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Scan or Scam: Clinical Decision Rules Eliminate Unnecessary CT Scans

Christopher Chen
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Under the bright lights of a Friday night game, a high school football player feels his

grasp on the incoming spiraling ball, only to be tackled to the ground, and clunks his head hard

on the turf. He wakes up after a few seconds and declares himself fine, but his mother rushes him

to the hospital, worried that he might have a concussion. The emergency room pediatrician

immediately orders a computed tomography (CT) scan. When they are faced with patients with

head injuries, such as concussions, emergency room pediatricians can generally solve the

problem with the CT scan, since the resulting image is extremely precise due to the powerful

technology. Most pediatric patients with a head injury are given a CT scan, regardless of the

severity of their condition. Some patients may just have an insignificant head injury that, as with

most concussions, will heal on their own. This leads to unnecessary CT scans, and overexposure

to radiation emitted from the scan. The thought that the football player’s scan, which may or not

be conclusive, could cause him cancer or even his life, never crosses his or his mother’s mind;

however, all patients must be aware of the dangers of CT scans. Just like an irritating sunburn

from one day at the beach, overexposure to electromagnetic radiation from basic medical

imaging can cause multitudes of complications, typically in the form of acute radiation

syndrome. The recent development of clinical decision rules has allowed doctors to thoroughly

evaluate patients’ conditions and history before deciding if and what tests or treatments their

patients require. Specific to pediatric head injuries, the Pediatric Emergency Care Applied

Research Network (PECARN) head injury guideline clinical decision rules help to thoroughly

evaluate a patient’s condition and history. The rules use this information to detect a clinically

important brain injury and to determine if a CT scan is necessary, helping to lower the number of

unnecessary CT scans. The PECARN clinical decision rules should be implemented in the

pediatric emergency room because they reduce the number of CT scans, lower patient
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costs, and decrease the overexposure to harmful amounts of ionizing radiation, which can

lead to dangerous complications.

The PECARN clinical decision rules simply reduce the number of CT scans because

most pediatric patients with head injuries simply do not require scans. Pediatric patients with

head injuries normally arrive with myriad of symptoms, whose apparent severity, complexity,

and quantity can occasionally lead doctors to detect brain injuries. However, it is tough to make a

diagnosis when there are fewer and less pronounced symptoms, such as loss of consciousness. A

CT scan can determine if a patient has a serious brain injury; however, it is significantly more

challenging to diagnose a minor brain injury from a scan because the results are almost always

negative in these cases. Therefore, CT scans should be avoided for mild head injuries, since

“prediction rules can augment clinician judgment and help obviate CT ordering for children at

very low risk of ciTBI” (Atabaki, Shireen M., et al.). Regardless of these known conditions, the

efficiency and sophistication of the scan make it so appealing to doctors that the majority of

pediatric patients with head injuries are ordered a scan. Of course, without a CT scan, doctors

would miss the chance of identifying any brain injury. The PECARN rules supplies the decision

and confidence doctors require to order a scan. A patient’s conditions and history can instead be

analyzed by the PECARN clinical decision rules. The rules are comprised of a variety of

guidelines that produce a result, which indicates the severity of the brain injury, highlights key

complications, and determines if a CT scan is necessary. The main objective of the rules is to

identify pediatric patients with a high risk of a clinically important, or serious brain injury.

Furthermore, the design of the PECARN rules allows them to be implemented “in different

settings, particularly non-academic and non-specialized centres, with the potential to reduce the

rates of unnecessary head CT utilization,” (Ghizoni, Enrico, et al.), displaying their flexibility
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and consistency of results. Through careful and methodical analysis of a patient, the PECARN

clinical decision rules make a sound decision as to whether or not a CT scan is necessary; in

most cases, the answer is no, and the majority of unnecessary CT scans are eliminated.

