The AIUM Practice Parameter for the Performance of the Extended Focused Assessment With Sonography for Trauma (EFAST).

Abstract

Journal of Ultrasound in MedicineEarly View Practice ParameterFree Access The AIUM Practice Parameter for the Performance of the Extended Focused Assessment With Sonography for Trauma (EFAST) First published: 10 June 2022 https://doi.org/10.1002/jum.16027AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Introduction The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of clinical practice parameters, and accreditation of practices performing ultrasound examinations. The AIUM practice parameter for the performance of the extended focused assessment with sonography for trauma (EFAST) was developed and revised by the AIUM in collaboration with other organizations whose members use ultrasound for performing this diagnostic test (see “Acknowledgments”). Recommendations for personnel requirements, the request for the examination, documentation, quality assurance, and safety may vary among the organizations and may be addressed by each separately. This practice parameter is intended to provide the medical ultrasound community with recommendations for the performance and recording of high-quality ultrasound examinations. The parameters reflect what the AIUM considers the appropriate criteria for this type of ultrasound examination but are not intended to establish a legal standard of care. Examinations performed in this specialty area are expected to follow the parameter with recognition that deviations may occur depending on the clinical situation. This practice parameter has been developed to provide assistance to practitioners performing EFAST. During the last 3 decades, particularly with its widespread growth in the early 1990s, the FAST included assessments of the peritoneal cavity, and analysis of the pericardial and pleural spaces for hemorrhage. In the early 2000s, the extended FAST (EFAST) added rapid evaluation of the chest for detection of pneumothorax, and this more thorough trauma examination is taught and used in standard practice today. The EFAST is a diagnostic test of information not otherwise obtained by physical examination. The EFAST is a proven and useful diagnostic test for the evaluation of the torso and abdomen after traumatic injury, particularly in the setting of hemodynamic instability. The examination has been shown to be highly specific, with varying sensitivity, in the identification of free intraperitoneal and intrathoracic fluid. Evidence indicates that ultrasound imaging is more sensitive for pneumothorax than supine plain-film chest radiography. It is important to note that the EFAST examination is a screening test, and false-negative examinations may occur, particularly early in the course of management. False-positive examinations for free fluid may also be encountered in patients with a history of ascites, those receiving peritoneal dialysis, and patients with concurrent pleural effusions. Before its development, more invasive procedures were required to evaluate these patients, including diagnostic peritoneal lavage and, at times, laparotomy. In the management of the trauma patient, adherence to the following parameter will maximize the probability of detecting free fluid in the acutely injured patient. The EFAST allows the analysis for possible hemopericardium, hemothorax, pneumothorax, and hemoperitoneum. The portability of ultrasound equipment allows the EFAST to be performed at the patient's bedside or in the rapid triaging of multiple individuals in mass casualty situations, including assessments in the field. Emergency medical services personnel have begun to use EFAST in several areas worldwide for these purposes. The use of ultrasound in a particular institution or setting must be based on access to equipment and appropriately trained or supervised personnel, and should be subject to an organized quality assurance program. Indications Indications for the EFAST primarily evaluate the torso and abdomen for evidence of traumatic injury in the peritoneal, pericardial, and pleural cavities (American College of Emergency Physicians [ACEP] guideline/ACEP Imaging Compendium). There are no absolute contraindications, although if it is clear that the patient requires emergent surgical intervention, then a relative contraindication to performing the test may exist. For example, it still may be necessary to exclude pericardial