EMERGENCY

RADIOGRAPHY
Swastika Pandit
[Link]. MIT 2nd year
NAMS, Bir hospital
Contents
• Introduction
• Patients condition and preparation
• Responsibilities of Radiographers
• Equipment
• Immobilization devices
• Grids
• Exposure factors
• Radiation protection
• Positioning & technique in Emergency/Trauma
• References
Introduction
• Emergency radiography is defined by the imaging and
imaging management of patients who are acutely ill
and injured.
• Emergency radiography can be an
exciting ,challenging as well as stressful environment
for the radiographer
• Depends on how prepared the radiographer is to
handle the situation
Emergency department
• “Emergency department” signifies a specific level
of emergency medical care.
• A medical emergency is an injury or illness that is
acute and poses an immediate risk to a person's life
or long term health.
Trauma
• Trauma is defined as any physical damage to the
body caused by a sudden, unexpected, dramatic,
forceful, violent or accident event or fracture etc.
• Emergency medical care often is the difference
between life and death.
• Radiographers in the emergency department (ED)
must be prepared for a variety of procedures on
patients in all age groups
ER at Bir Hospital
• DRGEM Company
• X-ray tube – Toshiba E7239X Model
• Manufactured – June 2014
• Maximum 120 kVp, minimum 40 kVp
• Focal spot 2.0/1.0
• Grid ratio 10:1
• Target angle 16’
Patient conditions and
preparation
• Closely supervise trauma patients at all times.
• A patient who requires examination of the whole
spine, chest & pelvis, lateral radiograph should be
performed before the anterior posterior radiograph
which avoids wasting time in moving the tube back
and forth between exposure.
Patient preparation
• To minimize risk of exacerbating the patient's
condition, the x-ray tube and lR should be positioned,
rather than the patient or the part.
• Patient history must be taken into consideration
• The items that might cause an artifact on the images
should be checked.
• facility for proper storage of a patient's personal
belongings is required.
Responsibilities of
radiographers
• should develop an understanding of the imaging equipment
utilized in ER.
• Should know the role of the radiographer as a vital part of the
ER team.
• present the common radiographic procedures performed on
emergency patients.
• Perform quality diagnostic imaging procedures as
requested
• Practice ethical radiation protection
• Provide competent patient care
Equipment
• To minimize the time required to acquire diagnostic x-
ray images, many ERs have dedicated radiographic
equipment
• It provide greater flexibility with a minimal patient
movement. to minimize movement of the injured
patient while performing imaging procedures
ER equipment
table.
• some ERs are equipped with specialized beds or stretchers
that have a moveable tray to hold the l R.
• This type of stretcher allows the use of a mobile
radiographic unit and eliminates the requirement and risk of
transferring an injured patient to the radiographic table
• Mobile radiography is widely utilized in the ER.
(Battery Powered & Capacitor Discharge)
• C-arms are utilized for fracture reduction procedures,
foreign body localization in limbs, and for reducing joint
dislocations
• Celling suspended tube, vertical Bucky, floating table top
with Bucky
• Skull Unit
Capacitor-discharge unit

• Carries two metal plates that hold electrical charge.

• Capacitor units must be charged prior to each exposure.

• Requires much less time to charge than battery-powered unit.

• Can’t sufficiently expose thick body parts due to voltage drop

during exposure.
 Battery powered unit
• Heavy to handle than CD type.

• Uses two different sets of batteries

 One for driving the machine
Next one provides power to the x-ray tube
• Can make many exposures in contrast to the CD type
• Can be driven to reasonable distances
• Needs special care and maintenance.
Fig: A, Dedicated C-arm type trauma
radiographic room with patient on the
table
Fig: B, Dedicated conventional trauma
radiographic room with vertical Bucky.
Fig : Mobile fluoroscopic C-arm.
Immobilization devices
• To stabilize injured patients.
• To prevent involuntary and voluntary motion
• Once injuries have been diagnosed or ruled out, the attending
physician gives the order for immobilization to be removed,
changed, or continued.
• Radiolucent foam pads, Sponges, sandbags, and the creative use
of tape are often most useful tools.
• I R holders helps to perform cross-table lateral projections on
numerous body parts with minimal distortion.
 Grids
• Grids and IR holders are necessities since many
projections require the use of a horizontal central ray.
• Focused grid, lower grid ratio ( 6:1),12:1 bulky patient
grids)
• Non-linear type grid which have wider film range and
better tolerance of central ray angulation and centering
• Correct FFD for the type of grid is used otherwise cutoff
artifact will result.
Exposure factors
• shortest possible exposure time that can be set should be
used in every procedure, except when a breathing
technique is desired.
• Radiographic exposure factor compensation may be
required when making exposures through immobilization
devices, like a spine board or backboard.
• Pathologic changes should also be considered when setting
technical factors. For instance, internal bleeding in the
abdominal cavity would absorb a greater amount of
radiation than a bowel obstruction.
Radiation
protection
• Collimation to the anatomy of interest to reduce scatter,
• Gonad shielding for the patients of child-bearing age
• Lead aprons for all personnel that remain in the room
during the procedure
• Exposure factors that minimize patient dose and scattered
radiation
• Announcement of impending exposure to allow unnecessary
personnel to exit the room
 Best practices in trauma
patients
• Speed - Performing Quick or rapid diagnostic examination
is critical to saving the patients life.
• Accuracy - must provide an accurate images with a minimal
amount of distortion and the maximum amount of recorded
detail.
• Quality - The quality of a radiograph does not have to
sacrifice to produce an image quickly.
• Positioning- careful precautions must be taken to ensure that
performance of the imaging procedure does not exacerbate the
patient’s injuries. As often as possible, the radiographer should
position the tube and the IR ,rather than the patient.

