5

X = xiphoid process

Use for bigger patients

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This podcast is on Focused Assessment with Sonography in Trauma, better
known as the FAST exam.
FAST exam is used to quickly evaluate patients in emergency situations. It is
useful to find internal bleeding or free fluids that are not apparent on initial
physical exam following blunt or penetrating trauma. It is particularly useful in
emergency situations because the Fast exam is FAST and if done correctly can
be finished in under 5 minutes.
For FAST scans both a convex or phased array probe may be used. It is best to
keep the ultrasound in abdominal setting for the duration of the exam. Since
the FAST exam is meant to be done quickly, a probe and setting should be
chosen that would allow each view to be seen and no time is spent changing
probes or settings during the exam.
A quick reminder of the purpose of the FAST exam, what can we visualize with
the fast exam?
Internal bleeding or free fluid after blunt or penetrating trauma
In the FAST exam we are looking to find any internal bleeding or free fluid.
There are several important spaces that must be checked during the fast
exam. We will briefly go through each of these spaces and the scans that are
required to view these spaces.
First I want to review some common pathologies we look for in the fast exam.
Pleural effusion is when fluid is found in the pleural of chest cavity
surrounding the lungs. A Hemothorax is an example of a pleural effusion when
there is blood in the pleural cavity.
A hemoperitoneum is when there is blood in the peritoneal, or abdominal,
cavity. This can occur between the liver and kidney on the right side or the
spleen and kidney on the left side of the body.
Finally, a pericardial effusion is fluid in the pericardial sac surrounding the
heart.
In the FAST exam we want to quickly look in four main windows in order to
assess for blood or fluid. First the RUQ, Cardiac, LUQ, Pelvis.
First we will focus on the Right upper quadrant. In this scan place the probe in
the CORONAL position.
Still in the right upper quadrant we next look at the hepatorenal recess. This is
a potential space, meaning normally the liver and the kidney are in direct
contact with each other. The space is only visible if there is fluid between the
two organs. The probe should still be in coronal orientation with the indicator
pointed toward the head. From the previous view of the diaphragm and liver
you will fan the prove posteriorly to aim the sound waves at the kidney.
In the Right upper quadrant we will look in several spaces. First, we want to
look for a mirror image artifact of the liver across the diaphragm. Remember,
a mirror image artifact of the liver is NORMAL. If black is seen across the
diaphragm that is indicative of the presence of fluid in the chest cavity or a
Pleural Effusion.
In the same quadrant we will also look in the hepatorenal recess, or
Morrisons pouch. Here we look for any abnormal fluid between the liver and
kidney. A hemoperitoneum, or fluid in the abdominal cavity may appear in
this area of the abdomen.

We do the right upper quadrant first because the hepatorenal recess in the
peritoneum is the most common place for fluid to accumulate in a supine
patient following blunt trauma.
Here is a normal example of the mirror image artifact seen across the
diaphragm. On the right we see the liver, the bright hyperechoic line is the
diaphragm and to the left we see the mirror image of the liver across the
diaphragm. The mirror image is a grainy image that has a similar echogenicity
as the liver on the right.
Here is a perfect example of abnormal scan in the upper right quadrant. Here
we see a pleural effusion, or fluid in the chest cavity. We can see the kidney,
liver, diaphragm and on the left black, which in ultrasound, shows the
presence of fluid. If the chest cavity and lungs were normal the air of the lungs
would scatter the ultrasound and in result we would see a mirror image of the
liver. Instead when the chest cavity has fluid black is seen like you can see
here.
Here we see a side by side comparison of a normal ultrasound scan and an
abnormal ultrasound showing a hemothorax. Which scan do you think shows
a hemothorax?

Corrrect the hemothorax is seen here on the left. On the right at the white
arrow we can see the normal mirror image artifact of the liver across the
diaphragm, however on the left we are seeing black showing the presence of
abnormal fluid.
Remember that Morrison’s pouch is a potential space and normally there will
be no space seen between the kidney and the liver. Here on the left we see
the typical grainy texture of the liver and on the right the hyperechoic cortex
of the kidney.
On the right is an example of fluid within morrison’s pouch. This yellow
indicates abnormal black seen in the ultrasound where fluid should not be
accumulating
As a reminder what is it called when there is fluid found in this region?
Hemoperitoneum.
See if you can identify what numbers 1 2 and 3 are.
Just to review lets go through and remember what each object in this image
is. The abnormal fluid is seen here in red. In the middle we see the liver, to the
right is the kidney and large hyperechoic line to left next to the liver is the
diaphragm.
Time for a quick question
The second view done in the FAST exam is the subxiphoid view. This is quick
way to view around the heart and check for a pericardial effusion. It is also a
quick way to check if the heart is beating in an extreme trauma situation.
Listen to the cardiac lecture for a full review on the subxiphoid view of the
heart. Remember to start with the probe on the upper right abdomen pointed
toward the chin in a transverse view. Sweep the probe toward the midline.
The main goal of the FAST exam is to quickly check for fluid around the
pericardial sac. In doing so it is ideal to keep the ultrasound in abdominal
setting and not spend time changing the settings during the exam. This
means the indictor should be pointed to the right

This is an animation of the view that is seen in ultrasound, because of the way
the heart is situated in the chest cavity the ultrasound probe will first hit the
right ventricle and atrium and they are seen on the top of the screen in an
ultrasound scan.
Here we can see a normal subxiphoid view on the right and an example of a
pericardial effusion of the left. Here on the right we see the bright
hyperechoic pericardium sitting right next the left ventricle and atrium.

