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UltrasoundFAST
Focused Assessment with Sonography in Trauma
Rohit Patel, MDUniversity of Florida Health
Director, Critical Care Ultrasound Surgical ICUCenter for Intensive Care
Gainesville, Florida
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A few points about didactic lectures
Hands on instruction better explained in Bedside Videos
Reading material important to cover aspects not discussed in this lecture portion
Important to mix hands on Active Learning with the reading/didactic material to best learn ultrasound application
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IntroductionFirst used in Europe 1970's, ATLS since 1997, later incorporated into surgery and emergency medicine residency curriculums
Objective: detect free fluid in pericardium and intraperitoneal in the setting of trauma
Alternatives: CT, DPL, OR, Observation; ultrasound has higher specificity for therapeutic laparotomy than DPL
Combination algorithmic approach seems best
McKenney, Journal of Trauma, 2001Wednesday, June 1, 16
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FAST and E-FASTFAST exam and pleural fluid assessment
Coined at international consensus conference in 1996 to describe an integrated, goal directed, bedside examination to detect fluid
FAST detects fluid as low as 100 mL but commonly cited as 250 to 620 mL
Sensitivity 79%Specificity 99%
Branney, SW. J Trauma. 1995.Stengel, D. Radiology. 2005.
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History of FAST
Focused assessment with sonography in trauma
Focused abdominal sonography in trauma
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Focused QuestionsIs there free fluid in the abdomen?
Is there fluid in the pericardium?
Extended FAST:
Is there fluid in the thorax?
Is there a pneumothorax?
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AnatomyRight paracolic gutter - Morrison's pouch to pelvis
Left paracolic gutter - not as deep as right and phrenocolic ligament blocks fluid movement
Morrison's pouch (hepatorenal recess) - space between Glisson's capsule on liver and Gerota's fascia of kidney
Splenorenal recess - between spleen and Gerota's fascia
Rectovesicle pouch - pocket formed by reflection of peritoneum from rectum to bladder; pouch of Douglass in female
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Probe selection and locationPhased array 5 MHz or Abdominal probes (bigger footprint)
Noble et al. Textbook. Manual of Emergency and Critical Care Ultrasound.Wednesday, June 1, 16
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Right upper quadrant
Noble et al. Textbook. Manual of Emergency and Critical Care Ultrasound.Wednesday, June 1, 16
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Right upper quadrant
Noble et al. Textbook. Manual of Emergency and Critical Care Ultrasound.Wednesday, June 1, 16
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Kidney
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Kidney
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KidneyDiaphragm-->
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Right upper quadrant
Kidney
<--free fluidpleural fluid-->
diaphragm-->
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Left upper quadrant
Noble et al. Textbook. Manual of Emergency and Critical Care Ultrasound.
More Posterior and Superiorthan RUQ
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Left upper quadrant
Noble et al. Textbook. Manual of Emergency and Critical Care Ultrasound.Wednesday, June 1, 16
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Suprapubic
Noble et al. Textbook. Manual of Emergency and Critical Care Ultrasound.Wednesday, June 1, 16
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Suprapubic
Noble et al. Textbook. Manual of Emergency and Critical Care Ultrasound.Wednesday, June 1, 16
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The heart
Noble et al. Textbook. Manual of Emergency and Critical Care Ultrasound.Wednesday, June 1, 16
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Back to the pump
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Pericardial fluid ------->
Pleural fluid-------->
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Pericardial fluid ------->
Pericardial fluid ------->
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Effusion around the pumpTamponade or not?
Hallmark: RV free wall inversion, best recognized during diastole
Right atrial inversion during systole (more common and early finding)
Increased respiratory variation of mitral or aortic inflow velocities (greater than 25%)
Dilated inferior vena cava with decreased inspiratory collapse
ASE Committee Recomendations. Am Soc Echocardiography. 2005
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Pericardial fluid ------->
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Pericardial fluid ------->
Pericardial fluid -------> RV
<-------
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FAST and e-FASTIf fluid found, move up one or two costal spaces, lung sometimes seen floating in pleural fluid
Sensitivity 92% and Specificity 100% in detecting hemothorax
in the Emergency Department, can detect 20 mL of pleural fluid VS supine CXR needs 175 mL
Head slightly elevated can help accumulate fluid just above diaphragm
McEwan K. Emerg Med J. 2007.Sisley, AC. J Trauma. 1998
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pleural fluid (could be hemothorax in trauma setting)
------->
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Ultrasound for pneumothorax
Kirkpatrick, J Trauma 2004
First described in a horse in 1986
In a normal lung, the visceral and parietal pleura are closely associated, and ultrasound shows shimmering or sliding at the pleural interface during respiration; absence of this indicates a pneumothorax
In trauma, US shown to be more than twice as sensitive for detecting occult pneumothorax with similarly high specificity (98%)
Comet tails are ultrasound artifacts that arise when ultrasound encounters a small air fluid interface
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Ultrasound for pneumothorax
Zhang M. Crit Care. 2006Lichtenstein. Chest. 1995
Chest radiography?
US relies on fact that free air is lighter than normal aerated lung tissue, accumulates in nondependent areas of thoracic cavity
Multiple studies show ultrasound to be more sensitive than supine chest radiography (CT gold standard)
Sensitivity 86 to 100%Specificity 92 to 100%Negative predictive value of 100% (Lichtenstein study)
Zhang study: sensitivity 86% vs 27% AND time to obtain study 2.3 minutes vs 19.9 minutes
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Ultrasound for pneumothorax
Lichtenstein D. Intensive Care Med. 2000
Supine
High frequency linear array best
Midclavicular line at third through fifth intercostal space to ID pleural line, but should look through several intercostal spaces
Lung point: area where pneumothorax interfaces with chest wall
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Lung SlidingParietal and visceral pleura can be seen sliding to each other
Graphically depicted using M-mode
Absence can also be seen in COPD bleb, consolidated pneumonia, atelectasis, main stem intubation
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Pleural line with sliding ------->
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Pleural line without sliding
<--------
optimal depth to evaluate is 3-7 cm
------------>
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Focused QuestionsIs there free fluid in the abdomen?
Is there fluid in the pericardium?
Extended FAST:
Is there fluid in the thorax?
Is there a pneumothorax?
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