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3/17/2015
Medical Imaging
through the Lifespan
Glynda Ramsey, MD
Mountain Empire Radiology, PC
March 23,2015
Disclosure Statement of Financial
Interest
I, Glynda Ramsey,
DO NOT have a financial interest/arrangement
or affiliation with one or more organizations that
could be perceived as a real or apparent conflict
of interest in the context of the subject of this
presentation.
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Disclosure Statement of
Unapproved/Investigative Use
I, Glynda Ramsey,
DO NOT anticipate discussing the
unapproved/investigative use of a commercial
product/device during this activity or presentation.
Objectives
The learner will be able to:

Describe issues related to patient safety in medical
imaging including use of ionizing radiation and
contrast agents.

Order medical imaging studies based on age
appropriate criteria.
Goals of Diagnostic Imaging

Answer a clinical question




Minimize patient risk



Determine etiology of clinical symptoms
Determine therapeutic approach
Assess effectiveness of therapy
Minimize use of ionizing radiation
Minimize use of intravenous contrast agents and other
pharmaceuticals
Limit over-utilization and cost


Utilize lower cost modalities when possible
Utilize the fewest number of exams to answer the
clinical question
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Pediatric Population
Minimize ionizing radiation, especially gonads
Minimize use of intravenous contrast agents
 Is sedation necessary?
 Comfort of patient to reduce anxiety
 Can he understand intent of exam?
 Can she understand and follow verbal
instructions?
 Parental participation or not?


Adults of Reproductive Age
Minimize ionizing radiation, especially gonads
Pregnancy
 Breastfeeding
 Highest incidence of contrast allergy
 Incidental findings more problematic due to
low incidence of disease
 Increase in age = increase incidence of disease
therefore more extensive exams


Mature Adults
Radiation is less of an issue than in younger
patients, more extensive exams used to increase
diagnostic yield
 Polypharmacy
 Renal insufficiency?
 Decreased respiratory function?
 Decreased cardiac function?
 Limited mobility?
 Dementia?
 If slow bowel transit, concern for barium impaction

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Contrast Agents

ENTERIC CONTRAST AGENTS
 Barium
 Water soluble enteric contrast (Gastrografin)

NON-ENTERIC CONTRAST AGENTS
 May be used intravenous, intra-arterial, intraarticular (arthrogram), and intrathecal (myelogram)
 Gadolinium contrast -used for MRI
 Iodinated contrast – used with all procedures that
use x-rays
Enteric Contrast Agents

BARIUM
 May cause constipation and impaction.
 Consider latex allergy in barium enemas.

WATER SOLUBLE ENTERIC CONTRAST
(Gastrografin)
 Used in case of possible bowel perforation.
 Used for most CT enteric contrast.
 Contains iodine, may cause anaphylaxis.
Nonenteric Contrast Agents

IODINATED CONTRAST AGENTS
 Used for CT, IVP, angiography including coronary
catheterization, hysterosalpingogram, myelogram.
 May cause anaphylaxis and contrast induced
nephropathy (CIN).

GADOLINIUM CONTRAST AGENTS
 Used for MRI.
 May cause anaphylaxis and nephrogenic systemic
fibrosis (NSF).
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SYSTEMIC Factors that Increase the Risk of
Adverse Reactions to Iodinated Contrast


Previous adverse
reaction
History of asthma or
bronchospasm



3-fold increase
History of allergy or
atopy
Cardiac disease*

Anxiety

Medication (B-blockers)

Hematologic and
metabolic disease




Sickle cell anemia
Thrombotic tendency
Multiple myeloma
Pheochromocytoma
* Symptoms of angina or congestive heart failure with minimal exercise, severe
aortic stenosis, primary pulmonary hypertension, or severe but well
compensated cardiomyopathy.
Factors that Increase Nephrotoxicity Reactions
to Iodinated Contrast Agents

Congestive heart failure
 New York Heart Association class 3 & 4

Dehydration

Renal disease
 Especially in diabetics treated with metformin
(Glucophage)

Nephrotoxic medications
 Aspirin
 NSAIDs
http://www.massgeneralimaging.org/newsletter/october2003
Immediate Adverse Reactions to
Iodinated Contrast Agents

Children have a lower risk of adverse systemic reaction than
adults.

