Eur J Trauma Emerg Surg (2016) 42:119–126
DOI 10.1007/s00068-015-0512-1
REVIEW ARTICLE
From FAST to E‑FAST: an overview of the evolution
of ultrasound‑based traumatic injury assessment
J. Montoya1 · S. P. Stawicki1,2 · D. C. Evans3 · D. P. Bahner4 · S. Sparks1 ·
R. P. Sharpe1 · J. Cipolla1
Received: 1 October 2014 / Accepted: 3 March 2015 / Published online: 14 March 2015
© Springer-Verlag Berlin Heidelberg 2015
Abstract Ultrasound is a ubiquitous and versatile diag-
nostic tool. In the setting of acute injury, ultrasound
enhances the basic trauma evaluation, influences bedside
decision-making, and helps determine whether or not an
unstable patient requires emergent procedural intervention.
Consequently, continued education of surgeons and other
acute care practitioners in performing focused emergency
ultrasound is of great importance. This article provides a
synopsis of focused assessment with sonography for trauma
(FAST) and the extended FAST (E-FAST) that incorporates
basic thoracic injury assessment. The authors also review
key pitfalls, limitations, controversies, and advances related
to FAST, E-FAST, and ultrasound education.
Keywords Ultrasound · Point-of-care testing ·
Pneumothorax · FAST · Abdominal trauma · Thoracic
trauma
* S. P. Stawicki
stawicki.ace@gmail.com; stanislaw.stawicki@sluhn.org
1
St Luke’s Regional Level I Resource Trauma Center,
Bethlehem, PA, USA
2
Department of Research and Innovation, St Luke’s University
Health Network, Bethlehem, PA 18015, USA
3
Department of Surgery, Division of Trauma, Critical Care,
and Burn, The Ohio State University College of Medicine,
Columbus, OH, USA
4
Department of Emergency Medicine, The Ohio State
University College of Medicine, Columbus, OH, USA
Introduction
Evaluation of patients with thoraco-abdominal trauma
continues to present a challenge for emergency practition-
ers and traumatologists. As many as 50 % of patients with
severe abdominal trauma and/or multiple injuries either
have a normal initial abdominal exam or are unconscious
and thus unable to provide a reliable abdominal exam
[1, 2]. Consequently, the unreliable nature of history and
physical exam in the trauma population has led physicians
to increasingly depend on diagnostic imaging. Computed
tomography (CT) is a widely used imaging modality but
involves ionizing radiation and is not the best option for
unstable or potentially unstable patients [3]. Concurrently,
the use of ultrasound has increased during the past dec-
ade, with sonography becoming an essential adjunct in the
trauma resuscitation area [4, 5].
History
Ultrasound-based methodology was formally introduced
into the trauma literature in 1996 [6, 7]. The focused
assessment with sonography for trauma (FAST) exam now
serves as an important component of trauma algorithms,
especially for the evaluation of unstable patients where
early surgical intervention of the abdomen may be life-
saving. Prior to the era of the FAST exam, diagnostic peri-
toneal lavage was utilized to evaluate for the need for lapa-
rotomy in the unstable trauma patient. In 1999, the FAST
consensus conference concluded that the ‘FAST’ abbrevia-
tion should stand for Focused Assessment with Sonogra-
phy for Trauma in order to capture the utility of not only
viewing the abdomen but also evaluating the heart, the per-
icardial and pleural spaces [8]. Since its more widespread
13
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clinical implementation, the extended FAST (or E-FAST)
that incorporates pneumothorax assessment was found to
offer sensitivities and specificities that are superior to those
of traditional chest radiography [9]. Currently, a number
of board certifying entities require that emergency physi-
cians, intensivists and surgeons be proficient in bedside
ultrasound evaluation of injured and critically ill patients
[10–13]. Subsequent sections of this manuscript will out-
line fundamental considerations of FAST, E-FAST, ultra-
sound education, and the cutting edge of related sonology
science.
The FAST exam
The FAST exam exemplifies the evolution of the general
trauma approach over the last two decades, from maxi-
mally invasive to minimally- or non-invasive [14]. The
overarching assumption of FAST is that all clinically sig-
nificant abdominal injuries are associated with hemoperito-
neum. The traditional FAST paradigm includes four basic
sonographic views (the four “Ps”, Figs. 1, 2, 3 and 4): (a)
Fig. 1  a Left normal interface between the spleen and the kidney.
There is no fluid between the two, indicating a “negative” result. Note
the hyperechoic “spine sign” in the far field. This is due to the con-
tinuation of the spine above the diaphragm in the presence of fluid
Fig. 2  a Left negative right
upper quadrant view displays
the liver with multiple anechoic
areas representing hepatic and
portal veins next to the elliptical
kidney with the hyperechoic
spine in the far field. Note how
the spine stops at the diaphragm
and is not visualized above
(cephalad) to this area. b Right
positive right upper quadrant
view with anechoic fluid seen
around the liver (arrow)
13
J. Montoya et al.
pericardial; (b) perihepatic; (c) perisplenic; and (d) pelvic
[15, 16]. This simple test has nearly eliminated the need for
diagnostic peritoneal lavage [17]. Not only do ultrasound-
based approaches take the decision-making directly to the
patient (i.e., point-of-care methodology) but also facilitate
repeated bedside evaluations when resources to perform
such assessments using CT or other advanced imaging
would be prohibitive [14]. While perhaps not immediately
clinically relevant, proprietary algorithms have been pub-
lished that may lead to better quantification of the amount
of fluid found on FAST examinations, allowing even more
informed decisions [18].
There are also important limitations to FAST. Among
those, the exam has been noted to have poor accuracy in the
very early post-injury phase, where sufficient hemoperito-
neum had not yet accumulated thus leading to false-nega-
tive results. In addition, its utility in detecting retroperito-
neal blood is very limited. Furthermore, FAST is unable to
identify hollow viscus or solid organ injuries not associated
with hemoperitoneum such as early bowel injury or pan-
creatic injury. Lastly, it has been anecdotally reported that
pericardial FAST window may be falsely negative in the
(seen as the sharp-angled anechoic area above the diaphragm) in the
pleural space. b Right positive spleno-renal window, with anechoic
fluid (arrow) seen clearly around the spleen
From FAST to E-FAST 121

