DISKUSI TOPIK Focussed

Assesment Sonography in Trauma

ADITYA ISLAMI
I1112009
KEPANITERAAN KLINIK RADIOLOGI RS UNTAN
 Introduction
The FAST scan is a 4 view scan reliant on detecting the
presence of fluid within the pericardium and most
dependent zones of the peritoneum in the horizontal
patient.
Relies on the principle that in the supine patient, free fluid
(FF) such as blood collects in certain anatomical sites
FAST scanning is indicated in any patient who has sustained
blunt abdominal trauma, whether haemodynamically
unstable or not.
ATLS principles the FAST scan is used as an adjunct to
the primary survey assessment of circulation
Capable of detecting more than 100-250ml of free fluid
The sensitivity of the FAST scan has been quoted as 78%
with a specificity of 99% in the evaluation of
intraabdominal injuries.
FAST is performed using abdominal probe with frequency
3.5 - 5.0 MHz.
 patients position
The patient should be in the supine position
with arms abducted slightly or above the head
to allow visualization of Morisons pouch and
the spleen.
Alternatively the patient may be asked to fold
their arms across their chest.
This maneuver will be determined by
consciousness level of the patient and the
presence of any upper extremity injury.
 FAST views
1. subxiphoid/subcostal view
2. right upper quadrant view
3. left upper quadrant view
4. pelvic view: transverse and sagittal
subxiphoid/subco
stal view
The probe is laid almost flat on the
patients epigastrium and angle
towards the head.
The heart will be surrounded by a
rim of echogenic pericardium.
Any discrete blackness between
this rim and the heart wall
represents fluid in the pericardial
sac. Pericardial fluid appears as a
black stripe.
 right upper
quadrant view
Morisons pouch and right lung
base
Morrison's pouch represents the
potential space between the
capsule of the liver and the fascia
around the kidney.
Probe parallel and between the
11th and 12th ribs with the beam
in a cranio caudal plane the
liver, kidney and diaphragm should
be demonstrated.
FF will appear as a black stripe in
Morisons pouch.
 left upper
quadrant view
The transducer is positioned
between the 10th and 11th ribs
and more posteriorly, in the
posterior axillary line. with the
ultrasound beam in a cranio caudal
plane demonstrates the spleen,
kidney and diaphragm.
FF will appear as a black stripe in
the lienorenal interface or
between the spleen and the
diaphragm (subphrenic FF).
Any evidence of a black rim
between the 2 organs represents
free intraperitoneal fluid.
Gross injury to solid organs may
sometimes also be seen.
Free fluid
suprapubic view
It is important that the patient
have a full bladder during this part
of the examination.
To observe transverse and sagittal
pelvic view.
Transverse pelvic view:
The transducer is placed
transversely in the abdominal
midline approximately 4 cm
superior to the symphysis pubis
and angled downwards in to the
pelvis demonstrates the bladder
Normal transverse Free fluid
pelvic view (arrowed)
suprapubic view
Sagittal pelvic view:
Probe placed in the midline just
above the pubis and angled
caudally at 45 degrees into the
pelvis demonstrates a sagittal
section of the bladder and pelvic
organs
FF will be around the bladder or
behind it (Pouch of Douglas).
Bladder

Uterus
Rectum

Pouch of
Douglas
 What FAST Can Tell You
FAST can determine the presence of the following:
Free intraperitoneal fluid
Pericardial fluid
Pleural fluid

What FAST Cannot Tell You

FAST cannot determine the following:
Source of free fluid
Nature of free fluid eg. blood versus ascites
Presence of solid organ or hollow viscus injury
Presence of retroperitoneal injury
 False negative scans: in the presence of small amounts of
FF in a single view of Morisons pouch or lienorenal
interface

False positives scans: due to fluid filled structures such as

inferior vena cava, gallbladder and intraluminal bowel fluid.
Other causes of false positive scans include:
Fat eg. pericardial fat pad
Ascites
Mirror artifact
cautions and contraindications
Absolute contraindications: the presence of a more pressing
problem (such as airway obstruction) or a clear indication for
emergency laparotomy (in which case FAST is not indicated)
Indicated only if it will affect patient management. Eg: stable
patient with blunt abdominal trauma, a negative FAST gives no
information about solid organs or hollow viscus injury CT
and/or small bowel series.
Children: FAST can be performed, but CT scanning remains the
investigation of choice in paediatric abdominal trauma. The
threshold for operative intervention in paediatric blunt abdominal
trauma is higher than for adults.
Timing: A very early scan may be falsely negative as sufficient
intra-abdominal blood may not have collected in the dependent
areas. Furthermore, occasionally a late scan may be falsely
negative as clotted blood is of similar echogenicity to liver and
may not be easily identified in Morisons pouch.
Operator: the accuracy of FAST is operator-dependent and the
inexperienced scanner should be particularly wary of ruling out
FF.
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