Post on 20-Apr-2020
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Slide 1JSOMTC, SWMG(A)
E‐FAST ExamPFN: SOMUSL02
Hours: 2.0
Instructor:
Slide 2JSOMTC, SWMG(A)
Terminal Learning Objective
Action: Communicate knowledge of the E‐FAST exam
Condition: Given a lecture in a classroom environment
Standard: Received a minimum score of 75% on the written exam and practical test IAW course standards
Slide 3JSOMTC, SWMG(A)
References
The Atlas of Emergency Medicine, 3rd
Edition
Tintinalli’s Emergency Medicine, 7th
Edition
Pre‐hospital Trauma Life Support, Military Edition, 7th Edition
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Slide 4JSOMTC, SWMG(A)
Reason
As a SOF medic you may have to make many triage, treatment and evacuation decisions. Competence with performing an E‐FAST exam will assist your decision making process by allowing for enhanced recognition of internal hemorrhage and pneumothorax.
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Agenda
Identify the E‐FAST exam definition, indications, goals and accuracy
Identify the internal and topographical anatomy necessary to perform and interpret an E‐FAST exam
Identify the characteristics of free fluid
Identify the E‐FAST exam scanning technique
Slide 6JSOMTC, SWMG(A)
Agenda
Identify how to perform and interpret an E‐FAST exam right upper quadrant view
Identify how to perform and interpret an E‐FAST exam left upper quadrant view
Identify how to perform and interpret an E‐FAST exam pelvic view
Identify how to perform and interpret an E‐FAST exam cardiac view
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Agenda
Identify how to perform and interpret an E‐FAST exam thorax view
Identify E‐FAST variants and pitfalls
Recall key points to consider when performing an E‐FAST exam
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Identify the E‐FAST Exam Definition, Indications, Goals and Accuracy
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E‐FAST Exam Definition
“Extended” Focused Assessment using Sonography in Trauma
Bedside ultrasound (US) exam of the thorax, abdomen, pelvis
Rapid, “focused”, goal‐directed
Involves scanning the chest, heart, abdomen and pelvis
“Extended” FAST involves scanning the chest for a pneumothorax
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E‐FAST Exam Indications
Blunt or penetrating abdominal or thoracic trauma
Hypotension of unknown cause
Hemorrhagic shock
• Hemoperitoneum
Obstructive shock
• Pericardial effusion with tamponade
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E‐FAST Exam Goals
Detect “free fluid” in the abdomen, pericardium and thorax
Surrogate marker of organ injury
Hemoperitoneum
Hemothorax
Pericardial effusion or tamponade
Direct organ injuries
Pneumothorax
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E‐FAST Exam Goals
Evaluate sick and injured patients in the operative environment using bedside ultrasound as a diagnostic tool
Assist you in triaging patients for emergent care in the field and allow for timely evacuation of the most ill patients
Patients with findings of internal bleeding on US need rapid evaluation and initial stabilization
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E‐FAST Exam Accuracy
Hemoperitoneum
Blunt trauma
• Sensitivity: 79%
• Specificity: 99.2%
Penetrating trauma
• Sensitivity: 46‐71%
• Specificity: 94‐100%
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E‐FAST Exam Accuracy
Pericardial effusion/tamponade
Sensitivity: 97‐100%
Specificity: 97‐99%
Hemothorax
Sensitivity: 97.5%
Specificity: 99.7%
Versus CXR sensitivity of 92.5%
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E‐FAST Exam Accuracy
Pneumothorax
Sensitivity: 95‐100%
Specificity: 78‐95%
Out performs supine AP CXR
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Identify the Internal and Topographical Anatomy Necessary to Perform and Interpret an E‐FAST
Exam
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E‐Fast Exam Anatomy
Important potential structures to identify
Abdomen
• RUQ: hepatorenal or RUQ recess (Morison’s Pouch)
• LUQ: splenorenal recess
• Pelvis: rectovesicular space
Thorax
• Heart: pericardial space
• Costophrenic angles
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Internal Organs of Abdomen
RUQ
Liver
Right lung
Right kidney
LUQ
Spleen
Left kidney
Left lung
Pelvis
Bladder
Uterus and vagina
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Thoracic Anatomy
Skin
Intercostal muscles
Ribs
Pleura‐parietal and visceral
Lung parenchyma
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Thoracic Anatomy
Skin
SQ tissue
IC muscle
Rib
Parietal pleura
Outer
Visceral pleura
InnerClemente’s Anatomy 1987
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Identify the Characteristics of Free Fluid
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Free Fluid (FF)
Free fluid (FF) = hemoperitoneum, hemothorax, and pericardial effusion
Free Fluid in trauma is usually blood but may be stool, bile, and urine
When fluid leaks into the pericardium, pleural interspaces, or abdomen it layers out due to gravity
It may take 5‐15 minutes for fluid to collect to the point of visualization on the US exam
