Madtown Sono

The eFAST exam

Objectives

  1. Understand the goals, applications, and limitations of the focused assessment with sonography in trauma (FAST) exam
  2. Understand the key components and goals of the FAST (the four cardinal views obtained in the abdomen)
  3. Understand the key components and goals of the extended FAST (eFAST) (the four cardinal views obtained in the thorax)

Lecture (presented by Hani Kuttab, MD)

Evaluation:

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What are the four key goals/questions which an eFAST can answer?

Four key questions:

  • Does my patient have free fluid in the abdomen?
  • Does my patient have free fluid in the thorax?
  • Does my patient have fluid in the pericardium?
  • Does my patient have a pneumothorax?

True or False? A negative FAST exam rules out the presence of an abdominal injury

False!

The goal of the FAST exam is to identify free fluid in the abdomen, not for the presence of abdominal injury

The FAST exam has variable sensitivity (73-96%), but high specificity (94-98%)

Thus, a normal FAST exam cannot rule out the presence of an abdominal injury!

Name the four key cardinal views of the eFAST exam which are obtained in the abdomen

Four key abdominal views

  • Right upper abdomen (RUQ): evaluate for free fluid between the kidney and liver, and at the inferior liver tip.
  • Left upper abdomen (LUQ): evaluate for free fluid between the kidney and spleen, paracolic gutter, and beneath the diaphragm.
  • Cardiac view (Subxiphoid): evaluate for the presence of a pericardial effusion.
  • Pelvic view: evaluate for presence of free fluid in the pelvis

Name the four key cardiac views of the eFAST exam which are obtained in the thorax

Four key thoracic views

  • Right anterior lung
  • Left anterior lung
  • Right lung base/hemidiaphragm
  • Left lung base/hemidiaphragm

Name at least three different causes of free fluid in the abdomen

  1. Traumatic abdominal injuries (e.g., liver/splenic injury, viscus injury, etc.)
  2. Ascites from cirrhosis or decompensated heart failure
  3. Physiologic free fluid (e.g., menstruating females, pediatric patients)

Which location is the most sensitive for detecting free fluid in the abdomen?

The inferior tip of the liver (located in the right upper quadrant).

Where are the places to evaluate for free fluid in the right upper quadrant view?

  1. Morison’s Pouch: between the right kidney and the liver
  2. Inferior tip (caudal) of the liver
  3. Above the diaphragm/liver, evaluating for a possible hemothorax

Where are the places to evaluate for free fluid in the left upper quadrant view?

  1. Splenorenal interface: between the left kidney and the spleen
  2. Paracolic gutter: inferior (caudal) portion of the left kidney
  3. Sub-diaphragmatic space (between the spleen and the diaphragm)
  4. Above the diaphragm/spleen, evaluating for possible hemothorax

Where are the places to evaluate for free fluid in the pelvis view?

  1. Free fluid outside of the bladder
  2. In males, between the rectum and bladder (rectovesicular space)
  3. In females, between the rectum and the uterus (rectouterine space, or the ‘Pouch of Douglas’) or between the uterus and bladder

What is the technique for obtaining the subxiphoid cardiac view (in the upper abdomen?)

Place hand on top of the probe, place inferior to the patient’s xiphoid process

Press downwards to sneak ‘underneath’ the xiphoid process to evaluate the heart

May rock the probe towards the patient’s liver or ask the patient to take a deep breath in to improve views

What is the appearance of normal lung and a pneumothorax on ultrasound? What about on M-mode?

Normal lung: lung sliding (visceral and parietal pleura sliding over one another); M-mode shows ‘Seashore sign’

Abnormal lung: no lung sliding (only visualization the parietal pleura); M-mode shows ‘Barcode sign’

What is the typical approach and appearance to evaluating for pleural effusion?

Ultrasound probe/indicator aimed up towards the patient’s head, in the mid-axillary line, fanning slightly towards the spine

In normal lungs, the space above the diaphragm cannot be visualized (obscured by the normal lung tissue)

In abnormal lungs (e.g., pneumonia, atelectasis, pleural effusion), the spine is visualized above the diaphragm (spine sign)