This patient arrives in the Emergency Department after sustaining penetrating chest trauma and is found to be hypotensive, tachycardic, and with a low oxygen saturation on room air. The first step in evaluating any trauma patient involves the primary survey. The primary survey is also known as the “ABCDEFs” of trauma. This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma). Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition. The primary survey should be conducted prior to taking a full history. After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history.
The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries. The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas. The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam. The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid. In the setting of trauma, free fluid is assumed to be blood. The presence of free fluid on a FAST exam is considered a “positive FAST exam”. This patient’s ultrasound shows fluid in the pericardiac sac which in combination with the patient’s hypotension and tachycardia, this supports a diagnosis of cardiac tamponade. See the image below for labelling.
Cardiac tamponade is considered a type of obstructive shock. As with other types of obstructive shock, such as pulmonary embolism and tension pneumothorax, there is a state of reduced preload and elevated afterload. This causes a reduction in cardiac output (Choice C) which leads to hypotension, tachycardia, and circulatory collapse. High cardiac preload (Choice A), low cardiac afterload (Choice B), and high cardiac output (Choice D) do not occur in cardiac tamponade. Treatment for cardiac tamponade includes IV hydration to increase preload, bedside pericardiocentesis, and ultimately, a surgical cardiac window performed by cardiothoracic surgery. Correct Answer: C
This patient arrives in the Emergency Department after an assault with penetrating abdominal trauma and is hemodynamically stable on exam. The first step in evaluating any trauma patient involves the primary survey. The primary survey is also known as the “ABCDEFs” of trauma. This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma). Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition. The primary survey should be conducted prior to taking a full history. After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history.
The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries. The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas. The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam. The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid. In the setting of trauma, free fluid is assumed to be blood. The presence of free fluid on a FAST exam is considered a “positive FAST exam”. This patient has no free fluid between the right kidney and liver. There also is no free fluid above the diaphragm to indicate a hemothorax. The question stem notes that all other FAST exam views are nonremarkable. Therefore, this patient has a negative FAST exam. See labelling of the FAST exam image below.
An exploratory laparotomy (Choice A) would be indicated in a patient with penetrating or blunt trauma, a positive FAST exam, and hemodynamic instability. This patient has a negative FAST exam and is hemodynamically stable. Packed red blood cell infusion (Choice B) would be indicated in the setting of hemodynamic instability and trauma, as this is assumed to be hemorrhagic shock. This patient is not tachycardic or hypotensive. A urinalysis to check for hematuria (Choice D) may be a helpful adjunctive investigation to evaluate for renal or bladder injury, but it is not the most crucial next step in management. Performing a CT scan of the abdomen and pelvis (Choice C) is the best next step as the patient is hemodynamically stable with a negative FAST exam and a penetrating abdominal injury. The CT scan will help further evaluate for any internal injuries that may require operative repair. See the algorithm below for further detail on an abdominal trauma work flow. Correct Answer: C
This patient arrives in the Emergency Department after an assault and has pallor (paleness), hypotension, and tachycardia on exam. The first step in evaluating any trauma patient involves the primary survey. The primary survey is also known as the “ABCDEFs” of trauma. This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma). Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition. The primary survey should be conducted prior to taking a full history. After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history.
The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries. The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas. The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam. The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid. In the setting of trauma, free fluid is assumed to be blood. The presence of free fluid on a FAST exam is considered a “positive FAST exam”. This patient has free fluid between the left kidney and spleen in combination with hypotension and tachycardia. This patient is in hemorrhagic shock until proven otherwise and needs prompt operative management. See labelling of the FAST exam image below.
us image showing bleeding
A CT scan of the chest, abdomen, and pelvis (Choice A) and a CT scan of the head (Choice C) may be helpful in the evaluation of this patient, but this patient is hemodynamically unstable. Radiographic tests that require the patient to leave the Emergency Department should be avoided if the patient is unstable. The specific location or cause of the hemodynamic instability can be diagnosed in the operating theater where there are opportunities to control the intraperitoneal bleeding (i.e., splenectomy, vessel ligation or cautery, etc.). Bedside diagnostic peritoneal lavage (Choice D) is not indicated in penetrating abdominal trauma when there is a negative FAST exam and CT scanning is available. This patient sustained blunt abdominal trauma, so a DPL is less informative. The best next step for this patient is exploratory laparotomy (Choice B) in the operating theater. Hemodynamically unstable patients with a positive FAST exam should always go to the operating theater for further diagnosis and treatment. See the algorithm below for further detail.