tamponade or pneumothorax before transferring a patient to the operating room for emergent surgery. Qualifications and Responsibilities of Personnel Physicians interpreting or performing this type of ultrasound examination should meet the specified AIUM Training Guidelines in accordance with AIUM accreditation policies. Sonographers performing the ultrasound examination should be appropriately credentialed in the specialty area in accordance with AIUM accreditation policies. Physicians not personally performing the examination must provide supervision, as defined by the Centers for Medicare and Medicaid Services Code of Federal Regulations 42 CFR §410.32. The EFAST examination provides information to aid in decision-making regarding further evaluation or testing, clinical management, and therapeutic interventions. Rapid provision and interpretation of such examinations are critical for appropriate patient care. The clinical care of patients in life-threatening situations should always take precedence over these guidelines. Physicians from a variety of medical specialties may perform the EFAST examination. If appropriately trained, advanced practice providers, emergency medical personnel, and sonographers can obtain the ultrasound images. Image interpretation should be performed by a supervising physician. Training of physicians in the diagnostic interpretation of EFAST examinations should be in accordance with specialty-specific guidelines. Physicians who supervise nonphysician sonographers should render a diagnostic interpretation in a time frame consistent with the management of acute trauma. Specification of the Examination The objective of the abdominal portion of the diagnostic study is to analyze the peritoneal cavity for free fluid. This requires examination of the abdomen (right upper and left upper quadrants as well as the pelvis), the pericardium, and if performing an EFAST, the bilateral pleura in the thorax. The ability to denote free fluid in the pelvis is aided by the presence of a fluid-filled bladder. As with all ultrasound examinations, orthogonal images (transverse, longitudinal, and coronal planes) help elucidate areas of concern seen in any single plane, and all areas of interest should be scanned through completely using a fanning motion in each plane. Changes in transducer angle and position can help improve analysis of a given area. Images may be obtained through anterior, lateral, or other approaches to denote free fluid in the evaluated areas. As with most imaging and ultrasound examinations, techniques evolve over time and with increased clinical and imaging experience. More specifically, primary ultrasound windows for the EFAST include the following: The Right Upper Quadrant View (also known as the Perihepatic, Morison Pouch, or Right Flank View)—This uses the liver as an ultrasound window to interrogate the hepatorenal space (Morison Pouch) for free fluid. The transducer is placed in a coronal orientation on the patient's right side with the probe marker pointed toward the patient's head. Slight cephalad movement of the transducer allows imaging of the right pleural space for free fluid. Care should be taken to carefully insonate the area between the dome of the liver and diaphragm to identify subdiaphragmatic free fluid. Caudal probe movement allows visualization of the inferior pole of the right kidney, the caudal liver tip, and right pericolic gutter for free fluid assessment. The transducer should be fanned throughout the anterior and posterior directions to interrogate the entire field. The Left Upper Quadrant View (also known as the Perisplenic or Left Flank View)—This uses the spleen as a window to interrogate the spleen and the perisplenic space above the spleen, below the diaphragm, and the splenorenal recess. The transducer is placed in a coronal orientation on the patient's posterior left side, with the probe marker pointed toward the patient's head. Scanning cephalad allows visualization of the left pleural space. Scanning caudad allows visualization of the inferior pole of the left kidney, the caudal spleen tip, and the left pericolic gutter. Again, the transducer should be fanned throughout the anterior–posterior space to interrogate the entire field. The Pleural Space Views—Each pleural space may be investigated via angulation and cephalad movement of the transducer along the ipsilateral flank. This can be performed in conjunction with