Transcript Pediatric Radiography

Pediatric Radiography
Children do not all reach a sense of understanding at the
same predictable age. This ability varies from child to child,
and the pediatric technologist must not assume that children
will comprehend what is occurring. Generally, however, by
the age of 2 or 3 years, most children can be talked through
a diagnostic radiographic study without immobilization or
parental aid. Most important is a sense of trust, which begins
at the first meeting between the patient and the technologist;
the first impression that the child has of the technologist is
everlasting and forges the bond of a successful relationship.
Successful radiographic studies are
dependent on two things:
• The technologist's attitude and approach to a child.
• The technical preparation in the room.
At the first meeting, most children are accompanied by
at least one parent or caregiver. The following steps
are important:
• Introduce yourself as the technologist who will be working
with this child.
• Find out what information the attending physician has given
to the parent and patient.
• Explain what you are going to do and what your needs will
be.
Tears, fear, and combative resistance are common
reactions for a young child. The technologist must take
the time to communicate to the parent and the child, in
language they can understand, exactly what he or she is
going to do. The technologist must try to build an
atmosphere of trust in the waiting room before the patient
is taken into the radiographic room. This includes
discussing the necessity of immobilization as a last resort
if the child's cooperation is unattainable.
Evaluate Parent's (or Caregiver's) Role
• Parent is in room as an observer, lending support
and comfort by his or her presence.
• Parent serves as a participator, assisting with
immobilization.
• Parent is asked to remain in the waiting area and
not accompany the child into the radiography
room.
.
Sometimes children who act fearful and
combative in the waiting room with the parent
present will be more cooperative without their
presence. This is the time when the
technologist's communication skills are tested
REPORTING SUSPECTED CHILD ABUSE
Most medical facilities have a procedure in place to report
suspected child abuse. In the past, the term used for this
was battered child syndrome (BCS). The current
acceptable term is nonaccidental trauma (NAT).
Generally, it is not the responsibility of the technologist to
make a judgment as to whether child abuse has occurred,
but rather to report the facts as they are seen or
suspected. If NAT is suspected, the technologist should
discuss this with the radiologist or other supervisor as
determined by departmental protocol. Laws vary on
technologists' responsibilities, and it is most important that
all technologists know what their responsibilities are
concerning this in the state or province in which they
are working.
Pediatric patients in general can include infants through
children up to ages 12 to 14. However, older children can be
treated more like adults, except for special care in gonadal
shielding and reduced exposure factors because of their
smaller size. In general, pediatric radiography should always
use as short exposure times and as high mA as possible
to minimize image blurring that may result from patient
motion. However, even with short exposure times, preventing
motion during exposures is a constant challenge in pediatric
radiography, and effective methods of immobilization are
essential.
Immobilization devices:
• Tam-em board
• Pigg-O-Stat
Tam-em board
Pigg-O-Stat
Pigg-O-Stat (set for PA chest).
A.Bicycle-type seat
B.Side body clamps
C.Film holder mount
D.Swivel base
E.Adjustable lead shield with markers
F.Mounting stand on wheels
G.Extra set of smaller body clamps
The simplest and least expensive form of immobilization
involves the use of equipment and supplies that are
commonly found in most departments. Tape, sheets or
towels, sandbags, covered radiolucent sponge blocks,
compression bands, stockinettes, and ace bandages, if
used correctly, are effective in immobilization.
Sandbags
Strong canvas-type material and children's coarse sterilized
playing sand should be used. Coarse sand is recommended
because if the bag should break open, the sand is more easily
cleaned up, and the chance of causing artifacts on
radiographs is minimized
Tape and bandage
Various types of “gentle” tape are used for surgical procedures and sensitive
skin. Adhesive tape may show on the radiograph and create an artifact that
could obscure the anatomic part of interest. Also, some patients have an
allergic reaction to adhesive tape. The fragile skin of infants can be injured
by adhesive tape, unless the tape is twisted so that the adhesive surface is
not against the skin. Gauze pads placed between skin and adhesive tape
also can be used effectively
A 4-inch ace bandage is best for small infants and
young children, whereas a 6-inch bandage works
well for older children. These are best used for
immobilizing the legs. When starting the wrapping
process, begin at the patient's hips and wrap down to
the patient's midcalf. Do not wrap too tightly; this
would cut off circulation.
