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Appropriateness Criteria

Variant 1: Child. 24 months of age or younger. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography skeletal survey Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 1 0 0 0 1 0 1 0 10
References Study Quality
87 (19948569) 4
86 (29154020) 4
82 (23812002) 4
85 (24630357) 3
37 (25917988) 4
5 (24470642) 4
4 (30602409) 4
88 (34742547) 4
CT head without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 7 7 1 0 0 0 2 2 4 1 3
References Study Quality
65 (26130384) 4
64 (23184067) 4
62 (26320000) 4
61 (20174986) 4
63 (26186360) 3
60 (17445894) 4
56 (26471745) 4
55 (26150078) 2
59 (25501731) 4
52 (23799250) 4
54 (24816086) 4
58 (30516697) 4
57 (30187091) 3
53 (30523144) 4
50 (15192615) 4
51 (12777556) 4
49 (24840754) 4
47 (29654352) 3
13 (29796797) 4
48 (20065898) 3
Radiography area of interest May be appropriate (Disagreement) Expert Opinion Varies Varies 5 5 4 1 3 0 3 0 3 1 0
References Study Quality
5 (24470642) 4
84 (-3194101) 4
82 (23812002) 4
80 (21940592) 4
81 (27749806) 4
83 (4833902) 4
79 (25765815) 4
77 (25609436) 3
78 (28938085) 4
4 (30602409) 4
CT chest without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 3 2 0 3 4 0 0 0 1
References Study Quality
46 (30249541) 2
45 (18562001) 2
41 (25480434) 4
44 (-3194104) 4
43 (18832412) 4
US abdomen Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 3 3 8 1 0 0 0 0 0
References Study Quality
20 (28609532) 1
89 (10845493) 2
US abdomen with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 4 3 2 0 3 0 0 0 1
References Study Quality
93 (25142944) 4
92 (33978795) 4
90 (30536214) 4
91 (28351519) 2
US head Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 1 4 1 0 0 0 0 1
References Study Quality
95 (37093305) 3
94 (26999586) 3
MRI head without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 6 2 3 0 1 1 0 0 0
References Study Quality
73 (19348842) 4
72 (25698365) 4
70 (25274619) 4
71 (30125430) 4
69 (30406272) 3
68 (28970241) 3
56 (26471745) 4
55 (26150078) 2
67 (25700122) 2
66 (25646200) 3
59 (25501731) 4
7 (28245144) 4
58 (30516697) 4
23 (31533974) 2
74 (33079214) 2
MRI head without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 0 3 6 2 2 1 1 0 0
References Study Quality
73 (19348842) 4
72 (25698365) 4
70 (25274619) 4
71 (30125430) 4
69 (30406272) 3
68 (28970241) 3
56 (26471745) 4
55 (26150078) 2
67 (25700122) 2
66 (25646200) 3
59 (25501731) 4
58 (30516697) 4
23 (31533974) 2
MRV head without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 3 1 2 0 0 0 0 1
References Study Quality
13 (29796797) 4
55 (26150078) 2
59 (25501731) 4
73 (19348842) 4
75 (33884464) 4
76 (36074163) 4
Bone scan whole body Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 2 1 0 0 0 0 0 1
References Study Quality
26 (26055408) 3
33 (-3194105) 4
32 (12716705) 3
31 (32935234) 4
30 (32767105) 4
29 (20308455) 3
27 (8256139) 4
28 (28417851) 4
CT abdomen and pelvis with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 1 5 1 3 1 0 0 0
References Study Quality
39 (21088831) 4
38 (26219741) 4
36 (19620197) 3
34 (20936274) 3
37 (25917988) 4
35 (12667774) 4
CT abdomen and pelvis without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 3 1 0 0 0 0 0 1
References Study Quality
39 (21088831) 4
CT chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 7 3 5 0 0 0 0 0 0
References Study Quality
41 (25480434) 4
44 (-3194104) 4
42 (31904738) 4
43 (18832412) 4
40 (34801840) 3
CT chest without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 7 5 0 0 0 0 0 0 1
References Study Quality
42 (31904738) 4
45 (18562001) 2
46 (30249541) 2
CT head with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 6 1 4 0 1 0 0 1 0
References Study Quality
66 (25646200) 3
65 (26130384) 4
62 (26320000) 4
64 (23184067) 4
61 (20174986) 4
63 (26186360) 3
56 (26471745) 4
55 (26150078) 2
59 (25501731) 4
54 (24816086) 4
58 (30516697) 4
57 (30187091) 3
53 (30523144) 4
60 (17445894) 4
52 (23799250) 4
50 (15192615) 4
51 (12777556) 4
49 (24840754) 4
47 (29654352) 3
13 (29796797) 4
48 (20065898) 3
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 0 0 0 0 0 0 1
References Study Quality
66 (25646200) 3
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 7 5 0 0 0 0 0 0 1
References Study Quality
39 (21088831) 4
38 (26219741) 4
37 (25917988) 4
