optimizing pediatric ct in the emergency...
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Optimizing Pediatric CT in the Emergency Department
Cristina T. Dodge, MS DABR
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Outline
• How is the pediatric patient different?
• Pediatric patient age and size
• The most common CT scan in the ER
• Step-by-step approach to establishing pediatric protocols
• Notes for the medical physicist
• Notes for the technologists
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Outline
• How is the pediatric patient different?
• Pediatric patient age and size
• The most common CT scan in the ER
• Step-by-step approach to establishing pediatric protocols
• Notes for the medical physicist
• Notes for the technologists
3
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http://www.jisppd.com
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http://www.rch.org.au5
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http://www.rch.org.au6
http://www.emsworld.com
Heat production1.5X of adult
BSA 4X of adult
Higher risk of hypothermia
The smaller the patient, the
greater the ratio of surface area
(skin) to size
Higher risk of dehydration
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http://www.rch.org.au7
http://www.emsworld.com
Epidermis is thinner
and under-keratinized
Affected more quickly and easily by
toxins absorbed
through the skin
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http://www.rch.org.au8
http://www.emsworld.com
More susceptible
to contaminants in food or water
Greater risk for increased loss of water and when ill or
stressedMedication
must be calculated
based on weight
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Adult heart increases its stroke volume by:
• strengthening contractions• increasing heart rate
Pediatric heart can only increase heart rate
• occupies much of the thoracic cavity
• children have less pulmonary reserve than adults
9
10-year-old
2-month-old
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http://image.wikifoundry.com
• Bone are not completely calcified –more flexible.
• Ribs are more horizontal than they are rounded.
http://www.emsworld.com
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http://image.wikifoundry.com
http://www.emsworld.com
Because bone is not fully calcified the subject contrast in kids is lower
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Outline
• How is the pediatric patient different?
• Pediatric patient age and size
• The most common CT scan in the ER
• Step-by-step approach to establishing pediatric protocols
• Notes for the medical physicist
• Notes for the technologists
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Patient size measured on CT images as a function of age at a tertiary care children's hospital
Kleinman PL, Strauss KJ, Zurakowski D, Buckley KS, Taylor GA. AJR Am J Roentgenol. 2010 Jun;194(6):1611-9. 13
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Kleinman PL, Strauss KJ, Zurakowski D, Buckley KS, Taylor GA. AJR Am J Roentgenol. 2010 Jun;194(6):1611-9
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Age versus head size - TCH
y = 145.8x0.0982
R² = 0.609
0
50
100
150
200
0.0 0.2 0.4 0.6 0.8 1.0 1.2
Late
ral d
ime
nti
on
(m
m)
Age (years)
y = 166.2x0.0834
R² = 0.662
0
50
100
150
200
0.0 0.2 0.4 0.6 0.8 1.0 1.2
AP
dim
en
tio
n (
mm
)
Age (years)
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Age versus head size – effective diameter
y = 12.9x0.5417
R² = 0.997
0
2
4
6
8
10
12
14
16
0.0 0.2 0.4 0.6 0.8 1.0 1.2
Effe
ctiv
e D
iam
ete
r (m
m)
Age (years)
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Kleinman PL, Strauss KJ, Zurakowski D, Buckley KS, Taylor GA. AJR Am J Roentgenol. 2010 Jun;194(6):1611-9
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Kleinman PL, Strauss KJ, Zurakowski D, Buckley KS, Taylor GA. AJR Am J Roentgenol. 2010 Jun;194(6):1611-9
18
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Kleinman PL, Strauss KJ, Zurakowski D, Buckley KS, Taylor GA. AJR Am J Roentgenol. 2010 Jun;194(6):1611-9
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Outline
• How is the pediatric patient different?
