in both dogs and cats.Figure 6.6. Correlation of AFAST acoustic windows with a dog in right lateral recumbency to an abdominal radiograph and CT. Sites are named by their target organs. In (A) the AFAST acoustic windows are labeled and correlate in (B) to a radiograph and (C) to computed tomography. The AFAST order is always the same: DH to SR to CC to HRU view. Note that the head is always to the left and tail to the right in both ultrasound and radiography. Computed tomography and radiograph courtesy of Dr Daniel Rodriguez, VETTEM, and Dr Jesús Paredes, CVM, Mexico City, Mexico.Source: Reproduced with permission of Dr Gregory Lisciandro, Hill Country Veterinary Specialists and FASTVet.com, Spicewood, TX.Figure 6.7. Longitudinal orientation for AFAST. (A) Kidney in longitudinal orientation, standard for all the AFAST views, because organs are more readily apparent in longitudinal over transverse scanning planes for most nonradiologist sonographers. (B) The same kidney as in (A) but in transverse orientation. The author keeps it simple – “fan (longitudinal planes), rock (direct the scanning plane cranial) and return to your starting point” is the AFAST mantra. Transverse orientation should be considered as an add‐on AFAST skill but is unnecessary for the detection of free intraabdominal fluid (Boysen et al. 2004). Computed tomography courtesy of Dr Daniel Rodriguez, VETTEM, Mexico City, Mexico.Source: Reproduced with permission of Dr Gregory Lisciandro, Hill Country Veterinary Specialists and FASTVet.com, Spicewood, TX.
CC view: Fan through the urinary bladder in both directions until the bladder disappears in both directions, and then rock cranially to image the “CC pouch”, its most gravity‐dependent region, and back to your starting point for one final look.
HRU view (right lateral recumbency): Fan through the small bowel and spleen in both directions and then rock cranially to image the cranial abdominal region before returning to the “HRU pouch”, its most gravity‐dependent region, for one final look. The left kidney may be viewed with increased depth through a single HR view, especially in cats and smaller dogs (Lisciandro 2014a; McMurray et al. 2016).
SRU view (left lateral recumbency): Fan through the small bowel and spleen in both directions and then rock cranially to image the cranial abdominal region before returning to the “SRU pouch”, its most gravity‐dependent region, for one final look. The right kidney may be viewed with increased depth through a single SR view, especially in cats and smaller dogs (Lisciandro 2014a).
HR5th bonus view (right lateral recumbency): Fan through the right kidney in both directions until the right kidney disappears in both directions and then rock cranially to image the right liver lobes before returning to your starting point of the right kidney for one final look. This view is generally unnecessary if the right kidney is imaged through the SR view.
SR5th bonus view (left lateral recumbency): Fan through the left kidney in both directions until the left kidney disappears in both directions and then rock cranially to image the spleen before returning to your starting point of the left kidney for one final look. This view is generally unnecessary if the left kidney is imaged through the HR view.
Pearl: For both those learning AFAST and experienced AFAST sonographers, only longitudinal (sagittal) orientation is necessary for the detection of free fluid at each view, with this standardization accelerating the learning process by building consistent sonographic expectations of the AFAST target organs. In time, transverse orientation may become an add‐on skill but it is unnecessary.
AFAST Diaphragmatico‐Hepatic View
| Questions Asked at the DH View | |
| Is there any free fluid in the abdominal (peritoneal) cavity? | Yes or no |
| How much free fluid is at the DH view using the AFAST AFS system? | 0, 1/2, 1 |
| Is there any pericardial effusion?Subjective amount? | Yes or noSmall (<1 cm), moderate (1–2 cm), large (>2 cm) (Candotti and Arntfield 2015)a Must be placed into clinical context |
| Is there any pleural effusion?Subjective amount? | Yes or noTrivial, mild, moderate, severe |
| What does the pulmonary‐diaphragmatic surface look like?Are there any lung lesions along the diaphragm? | Unremarkable (dry lung) or abnormalB‐lines and Vet BLUE B‐line scoring, shred sign, tissue sign, nodule sign, wedge sign |
| What does the gallbladder look like? | Unremarkable, halo sign (sonographic striation), abnormalities in its lumen or wall |
| What does the liver look like? | Unremarkable or abnormal |
| What do the caudal vena cava and its associated hepatic veins look like? | Unremarkable (bounce) or abnormal (FAT, flat): Tables 7.6 and 36.3 and Figures 36.8 and 36.9 |
| Could I be mistaking an artifact or pitfall for pathology? | Know pitfalls and artifacts |
a The AFAST target organ approach for parenchymal abnormalities is binary using “unremarkable” or “abnormal” to capture the case for additional imaging and confirmatory testing. Over time, more interpretative skills may be gained through experience and accompanied by additional POCUS study and training.
Source: Reproduced with permission of Dr Gregory Lisciandro, Hill Country Veterinary Specialists and FASTVet.com, Spicewood, Texas.
The classic AFAST DH view is in fact part of AFAST, TFAST, and Vet BLUE because it provides a huge amount of clinical information, including structures within both the peritoneal and pleural cavities.
The DH view begins with longitudinal placement of the probe with the probe marker towards the patient's head immediately caudal to the xiphoid process.
Figure 6.8. The DH view in a dog. In (A) is shown where the probe is placed immediately caudal to the xiphoid (top image) and directed cranial (arrow) in middle and bottom images with overlay of heart, diaphragm (curved white line), gallbladder (black oval), CVC (black rectangle with white line as near wall and longer white line as far wall). In (B) inverted correlating lateral thoracic radiographs in the top image, unlabeled, the middle image having arrows for direction of the ultrasound beam (scanning plane), white circle for probe placement, and bottom image with overlay of structures including the gallbladder, diaphragm, CVC, including A‐lines beyond its far wall through the far‐field from aerated (dry) lung, and the heart with ventricles as triangles and atria as circles. In (C) is CT for another correlation of the anatomy of the DH View. (D) and (E) are unlabeled and labeled ultrasound images of the DH view's anatomical features. Note the consistency of where the diaphragm is located in each of the ultrasound images. CVC, caudal vena cava; DIA, diaphragm; GB, gallbladder; Hrt, heart; HVD, hepatic venous distension; LIV, liver. Computed tomography courtesy of Dr Daniel Rodriguez, VETTEM, and Dr Jesús Paredes, CVM, Mexico City, Mexico.
Source: Reproduced with permission of Dr Gregory Lisciandro, Hill Country Veterinary Specialists and FASTVet.com, Spicewood, TX.
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