C H A P T E R 2

The FAST Exam

Robert A. Jones, DO, RDMS, FACEP, and Robert D. Welch, MD, FACEP

Evaluation of patients with thoracoabdominal trauma is often a

diagnostic challenge for emergency physicians and trauma surgeons, and
is made more difficult by the insensitivity of the physical examination
for detecting major internal injuries. Studies have shown that 20% to
43% of patients with significant abdominal injuries may initially have a
normal physical examination of the abdomen. Even patients with
intraperitoneal hemorrhage can be alert and asymptomatic on arrival. A
patient with a hemopericardium, hemothorax, or hemoperitoneum can
deteriorate quickly despite a benign initial presentation. Because of the
lack of reliability of the physical examination, physicians have come to
depend on ancillary tests to detect potentially life-threatening injuries.

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Ultrasonography in Trauma: The FAST Exam

Historically, diagnostic peritoneal lavage (DPL) and CT have been the preferred
initial diagnostic tests for identifying intraperitoneal hemorrhage. Diagnostic
peritoneal lavage is an invasive procedure (complication rate, 1% to 5%) that is overly
sensitive and results in numerous nontherapeutic laparotomies. Computed tomography
is very accurate, but it is contraindicated in unstable patients (because the CT suite is
an unsuitable place for resuscitation) and requires costly equipment and considerable
expertise. In contrast, bedside ultrasonography is fast, accurate, cost effective, and can
be performed in unstable patients. Multiple studies now support the use of
ultrasonography as the initial diagnostic modality in patients with blunt or penetrating
thoracoabdominal trauma.
Bedside ultrasonography performed by emergency physicians and trauma surgeons
in the evaluation of trauma patients has been given numerous names; the favored term
is the FAST exam. The acronym “FAST”—which originally stood for “Focused
Abdominal Sonography for Trauma”—first appeared in the literature in 1996.1 As the
role of ultrasonography in trauma expanded, some thought that this definition did not
appropriately describe all uses of trauma ultrasonography, including evaluation of the
heart and the pleural spaces.2 In 1997, the FAST Consensus Conference Committee
concluded that the abbreviation FAST should stand for “Focused Assessment with
Sonography for Trauma.”3 The term FAST is synonymous with trauma
ultrasonography and is clearly accepted as an integral part of the bedside assessment
of patients with blunt or penetrating trauma.

Goals of the FAST Exam

The current FAST exam has been developed as a bedside screening test for the
detection of hemopericardium and hemoperitoneum and not as a formal study to
identify all sonographically detectable pathology. Its success and growing popularity
are in large part due to the fact that the examination is noninvasive and accurate and
can be easily performed with limited training. The detection of hemothoraces,4,5
pneumothoraces,6 bowel injuries,7 and parenchymal injuries,8-10 although possible with
ultrasonography, is the subject of debate and is not a goal of the current FAST exam.
The interpretation of the FAST exam is straightforward. A positive FAST exam is
defined as the detection of intraperitoneal fluid on any of the three abdominal
windows or the detection of pericardial fluid on the cardiac window.11 The absence of
intraperitoneal fluid on the three abdominal windows and the absence of pericardial
fluid on the cardiac window constitute a negative FAST exam. An indeterminate
examination is one in which any of the windows is inadequately visualized and there
is no fluid detected on the views that are visualized.
The most important and easiest region in which to visualize large collections of
intraperitoneal blood is Morison’s pouch (Figure 2-1A). The subphrenic spaces also
are common sites for fluid collection and should be included in the FAST exam.
Novice sonographers frequently overlook the subphrenic spaces as they focus on
Morison’s pouch, the splenorenal fossa, and the pelvis. Failure to scan the subphrenic
spaces results in decreased sensitivity for the detection of hemoperitoneum. Blood
collects preferentially (Figure 2-1B,C) in several locations within the abdominal
cavity.12-19 Figure 2-1D illustrates the patterns of movement of free fluid within the
abdomen, which is described in more detail in Appendix C.

