The Focused AbdominalSonography for Trauma ScanPearls 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 inthe patient with trauma. The recent experience of other publications advocating newer applicationsof 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 focusedabdominal sonography for trauma scan. The focused abdominal sonography for trauma scan is usu-ally performed in the patient with blunt abdominal trauma and is used to check for free fluid in theabdomen or pelvis. There are certain pitfalls that need to be avoided and certain limitations of thefocused abdominal sonography for trauma scan that need to be recognized. These pitfalls and limita-tions are reviewed. More recently, sonography has been used to detect certain solid-organ injuries thathave a variety of appearances. Thus, sonography may be used to localize the specific site of injury inthese patients. More recently, sonography has been used to evaluate thoracic abnormalities in patientswith trauma, including pleural effusions, pneumothoraces, and pericardial effusions. Conclusions. Theuse 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 poten-tial pitfalls and limitations. Key words: abdominal parenchymal injury; abdominal sonography;focused abdominal sonography for trauma; Morison pouch; pitfalls.

Received February 25, 2002, from the Departmentof Radiology (J.P.M., M.G.) and Division ofEmergency Medicine (J.R.), University of CaliforniaDavis Medical Center, Sacramento, California.Revision requested March 14, 2002. Revisedmanuscript accepted for publication March 21,2002.

Special thanks to Debra Odam for technical sup-port in manuscript preparation.

Address correspondence and reprint requests toJohn P. McGahan, MD, Department of Radiology,University of California Davis Medical Center, Schoolof Medicine, 4860 Y St, Suite 3100, Sacramento, CA95817.

AbbreviationsBAT, blunt abdominal trauma; CT, computed tomogra-phy; FAST, focused abdominal sonography for trauma;IAI, intra-abdominal injury

he use of sonography in the detection of abdom-inal parenchymal injuries is not new; sonogra-phy as a diagnostic tool for detection oftraumatic hemorrhage of the spleen was

described more than 30 years ago.1 In an early report byAsher et al2 in 1976, the sensitivity of sonography fordetection of splenic injury from blunt abdominal trau-ma (BAT) was reported to be 80%. However, after theseearly reports, sonography was not routinely used forevaluation of injury from BAT, probably because ofwidespread use of computed tomography (CT) forBAT.3,4 It has only been in the 1990s that sonography hasbeen more widely advocated for the screening evalua-tion of patients with BAT.5

Sonographic Examination

The sonographic examination that is performed for eval-uation of the patient with BAT has changed considerablysince first described in the early 1990s. There has been a

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learning curve within the literature, and thisexamination has changed appropriately. Themain focus of the examination has been ondetection of free fluid within the abdomen ofpatients with acute trauma. One originaldescription of the use of sonography in BATwas to obtain a single view of the Morisonpouch to detect free fluid.6 However, thatexamination has been abandoned in favor of amore comprehensive examination, which hasbeen well described in the literature.7 Thisexamination has been named focused abdom-inal sonography for trauma (FAST). This usual-ly includes sonography of the right upperquadrant, including the hepatorenal fossa(Figs. 1 and 2); the left upper quadrant, includ-ing the perisplenic region; the right and leftparacolic gutters (Fig. 3); and the pelvis, per-formed to detect free fluid. Free fluid will grav-itate to the most dependent portion of thepelvis (Figs. 4 and 5), and as such, free fluid inthe pelvis may be missed if the patient has anempty bladder.7 In some instances, an exami-nation of the epigastrium to check for freefluid, free air, or both is also performed.8 Othercomponents of the examination include anintercostal or subdiaphragmatic view of theheart. Examination of the chest is performed if,in fact, there has been chest as well as abdom-inal trauma; such an examination will be dis-cussed below.

Sensitivity of FAST

The sensitivity of the FAST scan has rangedfrom 63% to 100%.5,7,9–18 In almost all of thestudies, sonographic specificities remainedhigh, in the range of 90% or greater. In a criticalreview of a number of these studies5,9–18 report-ing high sensitivity for sonography, Pearl andTodd19 found flaws in the study design. Theseflaws included the following: no trial used acompletely blinded format; only 2 of the 11specified consecutive patient enrollment;training for those performing the examina-tions ranged from 2 hours to many years ofexperience; and, finally, there was no standardof reference with which sonographic resultscould be compared. For instance, Rothlin etal16 clearly stated that, “It has become accept-able in Europe to calculate sensitivities andspecificities for sonography concerning onlythe patient’s course.” A number of studies havenot included clinical outcome, instead com-paring sonography with CT, diagnostic peri-toneal lavage, or laparotomy; these have hadsensitivities in the range of 63% to 69%.7,18,20 Inanalysis of these series with lower sensitivities,there is no doubt of 2 facts: (1) we can improvesensitivity by learning from our previouserrors; and (2) the FAST scan will not detect allhollow- or solid-organ injuries.

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Figure 1. Image from a 56-year-old woman with a splenic laceration andfree fluid after a fall. Free fluid is shown in the right upper quadrant(RUQ) of the abdomen. This patient required splenectomy. C indicatesrenal 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 theabdomen shows a trace amount of free fluid in the hepatorenal fossa(arrow). No splenectomy was required.

Sonographic Pitfalls

There are a few pitfalls that occur with the FASTscan. First, without a full bladder, free fluid inthe pelvis will often be missed.7 In analyzing ouroriginal work, we had 14 false-negative findings,of which 6 were in cases in which free fluid wasidentified in the pelvis on CT but not shown onsonography. These patients were examined withan empty bladder, because a Foley catheter wasplaced before the sonography was performed.If, in fact, there were a full bladder, we wouldhave theoretically identified free fluid in thepelvis, which would have decreased our false-negative findings to a total of 8. This would haveincreased our sensitivity from 63% to 79%. It is

therefore imperative that we use a full-bladdertechnique to detect free fluid in the pelvis.

Second, there have been a number of articlesthat have pointed out that sonography can missimportant organ injury that will require surgeryin the patient with trauma.7,20,21–24 For instance,Dolich et al22 reported 43 patients with false-negative sonographic findings, of which 10(33%) required surgery. Shanmuganathan et al24

studied more than 11,000 patients with BAT byusing sonography and found that 467 hadabdominal organ injuries with CT or laparotomycorrelation. In 310 (66%) of these, there was freefluid detected on sonography. However, 157(34%) of the 467 patients had no sonographicallydetected free fluid; 26 of these 157 patients

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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, Otherfree fluid is shown in the right lower quadrant (RTLQ) of the abdomen (open arrow).

A B

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

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

without free fluid required further surgical orangiographic intervention. Shanmuganathan etal24 therefore thought that the FAST scan mayfrequently miss patients with surgically cor-rectable injuries. Most of these studies’ authorsadvocate the use of sonography as the initialscreening examination but think that CT shouldremain the definitive imaging modality, especial-ly for hemodynamically stable patients.21,24 Wehave found sonography to be very useful for thetriage of unstable patients with appreciable freefluid in the abdomen but would agree that CTstill should be used for those stable patients whohave undergone sonography and in whom thereis suggestion of an intra-abdominal injury (IAI).

Finally, there is little doubt that sonographywill be limited or unable to show certain typesof injuries. These are not restricted to butinclude spinal and pelvic fractures, diaphrag-matic ruptures,25 vascular injuries,24 pancreaticinjuries,26 adrenal injuries, and some bowel andmesenteric injuries (Fig. 6).27

Free Fluid Scoring Systems

An initial sonographic scoring system proposedby Jehle et al6 included a single view of theMorison pouch to check for free fluid. This was asimple all-or-none system for identification of ahypoechoic “stripe” between the liver andkidney. With this protocol, Jehle et al6 reported asensitivity of 81.8%. However, Branney et al28

reported that when 400 mL of saline was infusedin the abdomen during diagnostic peritoneallavage with the patient in the Trendelenburgposition, only 10% of patients had fluid identifiedin the Morison pouch. It took 1 L of saline toidentify fluid in the Morison pouch in 97% ofcases. This illustrates the possible limitations ofa single-view scoring system of the upperabdomen for detection of free fluid. It alsoemphasizes the importance of gravity in thedistribution of fluid into the pelvis and theneed for a good acoustic window (full bladder)when examining the pelvis.

