CT scans are not necessary in the routine evaluation of abdominal pain.

The use of advanced imaging—particularly ionizing radiation—is of great concern to our pediatrics colleagues. Three of their five recommendations specifically address situations where

excessive low-yield imaging represents costs and harms in excess of the benefits. A shared decision-making conversation given a risk-averse parent represents a challenging patient encounter, but it is our responsibility to protect children from the harms of medical radiation.

American College of Physicians

In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain-imaging studies (CT or MRI).

If dizziness is the emergency physician’s least-favorite complaint, syncope cannot be far behind. Most inpatient syncope evaluations do not identify specific pathology related to syncope, and neuroimaging is of particular low yield. If patients do not have specific high-risk features related to trauma or other neurologic abnormalities, it is preferable to defer such imaging.

American College of Radiology

Don’t do imaging for uncomplicated headache.

This has been the subject of several recent publications as well as a Centers for Medicare & Medicaid Services (CMS) quality measure.^5,6 Atraumatic headache absent high-risk features by history of physical should not receive neuroimaging in the emergency department. CT, in particular, is sensitive primarily for hemorrhage but not malignancy, and it may provide false reassurance.

American Society of Anesthesiologists–Pain Medicine

Avoid imaging studies (MRI, CT, or X-rays) for acute low back pain without specific indications.

This recommendation is also supported by the American College of Physicians. Emergency physicians are very familiar with the red flags associated with an increased risk of serious pathology in the setting of acute, atraumatic back pain, and otherwise routine imaging is exceedingly low yield.

American Society of Hematology

Don’t administer plasma or prothrombin complex concentrates for nonemergent reversal of vitamin K antagonists (eg, outside of the setting of major bleeding, intracranial hemorrhage, or anticipated emergent surgery).

Prothrombin complex concentrates, including the recent four-factor product approved in the United States, are efficacious, small-volume means to emergently reverse the coagulopathy associated with warfarin. However, these products are costly and may have increased thrombotic complications compared with fresh frozen plasma. Excepting situations where extremely rapid reversal is necessary, fresh frozen plasma should be utilized for all other conditions necessitating urgent correction.

American Society of Nuclear Cardiology

Don’t perform cardiac imaging for patients who are at low risk.

This broad recommendation has many implications for emergency medicine—and conflicts in some fashion with the current standard of early provocative testing endorsed by the American Heart Association. This medico-legal risk associated with chest pain patients has led to a “zero miss” culture of aggressive, extensive, and low-yield care. It has also further spawned a boom industry in support of CT coronary angiograms in the emergency department. However, all these imaging studies have test characteristics resulting in excessive false positives in a low-risk population, and their suboptimal appropriateness should be part of shared decision making with patients and families.

Society of Hospital Medicine–Pediatric Hospital Medicine

Don’t order chest radiographs in children with uncomplicated asthma or bronchiolitis.