BJA Education, 18(2): 57e62 (2018)
doi: 10.1016/j.bjae.2017.10.003
Matrix codes: 1A03,
2A02, 3A10
Extended focused assessment with sonography in
trauma
N. Desai1 and T. Harris2,*
1
Department of Anaesthetics, St George’s Hospital, London, UK and 2Emergency Medicine, Barts Health
NHS Trust and the Queen Mary University of London, Royal London Hospital, Whitechapel, London, UK
*Corresponding author. E-mail: Tim.Harris@bartshealth.nhs.uk.
Key points
 Clinical examination is inaccurate in the setting
of blunt abdominal trauma and physiological
evaluation has limited sensitivity to detect
hypovolaemia.
 Early imaging is crucial to the identification of
traumatic injuries.
 Extended focused assessment with sonography
for trauma (eFAST) is a non-invasive point-of-
care test, which can guide clinical decision
making.
 Clinicians should be mindful of the strengths and
limitations of eFAST, and interpret results in the
context of the mechanism of injury and the
evolving clinical situation.
 Guidance from The National Institute for Health
and Care Excellence should be followed, and im-
mediate computed tomography or operative
intervention considered where appropriate.
Neel Desai, FHEA FRCA MRCP MRCS PGCert Medical Education, is
a specialty registrar at St George’s Hospital.
Tim Harris, FACEM FRCEM FFICM PGCert Ultrasound, is Professor
in Emergency Medicine at Barts Health NHS Trust and the Queen
Mary University of London. He is educational lead for ultrasound at
the International Federation for Emergency Medicine and was pre-
viously research lead for the subcommittee on ultrasound at the
Royal College of Emergency Medicine.
Accepted: October 31, 2017
© 2017 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com
Advance Access Publication Date: 28 November 2017
Trauma is an epidemic of our time with disproportionate
morbidity and mortality affecting young adults. Of all deaths
from trauma, 30e40% is caused by haemorrhage.1 However,
the evaluation of thoracic and abdominal trauma can be a
challenge. Clinical assessment, including physical examina-
tion, is inaccurate in the setting of blunt abdominal trauma2
and physiological evaluation has limited sensitivity to detect
hypovolaemia.3 In view of this, early radiological imaging is
crucial to the identification of traumatic injuries. For every 3
min of delay in patients who require a laparotomy, mortality
increases by approximately 1%.4 The focused assessment
with sonography in trauma (FAST) examination is a non-
invasive point-of-care test whose role is to guide clinical de-
cision making and direct angiographic or surgical in-
terventions. It can be used by clinicians to diagnose
haemopericardium or haemoperitoneum secondary to clini-
cally significant injuries on ultrasound (US). Extended FAST
(eFAST) is an evolution of the traditional FAST examination
and incorporates thoracic window assessment to identify
haemothorax and pneumothorax.
Feasibility
The FAST examination can be performed in 3e4 min at the
bedside.5 It avoids the risks associated with transport, does not
involve the use of ionising radiation and may be repeated.
Operator training and experience affect performance and the
number of supervised examinations required to acquire
competence is debated. In learning how to perform FAST, most
errors occur in the first 10 examinations and thereafter accuracy
improves.6 Further reading and recommendations concerning
57
Extended focused sonography in trauma
competencies, methods of training, and maintenance of skills
can be found at https://www.rcemlearning.co.uk/references/
ultrasound-in-emergency-medicine-level-1-instruction/.7
Utility
In adult trauma patients, a meta-analysis demonstrated FAST
to have a pooled sensitivity of 78.9% and a specificity of 99.2%.8
Sensitivity was increased with greater volumes of blood loss.
