Core Ultrasound Curriculum Pediatric Ultrasound Conference Limited ER Ultrasound: FAST Janis P. Tupesis M.D. University of Chicago Section of Emergency Medicine February 1, 2007 - PowerPoint PPT Presentation

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Core Ultrasound Curriculum Pediatric Ultrasound Conference Limited ER Ultrasound: FAST Janis P. Tupesis M.D. University of Chicago Section of Emergency Medicine February 1, 2007

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Allows us to make rapid decisions, identify life threatening diagnoses and ... Just superior to the iliac crest. Probe facing. Toward patient's head. FAST: RUQ exam ... – PowerPoint PPT presentation

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Title: Core Ultrasound Curriculum Pediatric Ultrasound Conference Limited ER Ultrasound: FAST Janis P. Tupesis M.D. University of Chicago Section of Emergency Medicine February 1, 2007


1
Core Ultrasound CurriculumPediatric Ultrasound
ConferenceLimited ER Ultrasound FAST Janis P.
Tupesis M.D.University of ChicagoSection of
Emergency MedicineFebruary 1, 2007
2
Introduction
  • Why are we doing this lecture?
  • Ultrasound becoming an integral part of the
    emergency physicians physical exam
  • Allows us to make rapid decisions, identify life
    threatening diagnoses and expedite operative
    management of emergent patients
  • Answering simple yes/no questions at the bedside
  • Examples AAA (Y/N), gallstones (Y/N),
    pericardial effusion (Y/N), pathologic fluid in
    the abdomen (Y/N)
  • Need to be competent in doing these exams when
    finish residency
  • Today review of the Focused Abdominal Sonogram
    in Trauma (FAST) exam

3
Goals of this lecture
  • Where do I put the probe?
  • How do I hold the probe?
  • What am I looking at? - Normal anatomy
  • What am I looking at? - Abnormal anatomy
  • What can I tell from the abnormal anatomy?
  • Pathologic fluid in the abdomen
  • Pathologic fluid in the pericardium
  • Does it make a difference?
  • Review of the literature

4
Trauma Ultrasonography
  • Intro
  • Applications
  • Anatomy
  • Comparison
  • Exam Technical Considerations
  • RUQ
  • LUQ
  • Subxiphoid/Subcostal
  • Pelvis
  • Ultrasonagraphic evaluation of pathologic states

5
FAST Intro and Applications
  • FAST exam Focused Abdominal Sonography in Trauma
  • Peritoneal
  • Pericardial
  • Pleural
  • Indications
  • Acute blunt or penetrating torso trauma
  • Trauma in pregnancy
  • Pediatric trauma
  • Subacute torso trauma
  • Goal to identify fluid in a location where it
    does not normally belong

6
FAST Comparison
Comparison of Ultrasound, Diagnostic Peritoneal
Lavage and Computed Tomography
Barry C. Simon. Ultrasound in Emergency
Medicine. Table 7-2. Pages 158-159.
7
FAST Anatomy
  • 7 dependent sites
  • Right Supramesocolic (Morisons pouch)
  • Left Supramesocolic (Splenorenal rescess)
  • Right Pericolic gutter
  • Right Inframesocolic
  • Left Inframesocolic
  • Left Pericolic gutter
  • Pelvic cul-de-sac

8
FAST Technical Considerations
  • Probe placement?
  • RUQ Morrisons Pouch
  • LUQ Splenorenal
  • Pelvis Pelvic cul-de-sac
  • Transverse
  • Longitudinal
  • Subxiphoid/Subcostal Pericardium
  • Remember Probe almost ALWAYS facing either
    patients right or patients head

9
FAST RUQ exam
  • Probe placed
  • Perpendicular
  • Mid-coronal plane
  • Just superior to the iliac crest
  • Probe facing
  • Toward patients head

10
FAST RUQ exam
  • Evaluating
  • Hepatorenal interface
  • Possibility of fluid in Morisons pouch - Right
    Supramesocolic space
  • Technical Problems
  • Body habitus
  • Bowel gas
  • Rib artifact

11
FAST RUQ exam
  • Where exactly is Morrisons Pouch?

12
FAST RUQ exam
  • Where exactly is Morrisons Pouch?

13
FAST RUQ exam
  • Normal Anatomy
  • In the supine patient, the hepatorenal space is
    the most dependent area
  • Also is the least obstructed for fluid flow
  • Morisons Pouch
  • Potential space between the liver and the right
    kidney in the hepatorenal recess

Morisons Pouch
14
FAST RUQ exam
  • Abnormal Anatomy
  • Pathologic Fluid - mild
  • L liver
  • D diaphragm
  • K kidney
  • RS rib shadow
  • FF1 free fluid
  • FF2 free fluid

15
FAST RUQ exam
  • Abnormal Anatomy
  • Pathologic Fluid - moderate
  • L liver
  • K Kidney
  • FF free fluid
  • RS rib shadow
  • D diaphragm

FF
L
K
RS
D
16
FAST RUQ exam
  • Abnormal Anatomy
  • Pathologic Fluid - massive
  • L liver
  • K kidney
  • FF free fluid

