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Midterm, Clinical semester 6.

Section A: Professional Practice (Medicolegal, Ethics, Communication and Workflow Decisions)
1-3%
Section B: Patient Management (Infection Control, Vital signs, Oxygen Therapy and Assessing
Medical Emergencies. Lines and tubes, Patient transfers) 9-13%
Section C: Radiation Health and safety and PPE 12-16%
Section D: Pharmaceutical Administration and Contrast Media 1-5%
Section E: Operation of Equipment Radiographic CR, DR (Grid review, Image production and
evaluation review, Image Quality and Characteristics, Quality Assurance) 6-10%
Section F: Operation of Equipment Fluoroscopic 2-6%
Section G: Operation of Equipment CT 4-8%
Section H: Procedure management (Skeletal fractures, Bone Disease,
Respiratory pathology, GI pathology, Urinary Pathology, Chest, Upper extremity, Lower
extremity, Spine, SI joints, Sternum, Ribs, Skull/ Sinuses/ Facial bones, Abdominal ) 22-26%
Section I: Digestive System 2-6%
Section J: Respiratory System 6-10%
Section K: Venipuncture, Urinary system, Enemas/ UGI 1-3%
Section L: Reproductive System, Mammography 1-3%
Section M: Sectional Anatomy, Head CT, CT brain pathology, Thoracic CT, Abdominal and
Pelvic CT, CT abdominal Pathology, CT spine pathology. 10-14%
Practice test:

Yellow- important to know

Blue- very important
Purple- know like the back of your hand

Section A:
Professional practice:
Ethics, medicolegal issues and communication pwpt:

CAMRT (Canadian association of medical radiation technologists)-

Certification exam, competency profile> curriculum, continued education, PLI

CMRTIO (College of medical radiation and imaging technologies of Ontario)-

License, regulatory body, legislated, protect Ontario public, mandatory enrollment

CMRITO council-
• Anyone can attend meetings as it protects the public
• CMRITO have to report the minister of health
• Most important is the executive committee (decision maker)
• All of the council works together
• The council consists of members that are paid but there are also people of the public on the council.

Executive committee- In order to change a policy they have to have approval of all the council
Registration- a subcommittee (in charge of registration- make sure they are up to date and all
qualifications are met.)
ICRC- Inquiry’s, complaints and reports committee (if members of the public come in with a complaint
they have to deal with it and investigate. Once the investigation they put forth recommendations to the
discipline committee)
Discipline committee- conduct a hearing and have a little court case regarding the discipline issue (where
MRT stands up for self). They also enforce the penalty.
Fitness to practice: for complaint from a manager about an employee
QA: responsible for the colleges QA program, we must follow the QA program to make sure the members
are qualified
Patient relations committee: Their job is to communicate with patients outside of the membership. There
number one mandate is the prevention of sexual abuse.

OAMRS (Ontario Association of Medical Radiation Sciences)-

Does not fall under ANY government legislation (Bunch of MRT that made a group), All involvement is
voluntary, provides education opportunities, count towards 25 hours

Professional ethics- standards set out for a group of people, standards of right and wrong in human
behaviour. Code of behaviour or conduct.
Professional codes-

Patients right:
• Have a medical professional provide information to you within their scope of practice
• Ask questions and express concerns
• Request a second opinion
• Participate in health care decisions
• Give or refuse consent for a procedure
• Receive safe and proper care
• Be assured that personal information is confidential
• Request to access their health information records.
• Request a transfer of their health records to another medical professional.

PIPEDA (Personal information protection and electronic documents act)- covers identifiable information
that is created or received by a health care provider, employer, life insurer, school or university or health
care clearinghouse related to past present or future health conditions, treatments or payments.

PHIPA- Personal health information protection act. Legislation that ensures a patient's health record
Tips: Log out, don’t gossip loud or with people not directly involved.

Elements of consent:
Consent: patients choose to have treatment or procedure based on the full understanding of the treatment
or procedure, its benefits and risk and any alternatives to the particular treatment or procedure. Mentally
capable patients have the legal right to accept or reject treatment. Consent is verbal, written or implied.
• If a patient is unable, substitute a decision maker.
• Must know info related to the treatment
• Patient is informed
• Given voluntarily
• Not be obtained through misrepresentation or fraud.
• Understand benefits and risk as well as alternatives that deliver a similar outcome.
• Higher risk the case, the more rigorous the consent

Medicolegal considerations:
-Professional misconduct
-Negligence
-Consent
-Standard of care
-Legal Theories

Patients rights:
• The rights canadians have within health care,
• The right to health care
• The right to timely health care

Duty of care:
• All healthcare providers owe a duty of care to a patient.
• Health care professionals have a duty to practice according to the standards of that particular
profession.
• Failure to act in a competent, responsible manner can result in medical malpractice and or lawsuit.

Civil vs criminal law:

Criminal law deals with crimes that a society perceives or defines as harmful to a person or property.
Civil law is a body of rules that defines and protects the private rights of citizens, offers legal remedies
that may be sought in a dispute and covers areas of law such as contracts, torts, property and family law.

Most medical legal issues fall under tort doctrine:

Tort law is a branch of civil law that is concerned with personal injury and civil wrongdoing.
Tort is a civil wrong, done by one person or entity to another which results in injury or property damage,
and frequently involves monetary compensation to the injured party.

Tort: Civil wrongdoing that’s either intentional or negligent.

Examples: false imprisonment, assault (threat to harm), battery (carry out threat, performing exam
without consent when patient has refused or exam on wrong patient), invasion of privacy, defamation,
slander.

Most tort is negligence theory of liability. negligence is failure to use the same care as a reasonably
prudent person would use under like or similar circumstances.
-reasonable person standard- what another person would have done in that situation.
Assessment of duty- what should have been done- it is determined by level of expertise done.- it is
determined by level of expertise possessed by the profession- standard of care required by the profession.

Negligence- Standard of care-

• A standard of care can be described as the degree of skill, knowledge and care ordinarily possessed
and employed by members in good standing within the profession.
• If a medical professional does not meet the standard of their profession or a person breaches the
standard, then medical malpractice can occur.
Ex. Patients injured when railings left down, imaging the wrong patient or wrong part, positioning
injuries, failing to inquire pregnancy status.

Duty of care
Negligence and misconduct-
-Patient abandonment
-Performing an unauthorized procedure
-Not being of sound mind or impaired
• Not following protocol or practicing outside your scope of practice

Respondeat superior- let the master answer- employer is responsible or jointly responsible for actions of
their employees. Shared negligence between the health care worker and the health care employer or
facility.

Res ipsa loquitur: the thing speaks for itself- responsibility or burden of proof shifts to the defendant
(patient with renal issues given a large dose of contrast and dies, if no contrast, no death.)

Malpractice: when a radiographer who performs an examination without an examination ordered. (Not
doing your job or not doing things in your job description)

Morality: Extends from a system of beliefs about what is right and wrong, encompassing a person's
values, beliefs, and sense of duty and responsibility.

Morals: Are what a person believes to be right and wrong regarding how to treat others and how to
behave in an organized society.

Values: Things important to an individual

Sense of duty: obligations a person has in response to another's claims on him or her.

Teleological theory: Defines an action as right or wrong depending on the result it produces.
Deontological theory: Demands that a moral and honest action is taken, regardless of the outcome.
Virtue ethics theory: States that a person of moral character will act wisely, fairly, and honestly and will
uphold the principles of justice.
Divine command ethics: Follows philosophies and rules set out by a higher power.

Principles related to health care: Beneficence, nonmaleficence, double effect (outcome that causes least
harm), respect, autonomy, truthfulness (keeping patient fully informed), fidelity, justice.

Summary:
MRTS are legally liable for their actions.
MRTs must understand the appropriate standard of care.
Information acquired must remain in confidence
Patients must be given enough information to give proper informed consent
Healthcare workers must stay current and follow standards. If not held liable under negligence if a patient
is injured along with the supervisor and facility.

Patient interactions best practice:

• Communication- verbal, non verbal (paralanguage (pitch and tone), Body language, touch,
appearance, visual contact.)
• Patient identification
• History
• Explanation
• Consent- ensure the patient is legally competent, full disclosure has been given, consent is specific
to procedure, patient can ask questions, consent is voluntary
(who can give consent: substitute decision maker, NOT the patient's physician, consent obtained in
patients language, consent can be withdrawn at any time.)

Questions:
• For a patient who is completely deaf, call an interpreter certified with sign language.
• If a patient refuses to have an IV started for contrast media injection for a CAP CT; document the
patient’s decision and consult with the ordering physician or radiologist.
 • If a patient consents to a barium enema, after it has started states they do not want to continue the
test, the MRT should stop the procedure and help them to the bathroom.
• A 16 year old mother may give consent for her 6 month old child and it is valid.
• A patient is unconscious, the emergency physician orders imaging, the ordering physician does not
need consent for treatment in this emergency situation.
• A signed consent form is not required for valid consent
• First task when beginning a radiographic examination of a patient is to verify patient identity.
• Discussing exam findings with a patient's spouse is a breach to the right of confidentiality

WORKFLOW DECISIONS PWPT:

Objectives:
Balance priorities- use available resources in most efficient way
• Uses information about patient
• Find clinical importance of this procedure
• Impact of timing on the patients management and care
• Priority of procedure or treatment based on history and conditions
• Complexity of treatment and procedure
• Other procedures to be performed and how they affect each other
• Resources available
• Other priorities.
Some departments need to accommodate procedures: reserved blocks of time, rescheduling based on the
rationale of previous elements discussed.

Collaborative decisions- bringing in a patient who has a scheduled appointment at the time of arrival.
Patients who need a chest xray but have a UGI. Balances the priorities of patients.

Communication with patients- how to tell a patient their appointment is changed to show respect to them:
explain why it's delayed, provide an idea of how long it will be, discuss potential options, if rescheduled,
reassure the patient they will be given appropriate status.

Summary:
Priorities are determined by clinical importance of the exam.
MRTs collaborate with other professionals that may also be completing exams for the patient
Communication to patients that may be impacted is crucial.
Common sequence of exams for patients requiring several imaging procedures: Non contrast, iv contrast,
lower GI, upper GI.
Procedures requiring fasting booked in morning and diabetic and peds fasting given priority.

Professional communication:
Patients chart may include:
• Patient history, diagnosis, prognosis,
• Medications
• Treatments
• Laboratory results
• Radiology reports

Entries must be:

• accurate , pertinent, and legible, and include date, time, statement of what occurred, and signature of
person making the entry.

Radiographic medical records:

 • Belong to facility acquired
• Retained for 7-10 years
• Pediatric images retained until patient is 18 years old
• Images shared through pacs system or released to patient or consulting physician with CD or
storage.

PACs: Picture archival and communications system

RIS: Research information system
HIS: Hospital information system
DICOM: Digital imaging and communications in medicine

Review test look over:

• DNR- no efforts can be made to assist the patient once the patient has gone into cardiac arrest or
respiratory arrest.
• Res ipsa loquitur- negligence caused the resulting injury
• Malpractice if imaging is done where the proper anatomy isn't included.
• Part of the history required when imaging a knee with chronic pain is factors that aggravate it.

Section B: Back to
top
Patient Management
Infection control, vital signs and oxygen therapy:

Objectives:
-Infection: Infectious agents, chain of infection, health care acquired infection, infection control (medical
and surgical asepsis, standard precautions, transmission based precautions
-Vital signs: Pulse, temperature, respiration, blood pressure
-Oxygen therapy: hypoxia and hypoxemia, low flow delivery vs high flow delivery.

Infection:
-Creation and growth of microorganisms (pathogenic) on or in a host resulting in injury to the host.
-Pathogens have 3 functions> multiply and obstruct, tissue damage, secrete organic exotoxins. Pathogens
are sometimes harmful and capable of producing disease.
-Exotoxins cause these side effects: high temperatures, nausea, vomiting, seizures.

Types of pathogens:
• Bacteria
• Viruses
• Fungi
• Parasitic protozoa

Chain of infection:
1. A pathogen- a disease containing disease causing microorganism
2. Reservoir- humans or animals as well as food, drink and objects.
3. Portal of exit (breathing, coughing, skin to object contact, blood)
4. A method of transmission (Contact, droplet or airborne)
5. Portal of entry (mouth, nose, eyes, skin, blood)
6. Susceptible host
Routes for disease transmission:
• Air
• Droplet
• Contact
• Exogenous (outside) or endogenous (normal organisms infect the body- perforated bowel)
• Vector- from another species vs fomite- from an inanimate object
• Fomite- disease transferred through an improperly cleaned image receptor.

HAI- Healthcare associated infection:

Patients have infections and people in hospitals are more likely to get infections.
Health care workers providing for more than 1 patient can carry germs.
Hand washing is the most effective method of preventing the spread of infection.

Nosocomial infection- hospital acquired disease

Iatrogenic infection- disease after treatment
Compromised patients- have a weakened immune system and have difficulty fighting off disease.
Personal flora- when in someone else's personal flora can cause illness.

Patient factors increasing nosocomial infections: Age, heredity, nutritional status, stress, inadequate rest
or exercise, personal choice habits, health history, inadequate defenses.

Blood borne pathogens: Disease causing microorganisms present in blood: HIV and HBV are concerns.

HIV: autoimmune disease in the host. Latent symptoms for many years. Asymptomatic for 10 years. 1
year for results of blood test to show positive for antibodies

HBV: biliary system (Liver). Leads to jaundice, some patients asymptomatic. Blood test positive 2-6
weeks after symptoms develop. Patients recover in 6-8 weeks but blood tests will always show exposure.

Infection control:

Medical asepsis- decrease the number of organisms (cleaning and disinfecting, barrier techniques,
handwashing, isolating patients with known infections)

Standard precautions- used when chance of coming in contact with blood, bodily fluids, secretions,
excretions, mucous membranes and nonintact skin or substances contaminated with these substances.
Includes- gloving, handwashing and PPE

Handwashing is the most effective method to prevent the spread of infection.

Surgical asepsis- complete removal or absence of pathogenic organisms in the clinical setting. Aseptic or
sterile technique most strictly applied in the operating room because of the extensive disruptions of skin
that can occur with many surgeries.

Barrier methods including the use of PPE and transmission based precautions.

Hand washing 5 moments: 1. before touching a patient, 2. before clean aseptic procedure, 3. after body
fluid exposure risk, 4. after touching a patient, 5. After touching patients surroundings

Minimum of 20 seconds for hand scrubbing component of washing hands required.

Putting on gown:
1. Put on before gloves
 2. Fasten back of neck and waist
Removing gown:
1. Untie the waist tie at front of gown (dirty)
2. Remove gloves first
3. Unfasten neck and then waist ties
4. Remove gown using peeling motion
5. Hold the removed gown away from the body, roll into a bundle and discard in the room.
When to wear gloves: (when anticipated to be in contact with):
Blood or body fluids, mucous membranes, non-intact skin, indwelling device insertion site, handling
potentially contaminated items in an environment.
• Use hand hygiene before and after applying gloves and change them between patients.

When to wear a gown: (when anticipating contact of clothing or exposed skin with blood or body fluids,
secretions or excretions)
• During procedures likely to generate splashes, prays or droplets of blood and body fluids
• When in contact with non intact skin
• Handling fluid containers likely to leak, splash or spill when moved.

Masks and eye protection: (wear during procedures likely to generate splashes, sprays or droplets of blood
and body fluids)

Transmission based precautions:

Contact: gloving and PPE (shielding)
Droplet: Pathogens coming out of mouth during talking, sneezing, coughing or drainage from the nose.
Gowning, gloving, eye coverage and mask wearing as well as 3 feet from patients.
Airborne: patient in negative pressure room, room remain closed and patient in room unless absolutely
necessary. Health care workers wearing all PPE and N95 masks that are properly fitted.
Protective: Cap, gloves, gown, mask

When a potential to coming into contact with fecal material, use contact precautions
Burn victims and chemo patients are under protective precautions,
Tuberculosis and varicella, H1N1 are under airborne precautions
Rubella (measles), mumps, Flu, covid is under Droplet precautions

Sharps disposal: do not recap needles. All containers are replaced when no more than 2/3 full.
All needles used and unused are to be disposed of in biohazard sharps bin.
BLOOD COVERED SHEETS IN BAG

Contaminated linen: all linen changed between each patient. Contaminated linen to be held away from
uniform. Soiled linen is to never be shaken, linen from one bed is not to be brought over to another
patient. Body fluid to be disposed of immediately, hands must be washed after handling a patient's bed
linen.

Questions:
• Bed sheets with saturated blood discarded in a biohazard bag
• During a mobile procedure, the dirty technologist touches the patient
• Leukemia and burn victims require protective or reverse/ protective isolation techniques.
• Patients with tuberculosis are placed in airborne precautions.
 • Droplets and dust can result in airborne transmission of infection.
• When entering an isolation room with mobile x-ray, you must wear a gown, mask and gloves.
• If Chemo patient and patient with VRE in same room, ensure VRE patient is wearing a mask.
• When a package becomes wet from an accidental spin of saline, consider the object contaminated
and replace it with a sterile item.
• Respiratory isolation does not require the use of gloves.
• For isolation patients, an IR protective covering must always be placed on the IR.
• The front of the gown, waist to shoulders is considered sterile

Conclusion:
• Infection involves the establishment of dissemination of a microorganism on or in a host.
• Infectious diseases are caused by pathogenic microorganisms
• Nosocomial infections are those acquired in the hospital setting.
• The human body has mechanical, cellular and chemical mechanisms that it uses to fight infection.
• Through aseptic techniques, environmental control of infection is simple.
• Medically aseptic hand washing techniques standard precautions and transmission based
precautions have contributed significantly in reducing the probability of spreading infectious
diseases.

Vital signs:
• Measurable objective data that provides clinical information about a patient's health.

Pulse: BPM, most common is the radial artery or carotid, average adult is 60-90, infants are increased
with 90-120 bpm. Measured for a full minute or with pulse oximeter

Temperature: oral, axilla, rectum or ear. Normal is 36 to 37.5 celsius

Respiratory rate: breaths per minute. 15 to 20 per minute for an adult. Infant is 30-60

Blood pressure: millimeters of mercury. Measurement taken in brachial artery at distal humerus. Normal
is 90-120/50-70 mmHg
Hypertension: stage 1 130-139/80-89
Hypertension: stage 2 consistently greater than 140 and above/ 90 and above
Hypertension crisis: higher than 180/higher than 120
Hypotension: lower than 90/ lower than 60.

Oxygen therapy:
Medical treatment for both acute and chronic conditions
Hypoxia: supply of oxygen is insufficient for the body tissues/ organs.
Hypoxemia: state where there is low arterial oxygen supply (measured arterially and expressed as arterial
oxygen partial pressure or PaO2)
Signs and symptoms of hypoxia are: cyanosis, tachypnea, dyspnea, use of accessory breathing muscles,
decreased O2 saturation levels, anxiety, change in mental status.
Pulse oximetry assessment is done to monitor oxygen saturation of hemoglobin, SAO2
Normal pulse oximeter reading is 95-100% values under 90 are hypoxic.
Continued low oxygen levels can result in cardiac arrest

Low flow oxygen systems:

Nasal cannula, simple face mask, face tent, non-rebreather mask (reservoir bag to deliver higher
concentration of O2 and a one way valve to prevent patient inhaling expired air 10-15 litres per minute.
Low flow devices have 1-6 litres per minute for mild hypoxia.
An appropriate flow rate through a nasal cannula would be 4 L/ min
Supplemental oxygen high flow systems:
Venturi mask, nebulizer, high flow nasal cannula, mechanical ventilation using corrugated tubing.
High flow systems usually use healed and humidified oxygen to prevent inflammation
Systolic is the highest pressure when the pressure of blood as a result of contraction with the ventricles.
Diastolic pressure is the lowest and is when ventricles are at rest

Suctioning:
• Hold thumb over the suctioning control port
• Slowly remove the catheter while twirling it between your fingers to remove mucus
• Limit suctioning to 5-10 seconds
• Once the catheter is out, clean it by dipping it in sterile water or saline and suctioning.

Review test look over:

• Minimum 20 seconds required for handwashing
• Vector is from another species, fomite is from an object.
• Clotted blood PPE (not squirting); gloves and gown.
• MRSA infection measures include gloves and gown and keeping any linen used in the patients
room.
• No PPE for HIV pt. if no contact with body fluids
• Pertussis/ whooping cough PPE gown, gloves, mask and eye protection.
• Bedpan urine transport PPE: gloves, gown, mask and eye protection.
• Airborne precaution patients wear a surgical mask and are transported by wheelchair or stretcher.
• Start by unting front of the gown before glove removal since the front of the gown is dirty.
• Cystitis caused by e coli requires antibiotics- antibiotics are bacteria killers. E coli is a bacteria.
• Rate of oxygen for a patient with emphysema is 3L/min or less
• When ruling out cyanosis, look at lips and nail beds.
• Orthostatic hypotension is when the systolic pressure decreases suddenly

Assessing patient condition and medial emergencies:

What constitutes an emergency?

• Any situation in which the condition of a patient or a sudden change in medical status requires
immediate action.

MRT's role:
• Preserve life
• Avoid further harm to the patient
• Obtain appropriate medical assistance as quickly as possible.
• Must be able to recognize emergency situations and initiate emergency measures

Emergency priorities:
• Ensure open airway
• Control breathing
• Take measures to prevent or treat shock
• Attend to wounds or fractures
• Provide emotional support
• Continually reevaluate and follow up appropriately

Crash cart: a wheeled container of equipment and drugs required in emergency situations
• You must know where the department crash cart is located
 • Become familiar with its contents and their locations
• The ready availability of emergency equipment and drugs reduces the time required to respond to
medical crises

Locate emergency equipment:

• Crash cart
• Oxygen
• Wall mounted suction
• AED- fully and semi automatic

(fully automatic- analyzes rhythm, determines if shock is advised, delivers shock if needed. Semi
automatic- analyses rhythm, determines if shock is needed, orders operator to deliver shock.)

Radiology emergencies:
• Shock
• Anaphylaxis
• PE
• Diabetic reactions
• CVA
• Cardiac and respiratory failure
• Syncope
• Seizures

Questions:
• A severe life threatening response to a drug is called: anaphylaxis
• When a patient is experiencing an episode of syncope, assist the patient to lie down and elevate the
feet.
• When a patient has a seizure, place them in a lateral recumbent position one the seizure is complete.
• In addition to imaging a trauma patient the radiographer must also assess patient condition, take
additional projection as indicated by the patient's condition or preliminary images, and provide
comfort and communication quietly with the patient whether the patient is conscious or
unconscious.
• When a patient is on the floor with no pulse, call assistance, start CPR
• CPR is 30 compressions to 2 breaths

Symptoms of anaphylaxis:
• Feeling lightheaded or faint
• Breathing difficulties- such as tachypnea or bradypnea
• Wheezing
• Fast heartbeat
• Clammy skin
• Confusion or anxiety
• Collapsing or losing consciousness
• Emesis
• Urticaria- Hives

Head injury:
• Assess patients LOC
• Clinical symptoms may not manifest right away
• Hematoma
• Brain swelling
 • CT is preferred, initial modality for assessment.

A patient who sustained a head injury in a motor vehicle accident arrived in the DI department alert and
well oriented. During the exam the patient was becoming drowsy, irritable and less coherent. The MRT
should notify the ordering physician of the change in the patient’s condition.

Levels of consciousness (LOC):

• Alert and conscious
• Drowsy but responsive upon stimulus
• Unconscious and reacts to painful stimulus
• Comatose (unresponsive to all stimuli)

Know your patient:

• Assess patient at beginning of procedure
• Don’t confuse with intoxication
• Note signs of deterioration from one level of consciousness to another
• Deteriorating head injury: irritability, lethargic, slow pulse rate, slow respiratory rate.

LOC-
• Ask patient to state name, date, address, and reason for coming to radiology
• As you instruct patient in positioning, note patients ability to follow commands
• Assess the patient's vital signs against the baseline to note changes
• Changes in patient's neurologic status or LOC must never be ignored.

Deteriorating situations:
• Signs
• Sudden irritability
• Lethargy
• Slowing pulse rate
• Slowing respiratory rate
• Change in level of consciousness
• Response
• Maintain an open airway
• Move patient minimally
• Stop radiographic procedure
• Get medical assistance ASAP
• Monitor patients vital signs

Shock:
• A failure of the circulatory system to support vital body functions. Bodies reaction to illness,
trauma, severe emotional disturbance.
• Interruption of blood flow to vital organs.
• A decreased ability of body tissue to use oxygen and other nutrients.
Symptoms: Sudden onset, decreased temp, weak thready pulse, rapid shallow respiration, hypotension,
cyanosis, apathetic, confused, restlessness, anxiety.

Shock continuum:
Compensatory stage:
• Cold, clammy skin,
• Decrease urine output
• Increased respiration
• Hypoactive bowel sounds
 • Normal BP
• Increased anxiety level of patient

Progressive stage:
• BP falls
• Respirations are rapid and shallow
• Severe pulmonary edema
• Tachycardia
• Patient complains of chest pain
• Confused mental state
• Problems occur with kidneys, liver, bowel and spleen

Irreversible stage:
• BP remains low
• Renal and liver failure occur
• Release of necrotic tissue toxins
• Overwhelming lactic acidosis

Classes of shock:
Neurogenic:
• Caused by spinal anesthesia or damage to upper spinal cord as well as concussion, physical trauma,
and spinal anesthesia.
• Associated with pooling of blood in the peripheral vessels
• B/P decreases as blood pools in veins= reduced cardiac output.
Signs and symptoms: Hypotension, Bradycardia, Skin warm and dry, subnormal body temp. Poor tissue
perfusion: cool extremities, diminishing peripheral pulses.
Actions: Summon emergency assistance. Notify dr. pt. Flat. have a crash cart beside pt. Stay with pt.
Offer support. Vitals every 5 minutes. Do not move patients with spinal cord injuries. Assist with oxygen,
Iv fluids and meds.

Hypovolemic shock: (decrease BP)- results when you lose more than 20 percent (one-fifth) of your body's
blood or fluid supply. Low volume of circulating blood. Internal or external hemorrhage. Loss of plasma
due to burns. Fluid loss: vomiting, diarrhea, heat prostration. Trauma that causes blood loss into a body
cavity. Results from sudden decrease in intravascular fluid (15-25%)
Symptoms: Restlessness, thirst, cold, clammy skin. Pallor; sweating; cyanosis. Rapid pulse, heart beats to
try and compensate for low BP. Rapid respiration, weakness, lethargy. Systolic B/P low hypotensive 60-
90mm
Actions: Stop exam, trendelenburg, notify dr, glove and apply pressure with dry, sterile dressing. Maintain
airway and vitals every 5 minutes. Assist with oxygen, i.V, meds. Don't overheat but keep patient Warm.
no fluids, don't leave the patient.
• Four levels of hypovolemic shock

Cardiogenic shock: -heart cannot pump enough blood and oxygen to the brain, kidneys, and other vital
organs.
• Caused by hearts failure to pump an adequate supply of blood to vital organs
Response: Call code, get a crash cart. Notify dr. Put the patient in a semi fowler's position, assist with O2,
IV and meds. Do not leave patients alone, explain and alleviate anxiety, assess vitals, do not give fluids,
prepare CPR.
For unresponsive: Shake and ask if all right, call a code, assess carotid pulse, place patient in supine
position on hard surface, start CPR.

Vasogenic shock:
• Takes place when pooling of blood takes place in peripheral blood vessels, resulting in decreased
venous return of blood to heart, decreased BP and decreased tissue perfusion
 • Three types of distributive shock:

o Neurogenic- most commonly a consequence of traumatic spinal cord injuries.

o Septic- a potentially fatal medical condition that occurs when sepsis, which is organ
injury or damage in response to infection, leads to dangerously low blood pressure and
abnormalities in cellular metabolism. CONTINUED BELOW
o Anaphylactic- allergies. Fatal reaction to drugs. Exaggerated hypersensitivity reaction to
an antigen that was previously encountered by the body's immune system.
▪ Histamine is released causing: vasodilation, peripheral pooling of blood, contraction
of nonvascular smooth muscles of the respiratory system. Respiratory failure and
death can occur within minutes.
▪ Causative agents: Drugs, iodinated contrast agents, foods, anesthetics, insects
▪ Entry to system: Skin, respiratory tract, gastrointestinal tract, systemic injections.
▪ Mild symptoms: Nasal congestion, periorbital swelling, itching, sneezing and
tearing of eyes, itching at site of injection, tightness in chest, mouth or throat.
Anxiety, nervousness.
▪ Moderate symptoms: Previous plus: Flushing, feeling of warmth, itching and
urticaria, bronchospasm and edema of the airways or larynx, dyspnea, cough and
wheezing.
▪ Severe: Abrupt onset any previous symptoms, decreased BP, weak, thready pulse,
rapid progression to bronchospasm, laryngeal, edema, severe dyspnea, cyanosis,
dysphagia, abdominal cramping, vomiting and diarrhea, seizures, respiratory and
cardiac arrest.
▪ Action: Don't leave patients, stop infusion or injection of contrast. Notify dr. of any
symptoms. Complaints of respiratory distress or severe symptoms- call the
emergency team. Put the patient in a semi-fowler position. Monitor vital signs.
Prepare to assist with O2, IV fluid and meds. Prepare to administer CPR.
▪ Meds given: Epinephrine (vasoconstrictor), diphenhydramine (Benadryl),
hydrocortisone, aminophylline (bronchodilator). CONTINUED BELOW

Septic shock:
• Severe systemic infections and bacteremia (bacteria in bloodstream)
• Signs and symptoms
• Early: Skin warm and dry, flushed
• Late: skin cold, clammy. Abrupt decrease in LOC.
• Tachycardia and tachypnea (fast heartbeat and fast respiration)
• Seizures, circulatory collapse and cardiorespiratory failure.
• Stop the procedure. Call for help.
• Patient flat, supine.
• Cover with sheet
• Vitals every 5 min
• Help with oxygen. IV

Common signs and symptoms of shock:

• Restlessness
• Apprehension or general anxiety
• Tachycardia
• Decrease in blood pressure
• Cold and clammy skin
• Pallor (unhealthy pale appearance)

How can shock be prevented:

• Maintain normal body temp
 • Avoid overheating
• Manage or reduce pain, stress or anxiety

1. Control hemorrhage of bleeding

2. Ensure adequate breathing
3. Stop bleeding if it presents
4. Elevate lower extremities and maintain a head low position except when contraindicated.
5. Immobilize fractures
6. Avoid rough or excessive handling
7. Transport the patient at a safe speed
8. Keep patients temp normal
9. Monitor consciousness
10. Do not feed the patient or give a beverage
Anaphylactic shock:
• Vasogenic shock
• Most common type of shock encountered in medical imaging
• May occur with contrast media administration
• Signs and symptoms must be monitored as routine procedure with contrast studies
• Alert physician when signs occur

From mild to severe:

Urticaria (hives) and itching
Nausea and vomiting
Laryngeal edema
Cardiac arrest

Contrast and renal failure:

• Almost entirely excreted by kidneys
• BUN and creatinine levels in normal range
• BUN- 10-20mg/dl
• Creatinine- adult males: 0.801.4, adult females 0.6-1.1
• Metformin- stopped for 48 hours post injection.

Pulmonary Embolism:
• An occlusion of one or more pulmonary arteries by a thrombus or thrombosis.
• Blood clot effects of O2 entering the bloodstream
• Signs and symptoms:
o Shortness of breath and tachypnea
o Tachycardia, apprehension, coughing and hemoptysis, diaphoresis (sweaty and clammy)
and syncope, hypotension, cyanosis, sharp/stabbing pain
o Rapidly changing levels of consciousness.
o Stop procedure and call for emergency assistance
o Notify Dr and get crash cart
o Monitor vital signs
o Don't leave pt. Reassure pt.
 o Prepare to assist with O2, IV meds and fluids.

(thrombus becomes an embolus when a part breaks off and travels)

Orthostatic hypotension- decrease in 20 in systolic bp and or 10 mm in diastolic pressure 2-5 min after
standing. Patients complaining of blurred vision and dizziness upon standing for an upright chest x-ray
may be experiencing this.

Parenteral route- any medication that is not given through a normal body opening.

Water seal apparatus- for chest drainage, placed under level of chest when transporting patients.

Cardiac arrest: heart malfunctions and stops beating from electrical problems. Arrhythmia, lack of blood
to vital organs. Most common signs are: loss of consciousness and pulse changes or stops, seizure, pupil
dilation, decrease bp, cyanosis. Causes: Myocardial infarction, ventricular fibrillation, hypovolemic
shock, cardiac tamponade, pulmonary embolism.
Heart Attack: blood flow to heart is blocked, circulation problems causing artery death.

Diabetes:
-healthy patient adjusts own insulin production and excretion to meet carbohydrate demands of the body
-patient with diabetes may be treated with insulin shot or diabetes pills and will need to adjust diet to
balance insulin depending on whether they are type 1 or 2
- Stop procedure, notify dr. Don't leave patients unattended. Monitor vital signs and prepare to administer
O2, Iv fluids and meds.

Diabetic coma:
• The result of an inadequate insulin supply that leads to unconsciousness, coma and death if not
treated.
• Caused by too much or not enough food, not taking insulin.

Hypoglycemia-
• Excessive insulin is present
• Can occur if patient takes normal dose of insulin and does not eat
• Signs of insulin shock
• Glucose required
• Patient often recognize early signs and need a quick form of carbs or take a glucose tablet
• Extremely hungry, weak, shaky, blurred vision, may sweat excessively, confused, nervous and
irritable, sometimes aggressive.

Hyperglycemia-
• Excessive sugar in blood and characteristic of diabetes
• Develops gradually over a period of hours or days
• Excessive thirst and urination, dry mucosa, rapid and deep breathing, drowsiness, and confusion
• Insulin required- leads to diabetic coma if left untreated.

Respiratory distress-
• Asthma
o Chronic condition
o Often occur when exposed to stressful situations
o Patient may exhibit wheezing respiratory effort
 o Mant asthmatics carry self administered inhalant

• Choking
o Recognized with universal sign for choking
o Administer heimlich maneuver
• Obstructed airway
o If foreign object is visible in the open mouth, the rescuer should perform a finger sweep.
o If unsuccessful, being CPR to force obstruction up
o Check the mouth for obstruction before each set of ventilations

CPR:
• Medical imaging professionals should be familiar with an institution's protocol for cardiac
emergencies.
• The professional technologist should be familiar with all required skills and to achieve certification
in all CPR procedures
• On realization that a patient has experienced cardiac arrest, the appropriate alert should be initiated
before CPR is begun.
• Must be initiated immediately on thorough verification that cardiopulmonary distress exists
• CABS of CPR: Compressions, airway, breathing.
• 30:2 if with someone else, 15-2 by self.

AED:
• Used for ventricular fibrillation
• Two types: fully automatic and semi automatic
• May interrupt CPR
• Considered a standard of care with CPR in most situations
• Time of AED intervention critical to survival.

CVA:
• Commonly called a stroke or brain attack
• More likely to occur in older patients bit can occur in any adult
• May develop gradually or suddenly
• Warning signs- paralysis, speech changes, extreme dizziness, vision problems, loss of consciousness
• Loss of consciousness may necessitate CPR
• Patient needs to be placed in recumbent position ASAP
• Burst blood vessel that supplies blood to the brain
• Vary in severity with little or no warning
• Referred to as brain attack or infarct

Signs and symptoms:

• Severe headache, collapse, altered LOC, Difficulty with vision or speech
• Confusion, seizures, Difficulty breathing, Unequal pupils, Loss of bladder and bowel control,
numbness/ paralysis (on one side)

Minor medical emergencies:

• Nausea or vomiting
• Epistaxis (nose bleed)
• Vertigo and syncope (fainting)
• Seizures
• Falls
• Burns
• Wounds
Epistaxis (nose bleed):
• Seldom life threatening
• Lean patient forward
• Pinch affected nostril against the midline nasal cartilage with finger pressure
• Keep patient upright in chair
• If bleeding persists, apply moist compress
• Seek medical attention if bleeding continues for 15 minutes.