Fig. 3  a Left the “bladder

view” provides visualization
of the pelvic structures and the
most dependent space in the
pelvis. This image depicts a
moderately filled bladder with
the typical “box-like” appear-
ance of a negative scan. b
Right top and bottom free fluid
(arrows) present in the pelvis
on a positive FAST scan. The
sonographer is more likely to
see irregularly shaped outlines,
often with sharp angles com-
pared with the more “rounded”
edges of the bladder in the
negative scan on the left

Fig. 4  a Left negative pericar-

dial view. b Right positive peri-
cardial view, with clearly visible
anechoic fluid (arrow) between
the heart and the pericardium.
This is a critical finding that
should prompt further immedi-
ate intervention(s)

presence of pericardial injury that has resulted in an adja-
cent pleural defect and thus a pleural effusion. In summary,
the FAST exam has a valuable role in the early evaluation
of trauma patients, but CT of the abdomen remains the gold
standard evaluation technique to exclude abdominal injury
in the hemodynamically stable patient who warrants further
evaluation due to specific symptoms or complaints. Also
FAST exam should not replace other techniques in the eval-
uation of penetrating trauma, such as traditional radiogra-
phy. In this context, the trajectory of the penetrating injury
and other imaging studies plays a greater role in decision-
making than FAST.
From FAST to E‑FAST
The FAST exam continues to gain popularity as it is easily
learned, readily accessible, portable, and more physicians
are becoming comfortable with point-of-care sonography in
general. At many institutions, protocols that encourage the
use of the FAST exam have resulted in significant reduc-
tion in computed tomographic (CT) scan use in trauma,
thus decreasing overall costs and radiation exposure [19].
In one study, the use of the FAST exam changed clinical
management in nearly one-third of patients and reduced CT
scan utilization from 47 to 34 % [19]. The determination
of when it is appropriate to limit abdominal evaluation to
FAST exam only is yet to be clearly delineated. More spe-
cifically, given the possibility of abdominal injury without
free fluid, patients with abdominal contusion, abdominal
pain, or altered mental state should not be evaluated with
FAST alone. As originally intended, FAST is best used as
an adjunct to quickly detect intra-abdominal fluid in trauma
patients. Ultrasound can easily detect as little as 200 mL of
fluid in Morrison’s pouch and can be completed in less than
1 min in the hands of an experienced operator [20–22]. The
E-FAST further adds to the basic information provided by
the FAST by including the examination of the thorax ante-
riorly to assess for the presence of pneumothorax and at the
flanks to assess for hemothorax [23, 24]. Pneumothoraces
are common in trauma and as many as half are missed on
a routine supine chest radiograph [25]. Regarding hemo-
thoraces, a supine or upright CXR requires up to 175 or
50–100 mL of fluid in order to be visualized, compared to
E-FAST which can detect as little as 20 mL of fluid in the
pleural space [26] (Table 1).

13
122 J. Montoya et al.

Table 1  Summary of selected clinical reports focusing on (thoracic) E-FAST, including basic study characteristics, traditional imaging
comparator(s), and diagnostic accuracy data for ultrasound
References Sonographers Patient Traditional E-FASTb E-FASTb E-FASTb E-FASTb
characteristics assessment Sensitivityc (%) Specificityc (%) PPVc (%) NPVc (%)
(n, % ptx)a

Alrajab Emergency Meta-analysis of 13 Chest X-ray 78.6 (68.1–98.1) 98.4 (97.3–99.5) Not reported Not reported
et al. [9] physicians studies (1514)d
Intensivists
Radiologists
Surgeons
Alrajhi Emergency Meta-analysis of 7 Chest X-ray 90.9 (86.5–93.9) 98.2 (97.0–99.0) 94.4 % 97.0 %
et al. [35] physicians studiese
Radiologists
Surgeons
Ianniello Emergency Trauma CT scan 77.0 (66.8–85.4) 99.8 (99.2–99.9) 98.5 % 97.0 %
et al. [69] radiologists (736, 11.8 %)
Nandipati et al. Surgeons Trauma Clinical exam 95.3 (76.1–99.2) 99.5 (97.0–99.9) 95.2 % 99.5 %
[61] (204, 10.3 %) CT scan
Chest X-ray

CT computed tomography, PPV positive predictive value, NPV negative predictive value
a
Some overlap between studies exists; However, the authors believe that the table represents the most comprehensive and realistic spectrum of
E-FAST sensitivities and specificities
b
Pneumothorax only
c
Includes 95 % confidence interval
d
Studies included are Abbasi [70], Brook [48], Chung [71], Donmez [72], Hyacinthe [73], Kirkpatrick [32], Nagarsheth [74], Nandipati [61],
Rowan [75], Soldati [76], Soldati [38], Zhang [77]
e
Studies included are Blaivas [36], Chung [71], Kirkpatrick [32], Rowan [75], Soldati [76], Soldati [38], Zhang [77]

