Clinician-performed focused sonography for the resuscitation

of trauma
Andrew W. Kirkpatrick, MD, FRCSC, FACS

Traumatic death remains pandemic. The majority of prevent-
able deaths occur early and are due to injuries or physiologic
derangements in the airway, thoracoabdominal cavities, or brain.
Ultrasound is a noninvasive and portable imaging modality that
spans a spectrum between the physical examination and diag-
nostic imaging. It allows trained examiners to immediately con-
firm important syndromes and answer clinical questions. Newer
technologies greatly increase the fidelity, accessibility, ease of
use, and informatic manipulation of the results. The early bedside
use of focused ultrasound as the initial imaging modality used to
detect hemoperitoneum and hemopericardium in the resuscitation
of the injured patient has become an accepted standard of care.
Widespread dissemination of basic ultrasound skills and technol-
ogy to facilitate this brings ultrasound to many resuscitative and
critical care areas. Although not as widely appreciated, the fo-
cused use of ultrasound may also have a role in detecting hemo-
thoraces and pneumothoraces, guiding airway management, and
detecting increased intracranial pressure. Intensivists generally
utilize a treating philosophy that requires the real-time integration
of many divergent sources of information regarding their patients’
anatomy and physiology. They are therefore positioned to take
advantage of focused resuscitative ultrasound, which offers im-
mediate diagnostic information in the early care of the critically
injured. (Crit Care Med 2007; 35[Suppl.]:S162–S172)
KEY WORDS: ultrasound; injury; resuscitation; physical examina-
tion; thoracic injury

A s evidenced by the contents of
this supplement, ultrasound
(US) is being used as an all-
purpose diagnostic and thera-
peutic tool in the critically ill. There are
many complementary medical imaging
modalities available today that allow pre-
cise and detailed imaging of the human
body. Computed tomography (CT), mag-
netic resonance, and angiography are op-
tions, but none are as accessible, safe, and
repeatable as US. US can precisely delin-
eate cardiac function, examine blood flow
to the brain, direct percutaneous aspira-
tion and cannulation, and detect venous
thromboses, among a myriad of other
utilities, when used by experts. In the
early minutes to hours after severe in-
jury, however, US can particularly assist
the clinician by combining the physical
examination with a focused goal-directed
From the Departments of Critical Care Medicine
and Surgery, Foothills Medicine Centre, Calgary, Al-
berta, Canada.
The author has not disclosed any potential con-
flicts of interest.
Supported, in part, by the Dr. Derrick Thompson
Grant of the Canadian Intensive Care Foundation.
For information regarding this article, E-mail:
andrew.kirkpatrick@calgaryhealthregion.ca.
Copyright © 2007 by the Society of Critical Care
Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/01.CCM.0000260627.97284.5D
test that can immediately confirm life-
threatening diagnoses. Although focused
US is typically interpreted in real-time
analog format, it represents anatomy and
physiology captured in a digital format.
US is also typically the first imaging that
can be brought to the critically injured,
often in remote or hostile settings (1, 2).
Traumatic Injury: A Continuing
Epidemic
Despite progress, trauma remains the
leading cause of death among people
15– 44 yrs of age (3). Trauma is also a
leading cause of death in low and middle
income countries, constituting 16% of
the world’s burden of disease (4). Al-
though the concept of the “golden hour”
is now ⬎20 yrs old, the majority of pre-
ventable trauma deaths still occur early
in hospitalization (5), constituting up to
48% of trauma deaths even in the West-
ern world (6). These fatalities are time-
dependent (7) and involve management
of the airway (7), thoracic injuries (6, 7),
and control of shock and hemorrhage (6,
8). Deaths from traumatic brain injuries
(TBI) are more frequent (42%) than hem-
orrhage (39%) (9), but primary therapies
for TBI remain limited at this time (10).
Recognizing these areas are a critical fo-
cus for clinicians, this article will specif-
ically examine the role of focused clinical
US in the initial assessment and resusci-
tation of the injured.
Origins of the Focused
Assessment with Sonography
for Trauma
US is a simple, portable, repeatable
test that involves no radiation and can be
completed at the bedside in seconds to
minutes. Its rapid ability to detect free
fluid as a marker of serious injury has
supported the dissemination of US into
resuscitative suites around the world and
introduced clinicians to the US-enhanced
physical examination (11–13). The pub-
lished evidence reflects the fact that any
discipline that, or individual who, under-
takes a commitment to learn, practice,
and review their results can attain profi-
ciency (14 –22). A focused screen to iden-
tify free intraperitoneal and intraperi-
cardial fluid constitutes the Focused As-
sessment with Sonography for Trauma
(FAST) (23). The term itself emphasizes
both the “focused” nature and the fact
that it is not limited to the abdominal
cavity. European and Asian investigators
initially used US to examine injured pa-
tients, quickly accepting it into their
practices and surgical curriculums (24).
Although the first North American report

S162 Crit Care Med 2007 Vol. 35, No. 5 (Suppl.)

was in 1992 (19), the FAST became
widely accepted so that within 7 yrs, it
had replaced the diagnostic peritoneal la-
vage as the initial screening modality of
choice for severe abdominal trauma in
⬎80% of North American centers sur-
veyed (25). The FAST is now taught in the
Advanced Trauma Life Support course
(26). Practice management guidelines
from the Eastern Association for the Sur-
gery of Trauma recommend it be consid-
ered the initial diagnostic modality to ex-
clude hemoperitoneum (27).
The FAST has been reported to guide
care, to save time and money, and to
reduce radiation exposure (28 –30). A
prospective nonrandomized trial of FAST
use recorded changes in management
plans in 33% of cases after FAST (12).
The FAST was quickly accepted into clin-
ical practice, predominantly based on the
premise that it could expedite triage of
the seriously injured. Hemorrhagic
deaths have been identified as the leading
cause of potentially preventable injury-
related death (31), causing 80% of early
hospital deaths, being most frequently
abdominal (32). Shock, synonymous with
cellular hypoxia, is time critical. Unfortu-
nately, the clinical abdominal examina-
tion is often inaccurate due to distracting
injuries, altered consciousness, and non-
specific signs and symptoms (13, 33, 34).
An autopsy study reported that abdomi-
nal injuries were the most frequently
missed conditions in traumatic emer-
gency department deaths, including a
number of potentially salvageable pa-
tients who had been transferred from
other hospitals (35). A patient who is ex-
sanguinating and requires a splenectomy
may have an identical physical examina-
tion to one who is dying from retroperi-
toneal bleeding, in whom laparotomy
might be detrimental. Transporting such
patients for CT scanning is contraindi-
cated, and thus, the diagnostic peritoneal
lavage had been favored as the preferred
modality to confirm intraperitoneal
blood. The diagnostic peritoneal lavage is
generally safe, but it has complications, is
time consuming, and forever changes the
results of physical examination and sub-
sequent imaging (36).
Expediency
With experience, the FAST can give
almost instantaneous positive results
when used to localize the major source of
hemorrhage in unstable patients (21). In
such circumstances, the primary goal is
Crit Care Med 2007 Vol. 35, No. 5 (Suppl.)
to detect large fluid collections, analo-
gous to a grossly positive diagnostic peri-
toneal lavage. A number of authors have
reported that among hypotensive cohorts
requiring laparotomy, all had positive
FAST examinations (20, 21, 37), includ-
ing children (38) and adults examined
with handheld machines (39). In hypo-
tensive patients, a massive hemoperito-
neum can quickly be detected with a
single view of the Morison pouch in 82–
90% of cases (21, 40), requiring a deter-
mination time of 19 secs on average (21).
A negative FAST takes longer to perform,
as the examiner can conclude a positive
determination with identification of a
single area, unless using a scoring system
requires evaluation of all peritoneal sites.
Although negative or minimally positive
FAST examinations may still represent
significant pathology, they direct the
search for the major site of bleeding
away from the peritoneal cavity (20, 41).