Vertigo:
• Patient experience dizziness
• Vertigo is often a precursor to syncope
• Watch for orthostatic hypotension and vertigo when sitting patient up from a recumbent position

Syncope
• Fainting
• Insufficient blood to the brain.
• Causes- heart disease, hunger, poor ventilation, extreme fatigue, emotional trauma.
• Syncope is a self correcting, temporary state of shock and the result of lack of blood flow to the
head
• Assist patient into a recumbent position

Respiratory Dysfunction:
• Airway obstruction caused by: Tongue falling backwards, foreign object lodged in throat, disease,
drug overdose, injury, results in inadequate gas exchange.
Signs and symptoms: Labored, noisy breathing, wheezing, using neck and abdominal muscles to try and
breath, neck vein distention, diaphoresis, anxiety, cyanosis. (diaphoresis, dyspnea, cyanosis.)
Response for partially blocked: call for help, do not leave pt. Pt in semi fowler position
Complete obstruction: call for help, abdominal thrust, unconscious patient

Seizures:
• Unsystematic discharge of neurons of the cerebrum that result in an abrupt alteration of brain
function
• Irregular activity in the brain that can cause sudden changes in behavior.
• Convulsion exhibited as a result of the conduction of seizures.
• Accompanied by change in level of consciousness
• Generally a symptom of an underlying condition
• Take note of seizure event
• Begins with little or no warning.
• Confusion, blacking out, sensing strong smells

Seizure patient care:

• Prevent from injury
• Secure patient to prevent injury
• Call for assistance
• Protect the patients privacy
• Do not insert hard objects into mouth or put your fingers in
• Remove dentures or foreign objects
• Ensure airway
• Do not finger sweep with your finger
• Place blanket or pillow under the patients head
• Observe seizure (onset, duration, left, right sided or both
 • After seizure, place the patient in sims position and place face downward to permit vomitus and
secretions to escape.
• After even ensure open airway

Trauma guidelines:
• Don’t remove dressings or splints
• Don’t move patients on stretcher or back board until ordered
• Initial lateral C-spine, never move neck or remove collar.
• Request direction when planning moves
• Dont disturb impaled objects
• Don’t remove pneumatic antishock garments
• Have O2 and suction ready
• Work quickly and efficiently and accurately
• Assess the situation, develop a plan.
• Determine mobility
• Get equipment and accessories needed
• 2 views at 90 degrees
• Routine imaging adapted
• Include all anatomy of interest, joint nearest trauma but ideally both joints.

Head Trauma:
• Keep head and neck immobilized until spinal cord injury ruled out.
• Do not remove sandbags, collar, dressing
• Do not flex patients neck or turn it to either side
• Check respiration and pulse during procedure
• Apply sterile dressing if bleeding becomes profuse and call emerge
• Observe patients LOC, notify dr for changed
• Be prepared to assist with O2 and other emergency assistance.
• Nasal suction performed

Facial injury:
• observe possible airway obstruction
• Don’t remove sandbags or collar
• Apply sterile dressing if bleeding is profuse
• Wear sterile gloves in contact with open wounds
• Be prepared to assist with O2
• Observe for symptoms of shock
• Change in LOC
• Nasal suction performed

Spinal cord injury:

• Monitor airways
• Maintain open airway
• Do not move patient or request that patient move
• Do not remove sandbags, collars, antishock garments, backboard
• Watch for signs of shock
• Keep patient warm

Conclusion:
• Recognize emergency conditions and act appropriately
 • Ask for assistance during emergency situation
• Maintain competency with basic emergency skills
• Become certified in CPR and AED use
• Use for medical common sense in emergencies
• Radiologist comes to monitor patients closely with anaphylactic symptoms

Questions:
• Call a code for a cardiac arrest when a patient's pulse cannot be found just below the mandibular
angle, using the carotid artery.

Lines and tubes:

Lines and tubes: Tracheostomy, Swans-Ganz Catheter, Central Venous Pressure (CVP), Hickman
Catheter, Peripherally inserted central catheter, Temporary or permanent pacemakers.

Tracheotomy:
• Allow access to the upper airway for patients with upper airway obstruction, permit easier, safer
suctioning of patients with excessive pulmonary secretions, and enable mechanical ventilation in
the presence of respiratory failure.
• Endotracheal tubes are inserted either through the nose (nasotracheal), or mouth (orotracheal) and
are used for short- term airway management.
• Tracheostomy tubes are inserted through an incision in the trachea below the vocal cords, usually
between the third or fourth tracheal rings.
• Need to be 5-7 cm above the carina. Positioning checked on Cxr.
• Checked daily.
• 20% of all endotracheal tubes require repositioning.

Chest tubes:
• Thoracostomy tubes are placed in the pleural or mediastinal cavity to remove excess fluid or air.
• When air or fluid leaks into the intrapleural space, either because of trauma, surgery or disease, a
chest drainage system is required to restore the closed environment.
• Chest tubes are indicated for hemothorax, pneumothorax, bronchopleural fistula, empyema, pleural
effusion, and mediastinal fluid.
• Water seal drainage system is established by connecting the chest tube that originates in the pleural
cavity to a clear tube that ends in a chamber containing sterile water or sterile normal saline
solutions.
• The tube leading from the chest tube remains below water levels at all times to maintain the seal.
• Be certain to maintain the level of the fluid container lower than the patient's lungs to avoid
backflow into the lungs.

Swan Ganz Catheter:

• A soft catheter with an expandable balloon tip that is used for measuring blood pressure in the
pulmonary artery. For heart function monitoring
• The catheter is introduced through a large vein- often the internal jugular, subclavian, or femoral
veins.
• From this entry site, it is threaded, often with the aid of fluoroscopy, through the right atrium of the
heart, the right ventricle, and subsequently into the pulmonary artery.

Central venous catheter:

• Used for long term medications, frequent blood transfusions or total parenteral nutrition.
 • You must be aware of their presence and purpose and be familiar with the precautions when in
place.
• When a patient does not have an adequate nutritional intake and cannot tolerate nourishment by
means of the Gi tract, he or she may be ordered to receive partial or total nutrition by an
intravenous route.

Hickman Catheter:
• A hickman line is an intravenous catheter most often used for the administration of chemotherapy or
other medications, as well as for the withdrawal of blood for analysis.
• Some types of hickman lines are used mainly for the purpose of apheresis or dialysis.
• Hickman lines may remain in place for extended periods and are used when long term intravenous
access is needed.

PICC:
• Inserted in a peripheral vein, such as the cephalic vein, basilic vein, or brachial vein and then
advanced through increasingly larger veins, towards the heart until the tip rests in the distal
superior vena cava.
• They are usually initially placed under fluoroscopic guidance in the fluoroscopic or interventional
radiographic suite. Some institutions have trained nurses to insert PICC lines bedside. Position is
checked with a portable CXR.

Temporary or permanent pacemakers:

• Artificial pacemakers are electronic devices that stimulate the heart with electrical impulses to
maintain or restore a normal rhythm in patients with slow heart rhythms.
• Temporary pacemaker- intended for short-term use, usually during hospitalization.
• They are used because the patient’s arrhythmia is expected to be temporary and eventually resolve,
or because the patient requires temporary treatment until a permanent pacemaker can be placed.
• Permanent pacemakers- pacemakers that are intended for long term use.

Nasogastric and nasoenteric tubes:

• An NG tube is threaded into the nasopharynx and into the stomach.
• This enables drainage of gastric contents, decompression of the stomach.
• A specimen of the gastric contents can be obtained or substances can be introduced into the GI
tract.
• NG tubes are often indicated for gastric immobility and bowel obstruction. They allow for drainage
and/ or lavage in drug overdose or poisoning.
• In trauma settings, NG tubes can be used to aid in the prevention of vomiting and aspiration, as well
as for assessment of GI bleeding.
• The NE tube is also inserted through the nose and advanced through the stomach and then into the
small intestine. Fluoroscopic guidance is often necessary.
• They are also used for decompression, diagnosis and treatment purposes.
• They are most often utilized as feeding tubes.

Patient transfers:
• When transferring a patient with left sided weakness, position the right side of the wheelchair next
to the table.
• When transferring a patient with hemiparesis from a wheelchair to the x-ray table, the wheelchair
should be positioned parallel to the x-ray table, with the patient’s strong side closest to the table.
• When two persons are assisting a patient to move from a stretcher onto a bed, they should position
on the same side of the stretcher.
 • The base of support refers to the line between the points of contact with a horizontal surface.
• When transporting a toddler to the department, transport them in a crib
• Best way to transfer a patient with spinal immobilization on a stretcher is to use a slider board

Section C: Back to top

Radiation Health and Safety:

• Avoiding unnecessary exposure to the developing fetus or embryo is essential due to the
radiosensitivity of rapidly dividing cells.
• The relative risk of fetal exposure to radiation should be weighed against the risk of failing to
diagnose serious disease in the mother and by realizing absolute risk remains very small.
• Irradiation of the unborn fetus increases the risk of somatic effects as well as genetic effects that
could be passed to subsequent generations.
o Exposure of less than 50 mgy has not been associated with an increase in fetal anomalies
or pregnancy loss.
• 10-55 asked before about the possibility of pregnancy. Response documented
• Pregnancy tests can be used to confirm a patient's pregnancy status before procedures that have the
potential for large doses of radiation to the fetus. Irradiation of certain sensitive areas,
examinations where radiation doses are high.
• Signage posted in waiting areas advising patients to declare pregnancy can aid in identification, but
does not replace the requirement to ask the patient. If pregnancy is identified after the procedure
or treatment, the mrt must notify the physician on duty, radiation safety officer or radiation
protection officer as applicable.
• The decision to undertake a procedure or a course of treatment, and the determination of the exact
limitations to be imposed are made collaboratively with the radiologist, radiation oncologist or
referring physician, and the patient.
o MRTs only proceed with procedures or treatment for pregnant patients after confirmation
that the radiologist or radiation oncologist has been consulted.
• ALARA guide decisions about pregnancy or possibly pregnant patients:
o Procedures or treatment are essential and the benefits outweigh the risks
o Procedures or treatment that cannot be delayed until after delivery
o Alternative investigations are considered where possible before proceeding
o Reductions in dose are considered, if possible.
• Department/ facility guidelines should be consulted before proceeding with any procedure.
• If examination of a pregnant patient must be carried out, modifications may help to minimize the
dose to the embryo or fetus.
o For imaging the chest or extremities, a well collimated x-ray beam with abdominal
shielding is used.
o For imaging of the pelvic area, full use of gonadal shielding is used (unless clinical
objectives will be compromised.
o PA positioning is used when possible to reduce radiation dose to the fetus
o In Nuclear medicine procedures, a reduced dose is recommended.

Patient pregnancy:
Preimplantation: 0-9 days results in embryonic death or no effects. All or nothing stage. .5-.15 gy all or
nothing
Organogenesis: 10 days to 6 weeks: Most susceptible to radiation- induced congenital abnormalities.
Present of fatal abnormalities will result in neonatal death
Fetal growth stage: 6 weeks to term. Congenital abnormalities
Risk most significant in organogenesis and early fetal period.

Dose reduction:
• Collimation to limit beam at source is most effective radiation protection for the patient and
personnel

Improving image quality:

Improved by limiting x-ray beam to the smallest field giving the required diagnostic information.
• Optimal collimation also reduces image noise caused by scatter radiation originating from outside
the region of interest
• Over-collimation and under-collimation lead to data recognition errors that affect the histogram in
digital imaging.

Image post-processing:
• Post- processing techniques such as shuttering/ masking, are not acceptable substitutes for
collimation
o Both are imaging modification techniques that only mimic collimation
o Neither shuttering nor masking limits the dose of radiation given to the patient.

Minimizing patient exposure:

Any level of radiation, no matter how small, has the potential to increase the risk of cancer. Important
factors of radiation dose

Radiation effects:
• Stochastic and deterministic effects of ionizing radiation.
• Different types of radiation measurements and know their uses.
• Outline ways of reducing dose to occupationally exposed personnel and patients
• Describe radiation dose reduction techniques in fluoroscopy
• Describe radiation dose reduction techniques in CT
• Primary and secondary barriers. (secondary: ceiling)
• Radiation with a high LET is highly ionizing (Linear energy transfer is the amount of radiation
deposited per unit length of tissue traversed by incoming photons)
• Leakage radiation is caused by the loss of the tube vacuum insert. The vacuum affects the electron
flow from the cathode to the anode and thus creates erratic tube current flow.

Radiation health effects: Stochastic and deterministic

• Two primary detrimental health effects are associated with ionizing radiation: stochastic effects and
deterministic effects
• Stochastic effects include radiation induced cancer (leukemia) and genetic effects.
• The probability of a stochastic effect increases with radiation dose, the severity in unaffected
• Deterministic effects occur when radiation dose exceeds a certain threshold of radiation exposure
• The severity of a deterministic effect increases with increasing radiation dose.
• The principal concern for any patient undergoing a diagnostic imaging exam or procedure is the risk
of developing a radiation- induced cancer (a stochastic health effect), which may be fatal or
nonfatal.
• Children are more sensitive to radiation than adults and have a longer life expectancy and as a
result, the risk for developing a radiation related cancer can be several times higher for a young
child compared with an adult. This particularly important for CT examinations
 • The relationship between cell growth rate on the sensitivity of tissues to ionizing radiation is
directly related. (the more your cell divides the more radiosensitive)

Imaging interactions:
X-rays can be transmitted, absorbed or scattered.
Coherent: Occurs at less then 10 kev. Change in direction of photon, wavelength same.
Photoelectric effect: Photons absorbed by matter incident photon with slightly more E than orbital
electron
Photoelectric absorption: photoelectron travels short distance in tissue and is absorbed or fills void
elsewhere. Three products: -ve ion, characteristic, +ve ion.
3 rules: sufficient energy needed, PE energy must exceed binding E, tighter bound more likely involved in
PE
Compton: Almost all scatter is this, incident & ejected electron in different direction. strikes free valence
shell electron of an atom, ejecting it from orbit.
Scatter radiation: causes fog, unwanted interaction of photons with matter
Pair production: Occurs at more than 1.02 Mev. Will fill void or interact with atom. Interacts with nuclear
field.
Photodisintegration: High energy photons colliding with nucleus of atom. Occurs @ more than 10 mev.

Radiation units:
• Many different units are used for measuring radiation
o Roentgen ®- used for measurements in air . Coulombs/kg of air
o Rad (radiation absorbed dose)- used for patient dose purposes. Gray (Gy)
o REM- (radiation equivalent man)- used for worker protection purposes. Sievert (Sv)
• They include:
o Exposure
o Air kerma
o Absorbed dose
o Equivalent dose
o Effective dose
• Common CT dose measurements include CTDI vol and DLP

Head dosimeter measures effective dose, waist under lead dosimeter measures absorbed dose.
OSL dosimeters may be scanned and reanalyzed an unlimited number of times

Exposure:
• Measures the amount of ionizations created in an air chamber by x-rays
• The unit of measurement is the coulomb per kilogram
• Most useful for measuring x-ray tube output, patient entrance exposure and scattered radiation
levels.
• Being replaced by air kerma

Air Kerma:
• Air Kerma (Kinetic energy released per unit mass of air) is used to measure the amount of energy
transferred to a mass of air by the photons
• The unit of measurement is the gray (J/KG)
• Most air kerma readings are in milligray
• Air kerma readings are replacing exposure or coulomb/kg readings
• Equipment may display the air kerma rate, particularly for fluoroscopic procedures.

Absorbed dose:
 • The absorbed dose is the radiation energy absorbed per unit mass of an organ or tissue. The actual
energy deposited in the irradiated tissue.
• The unit is in joule per kilogram which is gray
• The dose quantities equivalent dose and effective dose were devised to calculate the biological
effect of an absorbed dose.

Equivalent dose:
• The equivalent dose quantifies the risk of adverse effect for different types of radiation
• The absorbed dose is multiplied by a radiation weighting factor and is expressed in sieverts
• Equivalent dose is commonly used for radiation protection purposes.

Effective dose:
• Indicated the risk from a particular body exposure by using a tissue weighting factor
• Since most x-ray exams do not cover the entire body, effective dose is the sum of equivalent dose
multiplied by the tissue weighting factor
• More radiosensitive organs include breast, lung, colon and bone marrow.
• Effective dose is measured in sieverts and is commonly used for patient dose and equates non
uniform doses to whole body doses.

CT dose index:
CTDI is NOT a measurement of patient dose but is a parameter used in the CT scan which affect x-ray
tube output.

Dose length product (DLP):

• displayed for each series after a study is performed and is calculated based on the technique factors
used to acquire the data.
• CTDI provides a measurement of the exposure per slice of tissue exposed, the DLP provides a
measure of the total amount of exposure for a series of scans or, in other works, takes into
account the length of the scan

Dose limits:
• Occupationally exposed women, once pregnancy has been declared, the foetus must be protected
from x-ray exposure for the remainder of the pregnancy. For women who are also occupationally
exposed, an effective dose limit of 4 msv must be applied, for the remainder of the pregnancy,
from all sources of radiation. The monitor for the foetus is to be worn under the apron when a full
body lead apron is worn.
• For technologists in training and students, the recommended dose limits for members of the public
should apply 1 mSv
• NEW are allowed 20 mSv for 1 year and 100mSv for 5 years.

Reducing dose occupationally exposed:

• 3 principles of radiation protection: time, distance, shielding.

Time:
• Directly related to radiation dose received.
• Reducing time in a procedure room while x-rays are on will reduce occupational dose.
• Fluoroscopy, surgical procedures, interventional procedures and CT fluoroscopy are the most
common areas where "beam on" time is the highest
• Rotating personnel is one of the most effective ways to reduce exposure to staff

Distance:
• Spatial separation between staff and radiation
• Exposure reduction typically follows the inverse square law (meters in distance 2 equals the
 intensity reduction) (divergence of the x-ray beam)
• Medical personnel should only be near the patient when it is completely necessary
• All other medical personnel should leave the exposure area or stand behind the control panel or
other shielding barrier.
• Patient is source of radiation exposure for occupationally exposed personnel
• Standing at a right angle to the patient lowers dose
• Increasing kvp reduces MRT dose as scatter more likely to continue in a straight path, less back
scatter and side scatter produced
• At a distance of 1M, the scattered x-ray intensity is generally approximately 1/1000 of the intensity
of the primary beam
• At no time should medical personnel be exposed to the primary beam.
• As SID increases, beam intensity decreases and patient dose decreases.
• A MRT must stand 3 meters without lead shielding during mobile procedures.

Reducing dose, general info:

• Always wear personnel monitoring device
• Use immobilization devices for patient positioning. Only as a last resort should someone hold the
patient
• Rules for holding a patient: no individual should regularly hold patients, an individual who is
pregnant shall not hold patients, person holding shall not be younger than 18 years of age, a
parent or family member should be used to hold patients if necessary, a hospital employee who is
not occupationally exposed may be used to hold a patient if necessary

Shielding:
• Shielding includes physical barriers, most commonly the control panel and
• The use of lead thyroid collars, body aprons, leaded glasses and moveable shields also used for
protection.
• Gonadal contact shield- 1mm lead equivalent, reduces dose 50%- 90%

Scattered radiation:
• Poses the greatest occupational hazard in diagnostic imaging
• Use of any device or appropriate technique that lessens the amount of scatter radiation significantly
reduces occupational exposure of diagnostic imaging personnel

Anything that reduces patient dose can also reduce occupational exposure: Close collimation, filtration of
the primary beam, optimum kv, technique, high speed image receptors, proper positioning and
communication and avoidance of repeat exposures.

Factors affecting patient dose: technical factor setting

KVP:
• Increasing kvp without compensation for other factors results in increased patient dose
• Increase in kvp with compensation results in a significant reduction in patient dose
mAs:
• Decrease in mas results in less patient dose
• Mas directly related to patient dose.

Collimation:
• Accurate collimation is used to only expose the area of clinical interest to the primary beam
• Safety standards require light field and x-ray field congruence is within 2% of the SID or focal spot
to image receptor distance
• Divergence of the primary beam should always be taken into account when considering collimation
• This is very evident when the anatomic part is closer to the x-ray tube such as on a lateral lumbar
spine.
 • Positive beam limitation (PLB): maximum collimation is determined by the size of the image
receptor and collimation cannot exceed the size of the image receptor
• Manual collimation: the x-ray operator can manually reduce the collimation field size
• The practice of close collimation reduces patient dose in 2 ways: the volume of tissue irradiated
diminished, the amount of accompanying scatter is reduced and also improves image quality.
• The first choice to reduce exposure to the reproductive organs in every radiographic exam is to
collimate to include only the anatomy of interest as this decreases exposure to patient and
technologist.

Gonadal shielding:
• Gonadal shielding must be used in the primary beam or within 5cm of it
• Must contain .25millimeter of lead or lead equivalent
• Must be used for anyone of reproductive age or reproductive potential
• Should not be used when it interferes with necessary diagnostic information
• Used as a secondary protective measure to the collimation of the beam
• Contact shields used on female reproductive organs reduce exposure by 50%
• Contact shields used on male reproductive organs reduce exposure by 90-95%
• The most appropriate reason for the application of gonadal shielding is to safeguard the
reproductive potential of patients.

Filtration:
• Filtration reduces the number of low energy photons in the primary beam, this is referred to as beam
hardening.
• Correct filtration- reduces exposure to x-ray energies that do not contribute to the image.
• Minimum standards for filtration are as follows
o Use of filtration assists in reducing dose to the patient, especially the skin
o Total filtration of 2.5mm aluminum equivalent for equipment that operates above 70 kvp,
this includes mobile fluoroscopic units. This reduces the patient's skin dose due to the
decreased number of photons in the primary beam.
o Total filtration of 1.5mm of aluminum equivalent for equipment that operates at 50-70kvp
o Below 50 kvp- .5 mm of aluminum equivalency

Potentially pregnant or pregnant patient:

• 11-55 screened for possibility of pregnancy
• First trimester, foetus is most radiosensitive , pregnancy may not be known by female patient
• When uncertainty exists, the ordering physician or radiologist should be notified
• If a pregnant female's abdomen must be exposed to radiation, the following practices will reduce
dose to the foetus.
o Prone position, if possible
o Limited or reduced images, only essential images taken,
o Careful collimation should be used
o Lead shielding should be considered and placed to not interfere with necessary clinical
information
o Patients should be informed of risks.
• Dr. should discuss using other imaging modalities

Repeat images:
• Repeat imaging is predominantly needed for improper positioning
• Anytime a repeat image is required, the patients dose is increased
• Repeat images for technical factor errors has been greatly reduced with the use of digital imaging
• 5% varience

Dose reduction in fluoroscopy:

 • Use of intermittent fluoroscopy
• Use of pulsed fluoroscopy setting for example, 15 frames per second instead of 30
• Use of smallest possible field size, large field size increases scatter radiation production
• Use of last image hold
• Use of lead PPE and moveable shields

Dose considerations in CT (KVP):

• CT kvp ranges from 80-140
• Increasing kvp will increase the amount of radiation used in the exam
• Most of the abdominal CT examinations can be done using 120 kvp and earn 20% to 40% reduction
in radiation dose compared to a value of 140 kvp
• Most pediatric examinations can be successfully performed using 80-100 kvp resulting in sufficient
image quality.

MAS:
• Mas is a measure of the amount of radiation that is used to generate any radiographic or CT image
• Increases in MAS increase patient dose
• The CT mas used to scan pediatric patients should be reduced relative to those used for adults
• Tube current modulations adjusts the mas to compensate for different levels of attenuation of the
anatomy during both rotation and longitudinal movement of the patient through the x-ray beam
• TCM is an effective method of reducing patient dose during the scan.

Beam collimation and slice width:

• These are directly related to the detector configuration of the CT scanner
• Generally, wider x-ray beam widths result in more dose- efficient examinations
• Beam width must be carefully selected to address the specific clinical requirements.

Pitch ratio:
• Table increment distance per 360 degree rotation of the x-ray tube divided by the x-ray beam width
• Radiation dose is inversely proportional to pitch
• Doubling the pitch results in 50% reduction in dose

rotation/ (slice scannerx slice thickness)

Scan coverage:
• Scan length is the irradiated portion of the body in the z- direction
• Scan length is directly proportional to the patient radiation exposure
• The scan length should be set at the lowest possible value that will allow the clinical question to be
answered
• The scan length should be set at the lowest possible value that will allow the clinical question to be
answered
• Careful consideration should be given to pediatric CT examinations

Isocenter:
• Accurate patient centering is a critical method of dose reduction
• miss centering by only 2.2cm can increase CTDI by an average of 23%
• The patient appears to be thicker than they really are and the tube current modulation will increase
the milliamperes in response

Pediatric consideration:
• Limit region of coverage
• Adjust individual CT settings based on indication, region imaged and size of child
 • Use pediatric protocols based on age, weight, height, and clinical indications
• Significant decreases in dose can be achieved with lower kvp selections
• The small size of a child may require thinner CT slices compared with adults in order to improve
spatial resolution

Primary and secondary protection barriers:

• Primary shielding barriers are situated perpendicular to the x-ray beam and protect for primary
radiation
• Secondary shielding barriers protect against scatter and leakage radiation. Leakage radiation is
emitted through the x-ray tube housing.
• The primary beam is never directed towards the control panel as it is a secondary barrier. The
primary beam is the radiation that exits the x-ray tube through the collimator.

Radiation Weighting Factor:

• One is the factor for Gamma

Patient Safety:
• Inquire to all female patients 11-55 regarding pregnancy
• Questions asked in a private setting
• Response to question documented
• Pregnancy test may be used to confirm pregnancy for potential large dose exposure to a fetus
• Pregnancy identified after x-ray exposure; notify physician on duty, notify RSO and or RPO

Procedures for pregnant patients:

• Decision is made by radiologist or radiation oncologist's benefits outweigh risks, cannot delay
procedure or treatment, alternative methods have been considered, dose reductions considered.
• MRTs only proceed after confirmation.

When exam on pregnant patient must be completed:

• Chest or extremities: well collimated x-ray beam with abdominal shielding
• Pelvis area imaging: full use of gonadal shielding is used unless clinical objectives will be
compromised
• PA positioning is used when possible to reduce radiation dose to fetus
• Exposures and dose are documented

Collimation:
• Most effective radiation protection for patient and personnel
• Reduce tissue irradiated and scatter radiation

Reducing patient exposure- optimal collimation:

• Image quality is improved when contained to the smallest field required for diagnostic imaging
• Optimal collimation reduces image noise due to the reduction of scatter
• Over and under collimation can lead to data recognition errors and may affect the histogram

Collimation and image post processing:

• Shuttering/ masking are not acceptable substitutes for collimation
• Shuttering or masking does not affect the dose of radiation given to the patient

Radiation safety- communicating risk and benefit:

• MRTs assist patients and or caregivers in making informed decisions
• Consent based on fact and true description of benefit and risk
• Information is present so patient can understand- no medical jargon and acronyms defined
 • Information is current, accurate, structured and organized.
• Confirm patient understanding- given opportunity to ask questions and clarify concerns.

ALARA:
• Principles based off the model that any dose of radiation has potential to increase cancer risk
• Risk of increasing dose- minimum dose is applied while maintaining image quality
• Dose is controlled by the MRT for general radiographic procedures

Minimizing patient exposure- minimizing dose:

• Source of radiation, length of exposure, distance from source, protective measures
• Images that are diagnostic, with clearly identifiable pathology, should not be repeated
• Ask more experienced mrt or radiologist if uncertain about whether or not to repeat an image
• Equipment must work properly to ensure minimum dose- quality control
• Patient is given proper instruction
• Protect body parts more sensitive to radiation, when applicable
• Use appropriate scanning borders when performing CT
• Diagnostic exams are preserved for future use; do not need to repeat because of lost exams.
• Filtration- removes low energy photons
• Collimation- limits area exposed
• AEC- reduces repeat due to MAS technical factors
• Shielding- contact and shadow lead used
• Appropriate focal spot to skin distance
• Adaptation of technique for children and different body types

Mobile imaging:
• Radiation exposure to patients, personnel and public is kept low as possible when imaging outside
of an x-ray room
• Remove unnecessary persons in the area
• Give an audible announcement prior to the exposure and allow time for others to vacate the area
• Those that have left are asked to leave until x-rays are complete
• Any persons remaining are advised to stand as far away as possible from the patient
• Shielding is provided for those who must remain in the area, including the MRT operating the
equipment
• Direct primary beam away from occupied areas; this may involve moving the patient
• Fluoroscopy outside the department is only used when necessary.

Questions:
• The tissue in the bone marrow is more radiosensitive than skin tissue.
• The inverse square law relationship between radiation intensity and distance from a point of
radiation source is due to divergence of the x-ray beam. l^2xd^2 2= l^2x d^2 2
• When Pregnancy status, Adding additional images, or the order itself is in question, consult the
ordering physician
• A linear non threshold response has no dose that is considered completely safe.
• Minimum Pb for the whole body apron is o.5mm
• Radiation induced cancer, leukemia and genetic effects are linear, non threshold dose responses.
• Unit of absorbed dose is gray
• Highest entrance skin dose is lateral lumbar spine
• When peak voltage exceeds 100 kv and is less than 150kv, the attenuation equivalency of lead apron
must be .35mm
• Lead aprons should be tested for integrity annually
• Lead equivalency for ceiling mounted acrylic screens and moveable shields .5mm
 • MRT should be 3 meters away from the x-ray tube.
• The floor of an x-ray room can be struck with the primary beam but not a lead apron worn by a
worker, a secondary barrier or the control panel (secondary barrier)
• Increasing filtration decreases patient dose. Decreasing collimation = opening cones, increasing grid
ratio changes scatter on image, decreasing kvp requires an inverse change of MAS
• Collimation protects the patient the most from x-rays
• Air kerma is energy released in a unit mass of air
• DLP is the CTDI volume multiplied by the length scanned.
• Miscentering in CT decreases image quality (makes the patient look larger than they are), and
increases surface dose.
• Audible indication of 5 min of fluoro
• When cells are fully oxygenated they are most radiosensitive.
• All x-ray control panels must have a permanent sign prohibiting unauthorized use.
• Proper collimation results in the lowest patient dose.
• Collimation is used to reduce dose to radiosensitive tissues and organs.
• Law of bergonie and tribondeau states that the radiation sensitivity of cells is directly proportional
to their reproductive activity and inversely proportional to their degree of differentiation
• Radiation protection is based off a Linear- non threshold dose-response relationship
• High kVp, Low mAs and increased filtration reduce radiation dose. ?
• When insufficient light is produced by the image plate, a decrease of noise. Insufficient light means
over-exposure.
• To decrease noise, increase mA .

PPE:
• Protects from infectious agents.

Tips for gloves:

• Work from clean to dirty
• Limit opportunities for “touch contamination” to protect yourself, others, and the environment.
o Don’t touch your face or adjust PPE with contaminated gloves
o Do not touch environmental surfaces except as necessary during patient care.
• Change gloves
o If torn and when heavily soiled.
o After each patient
• Discard in appropriate receptacle
o Never wash or reuse disposable gloves.

Tips for Gowns and Aprons:

• Natural or man made, reusable or disposable, resistance to fluid penetration.
• Clean or sterile.

Face protection:
• Masks- protect nose and mouth
o Should fully cover nose and mouth and prevent fluid penetration
• Goggles- protect eyes
o Should fit snugly over and around eyes
o Personal glasses not a substitute for goggles
o Anti Fog feature improves clarity
Respiratory protection:
• Purpose: Protect from inhalation of infectious aerosols
• PPE types for respiratory protection
o Particulate respirators
o Powered air purifying respirators (PAPR)
• (N95, N99, N100, filter capable of excluding particles that are less than 5 microns in diameter.)

Key points:
• Don before contact with the patient generally before entering the room.
• Use carefully- don’t spread contamination
• Remove and discard carefully, either at the doorway or immediately outside the patient's room;
remove the respirator outside the room.
• Immediately perform hand hygiene.
• If hands become contaminated during ppe removal, wash hands before continuing removal.

Gowning sequence:
Gown, then mask or respirator, goggles or face shield, gloves.
Gowning removal sequence:
Gloves, Face shield or goggles, gown, masks or respirator. (Remove at doorway or before leaving patient
room or anteroom, remove respirator outside of room, after door has been closed.

Particulate respirator:
• Select a fit tested respirator
• PLace over nose, mouth and chin,
• Fit flexible nose piece over nose bridge
• Secure on head with elastic
• Adjust to fit
• Perform a fit check (Inhale, mask should collapse, exhale, check for leakage around face)
• (removal by grabbing the elastics from behind and over your head starting at the bottom and then
discard)

Standard precaution:
• Gloves- when touching blood, body fluids, secretions, excretions, contaminated items; for touching
mucus membranes and non intact skin.
• Gowns- use during procedures and patient care activities when contact of clothing/ exposed skin
with bloody/body fluids, secretions, or excretions is anticipated.
• Masks and goggles or a face shield- use during patient care activities likely to generate splashes or
sprays of blood, body fluids, secretions, or excretions.

Contact: gloves and gown

Droplet- mask if within 3 feet of the patient.
Airborne infection- particulate respirator.
Quiz:
• Giving a bath- no ppe
• Suctioning oral secretions- gloves and mask/goggles or a face shield, depends on open or closed
suction.
• Transporting a patient in wheelchair- n ppe
• Responding to an emergency where blood is spurting- gloves, fluid-resistant gown, mask/ goggles
or a face shield.
 • Drawing blood from a vein- gloves.
• Cleaning an incontinent patient with diarrhea- gloves and a gown
• Irrigated a wound- gloves, gown, and mask/goggles or a face shield
• Taking vitals- no ppe
• When two techs image a patient wearing blood soaked clothes who is unconcious, both techs will
wear gloves and one removes gloves to handle equipment

Section D: Back to top

Pharmaceutical administration:
• Adrenergic drugs- constrict blood vessels and stimulate the heart (Vasoconstrictor)
o stimulate certain nerves
o Mimic or interfere with the functioning of the sympathetic nervous system by affecting the
release or action of norepinephrine and epinephrine.
o Raise blood pressure, constrict blood vessels, open the airways to the lungs and increase
heart rate
o Useful in treating systemic trauma including bronchial asthma, shock, and cardiac arrest.
o Dopamine, epinephrine- used in cardiovascular, respiratory and allergic emergencies
▪ Side effects: tachycardia, palpitations and hypertension.

