FAST Ultrasound Scanning. (Focused Assessment with Sonography for Trauma) - Dr Gill

Hello and welcome back to the channel. You've joined myself, Dr. James Gill, and crucially, Dr. Katherine Hammerson, for another ultrasound video. Once again, I'm on the couch as it were. So today we're going to be doing the FAST scan, so F-A-S-T, and this is for Focused Assessment of Sonography in Trauma Patients. Basically, when you've got a patient who is rather banged up and you're trying to work out what's going on. Now, if you watch very closely, you can probably see Kat grinding her teeth as I basically butcher what it is she does. But essentially, what we're doing with these ultrasound scans is taking a patient who is very unwell, probably from a car crash or something like that, and we're doing a scan of their abdomen and part of their chest to determine is there fluid in there and what we're going to do. Is that patient being triaged towards a CT scan for us to get more data, or is that patient found to be so unwell and free fluid that we need to take them off to theatre to try to, for want of a better phrase, save their lives. So with that in mind, we've got the ultrasound probe over here. I'm going to hand you over to Dr. Anderson and prepare for the jelly. So it's really important first of all that your patient is lying down flat. So we're going to start there, if that's all right with you. Sure. And also adequately exposed. I'll take the microphone off, as if by magic. So traditionally in emergency departments, our patients will come in already having been packaged very nicely by our colleagues in the acute hospital environment. So patients will likely, trauma patients will come to you once you've immobilised in some way, having already been lying down an extended period of time. However, sometimes patients who are still quite unwell, you said through the front door, it happens and will continue to happen across the country. Those patients, if you're going to perform the scan, need to lie down for 20 minutes for their fluids to settle where we want to find them, essentially. I'm not expecting any problems with this scan, and we're hoping that there's no free fluids found. So we're not going to wait 20 minutes. We can cut a bit out. Yeah, who cares? It's so very difficult not to run a volunteer. So today we're going to be using the ultrasound probe with the curvy linear probe. It's really important using this one to look for deep structures. And when you're doing this, it's quite a quick procedure at the bedside whilst you're gaining access. You're doing other bits and pieces. Other clinicians are coming, nurses are coming to help you, but monitoring the patient. So we're not going to be swapping between different types of probes. We're just going to use one for all of them. And we'll go through all the different stages of what we're going to be doing. We're going to be starting in this right upper quadrant over here. So it's important that you get your patient to lie in the right position. And just, if that's okay with you, lie your arm off to the side for me. Perfect. We're going to be using this for the abdomen view. Your ultrasound probe might also come with a fast view, but it's very similar. Given there's a heatwave at the minute, at least the jellies are warmed compared to last time. And then you're going to put your ultrasound jelly on, and then you're just going to make sure that what you want to see at the top of the patient is on the left-hand side of the screen. So apologies, cold jelly. So you're coming in, in that right upper quadrant to start with. It can be a slightly awkward angle to find, but we can see on the right-hand side of the screen what looks like quite a dense gray structure with long lines in. And so you can see that. So that is a liver. And if we go up a little bit, we start to get some rib shadowing. You can feel it as I'm bumping over his ribs, but that would be lung up there where you can see the rib shadowing. And if you take a deep breath for me, you can see that diaphragm coming down now. Perfect. And then the liver pops back in. So we know we're almost in the right area here, but we don't want to see the liver. We want to see the paternal angle. So we're actually going to go a little bit further down into that flank. Sorry, it's a bit uncomfortable. Slightly, that's okay. Perfect. It's just not very soft red. I think it's fair with all of these things to say that we advise the patient to be in particular positions and things like that, but you have to work with what you've got. So rolling over slightly is entirely reasonable because we're trying to get the best of the patient. So now we can see another structure coming into the middle of the screen that looks slightly darker, roundish, with quite a white cortex. So that is a kidney. Very reassuringly, I can see no black, very, very dark fluid between the two of them, between the liver and the kidney and between the kidney and underneath there. So there's no fluids that I can see in that paternal angle there. So that's good. It's starting off well. So now you're going to do the same thing on the other side. Obviously this time, not looking for liver, but looking for the spleen. Pop your arms down for me. You did it a little bit close. So we've done a similar thing on this side where I can see some rib shadows and then we've got that greyish organ, which we're assuming is not a liver on this side. I hope not. You can always have a case study. And then there's another, can you see, roundish looking thing there with the cortex. That's going to be a couple of subcliminal cysts. That is our kidney there. And again, reassuringly, there is no fluid in between the kidney and the spleen or below the kidney. So no free fluid there. So we're going to be doing the sucrupulate use next, followed by the chest use. It's a little bit clinician preference. The most important thing is you've got that right up the quadrant first in order to get the most amount of accuracy. That's where the blood will be pooling first. Okay. Cold jelly apologies. So in here, you're looking, you're going to be