Radiate Positivity – ACEP Policy on Advanced Imaging in Pediatrics

September 26, 2024

Written by Joshua Belfer

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Advanced imaging, including ultrasound, MRI, and CT, is an important tool for diagnosing children in the emergency department. This policy statement provides guidance to help clinicians optimize the use of these diagnostic tools.

A picture is worth a thousand words…and sometimes a bit of radiation
Advances in diagnostic imaging have improved care in the pediatric ED, but imaging always carries risks, including radiation exposure, false-positive or incidental findings, increased ED lengths of stay, and potential need for transport away from the ED. WIth consideration of these risks, here are some of the highlights from the policy statement:

General Recommendations

1.  EDs should evaluate their pediatric readiness, including ability to both securely transmit images to receiving hospitals and to consult a pediatric radiologist.
2. Both general ED clinicians and primary care physicians who refer patients to the ED should familiarize themselves with pediatric imaging resources available at local EDs, using shared decision-making with families to determine where the best location to obtain imaging might be.

Condition-specific Imaging Recommendations

1. Seizures: Emergent neuroimaging is not recommended for simple or complex febrile seizures if the patient has a normal neurologic exam and returns to baseline.
2. VP Shunt Evaluation: Neuroimaging to evaluate for shunt malfunction is optimal when it can be compared to prior imaging; in the right setting, it might be appropriate to defer imaging until the patient is transferred to a center where definitive treatment can be delivered.
3. Stroke: Rapid MRI stroke protocols may be used to overcome challenges associated with traditional protocols in pediatric patients.
4. Trauma: While advanced imaging should be obtained if it allows the patient to be discharged from the ED or remain at the initial ED, it is best for trauma patients who have indications for transfer to a pediatric trauma center to not undergo advanced imaging at the referring center unless done in consultation with a receiving pediatric trauma center.
5. Trauma: Routine whole-body CT (i.e. “pan scan”) should not be performed in pediatric trauma patients.

How will this change my practice?
I think one of the most important aspects of this policy statement is the importance of collaboration between referring and receiving hospitals, and between primary care physicians and the ER. The old adage “Just because we can do something doesn’t mean we should” rings true here; thinking about where the patient will receive definitive care or where the imaging will be read by a pediatric specialist can help expedite care and avoid unnecessary burdens on patients and families. Research has shown that more imaging studies can lead to more radiation without clinically helping the patient. The push towards reduced-dose radiation protocols for CT and the ability for Rapid MRI is evident in my institution, and has allowed me to more expeditiously diagnose patients while minimizing the side effects. This policy statement is a helpful review for both pediatric clinicians and for those who treat pediatric patients in a general ED setting.

Source
Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement. Ann Emerg Med. 2024 Aug;84(2):e13-e23. doi: 10.1016/j.annemergmed.2024.03.023. PMID: 39032991.