This young female presents with dizziness, fatigue, nausea, generalized abdominal pain, hypotension, tachycardia, and a positive urine pregnancy test. The anechoic (black) areas on the bedside ultrasound indicate free fluid (blood) in the peritoneal space. See the image below for clarification. Yellow arrows indicates free fluids.
This patient is in a state of physiologic shock. Shock is an emergency medical state characterized by cardiovascular or circulatory failure. Shock prevents peripheral tissues from receiving adequate perfusion, resulting in organ dysfunction and failure. Shock can be categorized as hypovolemic, distributive, obstructive, or cardiogenic. The different categories of shock are defined by their underlying cause (i.e., sepsis, hemorrhage, pulmonary embolism, etc.) and their hemodynamics which sometimes overlap. The diagnosis of shock is largely clinical and supported by the history, vital signs, and physical exam. Additional studies, such as laboratory investigations, bedside ultrasound, and imaging tests help narrow down the type of shock, potential triggers, and guide management.
This patient’s condition is caused by a presumed ruptured ectopic pregnancy and intraperitoneal bleeding. This is considered hypovolemic/hemorrhagic shock (Choice A). The other types of shock in Choices B, C, and D are less likely given the clinical and diagnostic information in the case. The chart below details the categories of shock, each category’s hemodynamics, potential causes, and treatments.
Traumatic injuries are one of the leading causes of death, and intraperitoneal bleeds occur in approximately 12% of blunt traumas [1]. A quick assessment of trauma and detection of intraperitoneal fluid is increasingly essential in trauma patients’ assessment. The implementation of point-of-care ultrasound (POCUS) has had a significant impact on patient management, especially in a trauma setting. POCUS is easy to use at the bedside, non-invasive and inexpensive.
The Focused Assessment with Sonography in Trauma (FAST) is an ultrasound protocol used to assess hemoperitoneum and hemopericardium [2]. The FAST protocol is sensitive and specific for detecting intraperitoneal free fluid. According to previous studies, sensitivity ranges from 75-100%, and specificity ranges from 88-100% [3]. The FAST exam is rapid and can be completed in less than 5 minutes. It also has multiple advantages, including decreased time to interventions like surgery and length of stay at the hospital [4]. The Extended FAST (eFAST) protocol, which involves examinations of each hemithorax for hemothorax and pneumothoraces, has recently been introduced by several institutions [2].
Regions Examined
The FAST exam assesses the pericardium and multiple potential spaces within the peritoneal cavity for free fluid. The patient is often assessed in the supine position.
The right flank or right upper quadrant (RUQ) view assesses the hepatorenal recess (also known as Morrison’s pouch), as well as the right paracolic gutter, the hepato-diaphragmatic area, and the caudal edge of the left liver lobe [2]. The pericardial view, also known as the subcostal or the subxiphoid, is usually assessed next. The liver is commonly used as a sonographic window of the heart to evaluate pericardium. Ultrasound can detect little pericardial fluid with sensitivity and specificity approaching 100% [5]. The pericardial view also helps to differentiate between pleural and pericardial effusions and visualize right ventricular collapse during diastole [2]. Next, the left upper quadrant (LUQ) is used to visualize the splenorenal recess, the subphrenic space and the left paracolic gutter. If the eFAST protocol is being conducted, the RUQ and LUQ views are also used to examine the left and right hemithorax. Lastly, the pelvic or the suprapubic view is used to assess for free fluid in the rectovesical pouch in males and rectouterine and vesicouterine pouches in women [2]. The bladder acts as a sonographic window for this view.
While there are no complications related to the FAST exam itself, the use of ultrasound does have some limitations, one of which is the requirement for at least 150-200 cc of intraperitoneal fluid for an ultrasound to be able to detect. This can lead to false negatives when free fluid is in fact present [6]. False positives in the FAST exam may also occur and can be due to the presence of ascites, pre-existing pleural or pericardial effusions unrelated to the trauma, ruptured ovarian cysts or ruptured ectopic pregnancies [2]. Healthcare workers should be aware that POCUS and the FAST protocol have limitations dependent on the provider’s experience and the patient’s body habitus.
