Utilization of the FAST Exam in the PACU to Diagnose Critical Postoperative Hemorrhage

Introduction: The FAST (Focused Assessment with Sonography in Trauma) exam is designed to detect critical bleeding or free fluid in patients according to Advanced Trauma Life Support guidelines. The FAST exam is underused perioperatively, yet studies show it enables early detection of life-threatening complications with 85–96% sensitivity and nearly 100% specificity. Our case demonstrates use of the FAST exam in identifying postoperative bleeding in a patient who underwent complex pelvic surgery for resection of a mass.


Description: A 62-year-old female presented for an exploratory laparotomy and pelvic mass resection after an inconclusive biopsy. The tumor was attached to the external iliac vein and pelvic sidewall, thus the external iliac vein was ligated and tumor resected uneventfully. The patient was extubated at end of the procedure and transferred to the PACU where she complained of severe right leg pain with absent pedal pulses suggestive of Phlegmasia Cerulea Dolens. The patient emergently returned to OR for a right femoral-to-external iliac vein bypass using left saphenous vein and was subsequently started on a heparin drip. She was extubated and transferred to PACU where she became progressively hypotensive despite resuscitative measures. A FAST showed hemoperitoneum, thus Massive Transfusion Protocol was activated, and patient returned to OR for an exploratory laparotomy to successfully repair a pulsatile branch of the right femoral artery. She was kept intubated and transferred to the ICU, where she was extubated and discharged home on postop day 5.


Discussion: This case highlights utility of the FAST exam for perioperative patients who have undifferentiated hypotensive shock. While CTA is recommended for diagnosing intraabdominal bleeding, unstable patients may not tolerate transport, thus a FAST exam offers a bedside alternative for initial assessment or monitoring in the PACU, though further evaluation may be needed. The Indication, Acquisition, Interpretation, and Medical Decision-Making (I-AIM) framework has been used as a valuable teaching tool and diagnostic approach for the perioperative FAST exam. In conclusion, the FAST exam should be considered as an early diagnostic tool for hemodynamically unstable patients in the perioperative setting.