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version 1.1 – Dated 10 January 2013

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Contents 1.1 Introduction ................................................................................................................................. 3

The Image Gently Campaign: Working Together To Change Practice. .............................................. 3

2.1 Radiographs .................................................................................................................................. 8

Skeletal Survey ..................................................................................................................................... 8

Skull X-Rays .......................................................................................................................................... 9

Abdominal X-Rays .............................................................................................................................. 10

2.2 Fluoroscopy ................................................................................................................................ 11

Swallow / Meal (including via nasogastric tube or gastrostomy) ...................................................... 11

Oesophagogram ................................................................................................................................. 14

Naso-Jejunal Tube Insertion ............................................................................................................... 16

Contrast enema…………………………………………..…………………………………………………………………………………18

Air Enema Reduction For Intussusception ......................................................................................... 20

Micturating Cysto-Urethrogram (MCUG) .......................................................................................... 23

2.3 Intravenous Urography (IVU) ..................................................................................................... 25

2.4 Computed Tomography (CT) ...................................................................................................... 26

Weight And Age-Based Exposure Factors For CT In Children ............................................................ 26

General Rules For CT Scanning In Children ........................................................................................ 28

Brain ................................................................................................................................................... 30

Paranasal Sinuses ............................................................................................................................... 31

Neck / C-Spine .................................................................................................................................... 32

Chest (Combi-Scan) ............................................................................................................................ 33

Chest and Abdomen ........................................................................................................................... 34

Abdomen ............................................................................................................................................ 35

Bony Pelvis Hips ................................................................................................................................. 36

Angiogram .......................................................................................................................................... 36

2.5 Magnetic Resonance Imaging (MRI) .......................................................................................... 37

MRI Acronyms .................................................................................................................................... 37

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Brain ................................................................................................................................................... 39

Pituitary Gland ................................................................................................................................... 41

Orbits .................................................................................................................................................. 41

Internal Auditory Meati ..................................................................................................................... 41

Non-Accidental Injury ........................................................................................................................ 42

Face and Neck .................................................................................................................................... 42

Abdomen ............................................................................................................................................ 43

Pelvis .................................................................................................................................................. 46

Oncology ............................................................................................................................................ 47

Spine ................................................................................................................................................... 48

Angiograms ........................................................................................................................................ 51

Whole Body ........................................................................................................................................ 52

2.6 Urinary Tract Infection ............................................................................................................... 53

2.7 Sinus Disease .............................................................................................................................. 54

2.8 Sedation ..................................................................................................................................... 55

Sedation Guidelines For CT / MRI: ..................................................................................................... 55

Indications For General Anaesthesia: ................................................................................................ 55

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1.1 INTRODUCTION

The Radiological Society of South Africa (RSSA) and the South African Society of Paediatric Imaging (SASPI) support the image gently® campaign, an initiative of the Alliance for Radiation Safety in Pediatric Imaging which aims to change practice by increasing awareness of the opportunities to promote radiation protection in the imaging of children. The purpose of these paediatric imaging guidelines is to provide South African radiologists and technologists working in predominantly “adult” health care facilities (both in hospital and private practice) with tools to image children in line with the well-known ALARA (As Low As Reasonably Achieveable) principle. By nationalising these guidelines, we can collectively take the pledge to serve our paediatric patients and image gently®.

Excerpts from:

The Image Gently campaign: working together to change practice

Goske MJ, Applegate KE, Boylan J, Butler PF, Callahan MJ, Coley BD, Farley S, Frush DP, Hernanz-Schulman

M, Jaramillo D, Johnson ND,Kaste SC, Morrison G, Strauss KJ, Tuggle N. AJR Am J Roentgenol. 2008

Feb;190(2):273-4.

“We know radiologists and radiology technologists want to do the best for their pediatric patients but may be hampered by a lack of familiarity with pediatric protocols. ...The Image Gently Alliance is not just an alliance of organizations; it is a dynamic alliance of individual health care professionals—the radiologist, radiology technologist, medical physicist, and pediatrician. This team approach creates a powerful force that can change practice. We ask that each radiology practice take a fresh look at their protocols.

