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THE COMPLETE EFAST
I usually use the curvilinear (abdominal) transducer in the abdominal setting for the entire eFAST examination. However, if the pleural line is difficult to visualise, the linear transducer in the lung setting may help; similarly, the phased array (echo) transducer either in parasternal or subxyphoid may be needed for cardiac views.
Adjust the depth so that your focus is in the middle of the screen. So for pleura: about 6 cm, spine sign 15-20cm, RUQ snd LUQ 10-15cm, subxyphoid 15-20cm, pelvis 10-20cm.
Adjust the gain so that the vessels are anechoic. Too much or too little gain will mean you will miss free fluid.
The essential views are: Left and Right anterior chest, RUQ, LUQ, Pelvis and Subxyphoid. In the abdomen, if you see fluid in one abdominal quadrant, you don't need to look further. Free fluid in a quadrant is not indicative of which organ/ vessel has been injured.
In the periarrest/ arrested trauma patient, look at the subxyphoid for a pericardial effusion and the abdomen for free fluid only. Imaging the chest will get in the way of the thoracostomy.
These are the standard views for a complete eFAST:
ANTERIOR CHEST
A trauma patient is likely to have been supine for a prolonged period prior to arrival in hospital. Thus any free pleural air will collect in the anterior chest parasternally at the highest level of the chest which is usually at the 3rd or 4th rib space (1). Thus in the trauma patient, don't follow the typical lung US areas.
Begin scanning left and right parasternal in the 3rd and 4th rib space with the probe longitudinal on the chest, probe marker cranial. Decrease the depth so the pleura is in the middle of the screen and seen just below two ribs. Angle the transducer to the left and right until the pleura is crisp and bright white. Assess for pleural sliding in 2D. Live B mode assessment of pleural sliding has been shown to be highly accurate for diagnosing absent pleural sliding (2).
Save a clip of this or a still image of the m mode.
M mode of pleural sliding
RUQ
RUQ - SPINE VIEW
Following this, move to the RUQ, at about ribs 8-10, transducer longitudinal with the probe marker cranial. Visualise the diaphragm and liver. Have the transducer about midway along the AP height of the chest and angle the transducer posteriorly towards the bed. Increase the depth and visualise the hyperechoic triangle of vertebral bodies behind the liver. If the spine extends above the diaphragm - SPINE SIGN - this is indicative of lung pathology: haemothorax, significant contusion or aspiration.
Save a still image of the spine view.
RUQ - MORISON'S
I examine for FF in the RUQ first because studies have shown that in the supine patient, fluid collects around the paracolic gutter first and then the RUQ (2,3). For the trauma patient who has walked in: check the pelvis first.
This is why I look for a haemothorax on the right side first. From this position, translate your transducer caudally until you see the liver and kidney with a bright white line between them. This is Morison's pouch: the peritoneal reflection in which free fluid collects. Make sure you translate the transducer to the posterior axillary line because fluid is gravity dependent and imaging too high may miss FF. Angle anteriorly and posteriorly so that you look through the entire space.
Save a still representative image of Morison's pouch.
RUQ - PARACOLIC GUTTER
Next translate your transducer even more caudally until you see the caudal liver tip: the paracolic gutter. Again, make sure your transducer is as posterior as possible on the patient. If you are too anterior in this view, you may see a lot of bowel gas around the liver.
Save a still image of the paracolic gutter.
Ideal paracolic gutter view
Transducer too high on the chest
LUQ
LUQ - SPINE VIEW
The spleen, being smaller and more posterior will be imaged more cranially in the chest than the liver. So start with the transducer held longitudinally, marker cranial. If you can't find the spleen and you're only imaging the kidney, just translate the transducer cranially and posteriorly. For the spine view, translate the transducer cranially to view the diaphragm, have the transducer about midway along the vertical height of the chest and angle posteriorly, increase the depth and image the spine.
Save a still image of the spine view.
LUQ - SPLENO-RENAL RECESS
Now translate the transducer caudally and look for the spleno-renal recess. This should be bright white. However, unlike the RUQ where fluid typically collects in Morison's pouch and paracolic gutter, fluid in the LUQ may collect anywhere around the spleen. Thus fan through the entire space and make sure you look between the spleen and the diaphragm closely.
Save a still image incorporating the spleno-renal recess and the space between the spleen and the diaphragm, usually this can all be see in one image.
LUQ - STOMACH
Once again, remember to keep your transducer as posterior on the patient's chest as possible, otherwise you will image the stomach. The stomach can sometimes look like a splenic laceration on US. If you see something that looks heterogenous and weird instead of the normal homogenous spleen, translate the transducer posteriorly and angle up and have another look.
PELVIS
The most common mistake when examining the pelvis is to place the transducer straight onto the abdomen, looking straight down into the spine. If you do this, all you will see is bowel gas. To visualise the pelvis well, you need to angle (in transverse) and tilt (in longitudinal) the transducer into the pelvis like you're looking into a bucket.
PELVIS - TRANS
male and female pelvis trans
Start with the tranducer placed transversely, probe marker to the right, just above the symphysis pubis and angle into the pelvis. Identify the thick walled bladder just posterior to the shadow of the pelvic brim. In a female, the uterus sits posterior to the bladder and the rectum (seen as bowel gas with dirty shadowing) posterior to this. In a male, the rectum sits posterior to the bladder,. with the prostate between the bladder and rectum in some views.
In the male, at the bladder trigone, you will see the anechoic seminal vesicles which look like a bowtie around the bladder neck. It is easy to think this is free fluid. But remember that free fluid has angular corners whereas the seminal vesicles have rounded edges. Further, you usually won't see the seminal vesicles in longitudinal so check in another view.
Save a still image of the pelvis in trans.
sharp edges created by FF
Fluid collects superior, lateral and posterior to the bladder - never anterior to it. Angle cranially and caudally to look above and posterior to the bladder and then tilt the transducer left and right to look lateral to the bladder.
PELVIS - LONG
Place the transducer longitudinally, probe marker cranial, just above the symphysis pubis and tilt into the pelvis. The bladder will be most anterior with the uterus and rectum posteriorly. In this view angle right and left to look at the whole space. Free fluid will be posterior to and above the bladder.
Save a still image of the pelvis in long.
TOO MUCH FAR GAIN
Often, trauma patients have full large bladders. Remember from physics that the machine assumes the US beam is passing through soft tissue and so predicts a certain amount of attenuation as it travels posteriorly. Thus, it amplifies signals arriving from deeper structures automatically.
Remember also that fluid does not attenuate as much as soft tissue. Thus, the machine will amplify signals deep to the bladder which have not been attenuated. Due to this, you may notice that posterior to a large bladder, the image will be overgained. The problem with this is that you may miss free fluid.
To fix this, go to the TGC of your machine and decrease the far gain when looking at the pelvis.
Pelvis long: example of too much far gain. Interestingly what looks like the bladder is actually free fluid. The small collapsed bladder sits to the right of screen superiorly. So far gain is only really important when you try to refine your eFAST interpretation for small volumes of fluid.
SUBXYPHOID
Increase the depth to 20cm until you find the heart and then decrease the depth so the heart is in the middle of the screen. Also, if you've just been looking at the pelvis, don't forget to increase the far gain in the TGC.
This view is often difficult in the trauma patient due to tense rectus muscles, peritonitis and abdominal bruising. Start in the immediately subxyphoid space, with the transducer in transverse, probe marker to the right and your hand above the transducer pushing down and up into the space. Angle slightly to the left to visualise the heart. If the patient is cooperative, ask them to hold a deep inspiration to bring the heart closer to the transducer.
If you still can't visualise the heart, translate the transducer to the right and image through the liver. You should see the liver anteriorly and a four chamber view of the heart posterior to this.
In this view look for haemopericardium and cardiac contractility. Pericardial fluid will be seen anteriorly between the RV and liver and posteriorly between the LV and pericardium.
Save a clip of the heart.
PARASTERNAL VIEW OF THE HEART
If you are really struggling with the subxyphoid view, you can image the heart from the chest. You can also still use the curvilinear transducer. Place the transducer vertically on the patient's chest, L parasternal at about the 4th or 5th rib space, probe marker to the L hip. This will give you the typical parasternal view of the heart.
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REFERENCES
1. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, Melniker L, Gargani L, Noble VE, Via G, Dean A, Tsung JW, Soldati G, Copetti R, Bouhemad B, Reissig A, Agricola E, Rouby JJ, Arbelot C, Liteplo A, Sargsyan A, Silva F, Hoppmann R, Breitkreutz R, Seibel A, Neri L, Storti E, Petrovic T; International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence-based recommendations for point-of-care lung ultrasound
2. Lobo V, Hunter-Behrend M, Cullnan E, Higbee R, Phillips C, Williams S, Perera P, Gharahbaghian L. Caudal Edge of the Liver in the Right Upper Quadrant (RUQ) View Is the Most Sensitive Area for Free Fluid on the FAST Exam. West J Emerg Med. 2017 Feb;18(2):270-280.
3. Federle MP, Jeffrey RB Jr. Hemoperitoneum studied by computed tomography. Radiology. 1983 Jul;148(1):187-92.