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 The FAST Exam

Figure 2-1A

Figure 2-1D

Figure 2-1B

Figure 2-1C Figure 2-1E

A, Fluid in Morison’s pouch. Blood or fluid in this pouch appears as an anechoic (black) stripe between the liver and the right kidney. Clots
present within the blood may be echogenic (white). This is the most dependent region of the upper abdomen. This region is also referred
to as the hepatorenal pouch or hepatorenal space. B,C, Preferential locations for blood to accumulate. B, Locations on a longitudinal view.
C, Locations on an anteroposterior view of the abdomen. D, Intraperitoneal free fluid. The pattern of free fluid movement within the
abdominal cavity is shown. E, Views of the FAST exam. The FAST exam consists of pericardial (cardiac), perihepatic (RUQ), perisplenic
(LUQ), and pelvic views. Most physicians perform the RUQ view first in patients with blunt abdominal trauma and the cardiac view first in
patients with penetrating trauma to the chest. (B,C, Reprinted with permission from Sanders RC. Clinical Sonography: A Practical Guide.
2nd ed. Boston, Mass: Little, Brown; 1991:257. E, Courtesy of William Mallon, MD.)

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Ultrasonography in Trauma: The FAST Exam

Performing the FAST Exam

The standardized FAST exam recommended by the FAST Consensus Conference
Committee is a multiview examination (Figure 2-1E) that consists of these four
distinct torso acoustic windows3:

• Pericardial (cardiac)
• Perihepatic (right upper quadrant [RUQ])
• Perisplenic (left upper quadrant [LUQ])
• Pelvic

The goal of this focused study is simply to detect pericardial and intraperitoneal
fluid. A few authors perform the FAST exam in this order for all patients; however,
the order in which these views are obtained is not particularly important. Most
authorities perform the RUQ view first (highest yield) for patients with abdominal
trauma and the cardiac view first in patients with penetrating trauma to the chest.
For description of issues surrounding the FAST exam, including the use of
Trendelenburg, multiple versus single views, quantity of fluid detectable, pericardial
site of fluid collection, specific organ injuries, and pitfalls, see Chapters 3 through 5
and 7.

Pericardial Window (Cardiac)

Technique
The pericardial view can be obtained using either a subcostal (also referred to as
subxiphoid) or transthoracic window. The subcostal window is most commonly used
because it can be performed with the patient in the supine position and because it
provides information regarding pericardial fluid, gross chamber enlargement, and
gross wall motion abnormalities. The subcostal window is obtained by placing the
probe in the midline with the beam directed toward the patient’s left shoulder and the
probe indicator directed toward the patient’s right side (Figure 2-2).
If the desired four-chamber view cannot be obtained through slight angulation or
rotation of the probe, the patient is asked to take a deep breath, which will flatten the
diaphragm and bring the heart closer to the probe. Patients who are being
mechanically ventilated can be placed on inspiratory pause briefly while the desired
image is obtained. If “dirty shadowing” (shadowing with echoes) is present on the
screen, the probe is moved slightly toward the right infracostal margin; this will allow
more of the liver to be used as a sonographic window to the heart. Occasionally, air in
the stomach or duodenum prevents visualization of the heart and results in dirty
shadowing.
If failure to obtain the desired view is caused by other factors, such as morbid
obesity or midepigastric injury, then it is best to attempt a transthoracic window.
Pressure has to be applied to the probe to access the subcostal window; therefore, a
patient who has sustained a midepigastric injury (eg, stab wound) may not tolerate the
discomfort of this pressure. Similarly, it may be difficult to obtain access below the
rib cage, even with moderate pressure, in a morbidly obese patient. The parasternal
long-axis view is the preferred initial transthoracic view when an adequate subcostal
view is not possible. Transthoracic views are described in Chapters 3 and 4.

