1. Core Ultrasound Curriculum Pediatric Ultrasound Conference Limited ER Ultrasound: FAST Janis P. Tupesis M.D. University of Chicago Section of Emergency Medicine February 1, 2007

2. Introduction Why are we doing this lecture? Ultrasound becoming an integral part of the emergency physicians physical exam Allows us to make rapid decisions, identify life threatening diagnoses and expedite operative management of emergent patients Answering simple yes/no questions at the bedside Examples: AAA (Y/N), gallstones (Y/N), pericardial effusion (Y/N), pathologic fluid in the abdomen (Y/N) Need to be competent in doing these exams when finish residency Today: review of the Focused Abdominal Sonogram in Trauma (FAST) exam Why are we doing this lecture? Ultrasound becoming an integral part of the emergency physicians physical exam Allows us to make rapid decisions, identify life threatening diagnoses and expedite operative management of emergent patients Answering simple yes/no questions at the bedside Examples: AAA (Y/N), gallstones (Y/N), pericardial effusion (Y/N), pathologic fluid in the abdomen (Y/N) Need to be competent in doing these exams when finish residency Today: review of the Focused Abdominal Sonogram in Trauma (FAST) exam

3. Goals of this lecture Where do I put the probe? How do I hold the probe? What am I looking at? - Normal anatomy What am I looking at? - Abnormal anatomy What can I tell from the abnormal anatomy? Pathologic fluid in the abdomen Pathologic fluid in the pericardium Does it make a difference? Review of the literature Where do I put the probe? How do I hold the probe? What am I looking at? - Normal anatomy What am I looking at? - Abnormal anatomy What can I tell from the abnormal anatomy? Pathologic fluid in the abdomen Pathologic fluid in the pericardium Does it make a difference? Review of the literature

4. Trauma Ultrasonography Intro Applications Anatomy Comparison Exam: Technical Considerations RUQ LUQ Subxiphoid/Subcostal Pelvis Ultrasonagraphic evaluation of pathologic states Intro Applications Anatomy Comparison Exam: Technical Considerations RUQ LUQ Subxiphoid/Subcostal Pelvis Ultrasonagraphic evaluation of pathologic states

5. FAST: Intro and Applications FAST exam: Focused Abdominal Sonography in Trauma Peritoneal Pericardial Pleural Indications Acute blunt or penetrating torso trauma Trauma in pregnancy Pediatric trauma Subacute torso trauma Goal: to identify fluid in a location where it does not normally belong FAST exam: Focused Abdominal Sonography in Trauma Peritoneal Pericardial Pleural Indications Acute blunt or penetrating torso trauma Trauma in pregnancy Pediatric trauma Subacute torso trauma Goal: to identify fluid in a location where it does not normally belong

6. FAST: Comparison Comparison of Ultrasound, Diagnostic Peritoneal Lavage and Computed Tomography Barry C. Simon. Ultrasound in Emergency Medicine. Table 7-2. Pages 158-159.

7. FAST: Anatomy 7 dependent sites 1. Right Supramesocolic (Morison’s pouch) 2. Left Supramesocolic (Splenorenal rescess) 3. Right Pericolic gutter 4. Right Inframesocolic 5. Left Inframesocolic 6. Left Pericolic gutter 7. Pelvic cul-de-sac

8. FAST: Technical Considerations Probe placement? 1. RUQ: Morrison’s Pouch 2. LUQ: Splenorenal 3. Pelvis: Pelvic cul-de-sac 1. Transverse 2. Longitudinal 4. Subxiphoid/Subcostal: Pericardium righthead  Remember: Probe almost ALWAYS facing either patient’s right or patient’s head

9. FAST: RUQ exam Probe placed Perpendicular Mid-coronal plane Just superior to the iliac crest Probe facing Toward patient’s head

10. FAST: RUQ exam Evaluating Hepatorenal interface Possibility of fluid in Morison’s pouch - Right Supramesocolic space Technical Problems Body habitus Bowel gas Rib artifact

11. FAST: RUQ exam Where exactly is Morrison’s Pouch?

12. FAST: RUQ exam Where exactly is Morrison’s Pouch?

13. FAST: RUQ exam Normal Anatomy In the supine patient, the hepatorenal space is the most dependent area Also is the least obstructed for fluid flow Morison’s Pouch Potential space between the liver and the right kidney in the hepatorenal recess Morison’s Pouch

14. FAST: RUQ exam Abnormal Anatomy Pathologic Fluid - mild L = liver D = diaphragm K = kidney RS = rib shadow FF1 = free fluid FF2 = free fluid

15. FAST: RUQ exam Abnormal Anatomy Pathologic Fluid - moderate L = liver K = Kidney FF = free fluid RS = rib shadow D = diaphragm L K FF RS D

16. FAST: RUQ exam Abnormal Anatomy Pathologic Fluid - massive L = liver K = kidney FF = free fluid L K FF

17. FAST: LUQ exam Probe placed Perpendicular Mid - coronal plane Just superior to the iliac crest Probe facing Towards patient’s head

18. FAST: LUQ exam Evaluating Spleno-renal interface Possibility of fluid in splenorenal recess Technical Problems Body habitus Bowel gas, splenic flexure gas Rib artifact

19. FAST: LUQ exam Where exactly is Splenorenal Recess?

20. FAST: LUQ exam Where is splenorenal recess?

21. FAST: LUQ exam Normal Anatomy More difficult to evaluate than RUQ Left kidney more superior than right Do not have liver as acoustic window Splenorenal Recess Potential space between kidney and spleen Splenorenal Recess

22. FAST: LUQ exam Pathologic Fluid K = kidney S = spleen RS = rib shadow FF = free fluid

23. FAST: Subxiphoid exam Probe placed Patient’s epigastrium Just below xiphoid process of the sternum “entire” probe aimed at patients left shoulder Probe facing “notch” of probe placed toward patient’s right side

24. FAST: Subxiphoid exam Evaluating Fluid in the pericardium Wall dysfunction R heart strain Septal “bowing” Technical Problems Body habitus Inability to get probe under xiphoid

25. FAST: Subxiphoid exam Normal Anatomy Liver at very top of screen Right ventricle on top of screen Right atrium and left ventricle line up below right ventricle Left ventricle on bottom of screen

26. FAST: Subxiphoid exam Review Normal Subcostal view RV = right ventricle RA = right atrium LV = left ventricle LA = left atrium IVS = interventricular septum IVS

27. FAST: Subxiphoid exam Subcostal view Large pericardial effusion Where to you measure amount of blood or fluid? Answer: anteriorly between the heart and liver Measure here!

28. FAST: Subxiphoid exam Subcostal view Pericardial effusion Left ventricular collapse Can see left ventricle “bowing” in towards intraventricular septum Ventricular “bowing”

29. FAST: Subxiphoid exam Subcostal or Subxiphoid view Hemodynamically significant pericardial effusion Complete right ventricular collapse Ventricular Collapse

30. FAST: Pelvis LA exam Pelvis: Long Axis Probe placed longitudinally 2 cm superior to the symphysis pubis Midline of the abdomen “aimed” caudally into the pelvis Probe facing Toward patient’s head

31. FAST: Pelvis LA exam Evaluating Free fluid in the anterior pelvis Free fluid in the pelvic cul- de-sac (Pouch of Douglas) Technical Problems Body habitus Empty bladder (no landmarks) Bladder trauma (no landmarks)

32. FAST: Pelvis LA exam Pelvis: Long Axis Normal Anatomy Evaluating Bladder Uterus in female: usually superior to bladder Prostate in male: usually posterior to bladder

33. FAST: TV Pelvis exam Pelvis: Transverse Probe placed 2 cm superior to the symphysis pubis Midline of the abdomen Probe facing Toward patient’s right Probe rotated 90 degrees counterclockwise from longitudinal

34. FAST: TV Pelvis exam Evaluating Free fluid in the anterior pelvis Free fluid in the pelvic cul- de-sac (Pouch of Douglas) Technical Problems Body habitus Empty bladder (no landmarks) Bladder trauma (no landmarks)

35. FAST: TV Pelvis exam Pelvis: Transverse Axis Normal Anatomy Evaluating Bladder Well cirucumscribed Contains fluid that appears anechoic

36. FAST: Pelvis exam - Pathology Transverse scans with free fluid in pelvis Female (top): uterus posterior to bladder Male (bottom) B = bladder UT = uterus FF = free fluid S = spine

37. FAST: Literature 1980’s Wenig JV et al. Compared bedside ultrasonography by trauma surgeons to DPL and CT Sensitivity from 84 - 100% Specificity from 88 - 100% Largely unnoticed because published in German and had small sample size 1980’s Wenig JV et al. Compared bedside ultrasonography by trauma surgeons to DPL and CT Sensitivity from 84 - 100% Specificity from 88 - 100% Largely unnoticed because published in German and had small sample size 1990’s Tiling et al. Similar sensitivity and specificity First to incorporate pleural and pericardial spaces First to incorporate FAST into initial evaluation Ma et al. First study using ER physicians as ultrasonographers Same sensitivity, specificity and accuracy Point: ER physicians are able to detect occult blood with ultrasound at same rates as surgeons, CT, DPL.

38. Questions?Questions?

39. ReferencesReferences Heller, M. Ultrasound in Emergency Medicine. WB Saunders. 1995. Rosen, C. Ultrasound in Emergency Medicine. Emergency Medicine Clinics of North America. August 2004. Volume 22. Number 3. O. John Ma and James R. Mateer. Emergency Ultrasound. McGraw-Hill. Medical Publishing Division. 2003. Simon, B. Ultrasound in Emergency and Ambulatory Medicine. Mosby. 1997 Temkin, BB. Ultrasound Scanning: Principles and Protocols. WB Saunders. 1993. Heller, M. Ultrasound in Emergency Medicine. WB Saunders. 1995. Rosen, C. Ultrasound in Emergency Medicine. Emergency Medicine Clinics of North America. August 2004. Volume 22. Number 3. O. John Ma and James R. Mateer. Emergency Ultrasound. McGraw-Hill. Medical Publishing Division. 2003. Simon, B. Ultrasound in Emergency and Ambulatory Medicine. Mosby. 1997 Temkin, BB. Ultrasound Scanning: Principles and Protocols. WB Saunders. 1993.