The reported incidence of anaphylactoid reactions from
administration of the older ionic contrast is similar to other
drugs and bee stings:
 1-2% of exposure
 0.1- 0.2 % are severe (1/1000)
 Fatal reactions are reported at 1/10,000 – 1/40,000

The newer nonionic contrast has a more favorable reported
incidence of risk:
 0.04% are severe (4/10,000).
 Fatal reactions are rare.
Katayama,et al. Radiology 1990:175:621-8.
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Immediate Adverse Reactions to
Iodinated Contrast Agents

Mild - Self limited without evidence of progression
 Incidence - 3%
 Hives, nasal stuffiness, itching, headache, shaking, dizziness
 Nausea and vomiting are NOT due to contrast allergy but often self
reported as adverse event

Moderate – Clinical findings require treatment and careful
observation for progression
 Incidence, 0.04%
 Tachycardia, bradycardia, hypertension, hypotension,
 Dyspnea, bronchospasm, wheezing, mild laryngeal edema
 Pronounced cutaneous reaction

Severe- Severe, life threatening symptoms, usually requires
hospitalization
 Incidence, 0.0004%
 Laryngeal edema, convulsions, profound
hypertension, unresponsiveness
Pre-medication Recommendations

Immediate Adverse Reaction*
 Prednisone, 50 mg PO at 13 hr, 7 hr, and 1 hr before scan
 Diphenhydramine (Benadryl), 50 mg PO, 1 hr before
scan

Patients with history of severe reaction should not
receive CT contrast agents. Contact radiologist to
discuss alternate imaging options.

Nephrotoxicity
 If creatinine level > 1.3 mg/dl, consult radiologist
 Discontinue metformin for 48 hrs after scan, recheck
creatinine prior to use
 Hydrate all patients well before and after exam
https://www.med.umich.edu/rad/steroid-prep.pdf
Contrast Induced Nephropathy
Acute
renal failure occurring within 48 hours of
exposure to intravascular radiographic contrast material
that is not attributable to other causes.
Arbitrary
range of values of between 25% and 50% (an
increase in absolute values of 0.5–1.0 mg/dL) increase in
serum creatinine levels from baseline has been suggested
to define contrast-induced nephropathy.
Gleeson T, Bulugahapitiya S,
Am J Roentgenol 183(6):1673-1689, 2004.
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Contrast Induced Nephropathy

Incidence among patients with diabetes
 9–40% in patients with mild-to-moderate chronic
renal insufficiency
 50–90% in those with severe chronic renal
insufficiency.

In contrast, the incidence in the general population is
much lower and has been calculated to be less than 2%.
Gleeson T, Bulugahapitiya S,
Am J Roentgenol 183(6):1673-1689, 2004.
Risk Factors for Contrast-Induced
Nephropathy






Pre-existing renal
impairment
Diabetes mellitus with
renal impairment
Multiple myeloma
Uncontrolled HTN
Prolonged hypotension
Concomitant use of
diuretic and ACE
inhibitor

Reduced intravascular
volume






Congestive heart
failure
Hepatic cirrhosis
Nephrotic syndrome
Diuretics, especially
furosemide
Abnormal fluid losses
Advanced age
Risk Factors for Contrast-Induced
Nephropathy

Contrast media
 Large volume
 High osmolarity
 Repeated injections
within 72 hours

Metabolic disorders
 Diabetes mellitus
 Hyperuricemia

Nephrotoxic drugs
 Nonsteroidal antiinflammatory drugs
 Aminoglycosides
 Amphotericin B
 Cyclosporine A
 Platinum-based drugs
 Sulfonamide
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Contrast Induced Nephropathy

Hydration is most critical in preventing CIN. Hydration
following the procedure is of greater importance than
hydration prior to contrast administration.

Sodium bicarbonate is believed to work by alkalizing the
tubular environment, thereby reducing the formation of
free radicals.

The mechanism of action of n-acetylcysteine (NAC,
Mucomist) is the trapping and destruction of free radicals.
Gleeson T, Bulugahapitiya S,
Am J Roentgenol 183(6):1673-1689, 2004.
Contrast Induced Nephropathy

Length of time between two contrast procedures should be
at least 48-72 hours. Rapid repetition of contrast
administration has been found to be a univariate risk
factor for CIN.

