Justification of exposure including referral criteria and exposure protocols guidelines
IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department Justification of exposure including referral criteria and exposure protocols guidelines GENERAL RADIOGRAPHY Under the Ionising Radiation (Medical Exposures) Regulations 2000 no medical exposure to radiation can take place without prior justification of the exposure by a practitioner. General radiographic exposures can be authorised by the operator if the referral complies with the enclosed guidelines and criteria which have been approved by the entitled practitioner. Referrers should provide sufficient medical data relevant to the medical exposure requested to enable the operator who is authorising, or the practitioner, to decide whether there is a sufficient net benefit. Radiographers, acting as operator authorising the exposure, should be satisfied that the information provided by the referrer conforms to the approved referral criteria. Any referral not meeting the criteria should be referred to an entitled practitioner who will make a decision on the justification of the exposure. The person authorising or justifying the exposure should be recorded on the referral and the RIS according to the IRMER Pathways charts. Practitioner for General Radiography DR. S. ANTHONY Practitioner for Trauma, Musculoskeletal, Emergency Department and Orthopaedic Referrals ………………………. DR. S. OSTLERE ……………………… File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Issue Date: March 2011 Review Date: March 2012 Page No:1 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department CONTENTS 1. Referral Criteria for General Radiography 1.2 Exceptions to Recommended Referral Criteria 4 1.3 Contraindications to General Radiography 6 2. Adults 2.1 Justification Guidelines: Abdomen Examinations 8 2.2 Exposure Guidelines: Abdomen Views 9 2.3 Justification Guidelines: Chest Examinations 10 2.4 Exposure Guidelines: Chest Views 12 2.5 Justification Guidelines: Upper Limb Examinations 12 2.6 Upper Limb Views and Exposure Guidelines 13 2.7 Justification Guidelines: Lower Limb Examinations 14 2.8 Lower Limb Views and Exposure Guidelines 15 2.9 Justification Guidelines: Pelvis and Hip Examinations 16 3.0 Pelvis and Hip Views and Exposure Guidelines 17 3.1 Spine Examinations 18 3.2 Justification Guidelines: Cervical Spine 18 3.3 Justification Guidelines: Thoracic Spine 18 3.4 Justification Guidelines: Lumbar Spine 19 3.5 Spine Views and Exposure Guidelines 19 3.6 Justification Guidelines: Facial Bone Examinations 20 3.7 Facial Bone Views and Exposure Guidelines 20 3.8 Justification Guidelines: Skull Examinations 21 3.9 Skull Views and Exposure Guidelines 21 File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Issue Date: March 2011 Review Date: March 2012 Page No:2 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department 4 Paediatric 22 4.1 Justification Guidelines: Abdomen Examinations 22 4.2 Justification Guidelines: Chest Examinations 23 4.3 Justification Guidelines: Lower and Upper Limb Examinations 24 4.4 Justification Guidelines: Pelvis and Hip Examinations 24 4.5 Justification Guidelines: Spine Examinations 25 4.6 Justification Guidelines: Skull and Facial Bone Examinations 26 4.7 Justification Guidelines: Skeletal Surveys 28 5.0 Paediatric Views and Exposure Guidelines 29 5.1 Computed Radiography (CR) Views and Exposure Guidelines 5.2 29 Digital Radiography (DR) Views and Exposure Guidelines 33 File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Issue Date: March 2011 Review Date: March 2012 Page No:3 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department 1. Referral Criteria for General Radiography Referral Criteria Referral criteria will be based on the current version of Royal College of Radiologists (RCR) booklet entitled “Making the best use of clinical radiology services” (Version 6.03, 2007), MBUR 6th Edition. These RCR recommendations are available on the Trust’s intranet on the ‘Radiology and PACS’ site. 1.2 Exceptions to recommended referral criteria OUH referral criteria which deviates from the RCR Guidelines (version 6). Cardio-vascular / Thoracic System Referral Action Air entry decrease Added to guidelines Added to guidelines Anaphylactic reaction if pulmonary oedema suspected Aspiration Added to guidelines Chronic Cough Added to guidelines Cardiomegaly Added to guidelines Respiratory Tract Infection Tuberculosis File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Added to guidelines Added to guidelines Suggested Examination CXR PA or AP CXR PA or AP CXR PA or AP CXR PA or AP CXR PA or AP PA preferred to see enlargement of heart CXR PA or AP CXR PA or AP Issue Date: March 2011 Review Date: March 2012 Page No:4 of 20 IRMER Procedure Justification of Exposures Post CABG Days 1-5 Pyrexia Heart murmur Confusion over 65 yrs of age Consolidation Oxford University Hospitals NHS Trust Radiology Department Added to guidelines