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The FAST Scan

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views with subcutaneous air, gastric distension, obesity. Operator dependent. Limited eval of: ... Gastric distension from BVM ventilation. Obesity. Peritonitis ... – PowerPoint PPT presentation

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Title: The FAST Scan


1
The FAST Scan
  • Mila Felder MD
  • June 22nd, 2005

Contributing Authors / Design PJ Konicki DO,
RDMS Louise Rang-Nicholson MD,RDMS Anna
Kiernicki-Sklar MD
2
Goals
  • To discuss the history, principles, and use of
    US in trauma
  • To evaluate advantages and limits of FAST
  • To demonstrate FAST technique
  • To view normal and abnormal scans

3
Objectives
  • To learn everything you need to know about trauma
    scanning?..
  • Sorry, not so FAST ?)

4
How do we get started?
5
History
  • 1980s- US for trauma in Japan, Germany
  • US training has been required in Germany since
    the1970s
  • 1990s- US for trauma in North America
  • The term FAST introduced in 1996
  • Credentialing criteria and scoring systems are
    still evolving
  • 50 scans to confidence Feb 2004 J.Ma, Kansas

6
What does it Mean?
  • FAST
  • Focused
  • Abdominal
  • Sonography in
  • Trauma

7
So, how has it been used?
  • Quick look at stable or unstable trauma patient
  • Single or multiple casualty in military
    deployment (EM Journal Apr.2005)
  • International Space Station (J of Trauma-Inj
    Infection and Crit. Care Jan 2005)
  • Extended Assessment for PTX

8
Potential Uses
  • Acute and chronic musculoskeletal injury
  • Triage of patients in disasters
  • Remote use by flight physicians and nurses
  • Simultaneous transmission to trauma center/
    telemedicine
  • ATLS, prehospital use

9
Premise
  • Intraperitoneal organ injury ? hemoperitoneum
  • Predictable locations (GRAVITY)
  • Blood readily detectable on US as
  • free fluid (FF)
  • ? US a natural screening test for injury

10
Where can I see FF?
  • Accumulation in area of injury
  • Overflows into dependent areas (pouch of Douglas,
    Morrisons pouch) via rivers (paracolic gutters)

11
Intraabdominal Fluid Localization
  • Morisons pouch
  • Lienorenal
  • Rt. Paracolic
  • Rt. Inframesocolic
  • Lt. Inframesocolic
  • Lt. Paracolic
  • Pelvic cul-de-sac (pouch of Douglas)

Adapted from Simon B, Snoey E, Ultrasound in
Emergency and Ambulatory Medicine 1997
12
so
Perisplenic space
Morrisons Pouch
Pouch of Douglas
13
How much can I see?
  • Minimum detectable 200-650 cc

14
How much can I see?
  • Depends on
  • Site, speed of bleeding
  • Operator skill
  • Position of patient
  • CT 100-250 cc FF
  • DPL 20 cc blood (_at_100,000 RBC/ml)

15
How good is US?
  • 1995, n245 prospective trauma pts
  • ?FAST by EM docs
  • Various Gold Std.
  • Sens. 90 sp 99 (accuracy 99)
  • Blunt Penetrating

Ma and Mateer. J Trauma, 1995
16
US advantages (vs. CT or DPL)
  • Fast
  • Non invasive
  • Pregnancy, coagulopathy
  • Bedside test
  • CT Certain Termination
  • Repeatable
  • Eval quantity of fluid over time
  • Easy to learn

17
Limitations of US
  • Site of injury not identified
  • ? views with subcutaneous air, gastric
    distension, obesity
  • Operator dependent
  • Limited eval of
  • Bowel, retroperitoneum, diaphragm

18
Caveats
  • 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

19
What about DPL?
20
What about CT?
21
How does US fit in?
  • During primary or secondary survey

FAST
Positive
Negative
Indeterminate
unstable
stable
unstable
stable
OR
CT
OR
CT
Serial exam Repeat US CT
DPL
DPL
Adapted from Rozycki GS, et al. J Trauma, 1996
22
How do I do it?
1
Supine patient
2
4
3
Remember to do ALL VIEWS!
23
Start with proper stance and grip (kind of like
golf)
  • Ultrasonographer is at the pt's right, level with
    the umbilicus.
  • The machine is at the pt's right shoulder.
  • Hold the transducer much like you would a paint
    brush. The 4th 5th digits and the medial aspect
    of the hand provide the base.