Poletti, P. A., Mirvis, S. E., Shanmuganathan, K., Takada, T., Killeen, K. L., Perlmutter, D., Hahn, J., & Mermillod, B. (2004). Blunt abdominal trauma patients: can organ injury be excluded without performing computed tomography?. The Journal of Trauma, 57(5), 1072–1081. https://doi.org/10.1097/01.ta.0000092680.73274.e1
Brenchley, J., Walker, A., Sloan, J. P., Hassan, T. B., & Venables, H. (2006). Evaluation of focussed assessment with sonography in trauma (FAST) by UK emergency physicians. Emergency Medicine Journal, 23(6), 446–448. https://doi.org/10.1136/emj.2005.026864
Melniker, L. A., Leibner, E., McKenney, M. G., Lopez, P., Briggs, W. M., & Mancuso, C. A. (2006). Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Annals of Emergency Medicine, 48(3), 227–235. https://doi.org/10.1016/j.annemergmed.2006.01.008
Mandavia, D. P., Hoffner, R. J., Mahaney, K., & Henderson, S. O. (2001). Bedside echocardiography by emergency physicians. Annals of emergency medicine, 38(4), 377–382. https://doi.org/10.1067/mem.2001.118224
Von Kuenssberg Jehle, D., Stiller, G., & Wagner, D. (2003). Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. The American journal of emergency medicine, 21(6), 476–478. https://doi.org/10.1016/s0735-6757(03)00162-1
Cite this article as: Maryam Bagherzadeh, Canada, "Focused Assessment with Sonography in Trauma (FAST): An Overview," in International Emergency Medicine Education Project, September 20, 2021, https://iem-student.org/2021/09/20/sonography-in-trauma-fast/, date accessed: March 26, 2023
This patient has sustained blunt abdominal trauma from his seat belt. This is indicated by the linear area of ecchymoses, known as a “seat belt sign”. This is a worrisome physical exam finding that should raise a concern about a severe intra-abdominal injury. All trauma patients presenting to the emergency department should be assessed using an organized approach, including a primary survey (“ABCs”) followed by a secondary survey (more detailed physical examination). The FAST (Focused Assessment with Sonography in Trauma) examination is part of the primary survey in a trauma patient. Some sources abbreviate the primary survey in trauma as “ABCDEF”, which stands for Airway, Breathing, Circulation, Disability, Exposure, FAST exam. The primary survey attempts to identify any life-threatening diagnoses that need to be addressed in a time-sensitive manner. Examples include cardiac tamponade, tension pneumothorax, and intra-abdominal bleeding. The FAST exam includes 4 basic views: the right upper quadrant view (liver and right kidney), pelvis view (bladder), left upper quadrant view (spleen and left kidney), and cardiac/subxiphoid view (heart). An E-FAST, or extended FAST, includes the four standard FAST views plus bilateral views of the lungs to evaluate for pneumothorax. An abnormal FAST exam demonstrates the presence of free fluid on ultrasound. In the setting of trauma, free fluid is assumed to be blood. Free fluid on ultrasound appears black, or anechoic (indicated by yellow arrows in below image).
The space between the liver and right kidney (“Morrison’s Pouch”) is often the first location or blood to accumulate in a patient with intra-abdominal bleeding. Trauma patients who are hemodynamically unstable with a positive FAST exam (this patient) should go to the operating room for emergent exploratory laparotomy (Choice C) to determine the source of their bleeding. Performing a CT scan of the abdomen and pelvis (Choice A) would be the correct answer if the patient was hemodynamically stable and had a positive FAST exam. Allowing this patient to leave the emergency department for a CT scan would be dangerous as this patient could rapidly decompensate. Performing a Diagnostic Peritoneal Lavage (Choice B) would be the correct answer if the patient was hemodynamically stable but had a normal FAST exam. An emergent thoracotomy (Choice D) is more typically performed in patients with penetrating trauma who have cardiac arrest shortly before presenting to the emergency department. This intervention attempts to identify and treat any reversible causes of cardiac arrest. Correct Answer: C
Patients with hypotension or shock have high mortality rates, and traditional physical exam techniques can be misleading. Diagnosis and initial care must be accurate and prompt to optimize patient care. Ultrasound is ideal for evaluating critically ill patients in shock, and ACEP guidelines now delineate a new category of ultrasound (US)– “resuscitative.” Bedside US allows for direct visualization of pathology and differentiation of shock states (1). The RUSH is one of the most commonly used protocols for this purpose.
