Review Article

The Focused Abdominal Sonography for Trauma Scan

Pearls and Pitfalls
John P. McGahan, MD, John Richards, MD, Marijo Gillen, MD, PhD

Objective. To review the state-of-the-art use of sonography in evaluating the patient with trauma. Methods. We reviewed our experience in performing more than 5000 sonographic examinations in the patient with trauma. The recent experience of other publications advocating newer applications of sonography in the patient with trauma are discussed and presented in a pictorial fashion. Results. The main focus of sonography in the patient with trauma has been in performance of the focused abdominal sonography for trauma scan. The focused abdominal sonography for trauma scan is usually performed in the patient with blunt abdominal trauma and is used to check for free fluid in the abdomen or pelvis. There are certain pitfalls that need to be avoided and certain limitations of the focused abdominal sonography for trauma scan that need to be recognized. These pitfalls and limitations are reviewed. More recently, sonography has been used to detect certain solid-organ injuries that have a variety of appearances. Thus, sonography may be used to localize the specific site of injury in these patients. More recently, sonography has been used to evaluate thoracic abnormalities in patients with trauma, including pleural effusions, pneumothoraces, and pericardial effusions. Conclusions. The use of sonography in evaluating the patient with trauma has rapidly expanded in the past decade. Those using sonography in this group of patients should be aware of its many uses but also its potential pitfalls and limitations. Key words: abdominal parenchymal injury; abdominal sonography; focused abdominal sonography for trauma; Morison pouch; pitfalls.

Abbreviations BAT, blunt abdominal trauma; CT, computed tomography; FAST, focused abdominal sonography for trauma; IAI, intra-abdominal injury

Received February 25, 2002, from the Department of Radiology (J.P.M., M.G.) and Division of Emergency Medicine (J.R.), University of California Davis Medical Center, Sacramento, California. Revision requested March 14, 2002. Revised manuscript accepted for publication March 21, 2002. Special thanks to Debra Odam for technical support in manuscript preparation. Address correspondence and reprint requests to John P. McGahan, MD, Department of Radiology, University of California Davis Medical Center, School of Medicine, 4860 Y St, Suite 3100, Sacramento, CA 95817.

he use of sonography in the detection of abdominal parenchymal injuries is not new; sonography as a diagnostic tool for detection of traumatic hemorrhage of the spleen was described more than 30 years ago.1 In an early report by Asher et al2 in 1976, the sensitivity of sonography for detection of splenic injury from blunt abdominal trauma (BAT) was reported to be 80%. However, after these early reports, sonography was not routinely used for evaluation of injury from BAT, probably because of widespread use of computed tomography (CT) for BAT.3,4 It has only been in the 1990s that sonography has been more widely advocated for the screening evaluation of patients with BAT.5

Sonographic Examination
The sonographic examination that is performed for evaluation of the patient with BAT has changed considerably since first described in the early 1990s. There has been a

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learning curve within the literature, and this examination has changed appropriately. The main focus of the examination has been on detection of free fluid within the abdomen of patients with acute trauma. One original description of the use of sonography in BAT was to obtain a single view of the Morison pouch to detect free fluid.6 However, that examination has been abandoned in favor of a more comprehensive examination, which has been well described in the literature.7 This examination has been named focused abdominal sonography for trauma (FAST). This usually includes sonography of the right upper quadrant, including the hepatorenal fossa (Figs. 1 and 2); the left upper quadrant, including the perisplenic region; the right and left paracolic gutters (Fig. 3); and the pelvis, performed to detect free fluid. Free fluid will gravitate to the most dependent portion of the pelvis (Figs. 4 and 5), and as such, free fluid in the pelvis may be missed if the patient has an empty bladder.7 In some instances, an examination of the epigastrium to check for free fluid, free air, or both is also performed.8 Other components of the examination include an intercostal or subdiaphragmatic view of the heart. Examination of the chest is performed if, in fact, there has been chest as well as abdominal trauma; such an examination will be discussed below.

