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FAST SCAN
Dr. Muhammad Bin Zulfiqar
PGR NEW RADIOLOGY DEPARTMENT
SIMS/SHL
What does it Mean?
FAST
Focused
Abdominal (Assessment
with)
Sonography in
Trauma
Fast Application
• Indications:
– Acute blunt or penetrating torso trauma (stable or
unstable patient )
– Trauma in pregna...
FAST USG SCAN
• ANATOMY
• TECHNIQUE
• FAST DEMO
• FREE FLUID
• ABDOMINAL ORGAN INJURY
Where can I see FF?
• Free fluid usually appears anechoic by US
(black )
• Accumulation in area of injury
• Overflows into...
FAST: Anatomy
7 Dependent Sites
1. Right Supramesocolic
(Morison’s pouch)
2. Left Supramesocolic
(Splenorenal recess)
3. R...
FAST: Technical Considerations
Standard Views
• The Right Upper Quadrant View (Also Known as the
Perihepatic, Morison Pouc...
FAST: Technical Considerations
Extended Views
• The Pleural Space Views
• The Anterior Pleural Space View
• The Parasterna...
FAST: Technical
Considerations
• Standard views (standard FAST ):
1- Subxiphoid/Subcostal: Pericardium
2- RUQ: Morrison’s ...
FAST: Subxiphoid exam
• Normal Anatomy
• Liver at very top of screen
• Epicardial fat vs. effusion
– Thin layer anterior t...
Sonographic Representation of Heart Chambers
FAST: Subxiphoid exam
FAST: RUQ exam
• Probe placed
– Perpendicular
– Mid-coronal plane
– Just superior to the iliac
crest
• Probe facing
– Towa...
FAST: RUQ exam
• Normal Anatomy
• In the supine patient,
the hepatorenal space
(Morison’s Pouch) is
the most dependent
spa...
FAST: Pelvis exam
• Pelvis: Longitudinal Axis
– Normal Anatomy
– In the erect patient, the pouch of
Douglas (Retrovesical ...
FAST: Pelvis exam
• Pelvis: Longitudinally and Transvers Axis.
• Probe placed
– Transversally than Longitudinally
– Midlin...
FAST: Pelvis exam
FAST: LUQ Exam
• Normal Anatomy
• More difficult to evaluate than
RUQ (do not have liver as acoustic
window)
• Left kidney...
FAST: LUQ Exam
• Probe placed
– Perpendicular
– Mid - coronal plane
– Just superior to the iliac crest
• Probe facing
– To...
FAST: LUQ Exam
• Probe placed
– Perpendicular
– Mid - coronal plane
– Just superior to the iliac crest
• Probe facing
– To...
FAST: LUQ Exam
Extended FAST (E-FAST)
RUQ, LUQ views:
• Check above diaphragm for hemothorax
– CXR < US in detection of hemothorax
– 50-1...
FAST Demo
FAST
Focused Abdominal Sonography In
Trauma
Reliability
• accuracy 86 - 97 %
• sensitivity 88 - 91.7 %
• specificity 94.7 ...
How To Interpret FAST
–Positive:
• Fluid in pericardium or any 1 of 4 abdominal
windows
–Negative:
• No fluid in any windo...
Scoring System of Fluid
• In lower volumes, fluid accumulates in the pelvis
or near the site of injury.
• It is not until ...
Scoring System of Fluid
• One point is assigned to each anatomic site in which free fluid is
detected during the FAST scan...
Modified Scoring System
• Revaluated scoring system measures the
depth of fluid in the deepest pocket, and 1
point is adde...
Does FAST Make a Difference In Trauma
Management?
• During primary or secondary survey
FAST
Positive NegativeIndeterminate...
Pearls
• Lack of FF ≠ no injury
– Not enough to see (?too early)
– You missed it
– Hard-to-see places
• FF may not be bloo...
Advantages of FAST
 Easy & Early to Diagnose in
Resuscitation/Emergency room
 Rapid(1 – 2.5 min)
 Repeatable
 Non-inva...
 Difficult to distinguish
 Type of fluid
 Site of bleeding ,
 Solid organ injury
 Cannot evaluate retroperitoneum
 D...
Pitfalls and limits
• -Pre existing fluid collection ( Ascites , dialysis )
• -Pelvic fluid collection (female ) .
• -Flui...
Pearls
• The scan should be repeated during the secondary
survey and also if the patient demonstrates clinical
deteriorati...
Does FAST replace CT?
• Unstable patient, (+) FAST  OR
• Stable patient, low force injury, (-) FAST  consider observing ...
FREE FLUID
Pericardial Fluid
Pericardial Effusion
Types of pericardial effusions, subxiphoid cardiac view.
Left image: typical effusion, middle image: clotted effusion , ri...
