The most common clinical scenarios requiring imaging guidance were correlated amongst national Choosing Wisely campaigns in Australia, Canada, UK and USA; national priority areas in the USA; and UK iRefer Guidelines web hits. Message mapping was used to provide concise but precise guidance for appropriate use of imaging in such clinical situations in a format which could be used in a poster, leaflet or on-line web page.
The 10 most common clinical scenarios common to multiple sources which would benefit from image referral guidance are: headache, head injury, low back pain, abdominal pain, ureteric colic, chest pain, suspected pulmonary embolism, neck pain, first-onset psychosis, and lung cancer screening in asymptomatic individuals (Fig. 1).
Clinical problem
Key message
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What else should I know?
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What to look out for
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1. Headache
Only image if serious features are present or tumour suspected. MRI better than CT
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For sudden onset, severe headache or suspected subarachnoid haemorrhage, CT is best
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Serious features of headache:
1. Recent onset, increasing severity
2. Dizziness, clumsiness, tingling
3. Headache on coughing/sneezing
4. Malignancy/immunocompromised
5. Headache waking patient
6. Recent onset aged 50+ years
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2. Head injury
Only perform CT for significant head injuries
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Skull X-ray is not helpful in adults; only for suspected child abuse (non-accidental injury) as part of a skeletal survey in children 0–2 years of age
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Serious features for brain injury:
1. GCS
2. Open/depressed skull fracture
3. Any sign of basal skull fracture
4. Vomit >x1 in adults, 3 in children
5. Post-traumatic seizure
6. Bleeding risk
7. Focal neurological deficit
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3. Low-back pain
Imaging for low-back pain without serious features does not improve clinical outcomes
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For acute back pain
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Serious features of back pain:
1. Cauda equina syndrome (sphincter and gait disturbance, saddle anaesthesia, motor loss, neurological deficit)
2. Previous malignancy
3. Immunosuppression
4. Steroid use
5. Fever
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4. Abdominal pain
Need a strategy considering dose, habitus, equipment and expertise. CT is most sensitive, US and CT are both specific
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US is preferred in children and young people to show biliary, renal, gynaecological disease and appendicitis
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CT in adults is best to show sealed perforations, bowel ischaemia and the site/cause of obstruction
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5. Ureteric colic
CT without iodinated contrast is the most accurate investigation for suspected ureteric colic
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Low radiation-dose CT should be used, particularly for young patients with multiple episodes
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US and X-ray abdomen can be used in children and pregnant women but is less sensitive than CT
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6. Chest pain
Chest X-ray and echocardiography (+/– stress test) to show myocardial ischaemia and dysfunction when there is doubt
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CT coronary angiography for identification of degree of stenosis and other causes such as aortic dissection, pulmonary embolism and pericarditis
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Coronary angiography (+/– primary percutaneous intervention) needed if ECG shows ST elevation, or if the patient is still symptomatic even with adequate medical treatment
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7. Suspected pulmonary embolism
Only image after clinical probability and, when necessary, D-Dimers assessed
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CT pulmonary angiography is best. Ventilation/perfusion scintigraphy in pregnancy and renal failure
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Wells’ criteria:
1. Symptoms of DVT: 3 pt
2. No alternate diagnosis: 3 pt
3. Heart rate >100/min: 1.5 pt
4. Immobilisation or surgery: 1.5 pt
5. Previous DVT or PE: 1.5 pt
6. Haemoptysis: 1 pt
7. Malignancy: 1 pt
8. Needs D-dimer first if total ≤4 pt
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8. Neck pain
If no trauma, only perform MRI if there is radiating upper limb pain
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For trauma, X-ray or CT if there are serious features
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Serious features for neck trauma:
1. Can’t rotate neck 45° left/right
2. GCS score <15
3. Paraesthesia in extremities
4. Focal neurological deficit
5. Impossible to test neck movement (safe assessment if: rear-end collision; sitting position; ambulatory since injury; delayed neck pain; absence of midline tenderness)
6. Age ≥65
7. Dangerous injury (fall >1 m)
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9. First-onset of psychosis
Only request imaging if there are clinical features of intracranial pathology
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MRI is better than CT
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Specialist psychiatric assessment first – may exclude organic pathology
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10. Lung cancer screening in asymptomatic individuals
CT can detect early lung cancer but the value is only of benefit in those with high clinical probability
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Low-dose CT is best, chest X-ray is unreliable
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Features for higher probability:
1. People >55 years of age
2. Smoking 30-plus pack years
3. Asbestos or radon exposure
4. Other lung disease
5. Previous cancer treatment
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