Added to guidelines Added to guidelines Added to guidelines Added to guidelines Added to guidelines CXR PA or AP CXR PA or AP CXR PA or AP CXR PA or AP CXR PA or AP Bronchiolitis (wheeze or striddor) Collapse (excluding Added to vaso-vagal) guidelines Oxygen Sats low Added to guidelines CXR PA or AP Urological, Adrenal and Genitourinary Systems Renal stones See abdomen section or paediatric section Musculo-skeletal system Spine Added to Degenerative guidelines change/spondylosis Pagets Added to guidelines Shoulder – Impingement Cervical Rib File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Added to guidelines Added to guidelines Added to guidelines CXR PA or AP CXR PA or AP AP and Lateral X-ray affected area only- AP and lateral AP only (glenohumeral joint) Thoracic Inlet and CXR PA or AP Issue Date: March 2011 Review Date: March 2012 Page No:5 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department 1.3 Contraindications to General Radiography The following cannot be justified for general X-ray Clinical Problem Suggested Investigation Musculo-Skeletal Heel pain: Suspected plantar fasciitis Chronic Back Pain: Unless osteoporotic collapse Bony Metastases Soft tissue mass Radiolucent Foreign Body Rotator cuff shoulder Severs Disease (heel pain with no history of trauma) Sternoclavicular joints Trauma 2nd to 5th toes: undisplaced fracture Coccyx # Nasal Bones Fractured Ribs C-spine injury over 65 years of age Gastrointestinal System Abdominal Aortic Aneurysm GI Bleed Dysphagia/ Difficulty in Swallowing Heartburn/ Hiatus Hernia File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC NM, US, MRI MRI NM MRI US US None. Clinical management only CT None. Clinical management only None. Clinical management only None. Clinical management only None. Clinical management only CT US, CT, MRI CTA Ba Swallow Ba Swallow/Meal Issue Date: March 2011 Review Date: March 2012 Page No:6 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department 2. Justification Guidelines and Exposure Protocols This is a guide for radiographers for the following: Justification of referrals An exposure guide – please see specific exposures available in each X-ray room Expected dose levels – an average is given as these will differ dependent on X-ray equipment Comments to offer tips and advice File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Issue Date: March 2011 Review Date: March 2012 Page No:7 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department ADULTS 2.1 Justification Guidelines: Abdomen Examinations 28 day rule applies – 12 to 55 years Clinical Problem Investigation Gastrointestinal System Acute Abdominal Pain AP Supine Looking for either obstruction or (to exclude obstruction) perforation Erect CXR (to exclude perforation see ‘perforation’) Acute Small Bowel Obstruction AP Supine Acute Large Bowel Obstruction AP Supine Acute Pancreatitis AP Supine When non-specific acute pain (to exclude obstruction) Erect CXR (to exclude perforation see ‘perforation’) Chronic Pancreatitis AP Supine May show calcification Constipation AP Supine Maybe helpful in (Specialist request only) Geriatric/Psychiatric to show the extent of impaction Inflammatory Bowel disease AP Supine Looking for toxic dilatation Palpable mass Refer to radiologist Perforation Toxic Megacolon Urological, Adrenal and Genitourinary Systems Renal Stones Possible investigation: US/CT LT Lateral Decubitus or Erect CXR (Erect CXR preferred) AP Supine CTKUB if no imaging in last 6 months If imaging in last 6 months AP Supine film. Trauma Foreign Body AP Supine Stab Injury AP supine, Erect CXR File: justification-guidelines.doc Author’s Initials: DS Comments Version No: 5 Authorised By: MC Issue Date: March 2011 Review Date: March 2012 Page No:8 of 20 IRMER Procedure 2.2 Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department Exposure Guidelines: Abdomen Views Examination Views Exposure Abdomen AP Supine (To include diaphragm and symphysis pubis) Decubitus LT Lateral Erect (right side up) 75 KV and both side chambers using AEC (preferred method) 75KV + 25mAs with stationary grid 75KV and middle chamber using AEC upright bucky (preferred method) 75KV 25mAs With stationary Grid File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Expected Dose cGycm2 Issue Date: March 2011 Review Date: March 2012 150 Page No:9 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department 2.3 Justification Guidelines: Chest Examinations Please do PA erect image when possible Clinical Problem Investigation Gastrointestinal System Acute abdominal Pain Chest and Cardiovascular System Acute Chest Pain Angina (Unstable) Air Entry Decreased Anaphylactic Reaction (if pulmonary oedema) Aortic Dissection PA or AP Asthma PA or AP Aspiration PA or AP Bronchiectasis Bronchiolitis Cardiomegaly Chronic Cough COPD/COAD Collapse (excluding Vaso-vagal) Confusion (over 65 years) Consolidation Cystic Fibrosis Haemothorax Heart Failure Heart Murmur Hypertension