ULTRASOUND

FAST

PRESENTED BY:
DR. AROOBA SADIQ
DR. IFRAH INBISAT RAZA
DR. SHAHEERA YOUNUS
 INTRODUCTION

o FAST (Focused Assessment with Sonography for trauma) scan is a

rapid bedside Ultrasound examination that is used to assess trauma
patients for internal bleeding and other life-threatening conditions.
o It is an Ultrasound protocol that helps to assess hemopericardium
and hemoperitoneum.
o eFAST is a variant of FAST scan that assesses pneumothorax and
hemothorax.
o By adding both intra-abdominal and intra-thoracic surgeries,
eFAST becomes a more comprehensive tool for trauma assessment.
 PURPOSE

o The primary purpose of FAST scan is to quickly identify free

fluid in the pericardial and peritoneal cavities which can indicate
organ injury in trauma patients.
o It is also used as a triage tool to assess if a patient needs
immediate surgical intervention or requires further diagnostic
imaging.
o It is a non-invasive procedure that takes only a few minutes to
complete, allowing for rapid decision-making.
 It decreases the time of It can be repeated for
BENEFITS
diagnosis in patients with serial examination
blunt abdominal trauma without removing the
(BAT). patient from clinical area.

It is safe in pregnant
It leads to fewer
patients and children
diagnostic peritoneal
since it requires less
lavages (DPLs).
radiation than CT scan.
INDICATIONS AND CONTRAINDICATIONS

INDICATIONS CONTRAINDICATIONS

Hemodynamically unstable blunt Hemodynamically unstable

abdominal trauma. E.g, Car accidents penetrating trauma
and falls.
Hemodynamically stable penetrating Subcutaneous emphysema as it
trauma (e.g, stab wound, gunshot hinders US penetration
wound)
Patients with unexplained Hemodynamically stable patient with
hypotensive shock other reliable imaging available e.g,
CT scan.
Monitor ongoing resuscitation efforts
in trauma patients
 ANATOMY AND REGIONS ASSESSED

The anatomical regions assessed in U/S FAST are as followed;

o The hepatorenal recess (Morison pouch)
o The perisplenic area
o The subxiphoid pericardial window
o The suprapubic window (Douglas pouch or Rectouterine space
in women).
o Anterior Chest/thoracic view (specific to eFAST)
o Hemithorax view (specific to eFAST)
1. THE HEPATORENAL RECESS (MORISON POUCH)

BOUNDARIES:
Superiorly: Inferior surface of right lobe of liver
Inferiorly: Superior pole of right kidney
Medially: Inferior vena cava
Laterally: Right lobe of liver
Posteriorly: Peritoneal reflection over posterior abdominal wall
 1. THE HEPATORENAL RECESS (MORISON POUCH)

Place the U/S probe over Right upper quadrant view Free fluid in Morison pouch. In cases of
RUQ or laterally along acute hemoperitoneum, blood appears as an
the thoracoabdominal anechoic stripe in the recess.
junction
2. THE PERISPLENIC AREA

BOUNDARIES:
Superiorly: Diaphragm
Inferiorly: Splenic flexure of colon
Medially: Superior pole of left kidney
Laterally: Lateral abdominal wall
Anteriorly: Stomach
Posteriorly: Posterior abdominal wall and left kidney
 2. THE PERISPLENIC AREA

Place the probe over the Left upper quadrant view Blood in the splenodiaphragmatic
left flank along the recess
posterior axillary line
3. THE SUBXIPHOID PERICARDIAL WINDOW

BOUNDARIES:
Superiorly: Diaphragm of the heart
Inferiorly: Liver
Laterally: Left and right hemidiaphragm
Anteriorly: Xiphoid process
Posteriorly: Vertebral column
3. THE SUBXIPHOID PERICARDIAL WINDOW

The transducer-probe should be Subxiphoid view that demonstrates

placed in the subxiphoid area traumatic tamponade
and directed into the chest
toward the left shoulder to
provide a view of the diaphragm
and the heart
4. THE SUPRAPUBIC WINDOW

BOUNDARIES OF DOUGLAS POUCH BOUNDARIES OF RECTOVESICAL POUCH

Anteriorly: Posterior surface of uterus and Anteriorly: Posterior surface of bladder
posterior vaginal fornix Posteriorly: Anterior surface of rectum
Posteriorly: Anterior surface of rectum Superiorly: Peritoneal covering
Superiorly: Peritoneal covering Inferiorly: Seminal vesicle and prostate
Inferiorly: Perineal body and pelvic floor
4. THE SUPRAPUBIC WINDOW

Place the probe just above the Suprapubic view

pubic symphysis and direct
it inferiorly into the pelvis.
Easier to obtain when the
bladder is full and before a
Foley catheter is placed
5. ANTERIOR CHEST/ THORACIC VIEW

BOUNDARIES: NOTE: This view is specific for eFAST

Superiorly: Ribs and intercostal muscles scan.
Inferiorly: Diaphragm
Medially: Mediastinum
5. ANTERIOR CHEST/ THORACIC VIEW

Place your probe at the mid-clavicular line at the A normal US finding will show pleura
2nd intercostal space of the right and left lungs sliding over one another. This sign is also
respectively known as “Ants marching on a line”
6. BILATERAL HEMITHORACES

