What:
Extended Focused assessment with sonography in trauma
Trauma evaluation for blunt or penetrating chest/abdomen/back/pelvic trauma as well as in the evaluation of the unexplained hypotensive patient as part of the RUSH protocol and the patient with a possible ruptured ectopic pregnancy.
Why:
FAST has 82% sensitivity and 99% specificity for blunt intraabdominal injury in adult patients
When:
· Usually performed as a part of the primary survey but that is not an absolute.
· Use your clinical judgement to decide whether the FAST should performed during the primary survey or secondary survey.
· For example, if patient had a penetrating trauma to the extremity, secondary survey might be more important and urgent than performing an EFAST.
Who:
Adults and Pediatric patients with blunt or penetrating trauma
How:
Your patient should be kept supine to increase your accuracy
Sequence of EFAST
1. Subxiphoid
2. RUQ/ R thorax
3. LUQ/ L thorax
4. Pelvic
5. Anterior Lung view bilaterally
Subxiphoid first
· Traumatic cardiac tamponade/pericardial effusion is the first thing you want to rule out. Acute accumulation for a very small amount of fluid can put the patient in severe obstructive shock and cause cardiopulmonary collapse so make sure to rule that out first
· Increase the depth and go to the RUQ
· Next, RUQ- Why? It is the most sensitive location for identification of free fluid in the abdomen because the posterior peritoneum attaches in such a way that free fluid from any injury anywhere will travel to the right upper quadrant in a supine patient
· Place probe on the Horizontal Subxiphoid line with the marker towards patient head in the Mid Axially line
· The RUQ can be divided into 3 zones.
o Above/Below the diaphragm
o Morrison’s pouch (hepato-renal recess)
o Paracolic gutter: Around the inferior hepatic edge/inferior pole of kidney
· Evaluate above the diaphragm to evaluate for intrathoracic free fluid
· Evaluate below the diaphragm to evaluate for intraperitoneal fluid
· Evaluate between the liver and the entire superior pole of the kidney – Morrisons Pouch view. Make sure you visualize the liver tip- It is the most sensitive area for free fluid on the FAST Exam;
· Evaluate between the left edge of the liver and the entire inferior pole of the kidney.
· Move on to the LUQ next; The LUQ can also be divided into 3 zones:
o Above/Below the diaphragm,
o Spleno-Renal recess
o 3. Paracolic gutter: Around the inferior pole of kidney
· The only difference between the RUQ and LUQ here is that you should place your probe at the posterior axillary line on the left, instead of midaxillary line of the right. Have your “knuckles on the gurney”.
· Beware of the stomach Sabotage ??
· Evaluate above the diaphragm to evaluate for intrathoracic free fluid like the RUQ
· Evaluate below the diaphragto evaluate for intraperitoneal fluid. This is where free intraperitoneal fluid will usually develop first in the left upper quadrant (LUQ) (different from the RUQ where the first area of free fluid is usually around the inferior pole of the kidney and right paracolic gutter).
Pelvic View
· Make sure you obtain the pelvic view before the RN places the foley because you will loose the acoustic window that the bladder provides
· Always obtain a longitudinal and Transverse view
· Rectovesical pouch (male patients)
· Rectouterine / pouch of Douglas in female patients
· Do not be fooled by the seminal vesicles in males
Remember
· New blood is anechoic (black).
· Ascites is anechoic (impossible to differentiate.
· Clotted blood is echogenic (shades of gray)
Limitations
· Not a diagnostic test but a screening tool
· Injuries that do not cause free fluid
· Injuries causing retroperitoneal free fluid
· Injuries that cause <300 cc intraperitoneal free fluid (the lower the fluid amount the more likely to miss)
· Injuries causing free fluid where the FAST scan is done too early in free fluid accumulation, and, therefore, will not detect it
· Lower sensitivity in kids about 60-85%. Specificity 90-99%
References:
Dr Eitan Dickman
Rozycki, Grace S., et al. "Early detection of hemoperitoneum by ultrasound examination of the right upper quadrant: a multicenter study." Journal of Trauma and Acute Care Surgery 45.5 (1998): 878-883.
Shokoohi, Hamid, Keith S. Boniface, and Audra Siegel. "Horizontal subxiphoid landmark optimizes probe placement during the Focused Assessment with Sonography for Trauma ultrasound exam." European Journal of Emergency Medicine 19.5 (2012): 333-337.