Wherrett et al. (21) reported that none of
47 hypotensive patients with a negative
FAST required acute laparotomy for hem-
orrhage control. Further, the FAST was
negative in all but one with a retroperi-
toneal bleeding source, in whom it was
only trace positive (21). Recognizing that
bedside US can address the detection of
multiple life-threatening conditions, a
number of groups have recently formalized
resuscitative protocols for the patient with
undifferentiated hypotension. These proto-
cols emphasize the expedient detection of
hemoperitoneum, pericardial effusion, and
ruptured aortic aneurysms (42, 43) and the
focused evaluation of cardiac function in
trained hands (44).
Figure 1. Sonographic image of hepatorenal space (Morison pouch) demonstrating free fluid (arrow)
contrasted between the liver and right kidney. The patient was found to have an intraperitoneal bladder
rupture at laparotomy.
When making such decisions, it is cru-
cial that the sonographic windows have
been well visualized—meaning determi-
nate. In a small but significant number of
trauma patients, the FAST is indetermi-
nate, as the examiner is unable to visu-
alize the reference organs well enough to
make a determination (45, 46). The most
common causes are obesity and subcuta-
neous emphysema (45). In such settings,
the clinician should not consider the
FAST results in decision making.
Conduct of the Examination
The ultimate goal of the FAST is to
quickly localize fluid contrasted against
recognizable organs. For introductory
and training purposes, the basic FAST
technique was defined as the real-time
examination of four torso regions (four
Ps): pericardial, perisplenic, perihepatic
(Morison pouch), and pelvic (pouch of
Douglas) (13, 23). To interrogate these
areas, the US probe is typically first
placed in the subxiphoid area and di-
rected toward the patient’s left shoulder
to provide a four-chamber view of the
heart. The Morison pouch is then identi-
fied using a right intercostal view to iden-
tify any anechoic fluid between the liver
and right kidney (Fig. 1). The left inter-
costal view interrogates the interface be-
tween the spleen and left kidney, and
pelvic views examine for fluid around a
full bladder. Practically, the examination
is done before a bladder catheter is
placed, with the catheter placed and
clamped, or with fluid instilled into the
catheter if the bladder has been drained.
S163
 Others have augmented these basic
anatomic locations. Sisley et al. (47) and
Ma et al. (16) have recommended adding
supradiaphragmatic views for the detec-
tion of pleural fluid. Others routinely ex-
amine the pericolic gutters for fluid (28,
48). Maneuvers that increase the accu-
racy of scanning include repeated exam-
inations intended to detect newly accu-
mulated fluid from ongoing visceral leak
or bleeding. Blackbourne et al. (49) dem-
onstrated an increase in FAST sensitivity
from 31% to 72% in a select population
with few true positive scans by repeating
the FAST within 24 hrs. This is supported
by consensus recommending follow-up
FAST examinations and ⱖ6 hrs of clinical
observation before accepting a FAST as Figure 2. Sonographic image of pericardial fluid (arrows) that was hemodynamically compromising.
negative (23). The Advanced Trauma Life
Support course recommends a “control”
scan be repeated after a 30-min interval
(26). The patient may also be positioned
in Trendelenburg position to facilitate
fluid accumulation in the Morison pouch
(50). In practice, however, the most crit-
ically ill would typically be undergoing
definitive interventions or able to un-
dergo a CT scan within 30 mins of hos-
pital arrival.
If the patient is stable, initial evalua-
tion of the pericardial site allows gain
settings to be optimized for blood (47). If
the patient is unstable, the Morison
pouch may provide the quickest clinical
direction. A review of ⬎10,000 patients
confirmed that the right upper quadrant
or the Morison pouch as the most likely
place to detect major hemoperitoneum. Figure 3. Formal echocardiographic study that reveals an acute posttraumatic flail mitral valve leaflet
The Morison pouch was positive 86% of (arrow).
the time, whereas the left upper quadrant
and pelvis were only positive 55% and
43% of the times, respectively (47). the FAST (23). Some clinical series have resuscitation, the continued adoption
reported sensitivities of 100% and speci- and experience with echocardiographic
Pericardial Component ficities of 97–99% for identifying free skills in critical care provides an oppor-
pericardial fluid (16, 53). tunity for expedited diagnoses that might
Cardiac tamponade is a form of ob- Blunt cardiac injury refers to a spec- improve the care of this group.
structive shock for which clinical presen- trum of injuries ranging from simple
tation can vary from subtle to cata- electrocardiographic changes to free wall FAST as the Definitive
strophic. Although penetrating wounds rupture (54). Cardiogenic shock from Abdominal Imaging Test
to the precordium are typically obvious, a blunt cardiac injury is uncommon in sur-
high index of suspicion is required in vivors to hospital, although cardiac inju- In current practice, trauma US has
blunt trauma. Classic signs such as ries are common in autopsy series (51). taken on two congruous yet distinct
tachycardia, muffled heart sounds, and When pump dysfunction occurs after roles. One is the early identification of
increased venous pressure are easily blunt injury, it presents an exceedingly unstable trauma victims requiring urgent
missed (51). The FAST may quickly iden- difficult diagnostic challenge that may surgical interventions (40), and the other
tify pericardial fluid, allowing for imme- only be resolved with formal echocardi- more controversial role, is that of exclud-
diate bedside interventions or expedited ography (51, 55) (Fig. 3). Although de- ing stable patients from further abdomi-
transport to an operating room (16, 20, tecting intrapericardial fluid is well nal imaging (14, 15, 56 –58). A number of
52) (Fig. 2). Early FAST studies variably within the capability of clinicians, evalu- centers have reported on the efficiency of
included an examination of the pericar- ating cardiac function requires dedicated using the FAST as the sole abdominal
dial sac. Subsequently, consensus has training. Although this skill level is cur- imaging modality in hemodynamically
been to consider this a standard region of rently largely unavailable during trauma stable patients without high clinical sus-

S164 Crit Care Med 2007 Vol. 35, No. 5 (Suppl.)

picion of injury. A number of larger series
have shown this to be safe (20), with no
deaths related to missed injuries being
reported (37, 46, 59). Much of this evi-
dence accrues from larger series of pa-
tients with low injury acuity or in whom
there were few positive results (20, 37).
Clinicians need to be keenly aware of the
limitations of trauma sonography. It is a
very user-dependent examination. The
FAST may miss injuries that are not as-
sociated with free intraperitoneal fluid,
such as hollow viscus, mesenteric, intra-
parenchymal solid, or retroperitoneal in-
juries (59 – 62). Some recent series have
reported sensitivities as low as 31– 42%
(49, 62, 63). These injuries may also be
missed by CT, emphasizing that no im-
aging test is foolproof. Although CT
scanning will detect more pathology,
injuries detected often have no clinical
influence (49).
Algorithms to Reduce the Risk
of Missed Injuries
Identifying markers may direct pa-
tients at higher risk of sono-occult inju-
ries to undergo CT. These include severe
or persistent abdominal pain, seat-belt
signs or other abdominal wall contu-
sions, pulmonary contusion, hematuria,
or fractures of the lower ribs, spine, or
pelvis (20, 20, 37, 46, 64). Centers that
rely on sonography technicians have sug-
gested bypassing FAST for a screening CT
in these situations (37), although consid-
ering the FAST as a required component
of the physical examination is an alter-
nate philosophy.
Organ-Specific Injuries and
Focused Sonography
Accurate depiction of organ injury in
stable patients has revolutionized the
care of hemodynamically stable patients,
permitting successful nonoperative man-
agement in many cases. If the FAST ex-
amination is being used as a sole diagnos-
tic test, the ability to delineate specific
organ injuries is greatly diminished.
Groups with greater skills, however, have
demonstrated that US can detect specific
organ injuries. Holm and Mortensen (65)
set the stage for using US in the trauma
setting in 1968, reporting the identifica-
tion of a splenic rupture with associated
hematoma. In experienced hands, a sono-
graphic examination can identify specific
parenchymal injuries (57, 66 – 69), gener-
ally finding a greater sensitivity the
Crit Care Med 2007 Vol. 35, No. 5 (Suppl.)
higher the severity of injury (63, 67, 68).