Significant heterogeneity in sensitivity was observed, whereas
specificity remained reasonably constant across trials. Such
variation in sensitivity can be explained by differences in the
comparator reference standard used, such as computed to-
mography (CT), laparotomy or patient outcome. It confirmed
that FAST is accurate for injury when positive and more
readily identifies blood loss in haemorrhagic shock, but
cannot be used to rule out intra-abdominal injury. In the
setting of blunt torso trauma associated with hypotension and
penetrating praecordial wounds, FAST is most discriminatory
with a sensitivity of 100%.9
It has been shown that the use of US in adult trauma may
decrease CT utilisation10 and the time to operative interven-
tion; reduce the incidence of a composite measure comprising
of haemorrhagic or septic shock, multisystem organ failure or
death; shorten hospital stay; and lower costs.11 The National
Institute for Health and Care Excellence (NICE) advocates
FAST in patients who are haemodynamically unstable and not
responding to volume resuscitation.12 FAST should not be
used as a screening modality to determine the need for CT in
patients with major trauma. Immediate CT should be
considered in patients with suspected haemorrhage if their
haemodynamic status is normal or they are responding to
resuscitation. However, it should be noted that the evidence
supporting clinical pathways based on FAST remains poor in
suspected abdominal or multiple blunt trauma.10 In major
trauma, where diagnosis and intervention are time critical,
FAST can be a relative minor adjunct compared to the
emphasis on the use of CT and operative intervention.
In the evaluation of traumatic haemothorax, US appears
to have an increased sensitivity and a similar specificity
compared to chest radiography (CXR).13 Up to 76% of pneu-
mothoraces detected on CT are not visible and therefore
occult on supine CXR,14 but US could overcome these short-
comings as it is more sensitive than CXR in detecting pneu-
mothorax.15 Occult pneumothoraces do not however tend to
progress or result in respiratory distress and a conservative
approach is being increasingly supported.16 NICE recom-
mends that patients with chest trauma and severe respira-
tory compromise undergo immediate CXR or eFAST.12 If
severe respiratory compromise is not present and the hae-
modynamic status is normal, immediate CT should be
considered.
Physics of US
In US, once the mechanical waves are emitted from the
transducer, they pass through various body tissues and are
reflected back as echoes to the transducer, creating an image
on the screen. Acoustic impedance (Z) is a measure of the
resistance of particles in a medium to mechanical vibrations
and is proportional to the density of the tissue and speed of
the sound wave. The effect of Z becomes noticeable at the
interfaces between tissue types of different acoustic imped-
ances. As the difference in Z increases, more US is reflected
58 BJA Education - Volume 18, Number 2, 2018
back and less is transmitted. Intraperitoneal fluid, such as
fresh blood, has a constant Z resulting in no echoes (anechoic)
and so appears as a black stripe. Blood however which has
begun to clot, can become more echogenic and heteroge-
neous. In cases of a delayed presentation, this should be
considered if no obvious free fluid (FF) is evident. Soft tissues
have similar values of Z and so minimal reflection occurs.
Interfaces between air and soft tissue reflect most of the US
wave and so are poorly penetrated by US, producing artefact
and no structural imaging.
How to perform a FAST
Traditionally, the FAST examination consists of four basic
sonographic views: the right upper quadrant (RUQ), left upper
quadrant (LUQ), pelvic, and cardiac. In order to learn how to
acquire the appropriate views for lung US for the thoracic
component of eFAST, readers are referred to the recent article
by Miller.17
Probe selection
An US probe with a lower frequency, such as that of the
curvilinear (3e5 MHz) or phased array (3e4.5 MHz) type,
should be used to facilitate the evaluation of deeper struc-
tures. Compared to the phased array probe, the curvilinear
transducer provides better resolution in the abdomen but is
not ideal for imaging the heart. In contrast, the phased-array
probe has a smaller footprint and can be used to scan be-
tween the ribs, such as for the cardiac parasternal long axis
(PLAX) view. Linear transducers have a higher frequency
(8e12 MHz) and should be avoided although they result in
good resolution of superficial structures, depth penetration is
limited. Conventionally, in standard emergency and general
US imaging, the marker on the probe is directed to the pa-
tient’s head for longitudinal views or the patient’s right for
transverse views and it should correspond to the left side of
the image on the monitor. Conversely, in echocardiographic
imaging, the convention is reversed and an opposite marker
direction and screen orientation are used for most windows.
