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FAST - Focussed Abdominal Sonography The third is the retroperitoneal abdomen, which conin Trauma
1. Introduction Focussed Abdominal Sonography in Trauma (FAST) has rapidly become an accepted method of injury assessment in blunt abdominal trauma. Many trauma management guidelines have adopted FAST as a pivotal axis in the decision making algorithm. It is the current gold standard for the detection of intra-abdominal bleeding in the unstable hypotensive patient with blunt abdominal trauma. The technique of FAST is of interest to all clinicians involved in the care of serious trauma patients surgeons, emergency physicians, intensivists and anaesthetists. tains the kidneys, ureters, pancreas, abdominal aorta, and inferior vena cava. The fourth is the true abdomen, which contains the small and large intestines, the uterus (if gravid), and the bladder (when distended).

When performing a physical examination of the abdomen, a common division of surface landmarks may be used to divide the abdomen into 9 parts HC Hypochondrium (left and right upper quadrants) E Epigastrium L Loin (left and right) U Umbilicus The most important preoperative objective in the IF Iliac Fossa (left and right) management of the patient with abdominal trauma is HY - Hypogastrium to ascertain whether or not a laparotomy is needed, and not the diagnosis of specific injury - Polk 1983 If one agrees with the statement above, then ultrasound has many important advantages over traditional methods of abdominal assessment in trauma. When compared to physical examination, diagnostic peritoneal lavage (DPL) and computerised tomography (CT) it is non-invasive, rapid, portable and accurate. DPL is particularly sensitive, but not all patients with a positive DPL would require laparotomy. CT allows localisation of injury site and grading of severity but it is timeconsuming and requires a stable co-operative patient. Therefore, FAST has a specific role in the unstable patient with abdominal trauma, and according to current evidence is a highly useful modality in deciding which patients require emergency laparotomy. 2. Anatomy of the peritoneum relevant to FAST The abdomen can be arbitrarily divided into 4 areas. The first is the intrathoracic abdomen, which is the portion of the upper abdomen that lies beneath the rib Fig 1. Surface areas of the abdomen cage. Its contents include the diaphragm, liver, spleen, and stomach. The rib cage makes this area inaccessible for palpation and complete examination. The second is the pelvic abdomen, which is defined by the bony pelvis. Its contents include the urinary bladder, urethra, rectum, small intestine, and in females, the ovaries, fallopian tubes, and uterus.

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2.1 Sonoanatomy and technique of FAST The sole goal of FAST is to detect free intraperitoneal fluid. Diagnosis of organ injury, localisation of organ injury and grading of injury severity are more suited to formal ultrasound scanning or CT. The FAST examination is designed for rapid assessment; there are just 4 scanning positions in the examination. These are windows of ultrasound scanning and do not correspond to anatomical descriptions of planes such as sagittal or coronal. 1. Perihepatic structures in the right upper quadrant (RUQ) are visualised right lobe of liver, kidney and the hepatorenal space 2. Perisplenic structures in the left upper quadrant (LUQ) are visualised spleen, kidney, perisplenic area 3. Pelvis structures in the pelvic cul de sac are visualised Pouch of Douglas between bladder and uterus in females, or rectovesical pouch in males 4. Pericardial essentially a subcostal echocardiagraphic view of the heart, liver and pericardium

Figs 2 and 3. Plain abdominal radiograph and key Fig 4. The 4 scanning windows of the FAST examinaPlain abdominal films are unhelpful in acute trauma tion clockwise from top = pericardial, perisplenic, and are not part of the trauma radiography series. This pelvic and perihepatic normal film helps to demonstrate organ relationships. Note the close interposition of the liver and right kidney, and the spleen and left kidney.

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Attaining FAST views requires basic knowledge of ultrasound physics and familiarity with the ultrasound machine, correct transducer selection and depth settings and correct application of the probe. Knowledge of physics and knobology of the ultrasound machine will be assumed in this tutorial. It is recommended that candidates are fully able to describe and eliminate artifacts and anatomic pitfalls, and to fully operate the machine and optimise ultrasound images before progressing to scanning live patients. It is also recommended that an ultrasound machine with live 2-D mode (rapid B-mode) and transducer frequencies between 3-6MHz be used. Optimal depth settings will depend on patient body habitus a setting of 8 to 15 cm will suffice for most patients. A curved abdominal probe is ideal. Use the lowest depth setting that allows for adequate field of view this will enable the best possible image resolution to be attained. Adjust gain settings so that vascular structures are dark/ black and surrounding tissues are not overbright. It is important to use an adequate amount of gel to eliminate air gaps between the skin and the transducer which will degrade image quality. 1. Perihepatic Fig 6. Normal perihepatic FAST The probe is placed in the right mid to posterior axillary line at the level of the 11th and 12th ribs. Angle the probe until the hepatorenal space (RutherfordMorrison Pouch) is seen. In the normal patient the liver and kidney are closely aligned with with no visible fluid. Because this is the most dependant zone of the upper abdomen, intraperitoneal fluid should collect here first. Fluid is generally hypoechoic and is seen as a dark or black stripe between the liver capsule and the fatty Gerotas fascia of the kidney. As little as 70mls of fluid may be visualised as a positive scan in this area.