Potentially nephrotoxic drugs (eg, NSAIDs,
aminoglycosides, amphotericin B, cyclosporin,
tacrolimus) should be withdrawn at least 24 hours
beforehand, in patients at risk (eGFR < 60 mL/min).
http://emedicine.medscape.com/article/246751overview
Contrast Induced Nephropathy

Metformin can induce lactic acidosis if renal failure occurs.
Metformin should be stopped at the time of the procedure
and resumed 48 hours later if renal function remains
normal.

Angiotensin-converting enzyme (ACE) inhibitors and
angiotensin receptor blockers (ARBs) cause a 10-15% rise
in serum creatinine by reducing intraglomerular pressure.
Literature is unclear and controversial about whether
ACE/ARBs should be discontinued.
http://emedicine.medscape.com/article/246751overview. 12/05/2014.
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Contrast Induced Thyroid Dysfunction

Dose of iodine in contrast media is massive compared with the
recommended daily intake of 150 μg, (ninety to several
hundred thousand times).

In nested case-control retrospective study of 2,000 patients
followed for 20 years, use of iodinated contrast media was
associated with an increase risk of both hyperthyroidism and
overt hypothyroidism.

Exposure to iodinated contrast media almost doubled the risk
of developing hyperthyroidism, with a number needed to harm
of 23.
Pearce EN "Arch Intern Med 2012; 172(2): 159-161.
Contrast Induced Thyroid Dysfunction

Women were more likely to develop overt hyperthyroidism.

The association of hypothyroidism with contrast media was
significant only when the TSH level was greater than 10
mIU/L.

Development of thyroid dysfunction was independent of age
and prevalence of renal dysfunction.
Pearce EN "Arch Intern Med 2012; 172(2): 159‐161.
Contrast Induced Thyroid Dysfunction

These results may not apply to areas with insufficient dietary
iodine intake.

It is not know whether prophylactic strategies can be identified
to attenuate the risk.

“Consider follow-up testing in patients undergoing coronary
imaging and who are at risk for arrhythmias or have limited
capacity to deal with the consequences of iodine overload, such
as those with heart failure or cardiomyopathy.”
Rhee CM. Arch Intern Med 2012; 172(2): 159-161.
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Pregnancy and Breastfeeding

Ionizing radiation should be avoided whenever possible during
pregnancy, especially in the first trimester.

No known risks for MRI during pregnancy.
 Late effects on the fetus may be as yet unrealized since MR
scanning has been widely available for only approximately 20
years.

If gadolinium contrast agent is used in a breastfeeding mother
 Advise that Gadolinium passes into breast milk
 Mother may desire to abstain from breast-feeding for 24 hours

Abstinence from breast feeding may be even longer for nuclear
scintigraphic examinations (V/Q lung scan, bone scan).

No restrictions for the ingestion of enteric contrast agents.
Safety Considerations in MRI

MRI is generally very safe and adverse reactions to contrast
agents are extremely rare.

Cardiac pacemakers, implanted cardiac defibrillators,
otic/inner ear/cochlear implants, and metal fragments in the
eye are contraindicated.

In order to ensure patient safety, all implants that contain metal
must be verified as safe before an MRI procedure can be
performed. Have patients bring their device card with them.

Loose ferromagnetic objects can become dangerous missiles in
an MRI room.
http://www.massgeneralimaging.org/newsletter/february2005
Contra-indications for MRI
Absolute contraindication
Pacemaker
Otic, inner ear, cochlear implant
Metal in eye (e.g. construction
metal worker, welder)
Implanted cardiac defibrillator
Likely contraindication
Heart valve or aneurysm clip
installed before 1996
Possible contraindication
Heart valve or aneurysm clip
installed after 1996
Any type of prosthesis
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Contra-indications for MRI
Usually allowable 6-8 weeks after
implantation
Passive implants, weakly
ferromagnetic (e.g. coils,filters,
stents; metallic sutures or staples)
Usually allowable immediately after Passive implants, nonferromagnetic
implantation
(bone/joint pins, screws or rods;
coils, filter, stents; metallic sutures)
Rigidly fixed passive
implants,weakly ferromagnetic (e.g.
bone/joint pins, screws or rods)
Caution
Tattoos
Contra-indication to Gadolinium
contrast agents
Renal insufficiency with eGFR < 30
mL/min/1.73m2
Nephrogenic Systemic Fibrosis/Dermopathy
Associated with Gadolinium-Enhanced MRI

Nephrogenic fibrosing dermopathy (NFD) is a subset of
the generalized condition termed nephrogenic systemic
fibrosis (NSF).

NSF is a progressive form of fibrosis that develops in
many organ systems and can result in severe contractures
of joints secondary to fibrosis in the overlying skin.

NSF develops after gadolinium-enhanced MRI. The
features of these patients were:
 Chronic renal failure
 Metabolic acidosis
 MR angiographic (MRA) studies with Gd-DTPA-BMA
(Omniscan) as the MR contrast agent at high volume.
Ionizing Radiation

A form of radiant energy with the potential to induce cancer.
The controversy: “How much is too much?”

The scientific unit of measurement for radiation dose,
commonly referred to as effective dose, is the millisievert
(mSv). Other radiation dose measurement units include rad,
rem, roentgen, and sievert.

Measurements of dose delivery from CT scanners are usually
reported in dose length product (DPL). This is not the actual
patient radiation dose.

The actual dose to different parts of the body from an x-ray
procedure varies.
http://www.radiologyinfo.org/en/safety/index.cfm?pg=sfty
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Ionizing Radiation
Different
exposure.
tissues and organs have varying sensitivity to radiation
The
term effective dose is used when referring to the dose
averaged over the entire body.
The effective dose accounts for the relative sensitivities of the
different tissues exposed.
Effective
dose allows for quantification of risk and comparison
to more familiar sources of exposure that range from natural
background radiation to radiographic medical procedures.
http://www.radiologyinfo.org/en/safety/index.cfm?pg=sfty
Radiation Induced Cancers

Incidence of cancer is common in the general population.

Difficult to sort out which cancers have occurred as a direct
result from x-rays.

The latency period between exposure to x-rays and development
of cancer may be extremely long, up to 20 years, therefore the
association may be difficult to deduce and to prove.

The latency period between exposure and development of
malignancy


2-5 years for leukemias and other blood line tumors
10-20 years for solid tumors such as sarcoma, breast cancer
Naturally-Occurring “Background Radiation”
Exposure

Average person in the US receives an effective dose of about 3 mSv
per year from naturally occurring radioactive materials and cosmic
radiation.

Natural "background" doses vary throughout the country.

People living in the plateaus of Colorado or New Mexico receive about 1.5
mSv more per year than those living near sea level.

Largest source of background radiation comes from radon gas in
homes (about 2 mSv per year).

Radiation exposure from 1 chest x-ray is equivalent to the amount of
radiation exposure one experiences from natural surroundings in 10
days.
http://www.radiologyinfo.org/en/safety/index.cfm?pg=sfty
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Effective radiation dose
Effective radiation dose is:













Comparable to natural background radiation for:
Abdominal region:
Computed Tomography (CT)-Abdomen 10 mSv = 3 years
Intravenous Pyelogram (IVP) 1.6 mSv = 6 months
Radiography-Lower GI Tract 4 mSv = 16 months
Radiography-Upper GI Tract 2 mSv = 8 months
Central Nervous system:
Computed Tomography (CT)-Head 2 mSv = 8 months
Myelography- 4 mSv = 16 months
Radiography- Cervical Spine
<0.3 mSv>
-Thoracic Spine
<1.4 mSv>
-Lumbar spine
<1.8 mSv>
Chest:
Computed Tomography (CT)-Chest 8 mSv = 3 years
CT Pulmonary Angiogram
Radiography-Chest 0.1 mSv = 10 days
<20-40 mSv>
<20- 40mSv>
Effective radiation dose
Effective radiation dose is:







Comparable to natural background radiation for:
Children's imaging:
Voiding Cystourethrogram 5-10 yr. old: 1.6 mSv = 6 months
Infant: 0.8 mSv = 3 months
Women's Imaging:
Bone Densitometry (DEXA) 0.01 mSv = 1 day
Hysterosalpingography 1 mSv = 4 months
Mammography 0.7 mSv = 3 months
<13 mSv>
http://www.radiologyinfo.org/en/safety/index.cfm?pg=sfty
<http://www.medscape.com/viewprogram/5063>
Medical Radiation Exposure:
Risk versus Benefit

“Multidetector CT provides images of extraordinary
anatomical detail that can be rendered in 3D models.
For this reason, any discussion of radiation risks must
also be tempered with the recognition of the benefits of
CT scanning, which ultimately is intended to benefit
patients.”

