00:00:12 Today's topic is Pocus beyond Fast.

00:00:17 Pocus beyond fast.

00:00:23 Emergency fast exam, Fast means Pocus assessment, sonography for
trauma.

00:00:34 Indications are blunt and the penetrating cardiac trauma, and blunt and
penetrating abdominal trauma and blunt and penetrating chest trauma is emergency
fast exams indication.

00:00:56 Fast scan, bedside available, and non-invasive method, and repeatable, and
rapid and no contraindication.

00:01:15 Echogenicity is fluid, tissue, air and bone.

00:01:25 Fluid is Anechoic. Tissue is Hypoechoic or Isoechoic. Air is Hyperechoic and

Bone is reflective.

00:01:40 The Echogenicity is fluid is black anechoic, and pleural line in the rib.

00:02:11 Fluid is black anechoic and air and bone. Bone and air is white, air is white.

00:02:24 This is pleural line and this is rib, and this is a sternum bone.

00:02:29 White. Echogenic.

00:02:32 There are three types of probes. This is Linear probe. This is convex probe.
This is sector to probe.

00:02:51 The first linear probe is 5-12 megahertz low penetration, but high resolution.
This is linear probe image.

00:03:05 This is convex probe. 2-5 megahertz. The sector, 1-5 megahertz.
00:03:29 This convex and the sector probe, high penetration, low resolution.

00:03:35 Next slide is handling of probe. PART. P-A-R-T

00:03:50 P means pressure. A is alignment. R is rotation and tilting.

00:04:10 This means handling of probe, PART. P-A-R-T.

00:04:16 Emergency fast primary aim is, peritoneum, pericardium, pleural space, free
fluid correction, presence of free fluid, or absence of free fluid.

00:04:45 Pleural space, you can find presence or absence of pathologic air.

00:04:52 E-Fast extended aim is solid organ injury or a triage of multiple or mass
casualties.

00:05:05 This means there are 5 views and 12 zones.

00:05:12 Right side view, pleural space, subphrenic space, hepatorenal space, inferior
poor kidney.

00:05:24 The left side view, you can find pleural space, subphrenic space, splenorenal
space, inferior poor kidney

00:05:34 Pelvic view, recovascularor rectouterine space. Subcostal review, you can find
pericardial space inferior vena cava.

00:05:43 You can also find this. Hemoperitoneum, presence or absence of hemothorax,
hemopericardium and pneumothorax.

00:06:00 Technique. Start view. Blunt trauma. Right Upper Quadrant view. Most of the
sensitive view, right upper quadrant view.

00:06:13 Penetrating trauma, cardiac view. Rule out pericardial effusion.

00:06:20 Five views are right flank, left plank view, pelvic view, subcostal view and
anterior chest view.

00:06:44 First, right plank view. Perihepatic, Morrison's pouch, right upper quadrant
right side view.

00:06:54 Coronal plane in the mid-axillary line. 9th and 11th intercostal space. 4
potential space.

00:06:54 Right plank review 4 space means pleural cavity. Subphrenic space
Hepatorenal space, Inferior pole of the kidney.

00:07:22 Right plank view is Pleural space, Subphrenic space, Hepatorenal space,
Inferior pole of the kidney, using this probe.

00:07:44 Sonography find is Pleural space, Subphrenic space, Hepatorenal space,

Inferior pole of the kidney. You can find multiple collection of fluid.

00:08:00 Anechoic, the black fluid is black, black, black. Many space you can find fluid
collection.

00:08:13 One more time. P Pleural space, Subphrenic space, Hepatorenal space,
Inferior pole of the kidney. You can find many sites fluid collection in this patient.

00:08:34 Fluid. Fluid. Fluid.

00:08:54 Next is intercostal approach. This is liver. This is right kidney. This is
Morrison's pouch, and this is diaphragm.

00:09:14 You can find this Morrison's pouch, no evidence of fluid collection.

00:09:28 Next is mid-clavicular line. This is clavicle and mid-clavicular line. This is liver,
this is right kidney, and this is Morrison's pouch.
00:09:53 No evidence of fluid correction in Morrison's pouch.

00:10:00 Liver, kidney, Morrison's pouch, no evidence of fluid collection in Morrison's

pouch. Clavicle, mid-clavicular line. Echo findings like this.

00:10:20 This is play pleural space Anechoic or hypoechoic free fluid above the
diaphragm.

00:10:41 This is Subphrenic space. Anechoic or hypoechoic free fluid in the

subdiaphragmic space.