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 The FAST Exam

Sonographic Findings
Clinical findings associated with hemopericardium are nonspecific and insensitive.
Even with pericardial tamponade, Beck’s triad and pulsus paradoxus are not
consistently present. Hemopericardium is usually recognized clinically only after
deterioration has occurred. Cardiac ultrasonography is sensitive for detecting even
small amounts of fluid in the pericardial sac and allows for early recognition at the
bedside. Early recognition of cardiac injuries leads to immediate interventions that
decrease morbidity and mortality.20 Several studies have shown that hemopericardium
can be detected accurately by emergency physicians and trauma surgeons with limited
ultrasonography training.21,22
The subcostal window provides a four-chamber view of the heart (Figure 2-3). A
small portion of the liver is seen closest to the probe, with the heart behind it. The
hyperechoic pericardium is seen surrounding the heart. Normally, there is a small
amount of fluid between the parietal and visceral pericardium. This fluid is usually
not visualized; however, in some healthy patients, a small amount of fluid can be seen
in the dependent aspect of the heart, so clinical correlation is essential. If fluid is
present in a nondependent aspect of the heart, it should be considered abnormal.
The presence of pericardial fluid is demonstrated by separation of the visceral and
parietal pericardial layers (Figure 2-4A). Acutely, blood will appear anechoic (black);
however, echoes may be present if clotting has occurred (Figure 2-4B). When looking
at a pericardial window, the pericardium should be identified; there should be only
one hyperechoic line surrounding the heart. If two lines are seen surrounding the heart
and there is no evidence of anechoic fluid, then an isoechoic fluid collection is
possible. The presence of clotting can result in fluid collections that are isoechoic to
the surrounding cardiac muscle (Figure 2-4C). False-negative results have been
attributed to this in the literature.21

Figure 2-2 Figure 2-3

Probe placement for subcostal pericardial view. The probe
indicator is directed toward the patient’s right side (9 o’clock); the
beam is directed toward the left shoulder. The arrow indicates the
direction of the probe indicator. Imaging may be enhanced by
having the patient take a deep breath and hold it.
Normal subcostal pericardial view. RV, right ventricle; LV, left
ventricle; RA, right atrium; LA, left atrium. A portion of liver will be
visualized in the near field. (Courtesy of Dr. Jones and Dr.
Welch.)

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Ultrasonography in Trauma: The FAST Exam

Pericardial fluid can be mistaken for intraperitoneal or pleural fluid. Fluid in the
subdiaphragmatic space between the diaphragm and the liver can be visualized with
this window; therefore, it is important to make certain the fluid is located between the
two pericardial layers (Figure 2-5). Even though the pleural window is limited in this
view, a large hemothorax can be mistaken for hemopericardium22 (Figure 2-6). It is
also possible for a large hemothorax to obscure a small pericardial fluid collection.22
In such cases, repeat studies should always be obtained after tube thoracostomy
drainage.
Pericardial tamponade can be diagnosed based on the presence of a circumferential
fluid collection with diastolic collapse of the right atrium or ventricle seen on
real-time scanning (Figure 2-7). Patients with severe pulmonary hypertension can
demonstrate clinical cardiac tamponade without right-sided chamber collapse.

Figure 2-4A Figure 2-4C

A, Small amount of pericardial fluid. This subcostal (pericardial)
view demonstrates a small amount of anechoic (black) fluid in the
pericardial space. B, Large amount of pericardial blood with clots.
This subcostal (pericardial) view demonstrates a large amount of
blood in the pericardial space, and the right ventricle is
compressed. The echoes (white) that are seen within the dark
fluid represent blood clots. On real-time imaging, there was
diastolic collapse of the right ventricle consistent with pericardial
tamponade. C, Stab wound to the chest with a large amount of
pericardial clot. There is a large amount of clotted blood present
in the pericardial space that is isoechoic to the surrounding
cardiac muscle. There also is some anechoic (black) fluid present
in the pericardial space. (A,B, Courtesy of Dr. Jones and Dr.
Welch. C, Courtesy of Dr. Mandavia.)

