AFAST views, when performed properly, should look nearly the same independent of positioning.
Dorsal recumbency should never be used for AFAST (TFAST and Vet BLUE) for several reasons but most importantly because of increasing patient risk (Figure 6.5). A hemodynamically fragile patient placed in dorsal recumbency undergoes significant negative changes in ventilation and circulation, specifically venous return. Add to these respiratory and cardiovascular stresses and the increased oxygen demand in a struggling, anxious patient, and the patient risks acute and potentially catastrophic decompensation. Considering trauma, most dogs and cats have concurrent lung contusions and other thoracic‐related injuries (Powell et al. 1999; Sigrist et al. 2011; Lisciandro et al. 2008) and intraabdominal bleeding (Boysen et al. 2004; Lisciandro et al. 2009). Considering nontrauma, many hypotensive triaged patients have pleural and/or pericardial effusion, and intracavitary bleeds often accompanied by anemia (McMurray et al. 2016; Lisciandro 2016a,b). Moreover, the AFS system is not validated in dorsal recumbency and only subjective terms of mild, moderate, and severe can be used (Stander et al. 2010; Sutherland‐Smith et al. 2006). For clinicians who prefer performing complete detailed abdominal ultrasound in dorsal recumbency, perform a Global FAST first before moving the patient to the restraint of dorsal recumbency to best ensure patient safety.
Figure 6.4. Modified lateral‐sternal recumbency. The AFAST views are performed in the same order every time as follows: DH to SR to CC to HRU to HR5th bonus view. The final HR5th bonus view is not part of the abdominal fluid score.DH, diaphragmatico‐hepatic view; SR, spleno‐renal view; CC, cysto‐colic view; HRU, hepato‐renal umbilical view; HR5th, hepato‐renal 5th bonus view. Note that the images should look identical for each AFAST view regardless of positioning (including standing/sternal, modified sternal). AFAST views are nearly identical no matter the positioning because the respective target organs are imaged with the same methodology.
Source: Reproduced with permission of Dr Gregory Lisciandro, Hill Country Veterinary Specialists and FASTVet.com, Spicewood, TX.
Naming and Order of the AFAST Views
The AFAST sites in the preferred positioning of right lateral recumbency (over left) are named according to target organs at each acoustic window and performed in clockwise order as follows: (1) DH view, (2) SR view, (3) CC view, and (4) HR umbilical (HRU) view that completes the AFAST examination and is a favorable site for abdominocentesis, being most gravity dependent (Lisciandro et al. 2009; Lisciandro 2011; Boysen and Lisciandro 2013; McMurray et al. 2016). AFAST views are shown translated onto an abdominal radiograph and CT study in Figure 6.6. The final view is the HR5th bonus view to image the right kidney and nearby liver that is not part of the AFS; the HR5th bonus view is generally performed as the final view after AFAST, TFAST, and Vet BLUE have been completed.
In LL recumbency the order is as follows: (1) DH view, (2) HR view, (3) CC view, and (4) the SR umbilical (SRU) view that completes the AFAST examination and is a favorable site for abdominocentesis, being most gravity dependent (see Figure 6.3). Positioning of the cat is shown in Chapter 39. The final view is the SR5th bonus view to image the left kidney and spleen and is not part of the AFS; the SR5th bonus view is generally performed as the final view after AFAST, TFAST, and Vet BLUE have been completed (Lisciandro et al. 2009; Lisciandro 2011; Boysen and Lisciandro 2013; McMurray et al. 2016).
In summary, the four primary AFAST views are part of the AFS system. The AFAST 5th bonus view (HR5th and SR5th views depending on which lateral recumbency is being used) is not part of the AFAST AFS system, but important for acquiring information for that respective retroperitoneal space and any obvious soft tissue or parenchymal abnormalities of the kidney and its adjacent liver and spleen dependent on positioning. In cats and smaller dogs when using enough depth, both kidneys are often seen through the SR (or HR) view (Lisciandro et al. 2009; Lisciandro 2011, 2012, 2014a; McMurray et al. 2016) (see Figure 6.21).
Pearl: By imaging using the AFAST target organ approach, sonographic anatomy is better recognized, and the sonographer is building POCUS skills on every AFAST exam, with the only pressure being the recognition of free fluid.
Probe Maneuvering is Standardized
All AFAST acoustic views are imaged in longitudinal (sagittal) orientation with the marker of the probe always directed toward the head of the patient; with muscle memory, most sonographers quickly learn this repetitive probe motion. In longitudinal (sagittal) orientation target organs are more recognizable than in transverse orientation, especially for the nonradiologist sonographer (Figure 6.7). The single longitudinal (sagittal) orientation is supported by the original veterinary FAST study in which when longitudinal (sagittal) and transverse orientation were compared, they matched in 397 out of 400 views (Boysen et al. 2004). In time, rotating the probe to transverse orientation may be considered as part of each AFAST view as an add‐on skill but is unnecessary.
Figure 6.5. Never use dorsal recumbency without doing a Global FAST to assess stability. The use of dorsal recumbency on a hemodynamically fragile or unstable patient is potentially catastrophic. In (A) the computed tomography (CT) of a cross‐section of the thorax and abdomen is is compared to (B) in dorsal recumbency. Ventilation is changed from (A) to (B) by moving the most aerated, least perfused, least gravity‐dependent lung fields to a ventral and gravity‐dependent location. Moreover, the weight of the abdominal organs against the diaphragm further adversely affects ventilation. Venous return to the heart is also markedly changed from (A) to (B) in which the CVC (blue circle) next to the aorta (red circle) becomes compressed in dorsal recumbency from the weight of the abdominal organs. In hemodynamically fragile patients, there is real risk for decompensation.
Source: Reproduced with permission of Dr Gregory Lisciandro, Hill Country Veterinary Specialists and FASTVet.com, Spicewood, TX.
Every AFAST view is a “fan, rock cranially, and return to your starting position” of the probe by fanning through the target organ, rocking cranially, and then returning to your starting point (see Figures 6.2, 6.3, and 6.4).
DH view: Fan through the gallbladder in both directions until the gallbladder disappears in both directions, and then rock cranially to image the “cardiac bump” before returning to your starting point for one final look within the abdominal cavity.
SR view: Fan through the left kidney in both directions until the left kidney disappears in both directions, and then rock cranially to image the head of the spleen (fan on it too) before returning to your starting point of the left kidney for one final look. The kidney is retroperitoneal and the