L
FF
K
17
FAST LUQ exam
  • Probe placed
  • Perpendicular
  • Mid - coronal plane
  • Just superior to the iliac crest
  • Probe facing
  • Towards patients head

18
FAST LUQ exam
  • Evaluating
  • Spleno-renal interface
  • Possibility of fluid in splenorenal recess
  • Technical Problems
  • Body habitus
  • Bowel gas, splenic flexure gas
  • Rib artifact

19
FAST LUQ exam
  • Where exactly is Splenorenal Recess?

20
FAST LUQ exam
  • Where is splenorenal recess?

21
FAST LUQ exam
  • Normal Anatomy
  • More difficult to evaluate than RUQ
  • Left kidney more superior than right
  • Do not have liver as acoustic window
  • Splenorenal Recess
  • Potential space between kidney and spleen

Splenorenal Recess
22
FAST LUQ exam
  • Pathologic Fluid
  • K kidney
  • S spleen
  • RS rib shadow
  • FF free fluid

23
FAST Subxiphoid exam
  • Probe placed
  • Patients epigastrium
  • Just below xiphoid process of the sternum
  • entire probe aimed at patients left shoulder
  • Probe facing
  • notch of probe placed toward patients right
    side

24
FAST Subxiphoid exam
  • Evaluating
  • Fluid in the pericardium
  • Wall dysfunction
  • R heart strain
  • Septal bowing
  • Technical Problems
  • Body habitus
  • Inability to get probe under xiphoid

25
FAST Subxiphoid exam
  • Normal Anatomy
  • Liver at very top of screen
  • Right ventricle on top of screen
  • Right atrium and left ventricle line up below
    right ventricle
  • Left ventricle on bottom of screen

26
FAST Subxiphoid exam
  • Review
  • Normal Subcostal view
  • RV right ventricle
  • RA right atrium
  • LV left ventricle
  • LA left atrium
  • IVS interventricular septum

IVS
27
FAST Subxiphoid exam
  • Subcostal view
  • Large pericardial effusion
  • Where to you measure amount of blood or fluid?
  • Answer anteriorly between the heart and liver

Measure here!
28
FAST Subxiphoid exam
  • Subcostal view
  • Pericardial effusion
  • Left ventricular collapse
  • Can see left ventricle bowing in towards
    intraventricular septum

Ventricular bowing
29
FAST Subxiphoid exam
  • Subcostal or Subxiphoid view
  • Hemodynamically significant pericardial effusion
  • Complete right ventricular collapse

Ventricular Collapse
30
FAST Pelvis LA exam
  • Pelvis Long Axis
  • Probe placed
  • longitudinally
  • 2 cm superior to the symphysis pubis
  • Midline of the abdomen
  • aimed caudally into the pelvis
  • Probe facing
  • Toward patients head

31
FAST Pelvis LA exam
  • Evaluating
  • Free fluid in the anterior pelvis
  • Free fluid in the pelvic cul-de-sac (Pouch of
    Douglas)
  • Technical Problems
  • Body habitus
  • Empty bladder (no landmarks)
  • Bladder trauma (no landmarks)

32
FAST Pelvis LA exam
  • Pelvis Long Axis
  • Normal Anatomy
  • Evaluating
  • Bladder
  • Uterus in female usually superior to bladder
  • Prostate in male usually posterior to bladder

33
FAST TV Pelvis exam
  • Pelvis Transverse
  • Probe placed
  • 2 cm superior to the symphysis pubis
  • Midline of the abdomen
  • Probe facing
  • Toward patients right
  • Probe rotated 90 degrees counterclockwise from
    longitudinal

34
FAST TV Pelvis exam
  • Evaluating
  • Free fluid in the anterior pelvis
  • Free fluid in the pelvic cul-de-sac (Pouch of
    Douglas)
  • Technical Problems
  • Body habitus
  • Empty bladder (no landmarks)
  • Bladder trauma (no landmarks)

35
FAST TV Pelvis exam
  • Pelvis Transverse Axis
  • Normal Anatomy
  • Evaluating
  • Bladder
  • Well cirucumscribed
  • Contains fluid that appears anechoic

36
FAST Pelvis exam - Pathology
  • Transverse scans with free fluid in pelvis
  • Female (top) uterus posterior to bladder
  • Male (bottom)
  • B bladder
  • UT uterus
  • FF free fluid
  • S spine

37
FAST Literature
  • 1980s
  • Wenig JV et al.
  • Compared bedside ultrasonography by trauma
    surgeons to DPL and CT
  • Sensitivity from 84 - 100
  • Specificity from 88 - 100
  • Largely unnoticed because published in German and
    had small sample size
  • 1990s
  • Tiling et al.
  • Similar sensitivity and specificity
  • First to incorporate pleural and pericardial
    spaces
  • First to incorporate FAST into initial evaluation
  • Ma et al.
  • First study using ER physicians as
    ultrasonographers
  • Same sensitivity, specificity and accuracy

Point ER physicians are able to detect occult
blood with ultrasound at same rates as surgeons,
CT, DPL.
38
Questions?
39
References
  • Heller, M. Ultrasound in Emergency Medicine. WB
    Saunders. 1995.
  • 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.
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