Figure 2-4B

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 The FAST Exam

Figure 2-5 Figure 2-7

Subdiaphragmatic and right pleural fluid. This subcostal
(pericardial) view demonstrates perihepatic fluid and right pleural
fluid, which should not be mistaken for pericardial fluid. Note that
the perihepatic fluid follows the diaphragm, and the concavity of
this fluid is opposite of that expected for pericardial fluid.
(Courtesy of Dr. Kendall.)
Cardiac tamponade with right atrial diastolic collapse, which
usually is seen earlier than right ventricular diastolic collapse
because of the more distensible nature of the right atrium. This
image was obtained from an apical four-chamber view of the
heart.

Figure 2-6
Large right pleural fluid collection and small pericardial fluid
collection. The right pleural fluid collection is located adjacent to
the right side of the heart. There is a small pericardial fluid
collection that is not circumferential to the heart. (Courtesy of
Dr. Kendall.)

Perihepatic Window (Right Upper Quadrant)

Technique
The perihepatic view is obtained using an intercostal or a subcostal technique; the
intercostal technique is most commonly used. The probe is placed in the midaxillary
line between ribs 8 and 11 with the probe indicator directed toward the patient’s
posterior axilla (Figure 2-8). Rotating or angling the probe slightly can be helpful if
the desired view is not obtained on the initial attempt. The probe can be slightly
rotated counterclockwise to reduce rib shadowing (image beam parallel to ribs) to
obtain a better longitudinal view of the liver and kidney. The probe should be moved

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Ultrasonography in Trauma: The FAST Exam

in a cephalad direction if visualization of the diaphragm and pleural space is not

adequate. To visualize the paracolic gutter, the probe should be oriented in a coronal
plane and moved caudally until the lower pole of the kidney is seen (Figure 2-9).
The right subcostal technique is obtained with the probe at the right infracostal
margin, lateral to the midclavicular line (Figure 2-10). Having the patient “take a deep
breath and hold it” or “push out” the abdomen can help bring structures below the
costal margin into view. This technique requires significant patient cooperation
because respirations affect visualization. The presence of gas in the hepatic flexure of
the colon may also limit the success of this technique.

Figure 2-8 Figure 2-10

Probe placement for perihepatic or RUQ view (intercostal
approach). This provides excellent visualization of the diaphragm,
liver, and Morison’s pouch. A slight posterior angulation of the
probe reduces the amount of rib shadowing that is obtained by
imaging directly through an intercostal space. The probe indicator
is directed toward the patient’s posterior axilla. The arrow
indicates the direction of the probe indicator.
Probe placement for right subcostal view. Occasionally, it is
necessary to obtain additional perpendicular views of the RUQ to
clarify findings present on prior RUQ views. This view requires a
patient to take a deep breath and hold it or push out the
abdomen to visualize the liver below the costal margin.

Figure 2-9
Probe placement for perihepatic (RUQ) coronal view. This view is
used to visualize Morison’s pouch and the right kidney. The probe
is moved caudally to image the inferior pole of the right kidney
and the right paracolic gutter.

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 The FAST Exam

Sonographic Findings
The perihepatic view provides fractional views of the liver and right kidney and
allows visualization of fluid in Morison’s pouch, the subphrenic space, the right
pleural space, and the retroperitoneum (Figure 2-11A-D). Hemoperitoneum appears as
an anechoic area in Morison’s pouch or in the subphrenic space (Figure 2-12A-D).
Fluid in adjacent structures such as the gallbladder, hepatic flexure of the colon, and
duodenum can be mistaken for intraperitoneal fluid.23 To prevent this error, the user
must identify peristalsis during real-time scanning and demonstrate an echogenic
border surrounding the fluid. In addition, free fluid tends to form spicules or
triangulate as it follows the path of least resistance, whereas fluid within organs or
vessels has a rounded or cylindrical appearance (Figure 2-13A-C). Morison’s pouch is
a pooling site for excess pelvic fluid and perisplenic fluid; thus, it is particularly
important to adequately visualize this region.24-27 Placing the probe in a coronal plane

Figure 2-11A Figure 2-11C

Figure 2-11B Figure 2-11D

A-D, Negative studies of RUQ. Normal perihepatic views demonstrating diaphragm, liver, and kidney (left to right). The renal capsule
appears as an echogenic line surrounding the kidney. The renal cortex is slightly less echogenic than the neighboring liver, and the renal
pyramids appear as hypoechoic regions that point toward the center of the kidney. The renal sinus is a central echogenic portion of the
kidney. There is no anechoic (black) stripe visualized above the outer white border of the kidney. (A, Courtesy of Dr. Jones and Dr. Welch.
B, Courtesy of Dr. Reardon.)