Contrast-enhanced US may improve the
accuracy of solid organ imaging and re-
veal active contrast extravasation related
to active bleeding (70, 71). These studies
often rely on technicians or radiologists
(57, 67, 68), potentially reducing the
availability. The emphasis of the FAST is
simplicity, intended to be within the capa-
bilities of an on-site clinician. Thus, US
delineation of organ detail may warrant
further evaluation at patient follow-up
rather than at initial resuscitation.
Scoring Systems
Although the standard FAST is binary,
with any fluid constituting a positive re-
sult, authors have explored whether free
fluid can be quantified and whether this
might direct care. Huang et al. (72)
scored hemoperitoneum from 0 to 8, cor-
relating a score of ⱖ3 with 1000 mL of
intraperitoneal fluid. This was corrobo-
rated by Boulanger et al. (25), who noted
all hypotensive patients with a score of
ⱖ3 underwent therapeutic laparotomy.
McKenney et al. (73) described another
system that added 1 point for each of up
to four peritoneal regions to the depth in
centimeters of a fifth potential region.
When the hemoperitoneum score was
⬎3, 87% required a laparotomy, includ-
ing 89% of those who were initially nor-
motensive but deteriorated in shock
within 4 hrs. In the subacute phase of
care, hemoperitoneum scoring may have
utility in the nonoperative management
of solid organ injuries (63). Although no
single system has been universally ac-
cepted, future evaluation might consider
newer technologies. Three-dimensional
US seems to be a reliable and reproduc-
ible method of measuring irregular fluid
and blood collections (74, 75). Fully au-
tomated volume calculations combined
with transducers that automatically per-
form real-time sweeps of a predefined area
(four-dimensional) (75, 76) offer the poten-
tial for generating continuous real-time as-
sessment of visceral hemorrhage (77).
Evidence-Based Medicine
Despite the enthusiasm for the FAST,
well-validated scientific proof of utility
remains sparse. This criticism is easily
applied to the majority of care provided to
the critically ill, given the complexity of
the patents and inherent difficulties
studying them. Stengel et al. (78 – 80)
have performed a series of ongoing sys-
temic reviews, concluding that there is
insufficient evidence to justify the pro-
motion of US-based clinical pathways in
suspected blunt trauma (80). It is impor-
tant to note that there were insufficient
data to discriminate between hemody-
namically stable and unstable patients (a
critical distinction), trivial and nontrivial
injuries, or initial and repeated examina-
tions (79). An analysis of 62 publications
with 18,167 patients revealed an overall
sensitivity of 79% and a specificity of
99.2% for detecting free fluid, organ
damage, or both (79). Methodologic rigor
had a major effect on accuracy, with less
rigorous studies reporting higher accu-
racy. Overall, they corroborate that the
FAST has moderate sensitivity; when it
detects injuries or fluid it is decisive, but
a negative FAST should not be trusted
because the likelihood ratios of a negative
test were 0.2 to 0.35.
Inclusion in the Cochrane review re-
quired comparisons between the FAST
examination and either diagnostic perito-
neal lavage or CT scan (80). Although
these analyses are methodologically cor-
rect if one considers the FAST a stand-
alone diagnostic test, they may not reflect
the utility of using the FAST as a sub-
component of an algorithm or as simply
an extension of the physical examination.
A dedicated effort to elucidate the true
worth of the FAST would need to focus on
specific homogeneous patient groups,
notably hemodynamically unstable pa-
tients, and compare the physical exami-
nation with the FAST. All other aspects of
care of these complicated patients would
also need to be rigidly standardized, pre-
senting a monumental challenge. The ap-
propriate studies to allow meta-analytic
study may never be done. Clinicians have
come to depend on the FAST to the point
that they would not accept a control group
of patients. For example, a randomized trial
of the FAST examination was terminated
early because the investigators thought
they could no longer justify as ethical the
withholding of the FAST examination from
eligible patients (28).
FAST Examination for
Penetrating Trauma
The ability to quickly delineate major
abdominal fluid collections after pene-
trating thoracoabdominal trauma directs
operative planning. Asensio et al. (81) re-
gretted a limited use of early FAST in
directing surgical sequencing and
strongly recommended its increased
S165
use. A majority of surveyed US centers
reported using FAST for penetrating
trauma (25), and meta-analysis showed
no accuracy differences between studies
including and excluding penetrating
trauma (79). Studies have demonstrated
excellent specificities (94 –100%) but
only modest sensitivities (46 –71%) (52,
82, 83). Thus, a positive FAST is a strong
predictor of injury and should immedi-
ately direct patients to laparotomy,
whereas negative tests should prompt an-
other diagnostic strategy (83).
Hand-Carried Ultrasound
A number of portable handheld US
units have recently become available to
clinicians. The first such units were de-
veloped through a joint civilian–military
initiative to provide portable US capabil-
ities suitable for battlefield or mass casu-
alty situations (84). The primary benefit
of these devices for trauma care providers
will be earlier diagnosis, potentially even
in the prehospital setting, to expedite
transport priorities and disposition. Al-
though the fidelity and image quality of
early hand-carried US units did not
match that of the standard floor-based
machines, their diagnostic performance
regarding the FAST examination seems
comparable (11, 39, 85). This class of US
has been tested in many adverse envi-
ronments and found to be clinically
useful (2, 86 – 88).
Future of the FAST Examination
After an initial wave of enthusiasm,
the limitations of the FAST have been
more widely appreciated. These are
mainly its inability to detect injuries not
associated with free fluid and its general
inability to quantify the degree of organ
injury. In the decades since the North
American introduction of FAST, CT scan-
ning has made remarkable progress in
capabilities to become indispensable in
trauma care. This had led to routine use
of nearly whole-body CT scanning (89).
Although invaluable, CT scanning greatly
increases radiation exposure (90, 91).
With liberal use, this imparts a small but
finite risk of later cancer, especially in
younger patients (91). In one study, CT
contributed 97.5% of the total effective
radiation dose from all imaging in trau-
matized children (91). Optimal CT scan-
ning also requires nephrotoxic contrast
agents. US and CT scanning should thus
be used as complementary tests, with CT
S166
being of higher fidelity but with US being
readily repeated during the initial en-
counter and during routine reassess-
ments. How much should the medical
system pay to detect all the injuries de-
tected on CT that do not influence
medical care is a societal question that war-
rants formal economic analysis. Balancing
the FAST’s limitations, however, is the rap-
idly increasing scope of the examination to
encompass the entire primary Advanced
Trauma Life Support survey.
Extended FAST and Thoracic
Trauma
To save lives, the resuscitating clini-
cian must efficiently address life-threat-
ening thoracic injuries, which are re-
sponsible for 25% of trauma deaths (92,
93). Life-threatening thoracic injuries
that should be detected during a primary
survey include tension pneumothoraces
(PTXs), massive hemothoraces, cardiac
tamponade, and flail chest injuries (93).
Rib fractures are the most common seri-
ous thoracic injury and pneumothoraces
are the most common intrathoracic in-
jury after blunt trauma (92, 93). In all
these settings, focused US can provide
rapid diagnosis.
Hemothoraces
Sisley et al. (47) demonstrated that
thoracic sonography utilizing the same
probe used for the FAST examination
could accurately detect acute traumatic
effusions. US was 97.5% sensitive and
99.7% specific compared with chest radi-
ography’s (CXR’s) 92.5% and 99.7%, re-
spectively. Ma et al. (16) also demon-
strated a 96% sensitivity and 100%
specificity. Medical students can be
trained in short periods of time to detect
pleural fluid collections in critically ill
patients (47). This experience has led
many investigators to augment the stan-
dard FAST examination with routine
views of the pleural space.
Pneumothoraces
The direct depiction of a pneumotho-
rax by US is physically impossible because
air has extremely high acoustic imped-
ance, which causes almost complete re-
flectance of sound waves. Thus, only ar-
tifacts are seen deep to the pleura in the
normal lung (94). As both hemothoraces
and pneumothoraces are pleural-based
diseases, the underlying lung does not
need to be seen to detect them. The con-
cept of using US to exclude or infer the
presence of a PTX relies on the premise
that if the pleural surfaces are in apposi-
tion, then intrapleural air cannot be
present. The focused goal of the sonogra-
pher is simply to identify the contiguity
of the visceral and parietal pleura using
simple sonographic signs. We consider
this to be an extended FAST (EFAST)
(95).