Fluid in Morrison Pouch
Fluid in Morrison Pouch
Fluid in Morrison Pouch
L
K
FF
Fluid in Morrison Pouch
Fluid In Pelvis
Fluid In Pelvis
Fluid In Pelvis
Fluid in Splenorenal Pouch
Fluid in Splenorenal Pouch
Fluid in Splenorenal Pouch
Hemothorax
KD
S
PF
F
D
Pleural Fluid
Pleural Effusion
Right pleural effusion, transverse subxiphoid view
?
Is Pneumoperitoneum Can Be Detected
By US?
YES
Pneumoperitoneum
Hollow
Organs
Stomach
Gall bladder
Intestines
Ureters, Blad
der
Solid
Organs
Liver
Spleen
Kidney
Pancreas
Vascular
Injury
...
Blunt Injury
Abdominal Trauma
• Spleen 25%
• Liver 15%
• Hollow viscus 15%
– Ileum
– Sigmoid
• Kidney 12%
• Retroperitonea...
Solid-Organ Injuries (sonographic
patterns)
I. Contusion : patchy ill defined non-linear echogenic area .
II. Subcapsular ...
Liver laceration and hematoma
Subcapsular Liver hematoma
Liver laceration and hematoma
Splenic laceration
Spleen hematoma Subcapsular spleen
hematoma
Splenic laceration
Preinephric and
renal hematoma
Renal laceration
Subcapsular renal
hematoma
References
• Vicki E Nobil , Manual of emergency and critical care ultrasound , Cabridge university 2007
• Rosen, C. Ultra...
THANX
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Fast USG In Trauma

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  1. 1. FAST SCAN Dr. Muhammad Bin Zulfiqar PGR NEW RADIOLOGY DEPARTMENT SIMS/SHL
  2. 2. What does it Mean? FAST Focused Abdominal (Assessment with) Sonography in Trauma
  3. 3. Fast Application • Indications: – Acute blunt or penetrating torso trauma (stable or unstable patient ) – Trauma in pregnancy – Pediatric trauma – Subacute torso trauma(unexplained hypotension) • Goal: To identify fluid in a location where it does not normally belong and detect visceral injury.
  4. 4. FAST USG SCAN • ANATOMY • TECHNIQUE • FAST DEMO • FREE FLUID • ABDOMINAL ORGAN INJURY
  5. 5. Where can I see FF? • Free fluid usually appears anechoic by US (black ) • Accumulation in area of injury • Overflows into dependent areas (pouch of Douglas, Morrison’s pouch) via rivers (paracolic gutters) and into thoracic cavity
  6. 6. FAST: Anatomy 7 Dependent Sites 1. Right Supramesocolic (Morison’s pouch) 2. Left Supramesocolic (Splenorenal recess) 3. Right Pericolic gutter 4. Right Inframesocolic 5. Left Inframesocolic 6. Left Pericolic gutter 7. Pelvic cul-de-sac
  7. 7. FAST: Technical Considerations Standard Views • The Right Upper Quadrant View (Also Known as the Perihepatic, Morison Pouch, or Right Flank View) • The Left Upper Quadrant View (Also Known as the Perisplenic or Left Flank View) • The Pelvic View (Also Known as the Retrovesical, Rectrouterine, or Pouch of Douglas View) • The Pericardial View (Also Known as the Subcostal or Subxiphoid View) • The Right and Left Pericolic Gutter Views
  8. 8. FAST: Technical Considerations Extended Views • The Pleural Space Views • The Anterior Pleural Space View • The Parasternal View
  9. 9. FAST: Technical Considerations • Standard views (standard FAST ): 1- Subxiphoid/Subcostal: Pericardium 2- RUQ: Morrison’s Pouch 3-Pelvis: Pelvic Cul-de-sac (Douglas ) Transverse Longitudinal 4- LUQ: Splenorenal & perisplenic spaces • Extended views (E-FAST) :For pleural effusion Supine patient 1 42 3
  10. 10. FAST: Subxiphoid exam • Normal Anatomy • Liver at very top of screen • Epicardial fat vs. effusion – Thin layer anterior to RV – Not present posterior to LV
  11. 11. Sonographic Representation of Heart Chambers
  12. 12. FAST: Subxiphoid exam
  13. 13. FAST: RUQ exam • Probe placed – Perpendicular – Mid-coronal plane – Just superior to the iliac crest • Probe facing – Toward patient’s head Evaluating – Hepatorenal interface – Possibility of fluid in Morison’s pouch ( Right Supramesocolic space)
  14. 14. FAST: RUQ exam • Normal Anatomy • In the supine patient, the hepatorenal space (Morison’s Pouch) is the most dependent space Morison’ s Pouch
  15. 15. FAST: Pelvis exam • Pelvis: Longitudinal Axis – Normal Anatomy – In the erect patient, the pouch of Douglas (Retrovesical space ) is the most dependent space
