WARD AND OT RADIOGRAPHY

JUSTIN SAMSON

PLACE OF WORK

Intensive Care Unit Coronary Care Unit High Dependency Unit Resuscitation / Major trauma Wards Minor OT /(including recovery) Special Baby Care Unit

Examinations performed
Most common Chest radiographs Mostly AP projections

Sometimes extremities Trauma series Chest, C-spine lateral Pelvis Abdomen / Pelvis

Range of patients

Pediatrics Elderly patients Confused patients Unconscious patients Abusive patients Trauma patients Very ill patients Immunosuppressed Immobile

Abused pts

Subconscious pts

Immunosuppressed

Possible reasons for portable examinations Chest

Chest pain ? Pneumothorax / haemopneumothorax Chest drain in situ following treatment for a pneumothorax Cardiac arrest Acute Pulmonary Embolism Chest trauma Positioning of nasogastric (feeding) tube Acute Respiratory Distress syndrome (ARDS) Post pacing wire (Pneumothorax & positioning) Acute asthma / shortness of breath Aortic aneurysm

Other possible reasons for portable examinations

Post manipulation of fractures Post surgery radiographs Hips Femoral nailing Tibial nailing Not common with the advent of digital image intensification units

Patient identification & radiographic legends

Identification of patients outside the radiology department just as important Completed request form (valid, justified & signed) Unconscious & incoherent patients Wrist band Patient notes Nurse / carer verification Identification-Pregnant & unconscious patients 10 day rule Identification on radiographs and useful information Time, FFD, Exposure values, position of patient, marker

Portable technique considerations

Scatter considerations Shielding considerations Magnification of portable chest examinations FFD issues Accurate angulation of tube head Grid cut off Type of mattress for abdomen radiographs Recording dose Instructions for patients / relatives / staff

Exposure time Sufficient training and knowledge Range of densities for chest radiographs NG tube will require a denser appearance NG tube tip normally has a radiopaque tip

Using positioning aids Pillows Using optimal exposure factors Challenges of particular techniques

Radiation protection issues

Minimal exposure to patient, staff & relatives Utilisation of inverse square law Design of portable environment Consideration of other patients on ward Gonad shielding Pb rubber coats for staff Pb glass screen Pb cut out rubber sheet -

Health & Safety issues

Correct procedure for using mains supply in a portable environment Electrical connections Correct transportation and usage of equipment Trailing cables Correct storage of equipment Cleaning mobile equipment Safety

Image artefacts
ECG leads Patient artefacts Trauma scenario Patient artefacts Pacing wires Pacemakers NG tubes & safety pins Trauma spinal boards Chest drains Nebuliser units

Technique Charts
Exposure technique charts essential to optimum exam! Should be available for every machine
Should display standard technical factors for all projections performed with machine

Mobile radiography produces some of highest occupational radiation exposure for radiographers! Wear a lead apron! Wear film badge at collar or waist outside lead protection What is single most effective radiation protection measure? Distance! What is minimal safe distance ? 6 feet

Least exposure is at what angle to pt and primary beam?

Right angle

Safest Place to Stand

When should you shield pts gonads?

X-raying children

- Person is of reproductive age

Pt requests Gonads lie in or near useful beam When shield will not interfere with anatomy of interest

Radiation Safety contd

What is minimum source-to-skin distance? 12
Have visitors leave area Warn other personnel when you are about to make an exposure

 Never move patient or part without:

Assessing ability to move or ability to tolerate movement You should also:
Check with staff obtain assistance and permission to move a part that has had surgery or fractured

Inappropriate movement can further injure patient!

Patient Mobility

 Warn patient of potential discomfort from IR Cold Hard IR can damage skin of older patient Use cloth or paper cover to reduce risk of injury Protect IR from contamination by use of appropriate impermeable cover

Theatre radiography
Areas where mobile invasive procedures are performed

Areas where mobile invasive procedures are performed

CCU Pacing procedures Theatre Minor Major Post manipulation Endoscopy

Range of procedures performed

Coronary Care Unit Temporary pacing wire Post manipulation of trauma fracture Theatre Orthopedic cases (+) Trauma Vascular ERCPs Positioning of lines (central line, Hickman's line) Urology

Examples of orthopaedic procedures

Dislocations Hip pinning, Dynamic Hip Screws & plate Femoral nailing Tibial nailing Vascular investigation Trauma Max facial ERCPS Open Reduction Internal Fixation

K-wiring of wrist

Radiation protection considerations

Ensuring minimal dose for patients & staff Pulsing where possible Intelligent collimation Correct orientation for surgeon / team Correct positioning of Image intensification unit Availability of Pb rubber coats, Pb gonad shielding Theatre staff (+ environment) should be monitored Adequate notice of a controlled area to theatre

Radiation protection considerations

Has the patient recently had a radionuclide study? Ensure awareness of staff positions in theatre once exposures are being made Security of equipment Prevention of unnecessary exposures Recording dose of examination Print off digital radiographs

Patient identification & radiographic legends

Identification of patient Identification & verification of correct Anatomical area to be screened Pregnancy check Ensuring patient identification is placed on II unit Consent?