00:10:58 You can find on Anechoic or hypoechoic free fluid in the subdiaphragmic
space.

00:11:07 One more time. Fluid is black, fluid is Anechoic, fluid is black. Anechoic or
hypoechoic free fluid in the subdiaphragmic space.

00:11:40 Anechoic or hypoechoic free fluid above the diaphragm.

00:11:58 Hepatorenal space. This is liver, this is kidney, hepatorenal space Hypoechoic
mobile fluid in Morison’s pouch

00:12:24 Hypoechoic mobile fluid in Morison’s pouch. Fluid is black. Fluid is anechoic.

00:12:42 Inferior pole of the kidney. Inferior pole of the kidney. You can find Anechoic or
hypoechoic free fluid in inferior pole of the kidney

00:13:00 Anechoic or hypoechoic free fluid in inferior pole of the kidney.

00:13:12 Morrison's pouch and inferior pole of the kidney. You can find Anechoic or
hypoechoic free fluid.

00:13:45 Left flank view. Left flank view. Perisplenic or left upper quadrant, left side view
00:13:53 Coronal plane in the post-axillary line. 6th and 9th intercostal space. 4 potential
spaces and repositioning, right lateral decubitus position.

00:14:10 You can't miss perisplenic or left upper quadrant of the finding.

00:14:17 Left plank view, 4 spaces. Pleural cavity, Subphrenic space, Splenorenal
space, Inferior pole of the kidney.

00:14:38 Left plank view, Pleural space, Subphrenic space, Splenorenal space and
Inferior pole kidney

00:15:09 Fluid correction. Free fluid collection, you can find. Free fluid collection, you
can find

00:15:29 Free fluid collection, fluid is black. Free fluid is Anechoic or hypoechoic.
Echogenicity.

00:15:43 Plueral space, Anechoic or hypoechoic free fluid above the diaphragm.

00:15:51 Above the diagram, Anechoic or hypoechoic free fluid.

00:15:57 Subphrenic space, Subphrenic space. Anechoic or hypoechoic free fluid in the
subdiaphragmic space.

00:16:13 Anechoic or hypoechoic free fluid in the subdiaphragmic space. Anechoic or

hypoechoic free fluid in the subdiaphragmic space.

00:16:23 Anechoic or hypoechoic free fluid above the diaphragm, above the diaphragm.

00:16:38 Many times I emphasize, free fluid, black, free fluid on Anechoic or hypoechoic
echogenicity.

00:17:02 Splenorenal space. Splenorenal space, Anechoic or hypoechoic free fluid in

splenorenal recess. Splenorenal recess.
00:17:40 Free fluid. Anechoic or hypoechoic free fluid in inferior pole.

00:17:50 Anechoic or hypoechoic free fluid in inferior pole of the kidney.

00:18:16 The black shadow and Anechoic or hypoechoic echogenecity, means free fluid
collection.

00:18:27 Free fluid, Splenorenal recess. Splenorenal recess.

00:18:41 Splenorenal recess free fluid collection.

00:19:01 Anechoic or hypoechoic, free fluid in the inferior pole of the kidney. This is
Splenorenal space, Paracolic space.

00:19:14 Next is pelvic view. Pelvic view. Male, Suprapubic, retrovesical, and
rectovesical view. The female, Retrouterine, rectouterine, and pouch of Douglas view.

00:19:37 Most dependent peritoneal space in the supine position. Full filled bladder.
You need full filled bladder.

00:19:48 This pelvic view needs full filled bladder. Very important, full filled bladder.

00:19:57 You can easily found this view.

00:20:07 Transverse plane and sagittal plane

00:20:10 Pelvic view - transverse plane. Pelvic view - transverse plane.

00:20:19 This is bladder. Sagittal plane, sagittal plane. This is bladder.

00:20:28 Bladder consist of urine and urine fluid, so hypoechoic or anechoic

echogenicity means bladder, bladder.

00:20:45 Pelvic view - transverse plane, transverse plane. This is bladder, this is
bladder. hypoechoic or anechoic echogenicity. Bladder.
00:21:11 What is this? What is this? Right side, left side, both side is free fluid in
peritoneum.

00:21:21 This is bladder. This abnormal finding of free fluid in peritoneum.

00:21:29 Bladder, abnormal finding of free fluid in peritoneum. free fluid in peritoneum.

00:21:41 Pelvic view - sagittal plane. Bladder. This is female echo finding. This is
bladder. This is uterus free fluid, free fluid in peritoneum.

