Chest Pain-Child

Variant: 1 Child. Chest pain. Limited to the chest wall. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Radiography chest	Usually Appropriate	☢
US chest	May Be Appropriate	O
Radiography rib views	May Be Appropriate	☢
MRI chest without and with IV contrast	Usually Not Appropriate	O
MRI chest without IV contrast	Usually Not Appropriate	O
CT chest with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest without IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 2 Child. Chest pain. Suspected pneumothorax or pneumomediastinum. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Radiography chest	Usually Appropriate	☢
Radiography chest decubitus view	Usually Not Appropriate	☢
US chest	Usually Not Appropriate	O
US echocardiography transthoracic resting	Usually Not Appropriate	O
Fluoroscopy upper GI series	Usually Not Appropriate	☢☢☢
MRI chest without and with IV contrast	Usually Not Appropriate	O
MRI chest without IV contrast	Usually Not Appropriate	O
CT chest with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest without IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 3 Child. Chest pain. Suspected pulmonary embolism. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Radiography chest	Usually Appropriate	☢
CTA pulmonary arteries with IV contrast	Usually Appropriate	☢☢☢☢
V/Q scan lung	May Be Appropriate	☢☢☢
US chest	Usually Not Appropriate	O
US duplex Doppler lower extremity	Usually Not Appropriate	O
US echocardiography transesophageal	Usually Not Appropriate	O
US echocardiography transthoracic resting	Usually Not Appropriate	O
Arteriography pulmonary with right heart catheterization	Usually Not Appropriate	☢☢☢☢
MRA pulmonary arteries without and with IV contrast	Usually Not Appropriate	O
MRA pulmonary arteries without IV contrast	Usually Not Appropriate	O
CT chest with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest without IV contrast	Usually Not Appropriate	☢☢☢☢
CTA chest with IV contrast with CTV lower extremities	Usually Not Appropriate	☢☢☢☢

Variant: 4 Child. Chest pain. Known or suspected cardiac disease. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US echocardiography transthoracic resting	Usually Appropriate	O
Radiography chest	Usually Appropriate	☢
CTA chest with IV contrast	May Be Appropriate	☢☢☢☢
CTA coronary arteries with IV contrast	May Be Appropriate	☢☢☢☢
CT heart function and morphology with IV contrast	May Be Appropriate	☢☢☢☢
US chest	Usually Not Appropriate	O
US echocardiography transesophageal	Usually Not Appropriate	O
US echocardiography transthoracic stress	Usually Not Appropriate	O
Arteriography coronary with ventriculography	Usually Not Appropriate	☢☢☢☢
Arteriography pulmonary	Usually Not Appropriate	☢☢☢☢
MRA chest without and with IV contrast	Usually Not Appropriate	O
MRA chest without IV contrast	Usually Not Appropriate	O
MRI heart function and morphology without and with IV contrast	Usually Not Appropriate	O
MRI heart function and morphology without IV contrast	Usually Not Appropriate	O
MRI heart function with stress without and with IV contrast	Usually Not Appropriate	O
MRI heart function with stress without IV contrast	Usually Not Appropriate	O
CT chest with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest without IV contrast	Usually Not Appropriate	☢☢☢☢
V/Q scan lung	Usually Not Appropriate	☢☢☢
FDG-PET/CT heart	Usually Not Appropriate	☢☢☢☢
SPECT or SPECT/CT MPI rest and stress	Usually Not Appropriate	☢☢☢☢☢

Variant: 5 Child. Chest pain. History of sickle cell disease. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Radiography chest	Usually Appropriate	☢
US abdomen	Usually Not Appropriate	O
US chest	Usually Not Appropriate	O
US echocardiography transthoracic resting	Usually Not Appropriate	O
US echocardiography transthoracic stress	Usually Not Appropriate	O
MRI chest without and with IV contrast	Usually Not Appropriate	O
MRI chest without IV contrast	Usually Not Appropriate	O
CT chest with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest without IV contrast	Usually Not Appropriate	☢☢☢☢
CTA chest with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 6 Child. Chest pain. Suspected panic attack. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Radiography chest	May Be Appropriate	☢
US chest	Usually Not Appropriate	O
US echocardiography transthoracic resting	Usually Not Appropriate	O
US echocardiography transthoracic stress	Usually Not Appropriate	O
MRI chest without and with IV contrast	Usually Not Appropriate	O
MRI chest without IV contrast	Usually Not Appropriate	O
CT chest with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest without IV contrast	Usually Not Appropriate	☢☢☢☢