• Anesthetic drugs- result in a temporary loss of sensation or awareness

o Reversibly depress neuron function, producing loss of ability to perceive pain and/or other
sensations
o 2 types- general and local anesthetics
o General anesthetic (propofol) depress the central nervous system and cause loss of
consciousness
o Local anesthetic (lidocaine) block nerve conduction from a certain area
o Side effects propofol: fast or slow heart rate, high or low blood pressure, apnea- only given
for surgical procedures.
o Side effects of lidocaine: low blood pressure, redness at injection site, nausea, vomiting.
• Anti Anxiety- ease anxiety
o Act on the central nervous system to calm or relax
o Valium (diazepam) and ativan (Lorazepam) are benzodiazepines prescribed for the
treatment of anxiety, muscle spasms and seizures.
o Often used in diagnostic imaging in interventional radiological procedures to relieve
patient nervousness
o Side effects valium: drowsiness, dizziness, blurred vision
o Side effects ativan: drowsiness, dizziness, headache, muscle weakness
• Anticoagulant- reduce blood clotting
o Inhibit clotting of the blood or increase the coagulation time
o Can be oral (warfarin) or parenteral (heparin)
o The main side effect is excessive bleeding (blood in urine, blood in stool, severe bruising,
nosebleeds, bleeding gums, etc.)
o Important in diagnostic imaging for interventional procedures, patients may need to stop
these medications prior to a procedure or they must be monitored closely for severe
bleeding.
• Antidepressant- to treat depression
o These drugs are often required 6-12 weeks of administration to achieve their maximal
therapeutic effect
o Selective serotonin reuptake inhibitors- Zoloft, Prozac, Ciprolex, Fluoxetine
o Can also be used to treat anxiety
 o Side effect: nausea, weight gain, fatigue, drowsiness, insomnia
• Antidiabetic- to treat diabetes
o Diabetes mellitus- type 1- require insulin subcutaneous injection
o Diabetes mellitus- type 2- insulin deficient or resistant- metformin
o Metformin can be taken orally an is only given if patient still makes insulin- it increases
the action of insulin in the patient's body and decreases the amount of glucose produced
by the liver
o Metformin in combination with iodinated intravascular contrast media is a potential risk
for contrast induced nephropathy
o Side effects: physical weakness (asthenia), diarrhea, gas, low blood sugar.
• Antihistamine- to treat allergic disorders
o 2 major groups- sedating and non sedating
o Diphenhydramine (benadryl) is sedating- can be given orally or parentarel- injected
intramuscular for moderately severe allergic reactions
o Claritin and allegra are non sedating
o Side effects: drowsiness, dizziness, dry mouth
• Anticholinergic- reduce smooth muscle tone
o Reduce motility of the GI tract or secretions from the respiratory tract
o Atropine falls in this category; it reverses bradycardia and prevents salivary and bronchial
secretions (often given preoperatively)
o Side effects: headache, dizziness, weakness, blurred vision, nausea.
• Antiperistaltic/ Antispasmodic- slow contractions in GI system
o Antiperistaltic drugs also aid in the treatment of diarrhea and are often termed antidiarrheal
o Buscopan and glucagon are the most commonly used antiperistaltic (antispasmodic) agents
in diagnostic imaging- CT colonography
o Side effects buscopan: constipation, dry mouth, trouble urinating or nausea
▪ Contraindications: Angina, Heart Failure, Glaucoma
o Side effects glucagon: change in blood pressure, heart rate, allergic reactions, nausea,
vomiting and low blood sugar (hypoglycemia)
• Bronchodilator- for asthma and COPD
o Relax smooth muscles and dilate respiratory passage to ease breathing
o Usually administered by inhalation
o Albuterol, ventolin
o Side effects albuterol: headache, dizziness, sleep problems
o Side effects ventolin: nervousness, shaking, palpitations, headache
• Cathartic- increase elimination of feces
o Increase peristalsis
o Milk of magnesia
o Used as bowel preparation for barium enema exams, CT colonography
o Side effects: nausea, vomiting, diarrhea, rectal bleeding
• Diuretic- increased amount of urine excreted
o Increase urine excreted by the kidneys, therefore removing sodium and water form the
body; diuretics decrease overall blood volume
o Used most often for congestive heart failure- Lasix (Furosemide) and for acute pulmonary
edema and hypertension
o Side effects: increased urination, thirst, muscle cramps, dizziness, weakness
• Glucocorticoid/NSAIDs (non steroidal anti inflammatory drugs)
o Both reduce inflammation in the body
o Corticosteroids are hormones- prednisone, cortisone
o NSAIDS are non narcotic pain relievers- ibuprofen, naproxen
o NSAIDs also reduce fever
o Side effects ibuprofen: upset stomach, mild heartburn, nausea, vomiting
 o Side effects naproxen: indigestion, heartburn, stomach pain, nausea.
• Narcotics- used to control intense pain
o Opioid analgesics- kept under lock and key- may create dependence
o Morphine, Demerol, fentanyl- strongest
o Codeine, percocet- less severe pain
o Side effects: nausea, dizziness, sedation, itching, addiction, vomiting.
• Analgesics- relieve mild to moderate pain
o Reduce pain, fever and inflammation
o Moderate to mild pain, very often related to muscle or neurologic pain (headache)
o Advil, aspirin, Tylenol
o Side effects: constipation, confusion, dry mouth, nausea, vomiting
• Sedative- mild sedation
o Produce varying degrees of CNS depression ranging from mild sedation to sleep
o Ambien and lunesta
o Can lead to physical dependence with prolonged use
o Side effects: Drowsiness, dizziness, weakness, lightheadedness “drugged” feeling
• Tranquilizer- calming effect
o Used to reduce anxiety, fear, tension
o Diazepam (Valium), Alprazolam (Xanax)- benzodiazepines
o Many antidepressants are tranquilizers but not sedatives
o Side effects: dizziness, drowsiness, indigestion, loss of muscle coordination, slurred speech
• Thrombolytics- dissolve clots rt- PA (recombinant tissue plasminogen activator)
▪ Thrombolytic therapy is the administration of drugs called lytics or “clot busters” to
dissolve blood clots that have acutely (suddenly) blocked your major arteries or
veins and pose potentially serious or life-threatening implications.
▪ To be effective, the therapy needs to be initiated as soon as possible, before
permanent damage has occurred.
▪ There are two ways clot- busting agents (lytics) can be given: through a peripheral
IV (Systemic thrombolysis) or through a catheter (thin tube) that has been
navigated to the site of the clot.
▪ Side effect: Bleeding, nausea, vomiting, low blood pressure, dizziness
▪ Contraindicated for any intracraninal hemorrhage, subarachnoid hemorrhage, acute
head trauma.
• Vasodilator- cause blood vessels to dilate
o Useful in treating vascular disease, particularly angina
o Nitroglycerin can be administered sublingually, orally, topically or parenterally
o Side effects: headache, dizziness, lightheadedness, nausea and flushing.
• Fluids, Electrolytes and nutrients
o Need a correct balance to maintain homeostasis
o Dehydration (vomiting, diarrhea, sweating, high fever) and medication can deplete fluids,
electrolytes and nutrients
o Balance can be maintained by IV therapy- many are prepared combinations of fluid and
electrolyte solutions
o 0.9 NaCl is most common
o 5% dextrose in 0/9% NaCl
Isotonic- balanced movement of water molecules in and out of the cell
Hypotonic- more water molecules move into the cell
Hypertonic- more water molecules move out of the cell.

Multiple choice:
Common drug given in ED to relieve pain without drowsiness- tylenol
Abnormal heart rhythm would receive: antiarrhythmic drugs
Combination of drugs for mild sedation and pain management given during an ERCP procedure: Fentanyl
and versed
When a patient has a known allergic reaction to iv contrast, Prednisone (corticosteroid) should be
administered prior to the exam.
Nitroglycerin is a fast acting vasodilator used to lower blood pressure and relieve pain from angina
pectoris
Metformin and IV contrast without stopping for 48 hours after can result in lactic acidosis
If a patient is given an incorrect amount of fentanyl, they will be given Naloxone to reverse the effects of
the drug.
Buscopan is given for Barium enemas when the barium isn't emptying into the duodenal cap to facilitate
movement.
Contraindication to taking buscopan is angina, heart failure and glaucoma.
Midazolam is another name for versed
Most reliable predictor of a risk of an allergic response to IV contrast media is allergy history
Metformin should be discontinued for 48 hours after IV contrast injection

Contrast:
Isovue (iopamidol): Non ionic, water soluble iodinated contrast
Omnivue: Oral contrast media
Povidone-iodine:
Gastrografin: indicated for perforation of bowel. Ionic
Barium: Not indicated for perforation of the bowel
Air and CO2: Negative contrast

Low osmolar- less chance of causing allergic reaction

30 seconds post injection: arterial- all arterial structures

60 seconds post: venous- all venous structure
2 minutes post: Equilibrium- all organs are highlighted kidneys are blushing

5 minutes post injection for brain for blood brain barrier

Questions
• The contrast enhancement phase for liver mets would be dual phase (late arterial and portal venous)
• Iso-osmolar contrast is the same or less osmolality as blood.
• All contrast media today contains salts of organic iodine compounds
• When preparing to add antiseptic iodine to a sterile field, pour some liquid into the sink before
adding some to the sterile container in order to was the containers lip to prevent contamination

Section E: Back to top

Operation of Equipment

Contrast: Differences in adjacent tissue attenuations, influenced by subject contrast and scatter
production/control. Low contrast- similar values (greys), High contrast- values of great difference (black
and white)
Recorded detail- the factors that are beam related- penumbra production: controlled by: geometry,
distance, screen, FSS, motion. IMproved recorded detail by low OID, high SID, small FSS, and decreased
motion.
Imaging concepts:
Contrast:
• Contrast or shades of grey will allow detail to be seen
o Adjusted by changing window width on monitor
• Brightness in digital environment
o Adjusted by changing window level on monitor
• Image quality is the responsibility of the radiographer
• Image can be manipulated after exposure but the original exposure should be appropriate for the
exposure to the IR and the subject contrast.

Exposure:
• Exposure to the IR is the radiation that leaves a patient (remnant) and is used to create the image on
the image receptor
• The remnant beam usually consists of x-rays of varying energy (latent image)
• These x-ray energies create the shades of grey on the resultant image on the monitor.
• To increase exposure to the image receptor, increase mA, exposure time or kVp
• Many other factors affect the IR exposure.
• The factors that affect IR exposure can be separated into primary and secondary factors
• Primary factors include kVp, mAs and time. Secondary and influencing factors include distances,
grids, collimation, filters, CR, angulation and FSS

Exposure index:
• The exposure index is a numerical representation of the exposure that has reached the IR
• The exposure index is NOT an indication of patient dose since the number is part specific
• EI is only an indication that the patient may be over or under exposed because of software
manipulation.
• MRTs should ALWAYS use the appropriate technical factors for the part and are responsible for the
amount of radiation applied to the patient.

Digital imaging:
• If the exposure is too low, quantum mottle occurs
• If exposure is too high, the computer may not be able to adjust the image and the exposure index
will be too high.

Primary factors:
• To maintain IR exposure, an increase in mA requires a decrease in time and vice versa
• To increase or decrease IR exposure by a factor of 2 (2x or ½) double or half the mAs value
• KVP does not have a direct linear relationship with the IR
• MAS has a direct linear relationship with IR exposure
• If changes in mAs are required, a minimum change of 30% is necessary.
• A 15% change in kVp affects the IR exposure the same as a factor of 2 change in mAs

kVp affects:
• Xray beam quality and quantity
• X-ray beam penetration and absorption in anatomic tissues
o Increasing kVp increases penetration and decreases absorption
• Higher kVp allowes for lower mAs values which improve overall patient dose. Only change kVp to
change IR exposure if a change in contrast is also desired.
Imaging considerations:
Mobile and trauma imaging:
• Use a grid if the patient part thickness is more than 4 inches (10cm) and more than 60 kv is used.
• Use good radiation protection practices
• Never leave a confused patient or a trauma patient unattended in the imaging room
• Process the projections and evaluate them for positioning and technical accuracy
• Repeat any necessary projections
• Return the patient to the emergency room
• Disinfect all imaging equipment and devices used during the procedure.

Histogram errors:
• Caused from incorrect positioning and procedure
• Image terminates early, picture ends up being underexposed indicated by quantum noise.

Causes:
• Part selection from workstation menu: if wrong part or projection selected, the image will be
rescaled using the wrong LUT
• Central ray centering: CR not centered at VOI, collimation needs to be expanded to include all the
required anatomy
• INcreasing the collimation field size may result in additional anatomy or excessive background
values being included on the image histogram and identified as part of the VOI.
• Collimation: Collimating to a width of 0.5 in of the skin line prevents too much background data
from being included within the exposure field
• Scatter radiation control: Reduces the scatter radiation fog reaching the IR (tight collimation,
appropriate grid usage, placing a lead sheet along the edge of the exposure field.)

• Computed radiography only

• Clearly defining the VOI: using an IR size where the VOI will cover the entire IR eliminates any
exposure values from being recorded on the IR that are not of interest
• Coverage of 30%: the smallest possible IR size should be chosen.
• Multiple projections on one IR: the farther apart the projections are positioned from each other, the
less chance that they will be mistaken for a single projection
• Background radiation fogging: computed radiography plates are extra sensitive to scatter radiation.
Fogging can accumulate across the plate from the IR is left in the imaging room while other
projections are taken. Computed radiography plates are also sensitive to accumulated background
radiation during long periods of storage.

Technical factor conversions:

INFLUENCING FACTORS OF EXPOSURE TO THE IR-Summary

1. Anode Heel Effect-more dense or thicker part over area of greater beam intensity(cathode)

2. SID-the greater the SID, the less intense the beam, therefore an increase of mAs is required if SID is
increased

3. mAs compensation formula for changes to SID: mA1xD1^2/D2^2= mA2

2
mAs = (SID )
1 1
 2
mAs 2
(SID )
2

4. OID-OID should be kept to a minimum as much as possible to reduce unsharpness and

magnification. There is no formula for changing the mAs, but an increase of OID requires an increase of
mAs.

5. Grids-grids are placed between the patient and the IR to absorb scatter radiation. Grids do not reduce
the amount of scatter radiation but they do reduce the amount of scatter radiation reaching the IR.
Changes to grids requires changes to mAs.

Increase grid ratio or addition of a grid requires an increase of mAs

Decrease grid ratio or removal of a grid requires a decrease of mAs

Changes to mAs required if adding or increasing grid ratio using the formula:

Grid conversion formula

mAs = grid ratio (GCF )
1 1 1

mAs 2
grid ratio (GCF ) 2 2

6. Collimation-increasing collimation reduces the field of exposure size and decreasing collimation
increases the field of exposure size. If the field of exposure is smaller, there is less exposure to the IR,
requiring an increase of mAs. There is no formula for this.

7. Compensating filters: used with anatomy of varying size or composition. Compensating filters will
help to distribute the exposure to the IR evenly.

A. Wedge filter-AP foot(thin portion over toes)-at tube port

B. Chest filter-thicker part over lungs-at tube port

C. Boomerang filter-hips and shoulders, used on

table

D. Boomerang filter-attached to tube port

E. C/spine filter-thicker portion over skull-at tube

port

F. Adjustable filter-at tube port

8. Patient/part thickness-the thicker the part, the more mAs is required for exposure to the IR
Change mAs by a factor of 2 (2x or ½) for every 4 to 5cm thickness change (same part)

9. Pathology-pathology is classified as either additive or destructive. Additive pathology requires an

increase of mAs and destructive pathology requires a decrease of mAs.

10. Contrast Media-CM changes the atomic number of the anatomy. Positive CM increases Z (barium,
iodine), requiring an increase of mAs and negative CM (air, CO ) requires a decrease of mAs.
2

11. Casts: Adding a cast increases the overall density of the part and requires an increase of mAs

Type of Cast Increase in technical factors

Small to medium plaster cast Increase mAs 50-60% or +5-

7kVp

Large plaster cast Increase mAs 100% or +8-

10kVp

Fibreglass cast Increase mAs 25-30% or +3-

4kVp

Radiographic contrast:
• The degree of difference between adjacent densities
• Distinguishing differences in densities result in visualization of different anatomic tissues
• Tissue absorption characteristics vary resulting in different densities
• Detail between densities is optimized when contrast is maximized

High or short scale contrast:

• Few densities with great difference

Long or low scale contrast:

A large number of densities with little differences

Contrast is the result of the combination of:

• image receptor contrast-inherent properties of the film/screen system and processing
• Subject contrast- results from the absorption characteristics of the anatomic tissue radiographed and
the level of kVp

Controlling factors:
• KVp: the greater the kvp the longer the contrast

kVp and contrast:

kVp controls the desired level of contrast
For the same anatomic part:
• High kVp values create more densities with fewer differences or long scale (low contrast)
• Low kVp values create fewer densities or short scale contrast.

Influencing factors:
 • Grids
• mAs
• Image receptor
• Filtration
• Collimation
• OID/SID
• Anatomic part
• Contrast media
• Processing

kVp and scatter production:

• A higher kVp will increase the percentage of scatter radiation that could interact with the IR
• Scatter produces no useful information and is considered “fog”
• Increasing fog on the image always decreases contrast.

kVp and contrast:

• Inverse relationship: as kVp increases, contrast decreases resulting in a long scale contrast or low
contrast
• As kVp increases, the amount of scatter produced is increased, decreasing contrast resulting in long
scale or low contrast.

Influencing factors- grids:

• Grids prevent scatter radiation from reaching the image receptor
• Whenever a grid is added or increased in grid ratio, contrast will increase or become short scale,
high contrast.
• Grids and contrast are directly related: as grid ratio is increased, contrast is increased
• The result of using a grid is less scatter, therefore less fog, therefore higher contrast.

Influencing factors- anode heel effect and FSS:

• Changes to the focal spot size have a negligible effect on contrast
• Anode heel effect does not affect contrast

Influencing factors- collimation:

• As the field of exposure changes, the amount of tissue irradiated changes and the amount of scatter
changes.
• Directly related
• Increasing collimation (decreasing field size), decreases scatter radiation which increases contrast-
short scale contrast

Influencing factors- mAs:

• To evaluate contrast densities must be in the diagnostic range .25-2.5
• Over and under exposure that results in densities above or below the diagnostic range will move
contrast beyond the visible range.

Influencing factors- SID/OID:

Source to image receptor distance:
• SID alters image receptor exposure
• Can change the contrast as if there were change in mAs
OID:
 • Air gap technique
• Increases contrast

Influencing factors- filtration:

• Inversely related- as filtration is increased, contrast will decrease
• Increased filtration
o Increased average beam energy
o Decreased contrast

Influencing factors- subject contrast:

• Controlled by anatomy and pathology
• Atomic number of tissue types affect contrast- tissue of similar atomic number (abdomen) create
images of long scale contrast
• Tissue of differing atomic number (thorax) create images of short scale contrast
• Similar tissues of different thickness will affect contrast
• Thicker body parts create more scatter, therefore, a longer scale of contrast
• Adjacent body parts different thicknesses will result in short scale contrast
• Tissue density refers to the binding of atoms within the tissue- lung tissue is less bound than kidney
tissue
• This will affect differential absorption and therefore contrast

Influencing factors- contrast media:

• Contrast media is used when adjacent anatomic structures are of similar composition
• Contrast media will change the absorption characteristic of the tissue- increases or decreases
attenuation of the xray beam
• Positive contrast media increases beam attenuation (increase atomic number)
• Positive contrast media- barium- low OD

Math:
Direct square law: mAs1/mAs2= D1^2/D2^2 (How much more mAs needed when SID changes.)
Inverse Square law: I1/I2= D2^2/ D1^2 (intensity for exposure hitting you at different distances)

Questions:
• MAS relationship to quantity of x-rays produced is directly proportional.
• When thickness is decreased by a factor of 2, dose is increased by a factor of 2
• If slice thickness is deceased by a factor of 2, increase dose by a factor of two.
• For fiberglass cast, increase mAs 25% to 30% or 3-4 kvp
• There is required a minimum 30% change in mAs to see a visual difference in the image.

Grid review:
Grids:
• Primary purpose is to improve contrast by absorbing scatter before it reaches the image receptor.
• 3 factors contribute to an increase in scatter: increased kV, increased x-ray field size, increased
patient thickness
• Primary radiation passes through the radiolucent strips
• Grids are used when the body part is greater than 10 cm in thickness and/or when using a kVp
greater than 60.
 • Most common grid ratios are 8:1 or 12:1
• The focal range for most focused grids is between 100 cm to 180cm.
(If on CAMRT exam there is a grayed out image on the CAMRT exam and they are asking about image
correction make sure not to put technical factors/ positioning especially if it is a large anatomic part, the
answer my be using a grid)

Grid characteristics:
• The grid ratio is a measure of the height of the lead strips to the interspace distance and is a good
measure of the selectivity of primary to scatter transmission.
• A 5:1 grid will clean up 85% and a 16:1 grid will clean up 97% of scatter.
• A grid frequency is a measure of the number of grid lines per unit distance (inches or centimeters)
and is in the range of 40-50 lines/cm (100-120 lines/inch) for low frequency grids, 50-60 lines/cm
(120-150 lines/inch) for medium frequency grids, and 60-70 + lines/cm (150-170+ lines/inch).
• Low frequency grids are used with systems having a moving grid assembly (known as a bucky
device) that oscillates during the exposure to blur the grid lines.
• Low frequency grids are used with systems having a moving grid assembly (known as a bucky
device) that oscillates during the exposure to blur grid lines.
• Medium and high frequency grids are typically used with stationary grid holders (portable and DR
systems)
• High frequency grids use is particularly important for digital radiography systems to avoid aliasing
artifact

Grid Conversion factor:

Grid conversion factor is how to adjust technique (mAs) to accommodate the grid; aka bucky factor.
GCF= mAs with grid/ mAs without grid
No grid=1, 5:1=2, 6:1=3, 8:1=4, 12:1=5, 16:1=6

Grid types:
• Parallel grids: Lead strips run parallel to one another. Primarily used for mobile imaging.
• Focused grids: Lead strips are angled to match divergence of the primary beam; allows more
transmitted or primary radiation to reach the image receptor. Focused grids have a recommended
range of SIDs.
• Crossed grids: 2 grids at 90 degrees to each other.

Grid Cutoff:
A decrease in the number of transmitted photons that reach the image receptor because of some
misalignment of the grid.
Grid cutoff can occur as a result of four types of errors in grid use: Upside-down focused grid, off-level
grid, off center grid, off-focus grid
• Upside-down focused: Occurs when a focused grid is placed upside down on the IR, resulting in the
grid lines going opposite the angle of divergence of the x-ray beam. Exposure in the middle; lack
of exposure on both sides of the image.
• Off level: Occurs when the x-ray beam is angled across the lead, you will see grid cut-off through
the whole image, this most commonly occurs with portable imaging when the patient’s body
weight is not evenly distributed on the grid/image receptor.
• Tilted Grid: Causes the entire image to be too bright
• Off focus (incorrect SID): Occurs when the grid is used at a distance other than the recommended
range of SIDs, You'll see the grid cut off towards the edges or on the periphery of the image. It is
not as pronounced as when a focused grid is used upside down.
• Off center Grid: Primary beam must be centered on the center of the grid. Most common at a short
SID
 • Moire effect: Grid error that occurs with digital radiography. Occurs when the grid lines are
captured and scanned parallel to the scan lines in the imaging plate readers. Artifact demonstrated
when a stationary grid is used during CR imaging and the grid frequency is similar to the laser
scanning frequency.

Air Gap Technique:

A method of limiting scatter from reaching the image receptor. Increased OID will result in some scatter
missing the image receptor, and contrast is improved. An increase in OID will decrease spatial resolution.
A 10-inch air gap has a similar clean-up of a 15:1 grid.

Image Production:
To produce a radiographic image, x-ray photons must pass through tissue and interact with an image
receptor, the quantity and quality of the primary x-ray beam affect its interaction within the bodies tissues,
the composition of the anatomic tissues affects the x-ray beam interaction, the radiation that exits the
patient is composed of varying energies and interacts with the image receptor to form the latent or
invisible image.

Differential absorption: Anatomic parts do not absorb the primary beam to the same degree. Differential
absorption creates an image that structurally represents the anatomic area.
The term differential is used because varying anatomic parts do not absorb the primary beam to the same
degree. Anatomic parts composed of bone absorb more x-ray photons than parts filled with air.

Beam attenuation:
• Attenuation:
o Reduction in the energy or number of photons in the primary x-ray beam.
o Occurs as a result of the photon interactions with the anatomic structures that compose the
tissues
o Two processes occur in the diagnostic range
▪ Absorption
▪ Scattering
o As the primary x-ray beam passes through anatomic tissue, it loses some of its energy.
Fewer x-ray photons remain in the beam after it interacts with anatomic tissue.
• Absorption:
o Photoelectric effect: Total photon absorption depends on the energy of the incoming x-ray
photon and the atomic number of anatomic tissue.
1. Incident photon interacts with an inner orbital, K or L, electron, giving
all of its energy to the electron, ejecting it from orbit. The photon is
“absorbed”
2. The ejected electron (photo-electron) imparts the atom with energy equal
to the excess of the electron’s binding energy.
3. There is a vacancy in the inner orbital shell, K or L, which must be filled.
One of the electrons from the outer orbital shell, usually the next orbit
out, drops to the void.
4. As the electron drops to the void, it may shed its excess energy as a
secondary photon
o As the energy of the primary x-ray beam is deposited within the toms composing the
tissue, some x-ray photons are completely absorbed. Complete absorption of the
incoming x-ray photons occurs when it has enough energy to remove (eject) an inner-
shell electron. The ability to remove (eject) electrons, known as ionization, is one of the
 characteristics of x-rays.

• Scattering:
o Compton effect:

1. Photon interacts with an outer orbital electron, imparting some of its

energy to the electron, ejecting it from orbit.
2. The ejected electron (Compton electron) leaves the atom with an energy
equal to the excess imparted by the photon.
3. The photon continues on an altered path, scattered, with less energy
(longer wavelength) than before the collision
• The loss of some energy of the incoming photon occurs when it ejects an outer-shell
electron from a tissue atom. The ejected electron is called a Compton electron or
secondary electron. The remaining lower-energy x-ray photon changes direction and may
leave the anatomic part to interact with the image receptor.

Comparing photoelectric and compton effects:

Photoelectric:
• Incoming photon has sufficient energy to eject an inner-shell electron and be absorbed.
• An electron from an outer-shell fills the electron hole or vacancy.
• A secondary photon is created because of the difference in the electrons binding energies.
• The probability of this effect depends on the energy of the incoming x-ray photon and the
composition of the anatomic tissue.
• Fewer photon interactions occur at higher kVp settings, but those interactions, a smaller percentage
are photoelectric interactions.
Compton effect:
• Incoming photon loses energy when it ejects an outer-shell electron and changes direction.
• The scattered photon may be absorbed in the patient tissues, leave the anatomic part, interact with
the image receptor, or expose anyone near the patient.
• Scattered photons that strike the image receptor are not useful.
• Probability depends on the energy of incoming x-ray photon but not the anatomic tissue
• Of the few photon interactions that occur at higher kVp settings, a greater percentage are Compton
interactions.

The percentage of photoelectric interactions generally decreases at higher kVp voltages within the
diagnostic range, whereas the percentage of Compton interactions is likely to increase at higher
kilovoltage within the diagnostic range.
Scattered and secondary radiations provide no useful information and must be controlled during
radiographic imaging.

Scattering:
Coherent scattering:
• An interaction that occurs with low-energy x-rays, typically below the diagnostic range.
• Could occur within the diagnostic range of x-rays and may interact
Scattered photons:
• Do not contribute any useful information
• Contribute to the radiation exposure of the patients and others.

If scattered photons are absorbed within the anatomic tissues, they contribute to the radiation exposure to
the patient. In addition, if the scattered photon leaves the patient and does not strike the image receptor, it
could contribute to the radiation exposure of anyone near the patient.

Transmission:
• Transmission: x-ray photons that pass through the body without any interaction with the atomic
structures.
• Absorption and transmission of the x-ray beam creates an image that structurally represents the
anatomic part.
• Image quality is compromised if scattered photons strike the image receptor.
The combination of absorption and transmission of the x-ray beam provides an image that structurally
represents the anatomic part.
Because scatter radiation is also a process that occurs during interaction of the x-ray beam and anatomic
part, the quality of the image created is compromised if the scattered photon strikes the image receptor.

Factors affecting beam attenuation:

• Tissue thickness: For a given anatomic tissue, increasing its thickness increases beam attenuation by
either absorption or scattering. X-rays are attenuated exponentially and reduced by ~50% for each
4-5cm of tissue thickness.
o The amount of x-ray beam attenuation is affected by the thickness of the anatomic part, its
tissue atomic number and tissue density, and the energy of the x-ray beam.
o For a given anatomic tissue, increasing its thickness increases beam attenuation by either
absorption or scattering. A thinner patient transmits more radiation then compared to a
thicker patient and thicker patients absorb more radiation.
o X-rays are attenuated exponentially and generally reduced by approximately 50% for each
4-5 cm tissue thickness. The thicker the anatomic part, the more x-rays are needed to
produce a radiographic image. The thinner the anatomic part, the fewer x-rays are needed
to produce a radiographic image.
• Type of tissue: Tissue composed of a higher anatomic number (bone) attenuates the x-ray beam
more than tissue composed of a lower anatomic number (fat).
o Tissue composed of a higher atomic number such as bone attenuates the -ray beam more
than tissues composed of a lower atomic number such as fat. The higher atomic number
indicates there are more atomic particles for interaction with the x-ray photons. X-ray
absorption is more likely to occur in tissues composed of a higher atomic number when
compared with tissues composed of a lower atomic number. Tissues that absorb more x-
rays demonstrate increased brightness displayed in a digital image. Tissues that transmit
more x-rays (absorb fewer x-rays) demonstrate decreased brightness displayed in the
digital image.
• Tissue density: Atomic particles that are more dense or compact attenuate the x-ray beam more.
Bone, muscle, fat and air account most of the beam attenuation in the human body.
o Tissue density. Matter per unit volume- or the compactness of the atomic particles
composing the anatomic part- also affects the amount of beam attenuation. For, example,
muscle and fat tissue are similar in tissue composition; however, their atomic particles
differ in compactness and therefore tissue density varies. Muscle tissue has atomic
particles that are more dense or compact and therefore attenuate the x-ray beam more
than fat cells.
o Four substances account for most of the beam attenuation in the human body: bone,
muscle, fat, and air. Bone attenuates the x-ray beam more than muscle, muscle attenuates
the x-ray beam more than fat, and fat attenuates the x-ray beam more than the air. The
atomic number of the anatomic part and its tissue density affect x-ray beam attenuation.
• X-ray beam quality
o Higher penetrating x-rays
▪ Shorter wavelength with higher frequency
▪ More likely to be transmitted through anatomic tissue without interacting with the
tissue's atomic structures.
 o Lower- penetrating x-rays
▪ Lower wavelength with lower frequency
▪ More likely to interact with the atomic structures and be absorbed.
o The quality of the x-ray beam or its penetrating ability affect its interaction with anatomic
tissue.
o The kilovoltage selected during x-ray production determines the energy or penetrability of
the x-ray photon and this affects its attenuation in anatomic tissue.
o Beam attenuation is decreased with a higher- energy x-ray beam and increased with lower
energy x-ray beam.

Conclusion:
^ tissue thickness, ^ beam attenuation, ^ absorption, v transmission
^ atomic #, ^ beam attenuation, ^ absorption, v transmission
^ tissue density,^ beam attenuation, ^ absorption, v transmission
^ beam quality, v beam attenuation, v absorption, ^ transmission.

Imaging effect:
• Exit (remnant) radiation: composed of both transmitted and scattered radiation.
• Fog: unwanted exposure on the image caused by scatter radiation
• Shades of gray and brightness recorded in the radiographic image make tissues visible.
• When the attenuated x-ray beam leaves the patient, the remaining x-ray beam, referred to as exit
radiation or remnant radiation, is composed of both transmit and scattered radiation. The varying
amounts of transmitted and absorbed radiation (differential absorption) create an image that
structurally represents the anatomic area of interest.
• Scatter exit radiation (Compton interactions) that reaches the image receptor does not provide any
diagnostic information about the anatomic area. When the attenuated x-ray beam leaves the
patient, the remnant x-ray beam is composed of both transmitted and scattered radiation.
• The areas within the anatomic tissue that absorb incoming x-ray photons (photoelectric effect)
create white or clear areas (increased brightness) on the displayed image. The incoming x-ray
photons that are transmitted create the black areas (decreased brightness) on the displayed image.
Anatomic tissues that vary in absorption and transmission create a range of dark and light areas
(shades of grey).
• Skeletal bones are differentiated from the air-filled lungs because of their differences in absorption
and transmission
• Anatomic tissues vary in their absorption and transmission of x-ray photons to create the range of
brightness or gray levels that structurally represent the anatomic area of interest. Increased
brightness represents absorbed radiation, whereas decreased brightness represents transmitted
radiation.

Digital imaging:
Digital imaging receptors:
• Latent image acquisition
o Various types of digital detectors record remnant radiation.
• Computer image processing
o Exit x-rays intensities are converted to digital data.
• Display of digital image.
o Radiograph is displayed on a computer monitor and can be altered.
Digital imaging can be accomplished by using a specialized image receptor that acquires the latent image
and then the computer processes the visible image for display on a monitor. There are several types of
digital image receptors used in diagnostic imaging.
Regardless of the type of digital imaging receptor, the radiographic image is composed of digital data and
can be altered in a variety of ways.
The Digital Image:
• Digital image receptors can respond to a winder range of x-ray exposures (wide dynamic range)
o Anatomic areas of widely different attenuation can be more easily visualized with digital
image receptors.
o Moderately underexposed or overexposed images may still be of acceptable diagnostic
quality.
o Digital images are composed of numeric data that can be easily manipulated by a
computer.
Anatomic areas of widely different attenuation as soft tissue and bony structures can be more easily
visualized due to a wider dynamic range in digital imaging. In addition, due to computer processing,
moderately underexposed or overexposed imaging may still be of acceptable diagnostic quality.
• Matrix
o Image composed of numeric data combined in rows and columns
• Pixel
o Each pixel is recorded as a single numeric value.
• Quality is improved with a larger matrix size that includes a greater number of smaller pixels.
• Computer processing time, network transmission time, and digital storage space increases as the
matrix size increases.
• The numerical value assigned to each pixel is determined by the relative attenuation of x-rays
• Each pixel has a bit depth that controls the exact pixel brightness (grey level) that can be specified.
Pixels representing highly attenuating tissues, such as bone, are usually assigned a low value for higher
brightness (lower density) than pixels representing tissues of low x-ray attenuation.
Each pixel also has a bit depth or number of bits that determines the amount of precision in digitizing the
analog signal and this controls the exact pixel brightness (gray level) that can be specified. Bit depth is
determined by the analog-to-digital converter that is an integral component of every digital imaging
system. A larger bit depth allows a greater number of shades of gray to be displayed on a computer
monitor.

Image Quality and Characteristics: Image quality, Brightness, Contrast, Spatial resolution, FOV, Spatial
frequency, Modular Transfer Function, Detective Quantum Efficiency, Distortion, Scatter, Quantum
Noise, Signal to noise ratio, contrast to noise ratio, image artifacts
A quality radiographic image:
• Accurately represents the anatomic area of interest
• Information is well visualized for diagnosis
The process of creating the latent image is by differential absorption
Once the digital image has been acquired, it must be processed before displayed on a computer monitor.

Image quality:
The visibility of the anatomic structures and the accuracy of their structural lines recorded determine the
overall quality of the radiographic image.
Sharpness= Spatial resolution + Distortion
Visibility= Brightness + contrast
Visibility of the recorded detail refers to the brightness and contrast of the image.
The accuracy of the structural lines (sharpness) is achieved by maximizing the amount of spatial
resolution (or recorded detail) and minimizing the amount of distortion. Visibility of the anatomic tissues
is achieved by the proper balance of image brightness or density and contrast.