Variant 2: Child. Greater than 24 months of age. Concern for physical abuse based on clinical presentation or history. Neurological, skeletal, or visceral injuries not clinically apparent. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography area of interest Usually appropriate Limited Varies Varies 8 8 0 0 1 0 0 0 2 2 10
References Study Quality
85 (24630357) 3
96 (11239255) 4
41 (25480434) 4
40 (34801840) 3
Radiography skeletal survey May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 2 0 2 8 1 1 1 0
References Study Quality
85 (24630357) 3
86 (29154020) 4
97 (-3192269) 4
98 (34009892) 3
40 (34801840) 3
US abdomen Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 4 6 4 0 1 0 0 0 0
US abdomen with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 1 4 0 1 0 0 0 1
US head Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 3 2 0 0 0 0 0 1
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 2 2 0 0 0 0 0 1
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 3 5 0 0 0 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 3 1 1 0 0 0 0 1
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 3 0 0 0 0 0 0 1
CT abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 3 0 3 2 0 0 0 1
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 3 0 0 0 0 0 0 1
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 5 0 1 1 0 0 0 1
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 0 0 0 0 0 0 1
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 1 2 1 0 0 0 0 1
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 9 3 0 0 0 1 0 0 0
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 1 1 0 0 0 0 1 0
CT head without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 4 1 8 1 0 1 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 10 2 0 0 0 0 0 0 1
Variant 3: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs , symptoms, or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography skeletal survey Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 1 0 0 0 0 0 1 0 11
References Study Quality
37 (25917988) 4
110 (25589561) 3
82 (23812002) 4
86 (29154020) 4
109 (29040244) 4
87 (19948569) 4
CT head without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 1 0 0 0 0 0 1 2 9
References Study Quality
13 (29796797) 4
37 (25917988) 4
62 (26320000) 4
64 (23184067) 4
65 (26130384) 4
63 (26186360) 3
56 (26471745) 4
55 (26150078) 2
59 (25501731) 4
54 (24816086) 4
58 (30516697) 4
57 (30187091) 3
61 (20174986) 4
60 (17445894) 4
52 (23799250) 4
53 (30523144) 4
Radiography area of interest May be appropriate (Disagreement) Expert Opinion Varies Varies 5 5 1 2 3 2 3 1 2 1 0
References Study Quality
82 (23812002) 4
86 (29154020) 4
108 (23694887) 4
MRI complete spine without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 1 0 0 0 3 6 3 0 2
References Study Quality
99 (22069156) 4
100 (24687620) 4
102 (31901991) 4
107 (35018794) 2
MRI head without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 1 0 1 3 2 2 1 3
References Study Quality
73 (19348842) 4
72 (25698365) 4
70 (25274619) 4
71 (30125430) 4
69 (30406272) 3
68 (28970241) 3
56 (26471745) 4
55 (26150078) 2
67 (25700122) 2
66 (25646200) 3
59 (25501731) 4
7 (28245144) 4
58 (30516697) 4
23 (31533974) 2
74 (33079214) 2
MRV head without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 1 0 1 5 6 1 1 0 0
References Study Quality
13 (29796797) 4
55 (26150078) 2
59 (25501731) 4
73 (19348842) 4
75 (33884464) 4
76 (36074163) 4
US head Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 2 3 0 2 0 1 0 0
References Study Quality
94 (26999586) 3
95 (37093305) 3
MRI cervical spine without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 3 7 0 1 0 0 0 0
References Study Quality
82 (23812002) 4
102 (31901991) 4
100 (24687620) 4
99 (22069156) 4
101 (24557483) 4
MRI cervical spine without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 3 5 1 3 1 0 0 0
References Study Quality
82 (23812002) 4
102 (31901991) 4
100 (24687620) 4
99 (22069156) 4
101 (24557483) 4
106 (36261511) 4
MRI complete spine without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 2 4 0 3 0 0 0 0
References Study Quality
99 (22069156) 4
100 (24687620) 4
102 (31901991) 4
107 (35018794) 2
MRI head without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 4 2 5 4 0 0 0 0 0
References Study Quality
73 (19348842) 4
72 (25698365) 4
70 (25274619) 4
71 (30125430) 4