Fig 5. Position for perihepatic FAST The patient is in the supine position (as for all the scanning positions) The operator should stand or sit to the right of the patient and, ideally, scan with the dominant hand. The ultrasound machine should be at eye level or have the screen tilted to minimise reflection. Fig 7. Abnormal or positive hepatorenal FAST The dark stripe around the kidney indicates the presence of intrabdominal fluid which, in the context of trauma, is likely to be blood. One should also consider that ascites has an identical appearance and should be considered in the patient with liver disease or right heart failure etc.

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2. Perisplenic 3. Pelvic

Fig 8. Position for perisplenic FAST With the patient supine, the probe should be placed on the left posterior axillary line between the 10th and 11th ribs, angled to achieve a view of the spleen and left kidney interface.

Fig 10. Position for pelvic FAST Place the transducer in the midline, slightly above the symphysis pubis. The probe should be aligned with the umbilicus and a view of the bladder and Pouch of Douglas or rectovesical pouch obtained. Both transverse and longitudinal views can be obtained by simply rotating the transducer 90 degrees. As the most dependant part of the lower abdomen, fluid will often collect here before other areas. It has been described as the most sensitive of the four views in the FAST examination.

Fig 9. Positive perisplenic FAST In this scan there is a collection of fluid at the posterior aspect of the spleen (arrow). The left kidney is displaced inferiorly.

Fig 11. Positive pelvic FAST in a female In this scan there is free fluid posterior to the bladder in the pouch of Douglas. The uterus is displaced posteriorly.

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4. Pericardial

Fig 14. Normal pericardial FAST Fig 12. Position for pericardial FAST Place the transducer under the xiphisternum in the midline, and angle the probe slightly upward toward the left shoulder until a view of the heart and right lobe of liver is obtained. Ask the patient to bend his knees if able. This view is essentially the subcostal window used in transthoracic echocardiography, and is very useful for detecting the presence of pericardial fluid.

Fig 15. Positive pericardial FAST In this positive scan, the hypoechoic crescenteric areas anterior to the right ventricle and posterior to the left ventricle represent pericardial fluid. Normally, the right ventricle closely abuts the liver and moves with respiration. In the hands of an experienced echocardiographer, the subcostal window is also extremely useful for evaluating cardiac contractility and volume status, detecting cardiac injury and valve dysfunction. However, within the description of the FAST examination, this view Fig 13. Normal subcostal echocardiographic view and should be limited to the detection of pericardial fluid alone. anatomy Pericardial fluid may represent blood from cardiac or aortic injury, but it may also represent an effusion from malignancy, infection, inflammation etc. Care must be

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taken to interpret the findings in the context of the patients history. Pericardial tamponade indicates a severe life-threatening situation mandating pericardiocentesis and/or thoracotomy. The echocardiographic diagnosis of tamponade, particularly after cardiac surgery, is difficult and beyond the scope of this tutorial. However, when there is tamponade physiology (low cardiac output, hypotension and high venous pressures) and demonstrable pericardial fluid in the trauma patient, tamponade and therefore thoracic injury can be assumed. 3. Indications for FAST Many modern evidence-based trauma protocols have included FAST examination as a pivotal axis in the decision to go to laparotomy in the unstable patient. There is also literature favouring the use of ultrasound in stable patients, in penetrating trauma, in chest Fig 17. Algorithm for blunt abdominal trauma - stable trauma and for the detection of peripheral injuries such as bone fractures. Note that a positive FAST scan in a stable patient should lead to further investigation by CT scan according to the above protocol. The advantages of FAST over DPL include speed, non-invasiveness, and specificity. The advantages over CT include speed, portability, and ease of repeated scanning. An experienced operator can perform a FAST in less than 5 mins. Disadvantages of FAST include a significant falsenegative rate, in part due to early examination when only a small amount of fluid is present and not visualised by the scan. Serial examinations and/or DPL are recommended when there is ongoing haemodynamic instability and the initial FAST is negative. Retroperitoneal haemorrhage is a possibility when FAST is negative and there is ongoing shock. Obesity and subcutaneous emphysema may lead to Fig 16. Algorithm for blunt abdominal trauma - unsta- technically difficult or indeterminate FAST examinable tion a DPL may be necessary. FAST is poor at localisation and grading of organ inIn the stable patient, many algorithms also include jury CT has significant advantages in the stable paFAST as a screening tool for intra-abdominal haemor- tient. rhage

