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Emergency Ultrasound in Trauma

FAST Exam

Introduction
Ultrasound Physics Technique

FAST Exam

Indications for FAST exam Performing a FAST exam

Limitations
Questions

What is the FAST exam?


Focused Assessment by Sonography in Trauma Focused exam using ultrasound to diagnose hemorrhage in a trauma setting

Ideally takes < 3 min


4 primary views
RUQ LUQ Subxiphoid Suprapubic

Technique
Goal: to identify blood in body cavities where it is not supposed to be Unclotted blood appears black on US Clotted blood appears gray Abdominal probe with small footprint (between 1- 3 cm) with range of frequency between 2.0 Hz and 5.0 Hz Scan 4 areas RUQ Subxiphoid LUQ Suprapubic

Indications
Blunt thoracoabdominal trauma Penetrating thoracoabdominal trauma

Suspected pericardial tamponade


Trauma patient with unknown etiology hypotension on

Thoracoabdominal trauma in a pregnant patient

Algorithm
Blunt Thoraco-abdominal Trauma

Blunt Thoraco-abdominal Trauma Peritoneal Signs

Hemodynamically Unstable Ultrasound Free Fluid/Organ Injury Laparotomy Repeat U/S CT Scan

Laparotomy

Ultrasound Free Fluid/Organ Injury CT Scan

Laparotomy

Intraperitoneal Fluid Flow

Right Upper Quadrant


Sagittal view obtained by placing probe either in the midclavicular line on the lower rib cage or below the right costal margin May have to move probe laterally to avoid gas in hepatic flexure

Air-filled lung creates reflection artifact in which lung appears to be composed of liver parenchyma
Scan for black fluid in potential spaces

Normal RUQ

Abnormal RUQ

Subxiphoid
Probe placed under xiphoid almost parallel with skin surface directed towards patients left shoulder Parasternal view may be used when Subxiphoid unable to be obtained Consider pnuemothorax when unable to obtain images of heart and no apparent reason

Normal Subxiphoid

Abnormal Subxiphoid

Left Upper Quadrant


Most technically difficult to obtain Probe placed parallel with ribs in posterior axillary line Scan potential spaces between diaphragm and spleen and spleen and kidney for free fluid

Normal LUQ

Abnormal LUQ

Suprapubic
Entire pelvis should be scanned from top to bottom with transducer in transverse place and them side to side with transducer in sagittal plane Pouch of Douglas is the most dependent site in peritoneal cavity First sign of blood is often two small black triangles on either side of rectum Bow tie sign

Normal Suprapubic

Abnormal Suprapubic

Retroperitoneal bleeding
Inadequate volume of fluid

Not enough time elapsed since trauma to demonstrate bleeding


Solid organ bleeding trauma with encapsulated

Limitations

Image quality dependent on quality of US machine and probe, body habitus of patient, physical injuries Scan and dependent interpretation are operator

After a short training program, physicians can use FAST in early assessment of trauma patients with sufficient specificity to expedite decision making.

Increased physician ultrasound experience is associated with increased physician accuracy in FAST examinations. This can directly lead to a reduction in the use of CT scans, and ultimately, medical costs.