Health & Safety considerations

Electrical safety issues Using unit in the presence of flammable gases in theatre Trailing cables

Radiographic technique considerations

Providing an optimal service Effective liaison Consideration of X-ray tube in relation to II unit Correct & effective utilisation of equipment Angulation Anatomical orientation Positioning of II unit Storing images correctly

Manual handling & Cross infection

Transporting of IMAGE INTENSIFIER unit between theatres Correct movement of unit Locks & brakes Sideways & forwards movement Sterile covers for unit for open procedures Cleaning of unit Ensure unit is switched off first! Use solution for dealing with bodily fluids Warm soapy water afterwards Hard to reach places

Tibial Nailing

The role of the radiographer

Should be involved in a Trauma team Should respond to a trauma call- out Integral part of a theatre team Responsibility maintain rules & regulations observed in main department Manipulation of digital data & greater control of exposure / dose to patients and staff

WARD RADIOGRAPHY

AP Chest
Elevate the head of the bed as patient condition permits Pull the patient to the head of the bed before elevating if condition permits Make sure that the patient is not rotated Center MSP to cassette CR perpendicular to long axis of sternum, 3 inches below jugular notch

Positioning for an AP Chest X-Ray

Chest radiograph Trauma series

Decubitus Projections
Always place a firm support under the patient to elevate the body and keep patient from sinking down in the bed Raise both arms over the head if condition permits When possible, leave the patient on their side for five minutes before the exposure is taken to maximize visualization of air/fluid levels

Orthopedic Examinations
Always obtain at least two films at right angles to each other Obtain permission from the patients nurse prior to moving an injured patient Position patients very carefully once permission is obtained

LATERAL DECUBITUS POSITION ( AP PROJ.) : ABDOMEN

Pathology Demonstrated: Abnormal masses, air-fluid levels, and possible accumulations of intraperitoneal air are demonstrated. Technical Factor: IR size 35 x 43cm (14 x 17 inches), crosswise to the table (lengthwise with the patient) Moving or stationary grid 70 to 80 kV range

 Marker: Place arrow marker to indicate "up" side. Shielding:

Use gonadal shielding on males.

Patient Position: AP abdomen, left lateral decubitus position Lateral recumbent on radiolucent pad, firmly against table or vertical grid device Patient on from surface, such as a back board, position under the sheet to prevent sagging and anatomy cutoff Knees partially flexed, one on top of the other, to stabilized patient Arms up near head; clean pillow provided

 Ensure no rotation of pelvis or shoulders. Central Ray directed to center of IR, at about 2 inches (or 5cm) above level of illiac crest; use of a horizontal beam to demonstrate air-fluid levels and free intraperitoneal air Respiration: Make exposure at end of expiration.

DORSAL DECUBITUS POSITION (RIGHT OR LEFT LATERAL) : ABDOMEN

Pathology Demonstrated: Abnormal masses, accumulations of gas, air-fluid levels, aneurysms (a dilatation of the wall of an artery Technical Factor:

IR size - 35 x 43 cm (14 x 17 inches), crosswise Moving or stationary grid 70 to 80 kV range

 Patient Position: Supine on radiolucent pad, side against table or vertical grid device; secure cart so that it does not move away from table or grid device Pillow under head, arms up beside head; support under partially flexed knees may be more comfortable for the patient Part Position: Adjust patient and cart so that center of IR and CR is 2 inches (5cm) above level of iliac crest (to include diaphragm). Ensure that no rotation of pelvis or shoulders exist

 Central Ray:
CR horizontal to center of IR 2inches (5cm) above iliac crest and to midcoronal plane Minimum SID of 40 inches (100cm) Respiration: Expose is made at end of expiration.

CAPULAR Y LATERAL - ANTERIOR OBLIQUE POSITION: SHOULDER (TRAUMA)

Pathology Demonstrated: Fractures and/or dislocations of the proximal humerus and scapula are demonstrated. The humeral head will be demonstrated inferior to the coracoid process with anterior dislocations Technical Factor: IR size - 24 x 30 cm (10 x 12 inches), lengthwise Moving or stationary grid

 Patient Position: Perform radiograph with the patient in an erect position Part Position: Rotate into an anterior oblique position as for a lateral scapula with patient facing IR. Average patient will be in 45 degree to 60 degree anterior oblique position. Palpate scapular borders to determine correct rotation for a true lateral position of scapula. Central Ray: CR perpendicular to IR, directed to scapulohumeral [ 5 to 6 cm] below top of shoulder

CAPULAR Y LATERAL - ANTERIOR OBLIQUE POSITION: SHOULDER (TRAUMA)

AP PROJECTION : ELBOW (When Elbow Cannot Be Fully Extended

Pathology Demonstrated: Fracture and/or dislocation of the elbow and pathologic processes, such as osteomyelitis and arthritis Technical Factors: IR size - 24 x 30 cm (10 x 12 inches) Patient Position: Seat patient at end of table, with elbow partially flexed. Part Position: Obtain two AP projections Place support under wrist and forearm for projection

 central Ray: CR perpendicular to IR, directed to mid elbow joint, which is approximately 2 cm distal to midpoint of a line between epicondyles

THANK U 4 YR ATTENTION