Professional Documents
Culture Documents
Ver 60430
CONTENTS
Organisational chart of imaging departments
- Important people in the department
Pre-investigation preparation
- Contraindications
- Preparation
- Consent Taking and Risks of procedure
Radiological investigations
- FAQ
- Head And Neck / Neurology / Neurosurgery / ENT
- Respiratory / Cardiology / Cardiothoracic Surgery (CTS)
- Abdomen / Pelvis / Gastroenterology / HBS / Urology / Obstetrics /
Gynaecology / Breast
- Orthopaedics / Spine / Extermities / Trauma
Disclaimer
Back to top
Issues instruction
Collect contrast/prep after urgent
phamplets, oral contrast,
request is approved
etc.
Back to top
Pre-investigation preparation
Contraindications(By modality)
*- Implication: Keep the patient nil-by-mouth if you think you need the scan urgently!
Back to top
1. Age < 21
2. Pregnant women
3. Women who have missed their period, or are in 2nd half of cycle (for high dose Ix)
4. All interventional procedures (including biopsy)
Radiation dose
Risk from radiation is a slope, there is no one “cut-off” point below which it is “perfectly safe” -
even small radiation doses may have some risk. Therefore, statutory regulations require the dose
to be “as low as reasonably achievable”.
Having said that, there is no absolute “legal” limit to the dose a patient can receive - go ahead
and order the scan if you think the investigation is medically indicated, and the benefits outweigh
the risk.
What then, is the risk, and how do you explain it to patients in layman terms?
Equivalent of “normal”
Modality / Procedure Risk of fatal cancer / death
daily background radiation
Xray – Limbs 1 day 0.0001% (1 in a million)
* Eating 2 bananas a week for 1 year 1 day
Xray – CXR 3 days 0.0003%
Xray – Skull 9 days 0.001% (1 in 100,000)
* Smoking 1 pack of cigarettes - 0.001%
* Flight from Singapore to New York 1 month
Mammogram 2 months 0.005%
Xray - Abdomen, Pelvis, Spine 4 months 0.01% (1 in 10,000)
Tc-99m thyroid scan 6 months
IVU 1 year 0.03%
Barium swallow, meal, follow-through 1 – 1.5 years 0.03%
CT Head 10 months 0.03%
Tc-99m dynamic cardiac scan 2 years 0.05%
CT Chest, abdomen or pelvis 3.5 years 0.1% (1 in 1,000)
* Dying in a home accident each year - 0.1% (1 in 1,000)
* Smoking 1 pack of cigarettes a day x 1 year - 0.35%
(2) Extravasation
- Definition: When the contrast is forced outside the vein
- Background: About 50mls of contrast (which is as viscous as D50%) is injected as fast as
5mls/second under great pressure
(If you don’t believe, get a 20ml syringe, some D50%, a blue plug, and see if you can
inject everything out in 5 seconds!!).
- Problem: Vein bursts (damn, got to reset the plug ;-) --> Contrast leaks out into tissue -->
Draws water from surrounding tissues
--> (1)Dehydration (& cell death)of surrounding tissues and (2)Compartment
syndrome
- Prevention:
- i. Make sure plug works(They check, and you’ll just have to walk down to the
department to re-set it if it doesn’t work)
- ii. Large bore (Pink/Green) plug for procedures requiring high-injection rates (generally
anything vascular/arterial).
- iii. If all else fails, blue plugs (but not in tiny finger veins!) may be acceptable for slow-
injection rates (e.g. brain)
- iv. PICCs are NEVER acceptable. (1) The tiny tip can blast off into the pulmonary
arteries and (2) SVC rupture is not a pretty sight.
- Treatment:
- i. RICE (Rest, Ice-pack, Compress, Elevate extremity)
- ii. Watch for compartment syndrome, especially if large volume
Back to top
Radiological investigations
FAQ
Q: Does the scan require i/v contrast (a.k.a Do I need to set a plug)?
A: This is a tricky one. The full list is given below, but in general, the
following require contrast:
Most CT scans, including those looking at/for:
- Tumour
- Inflammation
- Blood vessels
Some MRI scans, especially those looking at
- Tumour
All interventional studies (except PermCath and Hickman lines, but
including PICC lines)
Common scans that do NOT require i/v contrast include:
CT head for stroke, trauma
CT spine and extremities for trauma
CT KUB for renal/ureteric stones
Q: How do I arrange for an “urgent” scan?