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Free Fluid (FF)
FF is usually seen at volume > 250 cc in abdomen, 100 cc in thorax, and 20‐50 cc in pericardial effusion/tamponade
Blood is usually hypoechoic (black) but will eventually clot and appear hyperechoic (gray)
FF tends to increase over time when due to ongoing leakage/hemorrhage
Slide 24JSOMTC, SWMG(A)
US Characteristics of FFThe “WEB Principle”
W =“Wall Principle”‐ “the wall trumps them all”
E = “Edge Principle”‐ “blood edges, bladders blunt”
B = “Bucket Principle”‐ “the body is a bucket”
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Identify the E‐FAST Exam Scanning Technique
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Sequential Series of Scans
RUQ
LUQ
Pelvis
Heart
Chest
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Scanning Areas for Heart and Abdomen
RUQ LUQ
Pelvis
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Scanning Technique for Heart and Abdomen
Patient position
Supine or trendelenberg
Keep in this position 5 minutes to allow free fluid to accumulate by gravity
Probe ‐ heart and abdomen
Curved, small foot print, low frequency (3‐5 MHZ)
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Scanning Areas for Chest
Mid Clavicular Lines
Anterior Axillary Lines
Clemente’s 1987
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Scanning Technique for Chest
Patient Position
Upright or supine
Last part of FAST exam
Probe
Linear or curvilinear probe 5‐7.5 MHZ
Preset
Linear‐ vascular or small parts
Curvilinear‐ abdomen or cardiac
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Perform and Interpret an E‐FAST Exam Right Upper Quadrant View
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Steps for RUQ View
1. Place probe in long axis (LA) oblique axis in right anterior axillary line intercostal spaces (ICS) 8‐11
2. Direct reference mark on the probe toward the patients head
3. Direct US beam toward the diaphragm
4. Watch the screen!
5. Visualize diaphragm, right costophrenic space and hepatorenal recess
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RUQ Probe Position
Anterior Axillary line
ICS 8-11
Reference Mark
Liver
R Kidney
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RUQ Structures
Important structures
Diaphragm
Liver
Kidney
Hepatorenal recess
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US RUQ Anatomy
Morison’s Pouch
Liver
Kidney
RUQ
Diaphragm
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RUQ Free Fluid
FF usually is hypoechoic and has sharp edges and fills the abdomen from bottom to top
Fills the RUQ recess
Liver
Recess
Kidney
Diaphragm
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RUQ Free Fluid
US Image
FF
Liver
Right kidney
Illustration
FF
Liver
Right kidney
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RUQ ‐ Name the Structures
RUQ RUQ
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RUQ Hemothorax
Characteristics
Blood has sharp edges
Hypoechoic
Superior to diaphragm
Diaphragm
Hemothorax
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FF in Thorax or Peritoneum?
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RUQ ‐ Normal or Abnormal?
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RUQ Scan Free Fluid
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Perform and Interpret an E‐FAST Exam Left Upper Quadrant View
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Steps for LUQ View
1. Probe position ‐ “superior and posterior”
2. Splenorenal recess is more cephalad and posterior on the left side
3. Place probe in left mid‐axillary line long or oblique axis in ICS 7‐10
4. Visualize diaphragm, left costophrenic space and splenorenal recess
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Spleen Topography
Spleen
ICS 7‐10
Probe position
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LUQ Probe Position
Position posterior axillary line ICS 7‐11
Angle probe footprint obliquely in ICS to decrease rib shadowing
Spleen and left kidney are superior and posterior
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US LUQ Anatomy
Spleen is less vascular and more homogenous than the liver
It is located more superior and posterior than the liver
US Image
A‐ Spleen
B‐ Left kidney
C‐ Shadow artifact
D‐ Splenorenal recess
E‐ Diaphragm
C D
E
D
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LUQ ‐ Name the Structures
LUQ
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LUQ Free Fluid
FF is hypoechoic and has sharp edges
It is usually seen between the spleen and diaphragm and recess
FF
Diaphragm
Spleen
Left kidney
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LUQ Free Fluid
US Image
Diaphragm
FF
Spleen
Left kidney
Illustration
FF
Spleen
Left kidney
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LUQ Free Fluid
Spleen
Free fluid
Left kidney
Diaphragm
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LUQ Injury
US Image
Hemoperitoneum
Splenic laceration
Left kidney
Illustration
Hemoperitoneum
Splenic laceration
Left kidney
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LUQ ‐ Normal or Abnormal?
