Introduction to Emergency

Ultrasound -FAST and Heart

Diane Hallinen, MD

Sliding

Moving the probe to a

new window

Requires plenty of gel.

Rocking

Centers the image in the middle of the screen

Tilting

Perpendicular to rocking. Allows other planes in the

same axis to come into view

Rotation

Allows the evaluation of the short and

long axis of a structure

Compression

• Pressing the probe into the patient.

• This can be uncomfortable.

• Useful for squishing bowel gas out of the way and

for the evaluation of blood vessels.

Choose your Probe

• Higher Frequency – decreased depth of

field, but better image.

• Lower Frequency – penetrates deeper, but

blurry

• Intracavitary- high frequency

– For transvaginal exams

– Peritonsillar abscess

FAST Exam

• The goal is to determine if there is free fluid

in the abdominal cavity or around the heart.

• It stands for Focused Assessment for the

Sonographic examination of the Trauma

patient or Focused Abdominal Sonography

for Trauma

• It really is fast, usually takes less than 1

minute if the exam is positive. If it is

negative it takes 2 - 5 minutes.

Technique

• Most importantly it should be done

simultaneously with the rest of the exam and

resuscitation during the secondary

survey.

• Should be done by a second physician if

possible.

• Repeat exam in 15 minutes increases

sensitivity.

FAST

• Heart

• RUQ

• LUQ

• Bladder

Also pay attention to

the diaphragms and

gutters.

Heart

• The primary goal is

to look for

hemopericardium.

• Pericardial

tamponade is evident

by collapse of the

right ventricle and

atrium.

Pericardial Fluid

Standard Subcostal

View

• Place the probe just

inferior to the xiphoid,

hand on top.

• Press down to get

under the sternum.

• Point slightly towards

the left nipple.

Standard Subcostal View

• Ideal view for pericardial effusions since there are no

pleural reflections between the liver and the heart.

While you are there - go check out the

hepatic veins - Rabbit sign

• The rabbit’s head is the vena cava, the ears

are the middle and left hepatic veins.

Limitations of the Subxiphoid

View

• Difficult to look at the heart when the

stomach is full of air from bagging or from

a prehospital esophogeal intubation.

• People with a beer belly can be difficult to

image.

• Pregnant women in the third trimester also

can be difficult to image.

Alternative views

are available, and

may provide a way

to confirm an

effusion, or give

you a better view

of the chambers

and valves. More

on this topic later.

Hemoperitoneum

• Free fluid is black, and it collects in the

dependant portions of the torso.

• An abdomen with more that 500 cc free

fluid can usually be detected in less than a

minute.

• For children the most dependant portion of

the abdomen is the bladder.

FAST

• Heart

• RUQ

• LUQ

• Bladder

Normal Bladder Exam

Bladder

• The bladder

must be

distended to do

an adequate

exam.

• The foley can be

clamped or

filled with

saline.

Free Fluid is Black

Bladder-Loop of Bowel

FAST

• Heart

• RUQ

• LUQ

• Bladder

RUQAnechoic (black)

fluid between the

liver and kidney.

RUQ

Morison’s

pouch is the

most common

area for blood

to accumulate,

in adults,

regardless of

the organ

injured.

FAST

• Heart

• RUQ

• LUQ

• Bladder

LUQ

Kidney-spleen interface

can be hard to see, and

blood doesn’t always

settle there. In fact it is

more common to see it

between the spleen and

diaphragm.

If there is fluid in the left

upper quadrant it is

probably from the spleen

or diaphragm.

LUQ

• PF is pleural

fluid seen above

the diaphragm

D. FF is seen

between the

spleen and

kidney.

Introduction - Vascular Exam

• Aorta

• Femoral artery and vein

• Subclavian artery and vein

• Internal jugular and carotids

Goal today is to find the vessels,

differentiate the artery from the vein and

explore doppler.

Aorta - Longitudinal

Aorta Transverse

Femoral Artery and Vein

• A deep vein thrombosis can be diagnosed

on the basis of incompressibility of the

femoral vein.

• The femoral vein is an idea access point for

a large bore line.

Carotid Artery Jugular Vein

The internal jugular vein is an excellent

access point for placing an internal pacer.

Peripheral IV Access

Why look at a the heart?

• In arrest -

– Cardiac activity

– Pericardial effusion

– Dilated right ventricle (massive PE)

– Empty heart - hypovolemia

• Many other uses ....hypotension, chest pain,

pericardiocentesis. Don’t worry, you will

get additional lectures.

Echo Probe Placement

• Traditionally the probe marker is to the

patient’s left, and the monitor indicator is on

the right side of the screen, which is

opposite from abdomen/pelvis scanning.

• Don’t worry about it today…work on

getting the images and figure out the

anatomy. Don’t memorize stuff, deduce it.

The major views

are the parasternal

long and short,

apical, and sub-

costal.

My favorite view

is the parasternal

long.

Parasternal Long

• The image is through the long axis of the

heart. The probe is placed between the 2nd

and 4th intercostal space. You might have

to SLIDE the probe to different interspace

to find the best “window.”

• The probe should be snuggled up right next

to the sternum.

Parasternal Long

Parasternal Long Axis

• Focus on the mitral

valve. Move the probe

so that you see the

anterior and posterior

leaflets opening and

closing.

• Usually you can see

the aorta in cross

section distal to the

inferior wall.Yale Atlas of Echo

Parasternal Long

Million dollar question…is this systole or

diastole?

Parasternal Long with

Tamponade

Parasternal short

Parasternal Short

• Rotate the probe 90

degrees while looking at

the aortic valve. Tilt the

probe to scan through the

mitral and ventricle levels.

• Used for wall motion

examination, check for 3

leaflets in the aortic valve,

etc.

Parasternal Short

Apical View

• Place the transducer on the point of

maximum impulse, between the ribs.

• Be sure to rotate, slide, and tilt.

Apical Four Chamber View

• Get a nice view of the

right heart, useful for

tamponade

evaluations.

• Wall motion views,

can see the apex.

• Used for evaluating

valve function via

doppler.

Apical Four Chamber View

Tamponade?

Dilated Cardiomyopathy