Brightness:
• Brightness is the amount of luminance (light emission) of a display monitor.
• The brightness level can be altered when displayed on a computer monitor.
 • A radiograph must have sufficient brightness to visualize the anatomic structure of interest.
• A radiograph that is too light has excessive brightness to visualize the structures of the anatomic
part.
• A radiograph that is too dark has insufficient brightness to visualize the structures of the anatomic
part.
• The radiographer must evaluate the overall brightness of the image.
• A greater margin of error exists for exposure techniques to yield acceptable image brightness.
• Digital image processing can compensate for exposure errors and maintain brightness.
• Under exposure may result in increased quantum noise.
• Extreme overexposure may result in saturation.
• The radiographer must evaluate the overall brightness on the image to determine whether it is
sufficient to visualize the anatomic area of interest. He or she then decides whether the radiograph
is diagnostic or unacceptable.
• In order to evaluate other attributes of radiographic quality, such as contrast and sharpness, the
image must have sufficient brightness to visualize the anatomic area of interest.
• Over exposure will and darkness will not show any soft tissue anatomy.
• The Exposure indicator provides a numeric value indicating the level of radiation exposure to the
digital image receptor.
• The industry is working towards standardization of the exposure indicator.
• The radiographer should evaluate the exposure indicator value along with the quality of the image
before determining whether a repeat image is warranted.
• Displayed image brightness needs to be optimized for human perception.
• The window level (or center) sets the midpoint of the range of densities visible in the image.
• Window level. Changing the window level increases or decreases the image brightness.
• A wide dynamic range is only useful if the displayed image brightness can be optimized for human
perception,
• Changing the window level on the display monitor allows the image brightness to be increased or
decreased throughout the entire range of pixel values.
• Moving the window level up to a high pixel value increases overall brightness on the display
monitor, increasing visibility or the darker anatomic regions.
• Moving the window level down to a low pixel value decreases the brightness on the display
monitor, increasing visibility of brighter anatomic regions.
• Assume that pixel values from 0-2048 are used to represent the full range of digital image
brightness levels. A high pixel value could represent a volume of tissue that attenuated fewer x-
ray photons and is displayed as a decreased brightness level or increased density. Therefore, a low
pixel value represents a volume of tissues that attenuates more x-ray photons and is displayed as
increased brightness.

Contrast:
• Differences in brightness levels (contrast) are needed to differentiate among anatomic tissues.
• Lack of contrast makes an object appear homogeneous.
• The range of brightness levels is a result of the tissue's differential attenuation of the x-ray photons.
• An image that has sufficient brightness, but no or little differences in absorption, appears as a
homogeneous object. This appearance indicates that the absorption characteristics of the object
are equal.
• To differentiate among anatomic tissues, there must be differences in brightness levels (radiographic
contrast).
• Radiographic contrast affects the visibility of the structural lines that make up the recorded image.
• When the absorption characteristics of an object differ, the image has varying levels of brightness.
The anatomic tissues are easily differentiated because of these differences in brightness.
• Tissues that attenuate the x-ray beam equally are more difficult to visualize because the brightness
levels are too similar to differentiate.
 • Radiographic contrast is the combined result of multiple factors.
• Subject contrast refers to the absorption characteristic of the anatomic tissue radiographed and the
quality of the x-ray beam
o The quality of the x-ray beam also affects its attenuation in tissues.
• Evaluating radiographic quality in terms of contrast is more subjective than evaluating brightness.
• Radiographic contrast is the combined result of multiple factors associated with the anatomic
structure, quality of the image receptor, and, in digital imaging, computer processing and display.
• Subject contrast refers to the absorption characteristics of the anatomic tissue radiographed and the
quality of the x-ray bea,. Differences in tissue thickness, tissue density, and effective atomic
number contribute to subject contrast.
• The level of radiographic contrast desired in an image is determined by the composition of the
anatomic tissue to be radiographed and the amount of information needed to visualize the tissue
for an accurate diagnosis.
• The chest is composed of tissues that vary greatly in x-ray lucency, such as the air-filled lungs, the
heart, and the bony thorax.
• This anatomic region creates high subject contrast because the tissues attenuate the x-ray beam very
differently compared with the abdomen for the same beam quality.
• The abdomen is composed of tissues that attenuate the x-ray beam similarly and is considered to be
a region of low subject contrast. The brightness levels representing the organs in the abdomen
are more similar. Therefore, it is difficult to distinguish the stomach from the kidneys.
• The quality of the x-ray beam also affects its attenuation in tissues, which alters subject contrast.
Increasing the penetrating power of the x-ray beam decreases attenuation, reduces absorption and
increases x-ray transmission- resulting in fewer differences in brightness levels in the
radiographic image. Decreasing the penetrating power of the x-ray beam increases attenuation
and absorption and decreases x-ray transmission- resulting in greater differences in the brightness
levels in the radiographic image.
• Contrast resolution is the ability of the system to distinguish between small objects that attenuate the
x-ray beam similarly.
• The contrast resolution of the human eye is limited.
• Window width adjusts the radiographic contrast (gray scale)
• In digital imaging, the number of different shades of gray that can be stored and displayed by a
computer system is termed gray scale.
• The contrast resolution of the imaging system determines the level of visibility of small objects
having similar densities or shades of gray. The depth of the pixel is determined by the bit depth,
which affects the number of shades of gray that increases the contrast resolution within the image.
An image with increased contrast resolution increases the visibility of recorded detail and the
ability to distinguish among small anatomic areas of interest.
• Because the digital image can display grayscale levels ranging from black to white, the display
monitor can vary the range or number of brightness levels visible on the image to show all of the
anatomy.
• Wide window width= lower contrast
• Narrow window width= higher contrast
• The midpoint of the window level and the width determine brightness and contrast.
• When the entire range of brightness levels are displayed (wide window width), the image has lower
contrast, or more shades of gray; when a smaller range of brightness levels are displayed (narrow
window width), the image has higher contrast, or fewer shades of gray.
• The center or midpoint of the window level and the width of the window determines the brightness
and contrast of the display image.

•
Spatial Resolution:
• A digital image is composed of discrete information in the form of pixels that display various shades
of gray. Spatial resolution is determined by the size of the pixel and its spacing (pitch).
 • A digital image is composed of discrete information in the form of pixels that display various shades
of gray. The size of the pixel is measured in microns. (100 microns= 0.1 mm)
• The greater the number of pixels in a matrix image, the smaller their size. An image consisting of a
greater number of pixels per unit area or pixel density provides improved spatial resolution. IN
addition to its size, the pixel spacing, or distance measured from the center of a pixel to an
adjacent pixel determines the pixel pitch.
• A major determinant of spatial resolution of digital images is the pixel size and its spacing.
• The greater the number of pixels in a matrix image, the smaller their size. An image consisting of a
greater number of pixels per unit area or pixel density provides improved spatial resolution.
• Refers to the smallest object that can be detected in an image
• Resolution is the ability to distinguish between two adjacent structures.
• The quality of radiographic image depends on both the visibility and the accuracy of the anatomic
structural lines recorded (sharpness). To produce a quality radiograph, the anatomic details must
be recorded accurately and with the greatest amount of sharpness.
• Spatial resolution refers to the smallest object that can be detected in an image and is a term
typically used in digital imaging.
• Resolution is the ability of the imaging system to resolve or distinguish between two adjacent
structures. Resolution can be expressed in the unit of line pairs per millimeter (Lp/mm). A
resolution test pattern is a device used to record and measure line pairs. The greatest number of
line pairs per millimeter resolved, the greater the resolution.
• In the space of 1 mm, the number of line pairs resolved determines the amount of sharpness.
• A radiographic image that has a greater resolution minimizes the amount of unsharpness of the
anatomic structural lines
• Resolution is the ability of the imaging system to resolve or distinguish between two adjacent
structures. Resolution can be expressed in the unit of line pairs per millimeter
• An imaging system that can resolve fever line pairs within 1 mm is said to have decreased
sharpness. The ability to discern small changes in spatial resolution when viewing radiographic
images is dependent on visual acuity and distance of the viewer.
• A small anatomic structure is best visualized when its brightness varies significantly from the
background.
• If unsharpness is increased, the visibility of small anatomic detail is compromised. An increase in
the amount of unsharpness recorded on the image decreases the contrast of small anatomic
structures, reducing the overall visibility of the structural lines. The spreading of the structural
lines with increased unsharpness decreases the differences in brightness between the structural
lines of the area of interest and the background. As a result, the difference in brightness between
the area of interest and the background becomes less (low contrast), and the visibility of the
anatomic structures is reduced.
• A radiographic image cannot be an exact reconstruction of the anatomic structure.
• Diagnostic quality is achieved by maximizing resolution and minimizing image distortion.
• Some information is always lost during the process of image formation. In addition, factors such as
patient motion increase the amount of sharpness recorded in the image.
• It is the radiographer’s responsibility to minimize the amount of information lost by manipulating
the factors that affect the sharpness of the recorded image. Diagnostic quality is achieved by
maximizing the amount of spatial resolution or recorded detail and minimizing the amount of
image distortion.

Factors affecting spatial resolution:

The ability to distinguish between object or structures that differ in density. A high spatial resolution is
important for one to discriminate between structures that are located within a small proximity to each
other.
• Field of view
o As the FOV increases, so do the pixel size; resulting in a decrease in spatial resolution
• Pixel size
 o The smaller the pixel size the higher the spatial resolution
• Focal spot size
o A larger focal spot will decrease the resolution
• Magnification
o Increasing magnification will decrease the resolution
• Motion of the patient
o Increasing motion will decrease resolution
• Pitch
o Is inversely related to the resolution, the higher the pitch the less the resolution
• Kernel
o Edge enhancement kernels will have a higher resolution than soft tissue kernels
▪ Edge enhancement will help view fractures and small, high contrast objects.
• Slice thickness
o The larger the slice thickness the lower the spatial resolution
• Detector size
o Increase in detector size decreases resolution

Field of View:
• There is a relationship among pixel size, field of view (FOV, the dimensions of an anatomic area),
and matrix size, as demonstrated in the following formula: Pixel size=FOV/matrix size
• This relationship demonstrates that if FOV is increased for a fixed matrix size, then the pixel size is
also increased (direct relationship).
• However, if the matrix size is increased for a fixed FOV, then the pixel size is decreased (inverse
relationship)
• Relationship between resolution and magnification (increased or decreased or no relationship)

Spatial Frequency:
Defined by the unit of line pairs per millimeter
• Small objects have higher spatial frequency and large objects have lower spatial frequency.
• Increasing the number of lp/mm resolved in the imaging system results in improved spatial
resolution.

Modulation Transfer Function:

• MTF is a measure of the imaging system’s ability to display the contrast of anatomic objects
varying in size.
o Values range between 0 and 1.0
o An imaging system that has a high MTF can display anatomic detail without improved
visibility.
o Most digital imaging systems MTF measures much lower than 1.0
o MTF= max intensity- min intensity/ max intensity+ min intensity

Detective Quantum Efficiency:

DQE is a measurement of the efficiency of an image receptor in converting the x-ray exposure it receives
to a quality radiographic image.
• The higher the DQE of a system, the lower the radiation exposure to produce a quality image,
thereby decreasing patient exposure.

Distortion:
Distortion results from radiographic misrepresentation of shape or size.
 • Size distortion refers to an increase in the image size compared with the object's actual size.
• Shape distortion can appear in two different ways radiographically
o Elongation: images of objects that appear longer than the true objects.
o Foreshortening: Images that appear shorter than the true objects.
• When the image is distorted, spatial resolution is also reduced.
• The term size distortion (or magnification) refers to an increase in the image size of an object
compared with its true, or actual, size. Radiographic images of objects are always magnified in
terms of the true object size. The source- to- image receptor distance (SID) and object-to-image
receptor distance (OID)) play an important role in minimizing the amount of size distortion of the
radiographic image.
• To decrease magnification, increase SID and decrease OID
• Misalignment of the central ray among these three factors- tube, part, or image receptor- alters the
shape of the part recorded.

Scatter:
• Fog does not provide information about the anatomic area of interest.
• Scatter decreases the contrast by masking the desired brightness levels and changing the degree of
differences.
• Scatter radiation can add unwanted exposure to the radiographic image as a result of Compton
interactions.
• Degrades or decreases the visibility of the anatomic structures.

Quantum noise: (Underexposed image that is fuzzy)

• Image noise contributes no useful diagnostic information and detracts from the image quality.
• The fewer photons reaching the image receptor to form the image, the greater the quantum noise.
Underexposure.
• It is important to minimize the amount of quantum noise or mottle on a radiographic image.

Signal to Noise Ratio:

A method of describing the strength of the radiation exposure (signal) in comparison to the amount of
noise apparent in the digital image.
If there is alot of noise in the image, increase mAs.
• Increasing the SNR means the strength of the signal is high compared to the amount of noise.
• Increasing the SNR will improve the quality of the digital image.
• Increased noise will decrease visibility of anatomic details.

Contrast to Noise Ratio: (Increased visibility of smaller details)

• CNR is a method of describing the contrast resolution compared with the amount of noise apparent
in a digital image.
• Increasing the CNR increases the visibility of anatomic details.

Image artifacts:
• an image artifact is any unwanted image on a radiograph.
• Artifacts are detrimental because they make visibility of anatomic information difficult or
impossible.
• An artifact can get in the way of pathologic condition, or patient identification information difficult
or impossible. They decrease the overall quality of the radiographic image.
• Digital image artifacts can be a result of errors during extraction of the latent image from the image
receptor, inadequate IR erasure, or performance of the electronic detectors.
• White lines from scratches on the imaging plate
 • Bright specks from dust or sand
• Ghosting or double exposure: Double exposure of the same plate
• Dark areas scatter through the back of the imaging plate.

Quality Assurance:
Daily: Equipment warm up, Meters operation, Equipment conditions, assessment of electronic display
devices.
Weekly: Visual inspection of cleanliness, viewboxes, laser printer film operation
Monthly: Cassette, screen, and IP cleaning, Retake analysis, Electronic display, laser film printer
operation
Quarterly: Collimator operation, interlocks,
Annually: Loading factors, linearity, reproducibility, filtration, AEC, Light field alignment, collimation,
Grid performance, Response function, exposure index, dynamic range, noise/ uniformity and image
artifacts, spatial resolution, contrast detectability, digital detector residual images, photon dose
measurements, electronic display performance, integrity of protective devices, general preventative
maintenance,

Linearity: Yearly. As mAs increases, so does exposure. +-10%. Equipment malfunction, decreased
quality, EI cannot be trusted, call repair.
Reproducibility: yearly and acceptance testing, same mAs= same exposure. Each value within 15% of
mean. Inconsistencies, decreased quality and EI, repair and retest.
Reciprocity- different mA and time, same exposure.
Light field alignment: Yearly. Nine-penny test, outside of light (outer part of pennies) should be to the
outside of the image. 2% of SID. shut down the room and repair.
HVL/ Filtration: yearly. 80kvp, add 1mm al until half the intensity of original value. Depends on kVp.
Decreased overall energy of the beam, quantum mottle, repair.
Timer Accuracy: 1 second or 7% Annually
Beam and bucky alignment: Yearly. Beam alignment tool, upper and lower ball bearing should be
superimposed. 1% of the SID. Could cause distortion or anatomy cut off, repair.
Warm-up procedures and meters: Daily. If not warmed up= 0 exposures. Check for condition and damage.
Either a yes or a no. QC tech, regular maintenance, upon repair and acceptance testing.
kVp accuracy: Acceptance and annually. Same kVp selected and kVp readout checked after every image.
+- 10% for kVp (or 5%). Decreased consistency between rooms, recalibrate.
Minimum irradiation time capability: Minimum irradiation time capability- the controlling timer or
automatic exposure control device must have a minimum irradiation time capability of 1/60 s or the time
required to deliver a current-time product of 5 mAs, whichever is greater
Lead aprons, Other shields and gonadal shields for patients: Yearly. Moveable for radioscopy quarterly.
.25mm 100kv or less, .35mm greater than 100kv and less than 150kv, .5mm 150kv or greater. Gloves or
gauntlets .25mmpb. Ceiling .5, pt gonad shielding minimum .25mm.
X-ray tube leakage: Shall not exceed an air kerma rate of 1.0 mGy/h at a distance of 1m away from the
focal spot.
Annual dose limits: Whole body=20msv, public=1, Lens of the eye=150msv, public=15, skin=500,
public= 50, hands=500, public=50, all other organs =500, public=50

Installation and acceptance testing of equipment:

• Responsibility of vendor/manufacturer
• QC must verify that acceptance testing specification has been met
• Include full disclosure of exact evaluation methods in specifications
o Provides baseline to reference with future QC testing
o Equipment will not be used until acceptance testing is approved.

External beam evaluation:

 • Tests should be performed by a radiographer or QC technologist
• Corrective action by authorized service person- if equipment the biomedical dept and if the
corrective action is for the digital imaging system and PACs system then IT must be contacted.

Diagnostic Radiographic systems testing- frequency in safety code 35:

• FSS estimation
• HVL- dosimetry used to determine the amount of filtration that will reduce beam intensity to one-
half its original value.
• Angulator or protractor accuracy- Can be evaluated using a large protractor +/- 1%
• Kilovoltage accuracy- done with a computerized dosimeter +/- 5%
• Time accuracy- stop watch
• Collimator, central ray and bucky tray accuracy- Light field and x-ray beam congruence crucial +/-
2% od SID allowance. Central ray 1% allowance
• Distances and centering indicators accuracy- Distance indicator +/- 10% of SID. Centering
indicator +/- 2%.
• mR/mAs and milliamperage linearity- Computerized dosimeter. +/- 10% between mA stations and
between high and low mA stations
• Exposure reproducibility- Computerized dosimeter +/- 5%

Questions:
• Display monitors should be monitored annually for frequency ?
• If the CR system indicates EI out of limits, all rooms are serviced ?
• CR plates be cleaned monthly ?
• Timer accuracy must be performed to ensure the validity of the mA linearity test.
• Using separate CR cassettes that are the same size ensures that all images acquired are displayed
with comparable spatial resolutions
• Mottle means not enough signal reaching the IR, increase mAs

Section F: Back to top

Operation of Equipment Fluoroscopic (Image Intensifier, Brightness Gain, Automatic brightness contro,
Magnification mode, Fluoro x-ray tube and generator, Components, Computer system, Spatial resolution,
Last image Hold, Flat-panel fluoroscopy, Image storage, Post processing, Rad protection- patient, Rad
protection- Worker and Quality Assurance
Image Intensifier:
• An electronic vacuum tube that converts the remnant beam to light, then electrons, then back to
light, increasing the light process.
• 5 basic parts:
o Input phosphor
o Photocathode
o Focusing lens
o The accelerating anode
o The output phosphor
• The entire tube is approximately 50cm in length and 15 58cm in diameter.
• The II is situated within the fluoroscopic tower and is attached to a camera tube. The method of
attachment depends on the image- capture feature of the system.
• The input phosphor faces the patient, absorbs the remnant radiation, and emits light in response.
• Emitted light exposes the photocathode, which emits electrons in proportion to the light intensity.
o Many light photons are needed to result in one emitted electron.
• Emitted electrons are accelerated to output phosphor by the accelerating anode and ‘focused’ on the
output phosphor by the electrostatic focusing lens.
• These high energy electrons result in many light photons being emitted from the output phosphor.
 • The result is increased image brightness.

Brightness gain:
• Brightness gain is an expression of the ability of an image intensifier tube to increase brightness of
the image.
• Traditionally, brightness gain was found by multiplying the flux gain by the minification gain.
• It is now common practice to express the increase in brightness with the term conversion factor.
• Flux gain is expressed as the ratio of the number of light photons at the output phosphor to the
number of light photons emitted in the input phosphor and represents the tube's conversion
efficiency.
• Minification gain is an expression of the degree to which the image is minified (made smaller) from
input phosphor to output phosphor. Generally, the input phosphors are 15-30cm and the output
phosphor is usually 2.5 cm.
• Conversion factor
o An expression of the luminance at the output phosphor divided by the input exposure rate.
o The higher the conversion factor, the greater the efficiency of the image intensifier.
• The image intensifier’s ability to increase brightness deteriorates with tube age.
o An ever-increasing patient dose is required for the same level of output brightness.
• Brightness gain= minification gain x flux gain
• Flux gain= # of output light phosphors/ # of input x-ray photons
• Minification gain= (di/do)^2
• Conversion factor= output phosphor illumination (cd/m2)/Input exposure rate (mR/s)

Automatic brightness control:

• A function of the fluoroscopic unit that maintains the overall appearance of the intensified image
(contrast and brightness).
• It automatically adjusts the kilovoltage peak (kVp), milliamperage (mA), or both.
• It operates by monitoring either the current through the image intensifier or the output phosphor
intensity and adjusting exposure factors if value falls below preset level.
• The ABC can be slow to respond to changes in patient tissue thickness and density as it is moved.

Magnification mode:
• Increases voltage to the electrostatic focusing lenses.
• This increase tightens the electron stream diameter.
• The focal point is shifted farther from the output phosphor.
• Only electrons from the center area of the input phosphor interact with the output phosphor, giving
the appearance of magnification.
• Magnification factor (MF)- full size diameter divided by selected input diameter.
• A trifocus image intensifier (30/23/15) can be operated in any of these three modes.
• Magnification improves the fluoroscopists ability to see small structures, but it also increases the
patient's dose.
• Magnification modes improve spatial resolution.
• MF 30/15=2x magnification

Digital Fluoroscopic x-ray tube and generator.

• The x-ray tube utilized for digital fluoroscopic equipment produces x-rays in pulses as opposed to
conventional fluoroscopic x-ray tubes.
• Higher mA values are used; the mA is sometimes 100 times higher in digital fluoroscopy compared
to conventional fluoroscopy (mA values used to be 0.5)
• Three phase or high frequency generators are used to produce rapid pulsing of the x-ray beam.
 • The high patient exposure that would result from higher mA values is offset by the fact that the x-
ray beam is not constantly activated; it is pulsed very quickly by a generator that switches on and
off very rapidly in a process known as pulse progressive fluoroscopy.

Image intensifier digital fluoroscopic components:

• Essentially two components are added to the image intensifier fluoroscopic imaging chain.
• These are the analog to digital converter and a computer.
• The analog to digital converter (ADC) is positioned between the TV camera or CCD camera and the
computer. The purpose of the ADC is to convert the output video signal into digital data for
processing by the computer. Just like in digital radiography the greater the bit number the more
shades of grey are displayed in the image. An 8 bit system can produce 256 shades of grey. Most
digital fluoroscopic units use 10 or 12 bit ADC

The Computer system:

• The computer in digital fluoroscopy receives dynamic digital data from the ADC and processes this
information quickly for image display and subsequent storage.
• The image is displayed as a matrix of pixels.
• The matrix of numbers is transformed into a grayscale image
• The bit depth determines the number of shades of gray that a single pixel in the matrix can assume.
• Each pixel in the image contains the atomic number and mass density characteristics of the tissue,
and a single number for the pixel represents this information

Fluoroscopic spatial resolution:

• The spatial resolution for a digital fluoroscopic image depends on the pixel size
• For the same field of view (FOV) as the matrix size increases, the pixel size decreases, and the
image appears sharper.
• The imaged object is more faithfully reproduced as matrix size increases and pixel size decreases.

Last image hold:

• In conventional fluoroscopy, the patient’s anatomy is displayed on the video monitor only when the
x-rays are turned on to produce an image on the image intensifier.
• When the x-rays are turned off, the display of the patient's anatomy is also turned off.
• Last image hold the digital information from the last frame (that is stored on the computer) and
continuously provides this to the video system so that the display monitor continuously provides
this to the video system so that the display monitor continuously shows the patient’s anatomy
even after the x-rays have been turned off.
• Use of this feature will dramatically decrease the ionizing radiation exposure to the patient and
medical imaging staff. If display of the patient’s anatomy required review on a system without
last image hold, x-rays would continuously be used during this time. With last image hold, the
display monitor can be studied with no additional dose to the patient.

Flat-Panel Fluoroscopy:
• Based upon TFT charge storage and readout technology
• Thin-Film- Transistor arrays
o Proven with radiography applications
o Just becoming available in fluoroscopy.
• CsI scintillator systems (indirect conversion)
• a-Se system (direct conversion)
A cesium iodide scintillator captures the x-rays as they exit the patient and converts them to light. This
light is turned into electronic signals by a matrix of amorphous silicon sensors.
In direct capture or direct to digital systems, x-ray energy is not converted to light.
Instead, it is captured by a thin film transistor matrix of a material such as amorphous selenium that
changes it into electronic signals. No intensifying screen is required, and none of the energy is lost
through scatterm as happens when x-ray energy is converted to light on its way to display an image.

Flat panel vs image intensifier:

The image display format when using a flat panel digital fluoroscopy imaging system is rectangular,
whereas it is circular for an image intensifier- based fluoroscopy system. The rectangular format matches
the display format of the television monitor. The pixels become distorted around the periphery with image
intensifier systems and in TFT type fluoroscopic systems no distortion occurs.

Image storage:
• Static radiographic images can be obtained and stored electronically and then subsequently on a
PACS system.

Post Processing:
• Gray scale image manipulation: Change the brightness (window level) and contrast (window width)
of the display image.
• Edge enhancement: Image sharpening
• Image reversal: Positive and negative. Accomplished through post processing and or dynamic
images produced can be displayed as positive images which can sometimes make pathology more
visually apparent.
• Other: All manufacturers have post processing capabilities. Software usually includes gray scale
processing, temporal frame averaging, edge enhancement and pixel shifting for digital subtraction
angiography.

Radiation protection in fluoroscopy- patient:

• Position the II or TFT as close to the patient as practicable
• Position the x-ray tube as far away from the patient as possible.
• Use the exposure pedal/switch as sparingly as possible.
• Use pulse fluoroscopy whenever possible with low pulse rates than high pulse rates or continuous
fluoroscopy.
• View and save images with last image hold.
• Position and collimate without using fluoroscopy.
• Collimate to use the smallest field of view practicable.
• Use magnification only when necessary.
• High dose or detail modes should be used only when necessary.
• Use highest kVp possible to produce acceptable image contrast
• Acknowledge timing alerts (5-minute intervals) during the procedure.
• Record and review patient dose.

Radiation protection in fluoroscopy- Health care professionals:

• Minimization of time spent in a radiation field is the first principle of radiation safety and exposure
reduction, therefore, fluoroscopy time should be minimized to protect both the patient and the
staff.
• Radiation dose rates decrease according to the inverse square law; whenever possible staff should
distance themselves from the source of radiation
• All nonessential personnel should be removed from the room.
• Lead garments, lead gloves, thyroid shields, leaded eyeglasses, lead drapes and clear leaded glass
barriers between the patient and the operator all reduce exposure to medical personnel from
 scattered radiation.
• If possible, stand on the image receptor side
• There is less scatter towards the image intensifier or TFT as compared to towards the x-ray tube.

Summary:
• Fluoroscopy is a significant source of occupational exposure
• Everything that reduces patient dose also reduces dose to occupationally exposed staff.
• At 1 meter away at a 90-degree angle to the patient you receive approximately 0.1% of the patient
dose.
• Lead aprons will provide further shielding from the scatter radiation produced.
• II should be placed above the patient to decrease dose to everyone in the room
• Work on opposite side of surgery side with fluoro

Fluoroscopy Quality Assurance:

Environmental Inspection: Condition of high-tension cables. mechanical condition of the image
intensifier tower and table. Exposure switch (dead-man type) must require continuous pressure for
activation- check for sticking or malfunction. Protective curtain- moves freely. Bucky Slot cover (if there
is one) should move in place. Table angle and motion. Compression devices easily move in and out of x-
ray beams.
Allowance: Equipment conditions should be checked daily. Pb curtains must contain .25mm Pb
equivalent- checked quarterly. Actual table angle should be within 2 degrees of table angle indicator-
check quarterly. Checked Quarterly.

Visual Indicators: The equipment must have visual indicators that display voltage (kVp) and current (mA)
continuously during activation of fluoro- SC35. Timer/ chronometer- Check with stopwatch
Allowance: check daily. A 5 minute reset timer with an audible signal is required- check quarterly.

X-ray beam filtration: Use half value layer for kVp used.
Allowance: Checked yearly. No variance for filtration

Daily start up/shut down: follow manufacturers guidelines- nothing specifically stated in SC 35

Automatic brightness control: An evaluation must be made of the automatic intensity control system of
radiographic systems. The automatic intensity control system is designed to maintain the rate of exposure
to the image intensifier with changes in thickness and composition of the anatomical region being imaged.
Use phantoms with different thicknesses; double size of phantom, double output.
Allowance: Check yearly.

Contrast and spatial resolution: Follow manufacturer’s test procedures, spatial resolution and contrast
resolution test tools used.
Allowance: Check yearly.

Focal spot to skin distance limits: Equipment must be able to limit focal spot to skin distance.
Allowance: Focal spot to skin distance no less than 30cm for mobile equipment and no less than 38 for
stationary equipment

High level irradiation control: Requires separate activation with continuous pressure on fluoro switch.
Audible signals must be emitted when high-level irradiation is used.
Load factors accuracy: Testing of generator- x-ray tube voltage (kVp) and x-ray tube current (mA)
Allowance: Must not deviate by more than: 10% for voltage, 20% for tube current. Checked yearly

Maximum air kerma rates: Expose a radiation detector using fluoroscopy, intensity of x-ray beam (patient
skin entrance doses) should not exceed values indicated in allowance.
Allowance: 50mGy/min without AIC, 100 mGy/min with AIC. Checked yearly.150 mGy for both AIC
and high level irradiation control

Questions:
• When the image intensifier is close to the table top, patient dose is lower and magnification is less.
• As you move away from the fluoro machine, the intensity of the beam decreases by a factor of 3 ?
• ABC in fluoro tested annually ?
• When fluoro is placed in mag mode, dose is increased due to flux gain
• To protect all personnel during C arm OR cases, Provide lead aprons, and place the II above the
patient.

Section G: Back to top

CT Scanning:
MSCT: Multislice CT scanner
• 1991- dual slice, 1998- four slice, 2002- 16 slice, 2003- 32 slice, today- 64 sub mm slices 126 sub
mm slices 0.4 s rotation, future- 256 and 320 slices.
• Image quality and scanner capabilities improving every year
• Produces a transverse or axial image perpendicular to the long axis of the body
• Digital post processing of the transverse data produces images in the sagittal, coronal or oblique
sections (MPR- multiplanar reconstruction)

Goals:
1. Reduce superimposition of anatomical parts
2. Improve image contrast
3. Post processing capabilities
4. Record extremely small differences in tissue contrast (Contrast resolution)
History:
• Invented in 1972 by Godfrey Houndfield
• First scanner was dedicated to only head imaging.
• Alan Cormac, medical physicist at Tufts, developed the math now used to reconstruct images
• Hounsfield, a research engineer with the famous electro-musical instruments developed the first CT
scanner

CT does not have an image receptor, or an image- intensifier tube, it utilizes a collimated x-ray beam. The
attenuated image- forming radiation is detected by a solid state image receptor.

Computed Axial Tomography:

• Conventional tomography was named axial tomography
• Plane of the image is parallel with the long axis of the body
 • CT image is transaxial or transverse image. Axial term is used in clinical practice.
• The image is perpendicular to the long axis of the body

First and second generation scanners:

• The first generation of CT scanner used what is referred to as translate- rotate geometry
• Translation mode is when the source-detector assembly makes one sweep
• The original EMI Mk 1 scanner used a pencil x-ray beam and a single detector
• During the translational motion of the gantry the transmitted x-ray beam was sampled 180 times to
produce a single profile.
• 180 rotations were made to cover the anatomy of the patients head
• Since the patients mass densities differ, the x-ray beam is attenuated according to their effective
atomic numbers
• The intensity of the radiation detected forms an intensity profile or projection
• Projection (Or view) is composed of a set of rays striking a detector array
• At the end of the translation, the source detector assembly returns to its starting position.
• It then begins the 2nd translation
• Took 5 minutes to scan the head
• Since the process is repeated many times there will be a large number of projections being
produced.
• These projections are stored digitally
• The principle limitations of second generation- CAT imaging systems was the time it took to scan
the patient
• Due to the complex mechanical motion of translation- rotation and the enormous mass involved in
the gantry, most units were designed for imaging times of 20 seconds or more per slice.

Third Generation:
• Utilized a wider fan shaped beam
• Curved detector array with 250 to 1000 detectors
• Fan shaped beam allowed for a 360 rotation within the gantry
• This eliminated the linear scan and rotation system
• IMages produced in less than 1 second
• X-ray beam is able to cover the entire field of view of the scanner
• This avoids the need for any horizontal motion; an entire line can be captured in an instant
• This allowed simplification of the motion to rotation of the x-ray source.

• Tubes and detectors

o Rotate around the patient gathering x-ray projections
• Projection data used to form slice images
o Filtered back projection

Helical CT:
• Continuous gantry rotation + Continuous table feed
• Scan data traces a helical path or spiral around patient
o Data used to form axial images

Isotropic imaging:
• 2D pixel in a CT image represents a 3D voxel
• Resolution is ideal when equal in all 3 dimensions
o Best results with slice thickness equal to (axial) pixel size
o Routine 0.5-1mm slice thickness achieves this goal
Multi-slice CT scanning:
• Many features in common with single slice (SSCT)
o Multiple parallel detector banks along z-axis
o Enables a number of projections to be acquired simultaneously

Detector banks:
Array extends in 2 directions
• X- length
• Z- height
• Xy plane
• Arc to collect many samples for each projection
• Z-axis
• Along the patient length
• Table movement during helical scanning
• SSCT
• Z-axis coverage: one element
• MSCT:
• Many z-axis elements

Slices and detectors:

4 slice scanners
• Just 4 detectors reduced options for scanning compared to 16, 32 or 64 slice scanners
• Narrow coverage (5mm for d=1.25)
• For more flexibility and greater coverage need more detectors
• Can collect data from grouping of detectors
o Individual detectors
▪ 4xd
o Pairs
▪ 4x2d
o Triples
▪ 4x3d
• GE light speed
o 4 slices
o 16 detectors in z-axis

Data acquisition system:

• Collection of information from the patient to produce a CT image.
• Conventional- individual slices collected
o Many revolutions to complete scan
• Helical (spiral)- volume of tissue is scanned as the x-ray tube rotates around the patient- single slice
per revolution
o Faster scanning- single breath hold techniques
• Multislice- multiple slices per revolution
o Sub-second scanning

Equipment:
Gantry:
• Houses apparatus necessary to produce and detect xrays in order to create a CT image
 • Gantry insides:
o External:
▪ Aperture- 50-85cm
▪ Microphone
▪ Sagittal laser alignment light
▪ Patient guide lights
▪ X-ray exposure indicator light
▪ Emergency stop button
▪ Gantry control panel
▪ Laser light alignment
▪ Patient couch
▪ ECG gating monitor
o Internal:
▪ Tube
▪ Filters, collimator and reference detector
▪ Internal projector
▪ X-ray tube heat exchanger
▪ High voltage generator
▪ Detect drive gantry monitor
▪ Rotation control unit
▪ Data acquisition system
▪ detectors
▪ Slip rings
▪ Detector temperature control
▪ High voltage generator 75-150 kvp
▪ Power unit AC-DC
▪ Line noise filter

• Patient couch- (lounging around in CT)

o What limitation does a patient couch have
o What is the most important when positioning patients:
▪ Part of interest is not over the scannable range (degree which patient can move
horizontally)
• X-ray generator
o Guess how many heat units required
o What type of generators are used

CT image quality:
Determined by 3 factors:
• Resolution
• Noise
• Contrast

Resolution:
The measure of how far two objects must be apart before they can be seen as separate details in the
image. For two objects to be seen as separate the detectors must be able to identify a gap between them.
Resolution is measured in line pairs per centimeter or the number of line pairs that can be imaged as
separate structures within one centimeter
There are two types of resolution in CT scanning:
• Transaxial resolution (7 lp/cm)
o Axial across the patient
• Z-sensitive (0.5-10mm)
 o Along the length of the patient in the z-direction

Transaxial resolution:
The minimum transaxial resolution is determined by the actual detector size are slightly different due to
the divergence of the beam. The smaller the “effective detector width” the higher the resolution

The transaxial resolution is affected by scanner (hardware) factors or scan and reconstruction parameters.

