Traumatic injury is the leading cause of death among individuals younger than 45

years old. Eighty percent of traumatic injury is blunt with the majority of deaths
secondary to hypovolemic shock. In fact, intraperitoneal bleeds occur in 12% of
blunt trauma; therefore, it is essential to identify trauma quickly. The optimal
test should be rapid, accurate, and non-invasive.

Bloom BA, Gibbons RC. Focused Assessment with Sonography for Trauma. [Updated 2020
Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
2021 Jan-.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK470479/

A.Emergency Indications
Indications for the eFAST include both blunt and penetrating traumatic injuries as
well as presentations of unexplained hypotension as part of an ultrasound shock
protocol (i.e., RUSH exam) to rapidly diagnose the cause of low blood pressure.

B.Contraindications
Contraindications to the eFAST are primarily situations in which performing the
study would delay or interfere with critical life-saving interventions including
emergent surgical intervention.

C.eFAST protocol steps

The premise behind the FAST exam is that free fluid accumulates in the dependent
areas of the abdomen. According to some experts, an extended FAST exam involves
several views. These are;
1.Subcostal or Parasternal Long Axis Cardiac
2.Right Upper Quadrant
3.Left Upper Quadrant
4.Suprapubic
5.Thorax for Hemothorax and Pneumothorax
6.IVC for volume status

https://iem-course.org/courses/efast/

*Subcostal Transducer Position*

To obtain this view, use the liver as the acoustic window. The transducer is
curvilinear—the transducer marker (triangle) aims to the right side of the patient.

*Normal Subcostal View*

The right ventricle (RV) is the closest cardiac chamber to the chest wall. The left
ventricle (LV) and both atria (LA and RA) are also visible. The bright white line
is the pericardium. Liver located closest to the top.

*Parasternal Long Axis Transducer Position*

The transducer is placed next to the left sternal border at the 2-4 intercostal
level. The transducer marker, depending on a user preference, can aim to 10 o’clock
(right shoulder) or 4 o’clock (left hip) direction. At this image, the transducer
marker aims to the right shoulder. Images on the right.

*Normal Parasternal Long Axis Cardiac View*

If an adequate subcostal view of the heart cannot be obtained, attempt the
parasternal long axis view. A subcostal view might be difficult in some trauma
patients if they have an abdominal injury, epigastric tenderness or abdominal
distention. In this view, the right ventricle is still the closest cardiac chamber
to the anterior chest wall. The left ventricle left atrium, and aortic outflow
tract are also visible.

*Right Upper Quadrant Transducer Position*

The right upper quadrant is the abdominal view that is the most likely to be
positive. The transducer is placed in the mid-axillary line with the probe marker
pointed toward the patient’s head. A low-frequency, curvilinear, or a phased array
probe should be used to obtain this view.

*Normal Right Upper Quadrant View*

First, identify the kidney and the liver. The kidney is often the easiest structure
to identify. It has a bright white center surrounded by the less echogenic cortex.
The hepatorenal space, the interface between the kidney and liver, is a potential
space that may contain free fluid. In this image, the patient’s head is toward the
left side of the screen, and the feet are toward the right side of the screen. The
diaphragm is the bright white line just superior to the liver. It is important to
visualize the tip of the liver as well as the inferior pole of the kidney to have
an adequate assessment of the hepatorenal space.

Key notes: Make sure to see and evaluate both tips of liver and both poles of right
kidney so we can exclude minimal hemorrhage in this area. If there is a free fluid
(anechoic) we can quickly scan for anomaly structure and find the potential source
of bleeding.

*Normal Hemithorax View*

The image above shows the kidney, liver, and diaphragm. However, as you transition
to the chest cavity at the insertion of the diaphragm, air scatters the ultrasound
beam, and you lose visualization of the spine. In addition, you can see a mirror
image artifact.

(A) Right upper quadrant view with normal pleural space. (B) Right upper quadrant
view with evidence of pleural effusion (*) and positive spine sign

*Left Upper Quadrant Transducer Position*

To obtain the left upper quadrant view, position the probe at the left posterior
axillary line near ribs nine and ten. Again, the probe marker is pointed toward the
patient’s head. Since rib shadows may obscure your view, it is sometimes helpful to
angle the probe obliquely in line with the intercostal space.

*Normal Left Upper Quadrant*

This normal view of the left upper quadrant shows the spleen and the kidney (see
image above). As with the right upper quadrant view, the patient’s head is to the
left of the screen, and the patient’s feet are toward the right of the screen.
The diaphragm is a bright white, hyperechoic curving line superior to the spleen.
On the left side, examine the space between the kidney and the spleen for free
fluid. However, it is more likely that fluid will accumulate around the dome of the
spleen and, therefore, you must image the dome of the spleen.

*Pelvic View Transducer Position*

The pelvic view is obtained by placing the transducer in a suprapubic position in
either a transverse or longitudinal orientation. Since the bladder is the acoustic
window, it is helpful to image the patient before the placement of a Foley
catheter.

On the transverse view, the transducer marker aims to the patient’s right side (see
image above). On the longitudinal view, the transducer marker aims to the patient
‘s head. For both exams, the transducer is placed just above the symphysis pubis
and aim downwards inside the pelvis, not toward to abdomen.

*Normal Transverse Pelvic View*

This normal, transverse suprapubic view fans through the bladder. Look for free
fluid lateral or inferior to the bladder.
In the pelvic view, fluid will accumulate in rectouterine space also known as the
pouch of Douglas in females and rectovesical space in males.

*Thorax View Transducer Position*

The extended FAST exam also images each hemithorax for pneumothorax. Using a high
frequency (linear) probe to obtain a longitudinal view of the lung between 3rd and
4th intercostal space, mid-clavicular line is a standard approach. The indicator
(transducer marker) pointed toward the patient’s head.

Since air rises, the transducer should be placed at the most superior region of the
chest. In the supine, trauma patient, this position is usually the third
intercostal space. If the patient is sitting, the apices of the lungs should be
imaged.

*Normal Thorax View*

Grab your transducer with your index finger and thumb like a pen. When you place
your transducer as defined above, you need to find two ribs (HYPERechogenic[white]
curved structures with a HYPOechogenic[gray-black] shadow behind) on the sides and
pleural line (hyperechogenic) in the middle. When you find the view, you need to
stand still at this position by using your other fingers as a tripod.

*Transducer Position for Volume Assessment*

Place the transducer on the abdomen with the probe marker pointed towards the
patient’s head. Visualize the vena cava about 3 cm proximal to the cavoatrial
junction.

*IVC View*
To visualize IVC, you can use various techniques. One of them is to finding the
subcostal 4 chamber view and rotating your transducer marker to 12 o’clock
(patient’s head). At this moment, you can see longitudinal anechoic vessels. If
your transducer tilted to the patient’s left side, this vessel is probably aorta,
and it has thick hyperechogenic borders and pulsates. If your transducers tilted to
the patient’s right side (liver), probably this vessel is inferior vena cava (IVC)
with thinner walls and changes its diameter with respirations. When you see IVC,
now you need to tilt your transducer inside the thorax to find the cavoatrial
junction.