What is appropriate medical imaging?

Having been in radiology a number of years, I know it can be difficult to decide what is the best study, if any, for each patient. Radiation? Cost? Wait time? Contrast or not? MRI vs CT scan?

The American College of Radiology teamed up with many specialist to create the Appropriateness Criteria. It has the goal of helping providers better choose which study is best for their patients.

There is terrific information in this project, however it can be intimidating to navigate.

I will summarize a few per week, with links to the source documentation, as a primer for my friends who are not necessarily radiologists.

Fellow providers, please leave comments and I will address them to the best of my ability. Patients please see below.

This is the entire Appropriateness Criteria:

http://www.acr.org/Quality-Safety/Appropriateness-Criteria

This is also accessible from here:

http://www.guideline.gov/search/search.aspx?term=acr+appropriateness



Radiologists in training may benefit from these posts as well as the ABR Core Exam asks specific question from the ACR AC.

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Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

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Tweeting some more good info here! @helpfulrads

Pulmonary hypertension?

Suspected pulmonary hypertension?

Summary

Suspected pulmonary hypertension =

Both echocardiography and right heart catheterization, next chest radiograph and CTA chest with contrast, if needed

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Acute pancreatitis? Ultrasound or CT? When?

#orderwhat #pancreatitis @AFPjournal @PCareProgress @AANP_NEWS @AAPAorg #choosingwisely

Imaging for acute pancreatitis

First time presentation, abdominal pain, and increased amylase and lipase with high clinical certainty of diagnosis; LESS THAN 48–72 hours after onset of symptoms; clinical score irrelevant; 

unknown cause  => US abdomen to assess for gall stones

Everything else, probably => CT abdomen with contrast, see below.  

Critically ill, systemic inflammatory response syndrome (SIRS), severe clinical scores (eg, acute physiology and chronic health evaluation [APACHE], bedside index of severity in acute pancreatitis score (BISAPS), and/or Marshall); GREATER THAN 48–72 hours after onset of symptoms. => CT abdomen with contrast

Continued SIRS, severe clinical scores, leukocytosis, and fever; >7–21 days after onset of symptoms. => CT abdomen with contrast

Initial presentation with atypical signs and symptoms, including equivocal amylase and lipase values (possibly confounded by AKI or chronic kidney disease) and when diagnoses other than pancreatitis may be possible (bowel perforation, bowel ischemia, etc). => CT abdomen with contrast

Known necrotizing pancreatic and peripancreatic pancreatitis, significant deterioration in clinical status, including abrupt decrease in hemoglobin/hematocrit, hypotension, tachycardia, tachypnea, abrupt change in fever curve, or increase in white blood cells; time
after symptom onset irrelevant. => CT abdomen with contrast

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Foot trauma? Foreign body? X-ray needed?

Acute foot trauma? - #orderwhat #footpain @AFPjournal @PCareProgress @AANP_NEWS @AAPAorg

Meet Ottawa Rules or not neurologically intact  => Xray

Concern for Lisfranc injury => Weight bearing Xray, if able or MRI foot

Does not meet Ottawa Rules => No study indicated

X-rays negative and concern for tendon injury or dislocation => MRI foot

Penetrating trauma and concern for foreign body => X-ray, then US if needed 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Pyelonephritis?

Acute pyelonephritis?

Uncomplicated patient = no imaging indicated

Complicated patient such as: diabetes, immunocompromised, prior renal surgery, prior stones or not responding to therapy = CT abdomen with, and possibly without, contrast (e.g. if history of stone), possibly renal ultrasound or MRI abdomen with contrast 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Knee Trauma

Acute knee trauma? - #orderwhat #kneepain @AFPjournal @PCareProgress @AANP_NEWS @AAPAorg

Acute knee trauma, fall or twisting injury with:

No focal tenderness or effusion and able to walk => no study indicated

Focal tenderness, effusion or unable to walk => X-ray then MRI if needed.

Suspect tibial plateau fracture on xray => CT knee

Suspect posterior dislocation => X-ray and MRI and possibly angiography. 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Ankle Trauma?

Suspect Ankle Fracture

Summary:

Ankle radiograph if patient meets Ottawa Rules: 

Can’t bear weight immediately after injury 

OR 

Point tenderness over medial malleolus, posteroinferior lateral malleolus, talus or calcaneus 

OR 

Cannot walk 4 steps in emergency department



If one of these describes the patient, an ankle radiograph is appropriate.

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon