Focused assessment with sonography for trauma
|Focused assessment with sonography for trauma|
Focused assessment with sonography for trauma (commonly abbreviated as FAST) is a rapid bedside ultrasound examination performed by surgeons, emergency physicians and certain paramedics as a screening test for blood around the heart (pericardial effusion) or abdominal organs (hemoperitoneum) after trauma.
The four classic areas that are examined for free fluid are the perihepatic space (also called Morison's pouch or the hepatorenal recess), perisplenic space, pericardium, and the pelvis. With this technique it is possible to identify the presence of intraperitoneal or pericardial free fluid. In the context of traumatic injury, this fluid will usually be due to bleeding.
The extended FAST (eFAST) allows for the examination of both lungs by adding bilateral anterior thoracic sonography to the FAST exam. This allows for the detection of a pneumothorax with the absence of normal ‘lung-sliding’ and ‘comet-tail’ artifact (seen on the ultrasound screen). Compared with supine chest radiography, with CT or clinical course as the gold standard, bedside sonography has superior sensitivity (49–99 versus 27–75%), similar specificity (95–100%), and can be performed in under a minute. Several recent prospective studies have validated its use in the setting of trauma resuscitation, and have also shown that ultrasound can provide an accurate estimation of pneumothorax size. Although radiography or CT scanning is generally feasible, immediate bedside detection of a pneumothorax confirms what are often ambiguous physical findings in unstable patients, and guides immediate chest decompression. In addition, in the patient undergoing positive-pressure ventilation, the detection of an otherwise ‘occult’ pneumothorax prior to CT scanning may hasten treatment and subsequently prevent development of a tension pneumothorax, a deadly complication if not treated immediately, and deterioration in the radiology suite (in the CT scanner).
FAST is most useful in trauma patients who are hemodynamically unstable. A positive FAST result is defined as the appearance of a dark ("anechoic") strip in the dependent areas of the peritoneum. In the right upper quadrant this typically appears in Morison's Pouch (between the liver and kidney). This location is most useful as it is the place where fluid will collect with a supine patient. In the left upper quadrant, blood may collect anywhere around the spleen (perisplenic space). In the pelvis, blood generally pools behind the bladder (in the rectovesicular space). A positive result suggests hemoperitoneum; often CT scan will be performed if the patient is stable or a laparotomy if unstable. In those with a negative FAST result, a search for extra-abdominal sources of bleeding may still need to be performed. Rip's absent organ sign has been described as suggestive for diaphragmatic rupture.
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- Gangahar R, Doshi D (2009). "FAST scan in the diagnosis of acute diaphragmatic rupture". Am J Emerg Med. 28 (3): 387. doi:10.1016/j.ajem.2009.07.004. PMID 20223407.
- Further reading
- Gillman, Lawrence M; Ball, Chad G; Panebianco, Nova; Al-Kadi, Azzam; Kirkpatrick, Andrew W (2009). "Clinician performed resuscitative ultrasonography for the initial evaluation and resuscitation of trauma". Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 17 (1): 34. doi:10.1186/1757-7241-17-34.
- Focus On: EFAST - Extended Focused Assessment With Sonography for Trauma: American College of Emergency Physicians (ACEP)
- eMedicine: Blunt abdominal trauma
- FAST exam tutorial
- The FAST examination from Trauma.org, includes tutorial videos.
- Lung ultrasound: ICU Sonography
- FOB Doc: Capt Ray Wiss, MD. By a pioneering teacher of FAST to ER and first responders, civilian and military.