• Pediatric patient age and size
• The most common CT scan in the ER
• Step-by-step approach to optimizing pediatric protocols
• Notes for the medical physicist
• Notes for the technologists
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Most common scan in TCH ER
NeuroCases per
month
N1 Trauma 208
N2 Headache 130
N3 VP shunt 94
N4 Infection +
N5Orbits infection/foreign body
9
N6Neck/soft issue/ infection/tumor staging
31
N7 CTA brain 6
N8 CTV brain 2
N9 Neck CTA 2
N10 Neck CTV -
N11 Sinuses -
N12 Temporal bone -
N13 Spine -
BodyCases per
month
B1 Pulmonary Mets 87
B2 Pulmonary Infection 45
B3Staging mediastinal/lymphoma
22
B4 Pleural diseases 6
B5 HRCT (CF, bronchiectasis) 9
B6Lung congential (CHD, CPAM)
12
B7 Pectus 6
B8 Lung Disease, Other 11
Abdomen + Pelvis
Cases per month
A1 Tumor staging 46
A2 Infection fungal 11
A3 Renal stone 7
A4Routine abdomen and pelvis
55
A5 Renal CTA 10
A6 Abdomen trauma 5
A7 Multiphase abdomen 2
A8Abdomen CTA/CTV (liver, PV, WC)
13
A9 Abd, pelvis, other -
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Indications for head CT
• Trauma
•Headache
•Dizziness and vomiting (intra-cranial pressure)
•MRI used to follow up findings or if the CT is negative and symptoms persist, then determine cause
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1/31 2/15 3/11
4/8 6/10
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Indications for head CT
• Looking for gross anatomy:• Fractures
• Masses
• Bleeding in an and around the brain
• The types of diseases are different in kids• CT protocols are not developed to detect the same type of
anatomy as in adults
• Lung cancer is not prevalent in the pediatric population – CT scans are not optimized to detect small lung nodules
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1.2 year old 1.6 year old
21.3 mGy250 mA
34.5 mGy350 mA
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Outline
• How is the pediatric patient different?
• Pediatric patient age and size
• The most common CT scan in the ER
• Step-by-step approach to establishing pediatric protocols
• Notes for the medical physicist
• Notes for the technologists
26
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http://imagegently.org/Procedures/Interventional-Radiology/Protocols
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http://imagegently.org/Procedures/Interventional-Radiology/Protocols 28
Establish pediatric patient thorax DRLs for all CT scanners in department.
Establish pediatric patient abdominal and abdominal/pelvic Diagnostic Reference Levels (DRLs) and scan parameters for all CT scanners in department.
Match image quality of all CT scanners in department to department’s primary CT scanner.
Establish acceptable scan parameters, CTDIvol and Size Specific Dose Estimate (SSDE) for adult size patients on department’s primary CT scanner.
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Achieve established DRLs with CT scanners using Automatic Exposure Control.
Establish reduced tube voltage (kV) techniques for all CT scanners in department.
Establish pediatric DRLs for all CT scanners in department with iterative reconstruction.
Establish pediatric head DRLs for all CT scanners in department.
http://imagegently.org/Procedures/Interventional-Radiology/Protocols
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http://imagegently.org/Procedures/Interventional-Radiology/Protocols
Step 1: Define the optimal protocol
Establish acceptable scan parameters, CTDIvol and Size Specific Dose Estimate (SSDE) for adult size patients on department’s primary CT scanner.
• Calculate CTDIvol and SSDE for the baseline scans that you have
• Compare those numbers to ACR or other sources or DRLs
• Talk to your radiologists to ensure that the images are adequate and not too noisy
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Goske et al. Diagnostic reference ranges for pediatric abdominal CT. Radiology. 2013 Jul;268(1):208-18.
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Goske et al. Diagnostic reference ranges for pediatric abdominal CT. Radiology. 2013 Jul;268(1):208-18. doi: 10.1148/radiol.13120730. Epub 2013 Mar 19.
DRRs based on 969 Abd/Pel patients
• 98% single phase
• 28% without TCM
• Pain was the most common indication (49%), then trauma (17%), tumor (9%)
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http://imagegently.org/Procedures/Interventional-Radiology/Protocols
Step 2: Uniformity across the enterprise
Match image quality of all CT scanners in department to department’s primary CT scanner.
• Match radiation dose (not protocol parameters such as mAs) across all scanners at the institution
• Monitor the changes to ensure clinical image quality is acceptable
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http://imagegently.org/Procedures/Interventional-Radiology/Protocols
Steps to establish pediatric size-specific protocols
1. Establish acceptable scan parameters, CTDIvol and Size Specific Dose Estimate (SSDE) for adult size patients on department’s primary CT scanner.
2. Match image quality of all CT scanners in department to department’s primary CT scanner.
3. Establish pediatric patient abdominal and abdominal/pelvic Diagnostic Reference Levels (DRLs) and scan parameters for all CT scanners in department.
