A negative FAST does not reliably exclude intraperitoneal hemorrhage and should be repeated again as part of the secondary survey. Grade 5 instability with a negative FAST examination is an uncomfortable scenario. It is not prudent to triage this patient to the CT scanner, rather this patient should stay in the trauma resuscitation room and differential diagnosis of refractory shock should be pursued. If a missed source of hemorrhage is still a concern, despite a second negative FAST in an unstable patient, a diagnostic peritoneal aspirate should be considered. A viable alternative is to go directly to the OR in patients at risk of imminent cardiac arrest for exploratory laparotomy.