The extended Focused Assessment with Sonography in Trauma asks one thing fast: is there free fluid or air where there shouldn't be? Four windows for blood in the abdomen and pericardium, plus the lungs for pneumothorax and hemothorax.
In the hypotensive trauma patient, a positive eFAST is a ticket to the OR — not to the CT scanner.
Curated from the POCUS 101 FAST / eFAST Ultrasound Exam Made Easy: Step-By-Step Guide. Their labeled images of each window and positive scans are the fastest way to calibrate what free fluid looks like.
Abdominal preset for the fluid windows; switch to a linear probe (or high-frequency) for the anterior thoracic pneumothorax views.
Free fluid pools in the most dependent spaces of a supine patient. Trendelenburg increases sensitivity for small volumes if the situation allows.
Blood is anechoic (black) and collects in potential spaces that are normally closed — a black line where two organs meet.
Mid-axillary line, ~8th–11th ribs · indicator cephalad · liver as the window
The hepatorenal recess (Morrison's pouch) between the liver and right kidney is the most dependent space in the supine trauma patient and the single most sensitive window. Fan through the whole interface, and don't stop there — also check the subphrenic space (above the liver) and the caudal liver tip.
Posterior axillary line, higher and more posterior than you expect · "knuckles to the bed"
The LUQ view is higher, deeper, and further back than the RUQ. Unlike the RUQ, fluid collects above the spleen (subphrenic) first, because the splenorenal ligament tethers the spleen to the kidney — so look in the subphrenic space and the splenorenal recess.
Just above the pubic symphysis, sagittal and transverse · bladder as the window
Fan through the retrovesical space (behind the bladder) and, in women, the rectouterine pouch (of Douglas). A full bladder improves the window; fan fully left and right along the bladder's lateral borders.
Flat under the costal arch, indicator to the patient's left · liver as the window
Look for an anechoic stripe within the pericardium and for signs of tamponade (RV diastolic collapse). If the subxiphoid window fails — common in trauma with abdominal tenderness — substitute a parasternal or apical cardiac view.
Anterior chest for pneumothorax · posterolateral bases for hemothorax
Over the anterior chest, absent lung sliding raises pneumothorax, confirmed by a lung point (see Lung, No. 011). At the posterolateral bases, look for anechoic fluid above the diaphragm and the spine sign — hemothorax.
| Window | Positive finding | Means |
|---|---|---|
| RUQ | Anechoic stripe in Morrison's pouch / subphrenic / liver tip | Free intraperitoneal fluid — most sensitive window |
| LUQ | Fluid above the spleen or in the splenorenal recess | Free intraperitoneal fluid; check subphrenic first |
| Suprapubic | Fluid retrovesical or in the pouch of Douglas | Free pelvic fluid (trace can be physiologic in women) |
| Subxiphoid | Pericardial stripe ± RV diastolic collapse | Pericardial effusion / tamponade |
| Anterior thorax | Absent sliding + lung point | Pneumothorax |
| Thoracic base | Anechoic fluid above the diaphragm, spine sign | Hemothorax |
Bottom line: positive FAST + hemodynamically unstable = laparotomy. Positive FAST + stable = CT. Negative FAST never rules out injury — repeat it and correlate.
It's the most sensitive window for free fluid and often positive first. In a crashing trauma patient with limited time, the RUQ and subxiphoid views give the most decision-changing information fastest.
The classic miss: the LUQ window is higher and more posterior than the RUQ, and fluid pools above the spleen, not below it. Put your knuckles on the bed and aim through the flank.
Early or slow bleeding can produce a negative FAST that turns positive minutes later. Serial exams and a low threshold for CT (in the stable patient) catch what the first scan missed.
A hypoechoic band of perinephric fat can fake a positive Morrison's. True free fluid is sharply anechoic and tracks into recesses; fat is more uniform and symmetric — compare sides.
Ascites, a ruptured cyst, urine, and prior peritoneal fluid all look identical to hemoperitoneum. The scan finds fluid; the clinical picture names it.
Penetrating "box" wounds kill through tamponade. The subxiphoid view is part of the exam, not an optional extra — and a parasternal view rescues it when the belly is too tender.
A starting template for a POCUS procedure note. Fields in blue are wildcards to complete. Build it as a SmartPhrase, then edit every field to match the actual study.
POINT-OF-CARE ULTRASOUND: eFAST EXAM
Indication: [***] blunt/penetrating trauma, hypotension
Exam type: Focused / limited, bedside
Operator: @ME@ Interpretation: independent, real-time
Probe: curvilinear (abdominal) and linear (thoracic)
Consent: emergent, not obtained / [***]
VIEWS AND FINDINGS
- RUQ (hepatorenal / Morrison's pouch, subphrenic, liver tip):
{no free fluid : free fluid present [***]}
- LUQ (perisplenic / subphrenic, splenorenal):
{no free fluid : free fluid present [***]}
- Suprapubic (retrovesical / pelvis, sagittal + transverse):
{no free fluid : free fluid present [***]}
- Subxiphoid / cardiac (pericardium):
{no effusion : effusion, no tamponade physiology : effusion with RV diastolic collapse}
- Right anterior thorax: lung sliding {present : absent, lung point seen}
- Left anterior thorax: lung sliding {present : absent, lung point seen}
- Thoracic bases: {no fluid above diaphragm : hemothorax present [side ***]}
IMAGE QUALITY: adequate / limited by [***]
Images saved and archived to [PACS / Qpath / ***].
IMPRESSION: {Negative eFAST : Positive eFAST for [***]}.
Findings correlated with clinical picture; [***] plan.
I personally performed and interpreted this study in real time.
Electronically signed: @ME@ @TD@ @NOW@
Sample template only — not a validated institutional SmartPhrase. Verify wording, image-archival, and attestation requirements against your department's POCUS credentialing, coding, and compliance policies before clinical use. Documentation supports, but does not replace, the medical record and QA workflow.