IOTW 11/30/20

18 y/o M p/w chest and abdominal pain s/p fall from motorcycle the night prior

  1. Which FAST exam view above does NOT contain free fluid?
    • The Subxiphoid view does NOT contain free fluid. All three other views are positive.
  2. The primary survey of ATLS follows the “ABCDE” protocol. Which part of the primary survey does the FAST exam further assess: A, B, C, D, or E?
    • C – Circulation. An Extended-FAST (E-FAST) would also further assess B – Breathing.
  3. Can you accurately name what each arrow is depicting in the images above labeled A-L?
    • A – Liver
    • B – Free fluid in Morrison’s Pouch
    • C – Rib shadow artifact
    • D – Spleen
    • E – Left subdiaphragmatic free fluid
    • F – Left hemidiaphragm
    • G – Urinary bladder in sagittal view
    • H – Pelvic free fluid
    • I – Intestines
    • J – Right ventricle
    • K – Left ventricle
    • L – Pericardium
  4. What is the minimum amount of free fluid that the literature suggests can be detected on a FAST exam?
    • It was suggested that a minimum of 500 mL of free fluid could be detected on a FAST exam. However, as ultrasound imaging technology and operator technique improves, newer literature suggests that as little as 100 mL of free fluid can be detected.
  5. If the patient in the above scenario had unstable vital signs, do ATLS guidelines recommend the next step to obtain a CT scan or to activate the OR? What if the patient had stable vital signs?
    • As per ATLS, an unstable patient with a traumatic mechanism of injury and a positive FAST exam should go directly to the OR for laparotomy. A stable patient with a traumatic mechanism of injury and a positive FAST exam should receive a CT scan.
  6. Does a positive FAST exam differentiate what type of fluid is present?
    • No. Ascites and blood, for example, may have a similar appearance on ultrasound. In certain settings, such as trauma or an unstable patient, the fluid should be assumed to be blood until proven otherwise.
  7. Does a positive FAST exam reliably identify the source of bleeding?
    • No. Free fluid in any quadrant can represent blood that has pooled from a different area.
  8. Where does free fluid tend to initially accumulate in the RUQ view? What about in the LUQ view?
    • In the RUQ view, free fluid most often will be initially visible in the paracolic gutter (liver tip and inferior pole of kidney). In the LUQ view, free fluid most often will be initially visible in the subdiaphragmatic space above the spleen. Be sure to include everywhere from diaphragm to paracolic gutter in both views because free fluid can hide in variable locations.

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