On the left we see fluid between the walls of the heart and the pericardium,
highlighted by the yellow here
Here is another example of a pericardial effusion in the subxiphoid view. We
can see fluid between the pericardial sac and the walls of the heart on both
the inderior and superior sides of the heart.
Which of these two views shows a pericardial effusion? Correct we can see a
pericardial effusion on the right, outlined by this yellow structure.
In this region we are looking for the splenorenal recess, the area between the
spleen and the left kidney. When looking into the splenorenal recess we still
want to have the probe in the coronal orientation with the indicator toward
the patient’s head. This recess is typically found more superiorly and posterior
as compared to the hepatorenal recess on the right side of the body. It can
help to angle the probe diagonally posteriorly toward the bed.
The third view for the FAST exam is the left upper quadrant. In the Left Upper
quadrant we are again looking for a loss of mirror image artifact across the
diaphragm. A mirror image is normal, if black is seen across the diaphragm it
is abnormal and may be a pleural effusion as we saw in the right upper
quadrant.

We are also looking for fluid between the spleen and kidney- the splenorenal
recess. If we see fluid in the abdominal cavity this may be a sign of a
hemoperitoneum.
This is a normal ultrasound of the left upper quadrant. Across the diaphragm
we do see a mirror image artifact, again, this is normal.
In this scan we can also see the point where the spleen and kidney meet and
we see no black or signs of a hemoperitoneum outlined here in red.
Let’s look at the spleen a little more closely. The spleen has similar texture in
ultrasound as the liver.
What does that make this white line the arrow is pointing to? Correct, the
diaphragm.

We saw pleural effusion before in the right upper quadrant. Does this patient
here have a pleural effusion?
No we can see the mirror image artifact on the far left of the screen indicating
there is no apparent pleural effusion.
In this example the spleen is seen on the left and the kidney on the right. Here
abnormal black space is seen representing fluid in the splenorenal recess.
Remember this is abnormal! The splenorenal recess is a potential space and
only has fluid in the case of disease
Here is another example of abnormal fluid found in the chest and abdominal
cavities. On the left of the screen we see there is no mirror image artifact
across the diaphragm and instead black is seen, representing fluid in the chest
cavity.
On the right we see black fluid surrounding the spleen and in the splenorenal
recess.
The fourth view in FAST in the suprapubic view. It is important to consider the
differences in male and female anatomy when performing the suprabpubic
portion of the FAST exam.

First let’s review the basic female anatomy.

The female pelvic region has three main organs. From anterior to posterior
they are:
-The Bladder
-The Uterus, which to extends laterally as the
fallopian tubes that project to the ovaries. The uterus extends as the cervix
and ends as the vagina
-Finally, we have the last organ, the rectum
The space between the bladder and the uterus is the Vesico-uterine pouch
and the space between the uterus and the rectum is the recto-uterine pouch,
also known as the Pouch of douglas.

In the male we only see one pouch, the recto-vesicular pouch between the
bladder and the rectum.
You can view the suprapubic region in two views, either sagittal or transverse.
In the sagittal plane keep the indicator toward the patient’s head and scan
right and left to see the whole bladder. In the transverse view the indicator
points toward the patient’s right and be sure to scan inferiorly to see the
whole bladder.

It is important to look in both the sagittal and transverse views at the kidney
to check for free fluid laterally, posterior and anteriorly to the bladder and
other pelvic structures.
This is an example of a suprapubic sagittal view in a male patient. The bladder
is the large anaechoic image on the right of the screen.
Remember the bladder is full of liquid making it low attenuating in ultrasound.
This makes everything behind it in ultrasound look bright, this is called
posterior acoustic enhancement. You may want to adjust by turning down the
far field gain. For review on this you may re-listen to the podcast on
ultrasound knobology.
SO this image is normal and there is no evidence of free fluid around the
kidney seen in this view.
In this sagittal view of a male, can you see the free fluid?
That is correct, there is free fluid visible as anaechoic structures in two places
in this scan.
Here is an example of a sagittal view of a female patient. Female patients are
more complicated since there are more organs present. From left to right we
see the rectum, the recto uterine pouch, the uterus, the vesicouterine pouch
and the bladder. Suprapubic views of the bladder may vary widely in females
because of the different possible positions of the kidney.

There is no evidence of free fluid in this scan because there are no anechoic
objects seen between any of the organs.
Here is a second example of a sagittal suprapubic ultrasound in a female. This
image is quite different than the last slide showing that female pelvic organs
can vary but it is important to scan through the spaces between the organs to
check for free fluid no matter the orientation while performing the FAST
exam.
Here is a sagittal female ultrasound and a large anaechoic area is seen both
between the uterus and the bladder FF in this image.

We can also see to the left of the image free fluid between the uterus and the
rectum.

There is clear evidence of abnormal free fluid surrounding the uterus in this
ultrasound scan
Now we will look at the pelvic organs in a transverse view. Remember we also
want to use the transverse view to make sure we check for fluid around the
entire bladder.
On the left we clearly see the bladder and no other anechoic structures near
the surface of the bladder.

On the right we do see evidence of free fluid. This arrow points to the
anaechoic area outside of the walls of the bladder. This is abnormal.
Here is a transverse view in a female that shows free fluid accumulation in the
pelvic area. At the top of our screen in a transverse view we will see the
bladder
Inferiorly to the bladder is the uterus. In this image we see black surrounding
the uterus Here and HERE, indicative of abnormal free fluid.
Correct we can see fluid in two spaces, first to the far left of the screen across
the diaphragm we see fluid in the pleural cavity. Secondly there is fluid
present in the hepatorenal recess on the right side of this image.

What orientation was the probe? Remember the probe is kept in a coronal
orientation on the right and left upper quadrants.