Scanner factors:
1. Focal spot
• Size
o Smaller focal spots give higher resolution, but the max mA is limited to prevent
damage to the anode.
o There are usually two available focal spot sizes on CT scanners. For example
▪ Fine= 0.7mm
▪ Broad= 1.2mm
• Properties:
o Flying focal spot: the position of the focal spot is rapidly altered in the transaxial
plane and/or the z-axis. Each focal spot position increases the number of
projections sampled and improves spatial resolution. For example, if the position
of the focal spot moves in the X-Y plane, then the in-plane resolution increases.
• Focus-detector distance (FDD)
• Focus-isocentre distance (FID)

2. Detector size
Smaller detectors give higher resolution but more detectors within an area also means more
partitions (dead space) and a reduced overall detection efficiency.

3. Detector design properties

Quarter ray detector offset: the center of the detector array is offset from the center of rotation by
one quarter the width of an individual detector. As the gantry rotates to 180 degrees the center of
the detector array is now offset by hald the width of the detector giving an interleaved sampling
of the patient.

Scan parameters:
1. Number of projections
• Larger number of projections gives finer resolution (up to a point)

2. Reconstruction filter
• Higher resolution or “sharp” kernels (bone reconstruction) have better spatial resolution
than soft kernels (Soft tissue reconstruction)
3. Pixel size
• The pixel size (d) in mm is given by the equation d=FOV/n (n=image matrix size)
• Highest spatial frequency that can be obtained (fmax) is called the Nyquist limit and is
given by: fmax= 1/2d
• From this equation you can see that the higher the pixel size, the lower the maximum spatial
frequency
• To improve spatial frequency we can
 o Reduce the FOV (smaller FOV= smaller pixel size as seen in the first equation. We
can do this in retrospectively by a targeted reconstruction of the original data into
a small field of view
o Increase the matrix size (larger n= small pixel size as seen in the first equation)

Z-sensitivity:
Z- sensitivity refers to the effective imaged slice width

Factors affecting z-sensitivity:

1. Detector slice thickness
• The wider (in the z-axis) the detector row, the lower the resolution

2. Overlapping samples
• Acquiring the data using overlapping slices can improve z-sensitivity. This is achieved by
using a low spiral pitch
3. Focal spot
• A fine focal spot improves the z-sensitivity

Importance of slice thickness:

1. Noise
• The thinner the slice the better the resolution BUT the worse the noise

2. Partial volume effect

• Thicker slices increase the partial volume effects

3. Isotropic scanning
• Thin slices allow isotropic scanning i.e. the pixels in the axial and the z-axis are the same
size (cubes). The advantages of this are:
o Reduced partial volume effect
o Better multi-planar reformatting
o Improved volume rendering e.g displaying 3D representations of the data (cardiac
imaging, vascular imaging, CT colonography)

Noise
Even if we image a perfectly uniform object, there is still a variation in the hounsfield units about a mean.
This is due to noise. Noise degrades the image by degrading low contrast resolution and introducing
uncertainty in the hounsfield units of the images.
We can measure noise in any uniform region of the image with a water phantom. The standard deviation
of the CT number in a selected region of interest gives the mean noise measurement

There are three sources of noise:

1. Quantum noise
2. Electronic noise
3. Noise introduced by the reconstruction process
Stochastic noise
This is the dominant source of noise in an image. Photon registration by the detectors is a stochastic
process. The number of photons detected will vary randomly about a mean value and that variation
artifactsis the noise. Increasing the number of photons reduces the amount of noise and, therefore,
anything that increases the number of photons (increase the photon flux) will reduce the noise. If we
doubled the number of photons we will reduce the noise by 2 squared.
Doubling the number of of photons can be achieved by:
• Doubling the tube current (mA)
• Doubling rotation time (s)
• Doubling the slice thickness
(Increasing the tube KV also increases photon flux but is not directly proportional.

Contrast:
Factors influencing contrast:
• Noise: a higher noise will obscure any contrast between objects. Higher noise= worse contrast
differentation
• Tube current: a higher tube current reduces the noise in the image
• Inherent tissue properties: the difference in the linear attenuation coefficient of the adjacent imaged
objects will determine the contrast between those objects
• Beam kilovoltage: a higher beam energy will generally reduce the contrast between objects
• Use of contrast media: increases contrast between objects

Filtration:
• Removes long wavelength x-rays which contributes to patient dose
o Beam becomes harder- may cause beam hardening artifacts
• Shapes the energy distribution across the radiation beam to produce uniform beam hardening when
x-rays pass through the filter and the object
(Bowtie filter is used to allow a uniform beam to reach detectors)

Collimation:
• What is the benefit to the patient that collimation provides?
• What are the two collimators utilized in CT?
• What does focal spot size have to do with collimation?

Detectors (in a nutshell)

• Must have efficient absorption, have quick response time, high reproducibility and stability
• Capture the radiation beam from the patient
• Convert it into electrical signals
• Those signals then converted into binary coded information (logarithmic conversion)

Artifacts and how to fix:

• Uncoupling effect-
• Beam hardening- metal, gastrograffin/ barium
• Out of edge- patient size/ habitus
• Streaking- motion
• Ring artifact- insufficient exposure results in concentric circles in the center of the field of view.
• Respiratory artifact- can be mistaken for fluid around the heart
• Periodic artifact- cardiac motion

• Phantom artifacts
• Double exposure
 • Moire
• Background radiation

Image Reconstruction:
• Algorithms- a mathematical formula for processing data
• Fourier transform
• Interpolation

Pitch:
• Relationship between the patient couch movement and the x-ray beam collimation
• Pitch= couch movement each 360 degrees/ slice thickness
• When pitch is increased, dose decreases

Resolution:
• What results when kVp is increased
• What results when mAs is increased
• What results when pitch is decreased

3D reconstruction/ post processing:

Surface rendering/ Shade surface display. Voxels on the surface of the structure used, largely replaced by
volume rendering. Best demonstrates facial bones.
MIP (maximum intensity projection)- selects highest voxel value. (high density areas)
MinIP (minimum intensity projection)- selects lowest voxel value. (low density areas)
Remasking: Used to improve quality of a subtracted image
VR (volume rendering) 3D semi transparent representation of the imaged structure, favored in 3D
imaging, All voxels contribute to the image. Allows the image to display multiple tissues and their
relationship to one another.
Endoluminal imaging: a form of VR that is done for colonoscopy, also called perspective volume
rendering or virtual endoscopy, looks inside a lumen of a structure.
3D modeling- using a 3D printer, used mostly for education, surgery, simulation.
ROI editing- done to remove obscuring structures from the 3D image, 3D software allows the editing to
be manual, automatic or semiautomatic fashion.
Degrade reformatted images- segmentation errors, image noise, artifact (motion, metal, stair-step)

Window level and width:

Windowing: (Histogram modification and contrast enhancement) is the process in which the CT image
greyscale component of an image is manipulated via the CT numbers.
• Changes the appearance of the image to highlight particular structures
• The brightness of the image is adjusted via the window level
• The contrast is adjusted via the window width
Window width:
• The window width is the measure of the range of CT numbers that an image contains.
• A wider window width (2000 hu), therefore will display a wider range of CT numbers
• Consequently, the transition of dark to light structures will occur over a larger transition area when
compared to a narrow window width.
• Wide window widths are best for imaging tissue types that vary greatly, when the goal is to see all
of the various tissues in one image.
• Responsible for providing optimal image contrast to demonstrate bony detail.

WW low or long scale contrast:

• Defined as 500-2000hu, best used in areas of acute differing attenuation values, a good example is
lungs or cortical tissue, where air and vessels will sit side by side.
• Many shades of grey (Not black and white) in a chest is a lung window in CT. This is used to view
lung parenchyma.

Narrow window- higher contrast:

• Defined as 50-500 HU, narrow window widths are excellent when examining areas of similar
attenuation (soft tissue)
• Image where shades displayed are mostly black and white are referred to as a bone window.
• Tissue types with similar densities should be displayed in a lower, or narrow, window width (50-500
HU)
• This approach is the best in the brain, in which there is not as much variation in CT numbers.
• A narrow width when displaying the brain makes it possible to differentiate the white and gray
matter of the brain.

Window level/ center:

• The window level is the midpoint of the range of the CT numbers displayed.
• When the window level is decreased the CT image will be brighter and vice versa.
• The window level for an image with the level 30 will be brighter than an image with a level of 80
• The window level is usually set at a point that is roughly the same value as the attenuation number
of interest (CT# of liver is approx 30-55 HU so you should expect a window level to be similar to
that value.

Upper and lower grey level calculation:

• When presented with a WW and WL one can calculate the upper and lower grey levels.
o Upper grey level (x) is calculated via WL + (WW/2)
o The lower grey level (y) is calculated via WL-(WW/2)
o For example a brain is W:80 L:40, therefore, all values above 80+ will be white and all
values below 0 are black
(Head and neck)
Brain: WW:130-300 WL:40
Subdural: WW:130-300 WL:50-100
Stroke: WW:8 WL:32
Temporal bones: WW:2800 WL:600
Soft tissues: WW:350-400 WL:20-60

(Chest)
Lungs: WW: 1500 WL:-600
Mediastinum: WW: 350 WL:50
(Abdomen)
Soft tissues: WW: 400 WL:50
Liver: WW: 150 WL:30

(Pelvis)
Soft tissue: WW: 400 WL:50
Bone: WW:1800 WL:400

(Spine)
Soft tissues: WW: 250 WL:50
Bone: WW: 1800 WL:400

CT numbers:
Linear attenuation coefficient
Hounsfield units- numerical information contained in each pixel
Bone: 1000-3000
Hemorrhage: +65-95
Blood: +30-45
Gray matter: +30-47
Muscle: +20-50
White matter: +20-30
CSF (Water): 0-15
Fat: -30 to -84 or -100--50
Soft tissue: -100--300
Lung: -700
Air: -1000

Questions:
• Abdominal aorta is best visualized at the level of the aortopulmonary window.
• Uncoupling results when the mAs and kVp are too high and a good image is still the result.
• Temporal resolution is how rapidly data is acquired. Controlled by gantry rotation speed, number of
detector channels in system and speed with which the system can record changing signals.
• Patients with brain mets who receive iodinated contrast have an increased risk of seizures.
• Scanning of the liver must take place before the equilibrium phase, which can begin as early as 2
minutes after the contrast bolus. This is particularly important when the clinical indication is to
evaluate for metastatic lesion. The impact of an unanticipated delay can only be estimated,
because factors such as speed of the scanner and how soon after the start of injection the delay
occurs affect the timing window. For purposes of illustration, let us assume the scanner at this
facility will acquire the scans through the liver in 20 seconds. Although the routine scan protocol
at this facility calls for a delay of 60 seconds between the start of injection and the start of
scanning, the scan could be delayed another 40 seconds and still acquire all the scans before 2
minutes has elapsed. Because the scan delay is so critical for many studies, it is best to prepare
the patient for any potential effects of the contrast injection before injection. Clear instructions
are helpful.
• It takes longer to reach a higher concentration of contrast when flow rate hasn't changed.
• By selecting an algorithm, the CT tech is selecting the mathematical formula for processing data.
• Most common WL setting for lung would be -600 (Air has a Ct number of -1000)
• Typical abdominal window of WL 50 WW of 350, a HU of 320 would cause it to appear all white
due to decreased WL
• The typical WL and WW of a lung window is WL -500/ WW 1600
• High resolution CT studies require a slice thickness to be reduced to 1.25mm
• A portion of cancellous bone has a CT number of +445, if the WL is set to -100 and WW is 650 the
 appearance of the cancellous bone is white. (any structure with a CT number above +225 Hu will
appear white given the WW and WL)

CT review:
• Prospective reconstruction is done as the image scans in CT. How you get axials in the first place.
• Retrospective uses information from the scan to reconstruct the raw data to generate new images/
slices.
• DAS is digital to analog in CT
• Binning- combining all data from different detector rows and making it into slices
• 3 basic components of helical scanning: table moving, x ray is always on and the tube is spinning
• Slip rings are the breakthroughs of CT which lead to decreased times.
• Smaller pitch the contrast is lower, which is opposite to spatial with high and low contrast as you
want the opposite
• table rotation per 360 rotation/ # slices x slice thickness= pitch
• Muscle CT number is 10-40
• Soft tissues- WW-400 WL 50
• Bone- WW+1800 WL 400
• Lung: WW:1500 WL -600
• WW / 2 add WL to that and subtract
• WW 300 WL 50
• Area of coverage formula:
o Single detector-
o Double detector- pitch x total acquisition time x1/rotation time x slice thickness x slices
per rotation
• Term for when tube factors are modified for the scout image- mA modulation
• Convolution- process of applying a filter function to an attenuation profile
• Attenuation profile- histogram of CT. All views (definition below) together to create a scan
• Ray- ray beam as it strikes the detector
• Ray sum- how much each upcoming ray has been attenuated as it hits the detector
• View- complete set of ray sums to complete one image.
• DFOV can never be bigger than scan field of view.
• A reconstruction algorithm is takes the SFOV and displays it in different ways
• Iterative reconstruction- similar to histogram as it has what the scan thinks it should look like to
match everything .
• Measuring spatial resolution in CT- line pairs phantom or MTF formula
• Spatial resolution: Pitch, Computer pixels and matrix, patient motion, slice thickness, reconstruction
algorithms depending on which you use (bone increase, soft tissue decreases), focal spot smaller
gives better.
• Contrast: Pitch, mAs, slice thickness, reconstruction algorithms, inherent patient contrast.
• Temporal resolution: How fast the DAS works and how fast the gantry turns, how many detectors
you have to record information.
• Beam hardening is most common through the brain ( posterior fossa) where there are areas of
density around areas of soft tissues as low energy tissues are absorbed.
• Partial voluming artifact- when a dense object is just outside of the field. (abdomen and calcification
on lung)
• Aliasing- not enough signal so it is blurry and wavy
• Edge gradient artifact- artifact from contrast and metal.
• To solve most artifacts= thinner slices
• Ring artifact: from faulty detectors in older generation CT detectors
• Windmill: when you choose the wrong set of detectors, outer rings pick up detectors.
• SFOV you are choosing the detectors but not the display.
 • MPR- different planes
• Curved planar- following a tubular organ to make a different plane of reformation
• SSD: Shell of organ or skeleton
• MIP- Displays contrast filled vessels and displays them.
• MinIP- Displays for lung bile pathway.
• Volume rendering- basically 3d
• Endoluminal imaging- is imaging of the inside of a tube
• Factors degrading reformatted images: patient movement, aliasing/ mA, metallic object.
• Pre patient collimation: controls thickness of beam
• Pre detector collimation: prevents scatter from reaching the detectors
• Slip rings are electromagnets

CT QA:
Daily:
• Equipment warm up
• Meters operations
• Equipment condition

Weekly:
• CT number accuracy- evaluate the CT number water. Uniform water phantom needs to be +-4.
• CT noise- measurement of CT noise, uniform phantom, define the mean value of ROI. Cannot value
from 10% or .2 HU. Typically do head and body scan
• CT uniformity: Consistency of CT numbers inside a homogenous scan field. 5 regions of interest,
cannot exceed 2 HU from baselines. Look at center and perimeter and not vary for 5 HU. Head
and body scan

Monthy tests:
• CT tomographic section thickness: Evaluation of thickness of slices. 2mm slices or greater, no
greater than 1 mm. From 2-1 cannot vary more than 50%, 1mm or less slice cannot vary by
.5mm.
• Calibration CT number: Mean CT number measured, water 0 +- 4, air 1000 +-10 hu
• CT number linearity: at all voltage, linearity assessed. Scan object with known CT number.

Quarterly:
• Interlocks: Door open, xray must not be performed.
• CT spatial resolution: 2 methods, MTF curve; measure a wire, must be in 15% of baseline values,
qualitative bar test: limit should be 5lppcm, visual assessment using test device, 1mm or less.
• CT low contrast detectability: Show CT detectors ability to display contrast, 1% or 10 HU of
surrounding material in established limits

Semi-annually:
• CT laser light accuracy: axial localizer: in 2mm of distance, sagittal: in manufacturer limits or
within 5mm
• CT patient dose: CTDI 100 must be determined for head and body as well as CTDIw from
CTDI100 within 20% of established value (CT machine gives info on dose after scan)

Annually:
• CT numbers depend on phantom position: water must not vary 5HU when water phantom is varied
over positions
 • Integrity of protective equipment 670mm squared or more is unacceptable.

Section H: Back to top

1:34 PM
Procedure Management H:
Skeletal Fractures:
Fracture: disruption in all or part of the cortex of a bone
Complete fracture: complete discontinuity between two or more fragments
Incomplete fracture: causes partial discontinuity with a portion of the cortex remaining intact (greenstick)
Dislocation: the bony components of a joint no longer are in contact with each other; there is a complete
disruption of the joint. (anteriorly dislocated shoulder shows humeral head inferior to the coracoid)
Subluxation: bony components of a joint are partially in contact with each other; there is partial disruption
of the joint.
Closed fracture: a broken bone that does not penetrate the skin
Compound or open fracture: fracture in which the bone end(s) penetrate the soft tissue and skin; it is also
termed an open fracture
Varus deformity: inward angulation of distal segment of a bone. (Distal fracture fragment are angled
towards the midline of the body)
Valgus deformity: outward angulation of the distal segment of a bone or joint
Avulsion fractures: fragments of bone are pulled away from the shaft of the bone. These fractures occur
around joints because the tendon or ligament pulls off a piece of the bone.
Bennett fracture: intra-articular fracture at the base of the 1st metacarpal
Bimalleolar fracture: involving both lateral and medial malleoli
Bimalleolar (potts) fracture: a fracture of the lower part of the fibula involving both malleoli with
dislocation of the ankle joint.
Trimalleolar fracture: posterior lip of the tibia as well as both medial and lateral malleoli
Blow-out fracture- a break in the bony orbital floor or walls caused by blunt force trauma to the eye or
orbit. Infraorbital contents are pushed into one or more of the paranasal sinuses.
Boxers fracture: fracture that extends through the metacarpal neck, most commonly of the 5th metacarpal,
most often the result of punching a person or wall.
Colles fracture: transverse fracture of the distal radius in which the distal fragment is displaced
posteriorly. As well as posterior and outward displacement of the hand and chip fragments of the ulnar
styloid process
Comminuted fracture: consists of more than 2 fragments. Fragments of bone separate along the edges of
the major fracture line.
Complete fracture: complete non comminuted fractures are those in which bone has separated in two
fragments. This type of fracture may be recognized according to the direction of the fracture line
(transverse, spiral, oblique etc.)
Compression fracture: produced by compaction of bone trabeculae and results in decreased bone length or
width. Most frequent type of injury involving vertebral bodies.
Coup: contusion formed on the side of the head where the trauma occurs is called a coup lesion
Contrecoup: a lesion formed on the opposite side of the skull in reference to the initial trauma site is
termed contrecoup lesion.
Depressed fracture: fracture of the skull with depression of the bone in towards the brain. These fractures
are caused by high velocity impact from small objects. Injury to the cerebral cortex may result, causing
bleeding into the subarachnoid space.
Displaced fracture: bone snaps in two or more parts and moves so that the two ends are not lined up
straight. If angulation or displacement is large, reduction of the bone may be required, in adults,
frequently requiring surgical care. These injuries may take longer to heal than injuries without
displacement or angulation.
Greenstick fractures: fracture in which the cortex breaks on one side without separation or breaking of the
opposite cortex. Greenstick fractures are found almost exclusively in infants and children under 10 years
of age because of the softness of the cancellous bone.
Torus fracture: greenstick fracture in which the cortex bulges or buckles outward with little displacement.
It is often referred to as a buckle fracture.
Hangman's fracture: fracture of the arch of the 2nd vertebra, usually accompanied by anterior subluxation
of the 2nd cervical vertebra on the 3rd cervical vertebra. These fractures are most often the result of
severe hyperextension of the head.
Clay shovelers: C6-c7 avulsion fracture of spinous process viewed with lateral.
Impacted fracture: occurs when the separated pieces of bone wedge into other bones. Falls, collisions or
other accidents are the prime cause of impacted fractures.
Incomplete fractures: does not extend through the full transverse width of a bone. An incomplete fracture
is most typical in children (buckle or greenstick)
Intertrochanteric fracture: occurs between the greater and lesser trochanter of the femur
Linear fracture: a fracture that extends lengthwise through the bone.
Longitudinal fracture: is a fracture that follows the long axis of the bone.
March (stress) fracture: fracture of the distal 3rd of one of the metatarsals occurring because of recurrent
stress. This fracture is often also termed a stress fracture.
Monteggia fracture: fracture in the proximal third of the ulnar shaft with dislocation of the radius
Oblique fracture: fracture that is diagonal to the bones long axis. This type of fracture is usually caused by
a force applied in the same direction as the long axis of the bone.
Pathologic fracture: occurs in abnormal bone weakened by a disease process.
Salter-harris fracture- fracture through a growth plate, therefore, they are unique to pediatric patients.
They are classified 1 through v according to the location of the fracture. The classification of the injury is
important because it affects the patients treatment and provides clues to possible long term complications
(37)
Simple fracture: an uncomplicated fracture which generally consists of two fragments in which the broken
bone does not penetrate the skin.
Smith's fracture: transverse fracture of the distal radius with palmer displacement of the distal fracture
fragment. This results from a backward fall onto the outstretched hand.
Spiral fracture: fracture in which the bone has been twisted apart, usually resulting from a rotary type
injury.
Supracondylar fracture: fracture of the distal humerus just above the epicondyles. This is rare in adults but
is common in children between 5-15. most commonly caused by a fall with the elbow hyperextended.
Transverse fracture: a complete noncomminuted fracture occurs at right angles to the long axis of the
bone. This type of fracture is generally caused by a force perpendicular to the shaft of the bone.
Undisplaced fracture: fracture in which the bone fragment remains in proper alignment. Two views at 90
degrees to help definitively determine fracture placement.

Radiographic pathology (Skeletal pathology):

Acromegaly: a condition due to the production of too much growth hormone by the pituitary gland after
the end of adolescence or puberty. Excessive growth hormone secretions may be caused by an adenoma
of the pituitary gland or by other causes. Diseases marked by progressive enlargement of the head, hands,
and feet caused by abnormal secretion of growth hormone.
Achondroplasia: inherited disorder of bone growth that causes the most common type of dwarfism.
Because this disorder affects the cartilage located in the epiphysis of long bones, people affected have
shortened extremities with a normal size torso.
Bone age: An interpretation of skeletal maturity, typically a PA of the hand and wrist is taken of the left or
nondominant hand
Ankylosing spondylitis: is a form of a rheumatoid arthritis of unknown etiology that affects the spine in a
progressive fashion, eventually fusing the spine into a rigid block of bone. Ankylosing spondylitis is
sometimes referred to as "bamboo spine". Early radiographic changes demonstrate the bilateral fuzziness
of the SI joints.
Aseptic necrosis: a bone condition that results from poor blood supply to an area of bone, causing
localized bone death. Can be caused by trauma, damage to the blood vessels that supply blood its oxygen,
poor blood circulation to the bone, abnormally thick blood and atherosclerosis or inflammation of the
vessel walls.
Cystic bone lesion: a benign lesion consisting of a wall of fibrous tissue filled with fluid. These frequently
occur in the long bones of children, most commonly in the humerus and proximal femur.
Hip dysplasia: a congenital or acquired deformation or misalignment of the hip joint
Gout: a kind of arthritis that occurs when uric acid builds up in blood and causes joint inflammation. It is
an inherited metabolic disorder that causes excess amounts of uric acid to be produced and deposited in
the joint and adjacent bone most commonly of the great toe.
Hyperparathyroidism: overactivity of the parathyroid glands causing excess hormone production, which
over stimulates osteoclasts, which are responsible for bone removal.
Kyphosis: over curvature of the thoracic vertebrae. Can be either the result of degenerative disease,
developmental problems, osteoporosis with compression fractures of the vertebrae, or trauma.
Legg-Calve-Perthes disease: osteonecrosis of the capital femoral epiphysis of the femoral head. When the
ball of the thigh bone in the hip doesn’t get enough blood, causing the bone to die. Usually occurs in boys
4-10. Ball of the hip collapses and becomes flat. Usually only one hip is affected. Blood supply returns
over several months, bringing in new bone cells. The new cells gradually replace the dead bone over 2-3
years.
Lordosis: inward curvature of a portion of the lumbar spine and cervical vertebral column.
Metastatic bone lesion: Virtually any type of bone cancer that metastasizes to bone. Goes to well vascular
places.
Multiple myeloma: most common type of cancerous bone tumor. Occurs in various parts of the body,
arising from bone marrow or marrow plasma cells. Appearance includes multiple osteolytic lesions
scattered throughout the affected bones.
Osgood Schlatter's disease: inflammation of the bone, cartilage, and/or tendon at the top of the tibia,
where the tendon from the patella attaches. Most often only one knee is affected. OSD usually strikes
active adolescents around the beginning of their growth spurts, the approximate 2year period during
which they grow most rapidly. Growth spurts can begin any time between the ages of 8 and 13 for girls,
or 10 to 15 for boys. Best visualized by a lateral knee
Osteoarthritis: known as degenerative joint disease, is a noninflammatory deterioration of the joint
cartilage that results from the aging process. It generally affects the weight bearing joints as well as
interphalangeal joints of the fingers.
Osteogenesis imperfecta: is a rare, but serious congenital disease affecting the newborn skeletal system.
With this condition, formation of osseous tissue is deficient and imperfect, leading to an abnormal
fragility of bones. Infants affected with this disease usually have multiple fractures at birth that heal only
to give way for new fractures. Most people with osteogenesis imperfecta have significant physical
handicaps
Osteomalacia: a condition marked by the softening of the bones, caused by lack of calcium in the tissues
and a failure of bone to calcify. This normally results from inadequate intake of absorption of calcium,
phosphorus or vitamin D. If osteomalacia occurs before growth plate closure, it is known as rickets.
Osteomyelitis: infection of bone, most often caused by staph infection, which may localize or spread to
the bone to involve the marrow and other bone tissues. The infection is most often delivered via the
bloodstream and It may also occur from direct infection with an open or compound fracture.
Osteoporosis: low bone mass and deterioration of bone tissue. This leads to increased bone fragility and
risk of fracture, particularly of the hip, spine and wrist. Osteoporosis is often known as the silent thief
because bone loss occurs without symptoms. Checked with BMD.
Osteosarcoma: A cancerous bone tumor that usually develops during the period of rapid growth that
occurs in adolescence. Most common cancerous bone tumor in children. The average age at diagnosis is
15. Terry Fox had osteosarcoma.
Paget's Disease: Common disease in the elderly. Disorder in normal bone turnover. Excessive breakdown
and formation of bone tissue causes affected bone to weaken, resulting in pain, misshapen bones,
fractures, and arthritis in the joints near the affected bone. Affected bones are characterized by an increase
in bone synthesis, resulting in a thickened and sclerotic "cotton wool' radiographic appearance. Usually
affects the pelvis, skull and long bones. Weight bearing bones affected can become bowed. When the
skull is affected there may be encroachment on the cranial nerves that result in neurological symptoms.
Rheumatoid arthritis: A chronic, systemic inflammatory disorder that may affect many tissues and organs,
but principally attacks flexible (synovial) joints. As the synovial tissues proliferate, they progressively
destroy the cartilage, bones, and supporting structures.
Scoliosis: Abnormal lateral curvature of the spine. Scoliosis does not generally become visually apparent
until adolescence.
Spina bifida: congenital disorder where there is incomplete closure of the vertebral canal, which is
particularly common in the lumbosacral area. Can be surgically closed after birth, but this does not
restore normal function to the affected part of the spinal cord (paralysis, bowel and bladder impairment).
The incidence of spina bifida can be decreased by up to 70% when daily folic acid supplements are taken
prior to conception.
Spina bifida occulta: outer part of some vertebrae are not completely closed. The split in the vertebrae is
so small that the spinal cord does not protrude. The skin at the site of the lesion may be normal, or it may
have some hair growing from it; there may be a dimple in the skin, or a birthmark. Many people with this
type of spina bifida do not even know they have it, as the condition is asymptomatic in most cases and
most people are diagnosed incidentally from spinal x-rays.
Spondylolisthesis: Forward displacement of one vertebra over another, usually caused by a developmental
defect in the pars interarticularis
Spondylolysis: cleft or breaking down of the vertebra between the superior and inferior articular
processes. Spondylolysis can be seen in both children and adults and is a common cause of low back pain
in adolescent athletes. 95% occur at level L5.
Spondylosis: degenerative osteoarthritis of the joints between the center of the spinal vertebrae and/or
neural foramina. Osteophyte formation. Mainly a problem of normal wear and tear of aging.

Respiratory pathology:
Asthma: A condition in which the airways are narrowed because hyperreactivity to certain stimuli
produces inflammation. In an asthma attack, the smooth muscles of the bronchi go into spasm, and the
tissues lining the airways swell from the inflammation and secrete mucus into the airway. The narrowing
effect that this has on the diameter of the airway requires the person to exert more effort to move air in
and out.
Radiographic appearance:hyperinflation of the lungs and bronchial wall thickening. Often not detectable
on chest x-ray.

Atelectasis: lung collapses becoming airless thus preventing the respiratory exchange of carbon dioxide
and oxygen. Symptoms include diminished breath sounds, a mediastinal shift towards the side of the
collapse, fever and increasing dyspnea. The main cause of atelectasis is an obstruction of a bronchus.
Smaller airways also become blocked. It can also be caused by pressure in the lung from fluid or air in the
pleural space or by pressure from a tumor outside the lung. If this persists, it may prevent lungs from
properly clearing mucus and lead to infections such as pneumonia. Can be fatal if not treated.
Radiographic appearance: White on one side and dark on the lower of the other side. Increased
radiodensity due to inflammation and accumulation of fluid.

AIDS:
Human immunodeficiency virus infection is an infection by one of two viruses that progressively drops
white blood cells called lymphocytes, causing acquired immunodeficiency syndrome or AIDS.
Tuberculosis and pneumocystis carinii pneumonia, which is an opportunistic infection caused by yeast
like fungus, are common chest infections that can occur in patients with AIDS.
Radiographic appearance: Bilateral interstitial infiltrates in an HIV-infected patient with pneumocystis
carinii pneumonia (PCP). very White patchy lungs

Bronchiectasis: irreversible widening (dilation) of portions of bronchi resulting from damage to the
bronchial wall. Bronchiectasis isn't a single disease; it's produced in several ways and results from several
conditions that injure the bronchial wall. Some areas of the bronchial wall are destroyed and chronically
inflamed; the cilia are destroyed or damaged and mucus production increases.
Radiographic appearance: An obstructive lung disease, along with emphysema, bronchitis, asthma and
cystic fibrosis. Fire lung

Bronchitis: inflammation of the bronchi usually caused by an infection. Can be acute or chronic: Acute:
characterized by the development of a cough, with or without the production of sputum. Acute bronchitis
often occurs during the course of an acute viral illness such as the common cold or influenza. Viruses
cause about 90% of acute bronchitis cases, whereas bacteria account for about 10%
Chronic bronchitis: a type of COPD characterized by the presence of a productive cough that lasts for
three or more per year for at least two years. Usually develops due to recurrent injury to airways caused
by inhaled irritants. Cigarette smoking is the most common cause, followed by exposure to air pollutants
such as sulfur dioxide or nitrogen dioxide, and occupational exposure to respiratory irritants.
Radiographic appearance: ‘Cigarette in lung’ visualization

Carcinoma of lungs: many lung cancer originates in the cells of the lungs; however, cancer may also
metastasize to the lung from other parts of the body. More than 90% of primary lung cancers start in the
bronchi; such cancer is called bronchogenic carcinoma. Metastatic lung cancer can occur from primary
breast, Gi tract, female reproductive organ, prostate, skin and kidney cancer.
Radiographic appearance: Radiopaque lesion with spiculated edges.

COPD: Chronic obstructive pulmonary disease is persistent obstruction of the airways caused by
emphysema and/ or chronic bronchitis.
Radiographic appearance: A typical chest x-ray will show increased AP diameter, flattening of the
diaphragm and decreased lung markings.

Cystic fibrosis: a hereditary disease that causes certain glands to produce abnormal secretions, resulting in
several symptoms, the most severe of which affect the digestive tract and the lungs. In the lungs excessive
mucus production results in difficulty breathing and frequent lung infections. It is not curable but is
managed throughout someone's lifetime.
Radiographic appearance: Starburst lung. Increase technical factors.

Emphysema: An enlargement of the alveoli and the destruction of their walls. A long term progressive
disease of the lungs that primarily causes shortness of breath due to over inflation of the alveoli. Lung
tissue involved in exchanging gases is impaired or destroyed. Included in COPD. Obstructive lung
disease as airflow on exhalation is slowed or stopped because of over-inflated alveoli do not exchange
gases when a person breathes due to little or no movement of gases out of the alveoli. Causes the chronic
over inflation of the lungs.
Radiographic appearance: Flat diaphragms and barrel chest due to easy intake of air but trouble exhaling
air. Widening of the intercostal spaces
Technical factors: Requires a reduction of exposure factors.

Epiglottitis: Inflammation of the epiglottis. Can interfere with breathing. Caused by a bacterial infection
(haemophilus influenzae type B). in western countries infants receive the HiB vaccine to prevent this
potentially deadly infection from occurring.
Radiographic appearance: enlarged epiglottis. No change in technical factors

Foreign body: Foreign body aspiration can be life threatening. A solid or semisolid object lodged in the
larynx or trachea. If the object is large enough to cause nearly complete obstruction of the airway,
asphyxia may rapidly cause death. Lesser degrees of obstruction or passage of the obstructive object
beyond the carina can result in less severe signs and symptoms.
Radiographic appearance: bright object in lung.

Hemothorax: Blood in pleural space usually resulting from a chest injury. Blood in the pleural space does
not clot fully, it is usually removed through a needle or chest tube.
Radiographic appearance: Entire lung white.
Hyaline membrane disease: Respiratory distress syndrome is a breathing disorder in which the alveoli in
an infant's lungs do not stay open because of high surface tension resulting from insufficient production of
surfactant. RDS occurs almost exclusively in premature infants. Surfactant is produced as the fetus’s
lungs mature, as early as 34 weeks gestation and almost always 37 weeks gestation.
Radiographic appearance: grainy appearance to lungs. Black branching lines.

Lung abscess: Pus-filled cavity in the lung surrounded by inflamed tissue and caused by an infection. The
usual reason an abscess forms is that bacteria from the mouth or throat are inhaled into the lungs, causing
an infection. Other causes include tumor blocking an airway and bacterial pneumonia.
Radiographic appearance: large circular dark and light appearance around the alveoli

Pleural effusion: abnormal collection of fluid in the pleural space. Normally only a thin layer of fluid
separates the two layers of the pleura. An excessive amount of fluid may accumulate for many reasons,
including heart failure, liver cirrhosis and pneumonia. Other types of fluid that may collect include blood,
pus and high cholesterol fluid.
Radiographic appearance: For right sided Pleural Effusion, patient lying on right side (Right lateral
decubitus) shows white and increased distance from rib to lung.
Left effusion: patient in left lateral decubitus for AP chest.

Pneumoconiosis: occupational disease from inhalation of harmful particles, mists, vapors or gases. The
substances are permanently deposited in the lungs and result in pulmonary fibrosis. The main substances
that result in pulmonary fibrosis are silicon, coal dust, and asbestos.
Radiographic appearance: Bright white bronchi and alveoli lung (tree of life lung)

Pneumonia: infection of the lungs that involves the alveoli and the tissues around them. Pneumonia isn't a
single illness but many different ones, each caused by different microorganisms. The microorganism that
causes pneumonia is usually inhaled into the lungs. In adults, the most common bacteria is strep or
viruses such as chickenpox or influenza. Some fungi can also cause pneumonia.
Radiographic appearance: Section of lobe where the alveoli and bronchi are indistinct and bright white.
Bilateral pneumonia> increases technical factors. Large pneumonia is decrease

Pneumothorax: air in chest cavity, caused by chest trauma such as stab or rib fracture, can occur
spontaneously with hyposthenic males. Do not use AEC when taking chest x-ray for this chest x-ray

Pulmonary edema: Fluid accumulation in the lungs most often caused when the heart isn't pumping
adequately. The fluid that collects in the alveoli makes it difficult to breathe and it leads to impaired gas
exchange and may result in respiratory failure.
Radiographic appearance: Whitening of the lung.

