How to use point-of-care ultrasound (POCUS) in trauma assessment

A patient presents to you with trauma, so you immediately start an advanced trauma life support protocol. This protocol was amended in recent years to include a point-of-care ultrasound exam called EFAST–but many clinicians are not quite up to speed with it yet. In this video from our Point-of-Care Ultrasound Essentials course, you'll cover the indications for a FAST exam, the 4 basic views involved, and the critical questions you need to ask when performing it.

In this course, you’ll learn how to use point-of-care ultrasound (POCUS) to diagnose the most important problems seen in the acute care setting. Ideal for anyone who’s just starting to use POCUS—be it in the emergency department, general ward, ICU, or private clinic. Learn to use POCUS to increase your success rate, and decrease complications, when performing common procedures.

[00:00:00] Let's begin with a case. A 32-year-old guy presents to your trauma bay, he's having a really bad day. He fell from the roof. He complains of some chest and abdominal pain, he's a little tachycardic, a little hypotensive. And on your exam, his abdomen is very tender. So, if you're in a trauma center like I am, you're probably going to start with the advanced trauma life support protocol or ATLS, which begins with the primary survey: A for airway, B for breathing,

[00:00:30] C for circulation, D for disability, and E for exposure. You're then going to move on to your secondary survey, a complete physical exam. But a few years ago, this protocol was amended to include a point-of-care ultrasound exam, called the FAST exam. You're supposed to perform the FAST exam after your primary survey but before your secondary survey. So, what are your indications for a FAST exam? Well, I already gave you one, trauma. What about unexplained shock? You have a hypotensive

[00:01:00] patient and you're not quite sure what the etiology of their shock is or an anemic patient where again, you don't really know where the source of their bleeding is. Or a young female where ruptured ectopic pregnancy is the top of your differential. Now, before you perform any point-of-care ultrasound exam, you have to know what your focused question is. For your FAST exam, it's very simple. Is there a free fluid in the peritoneal space or in the pericardium? Simply put,

[00:01:30] does your trauma patient have blood in the belly or blood around the heart. But be careful, there's always limitations. Remember that the FAST exam was only a screening tool. You actually need about 400 mL of blood or more before you're going to see it on your FAST exam. Remember, we're only going to talk about peritoneal blood. So, injury to your retroperitoneal structure like a kidney or aorta is not going to show up on your FAST exam. Your patient has to be supine. Your FAST exam is not sensitive

[00:02:00] in a patient that is sitting up. Also, it doesn't diagnose the source of your bleeding, so just because you see blood on the right side of your patient, doesn't mean that they actually don't have a splenic laceration. Now, a quick comment about the E. The E fast or the extended fast is the additional evaluation for a pneumothorax. Now, you don't always have to perform an E FAST but in your trauma patient, where they're short of breath, they have blunt trauma to their chest, their hypoxic or tachypneic, you may want to consider

[00:02:30] doing an E FAST as well. To perform your FAST exam, you're going to use the phased array probe and you have four basic views: a right upper quadrant, a left upper quadrant, a subxiphoid view, and a suprapubic view.