the right and left upper quadrant views. Abnormal fluid collections in the pleural space are visualized as anechoic collections above the echogenic diaphragm. Visualization of the thoracic spine (a “spine sign”) also indicates fluid or consolidation in the pleural space. At times, fluid that may be hemorrhagic, proteinaceous, or infectious will appear more echogenic or complex in nature. An upright or slight reverse Trendelenburg position of the patient may assist in the detection of pleural fluid. The Pelvic View (also known as the Retrovesical, and for female patients: Retrouterine, or Pouch of Douglas View)—This allows assessment of the most dependent space in the peritoneum for free fluid. Analysis through a fluid-filled bladder (which can be filled, if necessary, by fluid placed through a Foley catheter or clamping the Foley catheter) may help analysis for pelvic fluid. When free fluid is present, it is noted most often posterior or superior to the bladder and uterus in adults. The bladder should be scanned in its entirety in both the sagittal and transverse planes. The Pericardial View (also known as the Subcostal or Subxiphoid View)—Subxiphoid images can be obtained by placing the transducer on the upper abdomen and pointing superiorly midline or toward the left shoulder using the liver as an acoustic window. Alternative cardiac windows can be additive or may be necessary if an adequate subxiphoid view cannot be obtained in a particular patient. The parasternal long-axis view of the heart is typically the next most common view used; however, other views, including the apical 4-chamber, may be used, as long as the pericardium can be assessed circumferentially. The potential space of the pericardium is analyzed for the presence of any free fluid in anterior or posterior locations. The presence of free fluid prompts assessment for tamponade. The Anterior Thoracic View (Pleural Sliding Views)—The pleura normally oppose each other and slide against each other easily. The separation of the pleura by a pneumothorax and subsequent absence of this sliding may be imaged typically in a supine patient in the second or third intercostal space with a high-frequency transducer, although lower-frequency transducers may also be used. Other intercostal spaces may also be used for lung evaluation. Pleural sliding with reverberation artifacts (A-lines) is present in the normal lung. M-mode imaging may aid in the evaluation of the lung for pneumothorax. The identification of a lung point is highly specific for the diagnosis of pneumothorax and should be sought when time allows. A lung point represents the site where the lung adheres to the parietal pleura immediately adjacent to the pneumothorax. A lung pulse (subtle cardiac pulsation of the parietal pleura at the lung periphery) can differentiate the lack of ventilation, such as in apnea or main stem intubation, from pneumothorax. Additional dedicated views may include the following: The Right and Left Pericolic Gutter Views—Longitudinal and transverse views through peritoneal windows inferior to the level of the ipsilateral kidney and next to the ipsilateral iliac crest may reveal free fluid surrounding the bowel. These windows may be of limited use because of the absence of an acoustic window, such as a fluid-filled bladder or a solid organ. Air-filled bowel may also limit these views. The presence of larger amounts of fluid may aid in visualization. The images may be obtained laterally or from an anterior approach. The Parasternal View—The parasternal window allows visualization of the heart in the long or short axis. This view may be used when a patient's subcostal view is suboptimal. The Apical View—The apical view may allow visualization of pericardial fluid by placing the transducer around the nipple line at the left fifth intercostal space. This view may also be used when the subcostal view is not optimal. Supplemental views: Inferior Vena Cava (IVC) Views—Multiple views of the IVC are accessible by using either a subxiphoid or lateral approach. The lateral approach makes use of the liver as an acoustic window. The primary aim of IVC evaluation is to aid in the assessment of the intravascular volume status. IVC evaluation is particularly useful in those patients at the extreme ends of the spectrum: either hypovolemic (eg, secondary to massive hemorrhage) or severely fluid overloaded. Dynamic IVC evaluation has also been shown to be useful