24
Technique
  • Consistently using the same technique insures
    reproducible imagery. (An important consideration
    when confronted with an unlikely skeptical
    surgery attending.)
  • Every transducer has a marker signifying "north".
    For standard imagery "north" must always point
    its appropriate direction.

25
(No Transcript)
26
FAST Demo
Video
27
1) Subxiphoid View
28
Normal Subxiphoid View
29
Pericardial Effusion
30
(No Transcript)
31
Pericardial Effusion
Video
32
Tips Tricks
  • Look up and under sternum
  • Aim for left shoulder
  • Probe almost parallel to abdominal wall
  • Epicardial fat vs. effusion
  • Thin layer anterior to RV
  • Not present posterior to LV
  • Clinical picture

33
Clinical Picture, remember!
34
Tips Tricks
  • Subxiphoid view may be difficult in
  • Gastric distension from BVM ventilation
  • Obesity
  • Peritonitis
  • In these cases, try Parasternal or Apical view
  • If in doubt, get formal echo

35
(No Transcript)
36
More on this view
  • Several studies have suggested that use of ED US
    in pericardial eval of penetrating torso trauma
    will
  • 1) Decrease time to diagnosis of pericardial
    effusion
  • 2) Decrease time to OR (42.4 vs. 15.5 min)
  • 3) Improve survival (57.1 vs. 100)

Plummer et al. Ann Emerg Med, 1992
37
FAST
1
2
4
3
38
2) RUQ view
39
Normal RUQ
Liver
Kidney
40
RUQ Fluid
Many Faces of Morrisons Pouch!
Video
41
Many Faces of Morrisons Pouch!
42
Many Faces of Morrisons Pouch!
43
Many Faces of Morrisons Pouch!
44
Many Faces of Morrisons Pouch!
45
Many Faces of Morrisons Pouch!
46
Tips Tricks
  • Probe parallel to and between ribs
  • Fan thru whole hepatorenal space
  • May try transabdominal approach if unsuccessful

47
FAST
1
2
4
3
48
3) Suprapubic View
49
Bladder
Bladder
Uterus
Look here for FF
Transverse View
50
Bladder
FF
TRANSVERSE
51
Transverse
52
Pelvis Fluid
Video
53
Superior
Inferior
Longitudinal
54
Tips Tricks
  • Best with some urine in bladder
  • Acoustic window
  • Aim downward, into pelvis
  • Fan thru whole area

55
FAST
1
2
4
3
56
4) LUQ view
57
Normal LUQ
Spleen
Kidney
58
(No Transcript)
59
FF
60
FF
Spleen
Kidney
Diaphragm
61
Tips Tricks
  • Oblique probe angle
  • Parallel to and between ribs
  • Higher and more posterior than you think
  • Probe on the bed and in the arm pit
  • Fan thru whole space
  • ?Check above spleen (vs. RUQ)
  • Most common place for FF in LUQ is between
    diaphragm and spleen

62
Finesse FAST
  • RUQ, LUQ views
  • Check above diaphragm for hemothorax
  • CXR US in detection of hemothorax
  • Ma and Mateer. Ann Emerg Med, 1997
  • 50-175cc vs. 20cc
  • US does not replace CXR
  • Suprapubic view
  • Check uterus for pregnancy

63
Hemothorax
D
SP
FF
KD
64
Pleural Fluid
Video
65
Putting it ALL together FAST
Video
66
How can I practice?
  • You can try your FF-identifying skills on
  • Patients with ascites
  • Patients on CAPD
  • Before and during DPL
  • Attend hands on training

67
Pediatric FAST
  • Not as sensitive
  • 30-80 in various studies
  • 31-37 of kids with solid organ injuries do not
    have hemoperitoneum
  • Specificity still 95-100
  • If its positive, its positive
  • Rely on CT more in kids?

68
Summary
  • FAST easy, non invasive screening test
  • No FF? no injury!
  • 4 views- dependent areas
  • Fluidblack

69
F.A.S.T Training
  • New for 2004/2005
  • Who can attend Members ED, Surgery
  • When Dates TBA, Time 8 am
  • Planning every other month
  • ACMC Trauma surgery department
  • Why Promote US in trauma, hopefully improving
    care in our ED!

70
Questions?
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