A POCUS stewardship framework for optimizing pediatric FAST in trauma: A conceptual model and evidence synthesis

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.

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.

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.

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.