EM · Procedural & diagnostic ED skills
Focused Assessment with Sonography in Trauma (FAST and E-FAST)
Also known as FAST · Focused Assessment with Sonography in Trauma · E-FAST · Extended FAST · Trauma ultrasound
The FAST (Focused Assessment with Sonography in Trauma): the four views (the Morrison pouch or hepatorenal recess, the splenorenal recess, the pouch of Douglas or rectovesical space, and the pericardial or subxiphoid view), the E-FAST extension (bilateral chest for pneumothorax with lung sliding and the lung point, plus the IVC for volume status), the sensitivity of around two-thirds for abdominal injury, the specificity of around 95 per cent, the role in the hypotensive trauma patient (the positive FAST equals the operating theatre, not the CT), the technique with the curvilinear probe, the depth and the gain, and the pitfalls (the false positive from ascites or fat, the false negative from pelvic-only or retroperitoneal …
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Related topics
- The primary survey (ABCDE) — the trauma assessment framework
- Major trauma resuscitation — the team-based systematic approach
- Damage control resuscitation in trauma
- Chest trauma (the immediately and potentially life-threatening injuries)
- Pneumothorax (including tension pneumothorax)
- Abdominal aortic aneurysm (ruptured and intact)
- Point-of-care ultrasound: biliary and renal (and the incidental AAA)
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Red flags
- A positive FAST in the hypotensive trauma patient means the operating theatre, not the CT scanner
- A negative FAST does not exclude intra-abdominal injury — pelvic-only bleeding, the retroperitoneal haematoma and the hollow viscus injury are invisible to ultrasound
- The retroperitoneum is a blind spot — a renal pedicle injury, a pelvic vessel tear and a contained retroperitoneal haematoma can all produce shock with a negative FAST
- A full bladder produces a false positive at the pelvic view — decompress it before you read the pouch of Douglas
- The lung point is the most specific sign of pneumothorax — its absence does not exclude one, but its presence is diagnostic
Meet the patient
A 34-year-old man is brought to the major trauma bay after a high-speed motor vehicle crash — intoxicated, GCS 13, BP 78/50, HR 132. The airway is secure, the chest is clear, two large-bore cannulae are in, and during the circulation assessment your probe finds a black anechoic stripe in the Morrison pouch.[1]
That single stripe is the hinge of his next ten minutes. Positive FAST plus hypotension equals the operating theatre, not the CT scanner — the sentence every ACEM candidate is expected to say first. Now hold the next patient beside him: a 26-year-old with a single stab wound above the left nipple, distended neck veins, and absent breath sounds on the left. The pericardial view is negative, but the chest view shows no lung sliding and a barcode sign. Same probe, same protocol, two different emergencies — a bleeding abdomen and a tension pneumothorax — both read off the same machine during the primary survey.[1]
References5ShowHide
- [1]Nishijima DK, Simel DL, Wisner DH, Holmes JF. Does this adult patient have a blunt intra-abdominal injury? JAMA, 2012.PMID 22496266
- [2]Stengel D, Leisterer J, Ferrada P, et al. Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma Cochrane Database Syst Rev, 2018.PMID 30548249
- [3]Stengel D, Rademacher G, Ekkernkamp A, et al. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma Cochrane Database Syst Rev, 2015.PMID 26368505
- [4]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
- [5]Lichtenstein D, Mezière G, Biderman P, Gepner A. The lung point: an ultrasound sign specific to pneumothorax Intensive Care Med, 2000.PMID 11126253