Focused

Assessment
with
Sonography in
Trauma
PRESENTED BY:

BRANDIE BACH, BS,RDMS,RVS,RT (R)(S)(ARRT)

Objectives

▪ Describe the indications for the FAST exam

▪ Review the ultrasound windows & views
▪ Describe the different pathologies that are often
visualized on ultrasound in trauma patients
What is the FAST exam?

▪ The FAST (Focused Assessment with

Sonography in Trauma) examination
focused on identifying free
intraperitoneal or pericardial fluid in
blunt trauma patients.
▪ Now, the use of ultrasound in
trauma has expanded to identifying
a variety of traumatic injuries:
hemoperitoneum, pneumothorax,
hemothorax, hemopericardium with
or without tamponade.
Benefits of Performing FAST

• Noninvasive
• Decreases the time to diagnosis for acute abdominal injury in Blunt
Abdominal Trauma
• Helps accurately diagnose and assess degree of hemoperitoneum.
• Can be integrated into the primary or secondary survey and can be
performed quickly, without having to move the patient (or take them
to another area).
• Can be repeated for serial examinations.
• Is safe in pregnant patients and children.
 Clinical Indications

▪ Current indications for performing a FAST

examination include:
▪ blunt and penetrating cardiac and chest trauma
▪ trauma in pregnancy
▪ pediatric trauma
▪ undifferentiated hypotension
▪ evaluation of medical (non-trauma) patients for
ascites. 
FAST helps to answer these questions

Is there free fluid in the abdomen?

Yes No

Is there free fluid in the pericardium?

Yes No

Is there free fluid, or a pregnancy in the pelvis?

Yes No
Probe selection

3 – 5 MHz 2 MHz
Excellent resolution Provides more depth for larger patient
 Views

A. Right Upper Quadrant

1.Morrison’s Pouch (hepatorenal recess),
2.liver tip (right paracolic gutter) and
3.lower right thorax
B. Left Upper Quadrant
4.Subphrenic space
5.Splenorenal space
6.Splenic tip
7.Lower left thorax
C. Pelvis
8.Rectovesical pouch (male patients)
9.Pouch of Douglas (female patients
D. Cardiac
10.
Pericardium
11.
Heart chambers, especially right ventricle
General Technique

▪ The patient should be positioned

supine (not usually a problem during
a trauma).
▪ Most examiners prefer to stand to
the patient’s right, which allows you
to use your right hand to hold the
probe and your left hand to work the
controls and save images.
▪ Standing to the patient’s right may
not always be possible, so it’s good to
learn to be flexible. If your patient is
awake and cooperative, it can be
helpful to have them place their arms
behind their head, opening up the
lateral trunk.
 RUQ view

• Orientate the probe indicator towards

the patient’s head.
• Anchor your probe in the midaxillary line at
the 10th intercostal space.
• You may have to slide up or down a rib
space to identify the structures.
• These structures move as the diaphragm
contracts and relaxes during the
respiratory cycle. Consider asking your
patient to hold their breath to keep the
desired organs from moving. Also,
consider slightly rotating the
probe counterclockwise towards the bed
so that the probe fits better between the
rib spaces.
RUQ
 LUQ view

• Grasp the linear probe between

your thumb and first
finger, like holding a pencil.
• Orientate the probe
indicator towards the patient’s head.
• Anchor your probe in the posterior
axillary line around the 8th
intercostal space.
• You should have your knuckles to
the bed since the spleen is fairly
posterior
LUQ
 Pelvic view

• Ideally, scan your patient with a full

bladder (so the bladder can be used as an
acoustic window). Therefore, you might
try to initiate the scan prior to foley
catheter placement.
• Machine Depth: 10-15 cm
• Place the transducer with the indicator
pointing towards the patient’s head in the
patient’s midline, right above the pubic
symphysis.
• Rock the probe so that it points down
towards the pelvic cavity.
Male Pelvis
Female pelvis
 Cardiac view

▪ The FAST exam most commonly uses the

subxiphoid (AKA subcostal) view to assess
the pericardial space.
• Hold the probe in the palm of your hand and
use an overhand grip.
• Point the probe indicator towards
the patient’s right with the ultrasound
machine depth set to around 15-20 cm.
• Using the liver as the acoustic
window, simultaneously press the probe into
the patient’s abdomen while tilting the tail of
the probe towards the patient’s feet
• Aim the ultrasound beam towards the
patient’s left shoulder.
Cardiac
 Findings

▪ Free fluid Is anechoic (black) and has

irregular margins.
▪ Clot appears echogenic
▪ Ultrasound can not differentiate fluid
types (free fluid, urine, etc)
Findings
Findings

True finding: Fluid in Morrison’s False finding: This is the

pouch gallbladder
Findings
Normal scan: the spleen and kidney are
adjacent, with a hyperechoic line
separating them. The diaphragm is the
echogenic line just cephalad to the
spleen.
Abnormal scan: note the large amount of
fluid in the subphrenic space, despite
the lack of fluid in the splenorenal
space. Also note the fluid in the left
thorax.
Test your Knowledge…

▪ What area is this?

▪ Normal or abnormal?
Test your Knowledge…

▪ What area is this?

▪ Normal or abnormal?
Test your Knowledge…

▪ What area is this?

▪ Normal or abnormal?
 Test your Knowledge…

▪ What area is this?

▪ What are the arrows pointing to?
In conclusion

▪ Like all other procedures in medicine

(including many physical exam
techniques), experience is key.
▪ Practice doing FAST exams whenever
you can – as you perform more and
more, you will get faster at it and
better able to recognize
abnormalities.
▪ A great time to practice FAST exams
is immediately after a trauma patient
returns from the CT scanner. In
addition, because the patient already
had a CT, you can “check your
answers” by comparing your FAST
exam interpretation to the CT results.
References

▪ Lobo V, Hunter-Behrend M, Cullnan E, et al. Caudal Edge of the

Liver in the Right Upper Quadrant (RUQ) View Is the Most
Sensitive Area for Free Fluid on the FAST Exam. West J Emerg
Med. 2017;18(2):270-280. doi:10.5811/westjem.2016.11.30435
▪ Richards, J., McGahan, J. (2017). Focused Assessment with
Sonography in Trauma (FAST) in 2017: What Radiologists Can
Learn. Radiology 283(1), 30 – 48. 
https://dx.doi.org/10.1148/radiol.2017160107
▪ www.ultrasoundvillage.com
Thank you… Any Questions?