Sensitivity of FAST
The sensitivity of the FAST scan has ranged from 63% to 100%.5,7,918 In almost all of the studies, sonographic specificities remained high, in the range of 90% or greater. In a critical review of a number of these studies5,918 reporting high sensitivity for sonography, Pearl and Todd19 found flaws in the study design. These flaws included the following: no trial used a completely blinded format; only 2 of the 11 specified consecutive patient enrollment; training for those performing the examinations ranged from 2 hours to many years of experience; and, finally, there was no standard of reference with which sonographic results could be compared. For instance, Rothlin et al16 clearly stated that, It has become acceptable in Europe to calculate sensitivities and specificities for sonography concerning only the patients course. A number of studies have not included clinical outcome, instead comparing sonography with CT, diagnostic peritoneal lavage, or laparotomy; these have had sensitivities in the range of 63% to 69%.7,18,20 In analysis of these series with lower sensitivities, there is no doubt of 2 facts: (1) we can improve sensitivity by learning from our previous errors; and (2) the FAST scan will not detect all hollow- or solid-organ injuries.

Figure 1. Image from a 56-year-old woman with a splenic laceration and free fluid after a fall. Free fluid is shown in the right upper quadrant (RUQ) of the abdomen. This patient required splenectomy. C indicates renal cyst; and L, liver.

Figure 2. Image from a 26-year-old patient with a splenic laceration. Longitudinal sonography of the right upper quadrant (RUQ) of the abdomen shows a trace amount of free fluid in the hepatorenal fossa (arrow). No splenectomy was required.

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Figure 3. Free fluid in the abdomen. A, Longitudinal scan through the right (RT) paracolic gutter shows free fluid surrounding a loop of bowel. B, Other free fluid is shown in the right lower quadrant (RTLQ) of the abdomen (open arrow).

Sonographic Pitfalls
There are a few pitfalls that occur with the FAST scan. First, without a full bladder, free fluid in the pelvis will often be missed.7 In analyzing our original work, we had 14 false-negative findings, of which 6 were in cases in which free fluid was identified in the pelvis on CT but not shown on sonography. These patients were examined with an empty bladder, because a Foley catheter was placed before the sonography was performed. If, in fact, there were a full bladder, we would have theoretically identified free fluid in the pelvis, which would have decreased our falsenegative findings to a total of 8. This would have increased our sensitivity from 63% to 79%. It is

therefore imperative that we use a full-bladder technique to detect free fluid in the pelvis. Second, there have been a number of articles that have pointed out that sonography can miss important organ injury that will require surgery in the patient with trauma.7,20,2124 For instance, Dolich et al22 reported 43 patients with falsenegative sonographic findings, of which 10 (33%) required surgery. Shanmuganathan et al24 studied more than 11,000 patients with BAT by using sonography and found that 467 had abdominal organ injuries with CT or laparotomy correlation. In 310 (66%) of these, there was free fluid detected on sonography. However, 157 (34%) of the 467 patients had no sonographically detected free fluid; 26 of these 157 patients

Figure 4. Image from a 23-year-old woman with a splenic laceration and pelvic fluid after a motor vehicle accident. Longitudinal scan of the pelvis shows slightly echogenic free fluid (arrow) anterior and cephalad to the bladder (B). This patient required a splenectomy.

Figure 5. Image from a 25-year-old woman with physiologic free fluid after a motor vehicle accident. Longitudinal scan through the partially filled bladder (B) shows the uterus (U) and a trace of free fluid (open arrow) in the cul-de-sac. This free fluid was thought to be physiologic.