RUQ view
In the RUQ view, the perihepatic area and the potential space
between the liver and kidney, otherwise known as Morison’s
pouch, are assessed using the liver as the sonographic win-
dow. It is the most sensitive view for free intraperitoneal fluid,
as dependent fluid tends to distribute here in the supine pa-
tient, and thus should be the first view obtained in blunt
trauma. Trendelenburg positioning can further enhance the
detection of FF. The probe should be placed in a longitudinal
orientation anterior to the right mid-axillary line between the
seventh and eighth intercostal spaces and used to fan through
the entire interface of the liver and right kidney (Fig. 1). Small
fluid collections start near the caudal tip of the liver, which is
the beginning of the right paracolic gutter, and should not be
missed.
LUQ view
In the LUQ view, the perisplenic and the potential space be-
tween the spleen and kidney are assessed using the spleen as
the sonographic window. The probe should be placed in a

Fig 1 US image of the RUQ view demonstrating anechoic FF in the pouch of
Morison between the liver (L) and kidney (K) and around the liver.
longitudinal orientation near the left posterior axillary line
between the seventh and eighth intercostal spaces. Moving
the probe to a more posterior and superior approach means
that gas in the stomach and colon is not encountered, which
can otherwise obscure the view. Interference from the rib
shadows can be avoided by turning the probe into a more
oblique orientation parallel to the ribs. Compared to the RUQ,
fluid flows differently in the LUQ, as the phrenicocolic liga-
ment limits the passage of fluid down the left paracolic gutter.
Small fluid collections may be found superior to the spleen
and the interfaces between the diaphragm, spleen and kidney
should be seen (Fig. 2).
Pelvic view
In the pelvic view, an assessment is made for FF using the
bladder as the sonographic window. Reverse Trendelenburg
positioning and the presence of a fluid-filled bladder can
further enhance the detection of fluid. If the bladder is
emptied consequent to the insertion of an urinary catheter,
the detection of fluid can be compromised. The probe should
be placed just above the pubic symphysis and angled inferi-
orly towards the feet to fan through the bladder in both lon-
gitudinal and transverse orientations (Fig. 3). In males, FF is
Fig 2 US image of the LUQ view demonstrating anechoic FF around the spleen (S)
and its relationship to the kidney (K).
Extended focused sonography in trauma
Fig 3 US image of the pelvic view demonstrating a moderately filled bladder (B)
with the typical box-like appearance and rounded edges of a negative FAST ex-
amination. In a positive scan, the bladder is more likely to have irregularly
shaped outlines, often with sharp edges.
usually seen in the retrovesical space whilst in females, FF will
first be visualised posterior to the uterus and then anterior to
it as well once enough fluid collects. Clinical correlation is
needed as, in female patients of reproductive age, FF of up to
50 ml is physiological in the pouch of Douglas between the
rectum and the uterus.
Cardiac view
In the cardiac view, an assessment is made for FF within the
pericardium to evaluate for effusion and tamponade. The
probe should be placed in a transverse orientation just inferior
to the xiphoid process and angled towards the left shoulder. If
this subxiphoid view is difficult to obtain because of body
habitus or pain, the PLAX view can be used. The probe should
be placed between the second and fourth intercostal spaces
on the anterior chest wall just to the left of the sternum. For
this window, the marker is orientated towards the left hip
rather than the right shoulder, as would usually be the case in
standard emergency imaging, in order to obtain an image that
is consistent with the reversed echocardiographic convention
performed by cardiologists. It is essential that all of the heart
is visualised as pericardial effusions can start at the posterior
Fig 4 US image of the subxiphoid cardiac view demonstrating a pericardial
effusion (PCE) surrounding the heart causing tamponade. Right ventricle has
collapsed. Left ventricle (LV), left atrium (LA) and right atrium (RA) are visualised.