While ultrasound continues to gain popularity and more
healthcare teams embrace protocols that utilize FAST to
reduce unnecessary CT scan use, these protocols must be
used with caution as FAST does have a number of impor-
tant limitations [27]. As stated above, proper patient selec-
tion is crucial and there are many potential sources of
diagnostic bias, including the presence of obesity and sub-
cutaneous fat, body habitus and positioning, the presence
of abdominal or retroperitoneal injury without hemoperi-
toneum, ascites due to medical condition (i.e., hepatic cir-
rhosis), pre-existing pericardial effusion, and the presence
of intra-abdominal cysts or masses [28]. Pitfalls leading to
false positive readings in the cardiac window include clot-
ted hemoperitoneum, epicardial fat and pleural effusions
being mistaken for pericardial effusions [29, 30]. Patients
with the above characteristics or findings should also be
evaluated with CT scans, provided that they are hemody-
namically stable. In all cases, good clinical judgment is
essential and serial FAST exams may increase the overall
accuracy of the ultrasound-based assessment.
Focus on pneumothorax and thoracic trauma
The thoracic cavity is the site of two of the key critical phys-
iologic components: the respiratory and the cardiovascular
systems [31]. It is well recognized that pneumothorax is one
of the most common serious thoracic injuries, and regard-
less of blunt or penetrating mechanism, is among the major
causes of preventable death in trauma [32]. Consequently,
the need for quick and accurate diagnosis of pneumothorax
takes a critical role in the management of the injured.
The traditional approach to diagnosing pneumothorax
in trauma patients has been the supine chest X-ray (CXR);
however, traditional CXR studies are often inaccurate
because air may layer anteriorly and thus be difficult to see
or easy to underestimate when the patient is supine [33,
34]. Ultrasound may be a helpful adjunct in overcoming
the shortcomings of the supine X-ray as it tends to be more
sensitive than CXR at detecting pneumothoraces, both
clinically and statistically [35]. Despite concerns that the
presence of air in the pleural space may inhibit sonographic
visualization of intrathoracic structures, this very property
of air-ultrasound wave interaction has actually proven to be
beneficial, as the presence of air in the pleural space dis-
rupts the close association between the visceral and parietal
pleura and eliminates the usual “lung sliding” effect seen
in normal ultrasound exam [36]. Another finding seen in a
normal lung ultrasound is the “comet tail” artifact, which
is due to reverberation artifacts that appear as hyperechoic
lines that extend from the pleural line to the end of the
sonographic display as the pleura reflect sound waves back

