FAST

1. .
Dr. Ashraf Hussein Ismail
Emergency Medicine Consultant

2. What does it Mean?
FAST
Focused
Abdominal (Assessment with)
Sonography in
Trauma

3. INTRODUCTION
 1980s- US for trauma in Japan, Germany
 1990s- US for trauma in North America
 The term FAST introduced in 1996

4. Where can I see FF?
 Free fluid usually appears anechoic by US (black )
 Accumulation in area of injury
 Overflows into dependent areas (pouch of Douglas,
Morrison’s pouch) via rivers (paracolic gutters)

5. FAST: Anatomy
7 Dependent Sites
1. Right Supramesocolic
(Morison’s pouch)
2. Left Supramesocolic
(Splenorenal rescess)
3. Right Pericolic gutter
4. Right Inframesocolic
5. Left Inframesocolic
6. Left Pericolic gutter
7. Pelvic cul-de-sac

6. FAST: Technical Considerations
• Standerded views (standerded FAST ):
1- Subxiphoid/Subcostal: Pericardium
2- RUQ: Morrison’s Pouch
3-Pelvis: Pelvic Cul-de-sac (Douglas )
Transverse
Longitudinal
4- LUQ: Splenorenal & perisplenic spaces
• Extended views (E-FAST) :For pleural effusion
Remember: Probe marker almost ALWAYS facing
either patient’s right or patient’s head
Supine patient
1
4
2
3

8. 1) Subxiphoid exam
 Probe placed
 Transversally
 Midline plane
 Just below subxiphoid region
 Probe facing towards patient’s right

11. FAST: Subxiphoid exam
 Normal Anatomy
 Liver at very top of screen
 Epicardial fat vs. effusion
 Thin layer anterior to
RV
 Not present posterior
to LV
Anterior
Posterior
Left
Right

12. Normal Subxiphoid exam

13. FAST: Subxiphoid exam
Pericardial Effusion

14. Pericardial Effusion

16. Types of pericardial effusions, subxiphoid cardiac view.
Left image: typical effusion, middle image: clotted effusion , right image : with cardiac tamponade
.

17. 2)FAST: RUQ exam
 Probe placed
 Perpendicular
 Mid-coronal plane
 Just superior to the iliac crest
 Probe facing
 Toward patient’s head
 Evaluating
 Hepatorenal interface
 Possibility of fluid in Morison’s
pouch ( Right Supramesocolic
space)

20. FAST: RUQ exam
 Normal Anatomy
 In the supine patient, the
hepatorenal space
(Morison’s Pouch) is the
most dependent space
Anterior
Posterior
Inferior
Superior
Morison’s
Pouch

21. FAST: RUQ exam
L
K
FF
RS
D

22. FAST: RUQ exam
L
K
FF

23. 3)FAST: Pelvis exam
 Pelvis: Longitudinally and Transvers Axis.
 Probe placed
 Transeversally then Longitudinally
 Midline 2 cm superior to the symphysis pubis
 “aimed” caudally into the pelvis (prostate )
 Probe facing
 Toward patient’s head and right side.
 Best with some urine in bladder(acoustic window)
 Evaluating
 Bladder ,Uterus in female ,and Prostate in
male
 The potential spaces are Pouch of
Douglas (Cul de sac ) in female and
retrovesicle space in male

30. FAST: Pelvis exam
 Pelvis: Transverse Axis
 Normal Anatomy
 Evaluating Bladder
 Well cirucumscribed
 Contains fluid that
appears anechoic
Transverse
Anterior
Right Left
Posterior

31. Transverse

32. FAST: Pelvis exam - Pathology
Transverse

33. Bladder
FF
Transverse

34. 4)FAST: LUQ exam
 Probe placed
 Perpendicular
 Mid - coronal plane
 Just superior to the iliac crest
 Probe facing
 Towards patient’s head
 Evaluating
 Spleno-renal interface
 Possibility of fluid in splenorenal recess
and presplenic /subphrenic space( most
common space for fluid collection in
LUQ)

39. FF

40. Kidney
Spleen
FF
Diaphragm

42. FAST Demo

43. FAST
Focused Abdominal Sonography In Trauma
Reliability
 accuracy 86 - 97 %
 sensitivity 88 - 91.7 %
 specificity 94.7 - 99 %
Can detect 70 ml fluid (by linear probe can detect as
little as 10 ml or less)

44. How To Interpret FAST
 Positive:
 Fluid in pericardium or any 1 of 4 abdominal windows
 Negative:
 No fluid in any windows
 Indeterminate:
 If any one of the 4 windows is inadequately visualized

45. Does FAST Make a Difference In Trauma Management?
 During primary or secondary survey
FAST
Positive Negative
Indeterminate
unstable stable
OR CT
unstable stable
OR
DPL
CT
DPL
Serial exam
Repeat US/ CT
Adapted from: Rozycki GS, et al. J Trauma, 1996

46. Pearls
 Lack of FF ≠ no injury
 Not enough to see (?too early)
 You missed it
 Hard-to-see places
 FF may not be blood
 Urine, lavage fluid, ascites,
amniotic fluid, bowel contents, ruptured cyst

47. Advantages
 Easy & Early to Diagnose in
Resuscitation/Emergency room
 Rapid(1 – 2.5 min)
 Repeatable
 Non-invasive
 Low cost.

48.  Difficult to distinguish
 Type of fluid
 Site of bleeding ,
 Solid organ injury
 Cannot evaluate retroperitoneum
 Difficult in the obese patient , subcutaneous emphysema
 Examiner Dependent.
 Bowel gas interposition
 False –Negative : retroperitoneal & Hollow viscus injury
Disadvantages

49. Pitfalls and limits
• -Pre-exesiting fluid collection ( Ascites , dialysis )
• -Pelvic fluid collection (female ) .
• -Fluid filled bowel loops .
• -Contained injury (hollow viscus, bowel wall
contusion, pancreatic trauma and renal pedicle injury)
• -Echogenic clot.
The scan should be repeated during the secondary survey and
also if the patient demonstrates clinical deterioration, since free
fluid may have accumulated in the intervening time .
The quality of images obtained may also be a limiting factor with
patient obesity , gas in the bowel leading to degradation in image
quality , subcutaneous emphysema , non-mobile patient and
pnetrating injury.

50. Does FAST replace CT?

51. Does FAST replace CT?
 Unstable patient, (+) FAST  OR
 Stable patient, low force injury, (-) FAST  consider observing patient.
CT is far more sensitive than FAST for detecting and characterizing abdominal injury in
trauma. The gold standard for characterizing intraparenchymal injury.
“Death begins with a CT.” Never send an unstable patient to CT. FAST, however, can be
performed during resuscitation. FAST
Positive Negative
Indeterminate
unstable stable
OR CT
unstable stable
OR
DPL
CT
DPL
Serial exam Repeat US/
CT

53. Extended FAST (E-FAST)
RUQ, LUQ views:
 Check above diaphragm for hemothorax
 CXR = US in detection of hemothorax
Ma and Mateer. Ann Emerg Med, 1997
 50-175cc vs. 20cc or less
 US does not replace CXR
Suprapubic view:
 Check uterus for pregnancy

54. Hemothorax
KD
SP
FF
D

55. Pleural Fluid

56. Lung Scanning for Pneumothorax
Comet tails sign
and sliding lung

58. Loss of comet tail and lung
sliding movement

62. Questions?