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Similar to 6- Abdominal Trauma and FAST Scan.pptx
6- Abdominal Trauma and FAST Scan.pptx
- 1. . Dr. Ashraf HusseinIsmail Emergency Medicine Consultant
- 2. What does itMean? FAST Focused Abdominal (Assessment with) Sonography in Trauma
- 3. INTRODUCTION 1980s- USfor trauma in Japan, Germany 1990s- US for trauma in North America The term FAST introduced in 1996
- 4. Where can Isee 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 DependentSites 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
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- 16. Types of pericardialeffusions, 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
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- 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
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- 32. FAST: Pelvis exam- Pathology Transverse
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- 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)
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- 43. FAST Focused Abdominal SonographyIn 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 InterpretFAST 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 Makea 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 ofFF ≠ 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 todistinguish 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.
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- 51. Does FAST replaceCT? 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
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- 56. Lung Scanning forPneumothorax Comet tails sign and sliding lung
- 58. Loss of comettail and lung sliding movement
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