Imaging Pathways in Pediatric Thoracic Trauma: FAST-First Triage and Selective CT Escalation in Clinical Practice.

Background/Objectives: Pediatric thoracic trauma requires prompt stabilization and timely imaging; however, actual sequencing and escalation triggers are infrequently delineated at the pathway level. The aim of this study was to analyze imaging pathways observed in routine clinical practice at our institution and to outline a preliminary escalation framework integrating injury mechanism, clinical severity, and initial ultrasound findings. Methods: A retrospective cohort study was conducted at the "Louis Țurcanu" Clinical Emergency Hospital for Children, Timișoara, Romania, including 66 children admitted with primary thoracic trauma between January 2022 and December 2024. Clinical trajectory markers (transfer-in, ICU admission, length of stay) and imaging utilization/sequencing (FAST, CXR, CT, MRI/CTA) were extracted. We divided injuries into two groups: bony (like fractures of the clavicle or scapula) and non-bony. CT escalation was characterized as a chest CT conducted upon admission. Fisher's exact and Mann-Whitney U tests were used for comparative analyses. Results: FAST was done on all patients but was infrequently positive. Imaging followed heterogeneous but structured patterns, most commonly FAST with CXR, with or without CT. A large group of them had CT scans without first having any X-rays. CT escalation was associated with fracture-pattern injuries and higher-acuity trajectories (transfer-in and ICU admission), as well as prolonged hospital stays. Pathway-level assessment demonstrated that CT escalation effectively captured bony injury patterns, whereas FAST proficiently sorted ICU-level trajectories. Conclusions: Pediatric thoracic trauma imaging functioned as a selective escalation system: FAST served as a universal bedside entry step, and CT operated as an injury pattern- and acuity-linked severity gate. Making this escalation logic clear may help with standardization while still protecting against radiation.