Extended

Focused Assessment of
Sonography in Trauma
E-FAST
Case
 Objec>ves
• To discuss the indica>ons of POCUS in trauma

• To demonstrate the E-FAST scanning techniques

• To review normal and abnormal ultrasound

images

• To discuss piFalls of E-FAST exam

• To review the literate on the use of E-FAST in

trauma
FAST
FAST DPL
 Indica>ons for E-FAST

1 Blunt and penetra,ng cardiac trauma

2 Blunt abdominal trauma

3 Blunt and penetra,ng chest trauma

 Ques>ons you are
trying to answer
1 Intra-peritoneal hemorrhage?

2 Hemothorax?

3 Trauma,c pericardial effusion?

4 Pneumothorax?
 Ques>ons you are
trying to answer
1 Intra-peritoneal hemorrhage?

2 Hemothorax?

3 Trauma,c pericardial effusion?

4 Pneumothorax?
Probe Selec>on
Probe Selec>on
Scanning technique
 Scanning Techniques
1 Intra-peritoneal 2 Hemothorax?
hemorrhage?

3 VIEWS 9 Zones

Above Below Inferior

RUQ diaphragm Morrison’s
diaphragm pole kidney

Above Below Caudal

LUQ diaphragm Splenorenal
diaphragm Spleen ,p

Rectovesicular/Recto-
Pelvic
uterine space
1 Intra-peritoneal 2 Hemothorax?
hemorrhage?
Above Below Inferior
RUQ diaphragm Morrison’s
diaphragm pole kidney

Above Below Caudal

LUQ diaphragm Splenorenal
diaphragm Spleen ,p

Rectovesicular/Recto-
Pelvic
uterine space
 Anatomy RUQ View

Pleural
cavity space
Hepatorenal
Subdiaphragma,c Space
space

Inferior Pole
RUQ View
 RUQ View
Pleural Subdiaphragma,c Hepatorenal Inferior Pole
cavity space space Space

Liver
Liver
Kidney
Kidney

Diaphragm
RUQ View
RUQ View: Evaluate Pleural
Cavity
 Mirror Image Ar>fact

Diaphragm Liver

Lung
Lung
 Mirror Image Ar>fact
Normal Absence of mirror image

Liver Liver

Lung Lung
 RUQ View: Evaluate Pleural
Cavity

Liver
Diaphragm Kidney

Lung
 RUQ View: Evaluate Pleural
Cavity
Normal Spine sign

Liver Liver
Diaphragm Kidney Diaphragm Kidney

Lung Lung
Here are some examples…
What do you think?
 What do you think?

Free fluid in
Morrison’s
pouch
extending to
the ,p of the
liver
What do you think?
 What do you think?

Free fluid in
inferior pole
What do you think?
 What do you think?

Fluid

Fluid in the
pleural cavity

Spine sign
 Comparison

Normal Right pleural effusion

What do you think?
 What do you think?

Small amount
of fluid in fluids
in the
Morrisons
pouch and
Right pleural
cavity
What do you think?
 PiFall- cloRed blood may be
hypoechoic not anechoic

Anechoic Free fluid Hypoechoic cloWed blood

What do you think?
 PiFall- Perinephric Fat

Hypoechoic cloWed blood Perinephric fat

1 Intra-peritoneal 2 Hemothorax?
hemorrhage?
Above Below Inferior
RUQ diaphragm Morrison’s
diaphragm pole kidney

Above Below Caudal

LUQ diaphragm Splenorenal
diaphragm Spleen ,p

Rectovesicular/Recto-
Pelvic
uterine space
1 Intra-peritoneal 2 Hemothorax?
hemorrhage?
Above Below Inferior
RUQ diaphragm Morrison’s
diaphragm pole kidney

Above Below Caudal

LUQ diaphragm Splenorenal
diaphragm Spleen ,p

Rectovesicular/Recto-
Pelvic
uterine space
Anatomy

Pleural
cavity space
Subdiaphragma,c
space

Spleenorenal
Space

Caudal Spleen Tip

LUQ View
 LUQ View
Pleural Subdiaphragma,c Spleenorenal Caudal
cavity space space Space Spleen ,p

Spleen

Kidney Kidney

Diaphragm
Here are some examples…
What do you think?
 What do you think?

Normal LUQ
view
What do you think?
 What do you think?

Free fluid sub-

diaphragma,c
area
What do you think?
 What do you think?

Free fluid
subdiaphragma,c
area, spleenorenal
space
What do you think?
 What do you think?

Small amount fluid

,p of the spleen,
spleenorenal
space
What do you think?
PiFall- Stomach mistaken for
Free fluid
What do you think?
 PiFall

Renal Cyst Free fluid

1 Intra-peritoneal 2 Hemothorax?
hemorrhage?
Above Below Inferior
RUQ diaphragm Morrison’s
diaphragm pole kidney

Above Below Caudal

LUQ diaphragm Splenorenal
diaphragm Spleen ,p

Rectovesicular/Recto-
Pelvic
uterine space
1 Intra-peritoneal 2 Hemothorax?
hemorrhage?
Above Below Inferior
RUQ diaphragm Morrison’s
diaphragm pole kidney

Above Below Caudal

LUQ diaphragm Splenorenal
diaphragm Spleen ,p

Rectovesicular/Recto-
Pelvic
uterine space
Netter's
Clinical
Anatomy
Third
Edition
 Suprapubic View

Longitudinal view Transverse View

Suprapubic View
 Bladder
Bladder
Transverese Rectum Vagina

Male Female

Longitudinal Bladder Bladder

Uterus
Bowel gas
Here are some examples…
 What do you think?

Male Female
Normal Suprapubic view

Male Female
What do you think?
 What do you think?

Free fluid
posterior to the
bladder in the
longitudinal view
What do you think?
 What do you think?

Free fluid in the

transverse view
What do you think?
 What do you think?

Very small amount

of Free fluid in the
transverse view
What do you think?
 What do you think?

Very small amount

of Free fluid in the
Longitudinal view
What do you think?
Same pa>ent- longitudinal view
 Free fluid is more obvious in
the longitudinal view
compared to the transverse

Transverse Longitudinal
What do you think?
 PiFall

Normal Pelvic Free fluid

What do you think?
 What do you think?

Decompressed
bladder with foley
making the view
limited to evaluate
for free fluid
 Ques>ons you are
trying to answer
1 Intra-peritoneal hemorrhage?

2 Hemothorax?

3 Trauma,c pericardial effusion?

4 Pneumothorax?
 Ques>ons you are
trying to answer
1 Intra-peritoneal hemorrhage?

2 Hemothorax?

3 Trauma,c pericardial effusion?

4 Pneumothorax?
Netter's Clinical Anatomy,Third Edition
Sub-xiphoid View
Sub-xiphoid View

RV
RA LV
LA

Pericardium
Here are some examples…
What do you think?
Normal subxiphoid view
What do you think?
Large amount of circumferen>al
pericardial effusion
What do you think?
Posi>ve pericardial effusion
What do you think?
Posi>ve pericardial effusion
 Ques>ons you are
trying to answer
1 Intra-peritoneal hemorrhage?

2 Hemothorax?

3 Trauma,c pericardial effusion?

4 Pneumothorax?
 Ques>ons you are
trying to answer
1 Intra-peritoneal hemorrhage?

2 Hemothorax?

3 Trauma,c pericardial effusion?

4 Pneumothorax?
Probe Selec>on
 Lung- high frequency probe

Rib Rib

Pleural
line
Lung- low frequency probe

Rib

Pleural
line
Lung Sliding M mode
 Normal Pneumothorax

No sliding
Normal sliding

Seashore sign Barcode sign

Here are some examples…
What do you think?
 Lung sliding and comet tail

In the presence or
absence of lung
sliding, visible B
lines or comet tails
can rule out
pneumothorax
What do you think?
 Absent lung sliding

In trauma
setting, it is
highly likely
due to
pneumothorax.
 Beware of false posi>ve
Absent lung sliding

▪ Atelectasis
▪ Lung and pleura adhering
together
▪ Phrenic palsy
▪ Pulmonary fibrosis
▪ Cardiopulmonary arrest
▪ Poor operator skill
▪ Large infiltrates and
pleural effusions
What do you think?
 Lung point

In the absence of
lung sliding, B lines,
and comet tails, the
presence of a lung
point has 100%
specificity and PPV
for pneumothorax
Lung Point - M Mode
What do you think?
Lung pulse shows pleural
contact but no ven>la>on
Lung Pulse - M Mode
 Ques>ons you are
trying to answer
1 Intra-peritoneal hemorrhage?

2 Hemothorax?

3 Trauma,c pericardial effusion?

4 Pneumothorax?
 Sensi>vity of Ultrasound

Sensitivity Specificity

Intraperitoneal fluid 73-88% 98-100%

Hemothorax 96.2% 100%

Pneumothorax 92-98% 99.4%

 Proposed Protocol FAST
Results from an Interna>onal
FAST EXAM

Positive Negative

Stable unstable Stable unstable

Observe or Look for

CT scan OR other
CT scan
sources
• Over-reliance on ultrasound
• Delaying transport to opera>ng room
• Failing to scan the inferior pole of the kidney
• Failing to recognize cloRed blood:
• Failure to understand other limita>ons of EFAST
• Not Fanning fully
• Incomplete Views
• Too much gain
• Under-filled bladder
• Renal cyst, Seminal vesicles, Perinephric fats, stomach
 References
1. Dawson M, Mallin M. Introduc,on to Bedside Ultrasound. 2013
2. Lewiss, Resa. Saul, Turandot. Del Rios, Marina. Focus on: EFAST -
extended focused assessment with sonography for trauma.
Available at: hWp://www.acep.org/Clinical---Prac,ce-
Management/Focus-On--EFAST---Extended-Focused-Assessment-
With-Sonography-for-Trauma/. Accessed 05/2014, 2014.
3. Noble VN, Bret. Manual of Emergency and Cri,cal Care
Ultrasound. Cambridge University Press; 2011:356.
4. Scalea TMM, Rodriguez AM, Chiu WCM, et al. Focused
assessment with sonography for trauma (FAST): Results from an
interna,onal consensus conference. 1999;46(3).