By decreasing the number of CT scans, which are extremely expensive, the PECARN

clinical decision rules directly lower patient costs. With many pediatric patients being uninsured

for various reasons, CT scans can cost thousands of dollars. Since “the widespread use of head

CT in mild TBI further increases health care costs” (Ghizoni, Enrico, et al.), the more scans a

patient receives, the more they are charged by the hospital. Doctors generally make the decision

to order a CT scan, regardless of the patient’s economical status. Patients must be able and

willing to pay for scans should their insurance not pay for part or all of the costs. This creates an

evident issue: unnecessary CT scans are hurting patients financially because they are simply a

waste of money. By implementing the PECARN clinical decision rules, patients can focus less

on the costs of healthcare and more on the benefits. With every CT scan eliminated by the

PECARN rules, patients save a considerable amount of money, and are likely to be more

satisfied with their care. In the aforementioned multiple study analysis, the researchers found that

“compliance with available [PECARN] clinical decision rules for the use of head CT in pediatric

populations can potentially reduce health care costs” (Ghizoni, Enrico, et al.), showing their

understanding that decrease in CT scans is foreseeable to lower costs, provided that hospitals

adopt and implement the rules. The study Cost-Effectiveness of the PECARN Rules in Children

with Minor Head Trauma is a comprehensive economic analysis focused on the costs and

outcomes of the rules. The researchers found the rules to be very beneficial to patients “because

the PECARN strategy was more effective (less QALY loss) and less costly, [and] it dominated

the usual care strategy. (Nishijima, Daniel K., et al.)”. The rules are extremely patient-friendly
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since the cost of implementation is less than CT scans. The PECARN clinical decision rules

should be implemented in pediatric emergency rooms because they eliminate the need for

expensive CT scans, ensuring patients are not presented with an unavoidable financial burden as

part of their care.

Overexposure to harmful amounts of ionizing radiation can be reduced by the PECARN

clinical decision rules. The power and sophistication of CT scans can be attributed to the

substantial amount of ionizing radiation, which contains electromagnetic waves. One CT scan is

equivalent to over one hundred x-rays; therefore, one CT emits the amount of radiation from

over one hundred x-rays. Therefore, the high-quality of CT scans come with a trade-off value:

once a patient receives many CT scans, the amount of radiation that has been emitted on their

body becomes harmful; “Studies have found that there are potential long-term consequences of

CT radiation, particularly for children who are more vulnerable to the cancer-causing effects of

radiation” (Charles). The study Cranial Computed Tomography Use Among Children With

Minor Blunt Head Trauma focused on the use of CT scans for minor head injuries. When

discussing the conclusions, the researchers described problems of the scans, stating, “Cranial CT

use may be especially relevant because it is the standard of care for emergency diagnosis of TBI,

but irradiation is associated with increased long-term risk for malignant neoplasms [more

commonly known as tumors], particularly in children. This makes underuse or overuse of CT

problematic...” (Natale, JoAnne E., et al.). CT scans have become the mainstay of pediatric head

injury diagnosis; however, the negative effects of these scans on patients are shocking some. It is

ironic how a patient may be receiving a CT scan for a brain injury, and years later receives a

brain tumor from the overexposure of radiation. The use of the PECARN rules decrease the

amount of CT scans in pediatric patients with head injuries; therefore, less CT scans mean less
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patients are exposed to ionizing radiation. Those who truly require the scans are the only ones

exposed. The aforementioned cost- effectiveness study analyzed the financial aspects of the

rules. However, the researchers spotted additional aspects and beneficial consequences of the

rules, such as the impact on the quality of life. After the study was conducted, the researchers

found that the rules “used fewer cranial CT scans, resulted in fewer radiation-induced cancers…”

(Nishijima, Daniel K., et al.), showing the clear correlation between CT scans and radiation

complications. The researchers in this study specifically noted the cancers, which is one of the

more deadly effects of acute radiation syndrome. In a critical appraisal of the three major clinical

decision rules, the researchers summarize the benefits of using the PECARN rules in decreasing

CT scan radiation overexposure, stating, “The liberal use of head CT for mild TBI may

unnecessarily expose children to ionizing radiation, which in turn may increase the risk of

developing leukemia and brain tumors by up to three-fold. Currently, clinical decision rules for

the use of head CT are available to instruct families and guide medical practice, with the

advantage of potentially avoiding unnecessary ionizing radiation exposure in pediatric

populations...” (Ghizoni, Enrico, et al.). From these studies, it is clear that the PECARN rules are

prized for their ability to reduce overexposure to radiation, thanks to the decrease in CT scans.

