprapubic<br />Bladder<br />Bladder<br />Pouch of Douglas<br />Pouch of Douglas<br />Uterus<br />
  40. 40. Pelvic Free Fluid<br />Posterior to bladder<br />
  41. 41. Pelvic Free Fluid<br />Pouch of Douglas<br />
  42. 42. Extended FAST<br />Addition to 4 view FAST exam<br />Includes evaluation for hemothorax and pneumothorax<br />Two additional components<br />Expand UQ views to visualize diaphragm<br />Lack of mirror artifact indicates fluid/hemothorax<br />Scan anterior chest<br />Lack of lung slide indicates pneumothorax<br />
  43. 43. Hemothorax<br />Includes<br />Liver or spleen<br />Kidney<br />Diaphragm<br />Look for:<br />Lack of mirror artifact<br />Normally diaphragm acts as mirror, liver appears to be on either side<br />Indicates pleural effusion<br />
  44. 44. Hemothorax<br />
  45. 45. Hemothorax<br />lung<br />diaphragm<br />
  46. 46. Pneumothorax (ptx)<br />Occurs in 15-50% of pts with chest trauma<br />Supine CXR<br />Misses up to 1/3 of all pneumothoraces<br />Only 50-70% sensitive at detection ptx<br />Inaccurate for anterior ptx due to air layering<br />Ultrasound<br />Detects small or anterior ptx<br />Sensitivity 92-100% (equal to CT scan)<br />Negative predictive value 99-100%<br />
  47. 47. Pneumothorax<br />Use high frequency linear probe <br />(5-10 MHz)<br />Place probe on anterior chest wall, indicator to pt’s head<br />Slide down chest wall to interrogate each rib interspace<br />
  48. 48. Lung Fields<br />Includes<br />Rib with shadow<br />Subcutaneous tissue and muscle<br />Pleura<br />Look for: <br />Slide of the pleura<br />Lack of sliding indicates pneumothorax<br />
  49. 49. Lung Anatomy<br />rib<br />rib<br />pleura<br />
  50. 50. Pneumothorax<br />Watch for slide of the pleura<br />Lack of sliding indicates pneumothorax<br />B-Mode: direct visualization<br />M-Mode: “sandy beach”<br />May see the leading edge of pneumothorax<br />
  51. 51. Normal Lung Slide<br />
  52. 52. Pneumothorax: no slide<br />
  53. 53. Lung Slide<br />Normal Lung<br />Pneumothorax<br />
  54. 54. M-Mode<br />“sandy beach”<br />“bar code”<br />Normal<br />Pneumothorax<br />
  55. 55. Other US Uses in Trauma<br />Diaphragmatic injury<br />Evaluated using M-Mode<br />Watch for motion<br />Fractures<br />Can be used for closed reduction<br />Ocular<br />
  56. 56. Ocular<br />Increased ICP<br />Measure optic nerve diameter<br />Papiledema<br />Retinal Detachment<br />Foreign Body<br />
  57. 57. Ocular<br />Anterior Chamber<br />Lens<br />Optic Nerve<br />Retina<br />
  58. 58. Increased ICP<br />Measure the optic nerve<br />Measure 3mm from retina<br />Measure diameter of nerve<br />Measurements greater than 5mm indicate increased ICP (&gt;20mmHg)<br />
  59. 59. Pappilledema<br />
  60. 60. Retinal Detachment<br />
  61. 61. Questions?????<br />