Focused abdominal sonography

in trauma (FAST)
By: Syarifah Ranny Yulia Effendi
• Trauma pada abdomen adalah trauma yang
menyebabkan kerusakan organ abdomen
(lambung, usus halus, pankreas, kolon, hepar,
limpa, ginjal) yang disebabkan oleh trauma
tembus, biasanya tikaman atau tembakan; atau
trauma tumpul akibat kecelakaan mobil, pukulan
langsung atau jatuh.

• Trauma abdomen didefinisikan sebagai trauma

yang melibatkan daerah antara diafragma atas
dan panggul bawah
 • A ssessment of the abdomen for possible
intraabdominal injury due to trauma is a
common clinical challenge for surgeons and
emergency medicine physicians.

Physical findings may be unreliable

The true problem with torso because of altered patient
trauma is not to determine the consciousness, neurological deficit
presence of an organ lesion, but to associated with head injury or
identify clinically significant intra- spinal injury, medication, or other
abdominal injuries. associated injuries
CT remains the radiological standard USG is an easily accessible,
for investigating the injured abdomen portable, noninvasive, and
but: reliable diagnostic tool for
1. requires patient transfer to the CT assessment of abdominal
scan suite and delay trauma. It can be performed at
2. It is unsuitable for patients who are the bedside without causing
haemodynamically delay in the management of the
unstable. patient.

Focused abdominal
sonography in trauma
The idea of focused ultrasonography is
(FAST) is to identify the
to specifically identify the presence of
presence of
fluid i.e blood or enteral contents in the
haemoperitoneum in a
peritoneal cavity, pleura or pericardium
patient with suspected
intraabdominal
injury
• Ultrasound digunakan untuk mendeteksi adanya
darah intraperitonum setelah terjadi trauma
tumpul.

• USG difokuskan pada daerah intraperitoneal

dimana sering didapati akumulasi darah, yaitu
1. pada kuadran kanan atas abdomen (Morison's
space antara liver ginjal kanan)
2. kuadran kiri ats abdomen (perisplenic dan
perirenal kiri)
3. Suprapubic region (area perivesical)
4. Subxyphoid region (pericardium hepatorenal
space)
• The indications  pasien yang secara
hemodinamik unstable dengan kecurigaan
cedera abdomen dan pasien-pasien serupa yang
juga mengalami cedera ekstra-abdominal
signifikan (ortopedi, spinal, thorax, dll.) yang
memerlukan bedah non-abdomen emergensi.

Who should do FAST?

• FAST sebaiknya dilakukan oleh ahli bedah yang
hadir pada saat itu di IGD/ ICU sebagai prosedur
bedside  resusitasi dapat terus berlangsung.
• Free fluid (blood, intestinal contents) in the
peritoneal cavity appears  anechoic (black)
compared with the echogenicity of the surrounding
structures.

• The outline and echogenicity of the liver, spleen

and kidneys

• The pericardial and pleural cavities are assessed for

presence of fluid in the sub-xiphoid view of FAST.

• The pelvic window provides information about free

fluid in the pelvis and provides assessment of the
bladder.
Keuntungan USG :
• portabel
• dapat dilaksanakan dengan cepat
• tingkat sesitifitas sebesar 65-95%
dalam mendeteksi paling sedikit 100
ml cairan intraperitoneal.
• spesifik untuk hemoperitoneum
• tanpa radiasi atau kotras
• mudah dilakuakn pemeriksaan serial
jika diperlukan
• tekniknya mudah dipelajari
• non invasif
• lebih murah dibandingkan CT-scan
atau peritoneal lavage
Kelemahan USG
• cedera parenkim padat,
retroperitoneum, atau diafragma
tidak bisa dilihat dengan baik
• kualitas gambar akan dipengaruhi
pada pasien yang tidak kooperatif,
obesitas, adanya gas usus, dan
udara subkutan
• darah tidak bisa dibedakan dari
ascites
• tidak sensitif untuk mendeteksi
cedera usus.
 Focused Abdominal Sonography for
Trauma (FAST)
• Consists of 4 views
– Subxiphoid
(pericardium
hepatorenal space)
– Right Upper Quadrant
(Morison's space=liver
ginjal kanan)
– Left Upper
Quadrant(perisplenic
dan perirenal kiri)
– Pouch of Douglas
/Suprapubic region
(area perivesical)
• FAST direkomendasikan menggunakan 3,5 atau 5
MHz ultrasound sector transducer probe dan gray
scale ‘B mode’ ultrasound scanning.

• The scan starts with the sub-xiphoid region in the

sagittal plane in order to set the gain levels in the
machine (Fig. 1).

• The probe is then moved to the right to assess the

Morrison’s (hepato-renal) pouch in the sagittal
plane. Then the probe is moved to the left to scan
the spleno-renal recess in the sagittal plane. At
this point, the bladder is recommended to be
filled with 200-300 ml of sterile normal solution
through the urinary catheter.

• This provides an excellent sonological window for

visualization of the pelvis in the transverse plane.

• The total time taken for such a scan would be

around 5-8 minutes.
Gambar 3. Morison pouch normal
(tidak ada cairan bebas)

Gambar 4. Cairan bebas di Morison pouch.

1. Sub-xiphoid
Pericardial Fluid
Pericardial Effusion
Hepato-renal Fluid
 Right Lung Base

• Move probe cephalad

Spleno-renal Fluid
 Left Lung Base

• Move probe cephalad

2. Hepato-renal Recess

• Trendelenburg position
• Anterior axillary line
 RUQ
• Probe at right thoraco-
abdominal junction
• Liver : large acoustic
window
• Probe marker cephalad
• Rib interference?
– Rotate 30°
counterclockwise
 Scan Plane
• Same image if probe
positioned
– Anterior
– Mid axillary
– Posterior
 RUQ
• Image on screen:
– Liver cephalad
– Kidney inferiorly
– Morison’s Pouch*: *
*
space between
*
Glisson’s capsule and
Gerota’s fascia *
 Normal RUQ
• Image kidney
– Longitudinally
– Transversely
• Two toned structure
– Cortex/medulla
– Renal sinus
 Appearance of blood
• Fresh blood
– Anechoic (black)

• Coagulating blood
– First hypoechoic
– Later hyperechoic
 Normal
Morison’s Pouch

Free fluid in
Morison’s
Pouch
3. Spleno-renal Recess
 LUQ
• Probe at left posterior
axillary line

• Near ribs 9 and 10

• Angle probe obliquely

(avoid ribs)
 LUQ Scan Plane
• More difficult
– Acoustic window
(spleen) is smaller than
liver
– Mild inspiration will
optimize image
– Bowel interference is
common
 LUQ Scan

*
spleen *

* kidney
*

*Splenorenal fossa – a potential space

 Normal
Spleno-renal
view

Free fluid
around spleen
4. Pelvis
 Pelvic View
• Probe should be
placed in the
suprapubic position
• Either can be
transverse or
longitudinal
• Helpful to image
before placement of a
Foley catheter
Pelvic Free Fluid
Pelvis (Long View)
Pelvis: Transverse
 Normal
Transverse
pelvic

Fluid in pelvis
 Pelvic View – Sagittal
clot bladder
• Fluid in front of the
bladder
• If bladder is empty
or Foley already
placed:
Trick of trade
– IV bag on abdomen
– Scan through bag
Blood in the Pelvis
Free fluid in the pelvis