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Focused Assessment with Sonography for Trauma FAST Exam: Image Acquisition
Published on: September 22, 2023
A POCUS stewardship framework for optimizing pediatric FAST in trauma: A conceptual model and evidence synthesis
Kristofer Montoya1, Rebecca Weinstein2, Sigmund Kharasch3
1Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, USA; Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Insights
Point-of-care ultrasound (POCUS) stewardship can enhance the diagnostic utility of the FAST exam in pediatric trauma. This framework optimizes FAST-P use by aligning it with clinical context, improving accuracy and reducing unnecessary CT scans.
Area of Science:
- Emergency Medicine
- Pediatric Surgery
- Radiology
Background:
- The Focused Assessment with Sonography in Trauma (FAST) exam's role in pediatric blunt abdominal trauma is uncertain due to variable accuracy.
- Point-of-care ultrasound (POCUS) stewardship offers a framework to potentially optimize FAST in children (FAST-P).
Purpose of the Study:
- To evaluate how POCUS stewardship principles can improve FAST-P diagnostic performance and utility in pediatric blunt abdominal trauma.
- To assess the impact of integrating clinical context (indication, pre-test probability, patient stability, injury severity) into FAST-P.
Main Methods:
- Developed a conceptual POCUS stewardship framework based on established principles.
- Synthesized literature on FAST-P in pediatric blunt trauma (2000-2025).
- Analyzed diagnostic performance and CT utilization based on four framework components: clinical indication, pre-test probability, hemodynamic status, and injury severity.
Main Results:
- POCUS stewardship enhances FAST-P value by aligning use with clinical context.
- Intervention likelihood increased significantly with higher pre-test probability (0.4% to 41.4%).
- FAST-P performed best in unstable patients (sensitivity 78.6%) and with large fluid volumes (sensitivity 89%).
- Combined approaches improved accuracy (up to 96.9% sensitivity).
- FAST-P reduced CT rates across risk groups.
Conclusions:
- Integrating POCUS stewardship may improve FAST-P diagnostic utility in pediatric trauma.
- This framework aligns FAST-P use with clinical risk, potentially reducing unnecessary imaging.
- Prospective validation is needed, but the framework offers a structured approach to optimize FAST-P.
Objective:
The Focused Assessment with Sonography in Trauma (FAST) exam is widely used in adult trauma, but its role in pediatric blunt abdominal trauma remains uncertain due to variability in diagnostic accuracy. Point-of-care ultrasound (POCUS) stewardship offers a framework to potentially optimize pediatric FAST (FAST-P) by integrating clinical context, such as indication, pre-test probability, patient stability, and injury severity. This study evaluates how applying POCUS stewardship principles may potentially improve FAST-P diagnostic performance and utility in children.
Methods:
We developed a conceptual POCUS stewardship framework based on established stewardship principles, then synthesized current literature to support and refine the model. Studies on FAST-P in pediatric blunt trauma published from January 2000 through December 2025 were reviewed, focusing on four framework components: clinical indication, pre-test probability, hemodynamic status, and injury severity with free fluid volume. Diagnostic performance and CT utilization were analyzed when available.
Results:
POCUS stewardship provides a framework that may enhance diagnostic value by aligning FAST-P use with clinical context. Intervention likelihood rose from 0.4% in children with <1% pre-test probability to 41.4% in those with >50%, supporting the importance of proper indication and risk assessment. FAST-P performed best in unstable patients (sensitivity 78.6%, specificity up to 100%), and less effectively in stable ones (sensitivity 50-64%, specificity 83-95%). Adding physical exam findings and risk stratification improved accuracy, with combined approaches achieving up to 96.9% sensitivity and 98.6% negative predictive value. Sensitivity and specificity were highest with large fluid volumes (89%, 99%). FAST-P reduced CT rates from 22.5% to 18.6% in <1% risk patients, and from 92.3% to 78.9% in 6-10% risk.
Conclusions:
Integrating POCUS stewardship may potentially improve FAST-P diagnostic utility in pediatric trauma by aligning its use with clinical risk and reducing unnecessary imaging. This conceptual framework requires prospective validation but offers a structured approach to optimizing FAST-P application in clinical practice.
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