4. Establish pediatric patient thorax DRLs for all CT scanners in department.
5. Establish pediatric head DRLs for all CT scanners in department.
6. Establish pediatric DRLs for all CT scanners in department with iterative reconstruction.
7. Establish reduced tube voltage (kV) techniques for all CT scanners in department.
8. Achieve established DRLs with CT scanners using Automatic Exposure Control (AEC).
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http://imagegently.org/Procedures/Interventional-Radiology/Protocols 35
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http://imagegently.org/Procedures/Interventional-Radiology/Protocols
A few guidelines
1. Thorax versus abdomen techniques should be lowered by ~20% to account for the presence of air
2. A 5-year-old head is about 90% of the adult head size
3. A 1 year old’s head CT scan dose should be about ½ of the adult dose
4. Using iterative reconstruction can reduce the dose by 30%
5. Lowering kVp:1. Less energy of the photons – less penetration2. Increase noise in the image3. Used to increase subject contrast – can increase mAs to keep the dose and
noise the same as for the higher kVP
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www.aapm.org/pubs/CTProtocols
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From a fellow physicist….
•Work with one (head) radiologist
•Get insights on what features are relevant in that protocol
•Work with a good technologist •preferred recon views• contrast injection rate
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From a fellow physicist….
•A radiologist will not agree with a physicist’s idea of the best image acquired with the lowest dose possible
•Different units of the same manufacturer and model can behave differently• change focal spot at different mA stations
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From the radiologists…
•Pediatric scans are noisier•Pediatric brain isn’t completely myelinated yet•Difficult to tell the difference between a pixel and a
punctate bleed or calcification•Need to look at the noise pattern and decide if it’s
real or not• Less confident in subtle changes
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2 year old4D Dynamic
Lung
8.1 mGy80 kVp, 15 mAs
4 month old4D Dynamic
Lung
5.76 mGy80 kVp, 10.5 mAs
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Very good qualityExemplary quality Good quality
Diagnostic, limited Nondiagnostic
For each image, the dose was reduced by 1/2
Goske et al. Diagnostic reference ranges for pediatric abdominal CT. Radiology. 2013 Jul;268(1):208-18. doi: 10.1148/radiol.13120730. Epub 2013 Mar 19.
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From the radiologists…
•Use iterative reconstruction algorithms to smooth out images
•Co-operation in kids is often a major hurdle
•Smaller organs and smaller features•Difficult to visualize pediatric bile ducts
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Final thought…
• Indication-based CT protocols are the key to optimize dose and image quality in the pediatric population
•Historically, the indication for stroke (ischemic process) is one of the reasons to keep dose high in head CT but…
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even if it is detected, there is no treatment – will not impact patient care
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17 year old Renal stone
11 year oldAppendicitis
15.9 mGySD 8
7 mGySD 18
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16 year oldTraumaAbd/pel
5.3 mGySD 8
16 year oldRoutineAbd/pel
10.2 mGySD 12.5
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Outline
• How is the pediatric patient different?
• Pediatric patient age and size
• The most common CT scan in the ER
• Step-by-step approach to optimizing pediatric protocols
• Notes for the medical physicist
• Notes for the technologists
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TCH Adult Protocols
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Fixed mAs
• Routine Brain
• Sinuses
• Max-face and orbits
• Brain perfusion
• Stroke
• Brain CTA
• Brain shunt
• Mastoids
• 4D dynamic lung
• Chest biopsy
• Extremity: foot, hip, knee, ankle, shoulder, hand, wrist, elbow
TCM
• Neck
• C-spine
• Chest
• CTA/PE heart
• T-spine
• L-spine
• Chest/Abdomen/Pelvis (trauma, tumor)
• Liver
• Renal stone
• Appendicitis
• Pancreas
• Kidneys
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TCH Pedi Protocols
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Fixed mAs
• Routine Brain
• Sinuses
• Max-face and orbits
• Brain perfusion
• Stroke
• Brain CTA
• Brain shunt
• Mastoids
• 4D dynamic lung
• Chest biopsy
• Extremity: foot, hip, knee, ankle, shoulder, hand, wrist, elbow
• C-spine, Chest, CTA/PE heart < 30 kg
• NICU abdomen
TCM
• Neck
• C-spine > 30 kg
• Chest > 30 kg
• CTA/PE heart > 30 kg
• T-spine
• L-spine
• Chest/Abdomen/Pelvis (trauma, tumor)
• Liver
• Renal stone
• Appendicitis
• Pancreas
• Kidneys (donor)
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Noise index and patient size
kV mA CTDIvol Eff.mAs Collimation NI
Abdomen NICU ONLY (Volume) 100 150 2.3 53 0.5 x 320 ***
Abd/Pelvis (>15 kg) 120 R300 7.8 3 0.5 x 80 7.5
Abd/Pelvis (16-30 kg) 120 R350 8.6 5 0.5 x 128 10
Abd/Pelvis (31-45 kg) 120 R230 6.2 6 0.5 x 160 12.5
Abd/Pelvis (46-60 kg) 120 R160 5.2 6 0.5 x 160 15
Trauma Abd/Pelvis Child 120 R350 10.2 5 0.5 x 128 8
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Goske et al. Diagnostic reference ranges for pediatric abdominal CT. Radiology. 2013 Jul;268(1):208-18. doi: 10.1148/radiol.13120730. Epub 2013 Mar 19.