  16. 16. FAST: Pelvis exam • Pelvis: Longitudinally and Transvers Axis. • Probe placed – Transversally than Longitudinally – Midline 2 cm superior to the symphysis pubis – “aimed” caudally into the pelvis (prostate ) • Probe facing – Toward patient’s head and right side. • Best with some urine in bladder(acoustic window) • Evaluating – Bladder ,Uterus in female ,and Prostate in male – The potential spaces are Pouch of Douglas (Cul de sac ) in female and Retrovesical space in male – ‘
  17. 17. FAST: Pelvis exam
  18. 18. FAST: LUQ Exam • Normal Anatomy • More difficult to evaluate than RUQ (do not have liver as acoustic window) • Left kidney more superior than right • Splenorenal Recess , Potential space between kidney and spleen • Presplenic /subphrenic space between spleen and diaphragm ( most common space for fluid collection in LUQ)
  19. 19. FAST: LUQ Exam • Probe placed – Perpendicular – Mid - coronal plane – Just superior to the iliac crest • Probe facing – Towards patient’s head • Evaluating – Spleno-renal interface – Possibility of fluid in Splenorenal recess and presplenic /subphrenic space( most common space for fluid collection in LUQ)
  20. 20. FAST: LUQ Exam • Probe placed – Perpendicular – Mid - coronal plane – Just superior to the iliac crest • Probe facing – Towards patient’s head • Evaluating – Spleno-renal interface – Possibility of fluid in Splenorenal recess and presplenic /subphrenic space( most common space for fluid collection in LUQ)
  21. 21. FAST: LUQ Exam
  22. 22. Extended FAST (E-FAST) RUQ, LUQ views: • Check above diaphragm for hemothorax – CXR < US in detection of hemothorax – 50-175cc vs. 20cc or less • US does not replace CXR Suprapubic view: – Check uterus for pregnancy
  23. 23. FAST Demo
  24. 24. FAST Focused Abdominal Sonography In Trauma Reliability • accuracy 86 - 97 % • sensitivity 88 - 91.7 % • specificity 94.7 - 99 % Can detect 70 ml fluid (by linear probe can detect as little as 10 ml or less)
  25. 25. How To Interpret FAST –Positive: • Fluid in pericardium or any 1 of 4 abdominal windows –Negative: • No fluid in any windows –Indeterminate: • If any one of the 4 windows is inadequately visualized
  26. 26. Scoring System of Fluid • In lower volumes, fluid accumulates in the pelvis or near the site of injury. • It is not until there are larger intraperitoneal fluid volumes (>500 mL) that fluid is detectable in the perihepatic and perisplenic spaces. • Recent studies show that FAST scan can detect fluid ranges from approximately 250 mL to 620 ml. Abrams BJ, Sukumvanich P, Seibel R, Moscati R, Joelle D. Ultrasound for the detection of intraperitoneal fluid: Am J Emerg Med 1999;17(2):117–20.
  27. 27. Scoring System of Fluid • One point is assigned to each anatomic site in which free fluid is detected during the FAST scan, with a score ranging from 0 to 8. • Fluid of more than 2 mm in depth in the hepatorenal or the splenorenal space was given 2 points instead of 1. • Floating loops of bowel were given 1 point. • 96% of patients with scores 3 required exploratory laparotomy; however, 38% of patients with scores <3 still required surgery. • 84% sensitive and 71% specific for quantifying hemoperitoneum greater or less than 1 L. Huang and associates 1994
  28. 28. Modified Scoring System • Revaluated scoring system measures the depth of fluid in the deepest pocket, and 1 point is added for fluid in each of the other areas (four areas maximum.) • 85% of patients with a score[3 required a therapeutic laparotomy, whereas 15% of patients with a score of 2 required surgery. McKenney et al
  29. 29. Does FAST Make a Difference In Trauma Management? • During primary or secondary survey FAST Positive NegativeIndeterminate unstable stable OR CT unstable stable OR DPL CT DPL Serial exam Repeat US/ CT Adapted from: Rozycki GS, et al. J Trauma, 1996
  30. 30. Pearls • Lack of FF ≠ no injury – Not enough to see (?too early) – You missed it – Hard-to-see places • FF may not be blood – Urine, lavage fluid, ascites, amniotic fluid, bowel contents, ruptured cyst
  31. 31. Advantages of FAST  Easy & Early to Diagnose in Resuscitation/Emergency room  Rapid(1 – 2.5 min)  Repeatable  Non-invasive  Low cost.