COMPRESSION BANDS AND HEAD CLAMPS
Compression or retention bands are valuable aids for
immobilization. Compression bands, however, are more
effective with pediatric patients when used in combination
with sandbags,
WEIGHTED ANGLE BLOCKS AS HEAD CLAMPS
These are heavy steel angle blocks with thick, radiolucent
sponge pads attached. They are relatively inexpensive to
have made compared with the cost of commercially available
head clamps. They are very effective and versatile in
immobilization, especially when used in combination with
sandbags and/or tape, or if the patient is mummified,
MUMMIFYING,” OR WRAPPING WITH SHEETS OR
TOWELS
BONE DEVELOPMENT (OSSIFICATION)
The bones of infants and small children go through various growth
changes from birth through adolescence. The pelvis is an example of
ossification changes that are apparent in children. As shown in, the
divisions of the hip bone between the ilium, the ischium, and the pubis are
evident. They appear as individual bones separated by a joint space,
which is the cartilaginous growth region in the area of the acetabulum.
The heads of the femora also appear to be separated by a joint space that
should not be confused with fracture sites or other abnormalities. These
are normal cartilaginous growth regions.
MINIMAL REPEATS
Reduction of repeat exposures is critical, especially in young children,
whose developing cells are particularly sensitive to the effects of
radiation. Proper immobilization and high mA, short exposure time
techniques will reduce the incidence of motion unsharpness. Accurate
manual technique charts with patient body weights should be used.
Radiographic grids should be used only when the body part examined is
greater than 10 centimeters in thickness. Each radiology department
should keep a list of specific routines for pediatric imaging exams,
including specialized views and limited examination series, to ensure that
appropriate projections are obtained and no unnecessary exposures are
made.
GONADAL PROTECTION
Gonads of the child should always be shielded with
contact-type shields, unless such shields obscure the
essential anatomy of the lower abdomen or pelvic area.
Pre-exam Preparation
The following should be completed before the patient is brought into the room:
•The necessary immobilization and shielding paraphernalia should be in place
(sandbags, tape, Tam-em board if used, sheets or towels, stockinette, ace
bandages, and shielding devices for patient and for parents if assisting).
•Image receptors and markers should be in place and techniques set (if a solo
technologist is performing the exam).
•Specific projections should have been determined, which may require
consultation with the radiologist.
•If two technologists are working together, they should clarify the role that each will
play during the procedure. A suggested division of responsibilities is to have the
assisting technologist set techniques, make exposures, change the IRs, and
process the images while the primary technologist positions the patient, instructs
the parents (if assisting), and positions the tube, collimation, and required
shielding.
CHILD PREPARATION
After the child is brought into the room and the procedure is
explained to the child's and parent's satisfaction, the parent or
technologist must remove any clothing, bandages, and/or diapers
from the body parts to be radiographed. This is necessary to
prevent these items from casting shadows and creating artifacts
on the radiographic image because of low exposure factors used
for the patient's small size.
Chest AP
Technical Factors
• IR size—determined by the size of the patient
• IR crosswise (if supine, place cassette under patient)
• Grid not required
• Small focal spot
• 70 to 80 kV, shortest exposure time possible
Shielding
Contact lead shielding should be placed over the pelvic
area with upper margin to level of iliac crests.
Patient Position—With Patient Supine
• Patient is supine, arms extended to remove scapula from the lung fields.
• Arms are secured to the table with sandbags or Velcro straps if Tam-em board is used.
• Legs are extended to prevent rotation of pelvis. Hips and legs are secured by placing
sandbags at the level of the hip to the top of the knee. If a Tam-em board is used, hip and
legs are Velcro strapped to the board.
• With parental assistance (if parent is not pregnant), do the following: 1.Have parent remove
child's chest clothing.
2.Provide parent with lead apron and gloves.
3.Place child on the IR.
4.Parent should extend child's arms over head with one hand while keeping head tilted back
to prevent superimposing upper lungs. With other hand, hold child's legs at level of the
knees, applying pressure as necessary to prevent movement.
5.Place parent in a position that will not obstruct technologist's view of patient while exposure
is made.
6.Place lead gloves over the top of the parent's hands if parent is not wearing the gloves. (It
may be easier to hold on to the patient if not wearing the gloves.)