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Goske et al. Diagnostic reference ranges for pediatric abdominal CT. Radiology. 2013 Jul;268(1):208-18. doi: 10.1148/radiol.13120730. Epub 2013 Mar 19. 54
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2 year old4D Dynamic
Lung
8.1 mGy80 kVp, 15 mAs
11 year old4D Dynamic
Lung
14 mGy100 kVp, 52.5 mAs
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ACR accreditation• New definition of pediatric patient
• ≤ 18 years as of 7/27/15
• When do you need to submit pediatric patient images?• If you ever scan even ONE pediatric patient
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Outline
• How is the pediatric patient different?
• Pediatric patient age and size
• The most common CT scan in the ER
• Step-by-step approach to optimizing pediatric protocols
• Notes for the medical physicist
• Notes for the technologists
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• The most common mistake – not securing the patient• Will result in a re-scan
• Swaddle, swaddle, swaddle
• With pediatric patients, dose is on everyone's mind
brycescraniostory.blogspot.com
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Understand what kids can and can’t do
• They won’t hold still for very long • Be watchful and take that window of opportunity to scan
when you can• If missed, not likely to get another one
• Even for abd/pel scans, put the kids in the head holder and scan head first• Otherwise they will prop their feet on the gantry and try
to get out
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Sedation
•2 patients/week require sedation•Biopsies•Patients with developmental or intellectual delays (Down syndrome, Autism)
•Swaddle, swaddle, swaddle
•Child life department
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Minimizing sedation by Swaddling
•8 wash cloths on the side of the head + the strap across
•6 baby blankets around to body
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Minimizing sedation by protocol optimization
• Take advantage of the features available on your system
• Fastest rotation time
•Highest pitch that the radiologists will accept
•Volume scanning
•Projector or TV screen
www.luriechildrens.org
www.reddit.com
www.itnonline.com
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New Features
http://health.siemens.com/ct_applications/somatomsessions/wp-content/uploads/2015/12/S_DSCT_Fig2.jpg Curtesy of Toshiba
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Conventional Organ-Based Modulation
Organ-based tube current modulation
AAPM Computed Tomography Radiation Dose Education Slides64
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•Allow kids to hold toys or pacifiers
•Parents/caregivers can stay next to the table
www..philips.com
www.luriechildrens.org
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Minimizing sedation by protocol optimization
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IV contrast and delay timing
•Contrast by weight and body region:•1.5 mL/kg for chest•2 mL/kg for abdomen and pelvis•2.5 mL/kg for CTA
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IV contrast and delay timing
•Contrast depends on the age, IV location and exam:• 2 mL/sec for babies – up to 13 mL total• 2.5 mL/sec for small infants and when you don’t want to
blow the IV• 4-4.5 mL/sec for children – 70-90 mL total
• Faster rates for imaging the coronary arteries (it will cause them to open up more)
• 3-3.5 mL/sec if you can’t go to 4-4.5 because of a bad IV or if it is in the foot
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Radiation safety: staff holding the patient
Monitoring Period Total DDE Total LDE Total SDE
Lead technologist 2015 89 89 84
Day technologist1 2015 M M M
Day technologist2 2015 58 57 54
Evening technologist1 2015 M M M
Evening technologist2 2015 4 4 4
Weekend technologist1 2015 M M M
Weekend technologist2 2015 M M M
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Radiation safety: parents holding the patient
Gantry shadowTLD reading = M7 days 24 hr ER CT
Back go gantryTLD = 2230 mrem7 days 24 hr ER CT
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