00:22:07 Bladder, uterus. This Morrison's pouch. No, no, no, no. Douglas pouch in this
area, free fluid in peritoneum, small amount of free fluid in peritoneum, in Douglas
pouch.

00:22:31 You can find this free fluid, bladder, uterus. Free fluid, small amount of free
fluid in peritoneum

00:22:40 Bladder, uterus, free fluid in peritoneum. hypoechoic or anechoic echogenicity

in peritoneum.

00:23:17 Next is Subcostal view, Subcostal view.

00:23:24 Subxiphoid, pericardial view. Probe direction towards the left shoulder, left
shoulder. Probe direction is toward left shoulder.

00:23:36 Bend knee to relax abdominal wall musculature. Anterior abdominal trauma,
parasternal or apical four-chamber views

00:23:50 Angulation in a caudal direction. Inferior vena cava and hepatic veins.

00:23:58 This is Subcostal view, subcostal view. Left atrium, left ventricle. Right atrium,
right ventricle. This is liver.
00:24:10 Subcostal view, left atrium, left ventricle, right atrium, right ventricle. This is
liver.

00:24:24 How about this? Can you see abnormal findings? Not bad, not bad. But how
about this? Anechoic or hypoechoic free fluid in pericardium, pericardium.

00:24:51 This, this area, this area, pericardial effusion. Pericardial effusion. Pericardial
effusion.

00:25:03 This is right atrium, right ventricle, left atrium, left ventricle. But this area you
can find hypoechoic or anechoic free fluid in pericardium.

00:25:41 This is pericardial effusion, echo finding. Pericardial effusion, echo finding.

00:25:50 Parasternal view. In a patient of hypovolemic, shock patient. Hypovolemic

shocked patient, you can find.

00:26:16 You know, hypovolemic state, you can find hyperdynamic motion, tachycardia.
And you can find echo chamber size decreased finding.

00:26:33 This echofinding. In a hypovolemic shock or hypovolemic state. Hyper

dynamic tachycardia, hyper dynamic contractibility.

00:26:50 Tachycardia and the chamber side is decreased, the chamber side is
decreased.

00:26:57 Left ventricular. The chamber size decrease in hypovolemia, in hypothermic

shock patient, hypodynamic contractibility, tachycardia and decreased size of chamber

00:27:25 Left ventricular chamber size is decreased. This is Parasternal view.

hypovolemic shock and hypovolemic state. Hypodynamic contractibility. Tachycardia.
Decreased size of chamber.

00:28:08 Inferior vena cava. You can measure the size and you can find collapse with
the inspiration.
00:28:20 Inferior vena cava, this is inferior vena cava. This is inferior vena cava. This is
right, atrium. Inferior vena cava. You know, inspiration collapse, decreased size of
inferior vena cava diameter.

00:28:51 During inspiration, collapse or decreased size of inferior vena cava diameter.
Right atrium, inferior vena cava, during inspiration, collapse with the inspiration,
decreased size of inferior vena cava diameter.

00:29:21 Normal IVC, Imperial Vena Cava Plethora. Normal Respiratory Variation and
imperial vena cava plethora.

00:29:48 Normal respiratory variation during inspiration, during inspiration, negative

pressure in the chest.

00:29:56 During inspiration, negative pressure in the chest, in the chest. Increased flow
to the thoracic cavity, IVC, imperial vena cava during inspiration, before inspiration, after
imperial vena cava diameter collapse, imperial vena cava collapse.

00:30:24 Before inspiration, after inspiration, imperial vena cava diameter collapse
decreased.

00:30:46 But I will see inferior vena cava plethora means before inspiration, inferior
vena cava diameter. After inspiration, Inferior vena cava diameter.

00:30:53 No change, no change.

00:30:56 High right atrial pressure and imperial vena cava. Inferior Vena cava dilated
and not showing inspiratory collapse.

00:31:09 No more finding is inferior vena cava diameter before and after. Collapse,
decreased, but IVC plethora means before and after inspiration, inferior vena cava
diameter not changed, not changed, not collapsing.
00:31:35 Inferior vena cava dilated and not showing inspiratory collapse. Not changed
or slightly dilated. Normal collapse.

00:31:53 I will see plethora slightly increased or the same and not showing inspiratory
collapse. This means inferior vena cava plethora.

00:32:11 Inferior vena cava. This is liver, this is heart, this is imperial vena cava.
Junction of right atrium and the inferior vena cava and followed two or two three.

00:32:24 Junction of the right atrium and the inferior vena cava and tfollowed 2 to 3 cm
caudally along the vessel.