Part Position
• Place the patient in the middle of the IR with the shoulders 2 inches (5 cm) below
the top of the IR.
• Ensure that the thorax is not rotated.
Central Ray
• CR perpendicular to the IR, centered to the midsagittal plane at the level of
midthorax, which is approximately at the mammillary (nipple) line
• SID of 50 to 60 inches (127 to 212 cm); tube raised as high as possible
Collimation
Closely collimate on four sides to outer chest margins.
Respiration
Make exposure upon second full inspiration. If child is crying, watch respiration and
make exposure immediately after the child fully inhales.
.
Patient Position—With Patient Erect
• Patient is placed on seat with legs down through center opening. Adjust
seat to correct height so top of IR is about 1 inch (2.5 cm) above
shoulders.
• Arms are raised and side body clamps are placed firmly against patient
and are secured by base adjustment and adjustable strap.
• Lead shield is raised to a level about 1 inch above iliac crest.
• Correct R and L markers and “insp” (inspiration) marker are set to be
exposed on lower image.
• Ensure no rotation
Central Ray
• CR perpendicular to IR at level of midlung fields (at mammary line)
• SID of 72 inches (180 cm)
Collimation
Collimate closely on four sides to outer chest margins.
Respiration
If child is crying, watch respiration and make exposure as child fully
inhales and holds breath. (Children can frequently hold their breath on
inspiration after a practice session.)
Radiographic Criteria
Structures Shown: • Entire lungs should be included from apices (C7-T12 level) to
costophrenic angles. • The air-filled trachea from T1 down is demonstrated, as well as the
hilum region markings, heart, and bony thorax.
Position: Chin is sufficiently elevated to prevent superimposition of apices. • No rotation, as
evidenced by equal distance from lateral rib margins on each side to the spine and distance
from both SC joints to the spine. • Full inspiration—visualizes 9 (occasionally 10) posterior
ribs above diaphragm on most patients.
Collimation and CR: • Collimation margins on all four sides with equal margins on top and
bottom, indicating a correct CR location to midlung fields (T6 or T7).
Exposure Criteria: • Sufficient lung contrast to visualize fine lung markings within lungs. •
Faint outlines of ribs and vertebrae visible through heart and mediastinal structures. • No
motion, as evidenced by sharp outlines of rib margins, diaphragm, and heart shadows
Lateral Chest
Technical Factors
• IR size—determined by the size of the patient
• IR lengthwise under patient (unless horizontal beam is taken on Tamem board)
• Grid not required
• Small focal spot
• 75 to 80 kV, shortest exposure time possible
Shielding
Contact lead shielding should be placed directly over pelvic area with upper margin at the top
of the iliac crest.
Patient Position—With Patient Recumbent
• Patient is lying on side in true lateral (generally left lateral) position with arms extended
above head to remove arms from lung field. Bend arms at the elbows for patient comfort and
stability with head placed between arms.
• Place one sandbag across arm that is closest to the IR.
• Place a second sandbag over the top of the upside humerus.
• Place a third sandbag between the legs at the level of the knee while bending the legs
forward.
• A fourth sandbag is placed across the top of the hips to further immobilize the patient.
• If a Tam-em board is used, patient position does not change from the AP projection. Turn xray tube for horizontal beam projection, and place vertical cassette against the lateral wall of
the chest as shown .
• If parental assistance is required, perform the following steps:
Central Ray
• CR perpendicular to the IR centered to the midcoronal plane
at the level of the mammillary (nipple) line
• With use of Tam-em board, the x-ray tube centered in horizontal
beam lateral position to midcoronal plane of thorax at level of
mammillary line
• SID of 50 to 60 inches (127 to 212 cm)
Collimation
Closely collimate on four sides to outer chest margins.
Respiration
Make exposure upon second full inspiration. If child is crying,
watch respiration and make exposure when the child fully inhales.
Patient Position—With Patient Erect
• Patient is placed on seat and adjusted to correct height so top of film
holder is about 1 inch (2.5 cm) above shoulders.
• Arms are raised and side body clamps placed firmly against patient and
secured by base adjustment and by adjustable strap.
• Lead shield is raised to a level about 1 inch (2.5 cm) above iliac crest.
• Correct R and L markers and inspiration marker are set to be exposed on
image.