Lower Respiratory Tract Infection Lung Disease PA or AP PA or AP PA or AP PA or AP PA or AP PA or AP PA or AP PA or AP PA or AP + Lateral PA (+ Lateral over 50yrs) PA or AP PA or AP PA or AP PA or AP PA or AP PA or AP Malignancy PA or AP Haemoptysis File: justification-guidelines.doc Author’s Initials: DS Comments PA or AP PA or AP PA or AP PA or AP PA or AP Version No: 5 Authorised By: MC to exclude other causes when patient does not respond to treatment OR suffering from pyrexia/leucocytosis or localising pain when change in symptoms Issue Date: March 2011 Review Date: March 2012 Page No:10 of 20 IRMER Procedure Justification of Exposures Myocardial Infarction Oesophageal Perforation Osteosarcoma Oxygen Sats Decrease Perforation Pericarditis/pericardial Effusion PICC line insertion Pleural Effusion Pulmonary Embolism Pre-Cardiac Intervention Pneumonia Pneumonia Follow-up (usually 6 weeks time) Pneumothorax Post Biopsy (Lung) Post CABG Post Pace-Maker Insertion Pyrexia Respiratory Tract Infection Shortness of Breath Sternal Fracture Oxford University Hospitals NHS Trust Radiology Department PA or AP PA or AP PA or AP + Lateral PA or AP PA or AP (Erect) PA or AP PA or AP PA or AP (Erect) PA or AP PA or AP PA or AP PA or AP PA or AP PA or AP PA or AP PA or AP + Lateral PA or AP PA or AP PA or AP PA or AP + Coned Lateral Thoracic Inlet Obstruction Tuberculosis Valvular Heart Disease Trauma Stab Injury Foreign Body Pre-Employment/emigration (Specific jobs e.g. deep-sea diving – ask radiologist if not sure) Apical View Only PA or AP PA or AP ITU CXR AP PA or AP PA or AP PA or AP Inspiration only PA preferred to see mediastinal widening Specific paperwork required for emigration purposes when change in condition Pre-Op (Cardiac patients and PA or AP patients with a # NOF and are 65 years +) File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Issue Date: March 2011 Review Date: March 2012 Page No:11 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department 2.4 Exposure Guidelines: Chest Views Please refer to specific room settings Examination Chest Chest Chest Views PA Exposure Expected Dose cGycm2 FFD = 150cm 150kV + 2.5mAs (use Airgap) FFD = 100cm 85kV + 2.5mAs FFD = 120cm 150kV + 10mAs (use airgap) AP Lateral <5 < 10 < 20 2.5 Justification Guidelines: Upper Limb Examinations Refer to Views and Exposure Guidelines for Specific Investigation Clinical Problem Musculo-skeletal System Arthropathy Bony Mass/Primary Bone Tumour Bone Pain Diabetes – Hands Only Osteomalacia Osteomyelitis Painful Prosthesis Pagets AP (affected area only) AP + Lateral Comments for all cases of unresolved bone pain AP + Lateral DP AP + Lateral AP + Lateral AP + Lateral AP + Lateral (affected area only) Trauma Trauma Trauma Follow-up (e.g. post manipulation/reduction) Stress Fracture Subluxation Dislocation Foreign Body (Radio-opaque only) File: justification-guidelines.doc Author’s Initials: DS Investigation AP + Lateral AP + Lateral AP + Lateral AP + Lateral AP + Lateral AP and Lateral and tangential view of affected area. Version No: 5 Authorised By: MC Issue Date: March 2011 Review Date: March 2012 Use marker to indicate site/wound Page No:12 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department Remove dressings Foreign Body ? bony involvement (Radio-opaque only) AP and Lateral view of Object 2.6 Upper Limb Views and Exposure Guidelines Please refer to specific room settings Examination Fingers Hand Thumb Scaphoid Wrist Views DP, Lateral (45° Oblique for MCPJ) DP + Oblique (lateral if #’d MC) AP + Lateral DP, Lateral, Oblique, 25° Axial DP + Lateral Exposure 50-52kV + 1.4-1.6mAs 52-55kV + 1.6mAs (60Kv + 2mAs for lateral) 50-52kV + 1.4-1.6mAs 52-55kV + 1.5mAs – 2mAs Forearm AP + Lateral DP = 55kV + 2mAs Lateral = 56kV + 2mAs 55kV + 2.5mAs Elbow Humerus AP + Lateral AP + Lateral 60kV + 2mAs 65kV + 3.2mAs Shoulder (Trauma) AP+ Axial/modified axial (Lateral for proximal humerus) AP Oblique (45° to view gleno-humeral joint) + Axial/modified axial –see AP: 64.5kV + 4mAs Lateral/axial: 75kV + 3.2mAs Shoulder Joint (Trauma) (post manipulation and follow-up) File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Expected Dose cGycm2 <2 <3 <2 <3 <4 < 5 (for both views) <2 < 10 (for both views) <4 <8 AP: As above Axial: 75kV + 3.2mAs Issue Date: March 2011 Review Date: March 2012 <6 Page No:13 of 20 IRMER Procedure Scapula Clavicle ACJ Justification of Exposures protocol folder for modified axial projection. AP +Lateral AP + AP 20° Cranial Deviation AP Oxford University Hospitals NHS Trust Radiology Department Same as Shoulder 65kV + 2.5mAs Same as Shoulder < 10 (for both views) 64.5kV + 4mAs <4 2.7 Justification Guidelines: Lower Limb Examinations Refer to Views and Exposure Guidelines for Specific Investigation Clinical Problem Investigation Musculo-skeletal System Arthropathy Bony Mass/Primary Bone Tumour Bone Pain Diabetes (for osteomyelitis feet) Loose Body (Knee) Knee Pain without Trauma (Arthritic/arthropathy changes may be seen) Osteomalacia Pagets Osteomyelitis Painful Prothesis Hallux Valgus Other Stress Views/Weight bearing Trauma Trauma Trauma Follow-up (e.g. post manipulation/reduction) Tibial Plateau Fracture File: justification-guidelines.doc Author’s Initials: DS AP (affected area only) AP + Lateral Comments for all cases of unresolved bone pain AP + Lateral DP + 45° Oblique AP + Lateral AP + Lateral AP + Lateral AP + Lateral (affected area only) AP + Lateral AP + Lateral AP + Lateral AP + Lateral Trauma referral only AP + Lateral AP + Lateral AP + Lateral Version No: 5 Authorised By: MC Both 45° obliques if cannot see fracture but see Issue Date: March 2011 Review Date: March 2012 Page No:14 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department Foreign Body (Radio-opaque only) AP and Lateral and tangential view of affected area. Foreign Body ? bony involvement (Radio-opaque only) Dislocation AP and Lateral view of Object lipohaemarthrosis Use marker to indicate site/wound Remove dressings AP + Lateral 2.8 Lower Limb Views and Exposure Guidelines Please refer to specific room settings Examination Big Toe Toes Foot Calcaneum Ankle Tib/Fib Knee Patella File: justification-guidelines.doc Author’s Initials: DS Views Exposure Expected Dose cGycm2 DP + Lateral DP + 45° Oblique DP + 45° Oblique Lateral + 45° Axial (see protocols for Broden’s View) AP + Lateral (See protocols for gravity stress view) AP + Lateral (Obliques may be requested by Trauma) AP + Lateral (HBL for Trauma) AP + Lateral Knee (Skyline View may be requested by Trauma) 60kV + 1.4mAs 60kV + 1.4mAs <1 <1 60kV + 1.6mAs <2 Version No: 5 Authorised By: MC Lateral: 60kV + < 5 (for both 2mAs images) Axial: 63kV + 2.5mAs 60kV + 2mAs <4 65kV + 2.5mAs < 8 (for both images) 64.5kV + 4mAs < 15 (for both images) 64.5kV + 4mAs < 20 (for all images) Issue Date: March 2011 Review Date: March 2012 Page No:15 of 20 IRMER Procedure Femur Justification of Exposures AP + Lateral Oxford University Hospitals NHS Trust Radiology Department 70kV + AEC centre chamber (16mAs with Grid) < 15 2.9 Justification Guidelines: Pelvis and Hip Examinations 28 day rule applies – 12 to 55 years Clinical Problem Investigation Musculo-skeletal System Arthropathy Avascular Necrosis Bone Pain Hip Pain Osteomyelitis Osteomalacia Painful Prosthesis Post op – THR, ETS (All prosthesis must be included; DHS patients should have had X-rays in theatre) Primary Bone Tumour Sacroiliac Pain Pagets Trauma Trauma Trauma Follow-up (Post reduction) Acetabular Fixation/Fracture Fall Injury to pelvic ring File: justification-guidelines.doc Author’s Initials: DS Comments AP Pelvis AP Pelvis AP Pelvis and Lateral AP Pelvis + Lateral AP + Lateral AP + Lateral AP + Lateral AP Pelvis (Top of cassette at ASIS for hips) + HBL Lateral AP + Lateral AP Pelvis AP Pelvis(affected area only) AP Pelvis + (HBL Lateral for Hip, Judet views for acetabular) AP + Lateral Judet Views AP Pelvis + HBL Lateral Inlet and Outlet Trauma referral only Version No: 5 Authorised By: MC Issue Date: March 2011 Review Date: March 2012 Page No:16 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department 3.0 Pelvis and Hip Views and Exposure Guidelines Please refer to specific room settings Examination Pelvis Pelvis Pelvis Pelvis Hip Hip SIJ File: justification-guidelines.doc Author’s Initials: DS Views Exposure Expected Dose AP Use AEC both side chambers or stationary grid 85kV (+ 32mAs) Judet (45° Use AEC all 3 Oblique pelvis) chambers or stationary grid 90kV ( + 40mAs) Inlet (30° Use AEC all 3 down) chambers or stationary grid 95kV (4050mAs) Outlet (40° up) Use AEC all 3 chambers or stationary grid 95kV (4050mAs) Horizontal 85kV + 85mAs Beam Lateral with stationary grid AP or Use AEC Turned Lateral centre chamber or stationary grid 80kV (+ 25mAs) AP – 15 degrees cranial PA – 15 degrees caudal Version No: 5 Authorised By: MC Issue Date: March 2011 Review Date: March 2012 < 100 < 200 <200 < 200 < 350 < 100 Page No:17 of 20 IRMER Procedure 3.1 3.2 Justification of Exposures Spine Examinations Justification Guidelines: Cervical Spine Clinical Problem Investigation Musculo-Skeletal System Atlanto-Axial Subluxation (To identify congenital or structural abnormalities) Atlanto-occipital Subluxation Brachialgia Degenerative change/spondylosis Nerve Compression Trauma Suspected Ligamentous Injury Trauma Unconscious Trauma Foreign Body Neck Pain/Injury with Neurological Deficit 3.3 Oxford University Hospitals NHS Trust Radiology Department Comments Lateral Lateral Refer to radiologist AP + Lateral MRI Refer to radiologist MRI Flexion + Extension (movement undertaken by referrer) AP, Peg, Lateral – swimmers if C7/T1 is not visualised Refer to radiologist Lateral or tangential Views (dependent on location) AP, Peg, Lateral swimmers if C7/T1 is not visualised Trauma referral only CT CT If patient over 65 years of age Justification Guidelines: Thoracic Spine Clinical Problem Investigation Musculo-Skeletal System Degenerative change/spondylosis Osteoporotic Collapse Spondyloarthropathies Trauma Trauma Trauma with neurological deficit File: justification-guidelines.doc Author’s Initials: DS Comments AP + Lateral Lateral AP + Lateral AP + Lateral AP + Lateral Version No: 5 Authorised By: MC Issue Date: March 2011 Review Date: March 2012 Page No:18 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department 3.4 Justification Guidelines: Lumbar Spine 28 day rule applies – 12 to 55 years Clinical Problem Musculo-Skeletal System Acute Back Pain Degenerative change/spondylosis Osteoporotic Collapse Spondyloarthropathies Trauma Trauma Trauma with neurological deficit Investigation Comments Refer to radiologist AP + Lateral MRI Lateral AP + Lateral AP + Lateral AP + Lateral 3.5 Spine Views and Exposure Guidelines Please refer to specific room settings Examination Cervical Views AP Peg Lateral Swimmers Thoracic AP Lateral File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Exposure 65kV + 5mAs (no grid) 65kV + 5mAs (no grid) 65kV + 12mAs (no grid) Use AEC centre chamber or set exposure 85- 90kV (+ 150-300mAs) Use AEC centre chamber or stationary grid 80kV (+ 30mAs) Use AEC centre chamber or stationary grid 80kV (+ 4050mAs) Expected Dose cGycm2 < 20 (for all views) < 50 < 100 (for both views) Issue Date: March 2011 Review Date: March 2012 Page No:19 of 20 IRMER Procedure Justification of Exposures Lumbar AP Use AEC centre chamber or stationary grid 90kV (+ 40 mAs) Use AEC centre chamber or stationary grid 95kV(+50mAs) Lateral 3.6 Oxford University Hospitals NHS Trust Radiology Department < 300 (for both views) Justification Guidelines: Facial Bone Examinations Clinical Problem Investigation Trauma Blunt Injury Middle Third of Face Mandibular Trauma Dislocation Subluxation of TMJ Foreign Body Orbits ENT/Head and Neck Abscess Dental Reasons Impacted 8’S Other Pre-Op valve replacement ? tooth decay Comments OM +OM 30 OM +OM 30 OPG + PA Mandible OPG + PA Mandible OPG Tangential Views Orbit Views OPG OPG OPG OPG 3.7 Facial Bone Views and Exposure Guidelines Please refer to specific room settings Examination Facial Bones File: justification-guidelines.doc Author’s Initials: DS Views OM Version No: 5 Authorised By: MC Exposure Expected Dose cGycm2 Use AEC centre chamber or skull unit 85kV (+ 12mAs) Issue Date: March 2011 Review Date: March 2012 < 20 Page No:20 of 20 IRMER Procedure Justification of Exposures OM 30 Mandible Use AEC centre chamber or skull unit 85kV (+ 16mAs) 65kV + 12mA + 8sec OPG PA < 15 < 20 Justification Guidelines: Skull Examinations Clinical Problem Trauma Foreign Body Trauma 3.9 < 20 Use AEC centre chamber or skull unit 75kV (+ 12mAs) Use AEC centre chamber or skull unit 80KV (+ 16mAs) Obliques 3.8 Oxford University Hospitals NHS Trust Radiology Department Investigation Tangential View Refer to radiologist Comments CT Skull Views and Exposure Guidelines Examination Foreign Body File: justification-guidelines.doc Author’s Initials: DS Views Tangential View Version No: 5 Authorised By: MC Exposure 60 KV and 2mAs Expected Dose cGycm2 >2 Issue Date: March 2011 Review Date: March 2012 Page No:21 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department 4. PAEDIATRICS 4.1 Justification Guidelines: Abdomen Examinations 28 day rule applies 12 years + Clinical Problem Gastrointestinal System Abdominal Pain Constipation Distention GI bleeding (If necrotising enterocolitis or intussusception is suspected) Paediatric Transit Study (Image taken on day 5 post ingestion of pellets) Obstruction Perforation Position of epidural Baclofen pump Urological, Adrenal and Genitourinary Systems Renal Stones Investigation Supine Supine Comments Requested by Paed. Specialist Supine Supine Supine See local protocol in Children’s Radiology Dept. Supine Supine AXR and Erect AP/PA Chest Neonatal = decubitus abdomen Supine AXR and lateral thoracolumbar spine is requested Ultrasound and Supine Abdomen if requested by radiologist Show abdomen Xray first to radiologist. Pump sits in iliac fossa with lead entering spinal canal. Ultrasound first Discuss with Paed radiologist if unsure Larger children for CTKUB Supine Stent Position Trauma Ingested Foreign Body which Supine Abdomen is Sharp, >1 magnet, or Battery and PA/AP Chest File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Issue Date: March 2011 Review Date: March 2012 Page No:22 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department 4.2 Justification Guidelines: Chest Examinations In addition to those stipulated in the adult section Please refer to local protocol (protocol folder) for guidance for when to do AP/PA/Sitting/Standing in accordance with age of patient Clinical Problem Chest and Cardiovascular System Acute Chest Infection Cystic Fibrosis Perforation PA/AP PA/AP and lateral Comments Annual Review Abdominal U/S also required PA/AP Erect AP/PA Erect Chest Neonatal = decubitus abdomen PA/AP Mr Grant’s Lateral only if request = Lateral