With the implementation of the rules, more lives are defended from devastating radiation-related

diseases and cancers.

The PECARN clinical decision rules dramatically improve the methods in which

emergency room pediatricians treat and diagnose traumatic brain injuries. Unsurprisingly, the

rules are regarded as “the best clinical decision rule to accurately identify children at very low

risk of clinically important traumatic brain injuries (ciTBI) in the pediatric emergency

department,” based on the conclusions of a large-scale implementation study. (Bressan, Silvia, et

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al.).Through a systematic analysis of a patient’s condition and history, the rules determine if a

CT scan is necessary, which in most cases, is not. It has been established that unnecessary CT

scans cause an overexposure of radiation, which leads to severe complications and even cancer.

The rules have eliminated these pointless scans, except for clinically important brain injuries, of

which they can easily identify. The implementation of the rules in pediatric emergency rooms

benefits not only patients’ short term and long term health, but also their health care savings. The

rules provide necessary guidance and assurance that both doctors and patients can depend on.

Finding a reasonable balance between a thorough diagnosis and limited radiation exposure is not

as achievable as it seems. However, promising results from large cohort studies will influence

the introduction of new implementation studies that will target a broad spectrum of medical

institutions. Instead of automatically ordering a CT scan, the new norm should be to use the rules

as the first test. Could the aforementioned football player have a serious brain injury? What if his

diagnosis is simply a minor concussion that fails to show on his negative CT scan? Was his scan

only a tanning bed emitting harmful ionizing radiation? The PECARN rules would help to

answer these questions, pinpoint the true severity of his injury, and eliminate the need for a CT

scan, shielding his body from the unnecessary radiation. Emergency room pediatricians who

adopt the PECARN rules in their course of head injury evaluation are taking a monumental step

in providing the most complete care.

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Works Cited

Atabaki, Shireen M., et al. "Comparison of Prediction Rules and Clinician Suspicion for

Identifying Children With Clinically Important Brain Injuries After Blunt Head Trauma."

Annals of Emergency Medicine, www.ncbi.nlm.nih.gov/pubmed/26825755. Accessed 9

Jan. 2018.

Bressan, Silvia, et al. "Implementation of Adapted PECARN Decision Rule for Children

With Minor Head Injury in the Pediatric Emergency Department."Society for Academic
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Emergency Medicine Academic Emergency Medicine, onlinelibrary.wiley.com/doi/10.

1111/j.1553-2712.2012.01384.x/full.

Casey, Charles. "For Some Kids, Parent Fears Mean Extra CT Scans." Archives of Pediatrics &

Adolescent Medicine, www.futurity.org/for-some-kids-parent-fears-mean-extra-ct-scans/.

Accessed 9 Jan. 2018.

Ghizoni, Enrico, et al. "Indications for head computed tomography in children with mild

traumatic brain injury." SciELO, www.ncbi.nlm.nih.gov/pubmed/24573632.

Hurley, T., and P. Curran. "G335(P) € …The use of CT brain in children with head injuries in a

general hospital compared to PECARN guidelines." Disease of Childhood,

adc.bmj.com/content/101/Suppl_1/A195.

Natale, JoAnne E., et al. "Cranial Computed Tomography Use Among Children With Minor

Blunt Head Trauma." JAMA Pediatrics, jamanetwork.com/journals/jamapediatrics/

fullarticle/1263343.

Nishijima, Daniel K., et al. "Cost-Effectiveness of the PECARN Rules in Children with Minor

Head Trauma." Annals of Emergency Medicine, www.ncbi.nlm.nih.gov/pmc/articles/

PMC4275394/.