E‐FAST Exam PFN: SOMUSL02slides.jsomtc.org/SOMUSL02/SOMUSL02.pdfE‐FAST Exam Indications Blunt or...

9/1/2017

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Slide 1JSOMTC, SWMG(A)

E‐FAST ExamPFN: SOMUSL02

Hours: 2.0

Instructor:


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


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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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.


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


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


Identify the E‐FAST Exam Definition, Indications, Goals and Accuracy


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


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


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%



Pericardial effusion/tamponade

Sensitivity: 97‐100%

Specificity: 97‐99%

Hemothorax

Sensitivity: 97.5%

Specificity: 99.7%

Versus CXR sensitivity of 92.5%



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


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


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


Thoracic Anatomy

Skin

SQ tissue

IC muscle

Rib

Parietal pleura

Outer

Visceral pleura

InnerClemente’s Anatomy 1987


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


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


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


Sequential Series of Scans

RUQ

LUQ

Pelvis

Heart

Chest


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)


Scanning Areas for Chest

Mid Clavicular Lines

Anterior Axillary Lines

Clemente’s 1987


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


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


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


US RUQ Anatomy

Morison’s Pouch

Liver

Kidney

RUQ

Diaphragm


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


RUQ ‐ Name the Structures

RUQ RUQ


RUQ Hemothorax

Characteristics

Blood has sharp edges

Hypoechoic

Superior to diaphragm

Diaphragm

Hemothorax

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FF in Thorax or Peritoneum?


RUQ ‐ Normal or Abnormal?


RUQ Scan Free Fluid

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Perform and Interpret an E‐FAST Exam Left Upper Quadrant View


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


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


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


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


LUQ Free Fluid

US Image

Diaphragm

FF

Spleen

Left kidney

Illustration

FF

Spleen

Left kidney


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


LUQ ‐ Normal or Abnormal?


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


Pelvic Probe Position ‐ LA

Reference mark


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


Pelvic Hemorrhage ‐ LA


Pelvic FF with Clots ‐ LA

FFClots

Bladder

Bowel

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Pelvis ‐ LA

FF

Bladder

Cul de sac


Pelvis ‐ TA

Rectovesicular space

Bladder

Transverse


Pelvis Free Fluid ‐ TA

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Pelvic Scan Free Fluid


Perform and Interpret an E‐FAST Exam Cardiac View


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)


Pericardium Anatomy

Pericardium

Pericardium

Illustration Autopsy


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


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


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


Normal SC ‐ Illustration versus US

Pericardium

Illustration US


SC View ‐ Name Structures

r

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Pericardial Effusion

Etiology

Trauma

• Blunt

• Penetrating

Medical abnormalities

• Pericarditis

• Cancer

• Connective tissue diseases

• Renal failure


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


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


SC ‐ Pericardial Effusion


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


Cardiac Tamponade SC View


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


LPLA ‐ Illustration versus US

Illustration US


LPLA

C

D

F

A B

E

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Name the Structures


Pericardial Effusion LPLA View


Training Images

LPLA

B mode M‐mode

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Perform and Interpret an E‐FAST Exam Thorax View


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


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


US Characteristics of Thorax in LA

Skin

SQ tissue

Chest wall muscles

Ribs in TA

Intercostal muscles

Pleura Parietal and visceral

Lung parenchyma


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


Normal Lung Motion


Identify E‐FAST Variants and Pitfalls

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E‐FAST Variants ‐ Renal Cysts

Liver

Kidney

Cysts


E‐FAST Variants ‐ Renal Tumor

Kidney in LA

1 ‐ Tumor• Hypoechoic due to increased vascularity

• Mass like structure


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


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


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


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



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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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



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



Know the difference between effusion and tamponade

Effusion may be hyperechoic if blood has clotted

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Questions?


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


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


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.


References

The Atlas of Emergency Medicine, 3rd

Edition

Tintinalli’s Emergency Medicine, 7th

Edition

Pre‐hospital Trauma Life Support, Military Edition, 7th Edition

9/1/2017

40


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


E‐FAST ExamPFN: SOMUSL02

Hours: 2.5

Instructor:

E‐FAST Exam PFN: SOMUSL02slides.jsomtc.org/SOMUSL02/SOMUSL02.pdfE‐FAST Exam Indications Blunt or...

Documents

Transcript of E‐FAST Exam PFN: SOMUSL02slides.jsomtc.org/SOMUSL02/SOMUSL02.pdfE‐FAST Exam Indications Blunt or...