requested by Mr only Grant PH Probe Position PICC Line Insertion Post Pace-Maker Insertion Pulmonary Metastases Trauma Inhaled Foreign Body Investigation PA/AP - to include appropriate arm if brachial insertion PA/AP Views as requested by cardiologist PA/AP and Lateral May not always require a lateral view PA/AP to include neck Foreign Body AP + Lateral (Radio-opaque only) (affected area only) Ingested Foreign Body PA/AP (Abdomen not (Radio-opaque only) needed) Ingested Foreign Body which PA/AP and Supine is Sharp, >1 magnet, or Battery Abdomen File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Issue Date: March 2011 Review Date: March 2012 Page No:23 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department 4.3 Justification Guidelines: Lower and Upper Limb Examinations Clinical Problem Musculo-Skeletal System Bone Age Investigation Left Hand and Lt Wrist DP Rickets DP/AP 1 joint only Bone Pain (including ?Osgood Schlatter’s Disease on referral) AP and Lateral of Affected Bone Referrals from Plastics Clinic Views as requested by operating team Trauma Trauma ? FB (other than inhaled or ingested) Radio-opaque only Foreign Body ? bony involvement (Radio-opaque only) AP and Lateral of Affected Area AP and Lateral of affected area using marker to indicate site/wound Comments Must include complete hand /wrist and thumb to include tips of phalanges and soft tissues fingers just not touching, not spread out. Even if both have been requested Looking for bone tumour or infection See chest for inhaled or ingested Remove dressings AP and Lateral view of Object 4.4 Justification Guidelines: Pelvis and Hip Examinations 28 day rule applies 12 years + Clinical Problem Musculo-Skeletal System DDH (Developmental Dysplasia of Hips) Change of Plaster (Hip Spica) – for treatment of DDH File: justification-guidelines.doc Author’s Initials: DS Investigation Comments AP pelvis AP Pelvis Version No: 5 Authorised By: MC Patient needs to go to plaster room to have plaster cut first. Issue Date: March 2011 Review Date: March 2012 Page No:24 of 20 IRMER Procedure Justification of Exposures Limping Child-request to X-ray whole leg Oxford University Hospitals NHS Trust Radiology Department AP Pelvis and AP and lateral limb bones as directed by clinical team Limping Child ?Irritable Hip AP pelvis if requested by radiologist Perthes/Avascular necrosis Frog Legs Lateral only SUFE (Slipped Upper Femoral Frog Legs Lateral Epiphysis) – Approx. age 10-16 only yrs Trauma Trauma AP pelvis and HBL lateral Remove top section and Xray child whilst still in posterior section of cast. Child needs to be immobilised in cast for X-ray. Replace anterior section and bandage in place for transfer back to ward. Gonad protection not to be used on 1st image but should be used on subsequent imaging. U/S first 4.5 Justification Guidelines: Spine Examinations 28 day rule applies for L-Spine 12 years + Clinical Problem Musculo-Skeletal System Post Scoliosis Repair File: justification-guidelines.doc Author’s Initials: DS Investigation AP and Lateral Thoracic and Lumbar Spine Standing AP and Lateral views may be requested Version No: 5 Authorised By: MC Comments Images must overlap and include whole T and L Spine Images may be requested whilst Issue Date: March 2011 Review Date: March 2012 Page No:25 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department patient is sitting in their own wheel chair Spinal vertebral Anomalies Constipation with suspected underlying spinal cause Chronic Back Pain Spondylolisthesis C-Spine Instability/Subluxation Trauma Trauma AP and Lateral Lumbar/Sacral Spine AP Lumbar/scaral Spine Review with Pead. Radiologist as a lateral may also be required Refer to Radiologist Lateral Lumbar/Sacral Spine and review with Paed. Radiologist As requested May need Flexion and Extension Views. A Lateral may suffice Vertebral anomaly may affect nerve supply to bowel hence causing constipation. Often can’t see on AP due to constipation but this is view of choice. Often presents in sporty children Must be performed in presence of referring clinician AP and Lateral of Effected Area Peg view for C-spine injury 4.6 Justification Guidelines: Skull and Facial Bone Examinations Clinical Problem Musculo-Skeletal System Craniosynostosis (premature fusing of sutures) Post Cranio-Facial Surgery. Frontal Advancement ENT/Head and Neck Cochlear Implants File: justification-guidelines.doc Author’s Initials: DS Investigation Comments AP, Townes and Lateral Views as requested by cranio-facial team. With copper ruler on edge of image May ask for both laterals Coned AP Centre through EAMs Version No: 5 Authorised By: MC Issue Date: March 2011 Review Date: March 2012 Page No:26 of 20 IRMER Procedure Justification of Exposures Post Nasal Space for enlarged adenoids Shunt Insertion – to show position of Ventroperitoneal (VP)Shunt Trauma Facial Trauma Only need to see position of leads in cochlea No need to include the external component