Page 75 - JSOM Spring 2026

Contrast-Enhanced Focused Assessment
with Sonography for Trauma (cFAST) Far Forward

Contrast Visualization Methods Testing of
Six Field-Portable and Handheld Ultrasound Systems

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Maya Alexandri, JD, MD *; Christopher A. Mitchell, MD, RDMS ; David Korb, PA-C ;
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Eric J. Fellin, MD ; Chelsea E. Ausman, MD, RDMS ; Dan Brillhart, MD, RDMS 6

ABSTRACT
Introduction: The focused assessment with sonography in Introduction
trauma (FAST) is the most important ultrasound exam in
the operational environment, yet its sensitivity for diagno- The focused assessment with sonography in trauma (FAST)
sis of solid organ injury is limited. Contrast-enhanced FAST is the most important ultrasound exam in Combat Casualty
(cFAST) augments the diagnostic power of the FAST exam of Care. The Joint Trauma System Clinical Practice Guidelines
parenchymal and vascular injuries, and it rivals CT. Studies on both blunt abdominal trauma and prolonged casualty care
on cFAST have not used handheld ultrasound systems found call for the use of the FAST exam to support decisions about
1,2
in the combat environment. Methods: As part of a methods- medical evacuation and surgery. The forward clinician, be it
design process for a cFAST study, the authors tested six hand- physician, physician assistant, nurse practitioner, or medic, can
held and portable ultrasound systems for their ability to vi- be trained and maintain proficiency in performing the FAST
sualize contrast enhancement: Philips Lumify, Butterfly IQ3, exam. The clinician is expected to use the FAST exam to help
GE Vscan Air, Fujifilm Sonosite Edge II, Fujifilm Sonosite determine prioritization of patient movement in a contested
M-Turbo, and GE Venue (cart-based comparator). None had environment, even allowing that this function is not the origi-
dedicated “contrast” settings. Device settings were adjusted to nal purpose of the exam.
minimize gain and maintain a mechanical index below 0.3.
Three standardized patients received 0.02mL to 0.11mL in- Despite its critical role, the FAST exam has limitations. Its
travenous boluses of perflutren (Definity) followed by a 10mL sensitivity is suboptimal, especially among novice users of
3–7
saline flush. The right upper quadrant was scanned to assess point-of-care ultrasound. With respect to abdominal inju-
contrast visualization in the kidney. Results: Contrast en- ries, the strength of the exam is the identification of hemoperi-
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hancement was visualized on only one handheld device (GE toneum. Solid organ injuries, however, can present without
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Vscan Air) and the GE Venue (cart-based comparator). No hemoperitoneum, and the FAST exam does not identify in-
9,12,13
enhancement was seen with the others. Conclusions: Most traparenchymal injury well. FAST likewise poorly detects
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handheld and portable ultrasound systems currently used in active hemorrhage.
deployed medical settings failed to visualize contrast. While
the GE Vscan Air shows promise, further investigation is nec- Contrast-enhanced FAST (cFAST) augments the diagnostic
essary to determine whether system modifications, software power of the FAST exam, enabling visualization of solid organ
upgrades, or dosing adjustments can enable cFAST capabil- and vascular injuries (including active bleeding and contained
ity in the far-forward environment. Reliable handheld-based vascular injuries), evaluation and diagnosis of pancreatic in-
cFAST methods will advance research and implementation of jury, as well as identification of free intraperitoneal and peri-
9,14–17
this technology in military trauma care. cardial fluid. Using cFAST, visualization and grading of
solid organ injuries, as well as defining capsular extension and
vascular injuries, rivals the accuracy of multidetector CT. 9,13–15
Keywords: POCUS; point-of-care ultrasound; cFAST; contrast-
enhanced ultrasound; CEUS; blunt abdominal trauma; Moreover, a recent systematic review and meta-analysis found
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handheld; cart-based portable; perflutren; far forward; the overall sensitivity of cFAST to be 93%, a number that
military; deployed; austere; combat environment approaches acceptable levels for ruling out intrabdominal
injury. This same study found the overall sensitivity of non-
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contrasted FAST to be 56%.
*Correspondence to Department of Emergency Medicine, Carl R. Darnall Army Medical Center, 36065 Santa Fe Ave, Fort Hood, TX 76544 or
maya.alexandri.mil@army.mil
1 CPT Maya Alexandri is an Advanced Emergency Medicine Ultrasound Fellow, Department of Emergency Medicine, Carl R. Darnall Army Med-
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ical Center, Fort Hood, TX. COL Christopher A. Mitchell is the residency director, Department of Emergency Medicine, Carl R. Darnall Army
Medical Center, Fort Hood, TX. MAJ David Korb is an Advanced Emergency Medicine Ultrasound Fellow, Department of Emergency Medicine,
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Carl R. Darnall Army Medical Center, Fort Hood, TX. CPT Eric J. Fellin is affiliated with the Department of Emergency Medicine, Carl R.
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Darnall Army Medical Center, Fort Hood, TX. MAJ Chelsea E. Ausman is affiliated with the 67th Forward Resuscitative Surgical Detachment,
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Rhine Ordnance Barracks, Rhineland-Palatinate, Germany. LTC Dan Brillhart is the Advanced Emergency Medicine Ultrasound Fellowship
Director, Department of Emergency Medicine, Carl R. Darnall Army Medical Center, Fort Hood, TX.
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