EMERGENCY ULTRASOUND SECTION
EFAST: Essential or Overrated
T
he E-FAST Exam is Essential Alexis Salerno, MD FAAEM
The Focused Assessment with Sonography in Trauma (FAST) protocol was introduced in the United States in the 1990s. This exam was developed to evaluate for hemoperitoneum and hemopericardium in patients who presented to the emergency department for traumatic injuries.1 Prior to the incorporation of the FAST exam, physicians would perform a diagnostic peritoneal lavage, an invasive procedure, to evaluate for hemoperitoneum. Today, the non-invasive and easily repeatable FAST exam has essentially replaced the diagnostic peritoneal lavage. The FAST exam has revolutionized the initial trauma assessment and many institutions have now incorporated it into their initial trauma algorithm.1 I can understand why some may feel that the FAST exam may be overrated. With a pooled sensitivity at 74%, if the FAST exam is negative, additional testing should still be performed on the patient.2 In my own practice, even if the FAST exam is positive, most patients will undergo a CT scan for surgical planning while the staff prepares the operating room. However, I firmly believe that the FAST exam is essential to the evaluation of the critically ill trauma patient. If positive, this noninvasive, three minute exam can expedite care for trauma and non-trauma patients alike. Here are three reasons, along with examples of clinical scenarios, where a positive FAST exam changed the patient’s clinical course. Reason One
Reason Two
Performing the FAST exam can lead to unexpected diagnoses. A female in her late 40s presented to the emergency department with abdominal pain, nausea, and vomiting after working overnight. Initially, I was concerned for cholecystitis and performed a POCUS biliary exam. However, to my surprise, the patient had a collection of blood near the tip of her liver. Continuing with the FAST exam, I noticed more fluid in her pelvis. She was immediately taken to CT and found to have a ruptured ectopic pregnancy. Her time to OR was significantly reduced. I have encountered a few patients with a diagnosis of ruptured ectopic pregnancy where the FAST exam dramatically decreased their disposition time. Reason Three
The FAST exam may change your differential diagnosis. A middle-aged male presented to the emergency department in acute distress, experiencing vomiting and diaphoresis after attending a wedding. The immediate concern was for acute coronary syndrome, but the patient had a normal ECG. We then attempted to perform a POCUS cardiac exam. While performing the examination, we had poor visualization of the heart using the parasternal views. Continuing to the subxiphoid region, we evaluated both the heart and the abdominal aorta, and both exams yielded negative results. Therefore, we continued evaluating the patient using the FAST exam. To our amazement, we discovered an anechoic fluid collection with air bubbles near the tip of the liver. Surgery was consulted, the patient was transported immediately to the CT scanner, and they were diagnosed with Booerheaver’s syndrome.3 Performing the FAST exam significantly reduced the time to diagnosis for this patient.
Including the FAST exam as part of our standard trauma evaluation In conclusion, I agree that most of the time the FAST exam will be negaensures that we don’t miss obvious internal injuries. For instance, there tive, and you will need continued work up. However, sometimes the FAST was a middle-aged male with a history of housing instability who was reexam can save a life and for those rare occasions it is worth it. portedly hit by a car the day before presenting to our emergency depart>> ment. Bystanders contacted EMS twice, but the patient refused transport. EMS was dispatched a third time and the patient finally consented to transport. Upon arrival, the patient had reassuring vital signs. Although the initial trauma assessment showed no significant Pro side: “Most of the findings except for mild abdominal pain and leg pain, we performed a FAST exam due to the reported history time the FAST exam will of trauma. To our surprise, the exam revealed a large be negative, and you will amount of intraperitoneal blood in the abdomen with need continued work up… distortion of the splenic architecture. We immediately consulted surgery, and the patient was taken to CT sometimes the FAST exam can scan where there was a confirmed splenic injury. The save a life and for those rare patient’s time to the OR decreased dramatically due to occasions it is worth it.” our diligence in performing a FAST exam for any patient with reported trauma.
COMMON SENSE SEPTEMBER/OCTOBER 2023
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