Panel Members

Scott R. Dorfman, MD^a; Sherwin S. Chan, MD, PhD^b; Siraj Amanullah, MD, MPH^c; Brandon P. Brown, MD, MA^d; John Smith Hokanson, MD^e; George Koberlein, MD^f; Morgan P. McBee, MD^g; Anh-Vu H. Ngo, MD^h; HaiThuy N. Nguyen, MDⁱ; Emily S. Orscheln, MD^j; Elizabeth J. Snyder, MD^k; Shawn D. St. Peter, MD^l; George S. Wu, MD^m; Ramesh S. Iyer, MD, MBAⁿ.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1: Child. Chest pain. Limited to the chest wall. Initial imaging.

Variant 1: Child. Chest pain. Limited to the chest wall. Initial imaging.
A. CT chest with IV contrast

Variant 1: Child. Chest pain. Limited to the chest wall. Initial imaging.
B. CT chest without and with IV contrast

Variant 1: Child. Chest pain. Limited to the chest wall. Initial imaging.
C. CT chest without IV contrast

Variant 1: Child. Chest pain. Limited to the chest wall. Initial imaging.
D. MRI chest without and with IV contrast

Variant 1: Child. Chest pain. Limited to the chest wall. Initial imaging.
E. MRI chest without IV contrast

Variant 1: Child. Chest pain. Limited to the chest wall. Initial imaging.
F. Radiography chest

Variant 1: Child. Chest pain. Limited to the chest wall. Initial imaging.
G. Radiography rib views

Variant 1: Child. Chest pain. Limited to the chest wall. Initial imaging.
H. US chest

Variant 2: Child. Chest pain. Suspected pneumothorax or pneumomediastinum. Initial imaging.

Variant 2: Child. Chest pain. Suspected pneumothorax or pneumomediastinum. Initial imaging.
A. CT chest with IV contrast

Variant 2: Child. Chest pain. Suspected pneumothorax or pneumomediastinum. Initial imaging.
B. CT chest without and with IV contrast

Variant 2: Child. Chest pain. Suspected pneumothorax or pneumomediastinum. Initial imaging.
C. CT chest without IV contrast

Variant 2: Child. Chest pain. Suspected pneumothorax or pneumomediastinum. Initial imaging.
D. Fluoroscopy upper GI series

Variant 2: Child. Chest pain. Suspected pneumothorax or pneumomediastinum. Initial imaging.
E. MRI chest without and with IV contrast

Variant 2: Child. Chest pain. Suspected pneumothorax or pneumomediastinum. Initial imaging.
F. MRI chest without IV contrast

Variant 2: Child. Chest pain. Suspected pneumothorax or pneumomediastinum. Initial imaging.
G. Radiography chest

Variant 2: Child. Chest pain. Suspected pneumothorax or pneumomediastinum. Initial imaging.
H. Radiography chest decubitus view

Variant 2: Child. Chest pain. Suspected pneumothorax or pneumomediastinum. Initial imaging.
I. US chest

Variant 2: Child. Chest pain. Suspected pneumothorax or pneumomediastinum. Initial imaging.
J. US echocardiography transthoracic resting

Variant 3: Child. Chest pain. Suspected pulmonary embolism. Initial imaging.

Variant 3: Child. Chest pain. Suspected pulmonary embolism. Initial imaging.
A. Arteriography pulmonary with right heart catheterization

Variant 3: Child. Chest pain. Suspected pulmonary embolism. Initial imaging.
B. CT chest with IV contrast

Variant 3: Child. Chest pain. Suspected pulmonary embolism. Initial imaging.
C. CT chest without and with IV contrast

Variant 3: Child. Chest pain. Suspected pulmonary embolism. Initial imaging.
D. CT chest without IV contrast

Variant 3: Child. Chest pain. Suspected pulmonary embolism. Initial imaging.
E. CTA chest with IV contrast with CTV lower extremities

Variant 3: Child. Chest pain. Suspected pulmonary embolism. Initial imaging.
F. CTA pulmonary arteries with IV contrast

Variant 3: Child. Chest pain. Suspected pulmonary embolism. Initial imaging.
G. MRA pulmonary arteries without and with IV contrast

