By now, every emergency medicine physician and surgeon knows what FAST is. This valuable technique allows us to quickly (get it?) determine whether a patient has blood in the abdomen or around the heart which might require operative management. Extended FAST (E-FAST) is an extension of the original technique that allows us to detect the presence of pneumothorax or hemothorax more quickly and accurately than with the conventional chest x-ray.

Both hemothorax and pneumothorax can be missed by x-ray. It takes at least 200cc of free fluid in the chest to show on the chest x-ray, assuming an ideal body habitus. As little as 20cc can be detected using the E-FAST. Studies have also shown that 30-50% of pneumothoraces are missed by x-ray. This diagnostic inaccuracy is due to the fact that hemothoraces settle out posteriorly and pneumothoraces anteriorly. Since the vast majority of chest x-rays in major trauma patients are taken with the patient supine to protect their spine, the bulk of the blood or air have layered out and cannot be seen well. A chest x-ray is still needed, however, to determine injury to the mediastinum and lung parenchyma.

E-FAST exam can be performed by using the standard curvilinear probe. It is usually placed longitudinally on the anterior chest to detect pneumothorax, using the space between two ribs as the “window” to the pleura. The depth setting should be adjusted so that only about 4cm is visible on the display. The junction of the visceral and parietal pleura should be visualized at the backside of the ribs. With a very steady hand, the junction between the two sets of pleura should be scrutinized closely.

If the two sets of pleura slide freely over each other, pneumothorax is unlikely. If not, it may be present. Pneumothorax is not a uniform phenomenon, except when it is of large size. It may be necessary to move the probe to a few other rib spaces to ensure that a smaller pneumothorax is not present.

FALSE POSITIVE ALERT! If the patient is not ventilating well, or if they have a right mainstem intubation, the affected lung(s) may not show the sliding sign, leading the examiner to think they have a problem when they may not.

To detect a hemothorax, the probe is directed upward somewhat when doing the right and left upper abdominal views. A dark triangle located above the diaphragm indicates fluid in the chest (blood). The dark crescent on the left in the image below is a large hemothorax.

The bottom line: Extended FAST can be helpful in detecting a significant hemothorax or pneumothorax and can expedite the definitive management of those conditions. If you are already familiar with FAST, a little extra ultrasound training may be very helpful.