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without free fluid required further surgical or angiographic intervention. Shanmuganathan et al24 therefore thought that the FAST scan may frequently miss patients with surgically correctable injuries. Most of these studies authors advocate the use of sonography as the initial screening examination but think that CT should remain the definitive imaging modality, especially for hemodynamically stable patients.21,24 We have found sonography to be very useful for the triage of unstable patients with appreciable free fluid in the abdomen but would agree that CT still should be used for those stable patients who have undergone sonography and in whom there is suggestion of an intra-abdominal injury (IAI). Finally, there is little doubt that sonography will be limited or unable to show certain types of injuries. These are not restricted to but include spinal and pelvic fractures, diaphragmatic ruptures,25 vascular injuries,24 pancreatic injuries,26 adrenal injuries, and some bowel and mesenteric injuries (Fig. 6).27

Free Fluid Scoring Systems

An initial sonographic scoring system proposed by Jehle et al6 included a single view of the Morison pouch to check for free fluid. This was a simple all-or-none system for identification of a hypoechoic stripe between the liver and kidney. With this protocol, Jehle et al6 reported a sensitivity of 81.8%. However, Branney et al28

reported that when 400 mL of saline was infused in the abdomen during diagnostic peritoneal lavage with the patient in the Trendelenburg position, only 10% of patients had fluid identified in the Morison pouch. It took 1 L of saline to identify fluid in the Morison pouch in 97% of cases. This illustrates the possible limitations of a single-view scoring system of the upper abdomen for detection of free fluid. It also emphasizes the importance of gravity in the distribution of fluid into the pelvis and the need for a good acoustic window (full bladder) when examining the pelvis. To develop a scoring system, Huang et al13 infused saline during diagnostic peritoneal lavage and then used sonography to detect free fluid. He based his criteria on locating pockets of fluid with a thickness of 2 mm or greater. Each region or pocket of fluid 2 mm or greater received a score of 1. Patients with 3 pockets, or a score of 3 or greater, were taken to the operating room. Even with a score of less than 3, 14 of 24 patients were taken to surgery. McKenney et al29 proposed a scoring system in which all vertical heights of fluid measured in centimeters in the abdomen were added. A score of greater than 3 was associated with an increased need for surgical intervention. The subphrenic, subhepatic, and perisplenic areas and pelvis represented the 4 sites in which, if fluid were isolated, would most often result in a need for surgery.

Figure 6. Images from a 4-year-old boy with a colonic tear, an ileal tear, and a mesenteric laceration after a motor vehicle accident. A, Sonography of the right upper quadrant (RUQ) shows large amounts of free fluid in the hepatorenal fossa (open arrow). B, Computed tomography of the abdomen shows thickening of the small bowel (curved arrow) with free fluid noted in the abdomen (arrow). This patient had surgical repair of the small-bowel laceration.

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Sirlin et al30,31 published 2 articles describing a scoring system and location of fluid. For each anatomic region in which fluid was detected, 1 point was given. With a score of 0, 1.4% of the patients had an IAI; with a score of 1, 59% had an IAI; with a score of 2, 85% had an IAI; and with a score of 3, 83% had an IAI. With regard to surgical intervention, for patients with a score of 0, 0.4% required surgery; with a score of 1, 13% required surgery; with a score of 2, 36% required surgery; and with a score of 3, 63% required surgery. Therefore, the higher the score, the higher the rate of IAI and need for surgery.31 This group also found that hepatic injuries were likely to have associated free fluid in the right upper quadrant or the lower recesses, whereas for splenic injuries, free fluid was identified in either the right or left upper quadrant as well as the recesses.30 These scoring systems have a common denominator; that is, an increase in the amount of free fluid in the abdomen or pelvis raises the likelihood of major IAI. When we perform the examination at our institution, we analyze the amount of fluid subjectively. If large pockets of fluid are noted throughout the abdomen, we will often send these patients to surgery without confirmatory CT, especially if they are not hemodynamically stable.27

Serial Sonography
A few studies20,32 have shown that serial sonography performed as a part of the followup physical examination may be useful for detecting free fluid in patients with BAT. Certainly, an examination after stabilization of the patient will allow the sonographer more time for a comprehensive examination. If there is active bleeding in the abdomen, the amount of fluid should increase with time and would be more amenable to sonographic detection. The value of serial sonography has not been fully investigated.