Variant 3: Child. Chest pain. Suspected pulmonary embolism. Initial imaging.
H. MRA pulmonary arteries without IV contrast

Variant 3: Child. Chest pain. Suspected pulmonary embolism. Initial imaging.
I. Radiography chest

Variant 3: Child. Chest pain. Suspected pulmonary embolism. Initial imaging.
J. US chest

Variant 3: Child. Chest pain. Suspected pulmonary embolism. Initial imaging.
K. US duplex Doppler lower extremity

Variant 3: Child. Chest pain. Suspected pulmonary embolism. Initial imaging.
L. US echocardiography transesophageal

Variant 3: Child. Chest pain. Suspected pulmonary embolism. Initial imaging.
M. US echocardiography transthoracic resting

Variant 3: Child. Chest pain. Suspected pulmonary embolism. Initial imaging.
N. V/Q scan lung

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
A. Arteriography coronary with ventriculography

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
B. Arteriography pulmonary

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
C. CT chest with IV contrast

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
D. CT chest without and with IV contrast

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
E. CT chest without IV contrast

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
F. CT heart function and morphology with IV contrast

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
G. CTA chest with IV contrast

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
H. CTA coronary arteries with IV contrast

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
I. FDG-PET/CT heart

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
J. MRA chest without and with IV contrast

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
K. MRA chest without IV contrast

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
L. MRI heart function and morphology without and with IV contrast

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
M. MRI heart function and morphology without IV contrast

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
N. MRI heart function with stress without and with IV contrast

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
O. MRI heart function with stress without IV contrast

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
P. Radiography chest

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
Q. SPECT or SPECT/CT MPI rest and stress

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
R. US chest

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
S. US echocardiography transesophageal

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
T. US echocardiography transthoracic resting

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
U. US echocardiography transthoracic stress

Variant 4: Child. Chest pain. Known or suspected cardiac disease. Initial imaging.
V. V/Q scan lung

Variant 5: Child. Chest pain. History of sickle cell disease. Initial imaging.

Variant 5: Child. Chest pain. History of sickle cell disease. Initial imaging.
A. CT chest with IV contrast

Variant 5: Child. Chest pain. History of sickle cell disease. Initial imaging.
B. CT chest without and with IV contrast

Variant 5: Child. Chest pain. History of sickle cell disease. Initial imaging.
C. CT chest without IV contrast

Variant 5: Child. Chest pain. History of sickle cell disease. Initial imaging.
D. CTA chest with IV contrast

Variant 5: Child. Chest pain. History of sickle cell disease. Initial imaging.
E. MRI chest without and with IV contrast

Variant 5: Child. Chest pain. History of sickle cell disease. Initial imaging.
F. MRI chest without IV contrast

Variant 5: Child. Chest pain. History of sickle cell disease. Initial imaging.
G. Radiography chest

Variant 5: Child. Chest pain. History of sickle cell disease. Initial imaging.
H. US abdomen

Variant 5: Child. Chest pain. History of sickle cell disease. Initial imaging.
I. US chest

Variant 5: Child. Chest pain. History of sickle cell disease. Initial imaging.
J. US echocardiography transthoracic resting

Variant 5: Child. Chest pain. History of sickle cell disease. Initial imaging.
K. US echocardiography transthoracic stress

Variant 6: Child. Chest pain. Suspected panic attack. Initial imaging.

Variant 6: Child. Chest pain. Suspected panic attack. Initial imaging.
A. CT chest with IV contrast

Variant 6: Child. Chest pain. Suspected panic attack. Initial imaging.
B. CT chest without and with IV contrast

Variant 6: Child. Chest pain. Suspected panic attack. Initial imaging.
C. CT chest without IV contrast

Variant 6: Child. Chest pain. Suspected panic attack. Initial imaging.
D. MRI chest without and with IV contrast

Variant 6: Child. Chest pain. Suspected panic attack. Initial imaging.
E. MRI chest without IV contrast

Variant 6: Child. Chest pain. Suspected panic attack. Initial imaging.
F. Radiography chest

Variant 6: Child. Chest pain. Suspected panic attack. Initial imaging.
G. US chest

Variant 6: Child. Chest pain. Suspected panic attack. Initial imaging.
H. US echocardiography transthoracic resting

Variant 6: Child. Chest pain. Suspected panic attack. Initial imaging.
I. US echocardiography transthoracic stress

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.