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Perform and Interpret an E‐FAST Exam Pelvic View
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Steps for Pelvic View
1. Place probe superior to symphysis
2. Angle beam inferiorly and laterally into the pelvis in long axis and transverse axis
3. Visualize the bladder, uterus and rectovesicular space
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Pelvic Probe Position ‐ LA
Reference mark
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Female Pelvis
Anatomic structures
Urinary bladder
Uterus
Vagina
Rectovesicular space
Bowel
Rectum
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US Pelvic Anatomy ‐ LA
Rectovesicular recess
Uterus Bladder
Vagina
Abdomen
Endometrial stripe
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Pelvic Hemorrhage ‐ LA
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Pelvic FF with Clots ‐ LA
FFClots
Bladder
Bowel
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Pelvis ‐ LA
FF
Bladder
Cul de sac
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Pelvis ‐ TA
Rectovesicular space
Bladder
Transverse
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Pelvis Free Fluid ‐ TA
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Pelvic Scan Free Fluid
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Perform and Interpret an E‐FAST Exam Cardiac View
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Cardiac US Goals
Detect pericardial effusion and/or tamponade
Cardiac motion‐ presence or absence
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Important Structures to Identify inCardiac US
Pericardium
Right atrium (RA)
Right ventricle (RV)
Left atrium (LA)
Left ventricle (LV)
Interventricular septum (IVS)
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Pericardium Anatomy
Pericardium
Pericardium
Illustration Autopsy
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Cardiac Scanning Technique
Patient position
Supine
Left side after abdomen scanned
Probe
Convex or annular
3.5‐5 MHZ
Small footprint
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Cardiac Scanning Technique
4 windows (views) used
Subcostal (SC)
Left parasternal long axis (LPLA)
Left parasternal short axis (LPSA)
Apical
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Topographic Scanning Locations
This view not often used
2 Parasternal views
LPLA
LPSA
Apical
4 chamber view
Subcostal
Work horse view
2 or 4 chamber view
T-1
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SC View
Probe footprint is positioned at the xiphoid process
Reference mark is directed to the right shoulder
Probe is directed to the left shoulder
Push downward and flatten probe parallel to body
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Normal SC View
Probe with RM to right
Liver acting as acoustic window
Pericardium
Hyperechoic border
Cardiac chambers
RV
Septum
LV
RA
LA
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Normal SC ‐ Illustration versus US
Pericardium
Illustration US
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SC View ‐ Name Structures
r
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Pericardial Effusion
Etiology
Trauma
• Blunt
• Penetrating
Medical abnormalities
• Pericarditis
• Cancer
• Connective tissue diseases
• Renal failure
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Pericardial Effusion
Pathophysiology
Pericardium is made up of 2 layers
• Outer fibrous and inner serosa
• Between these layers is a potential space
Fluid (blood or transudate) can collect in this potential space
• This decreases the volume of blood flowing through the heart
• A large effusion can cause obstructive shock and lead to tamponade
Slide 78JSOMTC, SWMG(A)
Pericardial Effusion ‐ US Characteristics
The effusion is hypoechoic and has sharp edges
The fluid is between the pericardium and cardiac walls
Can completely or partially encircle the heart
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SC ‐ Pericardial Effusion
Liver
Pericardium
Effusion
RV wall
US Anatomy SC Pericardial Effusion
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SC ‐ Pericardial Effusion
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Cardiac Tamponade
Large pericardial effusion
Causes RA to collapse in systole and RV to collapse during diastole due to LV filling pressure
Obstructive shock ensues
Emergent treatment with IV fluids and pericardiocentesis
Emergent evacuation to a surgical facility for definitive care
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US Cardiac Tamponade SC View
Pericardial effusion
RV
RA collapse
Dilated LA and
LV
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Cardiac Tamponade SC View
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Cardiac Exam
Left Parasternal Long Axis (LPLA)
Probe placed in left ICS 2‐4
Probe directed to patient’s back
Reference mark positioned at 4 o’clock toward patient’s left foot
Left Parasternal Short Axis (LPSA)
Same as LPLA
THEN reference mark rotated to 8 o’clockposition toward patient’s right foot
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LPLA Probe Position
Reference Mark
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LPLA ‐ Illustration versus US
Illustration US
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LPLA
C
D
F
A B
E
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Name the Structures
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Pericardial Effusion LPLA View
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Training Images
LPLA
B mode M‐mode
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Perform and Interpret an E‐FAST Exam Thorax View
Slide 92JSOMTC, SWMG(A)