attached to head Most patients have bilateral Lateral Face Ideally with “Sniffing In” Collimate to avoid eyes VP shunt drains VP Shunt Series: from ventricles in Lateral Skull to the brain into the include neck peritoneum PA/AP chest to Treatment for include lower neck hydrocephalus Supine Abdomen to include lung bases to Important to get overlap of the symphysis pubis images to ensure that there are no breaks in the shunt OM and OM30° Head Trauma (18mths and under) File: justification-guidelines.doc Author’s Initials: DS Oxford University Hospitals NHS Trust Radiology Department AP/PA and Lateral, (even if CT requested) Version No: 5 Authorised By: MC If unsure speak to Consultant Paediatric If unsure speak to Consultant Paediatric Radiologist Issue Date: March 2011 Review Date: March 2012 Page No:27 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department 4.7 Justification Guidelines: Skeletal Surveys NAI Must be discussed with Abdomen to include Please see specific Paediatric Consultant folder in Paediatric Pelvis Radiologist Chest to include all Hospital or Level One ribs Oblique Ribs to For live children include all ribs arrange a mutually Lateral C-spine convenient time Lateral thoracowith the patient’s lumbar Spine nurse and the Skull AP and radiologist Lateral – lateral to Make sure the include mandible patient has had a Separate AP views on good feed and/or both: sleep and comes Feet to the dept with a Femurs dummy if they Tib/Fib have one Humeri 2 people will be Rad/Ulna required to Hands immobilise the patient. Ensure Additional views as that neither are directed by Consultant pregnant before Paediatric Radiologist they come to the dept If parent is assisting please ensure they know why the examination is being carried out before arrival to the X-ray Dept General As directed by radiologist Protocol for each individual patient File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Issue Date: March 2011 Review Date: March 2012 Page No:28 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department 5.0 5.1 Paediatric Views and Exposure Guidelines Computed Radiography (CR) Views and Exposure Guidelines Please refer to specific room settings Examinations Based on CR method Chest Chest 0 - 6 months Chest 6 months – 5 years Chest 5 years + Lateral Chest < 5 years Lateral Chest > 5 years Abdomen/Pelvis Abdomen or Pelvis Baby Views Supine 60 – 63kV + 1 - 2mAs 180 FFD AP Sitting 65kV + 1.6 – 3.2mAs 180cm FFD AP/PA 65-77KV + 2 Standing – 3.2 180cm FFD Lateral Sitting 70KV + or Standing 3.2mAs 180cm FFD Lateral Sitting 73KV + 4or Standing 5mAs 180cm FFD Supine Abdomen or Pelvis 1- 10 years Supine Abdomen or Pelvis 10 + years Supine File: justification-guidelines.doc Author’s Initials: DS Exposure Version No: 5 Authorised By: MC 60KV + 1-2 mAs 100cm FFD No Grid 65kV -75KV + 2-10 mAs 100cm FFD Use AEC, both side chambers 75kV (+1625mAs with stationary grid) 100cm FFD Issue Date: March 2011 Review Date: March 2012 Expected Dose cGycm2 1 1-2 1-5 3 5-8 1 -2 2-11 <150 Page No:29 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department Spine C-Spine Lateral 65-70KV + 6mAs 180cm FFD AP 60KV + 4mAs 100cm FFD 60KV + 4mAs 100cm FFD 75-80KV + AEC centre chamber or manual exposure of 80-120mAs 110cm FFD Peg Swimmers T-Spine <10 years Lateral <10 years AP >10 years Lateral >10 years AP File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC 65-75KV 10-16mAS 180cm FFD (no Grid – use air gap) 60-70KV + 6-10mAs (no grid) 70-80KV AEC centre chamber 100cm FFD 65-75KV + AEC centre chamber (10-16 mAs with stationary grid) Issue Date: March 2011 Review Date: March 2012 Whole series (no swimmers) <20 Whole series (with swimmers) < 150 Whole Series < 25 Whole Series < 200 Page No:30 of 20 IRMER Procedure Justification of Exposures Oxford University Hospitals NHS Trust Radiology Department L-Spine <10 years Lateral 70-75KV + 14-18mAs 180cm FFD (no Grid – use air gap) <10 years AP >10 years Lateral >10 years AP 65-75KV 1012mAs (no grid) 75-85KV + Whole AEC centre Series < chamber 500 100cm FFD 70-80KV + AEC centre chamber (18-25mAs with stationary grid) Skull <10 years AP <10 years Lateral >10 years AP >10 years Lateral Facial Bones <10 years OM File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Whole Series < 30 60-70KV + 2.5-4mAs (no Grid) 60-70KV + 2.5-4mAs (no Grid) 70KV + AEC centre chamber (10-16mAs with Grid) 65KV + AEC centre chamber (10mAs) Whole Series < 20 60-70KV + 2.5-4mAs (no Grid) Whole Series < 20 Issue Date: March 2011 Review Date: March 2012 Whole Series < 80 Page No:31 of 20 IRMER Procedure Justification of Exposures <10 years OM 30° >10 years OM >10 years OM 30° Upper and Lower Limbs Hands Oxford University Hospitals NHS Trust Radiology Department 60-70KV + 2.5-4mAs (no Grid) 70KV + AEC Whole Series < 80 centre chamber (10-16mAs with Grid) 70KV + AEC centre chamber (10-16mAs with Grid) Thumb DP + Oblique (lateral if #’d MC) DP, Lateral (45° Oblique for MCPJ) AP + Lateral