  32. 32.  Difficult to distinguish  Type of fluid  Site of bleeding ,  Solid organ injury  Cannot evaluate retroperitoneum  Difficult in the obese patient , subcutaneous emphysema  Examiner Dependent.  Bowel gas interposition  False –Negative : retroperitoneal & Hollow viscus injury Disadvantages of FAST
  33. 33. Pitfalls and limits • -Pre existing fluid collection ( Ascites , dialysis ) • -Pelvic fluid collection (female ) . • -Fluid filled bowel loops . • -Contained injury (hollow viscus, bowel wall contusion, pancreatic trauma and renal pedicle injury) • -Echogenic clot.
  34. 34. Pearls • The scan should be repeated during the secondary survey and also if the patient demonstrates clinical deterioration, since free fluid may have accumulated in the intervening time . • The quality of images obtained may also be a limiting factor with patient obesity , gas in the bowel leading to degradation in image quality , subcutaneous emphysema , non-mobile patient and penetrating injury.
  35. 35. Does FAST replace CT? • Unstable patient, (+) FAST  OR • Stable patient, low force injury, (-) FAST  consider observing patient. CT is far more sensitive than FAST for detecting and characterizing abdominal injury in trauma. The gold standard for characterizing intraparenchymal injury. “Death begins with a CT.” Never send an unstable patient to CT. FAST, however, can be performed during resuscitation. FAST Positive NegativeIndeterminate unstable stable OR CT unstable stable OR DPL CT DPL Serial exam Repeat US/ CT
  36. 36. FREE FLUID
  37. 37. Pericardial Fluid
  38. 38. Pericardial Effusion
  39. 39. Types of pericardial effusions, subxiphoid cardiac view. Left image: typical effusion, middle image: clotted effusion , right image : with cardiac tamponade .
  40. 40. Fluid in Morrison Pouch
  41. 41. Fluid in Morrison Pouch
  42. 42. Fluid in Morrison Pouch L K FF
  43. 43. Fluid in Morrison Pouch
  44. 44. Fluid In Pelvis
  45. 45. Fluid In Pelvis
  46. 46. Fluid In Pelvis
  47. 47. Fluid in Splenorenal Pouch
  48. 48. Fluid in Splenorenal Pouch
  49. 49. Fluid in Splenorenal Pouch
  50. 50. Hemothorax KD S PF F D
  51. 51. Pleural Fluid
  52. 52. Pleural Effusion Right pleural effusion, transverse subxiphoid view
  53. 53. ? Is Pneumoperitoneum Can Be Detected By US? YES
  54. 54. Pneumoperitoneum
  55. 55. Hollow Organs Stomach Gall bladder Intestines Ureters, Blad der Solid Organs Liver Spleen Kidney Pancreas Vascular Injury Aorta Vena Cava Major Branches Abdominal Organ Injury
  56. 56. Blunt Injury Abdominal Trauma • Spleen 25% • Liver 15% • Hollow viscus 15% – Ileum – Sigmoid • Kidney 12% • Retroperitoneal 13% • Mesentery 5% • Compression / deceleration • Crushing • Shearing • Avulsion
  57. 57. Solid-Organ Injuries (sonographic patterns) I. Contusion : patchy ill defined non-linear echogenic area . II. Subcapsular hematoma : under capsule. III. Intra-parenchymal hematoma : well defined rounded hyperechoic area . IV. Laceration : linear well defined hper / hypoechoic area. V. Multiple lacerations/vascular injury (organic fracture, disorganization )
  58. 58. Liver laceration and hematoma
  59. 59. Subcapsular Liver hematoma
  60. 60. Liver laceration and hematoma
  61. 61. Splenic laceration
  62. 62. Spleen hematoma Subcapsular spleen hematoma
  63. 63. Splenic laceration
  64. 64. Preinephric and renal hematoma Renal laceration
  65. 65. Subcapsular renal hematoma
  66. 66. References • Vicki E Nobil , Manual of emergency and critical care ultrasound , Cabridge university 2007 • Rosen, C. Ultrasound in Emergency Medicine. Emergency Medicine Clinics of North America. August 2004. Volume 22. Number 3. • O. John Ma and James R. Mateer. Emergency Ultrasound. McGraw-Hill. Medical Publishing Division. 2003. • Simon, B. Ultrasound in Emergency and Ambulatory Medicine. Mosby. 1997 • Temkin, BB. Ultrasound Scanning: Principles and Protocols. WB Saunders. 1993. • AIUM Practice Guideline for the Performance of the Focused Assessment With Sonography for Trauma (FAST) Examination • Wolfang Dahnert • Ppt by Dr. Derhim Alfaqeeh Radiologist Consultant HO The Radiology Dept University Of Science And Technology Hospital - Sana’a December 17, 2013
  67. 67. THANX
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