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Ultrasonography in Trauma: The FAST Exam

and sliding it caudally until the inferior pole of the kidney is seen will allow detection
of both supramesocolic and inframesocolic fluid around the tip of the liver that has
not yet reached Morison’s pouch (Figure 2-14A,B). Moving the probe in a cephalad
direction permits visualization of subphrenic space, a common site of fluid
accumulation.
Pleural fluid can be accurately detected using this limited view. Studies have shown
sensitivities in the range of 96.2% to 97.5% and specificities in the range of 99.7% to
100% for the detection of hemothoraces using ultrasonography.4,5 The patient should
be in the supine position, although reverse Trendelenburg positioning intuitively
should improve detection. Free pleural fluid is represented by the presence of an
anechoic area cephalad to the hyperechoic diaphragm (Figure 2-15A,B). Clearly
identifying the diaphragm prevents misdiagnosing a subphrenic fluid collection or
other intraperitoneal fluid as a pleural fluid collection (Figures 2-16 and 2-17). It has
been shown that, although supine and upright chest radiographs require a minimum of
175 mL and 50 to 100 mL of pleural fluid, respectively, for detection, ultrasonography
can detect a minimum of 20 mL of pleural fluid.4 The significance of a hemothorax

Figure 2-12A Figure 2-12C

Figure 2-12B Figure 2-12D

Perihepatic (RUQ) views with fluid in Morison’s pouch. B,C, The tip of the liver is “free floating.” (A,D, Courtesy of Dr. Jones and Dr. Welch.
B, Courtesy of Dr. Kendall. C, Courtesy of Dr. Reardon.)

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 The FAST Exam

Figure 2-13A Figure 2-13C

Perihepatic view with gallbladder visualized. A, Longitudinal view
of a normal gallbladder. Note the echogenic wall surrounding the
gallbladder. B, Perihepatic view of 25-year-old patient involved in
a high-speed motor vehicle crash. This transverse view of the
gallbladder demonstrates free intraperitoneal blood above the
gallbladder. C, Free intraperitoneal blood tends to form triangles
or spicules, whereas fluid in organs or vessels is round, oval, or
tubular. There is free blood present to the right of the gallbladder.
(A, Courtesy of Dr. Stahmer. B, Courtesy of Dr. Jones and Dr.
Welch.)

Figure 2-13B

Figure 2-14A Figure 2-14B

A, Longitudinal view (snowboarding injury with pelvic bleeding). B, Transverse view (motor vehicle crash with splenic laceration) of the
lower pole of liver and kidney. Blood is seen beside the inferior pole of the liver and kidney that has not yet reached Morison’s pouch.

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Ultrasonography in Trauma: The FAST Exam

Figure 2-15A Figure 2-16

Perihepatic view with a large amount of fluid noted in the
subdiaphragmatic space. (Courtesy of Dr. Kendall.)

Figure 2-15B
Perihepatic view with fluid noted in the pleural space. A, Fluid in
the pleural space makes a V shape on the longitudinal view,
whereas subdiaphragmatic fluid has a crescent shape. B, The
hemothorax is compressing the adjacent lung tissue, and the tip
of the atelectatic lung is clearly visible. (A, Courtesy of Dr. Jones
and Dr. Welch.)
Figure 2-17
Perihepatic view with echogenic liver contusion. The liver
hematoma has a heterogeneous appearance, and there is free
blood to the right of it between the liver and kidney. (Courtesy of
Dr. Jones and Dr. Welch.)

detected with ultrasonography and not visualized by plain radiography is not known;
for this reason, the detection of hemothorax is not a primary goal of FAST. Future
studies should examine the sonographic appearances of pulmonary contusions,
because a false-positive study for hemothorax has been reported in a patient with a
pulmonary contusion without hemothorax.5 When chest radiography is unavailable or
delayed, ultrasonography should be used.

