The FAST Scan

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The FAST Scan

• Mila Felder MD
• June 22nd, 2005

Contributing Authors / Design PJ Konicki DO,
RDMS Louise Rang-Nicholson MD,RDMS Anna
Kiernicki-Sklar MD
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Goals

• To discuss the history, principles, and use of
  US in trauma
• To evaluate advantages and limits of FAST
• To demonstrate FAST technique
• To view normal and abnormal scans

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Objectives

• To learn everything you need to know about trauma
  scanning?..
• Sorry, not so FAST ?)

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How do we get started?
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History

• 1980s- US for trauma in Japan, Germany
• US training has been required in Germany since
  the1970s
• 1990s- US for trauma in North America
• The term FAST introduced in 1996
• Credentialing criteria and scoring systems are
  still evolving
• 50 scans to confidence Feb 2004 J.Ma, Kansas

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What does it Mean?

• FAST
• Focused
• Abdominal
• Sonography in
• Trauma

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So, how has it been used?

• Quick look at stable or unstable trauma patient
• Single or multiple casualty in military
  deployment (EM Journal Apr.2005)
• International Space Station (J of Trauma-Inj
  Infection and Crit. Care Jan 2005)
• Extended Assessment for PTX

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Potential Uses

• Acute and chronic musculoskeletal injury
• Triage of patients in disasters
• Remote use by flight physicians and nurses
• Simultaneous transmission to trauma center/
  telemedicine
• ATLS, prehospital use

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Premise

• Intraperitoneal organ injury ? hemoperitoneum
• Predictable locations (GRAVITY)
• Blood readily detectable on US as
• free fluid (FF)
• ? US a natural screening test for injury

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Where can I see FF?

• Accumulation in area of injury
• Overflows into dependent areas (pouch of Douglas,
  Morrisons pouch) via rivers (paracolic gutters)

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Intraabdominal Fluid Localization

1. Morisons pouch
2. Lienorenal
3. Rt. Paracolic
4. Rt. Inframesocolic
5. Lt. Inframesocolic
6. Lt. Paracolic
7. Pelvic cul-de-sac (pouch of Douglas)

Adapted from Simon B, Snoey E, Ultrasound in
Emergency and Ambulatory Medicine 1997
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so
Perisplenic space
Morrisons Pouch
Pouch of Douglas
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How much can I see?

• Minimum detectable 200-650 cc

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How much can I see?

• Depends on
• Site, speed of bleeding
• Operator skill
• Position of patient
• CT 100-250 cc FF
• DPL 20 cc blood (_at_100,000 RBC/ml)

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How good is US?

• 1995, n245 prospective trauma pts
• ?FAST by EM docs
• Various Gold Std.
• Sens. 90 sp 99 (accuracy 99)
• Blunt Penetrating

Ma and Mateer. J Trauma, 1995
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US advantages (vs. CT or DPL)

• Fast
• Non invasive
• Pregnancy, coagulopathy
• Bedside test
• CT Certain Termination
• Repeatable
• Eval quantity of fluid over time
• Easy to learn

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Limitations of US

• Site of injury not identified
• ? views with subcutaneous air, gastric
  distension, obesity
• Operator dependent
• Limited eval of
• Bowel, retroperitoneum, diaphragm

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Caveats

• Lack of FF ? 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

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What about DPL?
Pros Cons
Sensitive Fast Portable Low complication rate Low specificity Invasive Misses retroperitoneal injuries
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What about CT?
Pros Cons
Specific Evaluates retroperitoneum Noninvasive Time consuming Requires patient to leave ED Expensive Requires contrast
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How does US fit in?

• During primary or secondary survey

FAST
Positive
Negative
Indeterminate
unstable
stable
unstable
stable
OR
CT
OR
CT
Serial exam Repeat US CT
DPL
DPL
Adapted from Rozycki GS, et al. J Trauma, 1996
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How do I do it?
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Supine patient
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4
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Remember to do ALL VIEWS!
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Start with proper stance and grip (kind of like
golf)

• Ultrasonographer is at the pt's right, level with
  the umbilicus.
• The machine is at the pt's right shoulder.
• Hold the transducer much like you would a paint
  brush. The 4th 5th digits and the medial aspect
  of the hand provide the base.

