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The FAST Scan

Goals. To discuss the history, principles, and use of US in traumaTo evaluate advantages and limits of FAST To demonstrate FAST techniqueTo view normal and abnormal scans. Objectives. To learn everything you need to know about trauma scanning?.. Sorry, not so FAST ?). How do we get started

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The FAST Scan

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    1. The FAST Scan Mila Felder MD June 22nd, 2005

    2. Goals To discuss the history, principles, and use of US in trauma To evaluate advantages and limits of FAST To demonstrate FAST technique To view normal and abnormal scans

    3. Objectives To learn everything you need to know about trauma scanning?.. Sorry, not so FAST… ?)

    4. How do we get started?

    5. History 1980s- US for trauma in Japan, Germany US training has been required in Germany since the1970s 1990s- US for trauma in North America The term FAST introduced in 1996 Credentialing criteria and scoring systems are still evolving 50+ scans to confidence… Feb 2004 J.Ma, Kansas

    6. What does it Mean? FAST Focused Abdominal Sonography in Trauma

    7. So, how has it been used? Quick look at stable or unstable trauma patient Single or multiple casualty in military deployment (EM Journal Apr.2005) International Space Station (J of Trauma-Inj Infection and Crit. Care Jan 2005) Extended Assessment for PTX

    8. Potential Uses Acute and chronic musculoskeletal injury Triage of patients in disasters Remote use by flight physicians and nurses Simultaneous transmission to trauma center/ telemedicine ATLS, prehospital use

    9. Premise Intraperitoneal organ injury ? hemoperitoneum Predictable locations (GRAVITY) Blood readily detectable on US as free fluid (FF) ? US a natural screening test for injury

    10. Where can I see FF? Accumulation in area of injury Overflows into dependent areas (pouch of Douglas, Morrison’s pouch) via rivers (paracolic gutters)

    11. Intraabdominal Fluid Localization

    12. so…

    13. How much can I see? Minimum detectable: 200-650 cc

    14. How much can I see? Depends on: Site, speed of bleeding Operator skill Position of patient CT: 100-250 cc FF DPL: 20 cc blood (@100,000 RBC/ml)

    15. How good is US? 1995, n=245 prospective trauma pts ?FAST by EM docs Various Gold Std. Sens. 90% sp 99% (accuracy 99%) Blunt = Penetrating

    16. US advantages (vs. CT or DPL) Fast Non invasive Pregnancy, coagulopathy Bedside test CT= Certain Termination Repeatable Eval quantity of fluid over time Easy to learn No contrast, radiation (vs. CT) and no infection, bleeding, complication risk (vs. DPL) DPL complication rate 1-4% Bedside test- instant result, stays in resusc areaNo contrast, radiation (vs. CT) and no infection, bleeding, complication risk (vs. DPL) DPL complication rate 1-4% Bedside test- instant result, stays in resusc area

    17. Limitations of US Site of injury not identified ? views with subcutaneous air, gastric distension, obesity Operator dependent Limited eval of: Bowel, retroperitoneum, diaphragm

    18. Caveats Lack of FF ? no injury not enough to see (?too early) you missed it hard-to-see places FF may not be blood urine, lavage fluid, ascites, amniotic fluid, bowel contents, ruptured cyst

    19. What about DPL?

    20. What about CT?

    21. How does US fit in? During primary or secondary survey

    22. *How do I do it?

    23. Start with proper stance and grip (kind of like golf) Ultrasonographer is at the pt's right, level with the umbilicus. The machine is at the pt's right shoulder. Hold the transducer much like you would a paint brush. The 4th & 5th digits and the medial aspect of the hand provide the base.

    24. Technique Consistently using the same technique insures reproducible imagery. (An important consideration when confronted with an unlikely skeptical surgery attending.) Every transducer has a marker signifying "north". For standard imagery "north" must always point its appropriate direction.

    26. FAST Demo

    27. 1) Subxiphoid View

    28. Normal Subxiphoid View

    29. Pericardial Effusion

    31. Pericardial Effusion

    32. Tips & Tricks Look ‘up and under’ sternum Aim for left shoulder Probe almost parallel to abdominal wall Epicardial fat vs. effusion Thin layer anterior to RV Not present posterior to LV *Clinical picture

    33. Clinical Picture, remember!

    34. Tips & Tricks Subxiphoid view may be difficult in: Gastric distension from BVM ventilation Obesity Peritonitis In these cases, try Parasternal or Apical view If in doubt, get formal echo

    36. More on this view Several studies have suggested that use of ED US in pericardial eval of penetrating torso trauma will: 1) Decrease time to diagnosis of pericardial effusion 2) Decrease time to OR (42.4 vs. 15.5 min)* 3) Improve survival (57.1 vs. 100%)*

    37. FAST

    38. 2) RUQ view

    39. Normal RUQ

    40. RUQ Fluid

    46. Tips & Tricks Probe parallel to and between ribs Fan thru whole hepatorenal space May try transabdominal approach if unsuccessful

    47. FAST

    48. 3) Suprapubic View

    49. Bladder

    52. Pelvis Fluid

    54. Tips & Tricks Best with some urine in bladder ‘Acoustic window’ Aim downward, into pelvis Fan thru whole area

    55. FAST

    56. 4) LUQ view

    57. Normal LUQ

    61. Tips & Tricks Oblique probe angle Parallel to and between ribs Higher and more posterior than you think Probe on the bed and in the arm pit… Fan thru whole space ?Check above spleen (vs. RUQ) Most common place for FF in LUQ is between diaphragm and spleen

    62. Finesse FAST RUQ, LUQ views: Check above diaphragm for hemothorax CXR = US in detection of hemothorax Ma and Mateer. Ann Emerg Med, 1997 50-175cc vs. 20cc US does not replace CXR Suprapubic view: Check uterus for pregnancy

    63. Hemothorax

    64. Pleural Fluid

    65. Putting it ALL together FAST

    66. How can I practice? You can try your FF-identifying skills on: Patients with ascites Patients on CAPD Before and during DPL Attend hands on training

    67. Pediatric FAST Not as sensitive 30-80% in various studies 31-37% of kids with solid organ injuries do not have hemoperitoneum Specificity still 95-100% If it’s positive, it’s positive Rely on CT more in kids?

    68. Summary FAST= easy, non invasive screening test No FF? no injury! 4 views- dependent areas Fluid=black

    69. F.A.S.T Training New for 2004/2005 Who can attend: Members ED, Surgery When: Dates TBA, Time 8 am Planning every other month ACMC Trauma surgery department Why: Promote US in trauma, hopefully improving care in our ED!

    70. Questions?

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