00:32:43 Collapse, collapse. Inferior vena cava right atrium bridge. Estimated right
atrium fluid. Estimated right atrial pressure.

00:32:56 The diameter inferior vena cava less than two point zero centimeter. Changes
in inspiration over 50 percent estimated right atrium. Pressure five millimeter mercury.

00:33:14 Inferior vena cava, diameter less 2.0 centimeter, changes in inspiration. Less
than 50 percent estimated right atrial pressure. 10 millimeters of mercury.

00:33:32 The diameter over 2.0 centimeter changes in inspiration. Less than 50
percent. Right atrium pressure estimated 15 millimeters of mercury.

00:33:51 Hypovolemia. Hypovolemia state, hypovolemic shock or Hypovolemia state,

inferior vena cava, flat. Inferior vena cava, flat, flat, flat inferior vena cava. Collapsing
over 50 percent.

00:34:17 Hemopericardium, Hemopericardium. Likely cardiac tamponade, cardiac

tamponade.

00:34:30 Hemopericardium, plethora effusion. Plethora effusion.

00:34:45 The Imperial vena cava collapse hypovolemia state, collapsing over 50
percent, but Hemopericardium cardiac tamponade state, Imperial vena cava diameter
increased or no change.

00:35:10 No changes or slightly increased Imperial vena cava. Not collapsing, not
collapsing, inferior vena cava means, one example is Hemopericardium cardiac
tamponade, you can think not collapsing inferior vena cava, not collapse.

00:35:34 You can think presence or absence of Hemopericardium. Presence of

Hemopericardium.

00:35:52 Collapsing Imperial Vena Cava means hypovolemia, hypovolemic shock.

Imperial vena cava during inspiration, not collapsing, means you can think
Hemopericardium, cardiac tamponade.

00:36:17 Collapse, not collapse.

00:36:30 Right flank view, right flank view, inferior vena cava diameter. Subcostal view,
inferior vena cava diameter plethora effusion.

00:36:45 Right ventricular, left ventricular. Fluid effusion, fluid effusion. Hypoechoic or
anechoic fluid effusion

00:37:00 Hemopericardium finding. Hemopericardium cardiac tamponade finding.

00:37:09 Inferior vena cava, inferior vena cava. Right ventricular, left ventricular. More
pericardium, cardiac tamponade.

00:37:26 Inferior vena cava size, dilatation not collapsing, not collapsing during
inspiration, you can think one diagnosis is Hemopericardium, Hemopericardium.

00:37:54 Inferior vena cava plethora. This is inferior vena cava. Lack of the inspiratory
collapse, lack of the inspiratory collapse of the inferior vena cava. Lack of the inspiratory
collapse of the inferior vena cava.
00:38:20 Diameter is not collapsing, not collapsing, not collapsing. Inferior vena cava
press, inferior vena cava plethora.

00:38:31 Is seen in cardiogenic shock and obstructive shock. Example, Tension,

pneumothorax or cardiac tamponade.

00:38:46 This is very important finding of inferior vena cava plethora. If you can find the
inferior vena cava plethora, you can think, number one is cardiogenic shock, number
two obstructive shock

00:39:05 Example tension, pneumothorax or cardiac tamponade. This is inferior vena

cava. This is inferior vena cava.

00:39:17 Inspiration, inferior vena cava diameter is 2.68 centimeter. Expiration, inferior
vena cava diameter, 2.64 centimeter

00:39:36 During inspiration, during inspiration, the normal finding is inferior diameter is
decreased, collapsing. But this state during inspiration inferior vena cava diameter
slightly increased, the slightly increased, not collapsing.

00:39:59 This finding means cardiogenic shock or obstructive shock. In example.

Tension, pneumothorax or cardiac tamponade, cardiac tamponade.

00:40:16 This is imperial vena cava plethora finding very, very important finding of
shock patients. Very sensitive and specific finding of imperial vena cava plethora in
cardiogenic or obstructive shock patient.

00:40:43 Next is Anterior chest pleural view, Anterior chest pleural view.

00:40:59 The anterior visceral and parietal lung slide during respiration, absence of
identifiable lung sliding; pneumothorax.
00:41:13 Absence of identifiable, lung sliding, this means diagnosed pneumothorax.
Sagittal plane, midclavicular line.

00:41:27 Anterior chest pleural view. Absence of identifiable lung slide sign, you can
diagnose pneumothorax, pneumothorax.

00:41:42 Upper thoracic area. This is rib, and this is pleural. This is rib and pleural line.