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Technique

• Consistently using the same technique insures
  reproducible imagery. (An important consideration
  when confronted with an unlikely skeptical
  surgery attending.)
• Every transducer has a marker signifying "north".
  For standard imagery "north" must always point
  its appropriate direction.

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FAST Demo
Video
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1) Subxiphoid View
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Normal Subxiphoid View
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Pericardial Effusion
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Pericardial Effusion
Video
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Tips Tricks

• Look up and under sternum
• Aim for left shoulder
• Probe almost parallel to abdominal wall
• Epicardial fat vs. effusion
• Thin layer anterior to RV
• Not present posterior to LV
• Clinical picture

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Clinical Picture, remember!
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Tips Tricks

• Subxiphoid view may be difficult in
• Gastric distension from BVM ventilation
• Obesity
• Peritonitis
• In these cases, try Parasternal or Apical view
• If in doubt, get formal echo

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More on this view

• Several studies have suggested that use of ED US
  in pericardial eval of penetrating torso trauma
  will
• 1) Decrease time to diagnosis of pericardial
  effusion
• 2) Decrease time to OR (42.4 vs. 15.5 min)
• 3) Improve survival (57.1 vs. 100)

Plummer et al. Ann Emerg Med, 1992
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FAST
1
2
4
3
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2) RUQ view
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Normal RUQ
Liver
Kidney
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RUQ Fluid
Many Faces of Morrisons Pouch!
Video
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Many Faces of Morrisons Pouch!
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Many Faces of Morrisons Pouch!
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Many Faces of Morrisons Pouch!
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Many Faces of Morrisons Pouch!
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Many Faces of Morrisons Pouch!
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Tips Tricks

• Probe parallel to and between ribs
• Fan thru whole hepatorenal space
• May try transabdominal approach if unsuccessful

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FAST
1
2
4
3
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3) Suprapubic View
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Bladder
Bladder
Uterus
Look here for FF
Transverse View
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Bladder
FF
TRANSVERSE
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Transverse
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Pelvis Fluid
Video
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Superior
Inferior
Longitudinal
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Tips Tricks

• Best with some urine in bladder
• Acoustic window
• Aim downward, into pelvis
• Fan thru whole area

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FAST
1
2
4
3
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4) LUQ view
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Normal LUQ
Spleen
Kidney
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FF
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FF
Spleen
Kidney
Diaphragm
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Tips Tricks

• Oblique probe angle
• Parallel to and between ribs
• Higher and more posterior than you think
• Probe on the bed and in the arm pit
• Fan thru whole space
• ?Check above spleen (vs. RUQ)
• Most common place for FF in LUQ is between
  diaphragm and spleen

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Finesse 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
• US does not replace CXR
• Suprapubic view
• Check uterus for pregnancy

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Hemothorax
D
SP
FF
KD
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Pleural Fluid
Video
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Putting it ALL together FAST
Video
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How can I practice?

• You can try your FF-identifying skills on
• Patients with ascites
• Patients on CAPD
• Before and during DPL
• Attend hands on training

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Pediatric FAST

• Not as sensitive
• 30-80 in various studies
• 31-37 of kids with solid organ injuries do not
  have hemoperitoneum
• Specificity still 95-100
• If its positive, its positive
• Rely on CT more in kids?

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Summary

• FAST easy, non invasive screening test
• No FF? no injury!
• 4 views- dependent areas
• Fluidblack

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F.A.S.T Training

• New for 2004/2005
• Who can attend Members ED, Surgery
• When Dates TBA, Time 8 am
• Planning every other month
• ACMC Trauma surgery department
• Why Promote US in trauma, hopefully improving
  care in our ED!

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Questions?