13
From FAST to E-FAST
Fig. 5  a Left pneumothorax,
with the “bat sign” seen as
marked (ribs = wings = x;
pleural line = body = arrow).
b Right normal lung on static
images, with the presence of
“comet tail” artifacts (arrow).
Motion picture in this case
would demonstrate “pleural/
lung sliding”
to the probe [37] (Fig. 5). Combined, these two findings
have a 100 % negative predictive value for pneumothorax
[37]. Using thoracic ultrasound has an additional benefit in
that many patients are able to provide a “control lung” on
the non-affected side, which can be easily compared to the
injured, “abnormal” side. This obviously does not apply in
patients with bilateral pneumothoraces. Kirkpatrick et al.
[32] noted that the overall performance of E-FAST was
poor in patients with bilateral pneumothoraces, most likely
because the “standard comparison” was lost. Although CT
of the chest remains the gold standard, using ultrasound to
rule out occult pneumothorax can limit cost and radiation
and has been shown to have similar specificity [38]. The
average cost for a CT chest with contrast and radiology
reading is $1200–$1500 depending on individual institu-
tion. Kirkpatrick et al. [32] studied the accuracy of diagnos-
ing occult pneumothorax and the natural evolution of pneu-
mothorax using ultrasound in the emergency department.
They found that ultrasound scans were not only excellent
in detecting pneumothorax, but their accuracy was almost
as high as that of CT scans, with specificity of 98.7 % and a
positive predictive value of 87.5 % [32].
While improved diagnosis of hemothorax and pneumo-
thorax could be useful, it is reasonable to question whether
findings noted on ultrasound but not chest X-ray require
treatment. Many of these ‘occult pneumothoraces’ do not
require treatment if detectable on CT but not on CXR [39].
Whether or not the same can be said of pneumothorax seen
on ultrasound has not yet been established. An additional
limitation of the E-FAST is its lack of ability to diagnose
traumatic aortic pathology. Consequently, E-FAST is not
a valid replacement for CT angiography in patients with
high-energy thoracic traumatic mechanisms.
Clinical ultrasound education: the “sonology”
approach
How long does it take to learn the FAST exam? How many
scans are necessary to become credentialed in focused
123
ultrasound? What is the proficiency curve? The authors will
attempt to answer these important questions in this section
of the manuscript. One study examined a hybrid curriculum
of online and hands-on material to learn how to perform the
FAST exam, with 89 % of students achieving a “high pass”
grade on the performance of a FAST exam by the time of
curriculum completion [40]. The curriculum itself consisted
of online materials that facilitated independent learning, fol-
lowed by a “hands-on” seminar with instructors, after which
trainees were brought back during the final week for an
assessment of practical performance of FAST [40]. In addi-
tion to achieving high overall levels of proficiency, the stu-
dents were noted to achieve test scores equivalent to those
of emergency medicine residents [40]. The literature fea-
tures a number of studies demonstrating that point-of-care
ultrasound skills can be taught to paramedics [41], nurses
[42, 43], be used in austere environments [21] and even in
outer space [44]. How best to learn this material and be able
to function in a proficient manner has not yet been clearly
defined, but coordinating the teaching of basic ultrasound
imaging patterns and the associated physiologic principles
may both improve the understanding of key concepts and
enhance long-term retention of knowledge.
The importance of skills maintenance in regard to FAST
and E-FAST examinations must be taken into considera-
tion within the overall context of practical application and
clinical use of point-of-care trauma sonography. One sur-
vey of Canadian surgical trainees found that 80 % indicated
the need for more than 20 exams (median 30 exams) to be
