E-FAST Stephanie Doniger, MD Emergency Ultrasound Fellow St. Luke’s-Roosevelt Hospital Center February, 2008

FAST Blunt trauma Penetrating trauma Yes/No questions Is there free fluid/blood in the abdomen? Is there fluid/blood in the pericardium?

E-FAST E = extended FAST Lung Yes/No questions Is there fluid/blood in the thorax? Is there a PTX?

E-FAST Technique Trendelenburg position 5-10 degrees Low frequency probe

E-FAST Views Morison’s Pouch Splenorenal Pelvic Pericardial/subcostal Thorax

Morison’s Pouch Most SN RUQ Ant axillary line 7th-9th IC space Oblique Look above diaphragms Courtesy of

Morison’s: Normal

Morison’s: Abnormal

Above the Diaphragm Diaphragm Liver

Splenorenal Courtesy of LUQ Posterior & superior Posterior ax 5th-9th IC space Oblique rotation ( deg)

Splenorenal: Normal

Splenorenal: Abnormal

Bladder Most dependent area of peritoneal cavity Best prior to Foley placement w/Foley: instillation of saline

Bladder Courtesy of Suprapubic TV & Longit views Often too superior

Bladder: Normal

Bladder TV: Normal

Bladder: Abnormal

Cardiac Detection of pericardial fluid Subxiphoid preferred Alternative: parasternal or apical

Cardiac SX Courtesy of Subcostal Probe almost flat Use L lobe of liver Bent knees

Cardiac: Normal SX

Cardiac: Abnormal SX

Cardiac: Abnormal PSL

Lung Detection of pleural fluid Detection of pneumothorax (1) Abdomen: superior to diaphragm (2) Lung: pleural interface

Lung Courtesy of MHz or 5-10 MHz Mid-clavicular line 3rd-5th IC space Longitudinal

Lung: Technique “Bat-sign” Ribs & pleural line Landmark to see pleural interface

Lung: Normal

Lung Comet tails US bouncing btwn 2 closely spaced interfaces Sliding Back & forth mov’t pleura w/respiration Abnormal: absence of comet tails & sliding

Lung: Comet Tails

Lung: Sliding Real-time M-Mode “Seashore” sign = normal Smooth lines above pleura; rough below “Stratosphere” or “bar-code” sign = abnormal Lines uniformly straight/smooth

Lung: Real-Time NormalPTX Courtesy of

Lung: M-Mode SeashoreStratosphere

Pitfalls Not having patient in Trendelenberg Improper probe positioning Not scanning through or viewing in multiple planes Not repeating E-FAST scans Failure to act on & document (+) scans

Questions ?