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Appropriateness Criteria

Variant 1: Adult. Minor blunt trauma from assault or ground-level fall with local chest tenderness. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Strong ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 0 1 2 7
References Study Quality
10 (33703916) 2
30 (33452092) 4
29 (29950261) 4
28 (35595942) 4
26 (34270354) 4
27 (30070227) 4
13 (25817167) 2
14 (27163732) 2
25 (29536276) 2
21 (37417996) 2
Radiography rib views Usually appropriate Limited ☢☢☢ 1-10 mSv ☢ <0.03 mSv [ped] 8 8 0 0 0 0 1 0 1 5 3
References Study Quality
31 (28716296) 2
32 (30470688) 4
CT chest with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 1 0 0 0 1 3 1 0 4
References Study Quality
7 (30175454) 4
20 (38071125) 2
17 (26215242) 4
16 (31648788) 4
18 (37278076) 3
19 (30676527) 2
14 (27163732) 2
12 (26708426) 3
21 (37417996) 2
CT chest without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 2 0 0 1 3 2 4 0 0
US chest Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 9 3 0 0 0 0 0 0 0
References Study Quality
50 (29580349) 3
49 (36754698) 3
45 (36658000) 3
48 (31061252) 4
46 (35435007) 2
47 (36456990) 2
44 (22828649) 1
43 (30066090) 4
37 (35461720) Good
39 (32702777) Good
40 (34932040) 3
38 (24060427) Good
41 (37171252) 3
42 (38395059) 4
35 (26683569) 2
36 (31317856) 4
34 (33218837) 1
33 (35437526) Not Assessed
51 (32814988) 3
MRI chest with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 6 2 1 0 1 0 0 0 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 1 1 0 1 0 0 0 0
MRI chest without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 6 0 1 2 0 0 1 0 0
References Study Quality
23 (23962879) 4
22 (33424019) 2
24 (31054749) 4
Bone scan chest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 8 2 0 0 0 0 0 0 0
Bone scan ribs Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 7 2 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] 3 3 2 2 6 0 0 0 1 0 0
V/Q scan lung Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 9 0 1 0 0 0 0 0 0
Variant 2: Adult. Minor blunt trauma from assault with right upper flank pain with hematuria or assault or fall or low speed motor vehicle collision with right upper quadrant pain. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 1 0 0 1 0 1 7
References Study Quality
53 (26046510) 4
54 (26169091) 3
CTU without and with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 7 7 1 0 0 0 1 1 5 0 4
References Study Quality
73 (35278492) 4
72 (30605143) 1
69 (28451770) 4
68 (38092717) 4
67 (27085822) 4
60 (38009413) 4
74 (27133737) 3
62 (31729629) 4
US abdomen Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 2 5 0 0 3 1 0 0 0
References Study Quality
78 (25578621) 4
77 (26368505) 4
76 (25498329) 3
37 (35461720) Good
79 (19457583) 2
Radiography abdomen and pelvis Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 4 6 1 0 1 0 0 0 0
References Study Quality
74 (27133737) 3
MRI abdomen without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 3 1 2 0 0 0 0 0
MRI abdomen without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 3 2 1 0 0 0 0 0
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 4 1 1 1 0 0 0 0
CTA abdomen with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 3 2 2 1 1 0 0 0
DMSA renal scan Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 8 1 1 0 0 0 0 0 0
DTPA renal scan Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 8 1 1 0 0 0 0 0 0
Liver spleen scan Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 7 1 1 0 1 0 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 2 2 6 0 0 0 1 0 0
References Study Quality
56 (23147187) 4
CT pelvis with bladder contrast (CT cystography) Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 2 4 0 0 1 0 0 0
References Study Quality
63 (28126218) 4
62 (31729629) 4
61 (25600513) 4
58 (25323027) 4
59 (28730297) 4
60 (38009413) 4
57 (30979861) 4
CTA abdomen and pelvis with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 2 2 4 2 2 0 0 0 0
References Study Quality
66 (25124459) 4
65 (35122178) 4
64 (31489487) 4
Variant 3: Adult. Minor blunt trauma as a result of fall from bicycle with handlebar injury. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 1 0 1 3 4 2
References Study Quality
80 (24838812) 3
81 (28291454) 3
83 (35803743) 4
82 (27641159) 4
84 (25294636) 4
85 (37125949) 3
US abdomen Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 7 4 1 0 0 0 0 0 0
References Study Quality
76 (25498329) 3
36 (31317856) 4
77 (26368505) 4
37 (35461720) Good
87 (32826121) 2
Radiography abdomen Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 8 4 0 0 0 0 0 0 0
MRI abdomen without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 1 2 1 1 0 0 0 0
References Study Quality