A: This varies by hospital, but here is a suggested approach:
Back to top
Fluoroscopy
Indication Investigation
(1)VFS if high % aspiration
Swallowing assessment / ?Aspiration
(2)Barium swallow (not gastrograffin)
(1)Gastrograffin swallow
FB throat / perforation / post-esophagect
(2)NB: CT neck better for FB
Nasolacrimal duct stenosis Dacrocystogram*
Salivary/Parotid duct stenosis Sialogram*
* - Specialised, rarely performed investigation
Ultrasound
Indication Investigation
Thyroid lump / goitre U/S thyroid
Young CVA U/S carotids
CT
Indication Investigation Contrast?
Stroke, hemorrhagic Head injury (see NICE criteria) CT brain No
Meningitis CT brain Maybe
Fits, brain tumour, mets CT brain Yes
Chronic sinusitis CT paranasal sinuses No
Hearing loss, conductive CT temporal bone No
Foreign body throat CT neck Maybe
MRI
Indication Investigation Contrast?
MRI brain (stroke protocol)
Stroke, hyperacute (< 12 hours) No
NB: CT is better to exclude bleed
Stroke, brainstem Posterior fossa lesions MRI brain (more sensitive than CT) Maybe
Hearing loss, sensorineural MRI IAM / MRI IAM screening Yes
Retrobulbar mass, orbital tumor MRI orbits Yes
Back to top
Fluoroscopy
Indication Investigation
Diaphragmatic paralysis Fluoroscopic sniff test*
* - Specialised, rarely performed investigation
CT
Indication Investigation Contrast
Most lung conditions CT Thorax / CT Chest
High resolution CT (HRCT) (NB: Slices are “skipped” – do not use for tumour
Interstitial lung disease No
detection)
Aortic aneurysm /
CT Aortogram / CT Thoracic aorta Yes (High rate)
dissection
Pulmonary embolism (PE) CT PE / CT Chest (PE protocol) Yes (High rate)
Coronary arteries CT Coronary Arteries / Cardiac CT Yes (High rate)
Back to top
ABDOMEN / PELVIS / GASTROENTEROLOGY / HBS /
UROLOGY / OBSTETRICS / GYNAECOLOGY / BREAST
Abdomen X-ray
Indication Investigation
Standard AXR view AXR (Supine)
Air-fluid levels AXR (Erect) or (Lateral decubitus)
Free air under diaphragm CXR (Erect) or (AP Sit)
Ureteric/bladder calculi KUB
General notes on AXR:
The ‘standard’ AXR does not always cover the pelvis. Order a KUB for pelvic pathology.
Erect or decubitus views are not routinely required, even in IO. The supine view shows bowel distribution better,
and free gas is better detected on the CXR.
Ultrasound
Indication Investigation Preparation Notes
Liver, gallbladder U/S liver / HBS Fast x 8 hours Includes a quick look at kidneys
Kidneys U/S kidneys -
Kidneys & bladder U/S kidneys + bladder Needs to have a full bladder Not routinely ordered
Renal arteries U/S renal artery Fast x 8 hours Specialised investigation
Aorta U/S abdominal aorta Fast x 8 hours CT preferred, if possible
Uterus/ovaries U/S pelvis Needs to have a full bladder May include endovaginal scan
Testes U/S testes -
General notes on ultrasound:
Do NOT order "ultrasound abdomen" – only solid organs can be scanned, and the vast majority of the “abdomen”
(including the bowel) is un-scannable.
You will either get a rejected request, a call from an irate radiologist, or a vague scan of the region based on the
clinical history in your form.
They will never scan the entire “abdomen”, so you might as well be more specific.
Fluoroscopy
Indication Investigation Requirements Notes
Esophagus /
swallowing Barium swallow Be able to stand
problem
Stomach / PUD / Be able to stand and
Barium meal
reflux / hiatus roll over.
Barium follow-through
Small bowel
pathology More invasive than follow-
Enteroclysis
through, but better results
Be able to stand and
Large bowel Barium enema roll over. No fecal
incontinence.
Include op details (incl
Water-soluble /
As for similar barium anastomosis type), and exact
?anastomotic leak gastrograffin swallow/
study. date study is required on
meal/ enema.
form.