Pulmonary embolism (PE): sudden block of an artery of the lung by an embolus. PE is most commonly
the result of DVT that breaks off and migrates to the lung. Common signs and symptoms include sudden
and unexplained shortness of breath, chest pain and a cough that brings up blood tinged sputum. PE can
be life threatening but immediate treatment with anti-clotting (tPA) medication can greatly reduce risk of
death.
Radiographic appearance: Seen on CT. No change in technical factors.

Pulmonary infarct: Death of lung tissue commonly caused from PE in combination with chronic left heart
failure. Occurs in a minority of PE patients 10-15%.
SARS: Severe acute respiratory syndrome is a severe pneumonia like respiratory disease. SARS is known
as atypical pneumonia because it is not caused by the typical bacteria or virus. (COVID). SARS causes
high fever, severe breathing problems, and flu-like symptoms.
Radiographic appearance: Opacity in both lungs, indicative of pneumonia, in a patient with sars.

Sinusitis: INflammation of the sinuses caused by an allergy or vital, bacterial or fungal infection.
Radiographic appearance: Whitening of a sinus

Subcutaneous emphysema: presence of free air or gas in the subcutaneous tissue. Caused by surgery and
trauma.
Radiographic and physical appearance: Rice krispy skin and skin with air fluid levels on image.

TB: Contagious potentially fatal infection caused by the airborne bacterium mycobacterium tuberculosis.
In active pulmonary TB, infiltrates or consolidations and/or cavities are often seen in the upper lungs with
or without mediastinal or hilar lymphadenopathy. However, lesions may appear anywhere in the lungs.
Airborne precautions.

Gastrointestinal Pathology:
Achalasia: The absence of esophageal peristalsis and impaired relaxation of the lower esophageal
sphincter in response to swallowing. Diagnosed through barium swallow
Symptoms:Dysphagia, regurgitation, chest pain.
Radiographic appearance: Evident in esophagogastric sphincter and the esophagus may become dilated
(megaesophagus)
Anemia: Condition in which you lack healthy red blood cells to carry adequate oxygen to your body's
tissues. Common types: Iron deficiency anemia (Not enough iron, due to blood loss or poor absorption
caused by ulcers, hemorrhoids or cancer. Vitamin deficiency anemia, low levels of B12 from poor diet.
Aplastic anemia, a rare bone marrow failure disorder that stops making enough blood cells. Hemolytic
anemia, caused by hemolysis, the abnormal breakdown of red blood cells, either in vessels or elsewhere
in the human body.
Ascites: abnormal accumulation of fluid. In the peritoneal cavity. Caused by cirrhosis of liver, cancer of
the abdomen, or CHF. requires an increase of technical factors
Bowel Obstruction: A partial or complete blockage in the small or large intestine, either mechanical or
functional that prevents normal movement of the products of digestion. Acute abdomen requested.
Appearance: Bowel proximal to obstruction accumulates fluid and gas, causing the typical radiographic
appearance of dilated bowel loops. Caused by hernia, volvulus, Intussusception, adhesion, tumor,
paralytic ileus
Hernia: Bowel protrudes through aperture in the abdominal wall. If allowed to persist, it becomes
congested and swollen. Bowel at this point can become trapped and strangulated. Blood flow out of the
herniated bowel is obstructed so it may die.
Volvulus: Bowel becomes twisted around itself, causing complete obstruction. Medical emergency due to
ischemia. Loop in the intestine twisted around itself and the mesentery that supports it resulting in a
bowel obstruction. Mesentery may become so tightly twisted that blood flow to part of the intestine is cut
off, resulting in ischemic bowel. Complications include: Bowel strangulation, gangrene, perforation, fecal
peritonitis, recurrent volvulus. Volvulus is a medical emergency that requires surgery.
Intussusception- Section of bowel folds into the section of bowel immediately distal to it. Caused by an
increased bulkiness of the bowel because of swelling or polyp, is then pulled into the distal bowel by
peristalsis. Consequences similar to hernia if not reduced. Typical age range is 3months to 6 years. One
segment of the intestine “telescopes” inside of another causing an intestinal obstruction. Can occur
anywhere but usually in the junction of small and large intestines. Can be treated with either barium or
water soluble contrast enema or an air contrast enema, which is diagnostic and interventional.
Adhesions- Can occur in the peritoneal cavity following surgery or peritonitis. Fibrosis following healing
of inflamed or damaged
Tumor- may become so large that it obstructs the passage of fecal material, or it may form a narrow
stricture.
Paralytic ileus- the muscular wall of the bowel fails to contract and becomes distended. Absence of
motility rather than a mechanical obstruction.
Carcinoma of stomach- Stomach cancer or gastric cancer develops from the lining of the stomach. Most
(90-95%) of gastric cancers are adenocarcinomas which develop from mucus producing cells that line the
stomach. Endoscopy is regarded as the most sensitive and specific diagnostic method.
Cholecystitis: Inflammation of the gallbladder that occurs most commonly because of an obstruction of
the cystic duct by gallstones arising from the gallbladder (cholelithiasis). Laparoscopic removal of the
gallbladder or cholecystectomy is common for this condition.
Cholelithiasis: gallstones are hardened deposits of digestive fluid (bile) that form in your gallbladder.
Most people have gallstones (80%) and never have a symptom. Biliary colic (gallbladder attack) can
result if a gallstone blocks the cystic or common bile duct. ERCP is used for examination and intervention
of biliary tree and pancreatic ducts.
Cirrhosis: Normal liver tissue is replaced by scar tissue. Typically the disease develops slowly over
months or years and is commonly caused by alcoholism, Hep B, Hep C and non alcoholic fatty liver
disease.
Colorectal cancer: Malignant tumors arising from the inner wall of the large intestine. The majority of
these cancers are thought to arise from polyps that over time transform from benign growths to
malignancies. Removal of polyps can prevent colorectal cancer and therefore regular screening is
important, starting at age 50, or earlier if there are added risk factors. Cases with liver and lymph node
involvement have a poor long-term prognosis. the typical apple core sign in the distal portion of the
descending colon.
Crohn’s disease: A chronic inflammatory disease that may occur anywhere in the alimentary tract but is
most common in the terminal portion of the ileum. Deep linear ulcers form, which may extend through
the full thickness of the wall and this may result in the formation of fistulae between adjacent bowel loops
or between the bowel and the skin surface. Crohns may affect several separate portions; the term skip
lesions is used. The bowel develops a thickened and fibrosed wall whilst the lumen becomes stenosed,
which may lead to bowel obstruction.
Diabetes: Body can't produce insulin or can't properly use the insulin it produces. Type I (insulin
dependent): The pancreas does not produce any due to loss of beta cells. Type II: The pancreas usually
produces some insulin but the cells in the body fail to respond to insulin. Gestational diabetes occurs
when a pregnant woman develops high blood sugar levels with no previous history of diabetes.
Diverticulitis: Blind-ended pouches of bowel mucosa on the outside of the bowel wall. Filled with feces
as well as stagnant and inflamed. The presence of diverticula is called diverticulosis and when one or
more are inflamed the condition is diverticulitis. Diverticulitis presents with abdominal pain, fever with
potential complications of abscess formation and perforation. CT is the imaging procedure of choice to
evaluate diverticular disease, as it can show many aspects of disease that are not recognizable by other
studies. Contrast enema can demonstrate diverticulosis and diverticulitis.
Dysphagia: Difficulty swallowing, sensation of difficulty in the passage of foods or liquids to the
stomach. Lack of pharyngeal sensation or various other inadequacies of the swallowing mechanism.
There are many causes of dysphagia; some common causes are nervous system issues (stroke, head
injury, MS or dementia), cancer, or gastro esophageal reflux disease. Complications include aspiration,
pneumonia, dehydration and weight loss.
Esophageal atresia: Congenital defect where the esophagus ends in a pouch rather than connecting to the
stomach. Complications include aspiration pneumonia, if feeding is attempted, and if a tracheoesophageal
fistula is present, stomach acid may flow into the lungs. Conditions must be treated as soon as possible
after birth.
Esophageal varices: Abnormally dilated veins of the esophagus. Main cause of varices is portal
hypertension from any serious liver disease, most commonly cirrhosis. Bleeding esophageal varices are
life threatening and immediate treatment is essential.
Foreign body: Plain radiography is often the initial imaging modality to detect foreign bodies. Dense
objects such as metal are radiopaque and are easily detected. Radiolucent objects such as wood and
plastic are easily missed with conventional imaging.
GERD: Acidic stomach juices or food and fluids back up from the stomach into the esophagus. Main
symptom is heartburn.
Hemangioma: Benign vascular tumors and many different types occur. Can occur in the skin, muscle,
bone and internal organs.
Hepatitis: Inflammatory liver condition. Most commonly caused by viral hepatitis A, B, C, D and E.
Other causes include heavy alcohol use, certain medications, toxins and other infections.
Hiatal Hernia: Stomach bulges up into your chest through the hiatus. Sliding (shifted esophagus) and
Paraesophageal (beside esophagus).
Inguinal hernia: When tissue such as part of the intestine, protrudes through a weak spot in the abdominal
muscle. Occurs when part of the intestine bulges through a weak spot in the abdominal wall at the
inguinal canal.
Hypertrophic Pyloric Stenosis: When thickening of the muscular layer of the pylorus prevents the normal
passage of liquids and food into the duodenum; the pylorus is extremely narrowed or stenosed. Projectile
vomiting is a primary symptom. This affects infants between birth and six months and requires surgical
intervention. Ultrasound is the modality of choice in the right clinical setting because of its advantages
over the barium meal are that it directly visualizes the pyloric muscle and does not use ionizing radiation.
Hypoglycemia: Low blood sugar, potentially dangerous for people with diabetes.
Symptoms: Blurred vision, rapid heartbeat, sudden mood changes, sudden nervousness, fatigue, pale skin,
headache, hunger, shaking, dizziness, sweating, trouble thinking clearly or concentrating. LOC, seizure or
coma. Mild to moderate treated with carbs. If unconscious, glucagon is administered through IV.
Ileus (paralytic ileus): An arrest, usually temporary, of intestinal peristalsis; it can cause signs and
symptoms of intestinal obstruction, but does not involve a physical blockage. Most common cause is
abdominal surgery specifically when intestines are manipulated. Other causes include infections, opioid
pain meds, parkinsons, diabetes, hirschsprung disease and hyperthyroidism. Demonstrates
radiographically as distended, air filled loops of the small bowel.
Liver cancer: Cancer that starts in the liver. Liver metastasis is more common. Leading cause is cirrhosis
due to hep B or Hep C or alcohol. Most common types are hepatocellular carcinoma and
cholangiocarcinoma.
Pancreatic cancer: Beings in the tissue of the pancreas, most commonly in the cells that line the ducts that
carry digestive enzymes out of the pancreas, pancreatic duct adenocarcinoma. ERCP to place a stent in a
blocked duct, can be completed to help with jaundice. Ultrasound, CT, MRI, and PET used to help
diagnose. Tissue biopsy and blood test also used.
Pancreatitis: Inflammation of the pancreas. Acute or chronic. Mild cases go away without treatment, but
severe can cause life threatening complications. Causes: Abdominal surgery, alcoholism, certain
medications, Cystic fibrosis, gallstones, hypercalcemia, infection, injury to the abdomen, obesity,
pancreatic cancer.
Peptic/Duodenal ulcers: Cause open sores on the gastric or duodenal mucosal lining. Usually formed as a
result of inflammation caused by [Link] as well as from erosion from stomach acids. Causes: Frequent
use of aspirin, ibuprofen, and other anti-inflammatory drugs, smoking, excessive use of alcohol, radiation
therapy and stomach cancer.
Situs inversus: Major visceral organs are reversed or mirrored from their normal positions.
Tracheoesophageal fistula: abnormal connection between the trachea and esophagus, often leading to
severe and fatal pulmonary complications. Congenital abnormality that can accompany esophageal
atresia.
Ulcerative colitis: Inflammation resulting in ulceration of the mucosal lining of the rectum and colon. The
ulceration may extend deep into the intestinal wall to put it at risk for perforation. Symptoms: Abdominal
pain, diarrhea and rectal bleeding. Water absorption impaired resulting in diarrhea

Urinary Pathology:
Adenocarcinoma- Renal cell carcinoma: Primary malignant adenocarcinomas that originate from the renal
tubular epithelium. It is the most common kind of kidney cancer. Common sites for metastases include
lung, liver, lymph nodes and bones.
Bladder carcinoma: Bladder cancer is a broad term used to describe all types of cancers affecting the
urinary bladder. They include: Transitional cell carcinoma (most common primary bladder neoplasm,),
Squamous cell carcinoma accounts for around 3-8% of all bladder cancers, and Adenocarcinoma (1% of
bladder cancer). Small cell carcinoma (extremely rare)
Renal Calculi: Kidney stones are hard deposits made of minerals and salts that form inside your kidneys.
Non contrast helical computed tomography of the abdomen provides greater sensitivity than KUB for
ureteral stones. CT can be quickly performed and is safer than intravenous pyelograms as there is no risk
of allergic or toxic reactions to contrast media. The increased number of incidental findings or other
reasons for acute pain, such as appendicitis or ovarian cysts, also make CTs more useful for renal calculi
investigation.
Cystitis: Inflammation of the urinary bladder from any cause. Symptoms: pain with urination, frequent
urination, feeling the need to urinate despite having an empty bladder. Most common cause of infection is
Escherichia coli, though other bacteria or fungi may sometimes be the cause.
Cysts: Kidney cysts are round pouches of fluid that form on or in the kidneys. They can be associated
with serious disorders that may impair kidney function. Kidney cysts are a type called simple renal cysts,
which are benign, asymptomatic lesions that rarely require treatment.
Polycystic kidney disease: A genetic disorder in which renal tubules become structurally abnormal
resulting in the development and growth of multiple cysts within the kidney. These cysts may begin to
develop in any stage of life.
Duplicated ureter: One of the most common congenital renal tract abnormalities, duplication can be
variable; at one end of the spectrum, there is merely a duplication of the renal pelvis, draining via a single
ureter. Two seperate collecting systems drain independently into the bladder or ectopically.
Ectopic kidney: A birth defect in which a kidney is located in an abnormal position. In most cases, people
with an ectopic kidney have no complaints. In other cases, the ectopic kidney may create urinary
problems, such as urine blockage, infection, or urinary stones.
Hydronephrosis: Condition that occurs when a kidney swells due to urine failing to properly drain from
the kidney to the bladder. This swelling most commonly affects only one kidney, but it can involve both
kidneys. Hydronephrosis isn't a primary disease, it is a secondary condition that results from some other
underlying disease. It is structural and is the result of an obstruction in the urinary tract.
Hydroureter: Abnormal dilation of the ureter and may occur in combination with hydronephrosis.
Renal Metastasis: Nonrenal cancers may metastasize to the kidneys. The most common cancer that
metastasizes to the kidneys are melanomas and solid tumors, particularly lung, breast, stomach,
gynecologic intestinal and pancreatic.
Benign prostatic hyperplasia: Prostate enlargement is a noncancerous increase in size of the prostate
gland. Symptoms: Frequent urination, trouble starting to urinate, weak stream, inability to urinate, or loss
of bladder control. Ultrasound is the first modality to assess.
Renal colic: Sudden onset flank pain radiating laterally to the abdomen and or to the groin. CT utilized
when diagnosis of kidney stones suspected. Self-limited conditions in the majority of patients, however,
CT can effectively guide therapy in the subset of patients requiring urologic intervention and can detect
conditions with signs and symptoms that can mimic renal colic but require intervention.
Renal Failure: Kidneys are functioning at less than 15% of normal function. Classified as either acute
kidney failure, which develops rapidly and may resolve;and a chronic kidney failure which develops
slowly.
Renal Vascular Hypertension: Type of secondary hypertension that develops because of renal artery
disease. There are a number of conditions that cause renovascular hypertension, but the most common
cause is atherosclerotic renal artery stenosis. A hormonal release by the kidneys occurs resulting in the
retention of sodium and water causing high blood pressure.
Vesicoureteral reflux: A condition where urine flows backwards from the bladder to one or both ureters
and sometimes to the kidney.

Chest: (*81)
PA Chest: Chin raised, hands on hips with palms out, roll shoulders forward. Center CR to the center of
the lung fields. Equal margins bilaterally. Ensure no rotation of the thorax. CR to T7 or 7 to 8 inches
below the vertebral prominens. Expose at the end of the second deep inspiration. 10 posterior ribs above
the diaphragm (if not larger inspiration needed), chin elevated, no rotation. If the left clavicle is closer to
the center of the spine than the right clavicle, turn the patient’s right side closer to the IR.
Expiration: An underexposed image if exposure is not increased when a manual technique is used, a
broader and shorter heart shadow, fewer than 10 posterior ribs above the diaphragm. Done for
pneumothorax
Lateral Chest: Left side against IR, arms raised above head and chin up. CR to level of T7, lowered an
inch from PA on average patients. Expose a second full inspiration. Apices to costophrenic angles, from
sternum to posterior ribs. Humeri are positioned vertically. Shoulders and posterior ribs and pelvis are
aligned perpendicular to IR.
Decub chest: patient in AP position. Lock stretcher, head and chin up, CR to T7, 3-4 inches 7.5cm in
below jugular notch. 180cm SID. end on second full inspiration. Fluid levels (pleural effusion) fluid side
down, pneumothorax (air in lungs) air side up. INclude both lung walls and apices and costophrenic
angles.
AP lordotic: hands on hips and palms out. Shoulders on board and stomach away from board or 15-20
degree cephalad angle. Second, full inspiration. Demonstrates the Apices of the lungs (good for TB
patients). Throws clavicles off of the chest cavity. Clavicles horizontal.
Soft tissue neck: CR to C6-7 between the laryngeal prominence of the thyroid cartilage and jugular notch,
arms down and chin raised. Exposure during slow, deep inspiration. Acquired during inspiration with
puffed out cheeks to ensure that the respiratory tract is filled with air and to better identify a foreign body
Ensure first ribs aren't clipped

Questions:
• On a PA chest with the patient's left SC joint over the vertebral column, the patient was turned
towards their left side.
• Expiration PA chest done to reduce lung volume.
• When the AEC center cell for PA chest is used, it will be overexposed with image contrast that is
too short.
• Patient in right lateral decubitus for left pneumothorax
• To decrease dose on chest image, increase SID, higher kVp, filtration

Upper Extremity:
Phalanges, Hand, Wrist, Forearm, Elbow, Humerus, Shoulder, Clavicle, AC joints
Fingers and thumb (*162 &170)
PA finger: Center to PIP joint. Distal phalanx to distal metacarpal.
PA oblique finger: 45 degree external or internally, centered to PIP. Distal phalanx to distal metacarpal.
Interphalangeal and MCP joints open.
Lateral finger: Center to PIP joint, external or internal lateral depending on finger. Include distal aspects
of metacarpal. Joints are open and visualization of concave anterior shafts
AP thumb: Hand internally rotated with palm out. Posterior surface of thumb on IR. CR perp to first MCP.
Include Proximal Metacarpal, trapezium and distal phalanx
PA oblique thumb: Abduct thumb slightly Center to MCP. Include entire metacarpal
Lateral thumb: Include the entire first metacarpal. Anterior surface of thumb concave

Hand (*179)
AP hand: CR perp to MCP joint of the 3rd digit, hand pronated and digits slightly separated. 1 inch of
distal forearm. IP and MCP joints [Link] appearance of shafts and metacarpals.
PA oblique hand: 45 degree rotation. Digits slightly separated and parallel to IR. Center to 2nd or 3rd
MCP joint. Digits parallel to IR, joints open. NO overlap of 3rd and 5th metacarpal
Fan and extension lateral hand: CR perp to 2nd metacarpal. Fingers fanned and digits not superimposed.
Digits in lateral position, distal radius, ulna and metacarpals superimposed.

When a patient is unable to extend their fingers for a PA projection, alternative positioning may include;
placing the IR parallel to the area of interest, directing the CR perpendicular to the area of interest,
supinating the hand.
Wrist (*190)
PA wrist: Hand in fist to lower OID, center to metacarpals, ensure forearm is in the same plane as wrist,
symmetry of proximal carpals and separation of radius and ulna.
PA oblique wrist: 45 degree oblique, center to midcarpals, no overlap of 3rd and 5th metacarpal bodies.
Lateral Wrist: ensure forearm on same plane as wrist, hand in true lateral, ulnar head superimposed with
distal radius. If ulna is positioned anterior to the radius, internally rotate the forearm.
Scaphoid: ulnar deviation with a 10-15 degree cephalad angle on the tube head. Center to scaphoid.
Scaphoid without foreshortening or overlap. Soft tissue and bony trabeculation required in the image

Forearm (*217)
AP forearm: ensure elbow and wrist joints included, have patients lean laterally for true AP. CR to mid
forearm, slight superimposition of radius and ulna at both ends. Ensure epicondyles are parallel
Lateral forearm: elbow flexed 90 degrees and thumb pointed up, hand and wrist in true lateral position, cr
to mid forearm, head of radius and ulna superimposed

Elbow (*224)
AP elbow: lean patient laterally, ensure epicondyles are parallel, center to midelbow joint, slight
superimposition of radius and ulna, epicondyles in profile.
AP oblique elbow: Medial best visualizes the coronoid process in profile, External: best visualizes radial
head and neck without superimposition of the ulna as well as the lateral epicondyle and capitulum in
profile. Rotate 45 degrees. Cr to midelbow. If the coronoid is not in profile and radial head is only partly
superimposed over ulna, increase medial rotation.
Lateral Elbow: elbow flexed, shoulder dropped to make it on the same plane as the humerus. Hand and
wrist in true lateral. Cr centered to mid elbow. Olecranon process and trochlear notch in profile. Radial
head, neck and tuberosity free of superimposition. Humeral epicondyles superimposed. Elbow flexed 90
degrees. Fat pads best demonstrated.
Coyle method to best show the radial head when pt is unable to extend elbow beyond 90 degrees or rotate
wrist. (pg 61)
CR recommended to demonstrate the coronoid process of the elbow when using the Coyle method is 45
degrees away from the shoulder

Humerus (*245)
AP humerus: include both elbow and shoulder joint abduct arm slightly, epicondyles parallel to IR, center
to mid humerus. No rotation, medial and lateral epicondyles seen in profile. Greater tubercle in profile. If
the relationship between the radius and ulna is open, no longer AP, too externally rotated.
Lateral humerus: epicondyles perp to IR, elbow flexed 90 degrees and patient turned 15-20 degrees away
from PA. CR to mid humerus. Epicondyles superimposed.
Transthoracic lateral: affected limb closest to IR, orthostatic breathing technique, minimum 3 second
exposure time. If unable to depress shoulder, angle 10-15 cephalad or caudal.

Shoulder (*254)
AP shoulder: Internal- epicondyles perp to IR for visualization of lesser tubercle, External- Epicondyles
are parallel with IR for greater tubercle visualization. Neutral (trauma)- neither greater tubercle or lesser
is demonstrated cr ¾ inferior to coracoid process. Arm slightly abducted. Center of IR to the
scapulohumeral joint and 1 inch inferior to the coracoid process. Proximal humerus and ⅔ clavicle.
Suspend during exposure. Must include medial border of the scapula.
Inferosuperior Axial: Arm abducted 90 degrees away from body if possible rule out hills- sachs defect.
CR directed 25-30 degrees medially towards the axilla. Suspend during exposure. Shows the relationship
between scapula and humerus. Scapular spine in profile. If unable to see posterior aspects of acromion
and humerus, elevate shoulder on sponge (Pg 75) (Acromion superior to coracoid and attached to clavicle.
Coracoid is inferior.) Inferior angle of the scapula must be included.
PA transaxillary shoulder: affected arm raised and head turned away. Centered to the glenohumeral joint.
Suspend respiration on exposure. Coracoid seen.
AP oblique- Glenoid cavity: patient 35-45 degrees away from IR, hand and arm in neutral position.
Suspend during exposure. OPen scapulohumeral joint space. Anterior and posterior rims of glenoid are
superimposed. If the posterior portion is seen over the humeral head, increase patient rotation.
PA oblique (scapular Y): patient turned 45-60 degrees. Center scapulohumeral joint. Suspend during
exposure. Perp Beam to the midpoint of the medial border of the scapula. true lateral view of humerus.
Body of scapula without superimposition.
Neer method: 10-15 caudad angle to better show the acromiohumeral joint space. Supraspinatus outlet
region is the open, thin body of the scapula seen on end; humeral head below supraspinatus outlet.
Transthoracic Lateral: Arm against IR at side in neutral position. Raise unaffected shoulder, or angle 10-
15 cephalad to prevent superimposition. Visualizes the shaft of the proximal humerus, humeral head and
glenoid cavity visualized.

Questions:
• If lateral margin of the scapula is over the ribs, patient is over rotated
• If medial margin of the scapula is over the ribs, patient is under rotated.
• AP shoulder demonstrating most of the articulating surface of the glenoid will also have the medial
end (sternal end) of the clavicle over the spine)
• Large deformity to the anterior shoulder, physician suspects anterior dislocation. Views would be
AP in neutral rotation and PA oblique scap Y

Clavicle (pg 94) (*285)

AP: CR to mid clavicle entire clavicle and both AC and SC joints. Suspend respiration at the end of
exhalation. The coronal plane of the thorax must be parallel with the image receptor
AP axial: 15-30 cephalad: Exposure on inspiration. Entire clavicle including both AC and SC joints. Done
to move the clavicle above the scapula and ribs as it superimposes the 2nd and 3rd rib and the sternal end.
Medial portion superimposed by first and second rib. When the sternal end of the clavicle is away from
the vertebral column it will transversely foreshorten the clavicle. For Asthenic patient, 15-2 degree
cephalad angle.

AC joints (*288)
AP bilateral Arms at side, one exposure without weights, one with 8-10lb weights (5-8 for smaller patient,
unless fracture present) CR to midpoint between AC joints above jugular notch. Suspend on exposure.
180 degree SID, when suspected separation, with weights.

Lower Extremity
Toes, Foot, Calcaneus, Ankle, Tib-Fib, Knee, Femur, Hip, Pelvis

Toes (300)
AP: CR angled 10-15 knee flexed with plantar surface of foot resting on IR. Centered to MTP joint of
interest. Entire joint and half of affected metatarsal. No overlap of surrounding digits and metatarsals; no
rotation, equal concavity on both sides of the shaft.
AP oblique: oblique foot 30-45 medially for first to 3rd toe and laterally for 4th and 5th toe. Support
placed under toes. Entire joint and half of affected metatarsal. Increased concavity on one side of the
phalangeal shaft.
Lateral: Mediolateral or lateromedial depending on toe of interest. CR perp to IP for first digit and PIP for
2nd to 5th. No superimposition of adjoining digits. Proximal phalanx visualized through superimposed
structures.
Foot (*311)
AP: Plantar surface flat on IR, CR to metatarsals 10 degree cephalad (posterior) angle. No rotation with
tarsals superimposed. TMT joints open, uniform exposure along the entire foot, and open medial to
intermediate cuneiforms.
AP medial oblique: 30-40 degree medial rotation. A higher arch requires closer to 45 degrees (can cause
closed lateral cuneiform-cuboid, navicular-cuboid and third through fifth intermetatarsal joint spaces. The
fourth metatarsal tubercle is demonstrated without fifth metatarsal superimposition.), a 30 degree will
demonstrate the space between the first and second metatarsals and 1st and 2nd cuneiforms as well as the
cuboid and tarsal sinus. CR to the base of the third metatarsal. 3rd to 5th metatarsals free of
superimposition. Cuboid clearly demonstrated; base of 5th metatarsal seen in profile.
Lateral foot: Centered to the area of the base of the 3rd metatarsal. Can do lateromedial but typically done
mediolateral. 1inch distal tib fib included. Tibiotalar joint open, distal metatarsals superimposed.

Calcaneus (*333)
Plantodorsal (axial): dorsiflex foot as near vertical as possible. Center CR to part with 40 degree cephalad
angle. Increase angle if foot is not dorsiflexed enough. Entire calcaneus from tuberosity to talocalcaneal
joint. NO rotation. If a patient can only dorsiflex 80 degrees, make CR 50 degrees
Lateral: on the affected side. Dorsiflex foot so plantar surface is near 90 degrees to leg. Center 1 inch
inferior to medial malleolus. Calcaneus in profile with talus to distal tib fib. Partially superimposed talus
and open talocalcaneal joint.

Ankle (*341)
AP: Leg extended with foot dorsiflexed, no rotation. CR midway between malleoli. ⅓ tib fib
AP mortise: leg extended with internal rotation of 15-20 degrees so intermalleolar line is parallel to
tabletop. CR to midway between malleoli. Open mortise.
AP oblique 45 medial rotation: Leg extended 45 degree medial rotation. CR midway between malleoli. #
the 5th metatarsal may be visualized on this projection. Malleolus is open with no or minimal overlap. If
the talus superimposes the distal tibia, insufficient rotation.
Lateral: Affected side down, dorsiflex foot, CR to medial malleolus. ⅓ distal tib fib. True lateral with no
rotation, distal fibula superimposed over posterior half of tibia. Tibiotalar joint open.
If the fib is in the front portion of the tibia, it is an external oblique, if it is in the posterior portion, it is a
lateral.

Tib/Fib (*356)
AP: Leg extended, no rotation of knee, lower leg or ankle. Include 1-1.5 inches above and below knee and
ankle. Min SID of 100, can increase to 112-123. Both joints included. No rotation, slight overlap with
both proximal and distal tib fib joints.
Lateral: Affected side down, unaffected limb behind to prevent over rotation. Support under foot to make
knee, foot and ankle in true lateral position. CR to the midshaft of the lower leg. Both joints included.
Tibial tuberosity in profile, distal fib overlaps posterior portion of fibula.

Knee (*363)
AP Supine: leg extended and slightly inward to place knee in true AP. Rotation of leg depends on femoral
epicondyles being parallel to the IR. ½ inch below the patella. CR parallel to articular facets. 3-5 degree
caudal angle for smaller physique. 0 for average physique. 3-5 cephalad for larger physique. Open
Femorotibial joint. Symmetric condyles. Medial half of the fibular head is superimposed by the tibia.
Intercondylar eminence seen. If the patient measured 20cm from ASIS, CR perpendicular entering 1.3cm
interior to patellar apex. Less than 19cm ASIS to TT 3-5 caudad, 19-24cm perp to IR, greater than 24 3-4
cephalad.
AP or PA wtb: for PA patients knees flexed 20 degrees and 10 degree caudal angle. AP horizontal beam
CR at level of ½ inch distal to the apex of the patella. Femoral tibial joint open. Articular facets in profile.
AP oblique (medial and lateral rotation): 45 both directions. Medial- demonstrates fibular head and
neck unobscured. Lateral- medial condyles of the femur and tibia in profile. Patient semi supine, leg
extended. Foot, ankle and lower leg turned. CR to midjoint space (½ inch interior to patella). Medial-
open proximal tibiofibular joint, lateral femoral and tibial condyles in profile. Lateral- medial femoral and
tibial condyles in profile. Medial- prox tibiofibular joint open; tibial lateral condyles are demonstrated.
Head and neck of the fibula and half of the patella are seen without superimposition. Lateral- proximal
fibula is superimposed by proximal tibia. Medial condyles of femur and tibia are seen in profile. Half of
patella should be seen free of superimposition by the femur.
Lateral knee: flex knee 20-30 degrees unaffected leg placed behind to prevent over rotation. Use a 5-7
degree angle cephalad. 1inch distal to medial epicondyle. No rotation, femoral condyles superimposed.
Patellofemoral joint open. When the knee is rotated towards the table and medial condyle is anterior to the
lateral condyle, less fibular superimposition and abductor tubercle will be seen on the anterior condyle.
(The medial condyle is always larger than the lateral condyle in lateral images due to magnification.)
Abductor tubercle on medial epicondyle
Tunnel (intercondylar eminence): 40-50 caudal angle on tube CR to distal margin of patella. Intercondylar
fossa, femoral condyles, tibial plateaus, and intercondylar eminence. Distal femoral condyles and
intercondylar eminence centered. CR perp to tib/fib
Skyline tangential- axial: knee flexed 90- 15-20 degree angle. Knee flexed 50-60 45 degree cr angle. CR
to mid patellofemoral joint.

Patella: (pg 139) (*401) Knee should not be bent more than 10 degrees for lateral (5-10 degrees)

Central ray location for an AP knee projection is 1cm below the apex of the patella
PA axial projection (holmblad method) for intercondylar fossa demonstrates the posteroinferior surface of
the femoral condyles.

Femur (*412)
AP: Supine, lower limb internally rotated 5 degrees for AP for lower femur and 15 internal for upper
femur and hip. Include 2 inches below the knee. CR to mid femur. For suspected femur fracture of the
right leg, do not turn the leg, place the anode end of the tube towards the foot.
Lateral: unaffected leg behind to prevent over rotation. Include sufficient amounts of either knee or hip at
one end of the IR. flex affected knee 45 degrees. CR perp to femur. Lowest margin of the IR should be
5cm distal to the knee joint

Hip: (*436)
AP: internally rotate leg 15-20 center to femoral neck. CR directed perpendicular to a point 2 inches
medial to the ASIS at the level of the superior margin of the greater trochanter. Suspend during exposure.
Proximal ⅓ of femur and adjacent parts of pelvic girdle. Greater trochanter in profile. Lesser trochanter
not visible. Femoral neck is demonstrated without foreshortening.
Unilateral frog: for femoral neck, flex affected knee and hip, and abduct femur 45 degrees. For the
femoral head, acetabulum and proximal femoral shaft, oblique the patient 35-45 degrees towards the
affected side and abduct the leg to table top. CR to mid femoral neck. Suspend during exposure. Prox ⅓
of the femur and adjacent parts of pelvic girdle. Greater trochanter in profile, lesser not seen or minimally.

Questions:
• The midcoronal body plane is at a 45 degree angle for an AP oblique projection of the acetabulum
• If there is a suspected injury and the patient’s leg is in a lateral position, do not reposition the leg.
• Center cell for a hip when using AEC
• If a patient comes in for hip imaging and there is evident foreshortening. Perform an AP and a
axiolateral (Danelius-Miller)
• For a patient who had an anterior approach hip, flexion less than 90 degrees is usually well
tolerated.
• To demonstrate minimal foreshortening of the femoral neck, the greater and lesser trochanters need
to be on the same transverse level for a cross table lateral hip
Pelvis: (*427)
AP: both feet, knees and legs equally rotated 15-20 degrees. Ensure no pelvis rotation. CR perp midway
between ASIS and symphysis pubis. 2 inches or 5cm distal to ASIS. Suspend during exposure. No
rotation, seen with symmetry of the obturator foramen. Greater trochanter visualized, not lesser.
When rotation towards the right hip, the left obturator foramen appears larger than the right obturator
foramen. When the left is narrower than the right, turn the pelvis to the right.
Inlet & outlet pg 167 bontrager.

