eFAST Ultrasound Knowledge Examination Identifier (Number): PGY__________ Date:

Instructions: The following test is designed to evaluate your knowledge in the eFAST ultrasound application. When choosing the best answer, guessing is discouraged. If you are unsure of the answer, and cannot eliminate some of the choices, answering with “I don’t know” is appropriate.

SECTION 1: BASIC PHYSICS AND INSTRUMENTATION

1. Which of the following transducer(s) are best suited to perform the abdominal portion of the eFAST exam?

a. High frequency linearb. Low frequency curvilinearc. Phased arrayd. Endocavitarye. B or Cf. I don’t know

2. When placing the transducer on your patient, the transducer marker should generally be directed towards:

a. The patient’s feetb. The patient’s head or to the patient’s right sidec. The patient’s left sided. I don’t know

3. What single imaging adjustment would most improve the quality of this RUQ eFAST exam image?

a. Increase the gainb. Decrease the gainc. Increase the depthd. Increase the frequency

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e. I don’t know

4. When performing an eFAST exam, you see the following image. What single adjustment would you make to best visualize the target structures pictured?

a. Increase the gainb. Increase the depthc. Decrease the depthd. Decrease the frequencye. I don’t know

5. Which of the following is correct regarding frequency of the ultrasound wave?a. The higher the frequency of a sound wave, the better the resolution of the image b. The higher the frequency of a sound wave, the better is its ability to penetrate deeper into the

bodyc. The higher the frequency, the quicker the ultrasound wave will be attenuated (weakened)d. A and Ce. I don’t know

6. Which of the following transducers is best to image the pleural interface when performing the lung/pneumothorax portion of the eFAST exam?

a. High frequency linearb. Low frequency curvilinearc. Phased arrayd. Endocavitarye. I don’t know

7. When an organ is described as “hyperechoic” in relation to other nearby structures, it means:a. The organ appears brighter that the nearby structuresb. The organ appears darker than the nearby structuresc. The organ is blurry compared to the nearby structures

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d. The organ is more clearly detailed that the nearby structurese. I don’t know

8. When performing an eFAST exam of the RUQ, you see the following image. Recognizing that something doesn’t look right, what should your first step be to correct the image?

a. Adjust the gainb. Adjust the depthc. Rotate the transducer 90 degreesd. Rotate the transducer 180 degreese. I don’t know

9. All of the following are true about the sonographic characteristics of free fluid in the abdomen EXCEPT:a. It is blackb. It is hyperechoicc. It fills potential spaces and appears to have “pointy” or sharp edgesd. It is anechoice. I don’t know

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10. What ultrasound artifact is demonstrated in this image?

a. Reverberationb. Mirror artifactc. Edge Artifactd. Posterior enhancemente. I don’t know

11. How would you characterize the artifacts depicted in the below image by the arrows, and what is causing them?

a. “dirty” shadow caused by airb. “clean” shadow caused by airc. “dirty” shadow caused by rib/boned. “clean” shadow caused by rib/bonee. I don’t know

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SECTION 2: ANATOMY

12. When attempting to obtain the left upper quadrant (LUQ) view of the eFAST exam, the target area commonly lies more ____________ and ____________ when compared to the target area of the right upper quadrant view (RUQ)

a. Anterior / Inferiorb. Posterior / Superiorc. Posterior / Inferiord. Anterior / Superiore. I don’t know

13. Which of the following best describes Morrison’s Pouch?a. The potential space covered by the pericardium surrounding the heartb. The area deep to the bladder where free fluid can collectc. The potential space between the liver and right kidney where free fluid can collectd. The space between the spleen and left kidneye. I don’t know

14. The most dependent area of the peritoneal cavity in a patient who is lying supine (face up) is:a. Left paracolic gutterb. Right paracolic gutterc. Splenorenal Recessd. Rectovesicular pouch / Pouch of Douglase. Morrison’s Pouchf. I don’t know

15. Match the letters found in the following image of the right upper quadrant (RUQ)to their corresponding anatomical landmark

______________ Kidney______________ Liver______________ Hepato-renal Recess / Morrison’s Pouch

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16. Match the letters found in the following image of the left upper quadrant (LUQ) to their corresponding anatomical landmark

___________ Spleen___________ Kidney___________ Spleno-renal recess___________ Diaphragm___________ Lung

17. Identify the anatomical structure represented by the bright stripe indicated by the arrowa. Liverb. Kidneyc. Gerota’s fasciad. Splenic capsulee. Diaphragmf. I don’t know

