The FAST Exam - IntermountainPhysician...FAST and Hemoperitoneum • Sensitivities range from 69% to...
Transcript of The FAST Exam - IntermountainPhysician...FAST and Hemoperitoneum • Sensitivities range from 69% to...
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WINFOCUS’ BASIC ECHO (WBE)!
Thomas White, MD, FACS
Trauma Surgery and Critical Care
Intermountain Medical Center
Salt Lake City, Utah
The FAST Exam
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Focused
Assessment
with Sonography
in Trauma
!
!
Text
FAST
ocused ssessment with onography in rauma
FAST
Not just for trauma…….
Finding/confirming ascites!Splenic artery or aortic aneurysm rupture, hollow viscus perforation, ectopic pregnancy, postop bleeding
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• A limited ultrasound examination for the detection of free fluid in the chest, abdomen or mediastinum
• Advanced/expanded
• Rapid detection of pneumothorax
• Not included
• identification of solid organ injury
Goals of FAST
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Indications for FAST
• Blunt and penetrating thoracoabdominal trauma
• Trauma or abdominal pain and pregnancy
• Unexplained hypotension in any patient
• CONTRAINDICATION - other indication for the OR
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How to - Quick review
• Probe marker always to patient’s head or to patient’s right
• Gentle compression – Eliminate bowel gas, improve skin-transducer
interface
• Low-frequency probe – Larger, deeper structures
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FAST – FOUR VIEWS
• sub-xiphoid !
• RUQ !
• LUQ !
• Pelvic !
based on 3 most dependent areas of peritoneum as well as view of the heart
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WINFOCUS’ BASIC ECHO (WBE)!
Subxiphoid
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RARV
LA LV
Subxiphoid
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RARV
LA LV
Subxiphoid
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Things to be concerned about….
Scalloping of Right
Ventricle
Things to be concerned about….
Things to be concerned about….
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!Parasternal Long View
• Probe is on left side of sternum
!• Used to visualize aortic
outflow tract
Nice alternative view for subxiphoid (obese, abdominal pain, postop).!!wrong probe, terrible technique
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Upper quadrant landmarks
RUQ LUQ
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• Potential space between Gerota’s fascia of the right kidney and Glisson’s capsule of the liver
• Dependent region of right upper abdomen in the supine patient
Morrison’s Pouch
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!Morrison’s Pouch - Anatomy
Spleen
R Kidney
Liver
L Kidney
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!Morrison’s Pouch - Anatomy
Spleen
R Kidney
Liver
L Kidney
(Morrison’s Pouch
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• Technique:
– Midaxillary line – Horizontal subxiphoid
line – Fan posteriorly
Morrison’s Pouch
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Morrison’s Pouch
• Examine for:
–Fluid in Morrison’s pouch
–Fluid in right paracolic gutter
–Fluid in subdiaphragmatic space
–Fluid in right pleural space (cephalad to diaphragm)
!
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Morrison’s Pouch
• REMEMBER the INFERIOR POLE of the kidney!
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Morrison’s Pouch
Morrison’s Pouch
Morrison’s Pouch
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Hemothorax
• Loss of mirror image artifact
• Anechoic wedge superior to the liver and spleen
• Extension of the Thoracic Line
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Mirror Image
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Mirror Image
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“spine sign”
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Splenorenal Recess
– Potential space between spleen and left kidney
– Dependent region of left upper abdomen
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Splenorenal Recess - Anatomy
Spleen
R Kidney
Liver
L Kidney
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Splenorenal Recess - Anatomy
Spleen
R Kidney
Liver
L Kidney
)
Splenorenal Recess
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•Technique:
• Posterior axillary line
• Horizontal subxiphoid line
• Fan posteriorly
Splenorenal Recess
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• Examine for:
– Fluid in splenorenal recess
– Fluid in left paracolic gutter
–Fluid in subdiaphragmatic space
– Fluid in left pleural space (cephalad to diaphragm)
Splenorenal Recess
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KIDNEY
DIAPHRAGM
SPLEEN FLUID
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FLUID ABOVE SPLEEN
LEFT LUNG
SPLEEN
DIAPHRAGM
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Splenorenal Recess
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Splenorenal Recess
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Splenorenal Recess
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Pelvis
• Pouch of Douglas/Rectovesicular space
• Dependent region of lower abdomen
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Pelvis – Female Anatomy
Rectouterine Pouch
(of Douglas)
Vesicouterine Pouch
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Pelvis – Male Anatomy
Rectovesical Recess
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Pelvis
•Technique:
• Suprapubic (2 cm above symphysis pubis)
• Start midline
• Longitudinal and transverse planes
• Ideally prior to emptying of bladder via Foley (clamp)
• FANNING!!