Spine: (C-spine, T-spine, L-spine, Sacrum and Coccyx)

Do not remove C-spine collar for any imaging

Intervertebral Zygapophyseal
Foramina Joints

Cervical POs demonstrate side furthest from Lateral

IR
AOs demonstrate side closest

Thoracic Lateral 70* anterior oblique

(LPO/RPO)
(Side closest to IR)

Lumbar Lateral 45° posterior oblique

(LAO/RAO)
(furthest from IR)
LPO side closest

C-spine: 176 bon

AP (Open mouth) C1-C2 atlas and axis: Supine or erect. Align lower margin of upper incisors to the base
of the skull perp to the table and or the IR or angle CR accordingly. Have the patient's mouth wide open
without moving your head. CR perp to midportion of open mouth. Suspend during exposure. Dens and
vertebral body of C2, lateral masses and transverse processes of C1 and C1-2 atlantoaxial joints. Upper
incisors and base of the skull superimposed. Entire dens demonstrated within foramen magnum. Base of
skull over dens, lower the upper incisors. Teeth over the dens, can angle 5 degrees cephalically.
AP (Fuchs) (PA (Judd)) for Dens: Do not attempt for trauma. MSP aligned to centerline. Elevate chin until
MML is near perp to IR (may require CR angle without sufficient chin tilt) . CR parallel to MML, inferior
to mastoid tips and angles of mandible. Close collimation of C1-C2 region. Suspend during exposure.
Dens within foramen magnum. Tip of mandible not superimposed over dens. Symmetric appearance of
mandible.
AP axial: Supine or erect, center midsagittal plane to CR. Raise chin slightly, as needed so the CR angle
superimposes the mentum of the mandible over the base of the skull or until the lower surface of incisors
and mastoid tips are aligned perp to IR. CR 15-20 cephalad to enter C4 (interior margin of thyroid
cartilage). Suspend during exposure. C3-T2 bodies and intervertebral joints. Joints open and spinous
processes equidistant to midline. Spinous processes aligned with the midline of cervical bodies. Position
of vertebrae will show if CR angle is proper.
Oblique: Anterior preferred for less thyroid dose. Entire torso and head turned 45 degrees to IR, C-spine
aligned to CR. Have the patient raise chin slightly looking straight ahead. CR15-20 cephalad to enter C4,
caudad angle for anterior oblique (RAO). Longer SID recommended (102-183cm). Suspend during
[Link] foramina open and pedicles. Intervertebral foramina uniformly open and pedicles
in profile. If the patient looks more AP than oblique, increase obliquity until 45. Intervertebral joint
spaces should be open
Lateral: Top of IR 1-2” above EAM, elevate chin slightly. Relax shoulders evenly. If C7 is not visualized,
swimmers. CR perp to C4 upper thyroid cartilage. 153cm-183. Longer for better visualization of C7.
expose on complete expiration. C1-7 minimum) intervertebral joint spaces and vertebral bodies
demonstrated. Near superimposition of zygapophyseal joints; no superimposition of mandible on C spine.
Ensure the midcoronal plane is aligned perp to IR and articular pillars and z joints are superimposed over
their opposite side. Tilt chin to not overlap over C1 and C2, but not too much as to superimpose the base
of the skull and C1 and C2
Swimmers: Elevate arm closest to IR and rotate this shoulder slightly anterior or posteriorly. Opposite
arm down, relax and depress shoulder, with slight opposite rotation to separate humeral heads from
vertebra. May also be taken in a lateral recumbent position with one arm and shoulder down and one arm
up. CR perp to T1 above level of jugular notch. Optimal 3-5 caudad angle to separate the two shoulders
for patients with limited flexibility. Expose on full expiration or orthostatic breathing. Vertebral bodies
and intervertebral disk spaces from C5-T3 demonstrated. Separation of humeral heads from C spine;
vertebral bodies in lateral perspective. Ensure there is no rotation (posterior ribs).
Lateral hyperflexion and hyperextension: Relax or depress shoulders as much as possible. Depress chin to
touch chest if possible for flexion. Elevate the chin as far as is comfortable for extension. CR perp to C4.
SID 153-183. Expose on full expiration. Range of motion and ligament stability demonstrated.
Hyperflexion: Spinous processes well separated. Hyperextension: Spinous processes in close proximity.

Questions:
• If unable to visualize C7 on a lateral cervical spine, take image on expiration, have patient hold
weights and take a swimmers image.

T-spine: 188 bon

AP: Supine, spine aligned and centered to midline of table and/or IR; flex hips and knees to reduce
lordotic curvature. Ensure the top of IR is at least 1 ½ (3cm) above shoulder. No rotation of thorax or
pelvis. CR perp to the center of IR (level of T7) 3-4 inches below the jugular notch. Expose on expiration
for more uniform density. 12 thoracic bodies, intervertebral joint spaces, and spinous and transverse
processes. SC joints equidistant from midline, no rotation. Disc spaces can be closed if the centering is
too low, center between the jugular notch and xiphoid.
Lateral: Recumbent, support under patients head, lateral with knees flexed, arms raised, and elbows
flexed. Align and center midaxillary plane to midline of table and/or IR. Ensure the top of IR is at least 1
½ above shoulders; no rotation. Support should align the spine near parallel to the table top. CR perp to
IR T7 3-4 inches below jugular notch or 7-8 inches below the vertebral prominens. A patient with broad
shoulders may require a 10-15 degree cephalic CR angle if the waist is not supported. Orthostatic
breathing technique recommended minimum 2-3 seconds, or on full inspiration. 12 thoracic bodies,
intervertebral joint spaces, and spinous and transverse processes. Intervertebral disk spaces open. Ensure
no rotation of the spine with the posterior ribs.
Oblique: Both sides imaged for comparison. Recumbent or erect, rotated posteriorly 20 degrees from true
lateral. Align and center spine to midline of table and/or IR; place arm away from IR behind back and arm
closest to IR up in front of head. Ensure the top of IR is at least 1 ½ above shoulders. Center to center of
IR to T7 3-4 inches below jugular notch or 2inches below sternal angle. Expose on expiration.

L-spine: 192
AP/PA: Supine, spine aligned to midline of table and/or grid. Flex hips and knees (to reduce lordotic
curvature). No rotation (ASIS same distance from table). Center IR to CR. CR perp to 1 ½ inches above
iliac crest. Or center at crest for 35x43 cm IR. Expose at the end of expiration. T12-S1 demonstrated.
Lumbar vertebral bodies intervertebral joints, spinous and transverse process, SI joints and sacrum. No
rotation evident by symmetry of transverse process, SI joints, and sacrum. Spinous processes are midline.
Look at spinous processes and pedicles to see rotation, shortest distance means rotated towards that side.
Lateral: Recumbent in true lateral position, flex hips and knees, align and center midaxillary plane to
centerline. Place support under the waist, as needed, place the entire spine parallel to the table top.
Provide support between knees. CR perp to level of 1 ½ above iliac crest or at iliac crest (for 35x43).
Expose at the end of expiration. May require a 3-5 caudal angle with wide pelvis and narrow thorax. L1-
L4 vertebral bodies, intervertebral joints, and foramina and spinous processes. Vertebral column parallel
to IR; intervertebral joint spaces and formaina open; no rotation. If posterior surfaces of the bodies are not
superimposed, posteriorly rotate the patients right side.
L5-S1 spot: Recumbent lateral position. Flex hips and knees, place support under the waist to place the
entire spine parallel to the table top. Center perp to IR if the entire spine is parallel to the tabletop, or 5-8
degrees caudad if the entire spine is not parallel (most often for females). Angle CR perp to the interiliac
plane. CR to 1.5” interior to iliac crest and 2” posterior to ASIS. Suspend during exposure. Open L5-S1
vertebral bodies, intervertebral joint spaces and intervertebral foramina. Intervertebral joint spaces and
intervertebral foramina open, no rotation. L5 distorted and no joint space if the body surface is not
parallel to the table, place a sponge under the patient.
Oblique Lumbar Spine: Rotate body 45 degrees for right and left posterior or anterior obliques. Align and
center spine to CR and midline of table and/or IR. CR perp to body of L3 at level of lower costal margin
and 2” medial to upside ASIS. Suspend during exposure. 50 degree oblique is best for L1-L2
zygapophyseal joints, and 30 degrees for L5-S1. LPO/RPO: L1-L4 downside zygapophyseal joints.
Scottie dog elements visible. LAO/RAO: L1-L4 upside zygapophyseal joints. Scottie dog elements
visible. Scottie dog head over front part of vertebrae- increase body rotation (Too flat). Scottie dog head
over back part of vertebral body- Decrease body rotation (Flatten the patient) or if SI joint looks open.a
Bending Left and Right: Spine centered to CR and midline of table and/or IR. Bend laterally as far as
possible (right then left) without tilting pelvis. No rotation of pelvis and upper torso. Lower margin of IR
1-2 inches below the iliac crest. Center perp to IR. Expose at the end of expiration.
Hyperflexion and hyperextension: Hyperflex or extend as far as possible. Maintain true lateral position.
Lower margin of IR 1-2 inches below the iliac crest. Expose at the end of expiration. Thoracic and lumbar
vertebra including 1-2 inches of the iliac crests. Lateral view of lumbar vertebrae. True lateral position;
Spinous processes open for hyperflexion, closed for hyperextension.

Questions:
• When a lumbar spine is underexposed and there is an increase of quantum mottle (too little x-rays)
and center cell AEC was used, the patient was not centered properly for the image.

Sacrum and Coccyx:

Ap axial sacrum: No rotation of pelvis, CR 15 degrees cephalad, at 2'' superior to pubic symphysis.
Suspend during exposure. No foreshortening. Sacrum free of superimposition and sacral foramina visible.
Ensure no rotation and proper angulation.
AP axial coccyx: CR 10 caudad, centered to 2” superior to symphysis pubis suspended during exposure.
No foreshortening. Coccyx free of superimposition and not rotated.
Lateral sacrum and coccyx: Back in true lateral position. Center sacrum to CR and midline of table and/or
IR. CR perp directed to 3-4 “ posterior to upside ASIS. Suspend during exposure. No rotation evident by
greater sciatic notches and femoral heads superimposed. Entire sacrum and coccyx included. Ensure L5-
S1 open, the patient's body not parallel to the table, and place a sponge.
Lateral coccyx: Back in true lateral position. Center coccyx to CR and midline of table and/or IR. CR
perp to 2 inches distal to level of ASIS and 3-4 inches posterior. Suspend during exposure.

SI Joints:
AP axial: Supine, no pelvis rotation. CR 30 degrees for male and 35 for females cephalad 2” below level
of ASIS. Suspend during exposure.
Posterior oblique: patient 25-30 degree posterior oblique with side of interest elevated. Align elevated SI
joint to CR and to midline of table and / or IR. CR perp to 1” medial to elevated ASIS. Suspend during
exposure. Angle 15-20 to best demonstrate the distal part of the joint. Open upside (farthest from IR).
LPO: Right SI joint open; no overlap of iliac wing and sacrum. RPO: Left SI joint open.

Sternum: 214 bon

RAO: Turned 15-20 with right side down. Center sternum to CR at midline of table or IR holder. CR perp
to midsternum (1” to left of midline and midway between jugular notch and xiphoid process. Entire
sternum is superimposed on the heart shadow. Correct patient rotation, sternum visualized alongside
vertebral column. 3-4 second exposure using breathing technique; lung markings appear blurred.
Lateral sternum: Arms behind back with shoulders back. Top of IR 1.5'' superior ro level of jugular notch.
CR perp to midsternum. Expose upon full inspiration. Entire sternum no rotation, sternum visualized with
no superimposition on the ribs. Shoulders and arms drawn back. No rotation, lateral rib margins equal
distance from vertebral column. Include the xiphoid process.

Ribs:
AP (PA) (Bilateral) above diaphragm: MSP to midline of table/ upright bucky and CR. Top of IR 1.5”
above shoulders. Roll shoulders forward, no rotation. Ensure that thorax is centered to IR. CR perp to
center of IR and 3-4 “ below jugular notch. Level of T7. Expose on inspiration. Ribs 1-10 visualized.
AP below diaphragm: MSP to midline of table. Inferior margin of IR at iliac crest. Ensure that both lateral
margins of thorax are included. CR perp centered to IR at a level midway between the xiphoid process
and the lower rib margin. Expose on expiration. Ribs 10-12 visualized. No rotation, lateral rib margins
equal distance from vertebral column.
RPO/ LAO: Oblique 45 degree, rotate spine away from area of interest., Involved region of thorax is
centered to the IR. CR perp to the center of IR to level of 7-8” below vertebral prominens. Above
diaphragm, expose inspiration. Elongates right axillary ribs. 45 should show axillary ribs in profile with
spine shifted away from the area of interest.
LPO: Top of IR 1.5” above shoulders. Rotate 45 degrees from AP, arm closest to IR up, resting on head;
opposite hand on waist with arm away from body. CR perp centered to IR to level midway between
xiphoid process and lower rib margin. Below diaphragm- expose upon expiration. Elongates left axillary
ribs. Ribs 1-9 seen above diaphragm, 10-12 seen below diaphragm. Axillary portion of ribs projected
without superimposition. 45 should show axillary ribs in profile with spine shifted away from area of
interest. For axillary ribs

Skull/ Sinuses/ Facial Bones:

Ap axial cranium: Bring OML or IOML prep to IR. 30 degrees caudal to OML or 37 degrees to IOML.
CR 2.5 inches or 6.5 cm above glabella. 100cm SID. Four margins of the skull don't include the mandible.
Suspend during exposure. PA is Haas method, forehead and nose, 25 degree CR exits 1 ½ superior to
nasion. Occipital bone, petrous pyramids, foramen magnum and dorsum sella
Lateral: Head in true lateral position, MSP parallel to IR, IPL perp to IR. Adjust chin to place IOML
parallel to upper and lower IR edges. Suspend during exposure. CR 2 inches superior to EAM. Entire
cranium and superimposed cranial halves. Entire sella turcica and dorsum sellae. Sella turcica in profile
and mandibular ramu superimposed
Caldwell- 0 or 15 degree caudad angle. Patients forehead and nose close to IR. no rotation or tilt, MSP
perp to IR. 0 degrees (PA) centered to exit glabella. 15 degree caudad to OML, centered to exit at nasion
100cm sid suspend during exposure. PA: frontal bone and crista galli demonstrated without distortion,
petrous ridges at level of superior orbital margin. PA axial 15 degrees: greater/ lesser wings of sphenoid,
frontal bone, and superior orbital fissures, petrous ridges projected in lower ½ of orbits. (If patient supine,
IOML perpendicular)
SMV: CR perp to IOML. IR parallel to IOML. 0.75 inches anterior to the level of EAM. Suspend
exposure. Demonstrates foramen ovale and spinosum, mandible, sphenoid and posterior ethmoid sinuses,
mastoid process, petrous ridges, hard palate, foramen magnum and occipital bone. Mandibular condyles
are anterior to the petrous portion of temporal bones. No tolt and no rotation.
Ap trauma caldwell: IOML perpendicular to the IR, Central ray approximately 8 degrees cephalad.
Townes: 30 degrees caudad at the OML passing midway between the EAM best demonstrated the
occipital bone. If OML is 10 degrees extended from perpendicular, increase CR to 40 degrees caudad

Facial bones:
Lateral: MSP parallel to IR, IPL perp to IR. Adjust chin to place IOML parallel to top and bottom edge of
IR. CR perp to IR to zygoma midway between EAM and outer canthus. Suspend during exposure.
Demonstrates superimposed facial bones, greater wings of sphenoid and sella turcica. Region from orbital
roofs to mentum demonstrated.
Parietoacanthial (waters): Extend head resting chin on IR. place MML perp to IR which places OML 37
degrees to IR. OML is 55 degrees to the plane of the IR, or line from junction of lips to EAM LML is
perp to IR, CR perp to IR, to exit at acanthion. Suspend during exposure. Demonstrates inferior orbital
rims, maxillae, and nasal septum. Petrous ridges just interior to the floor of maxillary sinuses. If teeth in
maxillary sinuses, head tilted too much.
Reverse waters: CR should be parallel to the MML and enter the acanthion
Caldwell: (Same as skull, smaller coning)

Bilateral SMV for zygomatic arches: IOML parallel to IR, ensure no rotation or tilt. CR angled as needed
to be perp to IOML, centered midway between zygomatic arches. Include zygomatic arches, suspend
exposure. Unobstructed view of bilateral arches, no rotation of arches.
Modified townes: 1 inch above nasion.
Waters: IML parallel to IR

PA and PA axial MANDIBLE: forehead and nose resting on tabletop, adjust head to place OML perp to
IR. No rotation or tilt, midsagittal plane perp to IR. CR perp to IR to exit at level of lips. Axial (optional)
20-25 cephalad centered to exit at the acanthion best demonstrates proximal ramus and condyles. Suspend
on exposure. Demonstrates mandibular rami and lateral portion of body. No rotation evident.
Lateral mandible: IPL perp to IR, suspend exposure, Include entire mandible, CR anterior and 1 inch
below TMJ. Superimposed ramus
Axiolateral and axiolateral oblique mandible: CR 25 cephalad, 10-15 head rotation for general survey. 0
degree head rotation for ramus, 30 degree rotation for body, 45 degree rotation for mentum. IPL perp to
IR. Centered to the downside mandible.

Axiolateral obliqueTMJS: Adjust chin to place IOML perpendicular to front edge of IR rotate skull 15
degrees towards IR. IPL remains perpendicular to IR. Portion of IR being exposed centered to IR. CR 15
degrees caudad, centered 1 ½ inches superior to upside EAM. Suspend exposure.

Sinuses:
Lateral: IOML perp to IR, turn head into true lateral. IPL erp to IR. CR horizontal to between EAM and
outer canthus. Suspend exposure.
Waters: No mandible needed. An equal distance from the lateral orbital margin to the lateral cranial cortex
on both sides. The bony nasal septum in alignment with the long axis of the exposure field and the
petrous ridges demonstrated inferior to the maxillary sinuses.
15 degree calwell: NO mandible needed

Nasal bone:
Lateral: Center nasal bones to half of IR and to CR. Adjust head so IOML parallel to top and bottom edge
of IR. Ensure true lateral, IPL perpendicular to IR, and midsagittal plane parallel to IR. .5 inches inferior
to nasion. Suspend during exposure.
Waters for deviated septum.

Abdominal Imaging:
AP supine: MSP aligned and centered to midline of table and or IR. Ensure no rotation of ASIS. Center to
iliac crests, ensuring that upper margin of symphysis pubis is included on lower margin. Perp CT.
Collimate to upper and lower abdominal soft tissue borders. Expose at the end of expiration. Outlines
liver, spleen, psoas muscle and kidneys to include symphysis pubis lower abdomen
AP erect abdomen: Patient should be on side for a minimum 5 minutes before exposure, a period of 10-20
minutes is preferred. MSP aligned and centered. IR 2inches above iliac crest to include diaphragm, Cr
horizontal. Expose at the end of expiration. Hemidiaphragms and significant portion of lower abdomen.
Left lateral decubitus: Patient should be on side for a minimum 5 minutes before exposure, a period of 10-
20 minutes is preferred. Patient on side, knees partially flexed, arms up near head. Adjust patient and
stretcher so that center of IR and table is approximately 2 inches above iliac crest (to include
hemidiaphragm. Adjust height of IR to ensure that upside abdomen included for possible free air. .
Exposure at the end of expiration. Air filled stomach and bowel and upside diaphragm
Dorsal decubitus: Patient supine. Side against table, arms above head. Center of IR and table at level of
iliac crest, 2 inches above to include hemidiaphragm. Exposure at the end of expiration.
AP neonate and infant supine: Supine, immobilize arms above head, immobilize legs with ACE bandage
or tape and sandbags. Expose on expiration or when the abdomen has least movement. If crying, time
exposure at full expiration
AP neonate and infant erect: Arms above head, side body clamps firmly in place. Lead at symphysis
pubis. CR 1 inch above umbilicus or an older child above height of iliac crest. Expose on expiration or
least motion. Demonstrates soft tissue and gas-filled structures; air fluid levels on erect.
Neonate and infant abdomen AP LLD- Right side up, arms above head. Expose on expiration.

Questions:
• If miss bladder on KUB, angle 10-15 caudad just bladder or collimate to just bladder, or open cones
more.
• Patient unable to stand for 3 views of the abdomen, do AP upright, LLD, AP supine.
• The duodenum and the jejunum is the junction of the small bowel that has the ligament of treitz.
• When imaging for a KUB looking at kidney stones, do images without using gonadal shielding
• Abdomen imaging always LLD
• Average kVp for an abdomen is Long low contrast so 80-85 kvp
• Patient with abdominal pain will be most comfortable in a fowler's position

Section I: Back to top

Digestive System:

Body habitus:

• Hypersthenic (largest):
o Broad and deep abdomen from anterior to posterior.
o Stomach high and lies transversely at T9- T12, with duodenal bulb at level of T11-T12.
o Colic flexure and transverse colon tend to be positioned high in the abdomen

• Sthenic
 ▪ The sthenic habitus is the most common
▪ The abdomen is less broad than the hypersthenic habitus, yet not as narrow as the
asthenic.
▪ The stomach also rests at a position between the hypersthenic and asthenic habitus
and typically extends from T10 to L2, with the duodenal bulb at the level of L1
to L2
▪ The small and large intestinal structures tend to be centered in the abdomen

• Hyposthenic:
o A combination of sthenic and asthenic

• Asthenic (smallest):
o Narrow
o Stomach positioned low in abdomen and runs vertically along the left side of the vertebral
column
o Extending from T11to L5, with duodenal bulb at level of L3 to L4
o Small and large intestinal structures tend to be positioned low in the abdomen.
o Produces the greatest visceral movement when a patient is moved from the prone position
to the upright position

RAO (PA oblique): Shows the esophagus on the left side of the spine. Fundus of stomach clear of
contrast, pylorus and duodenal bulb of stomach full of contrast.
Lateral projection: Shows esophagus anterior to the spine. Pylorus and descending duodenum containing
barium. Body and fundus full of air. Right lateral, entire stomach full of barium.
PA projection: Center of esophagus over the center of the spine. The pylorus and body are full of barium.
Fundus is full of air.
LPO anterior oblique: Fundus full of barium
AP supine: Barium in fundus and duodenal cap

Section J: Back to top

Respiratory system:
PA chest:
When a PA chest is taken with superior midcoronal plane tilted anteriorly, there is magnification of the
clavicles and the clavicles are thrown down
When a PA chest is taken with superior midcoronal plane tilted posteriorly
Flat ribs are the posterior on the PA chest, curved are anterior ribs.
10 posterior ribs should be visible with deep inspiration.
When the right sternal clavicular end is demonstrated farther from the vertebral column than left, The
right side of the chest was situated farther from the IR than the left.

Lateral Chest:
Rotation causes posterior rib separation.
If lung tissue anterior to sternum, the patient was rotated posteriorly, if no lung tissue anterior, patient
rotated anteriorly.
Eleventh thoracic vertebra should be superior to the hemidiaphragm, ensuring the patient takes deep
inspiration.
If patients hemidiaphragms are superimposed, shift hips away from the IR until MSP is parallel to IR.

AP chest:
Look at clavicles for rotation
Watch the clavicle's relationship to the ribs to ensure the CR angle is proper.

AP or PA (Right or left lateral decubitus):

Be aware of clavicle positioning to ensure the patient is not rotated.

AP axial projection:
Want to ensure clavicles are above the first rib.
Rest patients shoulders on board, do not get patients to arch their back. MCP and CR should form a 45
degree angle.
If clavicles over lung apices, increase CR angle.

AP chest neonate and infant:

Watch clavicles for body rotation. Right SC ends farther from the vertebral column, right posterior side of
the chest rotated towards the IR. Turn right side away from IR.
Anterior ribs above the corresponding posterior ribs, CR angle too cephalad, decrease angulation.

Lateral neonate and infant chest:

When the right lung is anterior, rotate the left side anteriorly. Also ensure chin and humeri are elevated.

Neonate and infant AP decubitus chest:

Ensure ribs and clavicles are in the proper place they would be for an AP image. Angle down or move
your chest and shoulders.

Chest x-ray recognition:

• Penetration- Should be able to see the T-spine through the heart
o Pitfall from under penetration (white image with reduced visibility and clearity)
• Inspiration- 8-10 posterior ribs visible. For hospitalized patients 9 is adequate.
o Posterior ribs run horizontally
o Anterior ribs are harder to visualize and at a 45 degree downward angle towards the feet.
o Poor inspiration will cloud lung markings and appear that the patient has an airspace
disease
• Rotation- if the spinous process of the vertebral body is equidistant from the medial ends of each
clavicle, there is no rotation. Spinous process between clavicles.
o If spinous processes are facing the right, the patient is rotated towards the left.
• Angulation- beam angled towards the head, apical lordotic view. Anterior structures are higher on
the film than posterior structures. Over 3rd rib

AP vs PA:
PA, heart is closer to the film and thus less magnified
AP film, the heart is farther from the film and is more magnified

Section K: Back to top

Venipuncture: & Urinary
Explanation:
• Procedural steps
• Expected duration
• Limitations and restrictions associated procedure performance
Anxiety can cause vasoconstriction
Assess and document:
• History of allergies- Food and medication, can determine potential adverse reactions
• Current medications- Diabetes medications interact adversely with contrast.
• Surgical procedures- Used to determine site for venipuncture.
• Past and current disease processes- Used to determine appropriate amount of contrast
• Laboratory values for blood urea nitrogen (BUN) and creatinine.- indicators of normal kidney
function

Infection control:
• Venipuncture may cause infection if performed incorrectly
• Strict aseptic technique and universal precautions must be used
• IV filters can reduce the risk of infection
o Reduces rate of injection too

Supplies and equipment:

• Needles
• Syringes
• Tourniquet
• Tape
• Gauze pads
• Skin preparation

Needles:
Are all single use only, disposed of properly after one use
Parts:
• Hubs= attaches to syringe
• Cannula or shaft= length of needle
• Bevel= slanted portion at tip
Gauge= diameter of needle bore
Types:
• Hypodermic
• Butterfly sets
• Angiocatheters
Depends on patient assessment, institutional policy, technologist preference.

Syringes:
Types:
• plastic= disposable, single use
• Glass= must be sterilized between uses

Parts:
• Tip= where needle attaches
• Barrel= has calibration markings and holds medication
• Plunger= fits snugly inside barrel and allows user to instill medication
Syringe size should be one size larger than volume to be injected.

Medication preparation:
IV administration cannot be retrieved and medication effects are almost instant
For this reason, safety precautions must be followed
Verify patient identity
Verify correct medication three times:
• Before preparation
• During preparation
• Before administration

Medication preparation:
Container:
• Single dose vials do not require preparation before withdrawal
• Multiple dose vials must be cleaned before drawing into syringe

Needle inserted into rubber stopper to hub

Air equal to amount of contrast needed injected into vial above fluid level
• Reduces air bubbles in contrast
After air is injected, pull needle back to below fluid level
Pull back on plunger until needed amount of fluid is aspirated into barrel
Lightly tap on the syringe barrel to remove air bubbles.

Procedure:
General rule: Select the most distal site that can accept the needle size and can tolerate injection rate and
solution.
• Site selection
o Primary factors to consider
▪ Suitability of location
▪ Condition of vein
▪ Purpose of infusion
▪ Duration of therapy
o Most common veins
▪ Anterior forearm
▪ Posterior hand
▪ Radial aspect of wrist
▪ Antecubital space of the elbow.
o Skin
▪ Skin must be prepared and cleaned
▪ If hair is present, shaving is not recommended, clip air for better visualization of
vein
▪ Antiseptic used for cleaning should be in contact with skin for at least 30 seconds
• Iodine tincture 1% to 2%
• Isopropyl alcohol 70%

• Site preparation
o Skin is cleaned in circular motion from the center of the injection site to approximately a 2
inch circle.
o Once cleaning swab is places on skin it should not be lifted off until cleaning is complete
o Local anesthetic may be used before IV access.
▪ Administered topically or by injection

• Venipuncture
o Two methods
▪ Direct or one-step entry
 ▪ Indirect method
o Steps:
▪ Radiographer puts on gloves and cleans patients skin
▪ Local anesthetic administered (optional)
▪ Tourniquet applied 6-8 inches above the puncture site.
▪ Hold limb with nondominant hand and anchor vein with thumb
▪ Using dominant hand , position needle bevel side up, at 45 degree angle to skin
surface
▪ Enter skin with a quick, sharp darting motion and decrease angle to 15 degrees after
entering the vein.
▪ Release tourniquet
▪ Look for blood return
▪ If no blood return, pull back on plunger slowly to aspirate blood and verify
placement in vein
▪ Anchor needle with tape
▪ Administer medication

• Administration
o Must occur at established rate
o During injection, site should be observed and palpated proximal to puncture site for signs
of infiltration
o Infiltration or extravasation means fluid has entered tissue instead of vein
o After contrast administration, remove tape or dressing
o Hold gauze pad over injection site and remove needle by pulling straight from vein
o Apply pressure to site with gauze
o Discard gloves, needles, and gauze in appropriate manner
o If patient has established IV site, Check compatibility before using contrast administration
o To administer contrast in existing IV line, stop infusion of medication
o Flush IV line with saline before and after contrast administration
o Restart infusion

Reactions and complications:

Categorized as:
• Mild-
o Sensation of warmth
o Metallic taste
o Sneezing
• Moderate-
o Nausea
o Vomiting
o itching
• Severe-
o Anaphylactic reactions
o Can cause cardiac or respiratory crisis

Infiltration symptoms:
• Swelling
• Redness
• Burning
• Pain
Treatment:
• Application of ice within 30 minutes of occurrence
• Application of warmth if more than 30 minutes since occurrence.

Documentation:
Adhere to and document the five “rights” of medication administration
• Right patient
• Right medication
• Right route
• Right amount
• Right time

Three phases of IV contrast enhancement:

• Bolus/ Arterial: 10 seconds
• Non-EquilibriumVenous: 40 seconds
• Equilibrium: 2 minutes

Different methods of triggering:

Bolus
Test bolus phase (test to see what time)

TPA: needs to be taken within 3 hours of a stroke (first signs)

Conclusions:
• Medications are intended to benefit patient with minimal harm
• Because medications carry inherent risk, proper administration is critical
• Radiographers must be knowledgeable and competent and must practice within their scope of
practice.

Review:
• Anxiety reaction from a contrast media is called a psychogenic reaction
• Swelling at the back of the throat and cough with contrast injection means the patient is in danger of
respiratory arrest and should call for assistance.
• IV contrast results in a enhanced image as it allows for enhanced structures to attenuate the x-ray
beam.
• Anterior surface of the elbow can become scarred or sclerotic of overused
• Needle displacement is the most common cause of extravasation. Causes swelling and pain
• The needle best suited for IV injection of contrast media with a mechanical power injector would be
an 18 gauge angiocatheter.
• The gauge of a needle is a measure of the Bore.
• During CT examinations, the administration of saline flush after bolus injection is to help alleviate
artifacts from dense contrast in the superior vena cava
• Maximum injection pressure in an automatic injection device is preset during contrast media
administration to prevent vessel damage

Urinary system:
The average adult kidney measures 4-5 inches in length
The adipose capsule allows the visualization of the kidney on radiographs.
Urine will travel from the major calyces to the renal pelvis
The average total capacity of the average adult bladder is 350-500ml
Numerous mucosal folds in the bladder are called rugae
Non-ionic contrast has low osmolality, the inability to dissociate into two separate ions and cless chance
of reaction.
Normal creatinine level is 0.6 to 1.5 mg/dl
Normal BUN (Blood urea nitrogen) levels in adults should never exceed 25 mg per 100ml
Prednisone given before IVU to reduce risk of reaction to contrast media
Bradycardia is a common vasovagal reaction symptom.
Laryngospasm is a anaphylactic reaction to contrast media
A high risk for contrast media studies of the urinary system are severe dehydration
Normal side effects to contrast media injections are metallic taste and hot flashes.
Leakage of contrast media into the surrounding tissues of the arm is extravasation
A high risk condition of an IVU exam is Anuria
Treatment for extravasation is place a warm towel over the injection site
The rapid introduction of contrast agents into the vascular system is termed bolus injection.
The technologist should leave a butterfly needle in the vein for the first part of the IVU following
injection
Patchy, blunting of the calyces is a radiographic sign of pyelonephritis
During a retrograde cystogram, contrast is introduced by gravity slow through a catheter
Recommended position for a male during a retrograde urethrogram is 30 degrees RPO
With AEC, the chambers open for IVU are the left and right upper chambers
If the symphysis pubis is over the bladder in imaging, there is insufficient CR angulation
If a patient has suspected nephroptosis, this is best visualized erect.
Enlarged prostate glands are visualized in AP erect pre voiding position
Vesicoureteral reflux patients who are sensitive to iodinated contrast media should have a radionuclide
scan.
Males having a voiding cystourethrogram should be in 30 degree RPO
A patient with a possible ureteric stone comes into ED for an IVU with a BUN of 50. Patient should have
a CT.
If a patient develops urticaria. The technologist should get medical assistance.
An IVU should be done before an IVU.
Renal agenesis: absence of a functioning kidney
Oliguria or hypouresis: Excretion of diminished amounts of urine.
Micturition: act of voiding
Anuria: Complete cessation of urinary secretion
Polyuria: Passage of a large volume of urine
Hematuria: Blood in the urine
Vesicocolic fistula: Artificial opening between the urinary bladder and aspects of the large intestine
Ectopic kidney: Normal kidney that fails to ascend into the abdomen, but rather, remains in the pelvis.
BPH (benign prostatic hyperplasia)- Age- associated enlargement of the prostate gland
Staghorn kidney stone: Large stone that grows and completely fills the renal pelvis
Horseshoe kidney: Fusion of the kidneys during development of the fetus
Urinary incontinence: Constant or frequent involuntary passage of urine.
• Retrograde urography is when contrast is injected back up through the ureters to the kidneys in
reverse of the normal flow.

Enemas:
Ask the patient to take slow deep breaths, and insert the tip during exhalation
• The stage of respiration the enema tip should be inserted into the rectum is suspended expiration
• The ideal kv range for double contrast barium enema range is 90-100
• AP barium enema projection reveals poor visualization of the sigmoid due to excessive
superimposition of the sigmoid colon and rectum. To fix this, angle the cr 30 to 40 degrees
 cephalad with AP projection
• Diverticulosis is visualized with a double contrast barium enema
• If there's resistance when attempting to insert an enema tip, have the radiologist insert it using
fluoroscopic guidance.
• Buscopan is used for enemas
• During a double-contrast BE, the radiologist suspects a polyp in the descending colon, right lateral
decubitus demonstrates this.
• Its important for the rad to check if a biopsy was performed as the biopsy of the colon may weaken
the portion of the colon and can lead to perforation.

UGI:
• A false statement about pediatric small bowel series is that the series should be scheduled for early
in the morning.
• PA rather than AP is recommended for small bowel series as better separation of loops of small
intestines
• Possible polyp in ascending colon LPO
• The position that provides the greatest gonadal shielding for both males and females is lateral
rectum
• The position best demonstrates a fistula a lateral rectum position
• For a defect with the right colic flexure RPO will best show this.
• Part of the small intestine that has a feathery appearance is the jejunum
• The part of the large intestine located the highest, or most superior in the abdomen is the left colic
flexure.
• The term for the 3 bands of muscle that pull the large intestine into pouches is taenia coli
• The parts of the colon most likely filled with air when the patients in a PA position is the right and
left colic flexure and the sigmoid colon
• Small bowel follow through series is a functional study
• Patients must be NPO 8 hours prior to small bowel series.