86 (24379625) 4
83 (35803743) 4
MRI abdomen without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 1 3 1 0 0 0 0 0
References Study Quality
86 (24379625) 4
83 (35803743) 4
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 3 2 0 2 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] 2 2 2 5 4 0 0 0 0 0 0
CTA abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 2 5 4 1 0 0 0 0 0
Variant 4: Adult. Minor blunt trauma from motor vehicle collision with seatbelt sign. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 1 1 2 6
References Study Quality
84 (25294636) 4
90 (32080763) 4
91 (23522505) 4
88 (29521798) 3
89 (31706587) 3
US abdomen Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 1 0 2 0 1 0 0 0
Radiography abdomen Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 4 3 1 1 1 0 1 0 0
MRI abdomen and pelvis with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 6 1 3 0 0 0 0 0 0
References Study Quality
86 (24379625) 4
83 (35803743) 4
MRI abdomen and pelvis without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 6 1 2 0 1 0 0 0 0
References Study Quality
86 (24379625) 4
83 (35803743) 4
MRI abdomen and pelvis without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 6 2 2 0 0 0 0 0 0
References Study Quality
86 (24379625) 4
83 (35803743) 4
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 3 2 1 1 1 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 2 4 5 0 0 0 0 0 0
References Study Quality
56 (23147187) 4
CT enterography Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 1 5 0 0 0 0 0 0
Variant 5: Adult. Minor blunt trauma from motor vehicle collision with gross hematuria. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 1 0 2 3 4
References Study Quality
61 (25600513) 4
54 (26169091) 3
71 (23354250) 2
64 (31489487) 4
92 (-3199126) 4
CT pelvis with bladder contrast (CT cystography) Usually appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 1 0 0 2 1 6
References Study Quality
63 (28126218) 4
94 (28836750) 4
61 (25600513) 4
93 (30489505) 4
62 (31729629) 4
60 (38009413) 4
58 (25323027) 4
59 (28730297) 4
57 (30979861) 4
Fluoroscopy cystography May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 1 0 2 0 5 2 0 1 0
References Study Quality
61 (25600513) 4
60 (38009413) 4
58 (25323027) 4
57 (30979861) 4
62 (31729629) 4
92 (-3199126) 4
64 (31489487) 4
US abdomen Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 2 2 6 4 1 0 0 0 1 0 0
References Study Quality
76 (25498329) 3
96 (33484276) 4
77 (26368505) 4
78 (25578621) 4
37 (35461720) Good
Radiography abdomen and pelvis Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 7 4 1 0 0 0 0 0 0
References Study Quality
75 (29267560) 4
MRI abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 2 1 1 1 0 0 0 0
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 3 1 1 0 0 0 0 0
MRI abdomen without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 3 1 1 0 0 0 0 0
MRI abdomen without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 3 1 1 0 0 0 0 0
Nuclear medicine cystography Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 6 1 1 0 2 0 0 0 0
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 4 3 0 1 0 0 0 0
DMSA renal scan Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 8 1 0 1 0 0 0 0 0
DTPA renal scan Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 7 1 0 2 0 0 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 2 3 4 1 1 0 0 0 0
References Study Quality
56 (23147187) 4
Variant 6: Adult. Minor blunt trauma from sports injury with left upper quadrant pain. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 1 0 0 2 3 5
References Study Quality
59 (28730297) 4
97 (31900381) 4
17 (26215242) 4
98 (27519599) 4
US abdomen Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 7 3 0 1 0 0 1 0 0
References Study Quality
17 (26215242) 4
99 (35286054) 4
Fluoroscopy small bowel follow-through Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 7 2 1 0 0 0 0 0 0
Fluoroscopy upper GI series with small bowel follow-through Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 6 2 1 1 0 0 0 0 0
Radiography abdomen and pelvis Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 7 3 2 0 0 0 0 0 0
MR enterography Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 6 3 1 0 0 0 0 0 0
MRI abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 6 1 1 0 2 0 0 0 0
MRI abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 6 2 2 0 0 0 0 0 0
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 6 2 1 0 1 0 0 0 0
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 2 4 2 0 3 0 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 1 4 4 1 1 0 0 0 0
References Study Quality
56 (23147187) 4
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.