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Introduction
Introduction
The FAST exam stands for “Focused Assessment for Sonography in Trauma”
It is typically completed after the primary survey in ATLS
It is extremely helpful in rapidly identifying free fluid in trauma patients
Indications
Indications
Cardiac trauma
Abdominal trauma
Chest trauma
Undifferentiated hypotension
Hypotensive patient too unstable for the CT scanner
Acquisition
Acquisition
Views
1. Perihepatic (RUQ)
2. Pericardial/Subxiphoid (SUX)
3. Perisplenic (LUQ)
4. Pelvic
Position
Supine
Probe
Curvilinear or phased array probe
1. Perihepatic Window (Right Upper Quadrant View)
1. Perihepatic Window (Right Upper Quadrant View)
The Moves
Place the probe with the indicator pointed cephalad along the right mid-axillary line between ribs 8-12
Recommended depth: ~15cm
Identify your landmarks. Dark shadows can form behind the ribs, making it hard to see. Try rotating the probe counterclockwise so that you can look in-between ribs.
Liver: large, hypoechoic organ with anechoic vascular structures within
Kidney: bean shaped structure below the liver with hyperechoic border
Diaphragm: bright, hyperechoic line above the diaphragm
Normal
Identify spaces that free fluid collects
Abdominal free fluid most commonly gathers at the caudal edge of the liver or Morrison’s pouch
Morison’s pouch
Morrison’s pouch is the space between Glisson’s capsule of the liver and Gerota’s fascia of the kidney
Lower edge of the liver
Lower right thorax
2. Pericardial Window (Subxiphoid View)
2. Pericardial Window (Subxiphoid View)
The Moves
Nestle the probe directly beneath the subxiphoid bone with the indicator pointed towards the right
Push down!
Recommended depth: ~21cm
Rock the probe until you are able to best visualize the heart
Rocking the probe to the right allows you to use the liver as a sonographic window and can actually improve your image!
The heart is surrounded by the pericardium, which appears hyper-echoic.
Make sure you are able to see all around the heart!
SUX Pathology
SUX Pathology
3. Perisplenic Window (Left Upper Quadrant View)
3. Perisplenic Window (Left Upper Quadrant View)
The Moves
Place the probe with the indicator pointed cephalad along the left mid-axillary line along ribs 6-9
Recommended depth: ~15cm
Identify your landmarks
Spleen: solid, hypo-echoic organ
Left kidney
Diaphragm
Identify spaces that free fluid collects
Free fluid collects first between the diaphragm and spleen
Subphrenic area
Surrounding the entire spleen
Rarely, splenorenal recess
Lower left thorax
Helpful tip: place your knuckles on the bed as fanning too anterior may cause stomach gas to obscure your view!
LUQ Pathology
LUQ Pathology
Fluid filled stomach can get misinterpreted as free fluid in LUQ
4. Pelvic Window (Posterior Cul de Sac View)
4. Pelvic Window (Posterior Cul de Sac View)
The Moves
Place the probe just above the pubic bone with the indicator pointed to the patient’s right
Identify your landmarks
Men
Bladder: anechoic in the near field
Prostate: hypoechoic in the far field
Women
Bladder: anechoic in the near field
Uterus: hypoechoic with a hyperechoic endometrial stripe toward the leading edge
Identify and fan through spaces that free fluid collects
Men
Rectovesical space: between the rectum and bladder
Women
Pouch of Douglas: between the rectum and uterus
This is the lowest point in the peritoneal cavity when a patient is lying supine. Fluid collects here before vesicouterine pouch!
Vesicouterine Pouch: between bladder and uterus
Repeat your exam with your probe rotated so that the indicator is pointed toward the patient’s head
Recommended depth: 12 cm
Helpful tip: start low in the pelvis
Male transverse
Male Sagital
Bladder Pathology
Bladder Pathology
Limitations
Limitations
False Negatives
Too little free fluid
< 500 cc
Retroperitoneal fluid/injury
Renal, pancreas
Not as sensitive for penetrating trauma
Hollow organ injury
Limited windows
Free air in abdomen
Habitus
False Positives
Ascites
Perinephric fat pad
Pericardial fat
Seminal vesicles
Cases
Cases
Cast 1: 32 y f with BP 50/30 and syncope. This is her ultrasound. Cause?
Click to see answer to case 1
Click to see answer to case 1
Ruptured ectopic. There is 2.5L of blood in abdomen
Ultrasound G.E.L. Podcast
Want to learn more? Take a listen to a review of the literature!
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