Thorax View Scanning Technique
Scan both sides of chest symmetrically
Scan in the long axis chest
Scan from top to bottom of chest anteriorly
Mid‐axillary and mid‐clavicular lines
Do both sides sequentially for comparison
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Scanning Areas for Thorax
Mid Clavicular Lines
Anterior Axillary Lines
Clemente’s 1987
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US and Lung Tissue
Soft tissue, bone, and pleura seen well
Visceral and parietal pleura slide on each other
Parenchyma tissue poorly visualized secondary to air
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US Characteristics of Thorax in LA
Skin
SQ tissue
Chest wall muscles
Ribs in TA
Intercostal muscles
Pleura Parietal and visceral
Lung parenchyma
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US and Lung Tissue
Pleural (lung) sliding noted “real‐time” when both layers are adherent and is a normal finding
“Comet‐tail” artifact is seen distal to the sliding pleural surfaces and indicates normal anatomy
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US Image of Normal Lung Motion “Comet Tail” Lines LA
Small arrow
Comet tail artifact
Normal lung sliding
Large arrow
Pleural surface
Dark shadow
Rib shadow
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Normal Lung Motion
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Identify E‐FAST Variants and Pitfalls
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E‐FAST Variants ‐ Renal Cysts
Liver
Kidney
Cysts
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E‐FAST Variants ‐ Renal Tumor
Kidney in LA
1 ‐ Tumor• Hypoechoic due to increased vascularity
• Mass like structure
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E‐FAST Variants ‐ Splenic Hemangioma
Characteristics
Appears hyperechoic due to increased vascularity
Smooth edges as compared with traumatic hemorrhage
Spleen
Diaphragm
Left kidney
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E‐FAST Variants ‐ Spleen Hematoma
Normal spleen
Hematoma with hyperechoic clotted blood
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E‐FAST Variants ‐ Bowel with Hemorrhage LA Pelvis
Characteristics
Outer layer mesentery is hyperechoic
Middle layer of bowel wall is hypoechoic
Inner layer of feces hyperechoic
Free fluid
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Pitfalls of US for PTX
False positives‐ no PTX, no pleural sliding
Pleural adhesions
• Chronic lung disease
• COPD
• Fibrosis
False negatives or indeterminate
Massive chest wall trauma
SQ emphysema
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Recall Key Points to Consider When Performing an E‐FAST Exam
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E‐FAST Exam Key Points
Scan should be performed with patient supine
Serial exams may be necessary to detect “evolving” hemorrhage
Full urinary bladder facilitates seeing the rectovesicular space
Fill bladder via Foley catheter with sterile saline
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E‐FAST Exam Key Points
Retroperitoneal bleeding
Inadequate volume of fluid
Have patient take a deep breath and hold if having difficulty seeing RUQ and LUQ
Pushes organs inferiorly
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E‐FAST Exam Key Points
Solid organ trauma with encapsulated bleeding
Image quality dependent on quality of US machine and probe, body habitus of patient, physical injuries
Scan and interpretation are operator dependent
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E‐FAST Exam Key Points
Must be able to image heart from 2 US windows
Have patient take a deep breath or turn on the left side to improve image of heart
Should be performed after abdominal component of E‐FAST exam is done
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E‐FAST Exam Key Points
Know the difference between effusion and tamponade
Effusion may be hyperechoic if blood has clotted
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Questions?
Slide 113JSOMTC, SWMG(A)
Agenda
Identify the E‐FAST exam definition, indications, goals and accuracy
Identify the internal and topographical anatomy necessary to perform and interpret an E‐FAST exam
Identify the characteristics of free fluid
Identify the E‐FAST exam scanning technique
Slide 114JSOMTC, SWMG(A)
Agenda
Identify how to perform and interpret an E‐FAST exam right upper quadrant view
Identify how to perform and interpret an E‐FAST exam left upper quadrant view
Identify how to perform and interpret an E‐FAST exam pelvic view
Identify how to perform and interpret an E‐FAST exam cardiac view
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Slide 115JSOMTC, SWMG(A)
Agenda
Identify how to perform and interpret an E‐FAST exam thorax view
Identify E‐FAST variants and pitfalls
Recall key points to consider when performing an E‐FAST exam
Slide 116JSOMTC, SWMG(A)
Reason
As a SOF medic you may have to make many triage, treatment and evacuation decisions. Competence with performing an E‐FAST exam will assist your decision making process by allowing for enhanced recognition of internal hemorrhage and pnuemothorax.
Slide 117JSOMTC, SWMG(A)
References
The Atlas of Emergency Medicine, 3rd
Edition
Tintinalli’s Emergency Medicine, 7th
Edition
Pre‐hospital Trauma Life Support, Military Edition, 7th Edition
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Slide 118JSOMTC, SWMG(A)
Terminal Learning Objective
Action: Communicate knowledge of the E‐FAST exam
Condition: Given a lecture in a classroom environment
Standard: Received a minimum score of 75% on the written exam and practical test IAW course standards
Slide 119JSOMTC, SWMG(A)
E‐FAST ExamPFN: SOMUSL02
Hours: 2.5
Instructor: