2 Efast PDF
2 Efast PDF
2 Efast PDF
Emergency
Ultrasound
Course
Dr Justin Bowra
ED Course Manual 2:
EFAST
Extended Focused
Assessment
with Sonography
in Trauma
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The Questions:
1. Is there free fluid (FF)
a. In the pleural space?
b. In the pericardial space?
c. In the peritoneum?
2. Is there a pneumothorax (PTX)?
Introduction
Extended Focused Assessment with Sonography in Trauma (EFAST) has supplanted FAST as the standard of
care in bedside imaging of the trauma patient.
It is a means of detecting:
• free intraperitoneal fluid
• free pleural fluid
• free pericardial fluid
• pneumothorax (PTX).
TOP TIPS:
1. Pneumothorax (PTX = air in the pleural space) collects at the anterior chest in the supine patient.
2. Haemothorax (HTX = blood in the pleural space) collects at the posterior lung bases in the supine
patient.
3. The amount of fluid is important in the pleural and peritoneal spaces, but less so in the pericardium.
What does this mean?
a. Pericardial blood collects rapidly in trauma. The pericardium doesn’t have time to stretch to
accommodate it. You don’t need much to cause a tamponade!
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b. But there’s more room to move in the pleural and peritoneal spaces. So if you see just a tiny bit
of fluid in these spaces in a shocked patient, then look elsewhere for the cause of the shock.
c. The only exception is patients that have not been lying flat- eg the shocked patient with a
ruptured ectopic pregnancy may have only a little FF in Morison’s Pouch. That’s because she
has been standing up and all the fluid is in the pelvis.
d. Free blood is only black (anechoic) if it’s fresh. If it’s been there for awhile (eg the patient
with ruptured EP that has been slowly bleeding) the blood may have clotted and it will no longer
be black: i.e. you may miss it.
Haemopericardium (blood in the pericardial space) collects first below the left side of the heart.
Haemoperitoneum (blood in the peritoneum) will first collect in certain potential spaces in the supine patient:
1. Right upper quadrant (RUQ): in the supine abdomen, FF will first collect around the liver. This will be in
one or more of the following spaces:
a. Morison’s pouch (between the liver and the right kidney)
b. The anterior recess (in front of the liver tip)
c. Between the diaphragm and the liver (supbphrenic space)
2. Left upper quadrant (LUQ): FF may collect around here, in one of the following areas:
a. Between the diaphragm and the spleen (supbphrenic space)
b. The lienorenal interface (between the spleen and left kidney)
3. Pelvis: FF will collect in the Pouch of Douglas (rectovesical pouch in the male) deep to the bladder.
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WINDOWS
The TRAUMA / SHOCK SWEEP
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• Pericardial fluid appears as a black stripe around the heart if the blood is fresh.
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SUBCOSTAL CARDIAC WINDOW
CLOTTED PERICARDIAL BLOOD
IMAGE COURTESY OF HENRY CURTIS
• In true cardiac tamponade the IVC distends, and the right ventricle will collapse during diastole.
However, this can be difficult to assess for the non-echocardiographer, so clinical likelihood of
tamponade (shock + chest trauma) must be taken into consideration when acting on a positive
scan. [FOR MORE DETAILS ON PERICARDIAL FLUID & TAMPONADE, SEE CRITICAL CARE
MANUAL]
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2. Right & left upper quadrants (RUQ / LUQ): is there free peritoneal fluid?
a. Scanning the RUQ
• Begin with the probe parallel and between the ribs where the costal margin meets the mid-axillary
line on the right of the patient.
• This window uses the liver as an acoustic window and should demonstrate right kidney, liver,
diaphragm (highly echogenic) and right lung base for pneumo/haemothorax.
• Sweep the probe anteroposteriorly and alter the probe angle to parallel the ribs until you obtain a
clear view of Morison’s pouch.
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THE SAN EMERGENCY ULTRASOUND MANUAL
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POSITIVE RUQ: BUT FREE FLUID (FF) IS SEEN JUST AT TIP OF LIVER.
MORISON’S POUCH FALSELY NEGATIVE.
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• The spleen is smaller, more posterior and higher than the liver, so this side is always trickier than
the RUQ
• Sweep the probe and alter its angle as above, until you obtain a clear view of left kidney, spleen,
diaphragm and left lung base.
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POSITIVE LUQ IMAGE: FREE FLUID BELOW THE DIAPHRAGM AND BELOW THE
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• As the patient breathes in, watch for the bright ‘scatter’ from air in the lung sweep down and
obscure the image. This is called ‘the lung curtain’ and its presence means that there is no pleural
fluid (such as haemothorax) at that site.
• Of course, there may still be a small amount of pleural fluid below this. So to increase your
sensitivity, scan the most inferior part of the thorax. In the supine patient, this means ‘scan as far
posteriorly as possible, just above the diaphragm’.
• Fluid will appear black / dark / clotted, just above the diaphragm, and sometimes you will see the
lung floating within a large effusion.
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THE SAN EMERGENCY ULTRASOUND MANUAL
4. Right and left anterior lung: pneumothorax (PTX) (see lung chapter for details):
• Air rises, so be careful to place the probe on the highest part of the thorax. In the supine patient,
this means scan the anterior lung.
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SCANNING THE ANTERIOR CHEST FOR PNEUMOTHORAX
• Probe and scanner settings as per lung US chapter, but you are only looking for PTX
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• Increase the depth so that you get a good view of the structures deep to the bladder.
• Scan in two planes, at 90 degrees to each other:
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o sagittal plane (see image below)
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• Scan all the way past the bladder, to be sure you aren’t missing anything.
• FF will be around the bladder or behind it (Pouch of Douglas).
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THE SAN EMERGENCY ULTRASOUND MANUAL
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THE SAN EMERGENCY ULTRASOUND MANUAL
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THE SAN EMERGENCY ULTRASOUND MANUAL
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THE SAN EMERGENCY ULTRASOUND MANUAL
Summary
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