comfortable performing a FAST ultrasound [45]. Arzola
et al. [46] examined anesthesiologists evaluating the pres-
ence of gastric alimentation using ultrasound, with 95 %
success rate after 33 sonographic scans. Another study
found that memory retention 2 weeks after a brief E-FAST
presentation (10–50 min) was only 12 % [47]. How the evi-
dence from the above studies will help shape educational
developments in sonology remains to be seen. However, it
is very likely that the information outlined above will be
incorporated into a number of credentialing, re-credential-
ing, and maintenance of certification programs.
13
124
A study examining radiology residents’ ability to detect
pneumothorax as part of an E-FAST exam found that essen-
tially all moderate sized pneumothoraces were detected
[48]. However, the inclusion of small pneumothoraces that
did not require intervention dropped the sensitivity to 47 %
while the specificity in this study was 99 %. An overall
negative (93 %) and positive (87 %) predictive value sug-
gest that E-FAST is an accurate and efficient tool to detect
clinically significant pneumothoraces [48]. It is suggested
that the educational learning curve, as supported by a num-
ber of guideline documents for different areas of clinical
focus is somewhere between 25–50 scans to 150–200 scans
in order for one to become proficient in performing each
respective exam type [49, 50].
A small longitudinal study of ultrasound-naive emer-
gency medicine residents demonstrated a steady learning
curve of about 18 months and the attainment of accept-
able accuracy rates after approximately 35 examinations
[51]. Another report highlighted the I-AIM approach that
places emphasis on the indications for the focused ultra-
sound exam (e.g. blunt abdominal trauma), the acquisi-
tion steps to performing the exam, the interpretation steps
and finally medical decision-making based on the ultra-
sound images in the clinical context [52]. This process is
uniquely distinct from traditional ultrasonography, which
applies solely to the technical acquisition of the ultrasound
images. In this paradigm, image acquisition is broken
down into setting up the patient and the machine, select-
ing and moving the probe, optimizing the image with
“knobology” (i.e., the “science” of fine-tuning image with
electronic knobs) [53] and completing a protocol such as
the FAST exam. The I-AIM approach also incorporates
critical elements necessary in the generated reports linked
to clinical reimbursement and revenue for the sustainable
ultrasound program.
The educational framework in most medical schools
and residency training programs is changing as general
approaches migrate toward patient safety, transparency, and
focus away from radiation-based diagnostics. Despite this,
the undergraduate and graduate medical education infra-
structure is slow to adapt to these shifts in the practice of
medicine toward more reliance on point-of-care ultrasound
use as a diagnostic aid and a way to better understand the
patient’s condition. The FAST was focused only on looking
for free fluid in four standard locations while the E-FAST
expanded to explore the thoracic space and look at the
lungs and the inferior vena cava [54]. Further addition of
extremity assessment to the E-FAST paradigm has also
been proposed [21]. Effective teaching of all the required
skills requires a realignment of the current educational sys-
tem where personnel are trained with ultrasound as an aid
to their clinical practice starting in medical school and con-
tinuing more seamlessly through residency and fellowship.
13
J. Montoya et al.
By the time the training is completed, this tool should be
used in various ways to provide important clinical informa-
tion on the injured, sick and critically ill patients so that
appropriate decisions can be made based on acquired infor-
mation. One major shortcoming is the fact that the quality,
standards, and state of ultrasound education continue to