• Anticipation- Anticipating required special projections or diagnostic

procedures for certain injuries makes the radiographer a vital part of
the emergency department team.
Practice standard precautions
• Gloves, mask, and gown must be properly worn.
• Protect the IR and sponges and keep all equipment and
accessory devices clean
• Wash hand frequently, especially between patients.
• Adhere to Code of Ethics for Radiologic Technologist
and the Practice Standards of professionalism
 Positioning and technique in
trauma
• Chest
• Ribs and sternum
• Abdomen
• Upper extremities
• Lower extremities
• Spine
• skull
 Chest
• AP
• Lateral
• Lateral decubitus AP
 chest
• Don’t elevate patient in erect position who have suspected spinal injury
• Head end of the bed can be elevated to achieve semi-erect positon
• Cassettes is placed 2 inch above the shoulder
• Arms should be internally rotated to remove scapulae out of lung field
• CR is directed 3-4 inches below the jugular notch with CR 3-5 inch
caudally
• SID 72 inches or 48 inches if not possible
Sternum
• AP
• Left posterior oblique (LPO)
• Lateral Horizontal beam
 Ribs
• AP
• Obliques
• Alternatives Oblique view
• For upper ribs patient is preferrd erect position , in cases of
trauma to prevent lungs puncture by fractured ribs
• For lower ribs patient is supine and scapula out of lungs field ,
if patient is stable
 Abdomen

• Supine AP
• Left lateral decubitus
• Dorsal decubitus
Abdomen

• If transfer to x-ray table is not possible ,ask to lift the patient

for IR to be placed.
• IR centered to MSP at level of iliac crest
• Image demonstrates entire abdomen with pubic symphysis
visible at lower border
pelvis
• Immobilize the patient
• IR is placed 2.5 cm above pubic symphysis
• Ensure arms are not in the anatomy of intrest
• Image demonstrates entire pelvis and proximal femur
 Upper
extremities
• AP, Obliques, Lateral ( Fingers, Thumb, Hands, Wrist,
Forearm)
• Elbow PA & Lateral
• Humerus AP & Lateral
• Shoulder AP, Lateral, Y-view
• Scapula AP
• Clavicle AP & Axial
Lower extremities
• Toe and foot ( AP & Lateral)
• Ankle ( AP, Mortice, lateral, lateromedial)
• Leg (AP)
• Knee ( AP & Lateral, Oblique with lateromedial angulation
• Thigh and Hip region ( AP & Lateral )
• Pelvis (AP , lateral)
Upper and lower limbs
• Obtain lift for IR placement
• Injured limbs should be lifted with support at both joints and
should only be lifted enough to place IR
• Do not attempt to rotate severly injured limbs for true
positions
• Minimize patient safety and comfort by moving tube rather
than injured limb
Spine
• Cervical spine(AP , open mouth ,lateral, oblique)
• Thoracolumbar( AP , lateral)
• Patient is supine and immobilized with spine board
• Horizontal CR centered to midpoint of image receptor
• For cervical spine ,if all the seven vertebra are not seen then
swimmers lateral is performed
•
Skull
• Lateral
• AP
• Townes view
• Facial bones (lateral ,reverse waters view)
• Mandible( AP, AP axial)
• Patient with head trauma are often refered to CT first
• When x-ray is to be taken ,AP and lateral projections are
taken
• Patient is supine and horizontal beam is given
• Patient with facial bone injury are refered to CT first
Other imaging modalities
• Computed tomography is extensively used
• ultrasonography
• Magnetic Resonance Imaging (multiple vertebral
injuries)
 References
• Clarks positioning 12th edition
• Text book of radiology for resident and technician, 5 th edition
• [Link]
• [Link]