Unless there are pleural adhesions
from previous disease or injury (a condi-
tion thus reducing the risk of PTX), nor-
mal respiration is associated with a phys-
iologic sliding or gliding of the two
pleural surfaces on one another, known
as lung sliding (LS) (95–98). LS is least at
the apices and greatest at the lung bases
(96). “Comet-tail” artifacts (CTAs) are re-
verberation artifacts that arise from dis-
tended water-filled interlobular septa un-
der the visceral pleura. They can be
considered the US equivalent of “Kerley
B-lines” (96, 99). Being related to the
visceral pleura, they can only be seen
when the visceral pleura is in apposition
to the parietal pleura (Fig. 4). The
marked difference in acoustic impedance
between the parietal pleura and a PTX
creates a marked horizontal reverbera-
tion artifact seen as the mirror image of
the chest wall. Lichtenstein et al. (100)
designate this the A-line, a brightly echo-
genic line recurring at an interval that
exactly replicates the interval between
the skin and pleural line.
Examining the pleural interfaces with
the color power Doppler mode can en-
hance the depiction of LS by emphasizing
motion, a finding designated the power
slide (101). Color power Doppler docu-
ments a physiologic process as a single
image, allowing for simpler archiving and
teletransmission. Similarly, the use of M-
mode documents the presence of LS (the
seashore sign) (Fig. 5) or its absence with
PTX (the stratosphere sign) (Fig. 6), as
the pleural movement will normally gen-
erate a homogeneous granular pattern
(96, 100). Another sign well documented
in M-mode is the “lung point”; when the
lung intermittently contacts the parietal
pleura with inspiration, thus regularly al-
ternating between the seashore and
stratosphere signs (Fig. 7).
The first description of the use of US
to investigate pneumothoraces was re-
ported in a veterinary journal in 1986
(102). Subsequent descriptions followed
after lung biopsy (94, 103, 104), in the
medical intensive care unit (105–107),
Crit Care Med 2007 Vol. 35, No. 5 (Suppl.)

Figure 4. Comet-tail artifacts (arrows) demonstrated on sonographic image of left chest of a patient
with acute respiratory distress syndrome.
Figure 5. Beach sign of normal pleural sliding deep to stationary chest wall, depicted using M-mode
ultrasound function.
Figure 6. Stratospheric sign of pneumothorax with absence of any pleural movement.
and in a mixed group that included stable
trauma patients (108). Thereafter, the fo-
cused use of US to assess PTXs received
impetus from a space medicine problem
Crit Care Med 2007 Vol. 35, No. 5 (Suppl.)
(97, 109). The International Space Sta-
tion supports US as the only diagnostic
imaging modality in an environment
with increased PTX risk (110, 111). This
prompted further investigations to eval-
uate the diagnostic potential both on
earth (95, 112), and in weightlessness
(110), suggesting that US is equal if not
more accurate than supine radiography
for detecting PTXs (98, 110, 113).
Lichtenstein et al. (100, 105–107)
have extensively studied the sonographic
diagnosis of PTXs. The “meaningful” CTA
(B-line) has five mandatory features: aris-
ing from the pleural line, well-defined
(laser-beam like), spreading to the screen
edge, erasing the A-lines, and moving
with LS (Fig. 2) (100). These specific fea-
tures distinguish it from the Z-line, a
CTA that is ill-defined, vanishes after a
few centimeters, does not move with LS,
and that seems devoid of pathologic
meaning (100). Subcutaneous emphy-
sema creates specific CTAs that rise above
the pleural line, resulting in an indeter-
minate examination. Subcutaneous em-
physema itself carries a seven-fold in-
creased risk and 98% specificity for
occult PTX, providing an indication for
chest drainage in the unstable patient
(114).
Occult Pneumothoraces
Several groups have reported on the
utility of US as an adjunct to the CXR
(112, 115). By using CXR as the gold
standard, however, these studies, by def-
inition, ignore the issue of occult pneu-
mothoraces, PTXs seen on CT but not on
CXR (114, 116). Their prevalence may
range up to 64% in intubated multi-
trauma patients (117). In centers using
frequent CT scan, more than one half of
all PTXs may be occult (95, 98, 113, 116,
118). Considering only PTXs seen on
CXRs considerably underestimates the
potential of the EFAST. Due to the effect
of gravity, the supine lung hinges dor-
sally, with air collecting anteromedially
(119, 120). Supine PTXs are most com-
monly anterior (84%), apical (57%), and
basal (41%), corresponding to the most
accessible chest locations for US (121).
Lichtenstein et al. (100) retrospec-
tively evaluated 200 consecutive intensive
care unit patients corroborated with CT.
The absence of LS alone had 100% sen-
sitivity but only 78% specificity for diag-
nosing occult pneumothoraces. When an
A-line was seen with absent LS, however,
there was a 95% sensitivity and 94%
specificity for diagnosing occult pneumo-
thoraces. The presence of a lung point
had 100% specificity for occult pneumo-
thoraces. A prospective study of hand-
S167

Figure 7. Lung point sign related to intermittent contact between visceral and parietal pleura,
resulting in the regular alteration between the stratospheric and beach signs.
Figure 8. Sonographic image of a 0.64-cm optic nerve sheath diameter of a victim of a motor vehicle
collision who developed brain death.
carried US focused on the most difficult
to diagnose subset, those patients re-
maining after the obvious PTXs (CXR or
clinical) were treated (95). In the remain-
ing patients, EFAST had a 49% vs. a 21%
sensitivity compared with CXR in the set-
ting of very high specificities and positive
likelihood ratio, being corroborated by
CT (95). A pitfall, as in other studies, was
bilateral PTXs, likely due to the loss of a
patient-specific “normal” comparative ex-
amination (95, 122). Another study of 176
patients using similar methodology (US,
followed by CXR and CT) used a protocol
examining four thoracic locations, allow-
ing a determination of PTX size (122).
The investigators systematically searched
for LS, supplemented by color power
Doppler, assessing the relative size of the
PTX through the relative topography of
LS. There was a 98% sensitivity for US
S168
compared with 76% for CXR, a specificity
of 99% vs. 100% for CXR, and a positive
likelihood ratio of 121 for EFAST (122).
Magnitude of Pneumothoraces
Although PTXs are dynamic, manage-
ment is often based on the perceived size.
Allowing for factors such as transport and
positive pressure ventilation, many small
pneumothoraces are managed expect-
antly, whereas large ones are drained
(116). The original description in horses
described scanning from ventral to dorsal
and noting the point where a static gas
artifact met the respiratory motion of the
lung (102). An early report by Sistrom et
al. (94) concluded that US was of no use
in determining the volume of PTX. This
may have related both to the lack of real-
time scanning and to using radiography
as a control (95, 100, 110). Subsequent
studies have suggested that sonography
may have utility in determining not only
the presence but actual size of a PTX.
Lichtenstein et al. (107) subsequently de-
scribed this fleeting appearance of either
LS or CTAs intermittently replacing a
PTX pattern as the lung point sign (Fig.
7). Sargsyan et al. (110) coincidentally
described this as partial sliding, imply-
ing that smaller or occult pneumotho-
races might be detected. Blaivas et al.
(122) noted good correlation between
the estimates of PTX size and CT findings
(Spearman rank correlation, 0.82) using
the relative thoracic topography of LS.
Probe Selection and Placement
Some groups favor high-frequency
linear array transducers that provide the
best resolution of the pleural interface
and whose footprint fits well between the
ribs (94, 95, 98, 123). This necessitates a
largely transverse scan in the upper rib
spaces that is perpendicular to the main
axis of LS (100). Conversely, other groups
have emphasized the practicality of using
a lower-frequency probe that can also be
used for the abdominal portion of the
EFAST, decreasing time spent exchang-
ing probes (122). The transducer is first
placed longitudinally on the chest, per-
pendicular to the ribs, to identify the
pleural interface in reference to the over-
lying (and acoustically impervious) ribs.