Section L: Back to top

Reproductive system: & mammography, Bone mineral density
Anatomy review:
Female anatomy:
• Ovaries
o Two small, glandular, almond- shaped organs
o Located one on each side near lateral wall of pelvis
o Internal secretion that controls menstrual cycle
o External secretion is ova, a female reproductive cell.
o Medulla= core of vascular tissue
o Cortex= outer, glandular tissue
▪ Contains ovarian follicles
▪ Each follicle contains one ovum
o Graafian follicle= fully developed ovarian follicle
o Ovulation= extrusion of an ovum by rupture of a follicle
• Uterine tubes
o Also called fallopian tubes
o Arise from lateral angle of uterus on each side
o Open into the peritoneal cavity
o Collect ovum released by ovaries and convey it to the uterine cavity
o 3-5 inches long
o Each tube divided into three parts
 ▪ Isthmus- Short segment near uterus
▪ Ampulla- Majority of tube
▪ Infundibulum- Terminal, lateral portion; flared in appearance
• Ends in series of irregular prolonged processes, called fimbriae

• Uterus
o Pear shaped muscular organ
o Situated in central part of pelvic cavity
o Posterior to urinary bladder
o Anterior to rectal ampulla
o Nulliparous uterus approximately 3 inches in length
o Consists of 4 parts:
▪ Fundus- blunt, rounded superior portion
▪ Body- Narrows from fundus to isthmus
▪ Isthmus- superior part of cervix; constricted area between body and cervix
▪ Cervix= cylindric vaginal end of uterus
• Vagina attached around circumference of cervix
• Approximately 1 inch long
▪ Uterine cavity appears triangular when viewed in frontal plane
▪ Endometrium= inner mucosal lining of uterine cavity
o Functions include receiving and retaining fertilized ovum until development of fetus is
complete
o Expel mature fetus during birth
• Vagina

Hysterosalpingogram:
Non pregnant females can go for a hysterosalpingography
Performed to:
• Determine size, shape, and position of the uterus and uterine tube
• Delineate lesions such as polyps, submucosal tumor masses, or fistulous tracts
• Investigate patency of the uterine tubes in patients who are unable to conceive. Infertility
assessment
• Involves the introduction of water-soluble radiopaque contrast into the uterus via a cannula
• Can be therapeutic as the pressure of the contrast can unclog the fallopian tubes
• Intestinal tract should be cleared before examination
o Laxative administered for constipation
o Cleansing enemas before examination
o Meal preceding examination withheld
• Procedure should be scheduled within 10 days following onset of menstruation
o Endometrium is least congested
o Least risk of irradiating fertilized ovum
• Before the procedure, the patient should
o Empty bladder
o Irrigate vagina and clean perineal region, as instructed with supplies provided by
radiographic technologist.
• Preliminary scout image made
• Patient placed in lithotomy position
• Physician places speculum into vagina
• Uterine cannula placed in cervix
• Contrast injected
o Fills uterus
 o Spills into peritoneal cavity if tubes are patent
• Images should demonstrate
o Pelvic region 2 inches above the pubic symphysis, centered
o All contrast media visible, including any “spill” areas
o Technical factors to show soft tissues and contrast media

Male Anatomy:
• Internal:
• Testes
• Ductus deferens or vas deferens-
o 16-18 inches long, extends from tail of epididymis to posteroinferior surface of
urinary bladder
o Ampulla= expanded end that serves as reservoir for seminal fluid
▪ Unites with seminal vesicle
• Prostate-
o An accessory genital organ
o Averages 1 ¼ inches long
o Encircles proximal portion of urethra
o Lies anterior to rectal ampulla
o Ducts open into the prostatic portion of urethra
• Ejaculatory ducts-
o Formed by union of ductus deferens and duct of seminal vesicle
o Average ½ inch long
o Originate behind neck of bladder
o The two ducts enter base of prostate
o Ducts eject sperm into urethra before ejaculation
• Seminal vesicles-
o 2 inches long
o Situated obliquely on lateroposterior surface of bladder
o Junction with ampulla of ductus deferens forms ejaculatory duct.
• Bulbourethral gland

• External:
o Penis
o Scrotum
o Structures enclosed by scrotal sac
▪ Testes-
• Ovoid bodies averaging 1 ½ inches in length and 1 inch in width and depth
• Divided into 200 to 300 partial compartments that constitute the glandular
substance
• Each compartment houses one or more convoluted, germ cell-producing
tubules
• Tubules unite to 15-20 ductules that exit testes and enter epididymis
▪ Epididymides
• Oblong structure attached to superior and lateroposterior aspects of testis
o Main duct is continuous with ductus deferens
▪ Spermatic cords
▪ Part of ductus deferens

Mammography:
Introduction:
• Breast cancer is second only to lung cancer as cause of death in woman
• Death rates have decreased
• Mammography became a reliable diagnostic tool in 1950
o First innovation since radical mastectomy introduction in 1898
• Research conducted in 1970s clearly showed mammography to be an essential part of early
diagnosis program
• Mammography was the first and only federally regulated imaging examination with the
implementation of mammography quality standards act. (MQSA)

Equipment:
• History and evolution
• Dedicated units have high frequency generators
o Provide more precise control of kVp, mA, and exposure time
• Full-field digital mammography (FFDM)
• Digital breast tomosynthesis
• Computer-aided detection (CAD)

Breast Cancer Screening:

• Defined as a procedure performed on an asymptomatic patient or a patient who presents without any
known breast problems.
• American Cancer society, American college of radiology, and the society of breast imaging
recommend screening annually for woman older than 40

Diagnostic Mammogram:
• Recommended for patients with clinical evidence of breast disease
• Problem-solving examinations that use specific projections to
o Rule out cancer
o Demonstrate suspicious area seen on screening
• Indicated if a woman presents with a palpable mass or other symptom

Breast cancer risk factors:

• Increasing age
• Potentially modifiable factors
o Obesity
o Postmenopausal hormone therapy
o Physical inactivity
o Alcohol consumption
• Dense breasts
• Dense bones
• Family history

Breast anatomy:
• Terms breast and mammary gland are synonymous
• Lobulated, glandular structures located in the superficial fascia of the anterolateral wall of the
thorax
• Female breasts are secondary sex characteristics
• Female breasts vary considerably in size and shape
o Depends on amount of fat and glandular tissue present and condition of the suspensory
 ligament
• Usually cone-shaped with base overlying the pectoralis major and serratus anterior muscles.
• Axillary tail of the breast extends from upper, lateral base to the axillary fossa
• Anterior end tapered, endin in the nipple
• Areola surrounds nipple
o Circular area of pigmented skin
• Cooper ligaments support breast
• 15-20 lobes in adult females breasts
• Each lobe divided into many lobules
• Lobules are basic structural unit of breast
• Lobules contain
o Several acini
o Draining ducts
o Interlobular stroma (connective tissue)
• Lobule size affected by age and hormones
• Involution is the normal process of decreasing lobule size with age and after pregnancy
• Acini are glandular elements of lobules
• Lactiferous ductules formed by openings of each acinus
• Lactiferous ducts formed by joined ductules
o One duct for each lobe
• Ducts join before opening into nipple
• Lymphatic vessels of breast drain into two sets of nodes
o Axillary lymph nodes, laterally
o Internal mammary lymph nodes, medially
• Axillary nodes are often evaluated on mammograms

Tissue variations:
• Glandular tissue:
o Increases during pregnancy and lactation
o Decreases postpartum and with age
• Connective tissue
o Dense and casts homogeneous shadow
o Primary component of postpubertal adolescent breast
• Fatty tissue
o Replaces glandular tissue after lactation and advancing age

Procedure:
• Patients dress in open-front gown
• Breasts must be barred for imaging
o Cloth will cause image artifact
• Remove deodorant and powder from axilla and breast
o Can mimic calcification on image
• Complete, careful history and physical assessment
o Notes made on location of scars, palpable masses, skin abnormalities, and nipple
alterations
• Examine previous mammograms for positioning, compression, and exposure factors
o Check for areas of improvement
• Explain procedure to patient, including possibility for additional projections
• Consider natural mobility of breast before positioning
• Support breast firmly so that nipple is directed forward
 • Profile nipple, if possible
• Apply proper compression to produce uniform breast thickness
o Essential to high-quality mammograms
• Place identification (ID) markers according to standard convention

ID for Mammograms:
• Facility name and address; examination date; patient name, age, DOB; and medical #.
• Side and projection
• Technologists initials
• Image receptor #
• Date
• Exposure factors
• Unit #
• First four are generally acquire, last ones are optional

Essential projections:
• Craniocaudal
o Patient position
▪ Standing or seated facing IR holder
o Part position
▪ Elevate inframammary fold to maximum height
▪ Adjust IR height to inferior surface of breast
▪ Gently pull breast onto IR holder with both hands while instructing patient to press
chest to IR holder
▪ Breast perpendicular to chest wall
▪ Center breast over automatic exposure control (AEC)
▪ Place nipple in profile, if possible
▪ Immobilize breast with one hand
▪ Use other hand to move opposite breast out of image
▪ Shoulder relaxed and in external rotation
▪ Rotate head away from breast being examined
▪ Lean patient towards machine
▪ Place hand on shoulder and slide skin over clavicle
▪ Compress breast slowly until skin is taut.
o Exposure made on suspended respiration
o Release compression immediately
o Central ray (CR) perpendicular to breast

• Mediolateral oblique
o Patient position
▪ Standing or seated upright facing IR holder
o Rotate C-arm until long edge of IR is parallel to upper one-third of pectoral muscle
▪ Degree of obliquity is 30-60 depending on body habitus
o Part position:
▪ Place top border of IR level with axilla
▪ Elevate arm of affected side over corner of IR holder
• Rest hand on grip adjacent to IR
• Elbow should be flexed
▪ Relax shoulder
▪ Have patient lean slightly anterior
▪ Place hand along lateral aspect of breast and gently pull breast and pectoral muscle
 anteriorly and medially
▪ Holding breast with thumb and fingers, lift up, out, and away from chest wall
▪ Rotate patients body towards IR
▪ Ask patient to bend slightly at waist
▪ Center breast with nipple in profile, if possible
▪ Hold breast up and out
▪ Compress breast slowly until taut
▪ Pull down on abdominal tissue to open inframammary fold
▪ Instruct patient to hold opposite breast laterally, out of anatomy of interest
o Exposure made on suspended respiration
o CR perpendicular to base of breast
▪ CR angle depends on body habitus
▪ Tall, thin patients require more angle.

Image evaluation:
CC:
• Posterior nipple line extending posteriorly to edge of image
o Measuring within ⅓ inch of PNL on MLO
• All medial tissue included
o Medial retroglandular fat seen
o Absence of fibroglandular tissue seen on posteromedial edge of image
• Nipple in profile (if possible) and at midline
• For emphasis of medial tissue, exclusion of some lateral tissue
• Pectoral muscle seen posterior to medial retroglandular fat
o Seen in approximately 30% of CC images
• Slight medial skin reflection at cleavage
• Uniform tissue exposure
o If compression is adequate

MLO:
• PNL measuring within ⅓ inch of PNL on CC
• Inferior aspect of pectoral muscle extending to PNL or below
• Pectoral muscle showing anterior convexity to ensure a relaxed shoulder and axilla
• Nipple in profile, if possible
• Open inframammary fold
• Deep and superficial breast tissues well separated
• Retroglandular fat well seen
• Uniform tissue exposure
o If compression is adequate

The most dominant interaction in the soft tissue of the breast during mammography is photoelectric effect
because at low photon energies, the photoelectric effect plays an important role in imaging soft tissue. It
can be used to amplify differences in attenuation between tissues with slightly different atomic numbers,
such as the breast tissue.

Bone mineral Density:

T-scores: your bone compared to an average 30 year old
Z- scores: compared to someone your age, height and weight.

T- score numbers:
-1 and greater= normal
-1 to -2.5= osteopenia
-2.5 and lower= osteoporosis

Section M: Back to top

CT anatomy and Pathology: Neurological imaging and pathology, Abdominal and pelvis imaging and
pathology, thoracic imaging, spinal imaging

Sectional Anatomy Review:

Three imaging planes:
• Axial/ transverse
o Divides body into superior and inferior portions
o CT images are usually in axial plane
o To view, imagine you are standing at a patient's feet looking towards head
▪ Patients right is on your left and vice versa
▪ Anterior surface at top of image
• Coronal
o Divides body into anterior and posterior portions
o View similar to radiographs- imagine you are facing patient
▪ Patients right on your left

▪
• Sagittal
o Divides body into right and left portions
o Planes pass through body from superior to inferior and anterior to posterior

CT images:
• Densities similar to x-ray
• Bone and other dense structures, such as radiopaque contrast media, appear white
• Air and other low-density structures appear black
• Fat, organs, etc., appear in varying shades of gray.

MRI:
• Generally structures that generate a strong signal are lighter gray or white
• Structures that do not return a strong signal tend to be darker
• Signals generated by structures dependent on magnetic field strength and characteristic of radio
frequencies used
• Contrast may be used to enhance signal intensity

Neurological imaging and pathology:

General imaging methods:
• Immobilize the patients head
• Program slices so that they are parallel to the supraorbital meatal line to reduce radiation exposure
to the lens of the eye
• Some protocols call for images to be taken in the direct coronal plane
o Can be accomplished either with the patient lying supine or prone
o Be sure to input the correct orientation before scanning
• Because of the dense bone of the skull beam-hardening artifacts are often seen in images of the
posterior fossa
o Thin slices can help to reduce these artifacts
• Routine head studies are most often done using the step-and-shoot method
• Helical mode is primarily used for studies that require 3D reformations or for CT angiography
• Because of the small difference in attenuation between the gray matter and the white matter, narrow
window widths are used to demonstrate the brain

Intracranial hemorrhage:
• CT is the most frequently used initial examination for imaging ICH
• The appearance of ICH will change with the passage of time
 • As a general rule ICH will appear
o Hyperdense to normal brain tissue for the first 3 days
o Hyperdense center surrounded by concentric areas of hyperdense and hypodense tissue
from 4-10 days
o Isodense center surrounded by areas of hypodense tissue from 11 days to 6 months
o Hypodense to normal tissue after 6 months
• Although most patients with an ICH are seen through the ED where images are reviewed by
radiologists are reported on quickly, some patients, particularly those with less acute presentations
may arrive in the CT department as outpatients
• In these situations, the technologist can play a vital role by bringing the scan to the radiologists
attention so that these patients receive prompt medical attention.
• Know how the brain reacts with this (movement of the medial boarders)

Chronic vs acute hematoma:

Acute subdural: (0-2 days) Blood appears hyperdense in pre-contrast CT scan
Chronic: Appears hypodense (lucent) as cellular elements dissolve

Epidural hematoma: out pouching(Convex) traumatic accumulation of blood between the inner table of
the skull
Subdural hematoma: traumatic accumulation of blood between the inner table of the skull and brain
keeping its shape to the side of the skull (concave)
Subarachnoid hematoma: Bleeding in and surrounding the brain that can be caused by an aneurysm
increasing intracranial pressure.

General imaging methods- neck:

• Performed supine with neck slightly extended
• Most often done in helical mode
• IV contrast is used, unless contraindicated
o Split- bolus injection technique is used by some institutions
• The goal is to allow sufficient time after contrast administration for mucosa, lymph nodes, and
pathological tissue to enhance, yet acquire images while the vasculature remains opacified.

CTA of the head and neck:

• Compared with traditional angiography, CTA has the advantages of being
o Less invasive
o Widely available
o Less expensive
o Time-saving
• Rapid, high-resolution scans are taken while contrast is in the arterial enhancement phase
• Goals are to
o Accurately measure stenosis of the carotid and vertebral arteries and their branches
o Evaluate the circle of willis for completeness using 3D reformation
o Detect other vascular lesions
• A modification of CTA, called CT venography (CTV), is used for the depiction of venous anatomy.

Spine protocols:
• In many circumstances MRI is the modality of choice for imaging the spine
• In some situations, such as the evaluation of bony abnormalities of the spine, CT is considered
superior to MRI
• Proper localization is essential in scanning the spine
 o All studies should include both AP and lateral scouts
• Visualization of intradural structures is improved by intrathecal administration of CM

Intrathecal administration of CM:

• CT examinations are performed after myelography to enhance or clarify findings
• A delay of 1 to 3 hours between the intrathecal injection and scanning is recommended to allow the
CM to dilute
o CM is too dense may mask intradural structures

Suspicion of stroke:
• Tissue plasminogen activator (t-PA) is a pharmacologic treatment for acute ischemic stroke
• To be effective t-PA must be administered within 3 hours of the first signs of stroke
• This means that the stroke victim must be transported to the hospital, diagnosed, and administered
the t-PA treatment before the 3 hour window has expired.
• ICH contraindicates t-PA therapy
• A noncontrast CT of the brain is routinely performed to differentiate ischemic stroke from
hemorrhagic stroke, to assess the state of cerebral circulation and tissue, and secondarily, to
assess the underlying disease
• CT brain perfusion provides additional information by allowing qualitative and quantitative
evaluation of cerebral perfusion
o Perfusion studies are obtained by monitoring the passage of iodinated contrast through the
cerebral vasculature

Neurologic protocols:
• Routine head
• Skull base (posterior fossa)
• Temporal bones
• Sinus screen
• Trauma facial bones
• Orbits
• Sella turcica
• Brain perfusion
• CTA- circle of WIllis
• CTA- circle of willis/carotid
• CTV- cranial venography
• Soft tissue neck
• Cervical spine
• Thoracic spine
• Lumbar spine
• CTA- spine

CT Brain Pathology:
• Axial CT
o Stroke- most strokes do not show on CT for 12-24 hours (important CT of head is done as
soon as possible)
▪ Ischemic- caused by an obstruction of an artery leading to or in the brain,
preventing oxygenated blood from reaching parts of the brain that the artery
feeds
▪ Hemorrhagic- Occurs when a vessel in the brain suddenly ruptures and blood begins
to leak directly into brain tissues and or CSF
 o Tumours- (contrast given to determine classification) (primary- grows originally in the
brain, secondary- a tumour that was spread to the brain from a different site in the body
such as lungs, bowel)
▪ CT image will vary depending on type of brain tumor
▪ Benign
• Non-cancerous
• Do not spread to other sites in the body
• Slow growth
• May cause increase pressure within the brain
• Shift of the structures of the brain is often seen
▪ Cancerous-
• Contains cancer cells
• Invade surrounding healthy tissues
• Rapid growth
• Shift of structures of the brain is often seen
• Ring around suggest malignancy
▪ Cystic
▪ MS plaque
o Skull fractures-
▪ Bone window used.
o Hematomas-
▪ Subdural- Forms to the shape of the skull, dark
▪ epidural - forms a ball into the brain from the side of the skull
▪ Intracerebral- Hematoma that is not touching the skull
▪ Intraventricular- in the ventricles.
o Subarachnoid hemorrhage:
▪ Blood in the subarachnoid space
o Hydrocephalus-
▪ may be congenital or acquired, adult or child
▪ Caused by a blockage of the drainage of CSF
▪ Congenital- infant has a shunt placed in the ventricle to drain the excess CSF
▪ Aqueduct stenosis is the most common cause of congenital obstructive
hydrocephalus, but can also be seen in adults as an acquired abnormal
o Meningitis- bacterial meningitis with abscess formation
o Cysts- Originate from cellular structures of the brain, non contrast study
o Aneurysm: outpouching and burst of a vessel.

Questions:
• Scanning protocol of a CT head to reduce exposure to eyes would be an axial scan with the gantry
tilted to be parallel to the glabellomeatal line

Abdominal and pelvic imaging and pathology:

General imaging modalities:
• Patient preparation is particularly important when imaging the abdomen or pelvis
• Most scans require oral contrast
• The rectal administration of CM is typically reserved for specific situations, such as colon cancer
staging
• The bladder is best appreciated on CT when filled with urine or contrast material
• IV contrast opacifies the blood vessels, increases the CT density of vascular abdominal organs, and
improves image contrast between lesions and normal structures
• The appropriate timing, rate, and dose of the IV contrast agent are essential
 o Or most examinations of the body, image acquisition must be completed before CM
reaches the equilibrium phase
• Multiphasic imaging is frequently used for specialized studies of the pancreas, liver, and kidney as
well as in many abdominal CTA protocols
• In any giving slice, much more information is present than can be displayed by a single window
width and level setting
o Hence , images are often reviewed in two or more window settings
• The DFOV should be just large enough to include the skin surface over the key areas being imaged
o If previous studies are available, it is generally advised to use the same DFOV, unless a
change in patient condition necessitates adjustment
• Although landmarks are used to set up the range of cross-sectional slices, technologists must verify
that the anatomy of interest has indeed been scanned
• Scanning should not start or stop in the middle of obvious abnormality
• For most protocols of the abdomen or pelvis, patient sare scanned in the supine position with the
arms elevated
• Patients are asked to suspend respiration during image acquisition to reduce movement and decrease
artifact.

Liver:
• Normal CT attenuation of the unenhanced liver is between 38 and 70 hu
• In healthy subjects the liver is at least 10 hu greater than the spleen, when the liver is 10 hu lower
than the spleen, fatty infiltration of the liver is indicated
• Fatty infiltrates and cavernous hemangioma are two common findings in the liver.
• For routine abdominal CT or as part of a chest, abdomen, and pelvic study, the liver is most often
scanned just once, during the portal venous phase
• For some indications, scanning in more than one enhancement phase may be of diagnostic benefit
o Hyperenhancing tumors may be better visualized with dual-phase imaging
• To detect tumor nodules for a triphasic CT examination of the liver, a late arterial phase will help to
detect it.
• Window settings to visualize abnormalities in the liver would be WW 150, WL 50

Pancreas:
• The pancreas is typically located between T12 and L2
• Water or low-attenuation oral contrast agents are preferred because dense contrast may obscure
small stones
• When initial scans fail to differentiate the margins of the pancreas from the duodenum, the patient is
often given additional oral CM and slices are obtained with the patient in the right decubitus
position.

Kidney:
• Most examinations use IV contrast
• Unenhanced CT of the kidneys and ureters is generally reserved to demonstrate calcification and
calculi that may be obscured by CM
• Enhanced phases of the urinary tract include
o Corticomedullary phase, 30 to 70 s after CM bolus
o Nephrogram phase, 100 to 120s after CM bolus
o Excretory phase, 3 minutes after CM bolus

CT Urography (CTU):
• A relatively new imaging examination designed to provide a comprehensive evaluation of the upper
 and lower urinary tract
• Many different protocols exist
• Some use a split-bolus injection
o These divide the CM dose into two bolus injections with a delay of between 2 and 15
minutes between injections
o The goal is to image a combined nephrographic excretory phase

CT of the Adrenal Glands:

• Determining whether an adrenal mass is benign or malignant is accomplished by assessing its
attenuation values and by evaluating the degree of CM that is washed out of the mass on delayed
imaging.
• An astute technologist can save a patient the time, money, and the radiation exposure of a repeat
examination by identifying an incidentaloma and tailoring the study to provide the radiologist
with the data necessary to characterize the mass as benign or malignant.
• Specialized adrenal imaging protocols attempted to characterize lesions of the adrenal gland.
• The goals of imaging are to reduce the number of unnecessary biopsies, the number of follow-up
studies needed for an accurate diagnosis, and the cost of care.
• Two unique features of adenomas on CT are used to differentiate benign from malignant lesions
o Intracellular lipid (Fat) content
o CM washout
▪ Washout can only be evaluated if delayed images are acquired

CT in the diagnosis of acute appendicitis:

• The variable position of the appendix is important because it contributes to the diverse clinical
presentation of acute appendicitis
• This variation in positioning also makes the appendix more challenging to locate on cross sectional
images
• Appendicitis protocols vary widely and use different combinations of oral, rectal, IV or no contrast
materials
o The techniques vary most in their rate of providing an alternative diagnosis when the
appendix is found to be normal

CT for urinary tract calculi:

• The terms kidney stones, renal stones, renal calculi, nephrolithiasis, and urolithiasis are often used
interchangeably
• There are four basic types of urinary stones; all can be seen on noncontrast helical CT (NCHCT)
o More than 99% of stones, including those that are radiolucent on plain film radiography,
will be seen on NCHCT
• Protocols use a helical scan mode from the top of the kidneys to the base of the bladder and a slice
thickness of 3mm or less
• The greatest drawback to NCHCT for the diagnosis of renal stones is the relatively high radiation
dose, particularly to the gonads
o This is of particular concern because many patients who have stone disease are young and
have a tendency to experience repeat stone formation.

Abdomen or pelvis protocols:

• Routine abdomen pelvis
• Abdomen pelvis aorta (Post-stent, nongated)F
• Arterial-venous liver
• Arterial-venous pancreas
• Mesenteric
 • Enterography
• Appendicitis or diverticulitis
• Colonography- can't biopsy or remove polyps.
• Adrenal mass (with delay)
• Renal mass
• Renal stone
• CT urogram

Pathology:
Fatty liver- lower HU around -10 (Fat -100--50)
Liver hemangioma: Non cancerous mass made up of a tangle of blood vessels.
Giant Cavernous Hemangioma: May take at least 5- 15 minutes for the contrast to fill into the extremely
large hemangioma.
Lacerated liver: Physical injury to the liver
Cirrhosis: Late stage disease where healthy tissue is replaced with scar tissue and the liver is permanently
damaged. Can lead to esophageal varices
CT scan of the upper abdomen shows multiple
Liver metastases:
masses of heterogeneous low attenuation in the liver with high-
attenuation iodized oil infused for chemoembolization. A mass
invading into the IVC is noted (arrow).
Chronic pancreatitis: inflammation of the pancreas (Left sitting
feather organ)
Gallstones: Calcified stones in the gallbladder (organ inside the
liver) with high attenuation
Kidney carcinoma: Kidney cancer with malignant cells
Kidney stones: Reduction in dose.
Adrenal gland tumours: ROI placed in the adrenal gland to
demonstrate fat presence. If a lipoma then treatment would be
different.
Ureteral stones will show blockage of flow from the kidney to
the bladder.
Abdominal aorta aneurysm (AAA): 3D volume rendering.
Measurements taken to see how wide the outpouching is.
Splenic rupture: Fluid around the liver.
Crohn's disease: Extra density around the colon.
Intraluminal CT colonoscopy: Flythrough of the colon to check
for polyps.
Carcinoma of the bladder: 10 minute scan delay.
Prostate gland tumor: Urethra is affected with an enlarged
prostate.
Ovarian cysts: Pushes surrounding structures, lower HU value
than liver.
Ovarian cancer; thickening and contrast enhancement with
tumor
Thoracic imaging:
General imaging methods:
• A short scan time helps to reduce artifacts created by respiratory motion
• Whenever possible, scans of the chest should be acquired within a single breath-hold
• Because of the high intrinsic natural contrast, CM is not necessary for all thoracic indications
o IV agents are typically used to differentiate vascular from nonvascular structures
• Airway imaging is routinely performed at both inspiration and expiration
• High resolution CT (HRCT) of the chest is used for the assessment of lung parenchyma in patients
with diffuse lung disease (requires a slice thickness of 1.25mm)
o Some HRCT protocols scan only a representative portion (about 10%) of lung parenchyma
o Others, called volumetric HRCT, use a helical mode to acquire images of the entire lung.
o Most HRCT protocols include more than one series of scans
o Prone images can help to differentiate actual diseases from densities related to the effects
of gravity that mimic diseases

CTA in the diagnosis of PE:

• Protocols to detect PE scan in a caudal-to cranial direction to minimize respiratory artifact
• Because of the radiation dose, the decision to use CTA for young or pregnant women requires
careful scrutiny
o The technologists role is to identify these patients and bring them to the attention of the
radiologist
• The dose, rate, and timing of IV contrast administration are critical to the creation of diagnostic
CTA examinations
o The use of a saline flush is recommended

Cardiac CT:
• Improvement in CT detector technology and in temporal and spatial resolution have resulted in
clinical results with cardiac CT that are similar to those obtainable with conventional catheter
coronary angiography
• The technologist's understanding of the structural anatomy and the path and timing of the circulation
is essential to the creation of high-quality cardiac CT images.

Cardiac CT techniques:
• To reduce motion artifacts on cardiac CTA images, a patient’s heart rate can be temporarily lowered
by the administration of Beta -blockers
• Cardiac gating attempts to use only those images acquired during periods of the lowest cardiac
motion
o Prospective ECG triggering
o Retrospective ECG gating
• Most institutions also give patients nitroglycerin sublingually before coronary CT examinations
o The intention is to dilate vessels to improve visualization
Pharmacologic heart rate control:
• Beta- blockers are used to lower the heart rate to less than 65-70 bpm and to make the rhythm more
regular
• The decision to give beta- blockers and the dosage to be given should be made by a physician, nurse
practitioner, or physician’s assistant
• To avoid complications when beta-blockers are administered, guidelines should be strictly adhere to

ECG Tracing:
• To understand how ECG gating is used in CT, a rudimentary understanding of the ECG tracing is
needed
• The ECG provides a profile of the heart's electrical activity with time
• Each heartbeat in a normally functioning heart exhibits a similar characteristic pattern consisting of
five waves
• The distance between two R waves represents one complete cardiac cycle and is sometimes referred
to as the R-R interval.

Prospective ECG triggering:

• Also known as sequential or cine-mode scanning
• Acquires images only in those portions of the cardiac cycle expected to have the lowest cardiac
motion
• Use a signal, usually derived from the R wave, to trigger axial mode image acquisition
• Minimizes radiation exposure
• Very sensitive to cardiac motion artifacts and image misregistration
o Particularly problematic in patients with irregular heartbeats.

Retrospective ECG gating:

• Helical data are acquired throughout the cardiac cycle and images are then reconstructed in
specified portions of the cardiac cycle
• As a general rule, image reconstruction is performed at 60% to 65% of the cardiac cycle
• Primary disadvantage is the relatively high radiation dose.
• ECG-pulse tube current modulation
o Developed to address concerns about the radiation dose
o Automatically decreased the tube current during the systolic phase of the ECG tracing
o Cannot be used for patients with arrhythmia

CT coronary calcium screening:

• A four detector row CT scanner with a 0.5 second gantry rotation time is the minimal requirement
for a coronary calcium measurement is done mainly as a screening examination in asymptomatic
patients, the radiation dose is of particular concern

Thoracic protocols:
• Routine chest
• Lung nodule
• High-resolution CT
• Tracheobronchial
• Chest/Abdomen
• Chest for pulmonary embolism
• Cardiac calcium scoring
 • Chest aorta
• CTA- heart (general)
• CTA- coronary arteries
• CTA- pulmonary veins

Spinal imaging:
CT myelography: injected into the spinal canal
DJD- degenerative joint disease
Osteoblastoma: Aggressive tumour.
Giant cell tumor: fusion and breaking of vertebral bodies.
Subluxation: partial dislocation of all or part of the vertebrae
Spinal cord compression: displacement or fracture causing disruption of the spinal cord
Lumbar spine trauma can cause neurologic injury to the conus and cauda equina.

Questions:
• An abscess on a contrast enhanced CT study is a low attenuation surrounded by a ring enhancement
• For a stroke protocol, CT of the head must be done as soon as possible in order to be able to
diagnose and give TPA
• If a patient has a Neck CT, a study that may cause a need for a change in CT prior to this test is a
nuclear medicine scan of the thyroid.

Practice test: Back to top

• To display abdominal organs better, apply high pass filter-edge enhancement ?
• Pulmonary emboli is no change in technical factors, large pneumonia is decreased, advanced
emphysema is decreased, epiglottitis is no change, severe cystic fibrosis is increased, bilateral
pneumonia is increased.
• A patient suddenly complains of intense chest pain, described as crushing pain. MRT should assume
Myocardial infarct.
• Choroid plexuses produces CSF
• Include the adrenal glands when ruling out metastatic disease of the chest.
• Contraction of the heart's chambers is termed Systole
• Lower concave area of the lungs is termed the base
• Out of the radial head, the trochlea, radial tuberosity and coronoid fossa, the radial tuberosity is
most distal.
• The right and left vertebral arteries are not apart of the circle of willis
• Dark line artifact on CR is cracks on IP
• Images can be remotely transmitted to an off site workstation
• If an inpatient requests a urinal and they need a specimen, provide supplies and instructions for a
mid stream specimen.
• In case of a fire, the first thing is to evacuate the area.
• CT patients required to be NPO are booked first
• Normal range for GFR is 90-120 (60-120?)
• Creatinine (0.5-1.5) BUN (8-24)
• When a patient is in a RPO position, their left kidney will be parallel with the plane of the IR.
• Left lateral decub marker placed on the side up near the shoulder
• Purpose of the bowtie filter is to shape the intensity of the primary beam.
• Filters remove long wavelength radiation.
• Scanner's ability to differentiate small differences in attenuation between closely spaced objects
refers to the term contrast resolution.
• The attenuation of a specific tissue related to water is the CT number.
• In order to demonstrate undistorted air/fluid levels, the CR must be directed parallel with the floor.
• For a patient who requires Abdomen series with left sided hip replacement, Dorsal decubitus, AP
upright, AP supine. But if only one can be chosen, dorsal.
• When positioning an ambulatory patient for an erect abdomen, the patient starts to fall, assist the
patient to the floor.
• PA axial for colon 30-40 caudad
• To visualize a diaphragmatic hernia put the patient trendelenburg with slight body rotation to the
left. Patient Supine
• The prefix pyelo is related to the renal pelvis
• Dorsal decubitus is indicated for AAA, umbilical hernia, calcification of the aorta
• Small FSS for detail
• When OML is out of AP towne images, if the head is flexed, increase caudad angle. IF plantodorsal
calcaneus axial foot, with decreased flexion, make the beam angulation more vertical. (AP same
PA opposite)
• Penumbra is caused by FSS and penumbra effects recorded detail
• Line focus principle: Through angling the target, the effective area of the target is made much
smaller than the actual area of the electron interaction.
• The Plia Circularis: Folds in the mucous membrane and small intestine for two thirds of the
intestines of the gus
• PSP’s are made of barium fluorohalide, direct scintillators and they are made of
o Direct is amorphous selenium
o Indirect is amorphous silicone cesium iodine or gadolinium oxysulfide.
• Dyspnea- difficulty breathing. Sit patient upright
• Elbows are most likely to get bruises during patient transfer
• Croup- steeple sign
• Epiglottitis- thumbprint sign
• Blow out fracture is of the orbital rim waters and caldwell
• Patients who are hard of hearing, speak in a low voice with a clear tone
• If you witness a coworker inappropriately touch a patient go to your supervisor immediately
• CT:
• Increase wl- darker image
• Increase ww- more shades of grey (high contrast areas want large ww)
• Lidocaine- 20%
• NaCl- 0.9%

•
• Increase pitch decrease dose- increasing pitch increases slice thickness. Decreased slice thickness
decreases dose

•
• ^ section thickness, ^ photons, v spatial resolution, ^ partial voluming (scanning thinner sections)
• ^snr: ^mas, ^wider section thickness, ^ detection efficiency, v aperture size

•
• Spatial resolution affected by: FSS & aperture width

•
• Arterial phase contrast CT- in aorta, abdominal aorta, kidney and bladder but none in the liver or
bowels. (Arteries but no veins)

• CT:
• Window width-
• Pitch-
• HU-
• Bone
• Clotted blood
• Muscle
• Cartilage
• Blood
• Csf
• Water
• Fat
• Air

• Low spatial frequency- greatest soft tissue detail

• X-ray:
• Long & low- increase of scatter makes a low and long scale contrast. Similar shades of grey.
Abdomen is inherently long. To create long from short, high kvp
• Short & high- black and white, chest is inherent short so Increase long kvp to make low contrast
• So for chest you want it high because you want It long and low and for abdomen you use a low kvp
because you want it short and high

•
• LLD chest. Pleural effusion, side down. Pneumothorax, side up.
• Noise: seen with inadequate mAs
• Image contrast and density (brightness): kVp and LUT's
• Demographic: patient/ facility name, patient ID #, DOB, exam date. Lead side markers.
• Failure of the system to find collimated edges results in histogram errors

•
• Grid conversion:
• 5:1 2
• 6:1 3
• 8:1 4
• 12:1 5
• 16:1 6