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WINFOCUS’ BASIC ECHO (WBE)!

Thomas White, MD, FACS

Trauma Surgery and Critical Care

Intermountain Medical Center

Salt Lake City, Utah

The FAST Exam

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Focused

Assessment

with Sonography

in Trauma

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!

Text

FAST

ocused ssessment with onography in rauma

FAST

Not just for trauma…….

Finding/confirming ascites!Splenic artery or aortic aneurysm rupture, hollow viscus perforation, ectopic pregnancy, postop bleeding

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• A limited ultrasound examination for the detection of free fluid in the chest, abdomen or mediastinum

• Advanced/expanded

• Rapid detection of pneumothorax

• Not included

• identification of solid organ injury

Goals of FAST

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Indications for FAST

• Blunt and penetrating thoracoabdominal trauma

• Trauma or abdominal pain and pregnancy

• Unexplained hypotension in any patient

• CONTRAINDICATION - other indication for the OR

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How to - Quick review

• Probe marker always to patient’s head or to patient’s right

• Gentle compression – Eliminate bowel gas, improve skin-transducer

interface

• Low-frequency probe – Larger, deeper structures

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FAST – FOUR VIEWS

• sub-xiphoid !

• RUQ !

• LUQ !

• Pelvic !

based on 3 most dependent areas of peritoneum as well as view of the heart

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WINFOCUS’ BASIC ECHO (WBE)!

Subxiphoid

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RARV

LA LV

Subxiphoid

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RARV

LA LV

Subxiphoid

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Things to be concerned about….

Scalloping of Right

Ventricle

Things to be concerned about….

Things to be concerned about….

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!Parasternal Long View

• Probe is on left side of sternum

!• Used to visualize aortic

outflow tract

Nice alternative view for subxiphoid (obese, abdominal pain, postop).!!wrong probe, terrible technique

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Upper quadrant landmarks

RUQ LUQ

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• Potential space between Gerota’s fascia of the right kidney and Glisson’s capsule of the liver

• Dependent region of right upper abdomen in the supine patient

Morrison’s Pouch

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!Morrison’s Pouch - Anatomy

Spleen

R Kidney

Liver

L Kidney

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!Morrison’s Pouch - Anatomy

Spleen

R Kidney

Liver

L Kidney

(Morrison’s Pouch

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• Technique:

– Midaxillary line – Horizontal subxiphoid

line – Fan posteriorly

Morrison’s Pouch

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Morrison’s Pouch

• Examine for:

–Fluid in Morrison’s pouch

–Fluid in right paracolic gutter

–Fluid in subdiaphragmatic space

–Fluid in right pleural space (cephalad to diaphragm)

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Morrison’s Pouch

• REMEMBER the INFERIOR POLE of the kidney!

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Morrison’s Pouch

Morrison’s Pouch

Morrison’s Pouch

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Hemothorax

• Loss of mirror image artifact

• Anechoic wedge superior to the liver and spleen

• Extension of the Thoracic Line

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Mirror Image

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Mirror Image

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“spine sign”

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Splenorenal Recess

– Potential space between spleen and left kidney

– Dependent region of left upper abdomen

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Splenorenal Recess - Anatomy

Spleen

R Kidney

Liver

L Kidney

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Splenorenal Recess - Anatomy

Spleen

R Kidney

Liver

L Kidney

)

Splenorenal Recess

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•Technique:

• Posterior axillary line

• Horizontal subxiphoid line

• Fan posteriorly

Splenorenal Recess

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• Examine for:

– Fluid in splenorenal recess

– Fluid in left paracolic gutter

–Fluid in subdiaphragmatic space

– Fluid in left pleural space (cephalad to diaphragm)

Splenorenal Recess

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KIDNEY

DIAPHRAGM

SPLEEN FLUID

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FLUID ABOVE SPLEEN

LEFT LUNG

SPLEEN

DIAPHRAGM

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Splenorenal Recess

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Splenorenal Recess

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Splenorenal Recess

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Pelvis

• Pouch of Douglas/Rectovesicular space

• Dependent region of lower abdomen

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Pelvis – Female Anatomy

Rectouterine Pouch

(of Douglas)

Vesicouterine Pouch

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Pelvis – Male Anatomy

Rectovesical Recess

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Pelvis

•Technique:

• Suprapubic (2 cm above symphysis pubis)

• Start midline

• Longitudinal and transverse planes

• Ideally prior to emptying of bladder via Foley (clamp)

• FANNING!!

clamp or lift bag to fill bladder (hey, its their urine after all...)

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• Examine for: –Fluid posterior to bladder

–Fluid posterior to uterus

–Fluid between bowel loops

Pelvis

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WINFOCUS’ BASIC ECHO (WBE)!

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Blunt Abdominal Trauma (BAT)

• Diagnostic Options:

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Blunt Abdominal Trauma (BAT)

• Diagnostic Options:

DPL

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Blunt Abdominal Trauma (BAT)

• Diagnostic Options:

CT

DPL

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Blunt Abdominal Trauma (BAT)

• Diagnostic Options:

CT

DPL

FAST

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FAST and Hemoperitoneum

• Sensitivities range from 69% to high 90’s • McGahan J US Med 1997 500 pts - sensitivity 63% >90%

• Specificities 95-100% in multiple studies

• Time < 4 minutes in most studies

• Reliably detects 200-650 cc of intraperitoneal blood

• 650 cc based on Branney study, single view

• CT 100-250 cc

• DPL - 100,000 RBC/mm3 = 20 cc in 1 L IVF

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Advantages to FAST• Compared to DPL:

– Noninvasive

– Repeatable

– Complication-free

– Not contraindicated by previous surgeries

– Capable of identifying pericardial and pleural fluid

– Cost-effective

– Higher specificity for therapeutic laparotomy

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Advantages to FAST

• Compared to CT: – Available for hemodynamically-

unstable patients – Portable – Rapid – Repeatable – Does not require contrast or

radiation – Cost-effective

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Disadvantages to FAST

• Operator-dependent

• Difficult in obese patients or those with subcutaneous air or excessive bowel gas

• Less accurate in diagnosing specific organ lesion

• Less accurate in diagnosing retroperitoneal injury

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Disadvantages to FAST

• infers rather than proves injury

• may miss retroperitoneal, or diaphragmatic injuries

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Outcome trials• Outcome Assessment:

– 135 PLUS, 127 controls – Time to operative care 64% less for PLUS

patients – PLUS patients spent 27% fewer days in hospital – PLUS patients underwent fewer CTs – PLUS patients had fewer complications – PLUS patient charges were 35% less

Melniker LA , Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. Randomized controlled clinical trial of point-of-care, limited sonography for trauma in the emergency department: the

first sonography outcomes assessment program trial. Ann Emerg Med 2006;48(3):227-35.

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Literature to know

• Echo decreases time to OR and mortality

Plummer, D, Brunnette D, Asinger R, Ruiz E. Emergency department echocardiography improves outcome in penetrating cardiac injury. Ann Emerg Med 1992; 21:709-712.

!Rozycki, GS, Feliciano DV, Ochsner MG, et al. The role of ultrasound in patients with

possible penetrating cardiac wounds: a prospective multicenter study. J Trauma 1999; 46:543-51.

US group 100% survival; time to OR 15 min

Controls 57% survival; time to OR 42 min

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FAST Algorithms

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Pitfalls in FAST

• Failure to scan all four views

• Failure to note echogenic clotted blood

• Failure to perform serial exams

• Failure to scan the inferior renal poles, subdiaphragmatic region on left and sagittal bladder view

• Humility with any new skill…

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