BJA Education - Volume 18, Number 2, 2018 59
Extended focused sonography in trauma
aspect of the pericardium (Fig. 4). This can be achieved by
asking the patient to breathe in deeply in the case of the
subxiphoid view, or increasing the depth on the US machine
for both views. If a substantial amount of fluid is found in the
pericardial space, cardiac tamponade is likely if collapse is
present in any chamber during the cardiac cycle.
Limitations
FAST cannot reliably grade solid organ injuries that do not
result in significant haemoperitoneum. For the FAST exami-
nation to be positive, a critical volume of fluid should be
present. The mean minimum volume of fluid needed for US
detection is 668 ml when supine and 444 ml when Trende-
lenburg18 in the RUQ view and 157 ml in the pelvic view19
compared to 100e250 ml with CT. Because of this, FAST
cannot be used as a diagnostic test to exclude small amounts
of intraperitoneal haemorrhage. It has been noted to have
poor accuracy in the early post-injury phase when sufficient
haemoperitoneum has not yet accumulated, leading to a
false-negative FAST. Delayed presentation after trauma is a
further risk factor for a false-negative result as when blood
begins to clot it can be difficult to differentiate from the sur-
rounding tissue. Retroperitoneal haemorrhage, which can be
secondary to a pelvic fracture or an injury to the aorta, inferior
vena cava (IVC), or kidneys, is not well visualised on US unless
it flows into the abdominal or pelvic compartments.20 Full US
visualisation can be obstructed by bowel gas, obesity, and
subcutaneous emphysema.
A FAST examination which is negative should not be
regarded as conclusive, and clinicians should consider further
imaging with CT. Mild abdominal and severe head injuries are
associated with a false-negative FAST.21 Severe head injuries
are related to a lack of patient cooperation and could distract
the evaluating clinicians from performing a thorough FAST. In
such cases, the liberal use of whole body CT could alternatively
result in the increased detection of incidental FF. Patients with
a false-negative FAST have been found to be less likely to un-
dergo a therapeutic laparotomy but do not incur increased
adverse outcomes related to mortality or length of stay. Serial
FAST scans should be considered in non-major trauma or
when access to CT is limited and can decrease the false-
negative rate by 50% and increase sensitivity from 69 to 85%.22
FF detected with FAST is assumed to be haemoperitoneum,
although it can also represent injury-related bile, bowel con-
tents or urine. Fluid filled bowel can be differentiated from FF
where appropriate by observing for peristalsis and repeating
the examination to ensure the fluid pockets are in the
appropriate tissue planes. Gallbladder or renal cysts, if
prominent, can be misinterpreted but fluid is free flowing,
unlike, the contained and circular appearance of body struc-
tures and cysts. Fluid as a result of non-traumatic conditions,
such as ascites, ovarian hyperstimulation or rupture, perito-
neal dialysate or ventriculoperitoneal shunt overflow, can
result in false positives. Massive intravascular volume resus-
citation can rarely cause fluid transudation from the intra-
vascular to intra-peritoneal compartment after a prolonged
period of time and hence a false-positive FAST.23 In some
patients who are obese, perinephric fat can widen the hep-
atorenal and splenorenal interface and be misinterpreted as
FF. Comparison views of each kidney and evaluation for the
double line sign, a wedge-shaped hypoechoic area bounded
on both sides by echogenic lines, caused by fat around the
kidneys can be beneficial in these cases.24
60 BJA Education - Volume 18, Number 2, 2018
In the US assessment for pneumothorax, bullae, adhesions
and contusions can contribute to false-positive results.
Loculated pneumothoraces can be difficult to identify and
subcutaneous emphysema can significantly interfere with
visualisation.