Perisplenic Window (Left Upper Quadrant)

Technique
The perisplenic view is obtained using an intercostal approach; it is technically
more difficult for the novice sonographer than the perihepatic view. With practice,
however, the user can obtain quality images in most cases. The intercostal approach is
similar to that of the perihepatic view, with a few exceptions. The probe should be

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 The FAST Exam

placed in the intercostal space between ribs 9 and 10 or 10 and 11. The bulk of the
spleen is located more dorsal than the liver and the organ is smaller; thus, the probe
placement must be more posterior. In a coronal plane, the probe is placed near the
posterior axillary line with the probe indicator directed cephalad (Figure 2-18A). To
place the probe in the proper plane, it is occasionally necessary to either turn the
patient slightly on the right side (this can be done only if it will cause no further
injury to the patient) or place the patient near the edge of the stretcher. The probe can
be slightly rotated clockwise to reduce rib shadowing (image beam parallel to ribs),
thus obtaining a better longitudinal view of the spleen and kidney (Figure 2-18B). The
beam is then swept anterior and posterior, as well as cephalad and caudal, to visualize
the regions of interest.
With more experience, the user can predict, with some certainty, the best probe
position based on patient body habitus. In most patients, a depth of 12 to 15 cm is
appropriate for this examination. More depth is useful if finding the spleen is difficult
(more depth translates into a larger field of view), and is required in very large
patients. Less depth helps magnify regions of interest. Asking the patient to slowly
take a deep breath helps bring the spleen into view. A significant amount of pressure
on the probe might be required to obtain a quality image in an obese patient and, as a
result, may not be tolerated if injuries are present in that region.
Ideally, portions of the left hemidiaphragm, spleen, and left kidney appear in a
single view (Figure 2-19). Occasionally, the sonographer cannot adequately visualize
the diaphragm (Figure 2-20). If this occurs, two (or more) separate views are needed.
The patient may take a deep breath, or the probe may be moved up one intercostal
space, or the beam may be directed more cephalad to visualize the spleen and left
hemidiaphragm. Moving the probe down one intercostal space and directing the beam
more caudally might be required to visualize the spleen and lower pole of the left
kidney (Figure 2-21A-C). If these structures are not visualized, the study must be
considered incomplete. The user must keep in mind that the subphrenic space is the
most frequent site for fluid accumulation in this region; failure to visualize the
diaphragm will result in a significant number of false-negative studies.

Figure 2-18A Figure 2-18B

Probe placement for perisplenic views. Arrow indicates the direction of the probe indicator. A, Coronal LUQ view. B, LUQ intercostal
approach. The intercostal approach may provide a clearer image with less rib shadowing than the coronal view.

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Ultrasonography in Trauma: The FAST Exam

Figure 2-19 Figure 2-21A

Normal perisplenic (LUQ) view with the structures as labeled.
(Courtesy of Dr. Jones and Dr. Welch.)

Figure 2-21B

Figure 2-20
Perisplenic view showing spleen and kidney. The diaphragm is
not well visualized in this view. There is fluid/blood seen at the tip
of the spleen. (Courtesy of Dr. Kendall.)

Figure 2-21C
Perisplenic views showing diaphragm and splenorenal fossa.
Multiple views of the LUQ often must be obtained to view the
diaphragm, spleen, and the entire kidney. A,B, Subdiaphragmatic
fluid/blood is seen in these views. The left kidney is poorly
depicted in A but nicely imaged in B. C, A small stripe of blood is
visualized in the splenorenal space. The diaphragm is not seen.
(Courtesy of Dr. Kendall.)