Feet DP + Oblique Toes DP + Oblique Long Bones + Joints (Humeri, tib/fib, radius/ulna, femora, elbow,) AP + Lateral (Scaphoid does not appear till about 10 years of age) 55-60KV + AP and 2mAs review Axial/modified axial (Lateral for proximal humerus) AP + Lateral 55-60KV + 2mAs Fingers Shoulder (Trauma) Scapula (Trauma) File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC 50-55KV + 1mAs <2 50-55KV + 1mAs <2 50-55KV + 1mAs 50-55KV + 1.6mAs 50-55KV + 1mAs 55-60KV + 2mAs <2 Issue Date: March 2011 Review Date: March 2012 <2 <2 <5 <5 <5 Page No:32 of 20 IRMER Procedure Justification of Exposures Clavicle/ACJ (Trauma) Skeletal Survey As per individual protocol and using views and exposures above AP only Oxford University Hospitals NHS Trust Radiology Department 55-60KV + 2mAs <5 <35 total for small baby 5.2 Digital Radiography (DR) Views and Exposure Guidelines Please refer to specific room settings Based on DR (Children’s Hospital) Chest Chest Supine 60-63KV + 10 - 6months (through table) 2mAs 120cm FFD Chest AP Sitting 65KV + 26 months – 5 3.2mAs (or years AEC both side chambers) 180cm FFD Chest 5 years + AP/PA 65-77KV Standing Use AEC, both side chambers, 180cm FFD Lateral Chest Lateral Sitting 70KV + 3.2 < 5 years or Standing mAs 180cm FFD Lateral Chest Lateral Sitting 73KV, Use > 5 years or Standing AEC centre chamber 180cm FFD Abdomen/Pelvis Abdomen or Supine 60KV + AEC Pelvis centre Baby chamber 110cm FFD File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Issue Date: March 2011 Review Date: March 2012 1 1-2 1-5 3 5-8 1 -2 Page No:33 of 20 IRMER Procedure Justification of Exposures Abdomen or Pelvis 1- 10 years Supine Abdomen or Pelvis 10 + years Supine Oxford University Hospitals NHS Trust Radiology Department No Grid 65kV-75KV + AEC both side chambers 110cm FFD Use AEC with Grid both side chambers 75kV 110cm FFD 2-11 <150 Spine C-Spine Lateral AP T-Spine <10 years Lateral <10 years AP >10 years Lateral >10 years AP File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC 65-70KV + AEC centre chamber 180cm FFD 65-70KV +AEC centre chamber 110cm FFD <10 for whole series 65-70KV AEC centre chamber 110cm FFD 65-70KV AEC centre chamber 110cm FFD 65-70KV AEC centre chamber using Grid 110cm FFD 65-70KV AEC centre chamber 110cm FFD <10 for whole series <30 for whole series Issue Date: March 2011 Review Date: March 2012 Page No:34 of 20 IRMER Procedure Justification of Exposures L-Spine <10 years Lateral <10 years AP >10 years Lateral >10 years AP Skull <10 years AP/PA <10 years Lateral >10 years AP/PA >10 years Lateral Facial Bones <10 years OM File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Oxford University Hospitals NHS Trust Radiology Department 65KV -75KV AEC centre chamber 110cm FFD 65-75KV AEC centre chamber 110FFD 65KV -75KV AEC centre chamber with grid 110cm FFD 65-75KV AEC centre chamber 110FFD <20 for whole series 63-75KV AEC Centre chamber 110cm FFD 63-75KV AEC Centre chamber 110cm FFD 63-75KV AEC Centre chamber with Grid 110cm FFD 63-75KV AEC Centre chamber with Grid 110cm FFD <15 63-75KV AEC Centre chamber <15 <150 for whole series Issue Date: March 2011 Review Date: March 2012 <15 <15 <15 Page No:35 of 20 IRMER Procedure Justification of Exposures <10 years OM 30° >10 years OM >10 years OM 30° Post nasal space Lateral Upper and Lower Limbs Hands DP + Oblique (lateral if #’d MC) Fingers DP, Lateral (45° Oblique for MCPJ) Thumb AP + Lateral Feet DP + Oblique File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Oxford University Hospitals NHS Trust Radiology Department 110cm FFD 63-75KV AEC Centre chamber 110cm FFD 63-75KV AEC Centre chamber with Grid 110cm FFD 63-75KV AEC Centre chamber with Grid 110cm FFD 63-75KV AEC Centre chamber 110cm FFD 60KV + 1.25mAs directly onto detector 110cm FFD 60KV + 1.25mAs directly onto detector 110cm FFD 60KV + 1.25mAs directly onto detector 110cm FFD 60KV + 1.25mAs directly onto detector 110cm FFD Issue Date: March 2011 Review Date: March 2012 <15 <15 <15 <10 <2 <2 <2 <2 Page No:36 of 20 IRMER Procedure Justification of Exposures Toes DP + Oblique Long Bones + Joints (Humeri, tib/fib, radius/ulna, femora, elbow,) AP + Lateral (Scaphoid does not appear till about 10 years of age) AP and review Axial/modified axial (Lateral for proximal humerus) AP + Lateral Shoulder (Trauma) Scapula (Trauma) Clavicle/ACJ (Trauma) AP only Skeletal Survey As per individual protocol and using views and exposures above File: justification-guidelines.doc Author’s Initials: DS Version No: 5 Authorised By: MC Oxford University Hospitals NHS Trust Radiology Department 60KV + 1.25mAs directly onto detector 110cm FFD 60KV + AEC Centre Chamber 110cm FFD <2 60KV + AEC Centre Chamber 110cm FFD <5 60KV + AEC Centre Chamber 110cm FFD 60KV + AEC Centre Chamber 110cm FFD <5 Directly onto detector where possible <35 total for small baby Issue Date: March 2011 Review Date: March 2012 <5 <5 Page No:37 of 20
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