Image Gently: Is overuse of CT in the emergency department harming our children?

Key Points

The use of medical imaging, specifically computed tomography (CT) scans, has improved our ability to care for many children in need of health care services. Imaging is an important component of care provided to children with acute injuries and illness and it also is used regularly in the management of chronic conditions.

The benefits of CT scans in pediatric patients include more accurate diagnosis of conditions such as appendicitis, more efficient treatment of children with head injuries and multiple trauma in the emergency department (ED), and improved care of patients with congenital heart disease, among others.^1-3

Emergency physicians and pediatric emergency medicine (PEM) physicians have come to rely on CT as a vital component of rapid diagnostic evaluation of children in the ED. Many hospitals now have CT scanners located in their EDs, making scans more available. The greater speed of newer scanners has reduced the need for sedation in many children, removing one of the risks of scanning without affecting the quality of the images.²

A recent study showed a marked increase in the use of CT scans in children who presented to EDs over a 14-year period between 1995 and 2008.² During this time, the number of pediatric ED visits that included a CT scan increased 5-fold (from 0.33 million to 1.65 million), even though the total number of ED visits during the same time period remained relatively constant.

Thus, the growth in the use of CT was caused by increasing frequency of use, and the most common complaints for which CT scans were obtained included head injury, abdominal pain, and headache.²

Similarly, the number of CT scans in adult patients evaluated in the ED across the United States increased by 330% from 1996 to 2007.⁴ In 1996, CT scans were obtained in approximately 3.2% of ED visits, and by 2007 the rate had risen to nearly 14%.

Although many PEM and ED physicians, pediatricians, and pediatric care providers have a good understanding of the benefit of CT examinations in children, they often are less cognizant of the risks of these studies.⁵ Over the past decade, radiologists and other experts in medical imaging have focused significant time and effort on the issue of radiation exposure and CT scans, especially in children. Pediatric patients are more sensitive to the harmful effects of radiation than are adults.

In a seminal paper published in 2001, researchers concluded that in an estimated 600,000 abdominal and head CT examinations performed each year in children younger than 15 years, 500 children ultimately would die from radiation-induced cancer.⁶

Although the accuracy of this statement was contested, the lay press quickly picked up on this information, and a front-page article in a national newspaper, "CT Scans in Children Linked to Cancer," was published in January 2001.⁷

Parents, understandably, became quite alarmed after reading this and other related articles. Pediatricians, radiologists, and ED physicians found themselves dealing with families who cancelled or refused CT scans that were felt to be medically indicated because of fear of an inordinate risk of cancer to their children.

Ultimately, widespread concerns led to enhanced measures by pediatric radiologists, radiation safety experts, manufacturers of imaging equipment, and regulatory agencies to address the issue of radiation exposure and CT use in children, as well as adults.