Thereafter, the transducer is rotated
transversely between the ribs to bring the
echogenic pleural stripe into profile, gen-
erating the “bat sign” as a basic landmark
(96, 100). Thereafter, the EFAST assesses
whether LS or CTAs at the interface can
be detected. If there is no LS and no
comet tails are visible, the examiner
should suspect the presence of a pneu-
mothorax, a suspicion further heightened
by the presence of the horizontal rever-
beration artifact (A-line). Color power
Doppler may accentuate LS and provide
documentation, as does M-mode. Detec-
tion of an image where partial sliding or
a lung point is present marks the lateral
aspect of the pneumothorax (lung point).
Airway Management
As US is increasingly available at the
bedside in critically ill patients, it may aid
in airway management. Endotracheal tube
(ETT) misplacement in those arriving at
emergency departments already intubated
Crit Care Med 2007 Vol. 35, No. 5 (Suppl.)
has been reported in up to 25% of cases
(124, 125). Moreover, end-tidal CO2, the
gold standard in ETT confirmation, may be
occasionally seen even with a mal-posi-
tioned ETT (124, 125). Kirkpatrick et al.
(95) noted two false-positive PTX diagnoses
when left-sided LS was absent after right
main stem ETT placement. LS and moving
CTAs returned after ETT repositioning.
Subsequently, Chun et al. (126) described
the potential utility of using US to con-
firm ETT placement. Weaver et al. (127)
randomly inserted an ETT into the main-
stem trachea, right main bronchi, or
esophagus of cadavers. Using the pres-
ence or absence of LS distinguished
esophageal from tracheal intubation with
a 95–100% sensitivity and 100% specific-
ity. Further, right main intubation was
distinguished from mainstem with a 69 –
79% sensitivity and 93–100% specificity.
Hsieh et al. (128) utilized a similar phi-
losophy by bilaterally imaging the dia-
phragmatic movements after intubation
from a subxiphoid window, describing re-
al-time correction of right main-stem in-
tubations. Lichtenstein et al. (129) de-
scribed CTAs oscillating with the cardiac
pulsation, but not with respiratory effort,
after selective right lung intubation as
the “lung pulse.” The lung pulse indi-
cated complete atelectasis of the left
lung. In conclusion, it should be empha-
sized that sonographic evaluation is best
utilized as either an adjunctive airway
management technique or in austere sit-
uations in which no other technologies
are available. These techniques may dem-
onstrate ventilation but not the adequacy
of such.
Posttraumatic Expanding
Intracranial Pathology
Management of serious closed head
injuries requires early identification of
intracranial hemorrhage amenable to
surgical intervention. It is possible that
clinicians can quickly infer increased in-
tracranial pressure from an early focused
examination of the optic nerve sheath,
which is anatomically continuous with
the dura matter and through which cere-
brospinal fluid percolates (130, 131) (Fig.
8). Although there is not great experience
as yet, early reports are encouraging
(132). A reference position 3 mm behind
the globe is chosen to give the greatest
US contrast, being the most distensible
part of the sheath and giving the most
reproducible results (133). Normal refer-
ence ranges are considered up to 5.0 mm
Crit Care Med 2007 Vol. 35, No. 5 (Suppl.)
in adults, 4.5 mm in children aged 1–15
yrs, and 4.0 mm in infants (130, 131).
Pediatric Patients
The use of the FAST is less established
in pediatric trauma care, although the
general principles remain unchanged.
The FAST is clinically useful when it pro-
vides a positive result, especially among
hypotensive patients, but should be sus-
pect when negative (38, 79, 134). Theo-
retically, there may be specific advan-
tages of US in children related to the thin
body wall and lack of intraperitoneal fat
stripes (135). The EFAST and other ex-
panded techniques are also applicable to
pediatric and even neonatal populations
(128, 131, 136), who are both at risk of
transportation to distant CT scanners and
more sensitive to ionizing radiation.
Future Directions
Critical care medicine, like our soci-
ety, lives in the information age. The ma-
jority of the information acquired and
analyzed in the critical care unit is digital
in nature (137). Most decisions regarding
patient care in critical care medicine are
now made on the basis of numerical in-
formation represented as bytes rather
than atoms (39). Satava (138) has
stressed the information system’s inte-
gration benefits of total body scans (ho-
lomers). Although conceptualized as sep-
arate tests, CT, US, and magnetic
resonance imaging are thus simply infor-
mation systems with different eyes (139).
In the future, it is probable that all infor-
mation acquired about a patient from the
first prehospital assessment onward will
be automatically compiled to build an
increasingly elegant holomer. This will
allow decision support, digital transmis-
sion, documentation, remote consulta-
tion, manipulation, and data fusion, with-
out delaying or distracting the clinician
from the clinical interaction. Despite
these powerful technologies, the essence
of the examination will remain the en-
hancement of the clinician’s bedside di-
agnostic capabilities.
ACKNOWLEDGMENTS
I thank Dr. Bernard R. Boulanger, De-
partment of Surgery, University of Ken-
tucky, Lexington, KY; and Dr. Rosaleen
Chun, Department of Anesthesia, Foot-
hills Medical Centre, Calgary, Alberta,
Canada.
REFERENCES
1. Sargsyan AE, Hamilton DR, Jones JA, et al:
FAST at MACH 20: Clinical ultrasound
aboard the International Space Station.
J Trauma 2005; 58:35–39
2. Kirkpatrick AW, Brown DR, Crickmer S, et
al: Hand-held portable sonography for the
on-mountain exclusion of a pneumothorax.
Wilderness Environ Med 2001; 12:270 –272
3. Canadian Institute for Health Information:
National Trauma Registry Report: Hospital
Injury Admissions 1998/1999. Toronto, The
Institute, 2001
4. Krug EG, Sharma GK, Lozano R: The global
burden of injuries. Am J Public Health
2000; 90:523–526
5. Maio RF, Burney RE, Gregor MA, et al: A
study of preventable trauma mortality in
rural Michigan. J Trauma 1996; 41:83–90
6. Papadopoulous IN, Bukis D, Karalas E, et al:
Preventable prehospital trauma deaths in a
Hellenic urban health region: An audit of
prehospital trauma care. J Trauma 1996;
41:864 – 869
7. Esposito TJ, Sanddal ND, Hansen JD, et al:
Analysis of preventable trauma deaths and
inappropriate trauma care in a rural state.
J Trauma 1995; 39:955–962
8. Trunkey DD: Trauma. Sci Am 1983; 249:
28 –35
9. Sauaia A, Moore FA, Moore EE, et al: Epi-
demiology of trauma death: A reassessment.
J Trauma 1995; 38:185–193
10. Clifton GL, Miller ER, Choi SC, et al: Lack
of effect of induction of hypothermia after
acute brain injury. N Engl J Med 2001;
344:556 –563
11. Kirkpatrick AW, Sirois M, Laupland KB, et
al: The hand-held FAST exam for blunt
trauma. Can J Surg 2005; 48:453– 460
12. Ollerton JE, Sugrue M, Balogh Z, et al:
Prospective study to evaluate the influence
of FAST on trauma patient management.