clamp or lift bag to fill bladder (hey, its their urine after all...)
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• Examine for: –Fluid posterior to bladder
–Fluid posterior to uterus
–Fluid between bowel loops
Pelvis
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WINFOCUS’ BASIC ECHO (WBE)!
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Blunt Abdominal Trauma (BAT)
• Diagnostic Options:
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Blunt Abdominal Trauma (BAT)
• Diagnostic Options:
DPL
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Blunt Abdominal Trauma (BAT)
• Diagnostic Options:
CT
DPL
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Blunt Abdominal Trauma (BAT)
• Diagnostic Options:
CT
DPL
FAST
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FAST and Hemoperitoneum
• Sensitivities range from 69% to high 90’s • McGahan J US Med 1997 500 pts - sensitivity 63% >90%
• Specificities 95-100% in multiple studies
• Time < 4 minutes in most studies
• Reliably detects 200-650 cc of intraperitoneal blood
• 650 cc based on Branney study, single view
• CT 100-250 cc
• DPL - 100,000 RBC/mm3 = 20 cc in 1 L IVF
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Advantages to FAST• Compared to DPL:
– Noninvasive
– Repeatable
– Complication-free
– Not contraindicated by previous surgeries
– Capable of identifying pericardial and pleural fluid
– Cost-effective
– Higher specificity for therapeutic laparotomy
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Advantages to FAST
• Compared to CT: – Available for hemodynamically-
unstable patients – Portable – Rapid – Repeatable – Does not require contrast or
radiation – Cost-effective
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Disadvantages to FAST
• Operator-dependent
• Difficult in obese patients or those with subcutaneous air or excessive bowel gas
• Less accurate in diagnosing specific organ lesion
• Less accurate in diagnosing retroperitoneal injury
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Disadvantages to FAST
• infers rather than proves injury
• may miss retroperitoneal, or diaphragmatic injuries
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Outcome trials• Outcome Assessment:
– 135 PLUS, 127 controls – Time to operative care 64% less for PLUS
patients – PLUS patients spent 27% fewer days in hospital – PLUS patients underwent fewer CTs – PLUS patients had fewer complications – PLUS patient charges were 35% less
Melniker LA , Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. Randomized controlled clinical trial of point-of-care, limited sonography for trauma in the emergency department: the
first sonography outcomes assessment program trial. Ann Emerg Med 2006;48(3):227-35.
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Literature to know
• Echo decreases time to OR and mortality
Plummer, D, Brunnette D, Asinger R, Ruiz E. Emergency department echocardiography improves outcome in penetrating cardiac injury. Ann Emerg Med 1992; 21:709-712.
!Rozycki, GS, Feliciano DV, Ochsner MG, et al. The role of ultrasound in patients with
possible penetrating cardiac wounds: a prospective multicenter study. J Trauma 1999; 46:543-51.
US group 100% survival; time to OR 15 min
Controls 57% survival; time to OR 42 min
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FAST Algorithms
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Pitfalls in FAST
• Failure to scan all four views
• Failure to note echogenic clotted blood
• Failure to perform serial exams
• Failure to scan the inferior renal poles, subdiaphragmatic region on left and sagittal bladder view
• Humility with any new skill…
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