tion of 41% of solid-organ injuries. However, most studies have not shown this high detection rate. This is not a new topic in sonography. In 1983, vanSonnenberg et al33 injected blood into cadaver organs and also noted the appearance of blood in the liver after fine-needle aspiration biopsy. These hematomas appeared as linear echogenic foci within the parenchymal organs. The FAST literature has paid little attention to the appearance of solid organs. However, there is some limited work on this topic. Stengel et al34 showed that with the use of a 7.5-MHz linear array probe, injuries were much more easily detected than with a 3.5MHz convex probe. Much of this work on classification of solid-organ injury has been performed by Richards, McGahan, and colleagues.28,3538 Although solid-organ injury is infrequently identified, there are certain patterns that predominate when shown. A diffuse heterogeneous pattern is a predominant pattern shown in splenic lacerations (Figs. 79), whereas a discrete hyperechoic pattern is shown most often in hepatic lacerations (Figs. 10 and 11). 35,36 It is of interest that this discrete hyperechoic pattern in the liver is very similar to the pattern originally described by vanSonnenberg et al33 in 1983. Also, in the spleen, subcapsular hematomas are shown as either hyperechoic or hypoechoic rims surrounding the splenic parenchyma (Figs. 12 and 13). Siniluoto and

Figure 7. Image from a 62-year-old man with a splenic laceration after a motor vehicle accident. Sonography of the left upper quadrant (LLUQ) of the abdomen shows a very disorganized and heterogeneous appearance to the spleen. There was free fluid in the abdomen. This patient was sent directly to the operating room for a splenectomy.

Solid-Organ Injuries
Most FAST examinations have focused on detection of free fluid in the abdomen. Only a few have focused on the use of sonography to directly detect parenchymal organ injuries. Rothlin et al16 reported sensitivity of 41.4% for detection of organ injury by sonography. McGahan et al7 also showed sonographic detecJ Ultrasound Med 21:789800, 2002 793

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Figure 8. Images from a 23-year-old man with a splenic laceration after a motor vehicle accident. A, Longitudinal sonography of the left upper quadrant (LUQ) of the abdomen shows a hypoechoic rim surrounding the spleen (arrows) and a heterogeneous appearance to the spleen. B, Computed tomography of the upper abdomen shows active extravasation of contrast (arrow) within the splenic bed. There was free fluid in the abdomen. This patient underwent a splenectomy.

associates39 showed that splenic lacerations not detected on initial sonography become hypoechoic over a few days. In kidneys, more severe injuries show a completely disorganized pattern (Fig. 14). There is only limited experience in identifying injuries to the pancreas, adrenal glands, and bowel on sonography.

The Chest
Sonography has been shown to be useful for diagnosing pleural effusions (Fig. 15),40 pericardial effusions (Fig. 16),41,42 and pneumothoraces (Figs. 17 and 18).43,44 Pleural effusions are easily identified on sonography and can be seen as a hypoechoic or an anechoic stripe in the dependent portion of the thorax when the right or left upper quadrant of the abdomen is examined. It is possible to diagnose pneumothoraces on the basis of sonography by noting the absence of the normal sliding lung sign and instead noting the comet tail that originates from the pneumothorax. The parietal pleura is fixed to the ribs and muscles of the thorax, whereas the visceral pleura is adherent to the lung. Sliding lung refers to the observation of the bright echogenic line of the visceral pleura, which is adherent to the lung, moving or sliding during normal inspiration and expiration. The comet tail sign may be more correctly a reverberation artifact of closely spaced echoes that are identified deep to a pneumothorax. Thus, in the region of the pneumothorax, sliding of the visceral pleura of the lung adjacent to the parietal pleura is not observed. Very high sensitivities have been reported for identification of pneumothorax by sonography.43,44 Many examiners incorporate the subcostal view of the heart as a portion of the FAST scan. This is useful in diagnosing a pericardial effusion. However, Blaivas et al42 pointed out the
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Figure 9. Image from a 35-year-old man with a splenic laceration after an assault. Sonography showed multiple mixed echogenic regions (open arrow) throughout the spleen. This patient required a splenectomy. Reprinted with permission from Radiographics.38