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… decrease radiation by doing four simple things. First, reduce or “child-size” the amount of radiation used. This can be accomplished simply by contacting your medical physicist and asking him or her to determine the baseline radiation dose for an adult for your equipment and compare that dose with the ACR Standards. Second, scan only when necessary. An increased awareness about the need to discuss the risk–benefit ratio for performance of a CT examination enhances the role of the radiologist consultant and provides an opportunity for educational interaction with the child's pediatrician, who has unique medical knowledge critical to the care of the patient. Third, scan only the indicated region. Protocols in children should be individualized. A follow-up CT scan in an asymptomatic child with an incidental lung nodule is unlikely to require that the entire chest be rescanned. Fourth, scan once; multiphase scanning is usually not necessary in children. CT with and without contrast material is rarely needed in children. Multiphase imaging often will double or triple the dose to the child and rarely adds to the diagnostic information of the study. It is estimated that between 4 and 7 million CT scans were obtained in children in 2007. That number is growing. There is a reported 300–400% increase in cervical spine and chest CT scans in the pediatric emergency setting. Many of these studies directly impact the clinical diagnosis of the referring physician; increase his or her confidence in the diagnosis; and in some settings, such as trauma, may obviate exploratory surgery. There is no question that CT is an extremely valuable diagnostic imaging tool in children. Although CT is often beneficial for the individual patient, the increase in radiation has become a public health issue. Radiologists and radiology technologists can follow the four steps listed earlier to comply with the ALARA principle.”

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Estimated Doses from Diagnostic Imaging in Children (www.imagegently.org)

Source Estimated Dose Equivalent to background

Natural background 3 mSv/year

Airline passenger cross

country

0.04 mSv

Chest x-ray (single view) 0.01-0.15 mSv 1 day of background radiation

Chest x-ray (2 view) 0.1-0.15 mSv

Head CT (adjusted)

Head CT (adult settings)

Up to 2 mSv

(30 – 60 mSv if a

neonate)

8 months of background / About 100 chest x-

rays

Chest CT (adjusted)

Chest CT (adult settings)

Up to 3 mSv About 150 chest x-rays

Abdominal CT (adjusted)

Abdominal CT (adult settings)

Up to 5 mSv

Up to 25 mSv

20 months background / About 250 chest x-

rays

Low level radiation by definition is below 100mSv

Above 100 mSv is in range with a clearly established cancer risk

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The risk of developing a radiation-induced cancer has been estimated to be 5%

per Sv at all ages but this figure is close to 15% if exposed in the first decade [1].

There is a 1 in 1000 risk for an exposure of 10 mSv [1, 2] (i.e. an abdominal CT).

The effective dose of a single paediatric CT ranges from 50 – 60 mSv [1].

The lifetime cancer risk from an abdominal CT in a 1 year old is 1 in 550 and for

head CT in a 1 year old is 1 in 1500 [3].

CTDI = CT dose index:

- Based on phantom (32cm or 16 cm) analysis - Includes radiation dose in a slice in mGy + penumbra + scatter - Depends on selected parameters and does not reflect actual dose - CTDIvol = contribution of pitch included - For same chosen parameters, the dose for the larger (32cm) phantom is always

less than for the smaller phantom (16cm) - NB Do not use large phantom for a child (underestimates dose by 2x)

DLP = dose length product

- dose in mGy.cm - Product of CTDI and Scan length (increases with scan distance)

Effective Dose = DLP x Conversion factor (not accurate in children)

- Conversion factor for head = 0.0023 - Conversion factor for chest = 0.017 - Conversion factor for abdomen = 0.015 - Conversion factor for pelvis = 0.019

1. Shah NB, Platt SL. ALARA: is there a cause for alarm? Reducing radiation risks from computed tomography scanning in children. Curr Opin Pediatr 2008, 20 : 243 – 247

2. Paterson A, Frush DP. Dose reduction in Paediatric MDCT: general principles. Clin Rad 2007; 62: 507 – 517

3. Brenner DJ, Elliston CD, Hall EJ, Berdon WE. Estimated risks of radiation induced fatal cancer form paediatric CT. AJR American Journal of Roentgenology 2011; 176: 289 – 296

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2.1 RADIOGRAPHS

SKELETAL SURVEY FOR NON-ACCIDENTAL INJURY

A skeletal survey should be performed during normal working hours by a radiographer experienced in imaging children.

i. Axial skeleton

Thorax (AP, Lateral and bilateral Oblique ribs), to include ribs, thoracic and upper lumbar spine

Pelvis (AP), to include mid lumbar spine

Lumbosacraml spine (Lateral)

Cervical spine (AP and Lateral)

Skull (Frontal and Lateral; additional views if necessary – Oblique or Towne’s view)

ii. Appendicular skeleton

Humeri (AP)

Forearms (AP)

Hands (PA)