• Ensure that no rotation exists.
Procedure if lateral follows PA projection: If patient is already in position
from the PA projection, then patient and swivel base are turned 90° to lateral
position. Lead shield remains in position, and lead marker is changed to
indicate correct lateral. IR is placed in film holder mount.
Central Ray
• CR perpendicular to IR at level of midthorax (mammillary line)
• SID of 72 inches (180 cm)
Collimation
Collimate closely on four sides to outer chest margins.
Respiration
If child is crying, watch respiration and make exposure as child fully inhales
and holds breath
Radiographic Criteria
Structures Shown: • Entire lungs from apices to costophrenic
angles and from sternum anteriorly to posterior ribs.
Position: • Chin and arms should be elevated sufficiently to prevent
excessive soft tissues from superimposing apices. • No rotation
should exist; bilateral posterior ribs and costophrenic angles should
be superimposed.
Collimation and CR: • Collimation borders on four sides with near
equal margins on top and bottom with CR to midlung fields.
Exposure Criteria: • No motion is evidenced by sharp outline of
diaphragm, rib borders, and lung markings. • Sufficient exposure to
faintly visualize rib outlines and lung markings through the heart
shadow and upper lung region without overexposing other regions of
the lungs.
AP and Lateral Upper Limbs
Technical Factors
• IR size determined by the size of the patient
• Grid not used for any body part smaller than 10 centimeters
• Extremity/detail screens used if available
• Small focal spot
• 55 to 65 kV, shortest exposure time possible
Shielding
Secure or place lead shield over entire pelvic area.
Patient Position
• Place patient in the supine position.
• Immobilize patient body part not to be radiographed either on the Tamem board or with sandbags before the part to be radiographed is
positioned.
• When radiographing a long bone, place IR under the limb to be
radiographed, including both proximal and distal joints.
• When radiographing a joint, place IR under the joint to be radiographed,
including a minimum of 1 to 2 inches (2.5 to 5 cm) of proximal and distal
long bones.
Immobilization
Immobilize the hand, forearm, and humerus with tape or
compression band, or have parent immobilize while wearing lead
gloves.
Central Ray
• CR perpendicular to the IR directed to the midpoint of the part to
be radiographed
• Minimum SID of 40 inches (100 cm)
Collimation
Collimate closely on four sides to area of interest
Radiographic Criteria
Position: • Generally two views 90° from each other should be obtained.
(An exception is the hand requiring a PA and oblique.)
Collimation and CR: • Collimation borders should be evident on four
sides without cutting off essential anatomy.
Exposure Criteria: • No motion is evidenced by sharp trabecular
markings and bone margins. • Optimal exposure demonstrating soft
tissue and joint space regions without underexposing the more dense
shaft regions of long bones
AP and Lateral Lower Limbs
Technical Factors
• IR size determined by the size of the body part to be radiographed, IR crosswise
• Grid not necessary for infants and small children
• 60 to 70 kV, shortest exposure time possible
• Small focal spot
Shielding
Male or female gonadal shields correctly placed so as not to obscure hips and
proximal femora
Patient Position and Central Ray
AP and lateral
• Patient is supine with IR under patient centered to affected limb or placed
diagonally for bilateral limbs if needed to include entire limbs from hips to feet.
• Immobilize with tape and/or compression band, or have parent hold leg in position
with one hand on the pelvis above the hip region and one hand holding the foot
(wearing lead gloves and apron.)
• For lateral, rotate leg externally and immobilize with tape, or have parent hold as
for AP projection.
• For bilateral limbs, abduct both limbs into “frog-leg” position. Immobilize with tape
or compression band across knees and/or ankles.
• CR is perpendicular to mid area of limbs.
• Minimum SID is 40 inches (100 cm).
KUB abdomen,
AP erect
Lateral and dorsal decubitus
Technical Factors
• IR size—determined by the size of patient, IR lengthwise
• High-speed film-screen
• Moving or stationary grid, if 10 cm or larger
• 65 to 85 kV NB to 18 years, shortest exposure time possible
Shielding
• Gonadal shield on all males—size appropriate for age (tape shield in place)
• No gonadal shielding on females
Patient and Part Position
• Patient is supine, aligned to midline of table and/or cassette.
• Immobilize with soft flexible sandbags and compression band.