69 (30406272) 3
68 (28970241) 3
56 (26471745) 4
55 (26150078) 2
67 (25700122) 2
66 (25646200) 3
59 (25501731) 4
7 (28245144) 4
58 (30516697) 4
23 (31533974) 2
74 (33079214) 2
Bone scan whole body Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 2 0 0 1 0 0 0 1
References Study Quality
26 (26055408) 3
28 (28417851) 4
CT cervical spine with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 3 3 0 1 0 1 0 0
References Study Quality
105 (23283258) 4
104 (23436856) 4
100 (24687620) 4
101 (24557483) 4
103 (21700979) 4
102 (31901991) 4
82 (23812002) 4
99 (22069156) 4
CT cervical spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 1 0 1 0 0 0 0 1
CT cervical spine without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 3 4 1 5 0 0 0 0
References Study Quality
105 (23283258) 4
104 (23436856) 4
100 (24687620) 4
101 (24557483) 4
103 (21700979) 4
102 (31901991) 4
82 (23812002) 4
99 (22069156) 4
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 6 5 3 0 0 0 0 0 1
References Study Quality
66 (25646200) 3
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 7 2 3 0 0 0 1 0 0
References Study Quality
66 (25646200) 3
Variant 4: Child. Greater than 24 months of age of age. One or more physical examinations or clinical findings suspicious for CNS injury due to physical abuse: neurologic signs or symptoms or other injuries (scalp bruises, hematoma, or skin injury to the head, neck, or spine). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography area of interest Usually appropriate Limited Varies Varies 8 8 1 0 0 1 2 1 0 2 6
References Study Quality
82 (23812002) 4
85 (24630357) 3
86 (29154020) 4
108 (23694887) 4
CT head without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 1 0 0 0 0 0 1 2 9
References Study Quality
65 (26130384) 4
64 (23184067) 4
62 (26320000) 4
61 (20174986) 4
63 (26186360) 3
60 (17445894) 4
56 (26471745) 4
55 (26150078) 2
59 (25501731) 4
52 (23799250) 4
54 (24816086) 4
58 (30516697) 4
57 (30187091) 3
53 (30523144) 4
37 (25917988) 4
13 (29796797) 4
Radiography skeletal survey May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 1 0 1 4 6 2 1 0 0
References Study Quality
96 (11239255) 4
97 (-3192269) 4
110 (25589561) 3
109 (29040244) 4
MRI complete spine without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 1 7 5 1 0 1
References Study Quality
99 (22069156) 4
100 (24687620) 4
102 (31901991) 4
107 (35018794) 2
MRI head without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 1 0 0 5 7 1 0 1
References Study Quality
73 (19348842) 4
72 (25698365) 4
70 (25274619) 4
71 (30125430) 4
69 (30406272) 3
68 (28970241) 3
56 (26471745) 4
55 (26150078) 2
67 (25700122) 2
66 (25646200) 3
59 (25501731) 4
58 (30516697) 4
23 (31533974) 2
MRV head without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 1 2 2 6 0 1 0 0
References Study Quality
59 (25501731) 4
73 (19348842) 4
US head Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 3 1 0 0 0 0 0 1
MRI cervical spine without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 5 0 5 1 1 0 1 0 0
MRI cervical spine without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 2 6 1 3 1 0 0 0
References Study Quality
82 (23812002) 4
102 (31901991) 4
100 (24687620) 4
99 (22069156) 4
101 (24557483) 4
106 (36261511) 4
MRI complete spine without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 5 6 0 0 0 0 0 0
References Study Quality
99 (22069156) 4
100 (24687620) 4
102 (31901991) 4
107 (35018794) 2
MRI head without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 4 1 3 2 2 1 0 0 0
References Study Quality
73 (19348842) 4
72 (25698365) 4
70 (25274619) 4
71 (30125430) 4
69 (30406272) 3
68 (28970241) 3
56 (26471745) 4
55 (26150078) 2
67 (25700122) 2
66 (25646200) 3
59 (25501731) 4
7 (28245144) 4
58 (30516697) 4
23 (31533974) 2
74 (33079214) 2
Bone scan whole body Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 3 0 0 1 0 0 0 1
References Study Quality
26 (26055408) 3
28 (28417851) 4
CT cervical spine with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 4 2 0 2 0 0 0 0
References Study Quality
105 (23283258) 4
104 (23436856) 4
100 (24687620) 4
101 (24557483) 4
103 (21700979) 4
102 (31901991) 4
82 (23812002) 4
99 (22069156) 4
CT cervical spine without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 7 3 1 0 0 1 0 0 1
References Study Quality
105 (23283258) 4
104 (23436856) 4