“The above being said, the BEIR VII report states that
medical x-rays cause cancer. BEIR VII also
emphasizes that there may be no safe lower limit.”
http://www.medscape.com/viewprogram/5063
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Medical Radiation Exposure:
Risk versus Benefit

“There is some uncertainty since the data on low-dose
radiation exposure is not from direct x-ray exposure studies,
but extrapolation from radiation exposure from atomic
bomb survivors.”

“Perhaps below the dose of a standard body CT, which is
approximately 10 mSieverts, there is likely negligible if any
risk for an individual test.”

ONE body CT scan (1 CT scan of only 1 of the following
regions: chest, abdomen, OR the pelvis) carries with it some
element of risk.
http://www.medscape.com/viewprogram/5063
Medical Radiation Exposure:
Risk versus Benefit

BEIR VII reports the risk as 1 in 1000 chance of
developing cancer from a 10 mSv radiation dose.

Risk in children is even higher, with a reported chance of 1
in 550 of developing cancer.

1 in 100 expected to develop solid cancer or leukemia from
a dose of 100 mSV.

42 of 100 would develop solid cancer or leukemia from
other causes unrelated to radiation exposure.
http://dels.nas.edu/resources/static-assets/materials-based-on-reports/reports-in-brief/beir_vii_final.pdf
What is the initial medical imaging you would order
to evaluate right lower quadrant pain
(r/o appendicitis) in a 6-year old female?
A. CT scan with oral contrast
B. CT scan with IV contrast
C. Transvaginal ultrasound
D. Transabdominal ultrasound
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What is the initial medical imaging you would order
to evaluate right lower quadrant pain
(r/o appendicitis) in a 6-year old female?
A. CT scan with oral contrast
B. CT scan with IV contrast
C. Transvaginal ultrasound
D. Transabdominal ultrasound
In a 69-year old male with shortness of breath (r/o
pulmonary embolism) is a nuclear VQ lung scan
better than CT Angiography since radiation dose is
higher for CTA?
A. True
B. False
In a 69-year old male with shortness of breath (r/o
pulmonary embolism) is a nuclear VQ lung scan
better than CT Angiography since radiation dose is
higher for CTA?
A. True
B. False
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Resources for Medical Imaging
Radiology information source for patients
http://www.radiologyinfo.org
http://www.radiologyinfo.org/en/safety/index.cfm?pg=ImageWiselyMenu
Contrast Induced Nephropathy
Renu Bansal,Chief Editor 12/05/2014.
http://emedicine.medscape.com/article/246751-overview
Premedication for Contrast Allergy –U. Michigan
https://www.med.umich.edu/rad/steroid-prep.pdf
ACR Manual on Contrast Media 2013
http://www.acr.org/quality-%20safety/resources/~/media/37D84428BF1D4E1B9A3A2918DA9E27A3.pdf/
Pregnancy and Lactation
http://radiology.ucsf.edu/patient-care/patient-safety/ct-mri-pregnancy
American College of Radiology Appropriateness Criteria
https://acsearch.acr.org/list
References on Risk Of Ionizing Radiation
in Medical Imaging

Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII-Phase 2.
2005. http://books.nap.edu/catalog/11340.html.

Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal
cancer from pediatric CT. AJR Am J Roentgenol. 2001;176:289-296.

Brenner DJ. Estimating cancer risks from pediatric CT: going from the qualitative
to the quantitative. Pediatr Radiol. 2002;32:228-223.

BEIR IV Report Summary http://dels.nas.edu/resources/static-assets/materialsbased-on-reports/reports-in-brief/beir_vii_final.pdf
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Pearls for Conventional X-rays

Order the smallest appropriate body part.

Order 3-4 views on joints.
Order 2 views (AP and lateral) on others.
Need to see both ends of a long bone if
fractured to rule out dislocation.
Order opposite side for comparison if needed,
especially useful in pediatrics.








Finger rather than hand, wrist rather than forearm.
Pearls for Abdominal
Ultrasound
RUQ ultrasound is best imaging exam for biliary
disease.
Abdomen Complete US includes all organs plus
aorta.
Retroperitoneal Complete includes kidneys and
bladder. Request post void if needed.
RLQ ultrasound for r/o appendicitis is
nondiagnostic in most patients.


Most useful in adolescent females
May be useful in pediatric male patients
Pearls for Pelvic Ultrasound



Worthless in male patients. Order CT if imaging
needed.
After hysterectomy, pelvic ultrasound is unlikely
to provide any information unless large pelvic
mass needs to be characterized.
Order with transvaginal imaging when possible.


Transvaginal imaging is recommended in
reproductive age females.
Order Pelvic Ultrasound with Doppler to r/o
ovarian torsion.
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Pearls for Barium Studies

Order barium studies after CT and other
modalities.


Order cervical esophagram for dysphagia work
-up.


Barium will interfere with the other exams.
Must use rapid sequence filming.
Air contrast barium enema is not feasible if
patient cannot hold air due to poor sphincter
control.
Pearls for Breast Imaging

Diagnostic mammogram:



All patients with clinical symptoms except cyclic
breast pain or chronic lump.
Order ultrasound first if patient is < 25 yo.
 May need mammogram if US does not answer
clinical question, especially if positive family
history.
Order ultrasound and mammogram on all
patients with new clinical findings if > 25 yo.
Pearls for Breast Imaging

Screening Mammogram:




Asymptomatic patients, or cyclic/chronic pain.
Baseline at age 35, annual screening
mammograms starting at age 40.
Begin screening exams 1 decade before age of
premenopausal cancer in first degree relative.
Must be 365 days (11 months some carriers)
since previous exam to avoid Medicare denial.
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Pearls for Nuclear Medicine

VQ lung scan:
Much less radiation than CT PE protocol
(2mSv vs 9-20mSv).
 Appropriate in patients with normal chest x-rays
and no pre-existing chronic lung disease.
 Best option when IV contrast is contraindicated.

Pearls for CT and MRI


Order with and without for tumor or infection.
Neuro:



MRI except in trauma.
When MRI is contraindicated:
 CT w and w/o contrast for brain
 CT without contrast for spine
ENT:




CT for facial trauma
Screening sinuses for sinusitis
CT with contrast for maxillofacial or neck, except trauma
MRI with contrast for orbits, except trauma
Pearls for CT and MRI

Chest:

Order CT chest with contrast.



PE protocol




Don’t need w and w/o.
Exception is f/u small pulmonary nodule.
does not include apices and bases unless requested.
High radiation dose. Order VQ scan if no chronic
lung disease and CXR is normal.
Order VQ if iodinated contrast is contraindicated.
High resolution does not include all lung tissue.
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Pearls for CT and MRI
 Extremities:
 Order
without contrast with reconstructions for
trauma.
 CT may miss nondispaced hip fractures, especially
in osteopenic patients.
 MRI with and without contrast for all other
indications, especially mass or infection.
 CT with contrast if MRI is contraindicated.
Pearls for CT and MRI

Abdomen/Pelvis:






Order as “CT Abdomen and Pelvis with oral and IV
contrast” for most indications.
May have false negative in mild diverticulitis, early
appendicitis and pancreatic cancer.
Stone protocol for painful hematuria
Negative exam does not entirely exclude
nonobstructing calculi
Starts at top of kidneys. Does not include lower lungs
or subphrenic spaces.
Triple phase (w and w/o, plus delays) for liver or
renal mass, include metastatic workup.
Pearls for Nuclear Medicine

HIDA scan:




Ultrasound should be ordered first for suspected
biliary pathology.
Complementary functional study for biliary
disease.
Order HIDA with CCK (or HIDA with EF) if
no gallstones.
CCK is contraindicated with cholelithiasis.
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Protocols for Ordering Diagnostic
Imaging

The following protocols are in use at all Mountain
States Health Alliance imaging facilities in Washington
and Carter Counties.

These protocols were revised in January, 2007. The
protocols will be continuously updated as new
techniques are developed.

If you have questions concerning specific clinical cases,
please contact the Diagnostic Imaging department
where you plan to schedule your patient’s examination.
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