To develop a scoring system, Huang et al13

infused saline during diagnostic peritoneallavage and then used sonography to detect freefluid. He based his criteria on locating pocketsof fluid with a thickness of 2 mm or greater.Each region or pocket of fluid 2 mm or greaterreceived a score of 1. Patients with 3 pockets,or a score of 3 or greater, were taken to theoperating room. Even with a score of less than3, 14 of 24 patients were taken to surgery.McKenney et al29 proposed a scoring system inwhich all vertical heights of fluid measured incentimeters in the abdomen were added. Ascore of greater than 3 was associated with anincreased need for surgical intervention. Thesubphrenic, subhepatic, and perisplenic areasand pelvis represented the 4 sites in which, iffluid were isolated, would most often result in aneed for surgery.

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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 ofthe right upper quadrant (RUQ) shows large amounts of free fluid in the hepatorenal fossa (open arrow). B, Computed tomography of the abdomenshows thickening of the small bowel (curved arrow) with free fluid noted in the abdomen (arrow). This patient had surgical repair of the small-bowellaceration.

A B

Sirlin et al30,31 published 2 articles describing ascoring system and location of fluid. For eachanatomic region in which fluid was detected, 1point was given. With a score of 0, 1.4% of thepatients had an IAI; with a score of 1, 59% had anIAI; with a score of 2, 85% had an IAI; and with ascore of 3, 83% had an IAI. With regard to surgi-cal 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% requiredsurgery; and with a score of 3, 63% requiredsurgery. Therefore, the higher the score, thehigher the rate of IAI and need for surgery.31 Thisgroup also found that hepatic injuries were like-ly to have associated free fluid in the right upperquadrant or the lower recesses, whereas forsplenic injuries, free fluid was identified in eitherthe right or left upper quadrant as well as therecesses.30 These scoring systems have a com-mon denominator; that is, an increase in theamount of free fluid in the abdomen or pelvisraises the likelihood of major IAI. When we per-form the examination at our institution, we ana-lyze the amount of fluid subjectively. If largepockets of fluid are noted throughout theabdomen, we will often send these patients tosurgery without confirmatory CT, especially ifthey are not hemodynamically stable.27

Serial Sonography

A few studies20,32 have shown that serialsonography performed as a part of the follow-up physical examination may be useful fordetecting free fluid in patients with BAT.Certainly, an examination after stabilization ofthe patient will allow the sonographer moretime for a comprehensive examination. Ifthere is active bleeding in the abdomen, theamount of fluid should increase with time andwould be more amenable to sonographicdetection. The value of serial sonography hasnot been fully investigated.

Solid-Organ Injuries

Most FAST examinations have focused ondetection of free fluid in the abdomen. Only afew have focused on the use of sonography todirectly detect parenchymal organ injuries.Rothlin et al16 reported sensitivity of 41.4% fordetection of organ injury by sonography.McGahan et al7 also showed sonographic detec-

tion of 41% of solid-organ injuries. However,most studies have not shown this high detec-tion rate. This is not a new topic in sonography.In 1983, vanSonnenberg et al33 injected bloodinto cadaver organs and also noted the appear-ance of blood in the liver after fine-needle aspi-ration biopsy. These hematomas appeared aslinear echogenic foci within the parenchymalorgans.

The FAST literature has paid little attentionto the appearance of solid organs. However,there is some limited work on this topic.Stengel et al34 showed that with the use of a7.5-MHz linear array probe, injuries weremuch more easily detected than with a 3.5-MHz convex probe. Much of this work on clas-sification of solid-organ injury has beenperformed by Richards, McGahan, and col-leagues.28,35–38 Although solid-organ injury isinfrequently identified, there are certain pat-terns that predominate when shown. A diffuseheterogeneous pattern is a predominant pat-tern shown in splenic lacerations (Figs. 7–9),whereas a discrete hyperechoic pattern isshown most often in hepatic lacerations(Figs. 10 and 11).35,36 It is of interest thatthis discrete hyperechoic pattern in theliver is very similar to the pattern origi-nally described by vanSonnenberg et al33 in1983. Also, in the spleen, subcapsularhematomas are shown as either hyperechoicor hypoechoic rims surrounding the splenicparenchyma (Figs. 12 and 13). Siniluoto and

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

associates39 showed that splenic lacerationsnot detected on initial sonography becomehypoechoic over a few days. In kidneys, moresevere injuries show a completely disorganizedpattern (Fig. 14). There is only limited experi-ence in identifying injuries to the pancreas,adrenal glands, and bowel on sonography.

