AUTHORS 

MATT JONES, MD

TAMARA ARMSTRONG, MD

 

Contributor

matt jones, md

 

 

EFAST

(Extended Focused Assessment With Sonography for Trauma)

In its current state, the EFAST is a point-of-care ultrasound protocol for critically ill trauma patients. With experience, healthcare providers can quickly and accurately identify pathology in the peritoneal, pericardial, and pleural spaces. The goal of this chapter is to provide a concise and accurate introduction to the EFAST.

 

Sequence of scanning 

At the consensus conference ***

 

 

 

Right Upper Quadrant

The goal is to obtain views of the pleural space,  the subphrenic space (between diaphragm and liver), the hepatorenal space (Morison’s pouch), and the inferior pole of the kidney. 

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Technique

  • Start with probe marker towards head. Place the probe lateral to the xiphoid process at the right mid-axillary line. Fan the probe toward the retroperitoneum. You will likely be in close proximity to the hepatorenal space (Morrison’s pouch). 

  • It may help to turn the probe oblique to get in between ribs.

  • Slide the probe superiorly to visualize the pleural space. Check for mirror artifact (the echogenicity of the liver= echogenicity of the pleural space). If this is absent and the pleural space is instead black, consider hemothorax. If you see black above the diaphragm and a piece of hyperechoic tissue waving, it is a hemothorax. The waving tissue is collapsed lung tissue. 

  • Slide the probe down over the next rib to visualize the interface between the liver and diaphragm. 

  • Angle/slide the probe inferiorly and scan anterior to retroperitoneal to visualize the hepatorenal space (Morrison’s pouch). 

  • Scan through the entire kidney to check for fluid accumulation both in the potential space (Morrison's Pouch) and at the inferior pole, sliding inferiorly if necessary.

 

RUQ Pathology

EFAST RUQ EXAM ARCHIVE

 

 

 

Left Upper Quadrant

Goal: Obtain views of the pleural space, the subphrenic space, splenorenal space, and the inferior pole of the left kidney.

Technique

  • Start with probe marker towards head. Place the probe lateral to the xiphoid process at the left posterior-axillary line (retroperitoneal) - dot to the head knuckles on the bed. The splenorenal space is visualized.

  • The spleen is smaller than the liver and tends to be more superior and posterior.

  • It may help to turn the probe oblique to get in between ribs.

  • Slide the probe superiorly to visualize the pleural space (lung). Check for mirror artifact (the echogenicity of the spleen = echogenicity of the pleural space). If this is absent and the pleural space is instead black, consider hemothorax. If you see black above the diaphragm and a piece of hyperechoic tissue waving, it is a hemothorax. The waving tissue is collapsed lung tissue. 

  • Slide the probe down over the next rib to visualize the interface between the spleen and diaphragm. 

  • Angle/slide the probe inferiorly and scan anterior to visualize the splenorenal space.

  • Scan inferior to the kidney to check for fluid accumulation at the inferior pole.

 

 

LUQ Pathology

 

 

 

SUPRAPUBIC

Goal: Obtain a view of the rectovesicle space (male) or rectouterine space (female) (aka Pouch of Douglas)

Technique

  • Start by holding the probe transverse just above the pubic symphysis, marker to patient’s right, and angle down into the pelvis.

  • Scan through the bladder by fanning the probe back and forth.

  • Turn the probe sagittal, marker towards head, and angle down into the pelvis.

  • Fan the probe to assess for free fluid in the potential space between the rectum and either the bladder or uterus.

SUprapubic pathology

 

 

 

 

SUBCOSTAL

Goal: Obtain a view of the pericardial space using the liver as an acoustic window.

Goal: Obtain a view of the pericardial space using the liver as an acoustic window.

Technique

  • Start by holding the probe like a TV remote and place it in transverse plane, inferior to the xiphoid process, marker toward the patient’s right.

  • The probe should be angled up towards the heart and will be almost be parallel to the floor.

  • Make sure the depth is adequate and enough pressure is used.

  • It may also be helpful to have the patient breath in and hold it.

  • Asses forf fluid in around the heart and overall pump function.

 

Subcostal Pathology

 

 

 

 

Pulmonary

Goal: Obtain views of lung slide to assess for pneumothorax.

Technique

  • Start with probe perpendicular to ribs, marker towards head.

  • Slide the probe superior or inferior until a good pleural line between rib spaces is visualized.

  • On the left side, try to find a space that is superior to the heart.

  • have the patient breath in and out to help visualize the slide.

  • The slide can be describes as “ants walking on a stick”.

  • M-mode can also be used to see “waves on a sandy beach”.

  • Dead ants in B-Mode or a “barcode” on M-mode suggests pneumothorax.

 

Pulmonary Pathology

 

 

 

Documentation

 

EFAST EXAM

EFAST EXAM (NEGATIVE STUDY)

FAST EXAM

FAST EXAM (NEGATIVE STUDY)

LIMITED ABDOMEN/EVALUATE FOR FREE FLUID

LIMITED ABDOMEN/EVALUATE FOR FREE FLUID (NEGATIVE STUDY)

 

 

 

Additional Educational Resources

 

SAEM E-FAST Lecture

ACEP: EFAST- Extended Focused Assessment With Sonography for Trauma. 

D’Agostino, J. (2009, July 20). Fast Exam

Reardon, R. Ultrasound in Trauma- The FAST Exam

Usefulness of Extended-FAST (EFAST-Extended Focused Assessment with Sonography for Trauma) in critical care setting. (Brazilian Review Article, WELL DONE)

http://www.aium.org/resources/guidelines/fast.pdf

 

 

HISTORICAL PERSPECTIVE 

 

The History of the FAST exam is fascinating. To view it in its entirety, illustrates beautifully the gradual development of a modern medical technology. I have started a slow process of mapping this out in The History of Ultrasound.

 

REFERENCES 

For ultrasound fellows, complete access to all articles found at Articles Trauma / EFAST

 

 

 

 

PAGE AUTHORS 

Matt Jones, MD

TAMARA ARMSTRONG, MD