18. The most common place to see free fluid when present in the left upper quadrant isa. Between spleen and kidney

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b. Between spleen and diaphragmc. Around the tip of the spleend. Both B and C are most commone. I don’t know

19. Match the letters found in the following subxiphoid image with their corresponding anatomical structure:

___________ Liver___________ Right Ventricle___________ Left Ventricle___________ Stomach Air with dirty shadow

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20. Match the letters found in the following eFAST image with their corresponding anatomical structures

___________ Skin / Dermis___________ Pleural Interface___________ Rib___________ Lung___________ Chest wall / pectoral muscle

21. What structures, which are commonly mistaken for free fluid, are represented by the arrows in the following image:

a. Bladderb. Uterusc. Seminal Vesiclesd. Prostatee. I don’t know

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SECTION 3: IMAGE INTERPRETATION

22. True or False: The following image is a positive eFAST

A. TrueB. False

23. What eFAST window do both of the the following images depict and which shows a pericardial effusion?

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a. Parasternal Long Axis / image Bb. Subxiphoid / image Ac. Subxiphoid / image Bd. Parasternal Long Axis / image Ae. I don’t know

24. What is your diagnosis based on the following image:

a. Peritoneal free fluidb. Pericardial free fluidc. Splenic laceration/ruptured. Pleural effusion or hemothoraxe. Diaphragm rupturef. I don’t know

25. In the following video, is a pneumothorax present or absent?a. Presentb. Absent

26. In the following video of a lung exam for pneumothorax, what are the findingsa. Normal exam with sliding lung presentb. Abnormal exam with sliding lung sign and lung point sign presentc. Abnormal exam with no sliding lung sign presentd. I don’t know

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27. True or False: The following image of the left upper quadrant is positive for free fluid

A. TrueB. FalseC. I don’t know

28. In the following video, is a pneumothorax present or absent?a. Presentb. Absent

29. Which of the following are sonographic signs that pneumothorax may be present?a. Sliding lung signb. Lung pointc. Absent sliding lung signd. Seashore Signe. B and Cf. I don’t know

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30. What anatomical structure is pictured and is there free fluid present?

A. Heart / YesB. Liver / NoC. Bladder / YesD. Lung / NoE. I don’t know

SECTION 4: GENERAL KNOWLEDGE

31. The FAST exam:a. Is easier to perform in obese patientsb. Is used to identify free intraperitoneal or pericardial fluid in the setting of traumac. Is sensitive for all intra-abdominal organ injuryd. Can differentiate blood from other types of fluide. All of the above

32. The optimal position to visualize free fluid in Morrison’s Pouch is:a. Trendelenburg (feet elevated 15-30 degrees above the level of the head)b. Right lateral decubitus (lying on right side)c. Left lateral decubitus (lying on left side)d. Reverse Trendelenburg (Head elevated 15-30 degrees above level of the feet)e. I don’t know

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33. The arrows found in the following image denote:

a. A new pericardial effusionb. An epicardial fat padc. Soft tissue of the chest walld. The right heart walle. I don’t know

34. In the LUQ viewa. The phrenicocolic ligament restricts the flow of free fluid to the LUQb. Blood freely flows between the left paracolic gutter to the LUQc. The LUQ view is typically found more anterior and inferior as compared to the RUQ viewd. The LUQ is the most easily visualized of the FAST viewse. All of the above

35. In the Pelvic (Suprapubic) view:a. Seminal vesicles may be incorrectly identified as free fluidb. Gain/posterior enhancement artifact can be problematic in this viewc. The probe should be placed at the level of the umbilicus (belly button) d. A and Be. All of the above

36.  When performing a lung examination for pneumothorax with ultrasound:a. Between two rib shadows, there is a notable echogenic line known as the pleural interfaceb. The transducer is placed longitudinally (pointed cranially toward patient’s head) in the

midclavicular linec. The transducer is moved inferiorly in a systematic fashiond. All of the abovee. I don’t know

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37. Which of the following can make the left upper quadrant view of the eFAST exam more difficult to obtain?

a. The spleen is not a good acoustic windowb. The target area is typically more posterior and superior than the RUQ viewc. The stomach, which is often air-filled, can interfere with the examd. B and Ce. None of the abovef. I don’t know