00:42:02 This may seem like a bat, bat, so we can call Rib pleural line. This shape
seems like a bat, bat, so we can call this sign is bat sign.

00:42:22 Bat sign, upper thoracic area. How about this? Rib, rib? Rib, rib. Pleural line,
Pleural line. Rib, rib, rib, rib. Pleural line.

00:42:46 Very little. Very, very little movement of pleural line. This means
pneumothorax. Absence or very, very little motion of pleural line.

00:43:06 This means pneumothorax, pneumothorax. Rib, rib, pleural line, the motion of
pleural line, is absence or very little. Very, very little movement means pneumothorax,
pneumothorax.

00:43:34 Normal lung and pneumothorax lung. This is lung slide is intact, lung slide is
intact.

00:43:52 Normal lung, normal lung. Rib, rib, rib, rib pleural line. Lung slide is intact; lung
slide is intact. But how about this? Rib, rib, rib, rib pleural line, pleural line, pleural line.

00:44:28 Well, absence of movement, the pleural line, absence or very, very little
movement of pleural line means pneumothorax. Normal finding this is pneumothorax.

00:44:54 Before slide, before slide. How about this? Rib, rib pleural line. How about this
pleural line? Normal finding of lung slide, normal finding of lung sliding, this.
00:45:24 Echocardiogram. This echo means rib, rib pleural line, the movement is
normal. The movement is normal, normal lung. No evidence of no evidence of
pneumothorax.

00:45:43 But how about this? Rib, rib. There is no movement of pleural line, this is, this
means pneumothorax.

00:45:57 How about this? Rib, rib, pleural line. Lung slide is intact, intact. No evidence
of pneumothorax. This is evidence of pneumothorax, pneumothorax pleural line.

00:46:24 Absence or very little movement of pleural line means pneumothorax. No

evidence of lung sliding sign. Normal, lung pneumothorax, M mode, M mode.

00:46:45 Normal lung seashore and chest wall and sandy beaches. Seashore sign, but
in the pneumothorax, barcode sign.

00:46:56 No evidence of sandy beach, no evidence of sandy beach. This is a lung

pulse, lung pulse.

00:47:07 In the M mode. No evidence of lung pulse. Only like barcode. The shape is like
barcode, so we can call this barcode sign or stratosphere sign.

00:47:31 This area, this area. Pleural line, pleural line in the M mode. Sandy beach you
can find; you can check lung pulse. This is normal lung, seashore sign.

00:47:52 But in the pneumothorax. no evidence of sandy beach. No evidence of lung

pulse. This is bar code, bar code sign, stratosphere sign.

00:48:04 The lung point, the CT finding of these. The lung point, highly specific for the
diagnosis of pneumothorax. How about this? How about this? Absence of movements.
Lung slide inside.

00:48:53 No evidence or very little movement of lung slide is a sign. This means
pneumothorax, pneumothorax.
00:49:09 You can use all probes, linear probe, sector probe, curvilinear probe, all using
lung sliding sign.

00:49:32 Using linear probe, you can find linear line movement. Using Sector probe,
you can find pleural line. Using curvilinear probe, you can find pleural line movement.

00:49:56 Ultrasonography person's chest X-ray for diagnosis of pneumothorax.

Sensitivity. Sensitivity. Sensitivity sonograph is 26-98% Chest x-ray for diagnosis of
pneumothorax sensitivity 28-75%

00:50:39 So the sensitivity of diagnosis of pneumothorax, the sono finding is priority.

The specificity is the same.100%, 98-100% specificity, specificity is the same ultrasound
versus chest X-ray

00:51:03 But sensitivities higher sonography. Ultrasonography has higher sensitivity

versus Chest X Ray on diagnosis of pneumothorax.

00:51:21 Rib, rib. Pleural line. There is no movement or very little movement of Pleural
line. You can diagnosis, pneumothorax, pneumothorax, chest X-ray find. You can find
this line.

00:51:50 This line is pneumothorax, pneumothorax. Light line, pneumothorax.

00:51:58 Ultrasonography find is rib, rib pleural line. No movement, no movement, or

very, very little movement of Pleural line.

00:52:13 You can find this, diagnosis is pneumothorax, pneumothorax. But

pneumothorax has a small side, and the position is apical or basal area, pneumothorax.

00:52:40 You cannot find pneumothorax. Pneumothorax missed conditions one is small
size, and next is apical or basal area. Pneumothorax, pneumothorax missed.

00:52:59 Okay. I will continue next time.