in assessing patients' response to volume resuscitation or transfusion of blood products. Other Considerations for the EFAST Examination Include the Following Points Trendelenburg positioning may increase the sensitivity of the ultrasound examination for visualizing free fluid in the right upper quadrant or left upper quadrant. Semi-Fowler positioning may increase the sensitivity of detection of a pneumothorax in the apical lung zones and detection of hemothorax at the lung bases. An EFAST examination is not designed to be performed only once, and it may be repeated during the patient's stay for reassessment of the patient's condition either routinely or as a consequence of clinical decompensation. As a caveat, one must remember that trauma ultrasound provides a picture of a patient's condition at one moment in time. It does not eliminate the possibility of injury or fluid collections that are below detectable thresholds. Acute hemorrhage appears as anechoic fluid collections described previously in this document. However, as the blood clots, fluid collections may appear complex, hypoechoic, or even isoechoic to surrounding structures. In some cases, areas within dense structures that are actively bleeding may appear hyperechoic to surrounding tissues. Contrast-enhanced ultrasound (CEUS) can be utilized in combination with the EFAST exam in the evaluation for solid organ injury in patients with abdominal trauma. There are currently 3 FDA-approved ultrasound contrast agents, but CEUS in EFAST exams is not widespread and the use of contrast media may be off-label for certain views. It is only mentioned here to bring awareness of this application. Providing recommendations for the use of CEUS is not within the scope of these practice parameters. For more information, please refer to the AIUM Practice Parameter for the Performance of Contrast-Enhanced Ultrasound Examinations.1, 2 Limitations There are limitations to EFAST assessments, including reduced ability to detect free fluid in children or exact locations of injury to mesenteric structures, diaphragm, bowel, or solid organs. The EFAST is also limited in identifying retroperitoneal hemorrhage, although injuries can at times be seen. The potential false-positive diagnosis of free traumatic fluid in the peritoneum may be due to fluid present in patients for physiologic reasons, including ruptured ovarian cyst, as well as pathologic reasons, such as patients with ascites or inflammatory processes in the abdomen or pelvis. One must also be aware that free fluid is typically present intraperitoneally in patients with ventriculoperitoneal shunts, in those who undergo peritoneal dialysis, and in those after recent peritoneal lavage and surgery. It can be difficult to identify free fluid in patients with severe polycystic kidney or ovarian disease. Additionally, perinephric fat may also be mistaken for free fluid. Ultrasound may also be technically limited in the trauma patient due to bowel gas, obesity, subcutaneous or peritoneal emphysema, patient positioning, the degree of injury and rate of bleeding, adhesions from prior surgery, and often in patients who are either in pain or combative secondary to traumatic injury. Like many diagnostic ultrasound examinations, the main limitation of the EFAST is that the operator must be knowledgeable in its clinical use and limitations, and be aware that a negative EFAST does not exclude all injuries. Limitations to the pericardial assessment for hemopericardium include pericardial fat pads, cysts, and preexisting pericardial fluid. Limitations to pleural assessment for hemothorax include pleural fluid from preexisting pleural disease as well as extension of fluid into the pleural space from the pericardium or peritoneum. Finally, the limitations in the evaluation for pneumothorax include mistaking the absence of pleural sliding after a mainstem bronchus intubation for a pneumothorax as well as failure to recognize the associated presence of a lung pulse, and false-positive examinations after pleurodesis or in patients with severe chronic obstructive pulmonary disease. Other lung or chest wall pathologies may inhibit adequate visualization of pleural sliding. Although the sensitivity in the detection of pneumothorax is very high, it is important to note that small apical, mediastinal, non-pleural-based, or localized pneumothoraces may not be visualized in a focused thoracic ultrasound examination. Further