The Chest

Sonography has been shown to be useful fordiagnosing pleural effusions (Fig. 15),40 pericar-dial effusions (Fig. 16),41,42 and pneumothoraces(Figs. 17 and 18).43,44 Pleural effusions are easilyidentified on sonography and can be seen as ahypoechoic or an anechoic stripe in the depen-dent portion of the thorax when the right or leftupper quadrant of the abdomen is examined. Itis possible to diagnose pneumothoraces on thebasis of sonography by noting the absence ofthe normal “sliding lung” sign and instead not-ing the “comet tail” that originates from thepneumothorax. The parietal pleura is fixed tothe ribs and muscles of the thorax, whereas thevisceral pleura is adherent to the lung. Slidinglung refers to the observation of the brightechogenic line of the visceral pleura, which isadherent to the lung, moving or sliding duringnormal inspiration and expiration. The comettail sign may be more correctly a reverberationartifact of closely spaced echoes that are identi-fied deep to a pneumothorax. Thus, in theregion of the pneumothorax, sliding of the vis-ceral pleura of the lung adjacent to the parietalpleura is not observed. Very high sensitivitieshave been reported for identification of pneu-mothorax by sonography.43,44

Many examiners incorporate the subcostalview of the heart as a portion of the FAST scan.This is useful in diagnosing a pericardial effu-sion. However, Blaivas et al42 pointed out the

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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 quad-rant (LUQ) of the abdomen shows a hypoechoic rim surrounding the spleen (arrows) and a heterogeneous appearance to the spleen. B, Computedtomography of the upper abdomen shows active extravasation of contrast (arrow) within the splenic bed. There was free fluid in the abdomen. Thispatient underwent a splenectomy.

A B

Figure 9. Image from a 35-year-old man with a splenic laceration after an assault.Sonography showed multiple mixed echogenic regions (open arrow) throughoutthe spleen. This patient required a splenectomy. Reprinted with permission fromRadiographics.38

potential pitfalls of overdiagnosing pericar-dial effusions. They set up a study in whichemergency medicine residents and fellowstrained in sonography had trouble discerningepicardial fat from effusions, and sonographyhad sensitivity of 73% and specificity of44%.40 Finally, cardiac tears or ruptures of theheart may be noted on sonography.45 Thus, inthe future, sonography will probably prove tobe a more useful tool in identifying abnor-malities in the chest with blunt and penetrat-ing trauma.

Summary

It is apparent that the use of sonography in theevaluation of patients with trauma has greatlyincreased over the last few years, and undoubt-edly there will be more widespread use ofsonography in the future. In the abdomen,sonography can show free fluid and, in somesituations, can identify solid-organ injuries. Ifappreciable free fluid is detected, this may, infact, indicate that patients should be sent forimmediate surgical intervention depending on

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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, Sonographyof the right upper quadrant (RUQ) of the abdomen shows a fairly well-demarcated echogenic region in the liver (arrow). B, Postoperative CT of theupper abdomen shows the corresponding hepatic laceration of the liver. Reprinted with permission from Radiographics.38

A B

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-demar-cated 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

A B

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

A

B C

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

Figure 12. Image from a 43-year-old man with an initial splenic lacera-tion after an assault. Sonography of the left upper quadrant (LUQ) of theabdomen shows a well-demarcated, echogenic subcapsular hematomaof the spleen (open arrow). This patient required a splenorrhaphy fol-lowed by a splenectomy. Reprinted with permission from Radio-graphics.38 LUQ indicates left upper quadrant.

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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 acutetrauma to the chest and abdomen.

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

Figure 17. Sonography of normal lung. A linear array transducer (A) anda sector transducer (B) show echogenic lines of the pleura (arrows). Withinspiration and expiration, the sliding lung can be identified on real-timesonography.

A

B

their clinical status. However, for patients inwhom no free fluid is identified, there remainsthe risk of an IAI.

The examiner must realize that certain abnor-malities may not be identified by sonographywithin the abdomen of a patient with acutetrauma. These limitations must be realized foreffective use of sonography as a screening tool.In the future, the use of sonography for patientswith chest trauma will also increase identifica-tion of pleural effusions and pneumothoraces.Sonography can also be used to diagnoseabnormalities of the heart, including pericardialeffusion and potential cardiac rupture.

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