38. Which of the following can’t typically be ruled out by a FAST exam:a. Bowel perforationb. Bowel wall contusionc. Pancreatic traumad. Retroperitoneal hemorrhagee. All of the abovef. I don’t know

39. All of the following may mimic a positive eFAST except:a. Perinephric Fatb. Ascitesc. Pericardial fat / epicardial fat padd. Small amount of physiologic free fluid in pouch of douglase. Full bladderf. I don’t know

40. Which of the following is not a standard view of the eFAST examinationa. Right upper quadrant (RUQ) / Morrison’s pouchb. Bladderc. Left Upper quadrant (LUQ) / Spleno-renal recessd. Subxiphoid / Parasternal Long Axis (PLAX)e. Lung for pneumothoraxf. Proximal aortag. I don’t know

41. While performing an eFAST exam which is otherwise negative, you are struggling to clearly visualize the heart from the subxiphoid view. Your next action should be:

a. Give up and call the scan “indeterminate”b. Continue to try to image from the subxiphoid regionc. Move to a parasternal window of the heartd. Call the exam negative, since all the other windows are negative.e. I don’t know

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SECTION 5: CLINICAL APPLICATION 42. All of the following are characteristics of the eFAST examination except:

a. Rapidb. Repeatablec. Distinguishes blood from other free fluidd. Non-radiatinge. Non-invasivef. I don’t know

43. All of the following are characteristics of the eFAST examination are true except:a. More difficult in obese patientsb. Difficult to distinguish blood from ascitesc. Does not specify which organ is injuredd. Allows for evaluation the retroperitoneal spacee. I don’t know

44. The only contraindication to performing the eFAST exam is:a. Patient has altered mental statusb. Patient is hypotensive / hemodynamically unstablec. Patient suffered penetrating abdominal traumad. Already a clear indication for urgent operative management (surgery)e. Pregnancyf. I don’t know

45. A patient presents with blunt abdominal trauma and stable vital signs. Initial eFAST was negative for free fluid. Thirty minutes later, the patient becomes hypotensive and tachycardic. At this time, the quickest, easiest, and most appropriate diagnostic test to perform would be:

a. CT scan of abdomenb. Diagnostic peritoneal lavagec. Repeat eFASTd. Chest X-Raye. CBCf. I don’t know

46. A 25y/o male presents to your aid station at a remote FOB without surgical capability following a rollover motor vehicle accident in which he was thrown from the turret of the vehicle. His vital signs are: P 90, BP 114/80, RR 14, SPO2 99%. The pelvic and RUQ views of your eFAST exam are positive. Which of the following is the most appropriate course of action?

a. He can be observed. No evacuation is necessaryb. He requires an immediate exploratory laparotomyc. Arrange for an urgent MEDEVAC, preferably to a location with both CT and surgical capabilitiesd. Prepare to perform a chest tube thoracostomye. I don’t know

47. A 20y/o soldier is brought to your aid station, which is co-located with a Combat Support Hospital. The soldier is conscious and tells you that he suffered a gunshot wound to the abdomen. His vitals are P 122, BP 80/40, RR18. Following your primary survey, you perform an eFAST exam which reveals the following:

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What is the best course of action:a. The patient should undergo a CT scanb. The patient should be taken directly to the ORc. This is normal. Seek other causes for this patient’s abnormal vitalsd. I don’t know

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48. You are at your battalion aid station caring for a casualty with a lower leg amputation and multiple penetrating wounds across his body. The casualty is already packaged and awaiting rotary wing MEDEVAC over high altitudes, which will arrive to your location in 30min. Your patient is increasingly complaining of shortness of breath so you decide to perform an ultrasound of his lungs and you see the following M-Mode Image of his right chest:

Your best course of action would be to:A. Continue with plan to evacuate upon arrival of MEDEVACB. Cancel evacuationC. Prepare to place a chest tube prior to arrival of MEDEVACD. Administer medication for pain and anxiolysisE. I don’t know

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49. You are caring for a patient that you highly suspect has peritoneal bleeding. You begin your eFAST scan in the right upper quadrant, where you note the following image:

Your next course of action should be:A. Move on to the left upper quadrant or bladderB. Nothing the exam is negative and your eFAST exam is completeC. Continue to scan the right upper quadrant, being sure to visualize the inferior pole of the

right kidney / tail of liverD. I don’t know

50. True or False: Performing the eFAST is so easy and quick that it is can/should performed while providing care under fire or while there is an active enemy threat in the area.

a. Trueb. False

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