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Summary of FAST vs CT vs DPL Speed Sensitivity Specificity Localisation Ease/portability Safety Cost FAST>DPL>CT DPL>CT and FAST CT>FAST>DPL CT>FAST>DPL FAST>DPL>CT FAST>CT>DPL DPL<FAST<CT 5. References and images
Fig 1 www.liv.ac.uk/HumanAnatomy/phd/mbchb/travel/surface1.html Dr P Dangerfield, University of Liverpool Figs 2,3 Meschan I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London Figs 4,5,6,7,8,10,12,16,17 www.trauma.org Dr Ng A. FAST examination Fig 13 http://info.med.yale.edu/intmed/cardio/echo_atlas/views/subco stal.html Yale Atlas of Echocardiography, Yale University Other figures www.sonosite.com www.medical.philips.com.au The FAST examination : The standard sonographic views Sisley et al. J Trauma 1998;44:291-7

4. Evidence

In 3 studies, as a decision making tool for the need for laparotomy in hypotensive patients (BP<90 sys), FAST Wherret LJ, Boulanger BR, McLellan BA et al. Hypotension after had a sensitivity of 100%, specificity of 96% and a blunt abdominal trauma: the role of emergent abdominal negative predictive value of 100% sonography in surgical triage. J Trauma 1996;41:815-820 (Wherret et al., Rozycki et al., McKenny et al.) In the detection of free intra-abdominal fluid when compared to a reference standard such as DPL/CT or laparotomy, FAST had a sensitivity of 75%, a specificMcKenny MG, Martin L, Lentz K et al. 1000 consecutive ultraity of 98% and a negative predictive value of 98% sounds for blunt abdominal trauma. J Trauma 1996;40:607-612 (18 studies, 6324 patients, 1992 to 2000)
Rozycki GS, Ballard RB, Feliciano DV et al. Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg 1998;228:557-567

The minimum amount of fluid that can be detected is ference Committee. Focused Assessment with Sonography for 70 250mls depending on the study (Jehle et al., Trauma (FAST): Results from an International Consensus ConferChambers et al., Goldberg et al.) ence. J Trauma 1999;46:466-472 Minimum standards for training have been released by many groups. The number of scans for official verification programs can be greater than 300 in some centres, but a minimum of 25 scans should be gained before flying solo. A recent study of surgeons who underwent an 8 hour training program attained an accuracy rate of 90% in their FAST examinations (n=5, 48-250 exams per surgeon). Interestingly, studies have shown that the longer the training programme, the better the accuracy of candidates FAST skills.
Rozycki GS, Shackford SR. Ultrasound, what every trauma surgeon should know. J Trauma. 1996;40:1-4 Shackford SR, Rogers FB, Osler TM et al. Focused abdominal sonogram for trauma: the learning curve of nonradiologist clinicians in detecting hemoperitoneum. J Trauma 1999;46:553-562 Godwin S. Introduction to Emergency Ultrasound Jacksonville Medicine Mar 1999 www.dcmsonline.org/jax-medicine/1999journals/march99/ultras ound.pdf Baker MJ. Trauma Ultrasound www.sitemaker.umich.edu/emergus/files/traumaus.pdf

Scalea TM, Rodriguez A, Chiu WC et al. FAST Consensus Con-

ECH O CA RD I O G RA P H Y
Bedside Limited Echocardiography
The recent move toward bedside haemodynamic assessment by portable ultrasound has led to the development of an easily applied, easily taught form of echocardiography that purports to give non-expert echocardiographers the ability to quickly ascertain ventricular function, volume status in unstable patients. Bedside Limited Echocardiography (BLE) or BLEEP (BLE by Emergency Physicians) is gaining popularity in many units and has been employed by intensivists and anesthesiologists for the rapid assessment of unstable patients . This next section of the Ultrasound Workshop aims to give participants a starting point for further training in this specialised technique. The BLEEP does not in anyway replace formal TTE or TOE, and training in BLEEP does not qualify an individual in formal echocardiography which remains a highly specialised technique
Echocardiography Transthoracic (TTE) and transoesophageal echocardiography (TOE) are powerful diagnostic modalities that have been used by cardiologists successfully for many years. The advent of portable technology has increased the attractiveness of these techniques for perioperative use, particularly for cardiac anaesthesia where TOE has found a specialised role. With great power comes great responsibility though, and there are many recommendations for the training and accreditation of echocardiography practitioners within the spheres of anaesthesia and ICU, just as there are for cardiology. It is recommended that expertise in TOE be gained in fellowship level training, in an adequately supervised environment taught by adequately qualied instructors. Typically this might be one year in duration. Formal accreditation by examination such as the NBE PTE exam (Echo boards) should follow. Minimum numbers of supervised TOE procedures have been recommended - 50 (level 1), 100 (level 2), or 150 (level 3), and that the status of the practitioner be advanced accordingly. Ongoing education, audit and review of practice is essential.

