Replies to This Discussion

Permalink Reply by Scott D Weingart on November 4, 2011 at 2:56pm

I phrase it a bit differently, but I always call a RUQ FAST inadequate if they don't visualize the inferior pole of the kidney (where obv you would be seeing the liver tip as well). This is the first place fluid will track up from the paracolic gutter and as you state this where you will find subtle signs of intra-p fluid.

 

However, many of the trauma surgeons who first learned FAST were taught it consists of placing the probe in 4 spots with no probe movement and any shot of the majority of the kidney is sufficient. This is probably one of the reasons for the wide range in sensitivities for FAST in the trauma literature.

Permalink Reply by Pattie Smith, RDMS on November 4, 2011 at 4:09pm

Thanks for your reply Scott. I have performed thousands of abdominal ultrasounds and several hundred FAST exams. Quite frequently, more than you would think, the inferior tip of the liver extends more caudal than the inferior pole of the right kidney (Riedel's lobe). This was the case yesterday, and in these cases, I would say that scanning to the inferior pole of the kidney is not enough. Seems most of the literature on FAST exam just concentrates on the inferior pole of the kidney.

 

I am just a sonographer with 23 years experience, and unfortunately none of it is published!

Take care,

Pattie

Permalink Reply by Scott D Weingart on November 4, 2011 at 4:13pm

Ah, I see. So the person who was arguing against the point was ok encompassing the entirety of the kidney in their scans, but not finding the liver tip. That might be a tougher sell to the non-ultrasound geek; I will certainly go down as far into the gutter as I can. But if my residents show me the whole kidney, I usually call that good enough. You may very well be right that we can increase the sens. further by always finding the tip of the liver.

Permalink Reply by Pattie Smith, RDMS on November 6, 2011 at 9:05am

Sonoguide is a resource for ED physicians in the ultrasound section of the ACEP website. ( I am sure you are well aware of this), but I revisited the site to see what they had to say on the matter.

If the link at the bottom doesn't work, copy and paste, or go to:

www.sonoguide.com

scroll down to "FAST", click on "FAST"
scroll down to "Right coronal and intercostal oblique views" --read the tutorial

Figures 5 and 6 in particular, demonstrate imaging the inferior tip of the liver.

http://www.sonoguide.com/FAST.html

I'm sorry, I am an "ultrasound geek" as you pointed out and just had to post this......

Permalink Reply by Joseph Minardi on November 6, 2011 at 2:19pm

I generally teach all of our faculty, fellows, residents, and students that the UQ views in the FAST include above the diaphragm, and scanning all the way down past the inferior poles of the kidneys into the pericolic gutters. I have seen too many times hemoperitoneum that's missed because the blood lies lower in the abdomen and not in the expected Morrison's pouch.

I also think it's important to teach that it is an US exam and not a point and shoot type of exercise.

If done efficiently, the whole exam, including views of the anterior chest for pneumothorax can be done in about 3 minutes.

Permalink Reply by Pattie Smith, RDMS on November 6, 2011 at 8:48pm

I couldn't agree more Joseph!

Permalink Reply by Jason T Nomura MD, RDMS on November 21, 2011 at 1:43am

Tip of the liver is a key point to evaluate, small amounts of fluid can be found there before other regions of the RUQ.  When I go through the FAST with my residents I remind them they don't look at just one slice of a CT scan, can't just look at one shot in the RUQ.