Tag Archives: FAST

EAST 2017 #6: FAST Exam After Rolling to the Right

The FAST exam is an integral part of trauma evaluation. Even after experience and credentialing of providers, there tends to be some variability in performance. This is especially true when the abnormal findings (or amount of fluid present) is relatively small.

Can we improve this by doing something as simple as using gravity to help? When the patient is supine, fluid tends to pool in the pelvis, where interpretation is a little more complicated.  The surgery program at Guthrie/Packer Hospital created a small pilot study to see if they might improve the sensitivity of FAST by rolling patients to their right briefly, before returning to the supine position and performing the exam.

They enrolled seven participants who were already undergoing peritoneal dialysis (PD), so there was easy access to the peritoneal cavity for administration of known amounts of free fluid. First, each patient was drained of any residual dialysate via their PD catheter. They then underwent a baseline FAST exam. Next, they were placed in the right lateral decubitus position for 30 seconds, then placed supine again and the FAST was repeated. Each patient then had 50cc of dialysate infused, and the process was repeated until a positive FAST was obtained.

Here are the factoids:

  • Of the seven patients recruited, one was excluded because the initial FAST was equivocal due to body habitus and polycystic kidney disease
  • A maximum of 3 aliquots were given (150cc max)
  • Two patients became positive after right side down before any additional fluid was infused
  • None of the four remaining patients had a positive FAST after infusion of any aliquot in the supine position
  • All four became positive after the right side down maneuver,  two after 50cc, one after 100cc, and one after 150cc

Bottom line: The authors conclude that this may be a valuable technique to help detect smaller quantities of fluid than we normally do. I’m not so sure. First, it’s a tiny study in a patient group that is very different from trauma. And it’s impossible to quantify how much dialysate was left after initial drainage of the PD catheter. Finally, we know that FAST can’t “see” small quantities of fluid, but we have constructed our management algorithms around this fact. So we have a good idea of when we should do further imaging or run off to the operating room. Making this test more sensitive may skew these practice guidelines toward doing more (and potentially unneeded) imaging and surgery.

Questions and comments for the authors/presenters:

  • Did you record the volumes and administration times of dialysate given prior to the study? This may correlate with the initial positives and volumes needed to give a positive result.
  • Similarly, did you look at BMI and body habitus to see if there might be a correlation?
  • Are you planning any type of followup study, as you suggested in the abstract?

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference: Can we be faster? FAST examination after rolling to the right dramatically increases sensitivity. Quick Shot #7, EAST 2017.

FAST Cardiac Ultrasound And Traumatic Arrest

Cardiac arrest in trauma patients is bad. Really bad. There are few survivors, mainly those who have some signs of life when they roll into the resuscitation room. One of the signs we look for is cardiac electrical activity, especially a narrow complex rhythm. But most of the time these patients don’t survive either. Could there be a way to fine tune the use of pulseless electrical activity (PEA) to better determine when further care is futile?

The trauma group at UCSF-East Bay did a nice, retrospective review on the use of the cardiac portion of the FAST exam to assess patients arriving in PEA arrest after either blunt or penetrating trauma. The numbers were a bit thin, but they were able to study 162 patients who had both FAST and EKG upon arrival. Of those patients, 71 had electrical activity, but only 17 had cardiac motion. However, 4 of these 17 survived (24%) vs only 1 of the 54 who did not have cardiac motion.

About a third of these 71 patients suffered blunt trauma, the remainder had penetrating injury. Of the 17 with cardiac activity, 14 were penetrating and 3 were blunt. And of the 4 survivors mentioned above, 3 were penetrating.

Only 1 of the 71 patients with PEA and no cardiac activity survived, and this was a blunt arrest(!).

Bottom line: Traumatic arrest is a generally fatal problem. However, it appears that use of the cardiac portion of the FAST exam in penetrating or blunt trauma can help fine tune the aggressiveness of resuscitation. PEA without cardiac activity is uniformly fatal (although there was one blunt survivor, the authors did specify the quality of this survival). It may be wise to forego further resuscitative efforts in PEA patients without cardiac activity because they will not survive, even as an organ donor.

Reference: The heart of the matter: Utility of ultrasound of cardiac activity during traumatic arrest. J Trauma 73(1):103-110, 2012.

Part 2: FAST Is Fast And FAST Is Last

I’ve received a fair amount of commentary on Twitter and via email regarding my statements about FAST. Many people said that FAST and physical exam can and should happen simultaneously.

In principle, I agree. My previous statements were based on the way that we organize our trauma team and trauma activations at this hospital. The reality is that everyone’s team is different and they may run their trauma activations differently.

The goal is to get all information critical to keeping your patient alive as quickly as possible. In some cases, knowing if there is a significant amount of fluid in the abdomen can be very important. Most trauma resuscitation schemes at trauma centers make use of multiple personnel so that various portions of the patient evaluation can be carried out simultaneously.

But there is also a tradeoff between speed, trauma team size and number of trainees. Centers with fewer or no trainees will have a leaner team with experienced examiners and more room around the patient. At our hospital, we have 8 people clustered immediately around the patient, with half of them being surgery or emergency medicine residents. This means it is more difficult for a physician to step in and do a FAST exam easily. So typically, this physician is the same resident doing the torso portion of the physical exam. This is the main reason for my exhortation to wait until the end of the physical exam and do the FAST quickly.

So it is really up to each center to determine their priorities for the FAST exam based on the people who make up their trauma team. At ours, it will have to remain fast and last.

Please comment or tweet your thoughts!