Aims

Emergency Ultrasound

To provide understanding of
Advantages and Disadvantages of
Modalities
Trauma
The Goals of the FAST Exam
Indications for FAST
Basic Relevant Anatomy
FAST / Chest Technique and Abnormal Findings
Pitfalls & Pearls

The FAST Exam What is FAST?

Focused
A focused, goal directed, sonographic

examination of the abdomen

Assessment
Goal is presence of haemoperitoneum

(with) or haemopericardium

An extension of clinical examination

Sonography

Part of the Primary Survey of any

(for) patient with signs of shock or

Trauma suspicion of abdominal injury

What FAST is NOT! Why FAST?

A definitive diagnostic investigation
20-43% of patients with significant

A substitute for CT

The answer to all our problems
abdominal injuries may initially have a
normal physical examination

These patients can deteriorate quickly
despite benign initial examination

FAST has been demonstrated to have
Sensitivity 86-99% for haemoperitoneum
Specificity 90-99% for haemoperitoneum

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 Diagnostic Modalities in
Indications
Blunt Abdominal Trauma

Acute Blunt or Penetrating Torso
Trauma

Diagnostic Peritoneal Lavage (DPL)

Subacute Torso Trauma

CT Scan

Ultrasound (FAST exam)

Special Cases
Trauma in Pregnancy
Paediatric Trauma

Diagnostic Peritoneal
CT Scan
Lavage

Advantages
Disadvantages
Advantages
Disadvantages
Very sensitive for Overly sensitive, Identifies specific Expensive
identifying intra- may result in too injuries equipment
peritoneal blood high a laparotomy Good for hollow 30-60 minutes to
106 RBC/mm3 rate
approx. 20 ml blood viscus and complete study
in 1L lavage fluid Invasive retroperitoneal Only for stable
Can be done at the Difficult in injury patients
bedside pregnancy, or with High sensitivity and Not for pregnant
Can be done in 10- many prior specificity patients
15 minutes surgeries
Can not be repeated

FAST Anatomy

Advantages
Disadvantages
In the supine patient, particular areas

Can be performed in Operator dependent of the abdominal cavity are dependent
5 minutes at the May not identify
bedside specific injury
Intraperitoneal fluid will pool in these
Non-invasive Poor for hollow areas and can be detected on
Repeat exams viscus or Ultrasound
Sensitivity and retroperitoneal
specificity for free injury
fluid equal to DPL Obesity,
and CT subcutaneous air
may interfere with
exam

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Anatomy Tranverse Anatomy Longitudinal
Section Section

Anatomy Right
FAST The views
Paramedian Section

Consists of 4 views
RUQ (Morisons
Pouch / Perihepatic)
LUQ (Splenorenal /
Perisplenic)
Pelvic
Sub-xiphoid

FAST Perihepatic Window

Increased sensitivity
with increased number
of views

Will identify pleural
effusions

Reliably detects as little
as 50-100cc in the
thorax

Sensitivity >96%,
specificity 99-100%

Transducer positioned
in right posterior-
axillary line between
11th and 12th ribs with
beam in coronal plane
(level with xiphi-
sternum)

Panning beam in this
plane demonstrates
liver, kidney and
diaphragm

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 Abnormal Perihepatic
Perihepatic Window
View

Perisplenic Window

Transducer positioned in
left posterior axillary line
between 10th and 11th
ribs with beam in coronal
plane.

Demonstrates spleen,
kidney and diaphragm

May be marred by
acoustic shadows from
ribs

May be improved by
imaging patient whilst in
full inspiration.

Abnormal Perisplenic
Perisplenic Window
View

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 Pelvic Window

Transducer placed
transversely in midline
approx 4 cm superior
to symphysis pubis

Angled downwards into
pelvis to demonstrate
bladder, rectum &
rectovesical pouch

Probe rotated thru 90o
to move beam into
sagittal plane

Pelvic Window Abnormal Pelvic View

Pericardial Window Pericardial Window

Transducer placed in
subxiphoid region of
chest with beam
projecting in coronal
plane

Demonstrates liver
and heart

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 Abnormal Pericardial
Sub-Xiphoid View
View

Interpretation

Positive FAST Scan
Detection of intraperitoneal free fluid on any of
the 3 abdominal windows or pericardial fluid on
the pericardial window

Negative FAST Scan
Absence of intraperitoneal free fluid on any of
the 3 abdominal windows and pericardial fluid on
the pericardial window

Equivocal or Indeterminate FAST Scan
Any of windows is inadequately visualised and
no fluid is seen on those that are well visualised

Application Pitfalls & Pearls

+ Pericardial fluid Theatre
Stable CT
FAST is a RULE IN Injury % % of
Absence those
+IP fluid Test of requiring
haemoper surgery
Unstable Theatre Gives answer of itoneum
Yes or Cant be Splenic 27% 15%
ruled out
Haemoperitoneum Hepatic 34% 0%

Results
is not present in all
N= 1540 pts, 80/1540 (5%) with FF Pancreatic 29% 0%
visceral injuries
Overall: Sens 83.3%, Spec 99.7%
PPV 95%, NPV 99% Renal 48% 16%
Precordial/Transthor : Sens 100%, Spec 99.3%
Hypotensive BAT: Sens 100%, Spec 100%

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Pifalls & Pearls Pitfalls & Pearls

Dont over rely on scans
CT can detect volumes of free fluid as

Each FAST series is only a single data low as 100ml
point in the clinical course of the patient
FAST can detect between 100-250ml
0.5cm in Morisons Pouch = 500ml
1cm in Morisons Pouch = 1000ml

Pitfalls & Pearls Pitfalls & Pearls

Certain injuries may not initially be well
Certain normal anatomical structures may
detected by ultrasound be mistaken for intraperitoneal free fluid
Perforation of a hollow viscus Gallbladder
Hepatic flexure of colon
Bowel wall contusion
Stomach
Pancreatic Trauma
Seminal vesicles
Renal pedicle injury

Premenopausal women may have a baseline
Diaphragmatic disruption
quantity of free fluid in the pelvis

FAST does not image the retroperitoneal
Potential for False Positive Results
space well

Pitfalls & Pearls Pneumothorax

Beware the excessively full bladder

Traditionally pelvic window best imaged
Gliding sign
with full bladder
Comet tails
A Grossly distended bladder may
obliterate the rectovesical pouch and
empty it, giving a False Negative result
A partially voided study may increase
sensitivity

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Conclusion

FAST is a rapid and safe extension of
Primary Survey

It should be used as a Rule In test

Dont be afraid to repeat it or proceed to
other imaging modalities

Scans should be classified as positive,
negative or equivocal/indeterminate

Be aware of the causes of false positive and
negative results