Indications

Rapid evaluation of blunt or penetrating trauma to the torso to evaluate for:

• Pericardial effusion with or without cardiac tamponade
• Intra-peritoneal bleeding
• Hemothorax (e-Fast)
• Pneumothorax (e-Fast)

Key Ultrasound Anatomy

Documentation 

At least 5 views must be documented:

1. RUQ - Morrison’s pouch and supra-diaphragmatic space
2. LUQ - Splenorenal and supra-diaphragmatic spaces
3. Subxyphoid or other cardiac view
4. Pelvis longitudinal view
5. Pelvis transverse view

Approach

4 standard views:

• Right Upper Quadrant / Hepatorenal – evaluating Morrison’s Pouch & base of right hemithorax 
• Left Upper Quadrant / Splenorenal – evaluating subdiaphragmatic space & base of left hemithorax 
• Pelvic / Suprapubic
• Subxyphoid Cardiac

PLUS lung exam for an e-FAST (extended-FAST)

Additional views:

• Paracolic gutters
• Apical or parasternal cardiac
• Trendelenberg positioning with upper quadrant views

Probe & Positioning

• 2-5 MHz curvilinear abdominal probe or smaller footprint curved array or phased array probe
• Patient is supine or Trendelenburg positioning

Clinical Question & Exam Interpretation

• Does this trauma patient have blood in the peritoneum, pleural spaces or pericardium?
  • Positive: Any anechoic collection of free fluid in the peritoneum, pericardial space, or pleural space
  • Negative: No quantity of fluid was seen and all 4 standard views were technically adequate
  • Equivocal/Inadequate:  Technical or artifact problems make the exam difficult to interpret
• Does the patient have a pneumothorax?
  • Positive: Visualized lung point or absence of lung sliding with clinical signs of pneumothorax
  • Negative: Lung sliding bilaterally in multiple intercostal spaces
  • Equivocal/Inadequate: Technical or artifact problems make the exam difficult to interpret

Pearls and Pitfalls

• May need multiple windows and probe positions to evaluate ALL perihepatic and perisplenic areas
• May need to rotate the probe in between rib spaces to evaluate eliminate rib shadow artifact in the RUQ (counterclockwise rotation) and LUQ (clockwise rotation) views
• Consider use of the anterior liver as a window to view Morrison's Pouch if the lateral window is technically difficult 
• Free fluid can be missed superior to the spleen on the LUQ view so be sure to visualize the diaphragm
• Consider reverse Trendelenburg to evaluate for hemothorax or pelvic free fluid
• Perinephric fat may be misinterpreted as intraperitoneal free fluid.  Look at the other kidney for comparison
• Consider obtaining your cardiac view with a parasternal long axis view in obese patient as the subxiphoid may be technically difficult
• Consider a repeat FAST exam if the initial exam is negative and clinical suspicion remains high