be very heterogeneous across countries, regions, and indi-
vidual hospital systems. Nevertheless, both the FAST, the
E-FAST, and other related ultrasound protocols are easily
learned and can have a significant impact on the critically
ill and injured patient [11, 55].
Clinical summary and cutting edge advances
in FAST and E‑FAST ultrasound
Performance of the FAST exam has been shown to reduce
the need for CT scans, decrease time to appropriate inter-
vention, shorten hospital stays, and decrease healthcare
resource use [19, 20, 56, 57]. A recent review reported that
FAST exams contributed to a decrease in abdominal CT
use by about 50 % [58]. Although it should be noted that
there was no difference in mortality or laparotomy rates
[58], the meta-analysis did not examine a number of clini-
cally relevant variables such as “time to definitive care”
or “cost savings”, both of which were shown to be posi-
tively affected by the use of point-of-care sonography [59].
Understanding the strengths and limitations of ultrasound
is essential, as is the ability to recognize when further test-
ing is indicated. Although E-FAST has gained popularity as
evidence emerged that it has greater sensitivity than CXR
and higher specificity than some CT scans, the use of each
modality should be considered on case-by-case basis [32,
35, 60, 61]. The E-FAST is a useful tool to evaluate the
post-injury thorax, should be encouraged during the initial
evaluation of all trauma patients, and can help provide a
wealth of clinical information directly at the point-of-care
[56, 62]. As this point-of-care paradigm evolves, wireless
probes and devices capable of short- and long-distance
image transmission to remote displays are already being
introduced [44, 63–65]. Miniaturization, virtual learning,
holography, and wearable technology will play important
roles as ultrasound technology evolves [64–68]. Collec-
tively, these and other developments will help shape the
future of bedside sonography for the critically ill and the
injured patient [64–68]. Although the way data is acquired,
displayed and shared may change, the protocols and goals
of each exam will remain the same. Moreover, while new
technologies and enhancements are almost certain to play
an important a part in our clinical future, the key question
resonating today will still remain, “Will we be able to ade-
quately educate future generations of physicians in sonog-
raphy and sonology?”
From FAST to E-FAST
Conclusions
The FAST and E-FAST ultrasound examinations are rou-
tinely performed in trauma scenarios to provide point-of-
care guidance for medical decision-making. The FAST
exam is easily learned and educational materials are abun-
dant both online (images and video) and in print. Perform-
ing E-FAST exams can help drive key decisions regarding
both intravascular fluid status management (via venous col-
lapsibility measurements) and invasive interventions (i.e.,
tube thoracostomy) by the sonologist. Using ultrasound as
a tool within the trauma algorithm can expedite both diag-
nostic and treatment time while mitigating the dependence
on computed tomography. Future research into cost savings,
efficient use of imaging, and patient outcomes will help drive
algorithms where serial use of FAST could be employed to
manage lower risk populations. As both FAST and E-FAST
increase in popularity, implementation of robust educational
programs will become increasingly important so that future
generations of practitioners are able to acquire high quality
sonographic images, interpret those images, and also make
real-time clinical decisions based on that information.
Conflict of interest Jacqueline Montoya, Stanislaw P. Stawicki,
David C. Evans, David P. Bahner, Richard P. Sharpe, MD, FACS, and
James Cipolla declare that they have no conflict(s) of interest related
to this work.
Compliance with ethical requirements This work is in compli-
ance with ethical requirements.
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