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Figure 10. Images from a 20-year-old man with multiple abdominal injuries including a hepatic laceration after a motor vehicle accident. A, Sonography of the right upper quadrant (RUQ) of the abdomen shows a fairly well-demarcated echogenic region in the liver (arrow). B, Postoperative CT of the upper abdomen shows the corresponding hepatic laceration of the liver. Reprinted with permission from Radiographics.38

potential pitfalls of overdiagnosing pericardial effusions. They set up a study in which emergency medicine residents and fellows trained in sonography had trouble discerning epicardial fat from effusions, and sonography had sensitivity of 73% and specificity of 44%.40 Finally, cardiac tears or ruptures of the heart may be noted on sonography.45 Thus, in the future, sonography will probably prove to be a more useful tool in identifying abnormalities in the chest with blunt and penetrating trauma.

Summary
It is apparent that the use of sonography in the evaluation of patients with trauma has greatly increased over the last few years, and undoubtedly there will be more widespread use of sonography in the future. In the abdomen, sonography can show free fluid and, in some situations, can identify solid-organ injuries. If appreciable free fluid is detected, this may, in fact, indicate that patients should be sent for immediate surgical intervention depending on

Figure 11. Images from a 46-year-old male pedestrian with a hepatic laceration after being hit by an automobile. A, Sonography shows a well-demarcated echogenic region in right lobe of the liver corresponding to the liver laceration (arrow). B, Computed tomography shows the liver laceration (arrow) extending into the periportal region. Reprinted with permission from Radiographics.38

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Figure 12. Image from a 43-year-old man with an initial splenic laceration after an assault. Sonography of the left upper quadrant (LUQ) of the abdomen shows a well-demarcated, echogenic subcapsular hematoma of the spleen (open arrow). This patient required a splenorrhaphy followed by a splenectomy. Reprinted with permission from Radiographics.38 LUQ indicates left upper quadrant.

Figure 13. Image from a 26-year-old man with a splenic laceration after a motor vehicle accident. Sonography shows a well-demarcated, echogenic subcapsular hematoma in the spleen (open arrow). There was free fluid in the abdomen. This patient required a splenectomy. LUQ indicates left upper quadrant.

Figure 14. Images from an 18-year-old woman with intra-abdominal injuries including a renal laceration after a motor vehicle accident. A, Sonography of the right upper quadrant (RUQ) of the abdomen shows a large hypoechoic region in the middle and lower pole of the right kidney (arrows). B, Computed tomography of the right kidney shows the renal laceration with surrounding hematoma. This patient required a nephrectomy. C, Sonography of the pelvis through the patients bladder (B) shows the uterus (U) but no free fluid in the abdomen or pelvis.

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Figure 15. Pleural effusion. Sonography of the right upper quadrant (RUQ) shows right pleural effusion (PL EFF; arrow) in a patient with acute trauma to the chest and abdomen.

Figure 16. Pericardial effusion. A subcostal view of the heart shows the right (R) and left (L) ventricles surrounded by a well-demarcated, hypoechoic rim corresponding to a moderately sized pericardial effusion (arrow).

Figure 17. Sonography of normal lung. A linear array transducer (A) and a sector transducer (B) show echogenic lines of the pleura (arrows). With inspiration and expiration, the sliding lung can be identified on real-time sonography.

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B
Figure 18. Sonography of a focal pneumothorax. A linear array transducer (A) and a sector transducer (B) show the echogenic interface of a normal lung (open arrow). There is a focal pneumothorax and a corresponding comet tail artifact (arrows). RT CHT ANT indicates right chest, anterior.

their clinical status. However, for patients in whom no free fluid is identified, there remains the risk of an IAI. The examiner must realize that certain abnormalities may not be identified by sonography within the abdomen of a patient with acute trauma. These limitations must be realized for effective use of sonography as a screening tool. In the future, the use of sonography for patients with chest trauma will also increase identification of pleural effusions and pneumothoraces. Sonography can also be used to diagnose abnormalities of the heart, including pericardial effusion and potential cardiac rupture.

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