J Trauma 2006; 60:785–791
13. Abdominal Trauma: Committee on Trauma.
Advanced Trauma Life Support Course for
Doctors. Seventh Edition. Chicago, Ameri-
can College of Surgeons, 2004, pp 131–146
14. Lingawi SS, Buckley AR: Focused abdomi-
nal US in patients with trauma. Radiology
2000; 217:426 – 429
15. Bode PJ, Edwards MJR, Kruit MC, et al:
Sonography in a clinical algorithm for early
evaluation of 1671 patients with blunt ab-
dominal trauma. AJR Am J Roentgenol
1999; 172:905–911
16. Ma OJ, Mateer JR, Ogata M, et al: Prospec-
tive analysis of a rapid trauma ultrasound
examination performed by emergency phy-
sicians. J Trauma 1995; 38:879 – 885
17. Lanoix R, Leak LV, Gaeta T, et al: A prelim-
inary evaluation of emergency ultrasound
in the setting of an emergency training pro-
gram. Am J Emerg Med 2000; 18:41– 45
18. Mandavia DP, Aragona J, Chan L, et al:
Ultrasound training for emergency physi-
S169
 cians: A prospective study. Acad Emerg Med
2000; 7:1008 –1014
19. Tso P, Rodriguez A, Cooper C, et al: Sonog-
raphy in blunt abdominal trauma: A prelim-
inary progress report. J Trauma 1992; 33:
39 – 44
20. Rozycki GS, Ballard RB, Feliciano DV, et al:
Surgeon-performed ultrasound for the as-
sessment of truncal injuries. Ann Surg
1998; 228:557–567
21. Wherrett LJ, Boulanger BR, McLellan BA, et
al: Hypotension after blunt abdominal trau-
ma: The role of emergent abdominal sonog-
raphy in surgical triage. J Trauma 1996; 41:
815– 820
22. Rozycki GS, Ochsner MG, Jaffin JH, et al:
Prospective evaluation of surgeon’s use of
ultrasound in the evaluation of trauma pa-
tients. J Trauma 1993; 34:516 –525
23. Scalea TM, Rodriguez A, Chiu WC, et al:
Focused assessment with sonography for
trauma (FAST): Results from an interna-
tional consensus conference. J Trauma
1999; 46:466 – 472
24. Rozycki GS: Abdominal ultrasonography in
trauma. Surg Clin North Am 1995; 75:
175–191
25. Boulanger BR, Kearney PA, Brenneman FD,
et al: FAST utilization in 1999: Results of a
survey of North American trauma centers.
Am Surg 2000; 66:1049 –1055
26. American College of Surgeons Committee
on Trauma: Advanced Trauma Life Support
for Doctors. Chicago, American College of
Surgeons, 2004
27. Hoff WS, Holevar M, Nagy KK, et al: Prac-
tice management guidelines for the evalua-
tion of blunt abdominal trauma: The EAST
practice management guidelines work
group. J Trauma 2002; 53:602– 615
28. Rose JS, Levitt MA, Porter J, et al: Does the
presence of ultrasound really affect com-
puted tomographic scan use? A prospective
randomized trial of ultrasound in trauma.
J Trauma 2001; 51:545–550
29. Arrillaga A, Graham R, York JW, et al: In-
creased efficiency and cost-effectiveness in
the evaluation of the blunt trauma patient
with the use of ultrasound. Am Surg 1999;
65:31–5
30. Branney SW, Moore EE, Cantrill SV, et al:
Ultrasound based key clinical pathway re-
duces the use of hospital resources for the
evaluation of blunt abdominal trauma.
J Trauma 1997; 42:1086 –1090
31. Champion HR: Epidemiological basis for fu-
ture improvements in trauma care. Semin
Hematol 2004; 41:173
32. Hoyt DB, Bulger EM, Knudson MM, et al:
Death in the operating room: An analysis of
a multi-center experience. J Trauma 1994;
37:426 – 432
33. Wilson CB, Vidrine A, Rives JD: Unrecog-
nized abdominal trauma in patients with
head injuries. Ann Surg 1965; 161:608 – 613
34. Rodriguez A, Dupriest RW, Shatney CH:
Recognition on intra-abdominal injury in
S170
blunt trauma victims. Am Surg 1982; 48:
456 – 459
35. Hodgson NF, Stewart TC, Girotti MJ: Au-
topsies and death certification in deaths due
to blunt trauma: What are we missing. Can
J Surg 2000; 43:130 –136
36. Soderstrom CA, DuPriest RW, Cowley RA:
Pitfalls of peritoneal lavage in blunt abdom-
inal trauma. Surg Gynecol Obstet 1980;
151:513–518
37. Sirlin CB, Brown MA, Deutsch R, et al:
Screening US for blunt abdominal trauma:
Objective predictors of false-negative find-
ings and missed injuries. Radiology 2003;
229:766 –774
38. Holmes JF, Brant WE, Bond WF, et al:
Emergency department ultrasonography in
the evaluation of hypotensive and normo-
tensive children with blunt abdominal
trauma. J Pediatr Surg 2001; 36:968 –973
39. Kirkpatrick AW, Simons RK, Brown DR, et
al: Digital hand-held sonography utilised
for the focussed assessment with sonogra-
phy for trauma: A pilot study. Ann Acad Med
Singapore 2001; 30:577–581
40. Rozycki GS, Ochsner MG, Feliciano DV, et
al: Early detection of hemoperitoneum by
ultrasound examination of the right upper
quadrant: A multicenter study. J Trauma
1998; 45:878 – 883
41. Farahmand N, Sirlin CB, Brown MA, et al:
Hypotensive patients with blunt abdominal
trauma: Performance of screening US. Ra-
diology 2005; 235:436 – 443
42. Rose JS, Bair AE, Mandavia D, et al: The
UHP ultrasound protocol: A novel ultra-
sound approach to the empiric evaluation of
the undifferentiated hypotensive patient.
Am J Emerg Med 2001; 19:299 –302
43. Bahner DP: Trinity: A hypotensive ultra-
sound protocol. J Diagnostic Med Sonogr
2002; 18:193–198
44. Jones AE, Tayal VS, Sullivan M, et al: Ran-
domized, controlled trial of immediate ver-
sus delayed goal-directed ultrasound to
identify the cause on nontraumatic hypo-
tension in emergency department patients.
Crit Care Med 2004; 32:1703–1708
45. Boulanger BR, Brenneman FD, Kirkpatrick
AW, et al: The indeterminate abdominal
sonogram in multisystem blunt trauma.
J Trauma 1998; 48:52–56
46. Dolich MO, McKenney MG, Varela JE, et al:
2,576 ultrasounds for blunt abdominal
trauma. J Trauma 2001; 50:108 –112
47. Sisley A, Rozycki G, Ballard R, et al: Rapid
detection of traumatic effusion using sur-
geon performed ultrasound. J Trauma
1998; 44:291–297
48. Rose JS, Richards JR, Battistella F, et al:
The FAST is positive, now what? Derivation
of a clinical decision rule to determine the
need for therapeutic laparotomy in adults
with blunt torso trauma and a positive
trauma ultrasound. J Emerg Med 2005; 29:
15–21
49. Blackbourne LH, Soffer D, McKenney M, et
al: Secondary ultrasound examination in-
creases the sensitivity of the FAST exam in
blunt trauma. J Trauma 2004; 57:934 –938
50. Jehle D, Guarino J, Karamanoukian H:
Emergency department ultrasound in the
evaluation of blunt abdominal trauma.
Am J Emerg Med 1993; 11:342–346
51. Harbrecht BG, Alarcron LH, Peitzman AB:
Management of shock. In: Trauma. Fifth
Edition. Moore EE, Feliciano DV, Mattox
KL (Eds). New York, McGraw-Hill, 2004, pp
201–226
52. Kirkpatrick AW, Sirois M, Ball CG, et al: The
hand-held FAST exam for penetrating ab-
dominal trauma. Am J Surg 2004; 187:
660 – 665
53. Rozycki GS, Feliciano DV, Oschner G, et al:
The role of ultrasound in patients with pos-
sible penetrating cardiac wounds: A pro-
spective multicenter study. J Trauma 1999;
46:543–552
54. Mattox KL, Flint LM, Carrico CJ, et al:
Blunt cardiac injury. J Trauma 1992; 33:
649 – 650
55. Sybrandy KC, Cramer MJM, Bugersdijk C:
Diagnosing cardiac contusion: Old wisdom
and new insights. Heart 2003; 89:485– 489
56. Boulanger BR, McLellan BA, Brenneman
FD, et al: Prospective evidence of the supe-
riority of a sonography-based algorithm in
the assessment of blunt abdominal trauma.
J Trauma 1999; 47:632– 637
57. McKenney MG, Martin L, Lentz K, et al:
1,000 consecutive ultrasounds for blunt ab-
dominal trauma. J Trauma 1996; 40:
607– 612
58. McKenney MG, McKenney KL, Hong JJ, et
al: Evaluating blunt trauma with sonogra-
phy: A cost analysis. Am Surg 2001; 10:
930 –934
59. Brown MA, Casola G, Sirlin CB, et al: Blunt
abdominal trauma: Screening US in 2693
patients. Radiology 2001; 218:352–358
60. Chiu WC, Cushing BM, Rodriguez A, et al:
Abdominal injuries without hemoperito-
neum: A potential limitation of focused ab-
dominal sonography for trauma (FAST).