Urethral stricture Ascending urethrogram Include op details if any
Vesico-ureteric
MCU Include op details if any
reflux
Post PCN Check nephrostogram
CT
Indication Investigation Contrast
Upper abdominal pathology CT abdomen Yes
Pelvic / gynae pathology CT pelvis Yes
Entire abdominal cavity required CT abdomen + pelvis (abdo/pelvis) Yes
Liver (Routine e.g. abscess) CT liver Yes
Liver lesion ?HCC CT liver (triphasic) Yes (High rate)
Liver HCC post-TACE CT liver (plain + triphasic) Yes
Pancreas CT pancreas (fine cuts) Yes
Renal /ureteric stone CT KUB (may differ by hospital) No
Kidneys CT kidneys Yes (High rate)
Kidneys, ureter, bladder CT urogram(may differ by hospital) Yes (High rate) and Lasix
Abdominal aorta CT abdominal aorta Yes (High rate)
Colon< td> CT colongraphy Yes and rectal gas
General notes on CT:
There are many, many different CT protocols for the abdomen (e.g. see CT liver above!). If unsure, it is best to
state the organ of interest, and provide sufficient history, rather than guess blindly.
Abdomen and Pelvis (in radiological protocol terminology) are completely different!! Your consultant may
casually order a “CT abdomen” for “?sigmoid CA” or “abd pain for ix”, when what he really means is “CT Abdomen
+ Pelvis”. The radiographers protocoling the scan are not medically qualified, and may or may not catch your
meaning, so make sure you fill the form in correctly! (As an aside, the main reason why the pelvis is not automatically
included in a “CT abdomen” is due to the high radiation dose to the gonads and bowel.)
Almost all abdo scans require fasting. If you’re clerking a patient and think he might need an urgent scan, keep
him NBM!
MRI
Indication Investigation Contrast
Liver MRI liver Yes
Bile duct stones MRCP Maybe
Pancreas MRI pancreas Yes
Kidneys MRI kidneys Yes
General notes on MRI:
There are many, many, many MRI protocols for the abdomen, even more than for CT. MRI liver for HCC alone
has 12 sequences. Don’t bother trying to specify them, just state the organ of interest, and provide sufficient history.
Breast
Indication Investigation Note
Screening Mammogram
Evaluation of breast lump Ultrasound + Mammogram
Biopsy of lump Ultrasound guided bx Specialised investigation
Biopsy of lesion on mammogram Mammotome / Stereotactic biopsy Specialised investigation
Implant rupture MRI breast Specialised investigation
Back to top
Plain x-rays
Skull
See head and neck
Spine
Cervical spine
Cervical spine (Swimmers view) or (Lateral pull-
down)
Open-mouth / Odontoid views
Thoracic spine
Lumbar spine
Oblique views of above
Coccyx
Upper limb
Clavicle
Scapula
Shoulder
Humerus
Elbow
Forearm or radius/ulna
Wrist
Scaphoid
Hand
x finger
Pelvis
Pelvis (AP)
Pelvis (Inlet / Outlet)
Judet views (for acetabulum)
Lower limb
Hip
Femur
Knee
Skyline (Patella)
Tib/Fib
Ankle
Calcaneum
Foot
Ultrasound
Indication Investigation
Rotator cuff pathology U/S shoulder
Carpal tunnel, cysts, neuroma U/S wrist
DDH / CDH (< 4-6 mths) U/S hip
MRI
Spine (specify region, level, and side of
symptoms)
Shoulder*
Wrist*
Hip
Knee
Ankle
General notes on MRI:
While MRI is highly detailed, it is not cheap, and before ordering one, ask yourself if it will affect subsequent
management.
* - These procedures may involve use of intra-articular contrast injection (arthrogram), which depends on
indication for the scan, and varies between hospitals. Once again, include all relevant details on the request form (esp.
suspicion of tears and any previous operation) and advise patient he may require an injection.
Back to top
Disclaimer: The author, publisher and server of this website and/or page provide no guarantees or reassurances whatsoever about the accuracy,
legitimacy, or any other statement of fact about the contents, explicitly or otherwise, of any of the pages above and will bear no responsibility of the
consequences arising from your use, abuse or misuse of the contents. The author/publisher have no authority to grant you permission to save,
download, duplicate, or reproduce in any form(electronically or otherwise), any of the contents, and by accessing any of these pages, you are
accepting full responsibilty for the consequences of your actions in using, misusing, or not using these pages, and absolving the author of
responsibility of any results arising from the use of these materials.