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 The FAST Exam

Sonographic Findings
The perisplenic view provides fractional views of the spleen, left kidney,
retroperitoneal region, and left pleural space (Figure 2-22). Hemoperitoneum appears
as an anechoic area in the subphrenic space or in the splenorenal fossa. Fluid in this
region preferentially goes to the subphrenic space, with overflow going to the
splenorenal fossa and across the midline to Morison’s pouch13 (Figure 2-23A-G). One
study found that, of 69 patients with isolated spleen injuries, only 33.3% had a
positive perisplenic view, whereas 77.3% had a positive perihepatic view.28 The
diaphragm must be clearly identified so that a pleural fluid collection is not mistaken
for a subphrenic collection. Once blood coagulates, the sonographic appearance is that
of varying echogenicity. With time, the clots can become isoechoic and difficult to
differentiate from solid organs. Fluid in adjacent structures such as the stomach or
splenic flexure of the colon can be mistaken for intraperitoneal fluid.23 Careful
inspection for the presence of peristalsis during real-time scanning and recognition of
the appearance of fluid in the gastrointestinal tract is crucial to prevent this error.23
Pleural fluid (hemothorax) in the left pleural space can be accurately detected on
this limited view as an anechoic region cephalad to the left hemidiaphragm (Figure
2-24A-C). Clearly identifying the diaphragm prevents misdiagnosing a subphrenic
fluid collection as a pleural fluid collection; this is described in more detail in
Chapters 3 and 6.
Ultrasonography is not as sensitive as CT in the detection of spleen injuries, but the
fractional view of the spleen seen on the perisplenic window might provide
information about parenchymal injury (Figure 2-25). Because intraparenchymal
hemorrhage can appear similar to the surrounding normal tissue, it can be easily
missed.27, 28 A complete description of solid organ injuries is provided in Chapter 5.

Figure 2-22
Normal perisplenic view. There is a mirror image of spleen
evident cephalad to the diaphragm (mirror artifact). (Courtesy of
Dr. Reardon.)

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Ultrasonography in Trauma: The FAST Exam

Figure 2-23A Figure 2-23D Figure 2-23G

A-G, Perisplenic views (LUQ) with free
intraperitoneal blood. In contrast to the
RUQ, blood appears most commonly in
the subdiaphragmatic area and less
frequently in the splenorenal fossa.
(A-D,F, Courtesy of Dr. Jones and Dr.
Welch.)

Figure 2-23B Figure 2-23E

Figure 2-23C Figure 2-23F

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 The FAST Exam

Figure 2-24A Figure 2-25

Perisplenic view of a 19-year-old man who was assaulted with a
baseball bat. Note the lack of homogeneity of this injured spleen
with a small stripe of free blood in the subdiaphragmatic space.
(Courtesy of Dr. Jones and Dr. Welch.)

Figure 2-24B

Figure 2-24C
Perisplenic views of left pleural fluid/hemothorax. A,B, A large
amount of anechoic fluid in the chest. C, Patient with a stab
wound to the left chest that displays free blood and echogenic
clot within the hemothorax. (Courtesy of Dr. Jones and Dr.
Welch.)

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Ultrasonography in Trauma: The FAST Exam

Pelvic Window
Technique
The pelvic view is best accomplished when the patient’s bladder is filled. For this
reason, the FAST exam should be completed before Foley catheter placement or
spontaneous bladder emptying. If a catheter is already in place, retrograde filling with
saline can create a sonographic window (but this is often impractical during a
resuscitation). Another option is to clamp the catheter long enough to allow normal
bladder filling. This is performed most frequently when repeat scans are done or when
a patient has been transferred from another facility. The goal of this view is to detect
pelvic fluid (hemoperitoneum) in the most dependent part of the peritoneum.
The pelvic view can be obtained in either a longitudinal or transverse plane.
Although Rozycki et al29 recommend only a transverse view, most recommend both
the transverse and longitudinal views as being necessary for optimal sensitivity.30 To
obtain the longitudinal view, the probe is placed on the patient’s abdomen in the
midline just above the pubic symphysis with the probe indicator directed toward the
patient’s head (Figure 2-26). The probe can be angled in a posteroinferior direction to
obtain better visualization of the pelvic structures. The transverse view is obtained by
placing the probe in the midline just above the pubic symphysis with the probe
indicator directed toward the patient’s right (Figure 2-27).
It has been noted that, in nontrauma patients, an overdistended bladder may
obscure free pelvic fluid. Some urine is needed in the bladder to create an acoustic
window, but a very large bladder can displace fluid from the pouch of Douglas
(cul-de-sac) in females and cause a false-negative study.31 If the bladder is noted to be
overdistended on the original scan, the bladder should be partially drained with a
Foley catheter and the pelvis rescanned. Further study is needed to determine if a
repeat partial void study increases sensitivity in injured patients.