J Trauma 1997; 43:617– 625
61. Shanmuganathan K, Mirvis SE, Sherbourne
CD, et al: Hemoperitoneum as the sole indi-
cator of abdominal visceral injuries: A poten-
tial limitation of screening abdominal US for
trauma. Radiology 1999; 212:423– 430
62. Miller MT, Pasquale MD, Bromberg WJ, et
al: Not so Fast. J Trauma 2003; 54:52– 60
63. Rozycki GS, Knudson MM, Shackford SR, et
al: Surgeon-performed bedside assessment
with sonography after traumas (BOAST): A
pilot study from the WTA multicenter
group. J Trauma 2005; 59:1356 –1364
64. Ballard RB, Rozycki GS, Newman PG, et al:
An algorithm to reduce the incidence of
false-negative FAST examinations in pa-
tients at high risk for occult injury. J Am
Coll Surg 1999; 189:141–151
65. Holm HH, Mortensen T: Ultrasonic scan-
ning in diagnosis of abdominal disease. Acta
Chir Scand 1968; 134:333–341
66. Ohta S, Hagiwara A, Yukikoa T, et al: Hy-
Crit Care Med 2007 Vol. 35, No. 5 (Suppl.)
 perechoiec appearance of hepatic paren-
chyma on ultrasound examination of pa-
tients with blunt hepatic injury. J Trauma
1998; 44:135–138
67. Richards JR, McGahan JP, Pali MJ, et al:
Sonographic detection of blunt hepatic
trauma: Hemoperitoneum and parenchy-
mal patterns of injury. J Trauma 1999; 47:
1092–1097
68. Richards JR, McGahan JP, Jones CD, et al:
Ultrasound detection of blunt splenic in-
jury. Injury 2001; 32:95–103
69. Stengel D, Bauwens K, Sehouli J, et al:
Discriminatory power of 3.5 MHz convex
and 7.5 MHz linear probes for the imaging
of traumatic splenic lesions: A feasibility
study. J Trauma 2001; 51:37– 43
70. Blaivas M, Lyon M, Brannam L, et al: Fea-
sibility of FAST examination performance
with ultrasound contrast. J Emerg Med
2005; 29:307–311
71. Catalano O, Cusati B, Nunziata A, et al: Active
abdominal bleeding: Contrast-enhanced
sonography. Abdom Imaging 2006; 31:9 –16
72. Huang MS, Liu M, Wu JK, et al: Ultrasonog-
raphy for the evaluation of hemoperito-
neum during resuscitation: A simple scor-
ing system. J Trauma 1994; 36:173–177
73. McKenney K, McKenney M, Cohn S, et al:
Hemoperitoneum score helps determine
need for therapeutic laparotomy. J Trauma
2001; 50:650 – 656
74. Riccabona M, Nelson TR, Pretorius DH:
Three-dimensional ultrasound: accuracy of
distance and volume measurements. Ultra-
sound Obstet Gynecol 1996; 7:429 – 434
75. Riccabona M, Fritz G, Ring E: Potential
applications of three-dimensional ultra-
sound in the pediatric urinary tract: Picto-
rial demonstration based on preliminary re-
sults. Eur Radiol 2003; 13:2680 –2687
76. Mehwald PS, Rusk RA, Mori Y, et al: A
validation study of aortic stroke volume us-
ing dynamic 4-dimensional color Doppler:
An in vivo study. J Am Soc Echocardiogr
2002; 15:1045–1050
77. Kirkpatrick AW, Campbell MR, Broderick T,
et al: Extraterrestrial hemorrhage control:
Terrestrial developments in technique,
technology, and philosophy with applicabil-
ity to traumatic hemorrhage control during
long duration spaceflight. J Am Coll Surg
2005; 200:64 –76
78. Stengel D, Bauwens K, Sehouli J, et al: Sys-
tematic review and meta-analysis of emer-
gency ultrasonography for blunt abdominal
trauma. Br J Surg 2001; 88:901–912
79. Stengel D, Bauwens K, Rademacher G, et al:
Association between compliance with meth-
odological standards of diagnostic research
and reported test accuracy: Meta-analysis of
focused assessment of US for trauma. Radi-
ology 2005; 236:102–111
80. Stengel D, Bauwens K, Sehouli J, et al: Emer-
gency ultrasound-based algorithms for diag-
nosing blunt abdominal trauma. Cochrane
Database Syst Rev 2005; 2:CD004446
81. Asensio JA, Arroyo H, Veloz W, et al: Pene-
Crit Care Med 2007 Vol. 35, No. 5 (Suppl.)
trating thoracoabdominal injuries: Ongoing
dilemma. Which cavity and when? World
J Surg 2002; 26:539 –543
82. Boulanger BR, Kearney PA, Tsuei B, et al:
The routine use of sonography in penetrat-
ing torso injury is beneficial. J Trauma
2001; 51:320 –325
83. Udobi KF, Rodriguez A, Chiu WC, et al: Role
of ultrasonography in penetrating abdomi-
nal trauma: A prospective clinical study.
J Trauma 2001; 50:475– 479
84. Wherry DC: Potential of a hand-held ultra-
sound in assessment of the injured patient.
Cardiovasc Surg 1998; 6:569 –572
85. Kirkpatrick AW, Simons RK, Brown DR, et al:
The hand-held FAST: Experience with hand-
held trauma sonography in a level-I urban
trauma center. Injury 2002; 33:303–308
86. Lapostelle F, Petrovic T, Lenoir G, et al:
Usefulness of hand-held ultrasound devices
in out-of-hospital diagnosis performed by
emergency physicians. Am J Emerg Med
2006; 24:237–242
87. Brooks AJ, Price V, Simms M: FAST on
operational military deployment. Emerg
Med J 2005; 22:263–265
88. Blaivas M, Kuhn W, Reynolds B, et al:
Change in differential diagnosis and patient
management with the use of portable ultra-
sound in a remote setting. Wilderness En-
viron Med 2005; 16:38 – 41
89. Salim A, Sangthong B, Martin M, et al:
Whole body imaging in blunt multisystem
trauma patients without obvious signs of
injury. Arch Surg 2006; 141:468 – 475
90. Kim PK, Gracias VH, Maidment ADA, et al:
Cumulative radiation dose caused by radio-
logic studies in critically ill trauma pa-
tients. J Trauma 2004; 57:510 –514
91. Kim PK, Zhu X, Houseknecht E, et al: Ef-
fective radiation dose from radiologic stud-
ies in pediatric trauma patients. World
J Surg 2005; 29:1557–1562
92. Richardson JD, Miller FB: Injury to the lung
and pleura. In: Trauma. Third Edition. Fe-
lician DV, Moore EE, Mattox KL (Eds).
Stamford, CT, Appelton and Lange, 1996, pp
387– 407
93. American College of Surgeons: Advanced
Trauma Life Support Course for Doctors.
Committee on Trauma. Instructors Course
Manual. Chicago, 1997
94. Sistrom CL, Reiheld CT, Gay SB, et al: De-
tection and estimation of the volume of
pneumothorax using real-time sonography:
Efficacy determined by receiver operating
characteristic analysis. AJR Am J Roentge-
nol 1996; 166:317–321
95. Kirkpatrick AW, Sirois M, Laupland KB, et
al: Hand-held thoracic sonography for de-
tecting post-traumatic pneumothoraces:
The extended focused assessment with
sonography for trauma (EFAST). J Trauma
2004; 57:288 –295
96. Lichtenstein DA: Pneumothorax and intro-
duction to ultrasound signs in the lung. In:
General Ultrasound in the Critically Ill. Ber-
lin, Springer, 2002, pp 105–115
97. Kirkpatrick AW, Nicolaou S, Rowan K, et al:
Thoracic sonography for pneumothorax:
The clinical evaluation of an operational
space medicine spin-off. Acta Astronaut
2005; 56:831– 838
98. Kirkpatrick AW, Ng AK, Dulchavsky SA, et
al: Sonographic diagnosis of a pneumotho-
rax inapparent on plain chest radiography:
Confirmation by computed tomography.
