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Imaging modalities in the pediatric patient: How to choose
To image or not to image?
Quality in health care, as defined by the U.S. Agency for Healthcare Research and Quality, is “doing the right thing for the right patient, at the right time, in the right way to achieve the best possible results.” When a pediatric patient presents in the emergency setting, the decision of which, if any, imaging test should be performed can be challenging. Factors to consider include patient factors, such as age, developmental stage, and coexisting illness, and facility factors, including available expertise in pediatric imaging, clinical support such as pediatric surgical services, and whether sedation capabilities are available if needed. One must consider whether the imaging test answers the clinical question, as well as myriad other questions: Can the child cooperate for the study? Can intravenous (IV) access be obtained if necessary? Is a test necessary or can the diagnosis be made clinically, either at presentation or after an observation period? Can testing be delayed until other resources are available (e.g., the only pediatric sonographer arrives at 7:00 a.m.)? Do the benefits of the test results outweigh potential risks? One must consider whether an imaging strategy follows the “ALARA” principle: keeping patient exposure to ionizing radiation “as low as reasonably achievable” (see Chapter 2 ) while ensuring diagnostic quality of the imaging. If considering a test involving ionizing radiation, is there an alternative mode of making the diagnosis with less risk (e.g., rapid magnetic resonance imaging [MRI] for hydrocephalus in a patient with a ventricular shunt)? There may be a role for shared decision making, educating the patient or the parent/guardian, and involving them in the decision. The clinician should also consider whether the patient is best served by imaging at the current facility or whether the patient should be transferred to a more specialized facility for diagnosis and management.
Transition to evidence-based medicine
Traditionally, medical decision making has been based on an individual practitioner’s experience and what the practitioner had learned from what has been termed “eminence-based medicine”; however, more recently, there has been a transition to evidence-based medicine, with a major goal of improving outcomes for patients. “Eminence-based medicine” has been described as reliance on learning from experts, especially those encountered through medical training, national publications, and meetings, and this approach relies on years of practice experience. In evidence-based medicine, it is assumed that a single practitioner does not arrive at an unbiased assessment through experience alone. In this paradigm, assessment of appropriate medical care should be based upon evidence-based research. The practitioner does not just accept information from the expert but assimilates and critically assesses the research evidence in literature to guide a clinical decision. In this process, one formulates a clinical question, identifies pertinent medical literature, judges the quality of studies, produces a summary of evidence, and applies evidence to arrive at appropriate clinical action. For an individual clinician, with the volume of medical literature and the pace of imaging innovation, this task can become overwhelming, especially for one practicing in an emergency center environment, caring for patients with a wide variety of illnesses and injuries. A need for evidence-based imaging guidelines and support has developed.
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