Figure 2-26 Figure 2-27

Probe placement for longitudinal pelvic view. Arrow indicates the Probe placement for transverse pelvic view. Arrow indicates the
direction of the probe indicator. direction of the probe indicator.

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 The FAST Exam

Sonographic Findings
In a female patient, fluid appears in the pouch of Douglas just posterior to the
uterus, with overflow fluid extending around the uterus (Figures 2-28A-C and
2-29A,B). A small amount of fluid may be present as a normal finding in
premenopausal females, and clinical correlation is essential. Although not a primary
indication of the FAST exam, the uterus should be observed for the presence of an
intrauterine pregnancy.
In a male patient, fluid appears in the rectovesicular pouch or cephalad to the
bladder (Figures 2-30A-E and 2-31A,B). The seminal vesicles are paired structures
that appear hypoechoic and lie posterior to the bladder; they can easily be confused
with free intraperitoneal fluid23 (Figures 2-32 and 2-33). They can be distinguished
from free fluid based on their appearance between the bladder and prostate and by the
fact that, on the longitudinal view, the seminal vesicles taper off in the cephalad
direction and do not extend beyond the bladder, in contrast to free intraperitoneal
fluid.

Figure 2-28A Figure 2-28C

Longitudinal pelvic views (female). A, Normal longitudinal view.
B,C, Longitudinal views with anechoic fluid/blood noted in the
pouch of Douglas. (B,C, Courtesy of Dr. Mandavia.)

Figure 2-28B

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Ultrasonography in Trauma: The FAST Exam

Figure 2-29A Figure 2-29B

Transverse pelvic views (female). A, Normal transverse view. B, Transverse view with anechoic fluid/blood noted in the pouch of Douglas.
(Courtesy of Dr. Mandavia.)

Summary
This chapter summarizes the techniques and the sonographic findings of the basic
FAST exam. The chapters that follow address clinical applications of the FAST exam,
specific organ injuries, pitfalls, and additional applications and provide a review of the
literature and issues regarding training and credentialing.

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 The FAST Exam

Figure 2-30A Figure 2-30D

Figure 2-30B Figure 2-30E

Longitudinal pelvic views (male) with large amount of anechoic
fluid/blood cephalad to bladder. Loops of bowel are nicely
visualized in A,D,E. (A,C, Courtesy of Dr. Jones and Dr. Welch.
D, Courtesy of Dr. Reardon.)

Figure 2-30C

35
Ultrasonography in Trauma: The FAST Exam

Figure 2-31A Figure 2-32

Longitudinal pelvic view (male) with a hypoechoic region posterior
to the bladder, which represents seminal vesicles. (Courtesy of
Dr. Jones and Dr. Welch.)

Figure 2-31B
Transverse pelvic views (male). A, Normal transverse view of the
pelvis demonstrating bladder and prostate. B, Anechoic blood
posterior to the bladder in a patient with intraperitoneal
hemorrhage.
Figure 2-33
Transverse pelvic view (male) with hypoechoic seminal vesicles
posterior to the bladder. Seminal vesicles vary in appearance and
do not always have the classic paired profile. (Courtesy of Dr.
Jones and Dr. Welch.)

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 The FAST Exam

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