J Trauma 2001; 50:750 –752
99. Lichtenstein D, Meziere G, Biderman P, et
al: The comet-tail artifact: An ultrasound
sign of alveolar-interstitial syndrome. Am J
Respir Crit Care Med 1997; 156:1640 –1646
100. Lichtenstein DA, Meziere G, Lascols N, et al:
Ultrasound diagnosis of occult pneumotho-
rax. Crit Care Med 2005; 33:1231–1238
101. Cunningham J, Kirkpatrick AW, Nicolaou
S, et al: Enhanced recognition of “lung slid-
ing” with power color Doppler imaging in
the diagnosis of pneumothorax. J Trauma
2002; 52:769 –771
102. Rantanen NW: Diagnostic ultrasound: Dis-
eases of the thorax. Vet Clin North Am
1986; 2:49 – 66
103. Targhetta R, Bourgeois JM, Chavagneux R,
et al: Diagnosis of pneumothorax by ultra-
sound immediately after ultrasonically
guided aspiration biopsy. Chest 1992; 101:
855– 856
104. Goodman TR, Traill ZC, Phillips AJ, et al:
Ultrasound detection on pneumothorax.
Clin Radiol 1999; 54:736 –739
105. Lichtenstein DA, Menu Y: A bedside ultra-
sound sign ruling out pneumothorax in the
critically ill: Lung sliding. Chest 1995; 108:
1345–1348
106. Lichtenstein D, Meziere G, Biderman P, et
al: The comet-tail artifact: An ultrasound
sign ruling out pneumothorax. Intensive
Care Med 1999; 25:383–388
107. Lichtenstein D, Meziere G, Biderman P, et
al: The “lung point”: An ultrasound sign
specific to pneumothorax. Intensive Care
Med 2000; 26:1434 –1440
108. Wernecke K, Galanski M, Peters PE, et al:
Pneumothorax: evaluation by ultrasound-
preliminary results. J Thorac Imaging
1987; 2:76 –78
109. Dulchavsky SA, Hamilton DR, Diebel LN, et
al: Thoracic ultrasound diagnosis of pneu-
mothorax. J Trauma 1999; 47:970 –971
110. Sargsyan AE, Hamilton DR, Nicolaou S, et
al: Ultrasound evaluation of the magnitude
of pneumothorax: A new concept. Am Surg
2001; 67:232–236
111. Kirkpatrick AW, Hamilton DR, Nicolaou S,
et al: Focused assessment with sonography
for trauma in weightlessness: A feasibility
study. J Am Coll Surg 2003; 196:833– 844
112. Dulchavsky SA, Schwarz KL, Kirkpatrick
AW, et al: Prospective evaluation of thoracic
ultrasound in the detection of pneumotho-
rax. J Trauma 2001; 50:201–205
113. Rowan KR, Kirkpatrick AW, Liu D, et al:
Traumatic pneumothorax detection with
thoracic US: Correlation with chest radiog-
S171
 raphy and CT. Initial experience. Radiology
2002; 225:210 –214
114. Ball CG, Kirkpatrick AW, Laupland KB, et
al: Incidence, risk factors, and outcomes for
occult pneumothoraces in victims of major
trauma. J Trauma 2005; 59:917–925
115. Knudtson JL, Dort JM, Helmer SD, et al:
Surgeon-performed ultrasound for pneu-
mothorax in the trauma suite. J Trauma
2004; 56:527–530
116. Ball CG, Hameed SM, Evans D, et al: Occult
pneumothorax in the mechanically venti-
lated trauma patient. Can J Surg 2003; 46:
373–379
117. Guerrero-Lopez F, Vasquez-Mata G, Alcazar-
Romero P, et al: Evaluation of the utility of
computed tomography in the initial assess-
ment of the critical care patient with chest
trauma. Crit Care Med 2000; 28:1370 –1375
118. Voggenreiter G, Aufmkolk M, Majetschak
M, et al: Efficacy of chest computed tomog-
raphy in critically ill patients with multiple
trauma. Crit Care Med 2000; 28:1033–1039
119. Moskowitz PS, Griscom NT: The medial pneu-
mothorax. Radiology 1976; 120:143–147
120. Tocino IM, Miller MH, Fairfax WR: Distri-
bution of pneumothorax in the supine and
semirecumbent critically ill adult. AJR Am J
Roentgenol 1985; 144:901–905
121. Ball CG, Kirkpatrick AW, Laupland KB, et
al: Factors related to the failure of radio-
graphic recognition of occult posttraumatic
pneumothoraces. Am J Surg 2005; 189:
541–546
122. Blaivas M, Lyon M, Duggal S: A prospective
comparison of supine chest radiography
and bedside ultrasound for the diagnosis of
S172
traumatic pneumothorax. Acad Emerg Med
2005; 12:844 – 849
123. Kirkpatrick AW, Nicolaou S: The sono-
graphic detection of pneumothoraces. In:
Thoracic Trauma and Critical Care.
Kharmy-Jones R, Nathens A, Stern E (Eds).
Boston, Kluwer Academic Publishers, 2002,
pp 227–234
124. Katz SH, Falk JL: Misplaced endotracheal
tubes by paramedics in an urban emergency
medical services system. Ann Emerg Med
2001; 37:32–37
125. Jones JH, Murphy MP, Dickson RL, et al:
Emergency physician-verified out-of-hospi-
tal: Miss rates by paramedics. Acad Emerg
Med 2004; 11:707–709
126. Chun R, Kirkpatrick AW, Sirois M, et al:
Where’s the tube? Evaluation of hand-held
ultrasound in confirming endotracheal tube
placement. Prehospital Disaster Med 2004;
19:366 –369
127. Weaver B, Lyon M, Blaivas M: Confirmation
of endotracheal tube placement after intu-
bation using the ultrasound sliding lung
sign. Acad Emerg Med 2006; 13:239 –244
128. Hsieh KS, Lee CL, Lin CC, et al: Secondary
confirmation of endotracheal tube position
by ultrasound image. Crit Care Med 2004;
32:S374 –S377
129. Lichtenstein DA, Lascols N, Prin S, et al:
The “lung pulse”: An early ultrasound sign
of complete atelectasis. Intensive Care Med
2003; 29:2187–2192
130. Newman WD, Hollman AS, Dutton GN, et
al: Measurement of optic nerve sheath di-
ameter by ultrasound: A means of detecting
acute raised intracranial pressure in hydro-
cephalus. Br J Ophthalmol 2002; 86:
1109 –13
131. Tsung JW, Blaivas M, Cooper A, et al: A
rapid noninvasive method of detecting ele-
vated intracranial pressure using bedside
ocular ultrasound. Pediatr Emerg Care
2005; 21:94 –98
132. Blaivas M, Theodoro D, Sierzenski PR: Ele-
vated intracranial pressure detected by bed-
side emergency ultrasonography of the op-
tic nerve sheath. Acad Emerg Med 2003;
10:376 –381
133. Helmke K, Hansen HC: Fundamentals of
transorbital sonographic evaluation of optic
nerve sheath expansion under intracranial
hypertension: II. Patient study. Pediatr Ra-
diol 1996; 26:706 –710
134. Soundappan SVS, Holland AJA, Cass DT, et
al: Diagnostic accuracy of surgeon-per-
formed focused abdominal sonography
(FAST) in blunt pediatric trauma. Injury
2005; 36:970 –975
135. Luks FI, Lemaire A, St-Vil D, et al: Blunt
abdominal trauma in children: The practi-
cal value of ultrasonography. J Trauma
1993; 34:607– 611
136. Liu DM, Forkheim K, Rowan K, et al: Utili-
zation of ultrasound for the detection of
pneumothorax in the neonatal special-care
nursery. Pediatr Radiol 2003; 33:880 – 883
137. Satava RM: The bio-intelligence age: Sur-
gery after the information age. J Gastroin-
test Surg 2002; 6:795–799
138. Satava RM: Disruptive visions: A robot is
not a machine . . . systems integration for
surgeons. Surg Endosc 2004; 18:617– 620
139. Satava RM: Looking forward. Surg Endosc
2006; 20:S503–S504
Crit Care Med 2007 Vol. 35, No. 5 (Suppl.)