looking for bladder, which you can see in the middle of the screen there. Sometimes it can be quite hard to visualise. We've got two lovely ureters. Can you see that coming down? And then bladder there. You should be able to see retina, prostate underneath, but it's a slightly difficult view today, but you've got a lovely view of the bladder there. Well, slightly better view there. You can see there's another white line underneath. Okay. So again, there's no fluid that we can see. Okay. And the other thing that you might be able to see in some of these views is free fluid around at the top near the cutaneous layer with small valve floating in it, because it is essentially a bit of a soup in there. The next one you're going to do is just twisting the probe 90 degrees. Okay. And again, trying to see if you can see any free fluid in there, which I can't. In women, it can be normal to have a small amount of free fluid, especially around that period of time. So, a small amount is nothing to be concerned about in the context of a stable patient. They're an unstable patient. You might want to get some more Xenia finishing or want to do serial scans to ensure that there's no progressing through fluid. Moving on to the chest views now. So, the first view we're going to be doing in the chest is called parasternal view, parasternal long axis. So, you're looking towards the bottom of the heart with your tip. These can always be slightly tricky just to get between the ribs, but take your time just trying to position it as best you can. No, that's beautiful. And you might have to push a little bit harder to get some of these views, just the slightly deepened structures. But you can see a beautiful heart beating there with outflow. So, right, let's talk through the anatomy of this. Are you happy for me to do that? Yeah. What we'll do is we'll redo this with the camera pointing directly at the screen and you can point at it. Yeah. So, do you want me to quickly do the other view so you've got the starting angle of the other view? Okay. And then the other view is going to be the sub-xiphoid view. So, you're pushing, it can be uncomfortable in some patients, but you want to kind of find where the edge of their sternum is and you're kind of going, trying to go underneath to have a look up at the heart. So, here's the sub-xiphoid view. I'm just trying to optimise it. And here's a really good view for looking at pericardial effusion because you can see the whole sac around the heart and you will be able to see a thin black line or a very large black line if your A little bit more in-depth look at the parasternal axis. So, there we can see the descending aorta is this part here. Yeah, you can see how that comes through. Yeah. You can see very good valves. Your aorta coming out the other side and your left atrium as well. Like you're talking about, you're getting the picture which is in the wrong location. So, you see that right circle at the bottom? That's your descending aorta. That's a greyish one. Yeah. So, you've got your ventricles to the left. You've got the outflow of your, well, the inflow of your aorta kind of in the middle and then left atrium on the bottom. That's where you can see the mitral valve and you should be able to see the aortic valve just kind of there. Essentially, you will be able to see pericardial effusion there. Okay. So, those are the main views that you're going to be looking at. So, you've got right and left quadrants. You've got your suprapubic tubes in two planes and you've got at least one but hopefully two cardiac effusion paracetamol and you're satisfied. Any positive findings in blood or fluid that you think you can see here, it's important that you subsequent examinations. So, it cannot be used at once. So, yes, there's blood, we need to go to CT scan. Yes, it can define what's going to happen to the patient and where you think the patient needs to be in the context of a larger trauma team and discussion about where this patient should go. However, patients, unfortunately, deteriorate and things change but they also deviate better. So, it's important if something changes with your patient, a lot of time passes while you're struggling to do other things but you re-examine the patient and you re-do that sup scan because things may have changed. A negative examination to start with may become positive once they have been lying down for a while or the patient becomes more acutely unwell and you worry that an ache has moving them from the ambulance to your trauma bay and you need to change the position or unlodge something. It is also taken in the greater context of the patient. So, in patients who are incredibly stable, who maybe have no mechanisms, you may not want to do a FAFSA scan. It should be used to guide your decision in part of the trauma team together. It's very hard not to just go with it. I think that really does reinforce what we've said many times with examinations. The purpose of an examination is what we're really seeing here is that we're using a dynamic investigation and we are dynamically using that investigation. So, we're going to change across the period of time that the examination was. Well, thank you very much for that. I'm going to go and remove some of this. Oh, I hope this has been a useful video for yourself and I hope you can see the real utility of the Ultrasound Scans. I have the opinion that the Ultrasound Scans to some degree could actually begin to replace the alternate super-CDs to retrieve the stethoscope, but I don't think we're actually meant to push tubes out. I think we're actually using these to augment things, aren't we? I definitely agree and I think in cases like this, when you're at a busy recess day and you've got lots of people, trying to hear muffled heart sounds and worry about pericardial bleeching can be quite difficult. Whereas, if you all can see it and you're on the same page, because the machine is right there in front of all of you, I think that also really helps the joint thinking of the team, rather than you just listening by yourself, figuring it all out. Thank you very much. Thanks.