The RUSH exam involves a 3-part bedside physiologic assessment simplified as “the pump,” “the tank,” and “the pipes” (2).
Seif D1, Perera P, Mailhot T, Riley D, Mandavia D. “Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol” Crit Care Res Pract. 2012;2012:503254.
Cite this article as: Murat Yazici, Turkey, "Rapid Ultrasound for Shock and Hypotension (RUSH) Protocol US Imaging – Illustrations," in International Emergency Medicine Education Project, May 29, 2020, https://iem-student.org/2020/05/29/rush-protocol-illustrations/, date accessed: March 26, 2023
As a part of our social responsibility initiative, iem-course.org will continue to provide free open online courses related to emergency medicine. We hope our courses help you to continue your education during these difficult times.
Please send us your feedback or requests about courses.
We are here to help you.
Best regards.
Arif Alper Cevik, MD, FEMAT, FIFEM
iEM Course is a social responsibility initiative of iEM Education Project
Hypotension is a high-risk sign which is associated with increased morbidity and mortality rate. The differential diagnosis for hypotension is broad and the treatment depends on the underlying etiology. In most cases of hypotension, patients present with limited history and physical examination may be inaccurate making the management of the condition a great challenge for emergency physicians.
The use of POCUS in undifferentiated hypotension has been shown to help correctly and rapidly identify the etiology and therefore initiate the appropriate management. Since 2001, there are many protocols published describing a systematic approach to the use of POCUS in undifferentiated hypotension.
In this course, we will focus on the Rapid Ultrasound in Shock and Hypotension (RUSH) protocol.
This course aims to provide the necessary information on ultrasonography, its use in a hypotensive patient, and to prepare you for a RUSH practice session.
The course content is prepared and curated from iEM Education chapters, iEM image and video archives, and various FOAMed resources.
At the end of this course, you will be able to;
Describe the basics of ultrasound (terminology, knobology, image acquisition, artifacts, etc.)
Describe indications of RUSH protocol
Describe patient and machine preparations
Describe ultrasound examination views
Recognize normal anatomical structures
Recognize abnormal findings
Feel confident to take a practical session for RUSH protocol
Who can get benefit from this course?
Junior and senior medical students (course specifically designed for these groups)
Interns/Junior emergency medicine residents/registrars
As a part of our social responsibility initiative, iem-course.org will continue to provide free open online courses related to emergency medicine. We hope our courses help you to continue your education during these difficult times.
Please send us your feedback or requests about courses.
We are here to help you.
Best regards.
Arif Alper Cevik, MD, FEMAT, FIFEM
iEM Course is a social responsibility initiative of iEM Education Project
Extended Focused Assessment With Sonography In Trauma (eFAST) is one of the most commonly used emergency ultrasound or Point-Of-Care Ultrasound protocols. It is a protocol that we use in trauma patients. However, the eFAST examination can also be a part of another protocol, such as RUSH protocol.
The early diagnosis of a bleeding trauma patient is essential for better patient care. Unfortunately, it is proven that our physical exam findings are not perfect in every case. Therefore, using a bedside tool in addition to the physical examination can improve patient management.
As a 21st-century medical student/young physician, you must learn how to use this tool to provide more comprehensive and accurate care to your patients.
This course aims to provide the necessary information on ultrasonography, its use in a multiply injured trauma patient, and to prepare you for an eFAST practice session.
Ultrasound evaluation for deep venous thrombosis (DVT) is one of the 11 core ultrasound applications for emergency physicians as listed in the 2008 American College of Emergency Physicians guidelines (1). Because ultrasound applications started to be implemented into medical school curriculum in many countries, learning basic ultrasound applications as early as possible will benefit medical students and junior residents. In this post, I will share lower extremity venous ultrasound illustrations with you.
Indications
The clinical indications for performing a lower venous ultrasound examination is the suspicion of a lower extremity DVT in a swollen or discoloured leg.
Transducer
Select a high-frequency linear transducer, (5-10) MHz transducer since it provides optimal venous copmression and image resolution.
Remember Risk Factors of DVT
Age > 60
Cancer
Central venous catheter/insertion
Genetic causes of hypercoagulopaty
History of DVT
Immobilization
Obesity
Pregnancy
Smoking
Trauma or recent surgery
Use of birth control pills or hormone replacement therapy
Wells Score for Deep Vein Thrombosis
Criteria
Score
Active cancer(treatment ongoing or within previous 6 months or palliative treatment)
1
Paralysis, paresis, or recent plaster immobilization or of the lower extremities
1
Recently bedridden for 3 days or more or major surgery within the previous 12 weeks requiring general or regional anesthesia
1
Localized tenderness along the distribution of the deep venous system
1
Entire leg swollen
1
Calf swelling > 3cm compared to asymptomatic leg (measuring 10 cm below tibial tuberosity)
A 45-years-old male with a week history of right leg swelling and redness presented to the ED. He has type II DM and hypertension. He denies fever; however, complaints about burning pain over the skin. Vitals were 156/98 mmHg blood pressure, 98 beats per minute heart rate, 16 respiration per minute, 36.7 degrees Celsius temperature and 98% oxygen saturation in room air. Physical exam revealed erythema over the right medial lower leg and calf area (images). Minimally painful with palpation. The area was hot compared to the left leg. Other examination findings were unremarkable.
Patients with red, swollen, painful leg may have very severe problems such as necrotizing fasciitis (infection involving muscular fascia) or infections involving muscles with or without gangrene. The patients having these infections are generally ill-looking, severely painful, and may have subcutaneous crepitations. Therefore, we should be aware of these red flags. This patient has no sign of crepitations, systemic illness, or severe pain.
Lipodermatosclerosis is chronic erythema. Patients show exacerbations because of vascular insufficiency (venous). It can be bilateral or unilateral. One of the discriminative findings from cellulitis is temperature over the lesion. Lipodermatosclerosis is not hot. In the case, the palpation showed warm skin compared to the left side.
Erysipelas is superficial and its’ borders are very sharp. The lesion is fluffy compared to the skin around the lesion. In the case, some areas of the skin were found a little bit raised compared to surrounding structures. However, its’ borders were not well-demarcated.
Other differentials are burns, contact dermatitis, urticaria, etc.
Bedside ultrasound imaging can help to identify cellulitis, abscess, foreign body, fracture, etc. Cobblestone finding is a typical finding for cellulitis.
Bedside ultrasound imaging was performed with Butterfly iQ with soft tissue settings. Cobblestone finding was found in the erythematous areas. This is a nonspecific finding and can be seen many different soft tissue infections. There were no gas/air artifacts (necrotizing fasciitis) or obvious abscess formation. However, there was a minimal fluid accumulation, which creates a suspicion of an abscess. In the case, there was no air artifact. However, x-rays can also help to show air accumulation in soft tissues.
An Example for Necrotizing Fasciitis
The ultrasound investigation in this video shows the air (white) artifacts in the soft tissue.
X-ray Image Showing Subcutaneous Air in Necrotizing Fasciitis
The patients with co-morbidities compromising immune response, periorbital or perianal locations, unable to tolerate oral medication, deep infections should be admitted.
References and Further Reading
Loyer EM, DuBrow RA, David CL, Coan JD, Eftekhari F. Imaging of superficial soft-tissue infections: sonographic findings in cases of cellulitis and abscess. AJR Am J Roentgenol. 1996 Jan;166(1):149-52. PubMed PMID: 8571865.
Shyy W, Knight RS, Goldstein R, Isaacs ED, Teismann NA. Sonographic Findings in Necrotizing Fasciitis: Two Ends of the Spectrum. J Ultrasound Med. 2016 Oct;35(10):2273-7. doi: 10.7863/ultra.15.12068. Epub 2016 Aug 31. PubMed PMID: 27582527.
Indications for clinicians to perform point-of-care hepatobiliary ultrasound include the evaluation of; abdominal pain, jaundice, sepsis and ascites.
Transducer
The most commonly used positions include; left lateral decubitus and supine position. A low-to medium-frequency (2–5 MHz) curvilinear ultrasound transducer will suffice for most ultrasound examinations of the gallbladder.
Patient positioning
Patient positioning plays a vital role in the hepatobiliary ultrasound examination. Transducer position according to gallbladder; longitudinal and transverse.