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FOCUSED ASSESSMENT WITH SONOGRAPHY FOR

TRAUMA (FAST)

INTRODUCTION
This parameter has been developed to supply assistance to practitioners performing focused
assessment with sonography for trauma (FAST) ultrasound examinations. It is a proven and
useful procedure for the evaluation of the trunk, thorax & rib cage for bleeding after traumatic
injury, in penetrating trauma.
Over the past years, there has been a significant increase in clinician-performed ultrasound
in many specialties. Advancement in technology have led to better image quality and smaller,
simpler and more cost-effective machines. At the identical time clinical research, improved
education and increasing awareness of the various uses of ultrasound
It doesn't must compete with or replace other imaging and assessment modalities, but it
complements them. Ultrasound is portable, will be immediately accessed, doesn't interrupt
resuscitation, is safe, repeatable.
Although it's unimaginable to detect every abnormality or injury using the FAST
examination within the management of the traumatized patient. the main limitation of
ultrasound remains that it's operator dependent, with training and knowledge in addition as
simple inter-operator variability playing a job. Ultrasound is additionally patient dependent;
some patients are tougher to image; this is often thanks to obesity but other factors may also
play a component.

UNFOLDING FAST SCAN

The United States was first used to study trauma patients in the 1970s in Europe. Although it
did not become popular in North America until the 1990s, during this time, the FAST
acronym was defined as "Focused Abdominal Sonography for Trauma." Later the acronym
was changed to Focused Assessment with Sonography for Trauma. Since then, FAST has
become the standard first screening modality in most trauma center in the United States and
around the world.

INDICATIONS/USES
Uses of ultrasound in trauma.
1.Immediate
➢ Blunt and/or penetrating abdominal and/or thoracic trauma
➢ Undifferentiated shock and/or hypotension (as part of the Rapid Ultrasound for
Shock and Hypotension (RUSH) exam).

2. Major trauma
➢ Assessment of the Basic Haemodynamic State
➢ Hemoperitoneum
➢ Hemopericardium
➢ Extended FAST (EFAST)
• Pneumothorax
• Haemothorax
➢ Intravascular filling status

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3. Regional trauma
➢ Cardiac and Thoracic aortic injury (trans-thoracic and trans-oesophageal
echocardiography)
➢ Fractures
• Sternal fractures
• Rib fractures
➢ Soft-Tissue injury
➢ Intubation confirmation and endotracheal tube placement
➢ Vascular access
➢ Foreign body removal
➢ Paracentesis/Intercostal drainage guidance.

❖ A positive eFAST scan helps the surgeon identify common bleeding areas (i.e.,
abdomen, heart, lungs) to plan the surgical approach.
If the initial eFAST examination is negative in a patient with a highly suspected
mechanism of injury, CT scans or serial eFAST examinations should be used to identify
particularly worsening clinical conditions (e.g., worsening vital signs, hemodynamic
instability, pain, etc.). may be beneficial in the context of abdominal examination).
because the patient may also be late for the presentation.

CONTRA-INDICATION
There is no absolute contra -indication for fast scan, but resuscitation and patient safety is
primary step to taken

CAUSES OF FALSE NEGATIVES

➢ obesity: severely limits assessment of the peritoneal cavity
➢ subcutaneous emphysema
➢ posterior acoustic enhancement caused by the fluid-filled bladder can result in free fluid
being missed in the pelvic view

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CAUSES OF FALSE POSITIVES

➢ epicardial fat pads, the descending aorta, and pericardial cysts have been mistakenly
identified as an effusion
➢ pre-existing ascites, pleural, and pericardial effusions due to medical conditions
➢ seminal vesicles mistaken for pelvic free fluid in the young male patient

EQUIPMENT
Curved (or abdominal) probes from 2MHz to 5MHz are used for
eFAST testing to avoid delays when switching between
transducers. However, phased array (or cardiac) probes are also
effective, especially at the parasternal window. Similarly, a 5MHz
to 12MHz linear (or vascular) probe is ideal for assessing pleural
displacement.

TECHNIQUE/STEPS
A. PATIENT PREPRATION
➢ Patient lye in supine position with the exam table flat or in the Trendelenburg position
(this increases the sensitivity of the exam but is not required).
B. MACHINE PREPRATION
➢ Place the machine on the patient’s right side. This
makes it possible to scan with your right hand and
manipulate ultrasound controls with your left hand
C. SEQUENCE & FINDINGS
1. RUQ Probe Position and Hand Placement
➢ Using the liver as an acoustic window, ‘lung, liver,
Morison’s Pouch, diaphragm, and the long-axis
of the right kidney’ can be seen.
➢ Morison’s Pouch is where usually THE free fluid in the RUQ view.

2. LUQ Probe Position and Hand Placement

✓ Using the spleen as a acoustic window, ‘spleen, peri splenic space, diaphragm &
long axis view of left kidney ‘can be seen.
✓ Free fluid in the LUQ is most frequently seen in the peri splenic space (between the
spleen and the diaphragm).

3. Pelvic Ultrasound – Longitudinal View

✓ In males, bladder (immediately posterior to the symphysis), prostate/seminal
vesicle, and rectovesical pouch in the longitudinal view.
✓ In Females, bladder, uterus, and Rectouterine Pouch (also called the Pouch of
Douglas).
✓ The Pouch of Douglas is where free fluid will accumulate in the female pelvis.

4. Cardiac Subxiphoid View

✓ Using the liver as the acoustic window, identify the liver, pericardium, right
atrium, right ventricle, left atrium and left ventricle

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5.Cardiac Parasternal Long Axis

✓ The parasternal window allows visualization of the heart in the long or short axis.
✓ These views are used in cases in which a patient’s subcostal view is suboptimal
6. Lung Probe Position
✓ The first lung ultrasound finding to confirm the probes are in the correct position is to
look for the two rib shadows or the “Batwing Sign.”
✓ The next finding is lung sliding during respiration. This is a simple finding but
extremely useful since lung sliding definitely means that the visceral and parietal
pleura are next to each other, effectively ruling out a pneumothorax.

CLINICAL SIGNIFICANCE

Practice points
1. Abdominal free fluid:
✓ Sensitivity 42–98% (most studies 64–98%); specificity 95–100%,
✓ Sensitivity improves with experience,
✓ Sensitivity is better for larger volumes of free fluid, and in hypotensive
patients requiring laparotomy for intra-abdominal bleeding the volume
of fluid is likely to be large
✓ Serial FAST examination may improve sensitivity as bleeding
continues to create larger collections of free fluid.
2. Solid-Organ Injury
✓ 22% of adults with intra-abdominal injury have no free fluid.
✓ The ultrasound appearance of abdominal organ injury is highly
variable and changes with time after the injury.
✓ The technical skill and knowledge needed to comprehensively assess
the abdomen with ultrasound is far greater than for FAST
3. Haemothorax
✓ Sensitivity is 83.6–97.5% in the supine patient and specificity 99.7–
100%.
✓ Ultrasound can be performed more rapidly than chest radiography

INTERPRETATIONS
1. HEMOPERITONIUM
➢ The eFAST is moderately sensitive (approximately 80%) and highly specific (>90%)
for detecting free fluid from hemoperitoneum.
➢ The three common locations for free fluid to accumulate in the RUQ & LUQ of the
eFAST scan are the:
• Hepatorenal Space or “Morison’s Pouch”
• Caudal Tip of the Liver
• Supra hepatic Space
• Peri splenic Space (most common site in LUQ)
• Spleen Tip
• Splenorenal Recess

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2. HEMOTHORAX
➢ Since the aerated lung will reflect all of the ultrasound waves back, a normal lung
will have a Mirror Image Artifact and won't be able to see the spine protruding over
the diaphragm.
➢ Since ultrasound waves are easily able to flow through free fluid in the chest cavity,
seeing the patient's spine above the diaphragm means that there is free fluid (such as
blood) in the thorax. An example of a Positive Spine Sign is this.

3. PERICARDIAL EFFUSION AND TAMPONADE

➢ A pericardial effusion can develop when anechoic free fluid builds up in the
pericardial sac.
➢ The presence of a pericardial effusion alone does not indicate cardiac tamponade in
the patient. Instead, for the fluid to be called tamponade, it must be preventing heart
filling
When the following is seen, take tamponade into consideration:
• Right Atrial Systolic Collapse, which is the most early and sensitive
tamponade echocardiographic result known as the Trampoline Sign.
• The most accurate echocardiographic sign of tamponade is right ventricular
diastolic collapse.

4. PNEUMOPERITONEUM
➢ The most common finding in the peritoneal cavity during trauma, especially
penetrating trauma, is pneumoperitoneum, or free air.
➢ The Enhanced Peritoneal Stripe Sign is the most typical pneumoperitoneum finding
on abdominal ultrasonography (EPSS). When this occurs, air in the peritoneal space
rises and "echoes" the abdominal wall's single, hyperechoic peritoneal stripe, which
divides the abdominal wall from the underlying peritoneal fluid and fluid-filled
organs.

5. PNEMOTHORAX
➢ Look for the Lung Point Sign to indicate the presence of a pneumothorax.
➢ The lung point is the point at which we may observe the change from normal lung
sliding to no lung sliding. The distinction between a collapsed lung and a healthy
lung is made at this location. Pneumothorax is definitely ruled out if this symptom
is present. The Lung point sign also aids in determining the size of a
pneumothorax.

CONCLUSION
In conclusion, ultrasonography is now generally acknowledged and used in trauma
situations. The use of ultrasound is crucial in a variety of situations, including the triage
and resuscitation phase as well as later when a patient is being thoroughly evaluated.
How to assure proper training and competency in such a user- and experience-dependent
technology is a big worry for both doctors and radiologists, and this is the current key
difficulty.

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Accuracy of Focused Assessment with Sonography for Trauma (FAST)

in Blunt Trauma Abdomen—A Prospective Study
doi: 10.1007/s12262-013-0851-2
Subodh Kumar, Virinder Kumar Bansal,corresponding author Dillip Kumar Muduly, Pawan
Sharma, Mahesh C. Misra, Sunil Chumber, Saraman Singh, and D. N. Bhardwaj
Abstract
Focused assessment with sonography for trauma (FAST) is a limited ultrasound examination,
primarily aimed at the identification of the presence of free intraperitoneal or pericardial fluid.
In the context of blunt trauma abdomen (BTA), free fluid is usually due to haemorrhage, bowel
contents, or both; contributes towards the timely diagnosis of potentially life-threatening
haemorrhage; and is a decision-making tool to help determine the need for further evaluation or
operative intervention. Fifty patients with blunt trauma abdomen were evaluated prospectively
with FAST. The findings of FAST were compared with contrast-enhanced computed
tomography (CECT), laparotomy, and autopsy. Any free fluid in the abdomen was presumed to
be hemoperitoneum. Sonographic findings of intra-abdominal free fluid were confirmed by
CECT, laparotomy, or autopsy wherever indicated. In comparing with CECT scan, FAST had a
sensitivity, specificity, and accuracy of 77.27, 100, and 79.16 %, respectively, in the detection of
free fluid. When compared with surgical findings, it had a sensitivity, specificity, and accuracy
of 94.44, 50, and 90 %, respectively. The sensitivity of FAST was 75 % in determining free
fluid in patients who died when compared with autopsy findings. Overall sensitivity, specificity,
and accuracy of FAST were 80.43, 75 and 80 %, respectively, for the detection of free fluid in
the abdomen. From this study, we can safely conclude that FAST is a rapid, reliable, and
feasible investigation in patients with BTA, and it can be performed easily, safely, and quickly
in the emergency room with a reasonable sensitivity, specificity, and accuracy. It helps in the
initial triage of patients for assessing the need for urgent surgery.
Conclusion
From this study, it can be reliably concluded that FAST is a feasible investigation in patients
with BTA, and it can be performed easily and quickly in the emergency room with a reasonable
sensitivity, specificity, and accuracy. It helps in the initial triage of patients for conservative
management or immediate operation. FAST can be used safely in patients with blunt abdominal
and chest trauma for the diagnosis of intraperitoneal bleeding and traumatic pericardial
tamponade, without any added complications. CECT scan can be used in BTA for the diagnosis
of hemoperitoneum and hollow viscus injuries. CECT scan is more sensitive and specific in
detecting free intraperitoneal fluid following BTA than FAST, but it is time consuming and
expensive. Though the present study was a small pilot study, we need to perform a larger study
to reach a definite conclusion.

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NURSING ROLES AND RESPONSIBILITIES

1. Triage
❖ Based on the urgency and seriousness of a patient's condition, an emergency room nurse assists
personnel in setting priorities for care.
❖ Because of their medical expertise, fast thinking, and attention to detail, nurses can help patients by
thoroughly evaluating their needs, gathering their personal and medical information, and seeking a
doctor's rapid evaluation for life-threatening problems.

2. Vital signs
❖ Throughout a patient's stay in the emergency room, vital signs are taken, including their temperature,
pulse rate, and breathing & blood pressure.
❖ Vital signs give nurses a bird's-eye perspective of a patient's status and warn them of changes that
may need a doctor's care.

3. Patient Preparation
❖ Patient lying supine with the exam table flat or in the Trendelenburg position (this increases the
sensitivity of the exam but is not required).

4. Machine Preparation
❖ Ultrasound Machine Placement: Place the machine on the patient’s right side. This makes it possible
to scan with the right hand and manipulate ultrasound controls with the left hand.

5. Assist with Testing

❖ Nurses assist patients and other healthcare professionals during diagnostic testing. During the test,
they respond to the patient's needs, which may include giving medicine as necessary. In order to do
the required diagnostic testing, nurses must assist patients in positioning themselves correctly, such
as rolling over.

6. IV Access
❖ A patent IV access allow the nurse to administer all the required medications such as pain medication
and other antibiotics.

7. Monitoring Patients
❖ During diagnostic tests, nurses keep an eye on the patient’s current health, particularly for individuals
who are regarded unstable.
❖ They must analyse a patient's physical health, check their vital signs (blood pressure, pulse, and
breathing rate), and keep an eye on any monitoring the patient needs to be connected to throughout
the test, like a heart monitor or ventilator.
❖ Any monitors or other devices that can interfere with the testing may also need to be connected or
disconnected by nurses.

8. Documentation/Charting
❖ All patients' medical histories, contact details, current conditions, medications, and treatments must
be recorded by nurses.
❖ In order for other members of the medical team to respond appropriately during the course of the
patient's examination and treatment, accurate documentation in the patient's chart is essential.
Effective and careful charting also shields hospitals and staff from future legal liabilities.

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REFRENCES

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J, Hamilton P. Emergent abdominal sonography as a screening test in a new
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7) Kumar S, Bansal VK, Muduly DK, Sharma P, Misra MC, Chumber S, Singh
S, Bhardwaj DN. Accuracy of Focused Assessment with Sonography for
Trauma (FAST) in Blunt Trauma Abdomen-A Prospective Study. Indian J
Surg. 2015 Dec;77(Suppl 2):393-7. doi: 10.1007/s12262-013-0851-2. Epub
2013 Jan 31. PMID: 26730032; PMCID: PMC4692944
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