Matt Jones, MD, MS
FACEP, AEMUS-FPD, CCEeXAM, RDCS
EFAST
EXTENDED FOCUSED ASSESSMENT WITH SONOGRAPHY FOR TRAUMA
No Disclosures
Outline
Source of Photos:
Wellcome Library, London
Read about James Rutherford Morison from:
https://www.ob-ultrasound.net/goldberg.html
EVALUATION OF ASCITES BY ULTRASOUND
GOLDBERG BB; GOODMAN GA; CLEARFIELD HR
RADIOLOGY. 96(1):15-22, 1970 JUL.
Purpose of the FAST
Designed as a diagnostic assessment tool for the initial evaluation and management of unstable trauma patients.
It allows us to identify immediately critical pathology
It allows us to appropriately triage trauma patients
Traumatic Shock
Hypovolemic, Distributive, Obstructive, Cardiogenic
(Hemorrhagic shock, Neurogenic Shock, Tension PTX, Pericardial Tamponade, Blunt Cardiac Trauma)
Experience Matters
The accuracy of eFAST exams increases with a more experienced examiner
E-FAST Views
Scanning Sequence?
The sequence of scanning the individual regions is not critical and may be left up to individual preference. The majority of the panelist, in their own practices, begin scanning with the perihepatic view, primarily for the technical ease in identifying the liver. Their sequence then proceeds to the perisplenic, pelvic, and finally the pericardial view.
Scanning Sequence?
Take away point:
Scanning sequence is not critical and the provider may scan in the order that is most appropriate for the given case.
Right Upper Quadrant (RUQ)
RUQ
1998, Rozycki GS, et al- Early Detection of Hemoperitoneum by Ultrasound Examination of the Right Upper Quadrant- A Multicenter Study- The Journal of Trauma- Injury, Infection, and Critical Care.pdf
RUQ
1998, Rozycki GS, et al- Early Detection of Hemoperitoneum by Ultrasound Examination of the Right Upper Quadrant- A Multicenter Study- The Journal of Trauma- Injury, Infection, and Critical Care.pdf
RUQ is where you are most likely to find fluid.
RUQ
1998, Rozycki GS, et al- Early Detection of Hemoperitoneum by Ultrasound Examination of the Right Upper Quadrant- A Multicenter Study- The Journal of Trauma- Injury, Infection, and Critical Care.pdf
Where to find free fluid in RUQ
Pleural
Subphrenic
Hepatorenal Recess
Paracolic Gutter
Complete RUQ View
RUQ Superior (Cranial) View
RUQ Superior (Cranial) View
RUQ Inferior (Caudal) View
RUQ Inferior (Caudal) View
RUQ Pathology
Right Upper Quadrant
Spine Sign
(Look for this finding in both RUQ and LUQ views)
Right Upper Quadrant
Right Upper Quadrant
Right Upper Quadrant
RUQ View Pitfalls
False Negatives from incomplete view
False Negative from body habitus
False Positive from perinephric fat
False Positive - Cirrhosis, ESRD, Chronic Illness
BMI 57
Perinephric fat can be incorrectly interpreted as free fluid in Morison's pouch on the eFAST exam
Perinephric fat can be incorrectly interpreted as free fluid in Morison's pouch on the eFAST exam
Left Upper Quadrant (LUQ)
Where to find free fluid
Subphrenic
Splenorenal Recess
Pleural
Paracolic Gutter
Left Upper Quadrant
Diaphragm
Lung
Pleural Space
Subphrenic Space
Kidney
Spleen
Kidney
Spleen
Splenorenal Space
Diaphragm
Pleural Space
Lung
Subphrenic Space
Paracolic Space
Kidney
Spleen
Psoas
Splenorenal Space
LUQ Patholgy
Left Upper Quadrant
Left Upper Quadrant
Left Upper Quadrant
Left Upper Quadrant
LUQ View Pitfalls
False Negatives from incomplete view
False Negative from body habitus
False Positive - Cirrhosis, ESRD, Chronic Illness
BMI 57
Suprapubic Views
Rectovesical Pouch
Pelvic View Pitfalls
False Negative from empty bladder
False Positive in women with physiologic free fluid
False Positive in men with prominent seminal vesicles
False Positive - Cirrhosis, ESRD, Chronic Illness
Without a full bladder, free fluid in the pelvis can be missed.
***In this study free fluid was missed in patients with foley catheters placed in the trauma bay
female patients of reproductive age often have small amounts of physiologic fluid in the Pouch of Douglas which can be misinterpreted on the eFAST exam as traumatic free fluid (ie, blood).
Trace free fluid can be normal in women
“In our study we also noted prominent seminal vesicles were a common finding in pelvis views which were interpreted as falsely positive.”
“In our study we also noted prominent seminal vesicles were a common finding in pelvis views which were interpreted as falsely positive.”
Limited Echo
Limited Echo Views - Normal
Hyperdynamic Left Ventricle
https://www.youtube.com/watch?v=Hdje3I-emb4
Pericardial fat pads are frequently mistaken for pericardial effusions with EFAST
149
147
150
What other finding can you look for to demonstrate if there is obstructive shock from Tamponade???
What other finding can you look for to demonstrate if there is obstructive shock from Tamponade???
RAP (IVC)
***Spontaneously breathing and not on positive pressure ventilation***
+
=
Tamponade
+
=
Tamponade
***This may not hold true if the peritoneum is loaded with blood***
+
=
Tamponade
***This may not hold true if the peritoneum is loaded with blood***
What if you cannot find the heart and the IVC is shown below?
What if you cannot find the heart and the IVC is shown below?
What if you cannot find anything in the chest and all you see is the following image?
Lung Views
PTX
PTX
PTX
Thoracic Views Pitfalls
False Negative 2/2 body habitus
False Positive 2/2 other causes of loss of pleural Slide
75 F MVC
ULTRASOUNDIDIOTS.COM
EFAST Image Review
RUQ Cases
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7
Case 8
Case 9
Case 10
Case 11
LUQ Cases
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7
Case 8
Case 9
Case 10
Pelvic Cases
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7
Case 8
Case 9
Case 10
Cardiac Cases
Case 1
Case 2
Case 3
Case 4
Case 4
Case 5
Case 6
LA
LV
RVOT
LVOT
AV
DAo
Case 7
Case 8
Case 8
Case 9
Case 10
Chest Cases
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 6
Case 7
Case 8
PTX with Lung Point
Case 9
Case 10
Random Images
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