information may be obtained by referring to the ACEP Emergency Ultrasound Imaging Criteria Compendium—Trauma.3 Documentation Accurate and complete documentation is essential for high-quality patient care. Written reports and ultrasound images/video clips that contain diagnostic information should be obtained and archived, with recommendations for follow-up studies if clinically applicable, in accordance with the AIUM Practice Parameter for Documentation of an Ultrasound Examination. The diagnostic interpretation of findings in an EFAST examination is limited to those areas assessed and imaged. In particular, an EFAST analysis does not allow the diagnostic evaluation of all abnormalities in the chest, abdomen, or pelvis. A guide for documentation may also be found in the ACEP standard reporting guidelines.4 Equipment Specification The EFAST examination may be conducted with any device that provides diagnostic quality. The equipment should be adjusted to operate at the highest clinically appropriate frequency, realizing that there is a trade-off between resolution and beam penetration. For most preadolescent pediatric patients, transducers with a smaller footprint (including phased array transducers) are preferred. In neonates and small infants, a higher-frequency transducer may be necessary. For adults, mean frequencies of 3.5 and 5 MHz are most commonly used. Occasionally, very large patients may require a lower frequency such as 2 MHz for analysis. Quality and Safety Policies and procedures related to quality assurance and improvement, safety, infection control, and equipment performance monitoring should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practices. ALARA (As Low as Reasonably Achievable) Principle The potential benefits and risks of each examination should be considered. The ALARA principle should be observed for factors that affect the acoustical output and by considering transducer dwell time and total scanning time. Further details on ALARA may be found in the current AIUM publication Medical Ultrasound Safety. Infection Control Transducer preparation, cleaning, and disinfection should follow manufacturer recommendations and be consistent with the AIUM Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers Between Patients, Safe Handling, and Use of Ultrasound Coupling Gel. Equipment Performance Monitoring Monitoring protocols for equipment performance should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practice. Policies and procedures related to image quality, equipment performance monitoring, infection control, and patient safety as well as patient education with regard to the EFAST should be developed and implemented in accordance with either the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practices or the guidelines developed by specialty specific organizations such as the ACEP. Acknowledgments This parameter was developed by the AIUM in collaboration with the American College of Emergency Physicians (ACEP). We are indebted to the many volunteers who contributed their time, knowledge, and energy to developing this document. Collaborative Subcommittees AIUM Rachel Liu, MD Vivek Tayal, MD, FACEP, FAIUM Nova Panebianco, MD MPH Daniel Theodoro, MD MSCI Penelope Lema, MD ACEP Elaine Situ-LaCasse, MD Michael Gottlieb, MD AIUM Expert Advisory Group Alyssa Abo, MD AIUM Clinical Standards Committee James M. Shwayder, MD, JD, chair Rachel Bo-ming Liu, MD, vice chair Creagh T. Boulger, MD Bryann Bromley, MD Nirvikar Dahiya, MD John R. Eisenbrey, PhD Rob Goodman, MBBCh, MBA, BMSc Ethan J. Halpern, MD Oliver Daniel Kripfgans, PhD Jean Spitz, MPH, CAE, RDMS John Stephen Pellerito, MD Margarita Revzin, MD Original copyright 2007; Revised 2014, 2022 References 1AIUM practice parameter for the performance of contrast-enhanced ultrasound examinations. J Ultrasound Med 2020; 39: 421– 429. Wiley Online LibraryPubMedWeb of Science®Google Scholar 2Zhang Z, Hong Y, Liu N, Chen Y. Diagnostic accuracy of contrast enhanced ultrasound in patients with blunt abdominal trauma presenting to the emergency department: a systematic review and meta-analysis. Sci Rep 2017; 7: 4446. https://doi.org/10.1038/s41598-017-04779-2. CrossrefPubMedGoogle Scholar 3 Emergency Ultrasound Imaging Criteria Compendium. American College of Emergency Physicians website. https://www.acep.org/by-medical-focus/ultrasound/. Accessed April 26, 2022. Google Scholar 4Liu RB, Blaivas M, Moore C. Emergency ultrasound standard reporting guidelines. American College of Emergency Physicians website. https://www.acep.org/by-medical-focus/ultrasound/. Accessed April 26, 2022. Google Scholar Suggested Reading 1Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington SD. Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg 1998; 228: 557– 567. CrossrefCASPubMedWeb of Science®Google Scholar 2Wherrett LJ, Boulanger BR, McLellan BA, et al. Hypotension after blunt abdominal trauma: the role of emergent abdominal sonography in surgical triage. J Trauma 1996; 41: 815– 820. CrossrefCASPubMedWeb of Science®Google Scholar 3Rozycki GS, Feliciano DV, Ochsner MG, et al. The role of ultrasound in patients with possible pene-trating cardiac wounds: a prospective multicenter study. J Trauma 1999; 46: 543– 552. CrossrefCASPubMedWeb of Science®Google Scholar 4Plummer D, Brunette D, Asinger R, Ruiz E. Emergency department echocardiography improves out-come in penetrating cardiac injury. Ann Emerg Med 1992; 21: 709– 712. CrossrefCASPubMedWeb of Science®Google Scholar 5Boulanger BR, Kearney PA, Tsuei B, Ochoa JB. The routine use of sonography in penetrating torso injury is beneficial. J Trauma 2001; 51: 320– 325. CrossrefCASPubMedWeb of Science®Google Scholar 6Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment With Sonography for Trauma (EFAST). J Trauma 2004; 57: 288– 295. CrossrefCASPubMedWeb of Science®Google Scholar 7Dulchavsky SA, Schwarz KL, Kirkpatrick AW, et al. Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma 2001; 50: 201– 205. CrossrefCASPubMedWeb of Science®Google Scholar 8Ball CG, Kirkpatrick AW, Laupland KB, et al. Factors related to the failure of radiographic recognition of occult posttraumatic pneumothoraces. Am J Surg 2005; 189: 550– 556. CrossrefWeb of Science®Google Scholar 9Lichtenstein D, Meziere G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med 2005; 33: 1231– 1238. CrossrefPubMedWeb of Science®Google Scholar 10Tayal VS, Beatty MA, Marx JA, Tomaszewski CA, Thomason MH. FAST (focused assessment with sonography in trauma) accurate for cardiac and intraperitoneal injury in penetrating chest trauma. J Ultrasound Med 2004; 23: 467– 472. Wiley Online LibraryPubMedWeb of Science®Google Scholar 11McGahan J, Richards J, Fogata M. Emergency ultrasound in trauma patients. Radiol Clin North Am 2004; 42: 417– 425. CrossrefPubMedWeb of Science®Google Scholar 12Jehle D, Guarino J, Karamanoukian H. Emergency department ultrasound in the evaluation of blunt abdominal trauma. Am J Emerg Med 1993; 11: 342– 346. CrossrefCASPubMedWeb of Science®Google Scholar 13Kimura A, Otsuka T. Emergency center ultrasonography in the evaluation of hemoperitoneum: a prospective study. J Trauma 1991; 31: 20– 23. CrossrefCASPubMedWeb of Science®Google Scholar 14McGahan JP, Rose J, Coates TL, Wisner DH, Newberry P. Use of ultrasonography in the patient with acute abdominal trauma. J Ultrasound Med 1997; 16: 653– 662. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 15Soudack M, Epelman M, Maor R, et al. Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients. J Clin Ultrasound 2004; 32: 53– 61. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 16Hahn D, Offerman S, Homes J. Clinical importance of intraperitoneal fluid in patients with blunt intra-abdominal injury. Am J Emerg Med 2002; 20: 595– 600. CrossrefPubMedWeb of Science®Google Scholar 17Blaivis M, Debehenke D, Phelan B. Potential errors in the diagnosis of pericardial effusion on trauma ultrasound for penetrating injuries. Acad Emerg Med 2000; 7: 1261– 1266. Wiley Online LibraryPubMedWeb of Science®Google Scholar 18Dolich M, McKenney M, Varela J, Compton RP, McKenney KL, Cohn SM. 2,576 ultrasounds for blunt abdominal trauma. J Trauma 2001; 50: 108– 112. CrossrefCASPubMedWeb of Science®Google Scholar 19Scalea TM, Rodriguez A, Chiu WC, et al. Focused assessment with sonography for trauma (FAST): results from an international consensus conference. J Trauma 1999; 46: 466– 472. CrossrefCASPubMedWeb of Science®Google Scholar 20Melniker LA, Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the First Sonography Outcomes Assessment Program Trial. Ann Emerg Med 2006; 48: 227– 235. CrossrefPubMedWeb of Science®Google Scholar 21 American College of Radiology. ACR Appropriateness Criteria—Blunt Abdominal Trauma. Reston, VA: American College of Radiology; 2012. Google Scholar Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation