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

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

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

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

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

7. Morison’s Pouch Most SN RUQ Ant axillary line 7th-9th IC space Oblique Look above diaphragms Courtesy of http://sinaiem.ushttp://sinaiem.us

8. Morison’s: Normal

9. Morison’s: Abnormal

10. Above the Diaphragm Diaphragm Liver

11. Splenorenal Courtesy of http://sinaiem.ushttp://sinaiem.us LUQ Posterior & superior Posterior ax line @ 5th-9th IC space Oblique rotation (10- 20 deg)

12. Splenorenal: Normal

13. Splenorenal: Abnormal

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

15. Bladder Courtesy of http://sinaiem.us Suprapubic TV & Longit views Often too superior

16. Bladder: Normal

17. Bladder TV: Normal

18. Bladder: Abnormal

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

22. Cardiac SX Courtesy of http://sinaiem.us Subcostal Probe almost flat Use L lobe of liver Bent knees

23. Cardiac: Normal SX

24. Cardiac: Abnormal SX

25. Cardiac: Abnormal PSL

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

27. Lung Courtesy of http://sinaiem.us 3-5 MHz or 5-10 MHz Mid-clavicular line 3rd-5th IC space Longitudinal

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

29. Lung: Normal

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

32. Lung: Comet Tails

33. 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

34. Lung: Real-Time NormalPTX Courtesy of http://sinaiem.us

35. Lung: M-Mode SeashoreStratosphere

36. 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

37. Questions ?