100 (24687620) 4
101 (24557483) 4
103 (21700979) 4
102 (31901991) 4
82 (23812002) 4
99 (22069156) 4
CT cervical spine without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 1 6 1 4 0 0 0 0
References Study Quality
105 (23283258) 4
104 (23436856) 4
100 (24687620) 4
101 (24557483) 4
103 (21700979) 4
102 (31901991) 4
82 (23812002) 4
99 (22069156) 4
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 8 2 1 1 0 1 0 0 0
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 1 0 1 1 0 0 0 1
Variant 5: Child. 24 months of age or younger. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography skeletal survey Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 1 0 0 0 0 0 1 3 8
References Study Quality
37 (25917988) 4
85 (24630357) 3
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 1 1 0 0 1 2 8
References Study Quality
39 (21088831) 4
38 (26219741) 4
36 (19620197) 3
34 (20936274) 3
37 (25917988) 4
35 (12667774) 4
32 (12716705) 3
Radiography area of interest May be appropriate (Disagreement) Expert Opinion Varies Varies 5 5 3 0 3 1 4 1 2 0 1
References Study Quality
4 (30602409) 4
CT chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 3 2 3 6 1 0 0
References Study Quality
42 (31904738) 4
45 (18562001) 2
41 (25480434) 4
44 (-3194104) 4
43 (18832412) 4
112 (29337841) 4
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 2 9 3 1 0 0
References Study Quality
42 (31904738) 4
45 (18562001) 2
41 (25480434) 4
44 (-3194104) 4
43 (18832412) 4
US abdomen Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 5 1 8 1 0 0 0 0 0
References Study Quality
20 (28609532) 1
89 (10845493) 2
113 (33755750) 4
US abdomen with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 3 7 0 1 0 0 0 0
References Study Quality
113 (33755750) 4
92 (33978795) 4
90 (30536214) 4
91 (28351519) 2
Bone scan whole body Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 0 1 0 1 0 0 0 1
References Study Quality
28 (28417851) 4
27 (8256139) 4
26 (26055408) 3
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 10 1 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 2 0 2 0 0 0 0 1
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 6 1 4 1 0 1 0 0 0
Variant 6: Child. Greater than 24 months of age. One or more physical examinations or clinical findings suspicious for visceral injury due to physical abuse: abdominal pain or other injuries (bruising, hematoma, or skin injury to the chest wall or trunk). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography area of interest Usually appropriate Limited Varies Varies 7 7 0 0 0 0 3 2 5 3 2
References Study Quality
85 (24630357) 3
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 1 0 0 0 0 1 1 10
References Study Quality
39 (21088831) 4
38 (26219741) 4
36 (19620197) 3
34 (20936274) 3
37 (25917988) 4
35 (12667774) 4
Radiography skeletal survey May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 0 2 3 6 2 1 1 0
References Study Quality
85 (24630357) 3
CT chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 4 1 9 0 1 0 0
References Study Quality
43 (18832412) 4
44 (-3194104) 4
42 (31904738) 4
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 2 4 6 2 0 0
References Study Quality
43 (18832412) 4
44 (-3194104) 4
42 (31904738) 4
US abdomen Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 5 2 7 0 1 0 0 0 0
References Study Quality
20 (28609532) 1
89 (10845493) 2
US abdomen with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 4 5 4 0 2 0 0 0 0
References Study Quality
113 (33755750) 4
92 (33978795) 4
90 (30536214) 4
91 (28351519) 2
Bone scan whole body Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 3 0 0 1 0 0 0 1
References Study Quality
28 (28417851) 4
27 (8256139) 4
26 (26055408) 3
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 8 3 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 7 3 1 1 0 0 0 0 1
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 7 1 1 2 0 1 0 0 1
Variant 7: Child. 24 months of age or younger. Suspected physical abuse. Negative initial skeletal survey and CT head. Follow-up imaging within 10 to 14 days.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography skeletal survey Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 0 0 1 0 0 0 1 0 11
References Study Quality
12 (-3192268) 4
37 (25917988) 4
121 (25070311) 4
120 (16315349) 4
119 (21910901) 3
122 (20846722) 3