Newborns and young infants
• Position the arms away from the body and mold a large flexible sandbag over each
arm. Because it is difficult to straighten the little, short legs of infants, place one
sandbag under their knees and another over the top to immobilize their legs. Babies,
if they feel snug and warm, are usually calm unless they are in pain. If a baby is
crying, a pacifier may help and will not interfere with the exam.
Infants and toddlers
• Restrain the arms the same as for younger infants. Place a sandbag
under the knees and tighten a compression band over both femora and
knees. Be sure to place padding under the band so that it does not cut
into the child's legs. Compression bands on most x-ray tables are
designed for adults, so this restraint works best if the spaces between
the band and the patient are padded with foam sponges or towels.
If parents are providing assistance, do the following:
•Provide parent with lead apron and gloves.
•Position tube and cassette and set exposure factors before
positioning.
•Position patient so that technologist's view is not obstructed.
•Usually, it is necessary to have a parent hold only the child's arms.
The legs can be satisfactorily immobilized as described above.
Central Ray
• With infants and small children, CR and cassette centered 1 inch (2.5
cm) above the umbilicus
• With older children and adolescents, CR centered at the level of iliac
crest
• Minimum SID of 40 inches (102 cm)
Respiration
• With infants and children, watch the breathing pattern. When the
abdomen is still, make the exposure. If the patient is crying, make the
exposure as the baby takes a breath to let out a cry.
• Children over 5 years of age usually can hold their breath after a practice
session.
Radiographic Criteria
Structures Shown: • Soft tissue border outlines and gas-filled
structures such as the stomach and intestines, calcifications (if
present), and faint bony skeletal structures are shown.
Position: The vertebral column is aligned to the center of the
radiograph. • No rotation should exist: pelvis, hips, and lower rib cage
should be symmetric.
Collimation and CR: Collimation borders from symphysis pubis to
diaphragm and to bilateral borders of abdomen.
Exposure Criteria: No motion should be evident, and diaphragm and
gas patterns should appear sharp. • Optimal contrast and exposure will
visualize bony structure outlines such as ribs and vertebrae through
abdominal contents without overexposing gas-filled structures.
AP Erect
Respiration
• With infants and children, watch the breathing pattern. When the
abdomen is still, make the exposure. If the patient is crying, make the
exposure as the baby takes a breath in to let out a cry.
• Children older than 5 years of age usually can hold their breath after
a practice session
Radiographic Criteria
Structures Shown: • Entire contents of abdomen, including gas
patterns and air-fluid levels and soft tissue if not obscured by
excessive fluid in distended abdomen.
Position: • The vertebral column is aligned to the center of the
radiograph. • No rotation should exist: pelvis and hips should be
symmetric.
Collimation and CR: • Collimation to borders of abdomen from
symphysis pubis to diaphragm.
Exposure Criteria: • No motion should be evident, and diaphragm
and gas pattern borders should appear sharp. • Bony pelvis and
vertebral body outlines should be evident through abdominal
contents without overexposing air-filled structures.
Lateral Decubitus and Dorsal
Decubitus
Lateral decubitus
• Patient on side on a radiolucent foam block with back against IR
• Horizontal CR directed to 1 inch (2.5 cm) superior to umbilicus
Dorsal decubitus
• Patient is supine on a rectangular radiolucent foam block.
• Legs are immobilized with sandbags as for a supine AP abdomen.
• Gently pull arms above head and ask parent to hold arms and
head with newborn or small infant.
• Place IR lengthwise, parallel to the midsagittal plane against side
of patient (support with cassette holder device or with sandbags).
Radiographic Criteria (Dorsal Decubitus)
Structures Shown: • Abdominal structures in the prevertebral
region as well as air-fluid levels within abdomen; diaphragm
included superiorly and pelvis and hips inferiorly.
Position: • No rotation should exist: posterior ribs should be
superimposed.
Collimation and CR: • At least minimal collimation borders should
be visible on four sides, with center of collimation field (CR) to
midcoronal plane, midway between diaphragm and symphysis
pubis.
Exposure Criteria: • No motion should be evident, and diaphragm
and gas patterns should appear sharp. • Abdominal soft tissue detail
should be visible without overexposing gas-filled structures. • Faint
rib outlines should be visible through abdominal contents