Equipment
A portable ultrasound machine with cardiac measurement software, Pulse Wave, Continuous Wave, and Colour Doppler capability as a minimum. An appropriate low frequency, small footprint probe (e.g 15MHz square window) is essential as scanning depths may exceed 16cm. A method of information storage and patient identification is a requisite - internal hard drive, flash card, magneto-optical disk, DVD or direct link via ethernet to PC have all been used successfully. The ability to review exams offline (digitally or by VHS) is desirable A formal report should be entered in the patient record for future reference echocardiography is a diagnostic intervention and formal results should be treated as such.

Method
The Bedside Limited Echocardiogram (BLE) consists of 2 views of the heart - the parasternal short axis view (PSAX) and the subcostal view (SUB). To achieve the PSAX view, position the patient in a semilateral recumbent position as pictured. Place the probe on the left sternal edge and and rotate the index marker to the right shoulder. This should give the long axis view first - once this is attained then rotate the probe 90 degrees clockwise until the index marker points to the left shoulder to give the PSAX view. The long axis view therefore serves as a marking position to achieve the PSAX view.

Probe position for the parasternal views

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end systolic distance (LVESD) and LV end diastolic distance (LVEDD), which then allow calculation of fractional shortening (FS%) which is the change in LV linear dimension during systole FS% = LVEDD-LVESD LVEDD Normal LVEDD = 3.5-5.8 cm Normal LVESD (end systolic dimension) cm (mean + 2SD), Mean 3.1cm Normal FS% = 28 to 44 % Ejection fraction (EF) can be estimated as 2 x FS% The advantage of this form of quantitative analysis is that it is a standardised repeatable measurement. A less objective method of estimating ventricular function can be performed in the PSAX view by eyeballing the ventricles - observing their movement and thickening during the cardiac cycle. An experienced observer can estimate whether global LV function is normal, mildly impaired, moderately impaired, or severely impaired. Regional wall motion abnormalities (RWMAs) can also be seen in the PSAX and graded according to severity, and although not strictly part of the BLE this is used to assess regional myocardial function . 2.2-4.0

Parasternal short axis views

M-Mode measurement of LVEDD and LVESD LV filling assessment can be performed subjectively or objectively in the PSAX but it is not strictly in the description of the BLEEP.

For the purposes of the BLE, the PSAX view is used to formally assess ventricular function by quantitative analysis - M-Mode ultrasound is used to measure LV

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The kissing papillary muscle sign occurs when the LV end systolic volume is low and the papillary muscles touch at end-systole. It is a good indication of hypovolemia when LV end diastolic volume is also reduced. The second view required in the BLE examination is the subcostal view which has been described in the chapter on FAST. The probe must be rotated 90 degrees and angled slightly to achieve a view of the inferior vena cave (IVC) as it courses through the liver from its junction with the right atrium Subcostal View with IVC in long axis A BLE gives therefore valuable information about global LV function and CVP which can be rapidly used by the clinician to assess haemodynamic status. It has been recommended as a tool for the management of the unstable or hypotensive patient in the emergency room or intensive care unit. The function of the BLE is not to replace formal echocardiography which gives a much greater diagnostic yield and requires a much greater degree of formal training to perform and interpret. It is rather an aid to clinical examination in the bedside assessment of unstable patients, fulfilling the role of a FAST exam for the heart and circulation. References
Westmead TOE Manual Dr Lenore George Westmead Hospital Sydney Bedside Limited Echocardiography by the Emergency Physician Is Accurate During Evaluation of the Critically Ill Patient - Jay Pershad, MD*,, Sharon Myers, Cindy Plouman, Cindy Rosson, Krista Elam, Jim Wan, PhD and Thomas Chin, MD, FACC, FACS|| PEDIATRICS 2004-0881 Limited Bedside Echocardiography Performed in the MICURoman Melamed, MD*, Steven Hanovich, MD, Robert Shapiro, MD, Mark Sprenkle, MD, Valerie Ulstad, MD and James Leatherman, MD CHEST 128 (4) : 207S 2005

Probe position for the subcostal view Central venous pressure (CVP) can be estimated by measuring the diameter of the IVC in the subcostal (SUB) view, and eliciting the sniffing sign from a spontaneously breathing patient. This has been well validated by many studies as a means of estimating right sided filling pressures. The following table is used for IVC size vs CVP IVC (cm) Small <1.5 1.5-2.5 1.5-2.5 >2.5 Sniffing collapsed >50% <50% <50% CVP(mmHg) 0-5 5-10 10-15 15-20 > 20

>2.5 + no change dilated hepatic veins