Special circumstances
Traumatic cardiac arrest
The focus of resuscitation in traumatic cardiac arrest (TCA) is
the rapid and simultaneous identification and treatment of
reversible causes, such as cardiac tamponade, hypovolaemia
or tension pneumothorax.25 US assists in the diagnosis of
these reversible causes and should be prioritised. In such
circumstances, chest compressions are unlikely to be as
effective as in normovolaemic cardiac arrest and take a lower
priority compared to medical cardiac arrest. Lack of cardiac
motion on US in traumatic cardiac arrest has been associated
with a negative predictive value of 99% for survival to hospital
admission but further studies are needed.26
Pregnant patients
For pregnant patients who have sustained trauma, US is ad-
vantageous in that there is no contrast or radiation exposure
to the mother or fetus. Patients should be positioned in the left
lateral position to avoid hypotension from uterine IVC
compression. In blunt abdominal trauma, FAST in pregnant
patients has similar sensitivities and specificities to that in
non-pregnant patients.27 The most common pattern of FF
accumulation is in the RUQ, LUQ, and pelvis.28 Careful tech-
nique is required as the gravid uterus can distort the usual US
landmarks in the pelvic view. It can be difficult to distinguish
between intrauterine and extrauterine fluid; free intraperito-
neal fluid can be secondary to haemorrhage, amniotic fluid
from uterine rupture or both. US can also be used to assess for
fetal heart motion, fetal activity and injury, approximate
gestational age, amniotic fluid volume and placenta. For pa-
tients with negative or equivocal US findings, continuous
cardiotocographic monitoring should commence as early as
possible to screen for placental abruption.
Children
Similar to practice in pregnant patients, FAST has been used
in children to decrease radiation exposure to CT. A meta-
analysis has demonstrated paediatric FAST to have a sensi-
tivity of 66% and a specificity of 98%.29 Negative tests have
questionable utility as the sole diagnostic modality to rule out
the presence of intra-abdominal injury. In a recent rando-
mised controlled trial, the use of FAST compared to standard
care alone after blunt torso trauma in haemodynamically
stable children did not improve outcomes.30 NICE does not
advocate the use of FAST in children, but supports the
consideration of CXR and US, rather than the routine use of
CT, for first-line imaging in chest trauma.12
Current and future directions
Clinicians are now incorporating the eFAST examination into
prehospital protocols as it has the potential to influence
significantly trauma management at the scene. eFAST has
similar sensitivities and specificities in the prehospital envi-
ronment compared to when performed in hospital. It could

cause a delay in prehospital transfer time, but can be under-
taken in parallel with other procedures or during transport of
the patient where the examination can be truncated once
adequate diagnostic information has been obtained. US im-
ages acquired by paramedics can be transmitted to expert
reviewers in trauma centres for evaluation and triage, which
can then facilitate the targeted preparation of the resuscita-
tion room and/or operating theatre by the receiving hospital.
Other US protocols include an evaluation of the IVC.
Changes in the diameter of the IVC correlate with intravas-
cular volume status and a flat IVC, usually assessed in the
subxiphoid view, has been shown to be an indicator of poor
prognosis in unintubated trauma patients.31 The role of
contrast-enhanced US for trauma is as yet not clear, but it
appears to be more effective in the detection of solid organ
injury.
Conclusions
Evaluation with eFAST can provide critical information during
the real time assessment of complex trauma patients. It can
diagnose haemothorax and pneumothorax and identify FF
suggestive of haemopericardium or haemoperitoneum.
However, clinicians should be mindful of the inherent
strengths and limitations of the US examination and follow
guidelines from NICE, remembering that eFAST can be a
relative minor adjunct in major trauma.
Declaration of interest
None declared.
MCQs
The associated MCQs (to support CME/CPD activity) can be
accessed at www.bjaed.org/cme/home by subscribers to BJA
Education.
Supplementary material
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.bjae.2017.10.003.
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