Place your probe at the subcostal region between Fluid in the right hemithorax
the mid axillary and posterior axillary line
PROTOCOL FOR BAT
 INTERPRETATION OF RESULTS

1. Hepatorenal recess (Morrison’s pouch)

Causes
• Blunt trauma or laceration of the Liver or Right Kidney (less common)
• Ruptured Liver cyst
• Injury to the spleen (In case of significant damage and bleeding)
• Damage to major blood vessels:
 Hepatic Artery
 Portal Vein
 Renal Vein
 IVC
• Ruptured ectopic pregnany (rare)
INTERPRETATION OF RESULTS

Zoomed in. Fluid denoted by arrow

INTERPRETATION OF RESULTS

A small streak of fluid/ blood Zoomed in. Fluid denoted by arrow

can be seen in the morrison’s
pouch
 INTERPRETATION OF RESULTS
Hematocrit Sign
As time passes, cellular content in older
blood settles down, becoming more
echogenic compared to newer blood, which
appears anechoic. This creates a fluid-fluid
level which is mostly seen in case of
hematomas but can be seen in BAT.
 INTERPRETATION OF RESULTS

2. Splenorenal space
Causes
• Blunt trauma or laceration of the spleen
• Pancreatic or gastric injury
• Ruptured pancreatic cyst
• Injury to the left kidney (In case of significant damage and bleeding)
• Damage to major blood vessels:
 Splenic Artery and Vein
 Pancreatic Arteries and Veins (less common)
 Short Gastric Artery (branch of Splenic Artery)
INTERPRETATION OF RESULTS
COMPARISION WITH CT SCAN
 INTERPRETATION OF RESULTS

3. Suprapubic (Pouch of Douglas or Rectovesical pouch)

Causes
• Pelvic Fracture
• Bleeding from the venous plexus (Iliac Vessels) 2* to fracture
• Ruptured ectopic pregnancy
• Ruptured ovarian cyst
• Uterine or bladder injury (rare)
• Injury to the prostate gland
INTERPRETATION OF RESULTS
 INTERPRETATION OF RESULTS

4. Subxiphoid/ Pericardial Space

Causes
• Blunt trauma causing cardiac contusion or Coronary Artery rupture
• Penetrating trauma
• Ventricular rupture (mostly Right Ventricle)
• Ruptured Aorta/ Traumatic Aortic injury

Most of these injuries will cause hemopericardium which will eventually lead to Cardiac
Tamponade.
INTERPRETATION OF RESULTS
 LIMITATIONS AND PITFALLS

o Operator dependent image quality

o Needs at least >200ml of fluid for visualization
o Patient factors like movement, obesity, bowel full of gas, etc
o Equipment limitations such as image resolution, probe selection,
etc
o Hollow viscus injuries are difficult to diagnose as small amounts
of gas are difficult to assess
o Less sensitivity for organ injury without hemoperitoneum (29-
35%)
 LIMITATIONS AND PITFALLS

o FAST is less sensitive in the setting of penetrating trauma than

blunt trauma
o It cannot distinguish between urine and blood in severe pelvic
trauma and cannot evaluate retroperitoneal hemorrhages
o Rib shadowing
o Inadequate reporting or documentation
o Time constraints
 FALSE POSITIVE RESULTS

o Intraperitoneal fluid may not necessarily be hemoperitoneum.

Consider ascites, urine, peritoneal dialysate
o Fatty tissue may be mistaken as free fluid
o FAST cannot distinguish between urine and blood
o Massive intravascular volume resuscitation may rarely give false
positive results from intravascular to intraperitoneal fluid
transudation
 FALSE NEGATIVE RESULTS

o Hemoperitoneum may take time to accumulate and may give

false negative results
o Delayed presentation of patient whose hemorrhage has clotted
causing mixed echogenicity rather than anechoic appearance of
fresh blood or fluid
o Mild abdomen and severe head injury may give false negative
due to lack of patient cooperation
 HOW TO MINIMIZE ERRORS

o Ensure proper training and experience for operators

o Use high-quality equipment and probes
o Take sufficient time to perform the scan
o Do serial ultrasound
o Update knowledge and skills with current guidelines
COMPARISON WITH OTHER IMAGING MODALITIES

Ultrasound FAST CT Scan

Hemodynamically unstable patients with Hemodynamically stable patients with
BAT BAT
Does not show source of bleeding Shows source of bleeding
Inexpensive, quick and available at Expensive, slower and not available at
bedside bedside
Uses sound waves Uses ionizing radiations
Not suitable for solid organ pathology ‘Gold standard’ for solid organ injuries
especially without intraperitoneal rupture
of blood vessels
No contraindications Some contraindications
Good soft tissue resolution Poor soft tissue resolution
COMPARISON WITH OTHER IMAGING MODALITIES

Ultrasound FAST DPL

Non invasive Invasive

Quick to perform Takes more time than FAST

Easy repeatability Rarely repeated

More sensitive for detecting organ More sensitive for detecting small
damage amounts of free fluid

>200ml of blood is considered positive >10ml of blood considered dpl positive

FAST
THANK YOU