117 (23400607) 4
118 (26342432) 4
116 (16416103) 4
MRI head without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 2 1 3 4 0 3 0 1
References Study Quality
59 (25501731) 4
73 (19348842) 4
115 (15492737) 4
Bone scan whole body May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 3 10 1 1 0 0
References Study Quality
114 (19403511) 4
33 (-3194105) 4
32 (12716705) 3
31 (32935234) 4
30 (32767105) 4
29 (20308455) 3
26 (26055408) 3
27 (8256139) 4
28 (28417851) 4
CT chest without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 2 0 2 2 7 1 1 0 0
References Study Quality
45 (18562001) 2
43 (18832412) 4
41 (25480434) 4
46 (30249541) 2
40 (34801840) 3
US abdomen Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 4 0 0 1 0 0 0 0
References Study Quality
39 (21088831) 4
89 (10845493) 2
123 (10993539) 4
US abdomen with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 0 2 0 0 1 0 0 1
US head Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 8 2 1 1 0 0 0 0 1
References Study Quality
95 (37093305) 3
94 (26999586) 3
MRI cervical spine without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 1 0 0 0 0 0 1
MRI cervical spine without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 3 1 1 0 0 0 0 1
MRI complete spine without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 0 0 0 0 0 0 1
MRI complete spine without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 4 0 0 0 0 0 0 1
MRI head without and with IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 1 1 7 2 1 1 1 1 0 0 0
References Study Quality
59 (25501731) 4
73 (19348842) 4
7 (28245144) 4
115 (15492737) 4
74 (33079214) 2
MRV head without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 3 3 2 1 0 0 0 1
References Study Quality
13 (29796797) 4
76 (36074163) 4
70 (25274619) 4
72 (25698365) 4
71 (30125430) 4
75 (33884464) 4
56 (26471745) 4
55 (26150078) 2
58 (30516697) 4
CT abdomen and pelvis with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 7 3 0 1 1 1 0 0 0
References Study Quality
34 (20936274) 3
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 0 0 0 0 0 0 1
CT chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 0 1 1 3 0 0 0 0
References Study Quality
41 (25480434) 4
45 (18562001) 2
42 (31904738) 4
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 0 0 1 0 0 0 0 1
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 12 0 0 0 0 0 1 0 0
Variant 8: Child. 24 months of age or younger. Asymptomatic, who shares a home with a child with suspected or known physical abuse. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography skeletal survey Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 0 0 1 0 0 0 1 0 11
References Study Quality
9 (22778300) 3
37 (25917988) 4
130 (29195170) 4
129 (30177540) 4
MRI head without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 0 3 3 4 3 1 1 0
References Study Quality
13 (29796797) 4
CT head without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 1 1 0 1 4 0 5 1 2
References Study Quality
13 (29796797) 4
128 (19809839) 2
62 (26320000) 4
127 (19797789) 3
64 (23184067) 4
63 (26186360) 3
50 (15192615) 4
51 (12777556) 4
49 (24840754) 4
47 (29654352) 3
48 (20065898) 3
126 (36877504) 4
US abdomen Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 1 1 0 1 0 0 0 1
US abdomen with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 0 0 1 1 0 0 0 1
US head Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 0 2 1 0 0 0 0 1
MRI head without and with IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 1 1 8 0 2 1 1 0 0 1 0
References Study Quality
7 (28245144) 4
74 (33079214) 2
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 0 2 0 1 0 0 0 1
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 0 1 0 0 0 0 0 1
CT abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 0 0 1 0 0 0 0 1
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 0 0 0 0 0 0 1
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 0 0 0 0 0 0 0 1
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 0 0 0 0 0 0 1
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 0 0 2 0 0 0 0 1
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 9 1 1 1 0 0 0 0 1
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 1 1 0 0 0 0 0 1
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 11 1 0 0 0 0 0 0 1
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.