Femora (AP)

Lower legs (AP)

Feet (PA or AP)

Additional views if necessary (centred on joints or lateral views)

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SKULL X-RAYS

i. Indications

NOT indicated in the management of head injuries in children at institutions with CT scan facilities

In an institution with no available CT, a skull x-ray may be used in mild head injury – a visualised fracture must then be considered an indication for CT

Skull x-rays may be requested in suspected non-accidental injury (NAI) as part of the skeletal survey after discussion with the attending consultant (however, SXR is unnecessary if the patient is undergoing a volume scan on multi-slice CT)

CT (not SXR) should be performed for head shape abnormalities / craniostenosis and referred by a neurosurgeon

ii. Imaging protocol for head injuries

No role for skull x-rays

Currently no role for cranial ultrasound

CT head – low threshold for imaging except in resource-limited setting, then employ the following guidelines for CT referral:

o GCS ≤ 14 on assessment at hospital after adequate resuscitation o Abnormal drowsiness o Focal signs o Penetrating injury o Suspected base of skull fracture o Clinical suspicion of occipital / suboccipital fracture o NAI o Post-traumatic seizure o Vomiting > 3 times or > 2 hours post injury

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ABDOMINAL X-RAYS

i. “Series” (abdominal pain)

Requests for an abdominal x-ray for abdominal pain should routinely include:

o Supine AXR including the pubic symphysis o Erect CXR including the diaphragms

ii. Constipation

NOT indicated in the initial or routine management of constipation.

Marker study – only performed if recommended by a GIT paediatrician, and to follow a defined protocol.

iii. Encopresis

An abdominal x-ray is indicated.

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2.2 FLUOROSCOPY

SWALLOW / MEAL (INCLUDING VIA NGT OR GASTROSTOMY)

INDICATIONS:

Assessment of oesophageal and gastric anatomy, strictures, hiatus hernia, malrotation, volvulus and reflux. May rarely be indicated for assessment of pyloric stenosis.

Assessment of integrity of fundoplication.

CONTRA-INDICATIONS:

Known perforation.

Non-resuscitated, fluid-depleted, sick baby.

Recent feed (relative contra-indication). RISKS / HAZARDS:

Aspiration. Constipation from barium.

Barium leak from unsuspected perforation. Vomiting due to full stomach.

PREPARATION:

Starve: Neonate - 3hours Infant - 4 hours Child - 6 hours

Remove metallic objects from neck to mid-

abdominal area; no need to remove all

clothes / change into gown.

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MATERIALS: (*LOCM = low osmolar contrast medium)

Contrast used depends on age of patient and perceived risk / likelihood of aspiration / urgent surgery

LOCM 150-300mgl/mL

if child < 6 months or urgent surgery possible Dilute Barium (Baritop® 1:1 with water) and choice of flavouring – better contrast definition especially if follow-through reqd

if child > 6 months

According to age of patient:

Bottle and teat Feeding cup

Cup and straw

Swabs

2 cups for barium / water

50ml / 20ml syringes if using NGT or

gastroscopy – check compatibility with tube

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TECHNIQUE: (* Collimate; use pulsed fluoroscopy 3p/s; intermittent screening)

- Swallows in right or left lateral position

(lying down)

- Observe swallow mechanism.

- Assess oesophageal calibre, peristalsis and impressions

(posterior).

- Wait for contrast to start to fill 2nd part duodenum.

- Once 2nd part duodenum filled, position true supine to

check position of DJ flexure.

- Continue drinking - supine.

- Well-filled stomach to assess for hiatus hernia and

reflux.

- Intermittent screening for 3 minutes maximum for

reflux. Assess highest level of reflux if seen.

- LAO view to assess fundus / fundoplication.

VIEWS:

‘Image capture’ only, if possible. Views of:

- lat nasopharynx - lat oesophagus - lat D2 - AP DJ flexure – cones open to include anterior ribs /

lower heart to check straight / supine - AP oesophagus - Full stomach - Highest level of reflux seen - LAO fundus if fundoplication present

AFTERCARE: If possible, aspirate contrast if NGT/ gastrostomy used

(unless follow-through).

Resume normal feeds if well.

Warn parents / child of possible constipation

+ change in stool colour from barium – drink plenty.

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TUBE OESOPHAGOGRAM

PERFORMED BY CONSULTANT WHEN HIGH CLINICAL SUSPICION DESPITE NORMAL CONVENTIONAL SWALLOW

INDICATION: Detection of H-type tracheo-oesophageal fistula. Typical history and normal conventional swallow.

CONTRA-INDICATIONS: Ensure other causes of symptoms (such as reflux) previously excluded.

RISKS / HAZARDS: Vagal response to oesophageal dilatation/ tracheal filling resulting in asystole.

Massive aspiration of contrast.

PREPARATION: NGT in situ if child unable to swallow

Experienced staff in paediatric

resuscitation present during

examination (clinical team must include

paediatrician)

O2

Suction

Resus box / trolley in room

Saturation monitor on patient

MATERIALS: 20ml syringes LOCM 300mg l/mL

TECHNIQUE:

1. If the child is able to swallow :

Baby lateral or prone oblique position - bed horizontal

2. If the child cannot swallow:

Insert a nasogastric tube

Baby in lateral or prone oblique position - bed horizontal

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TECHNIQUE cont.

- Inject large and fast boluses of contrast into oesophagus in 3 positions: distal, mid and proximal third.

- Stop bolus injection when fistula seen into

anterior (lower) trachea or if overspill occurs from epiglottis.

VIEWS: Continuous screening - save cine loops. If no fistula and stable, can convert to UGI exam to see stomach / DJ flexure +/GOR.

AFTERCARE: May need suctioning after procedure.

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NASO-JEJUNAL TUBE INSERTION

INDICATION:

Feeding in cases of GOR, gastric stasis / paresis.

Rapid feeding in burns, prems etc. CONTRA-INDICATIONS:

Gastric outlet obstruction Perforation

RISKS / HAZARDS:

Nasal obstruction

Bronchial intubation

Aspiration

Vomiting

Perforation PREPARATION:

NJ tube to be inserted in ward and guidewire removed.

Patient restrained, given Maxolon® and lying right

side down.

MATERIALS: (*LOCM = low osmolar contrast medium)

Gloves

KY jelly®

Guidewire 2 x 10ml syringes; one with LOCM, one with water Tegaderm®

Red sticker to mark tube

Patient sticker to mark guidewire

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TECHNIQUE:

- Screen to visualise tube position. - Insert guidewire. - Attempt to pass tube to level of DJ flexure. - Screen immediately – maximum 5 minutes screening time, then call consultant.

- Confirm tube position with contrast and capture

image.

- Tape securely in place, red marker in position.

- Keep guidewire in department marked with

child’s name.

AFTERCARE: Restrain patient in ward

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CONTRAST ENEMA

INDICATION:

(e.g. for Hirschprung; Meconium ileus; Small left colon syndrome; ileal or colonic atresia)

Evaluation of low intestinal obstruction in neonate. Evaluation of distal defunctioned bowel if no mucous fistula / loop stoma present. Evaluation of distal colon / rectum post anorectal repair with voiding difficulties. Assessment of possible leak post anorectal repair.

CONTRA-INDICATIONS: Known perforation Recent full thickness (not suction) biopsies Active colitis

RISKS / HAZARDS: Perforation Barium impaction (DO NOT USE BARIUM OR GASTROGRAFIN) Fluid balance shift with circulatory collapse Hypothermia

PREPARATION: CONSULTANT IN ROOM Must have IV line running (neonates). No rectal prep needed. No PR examination.

MATERIALS: Jacques / Foley catheter (small size) - DO NOT INFLATE THE BALLOON Warm LOCM 300 diluted 1:1 with water (prepare at least 100ml) 50ml syringes Linen savers Sticky tape Gloves Gauze

TECHNIQUE: Have recent AXR or expose abdomen to assess degree of dilatation and evidence of perforation

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- Insert catheter tip just beyond anal margin and tape buttocks together.

- With child in true left lateral position and rectum and sacrum visible, screen whilst instilling contrast to assess pre-sacral space and calibre of recto-sigmoid (To avoid missing low Hirschprung’s, do not insert catheter too far initially).

- Turn supine, (may need to grip buttocks), continue to instil contrast until dilated loops of bowel reached (may need 50-100ml contrast.

TIP: Treat all distal obstructions like Hirschsprung’s

VIEWS: ‘Image capture’ all unless poor visualisation - Lateral rectum / recto-sigmoid - Frontal view of contrast to splenic flexure - Frontal view demonstrating contrast to

terminal ileum - Frontal view of most proximal site reached

by contrast

AFTERCARE: Observe hydration state of patient - may need fluid bolus 20ml/kg. Dry and warm thoroughly.

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AIR ENEMA REDUCTION FOR INTUSSUSCEPTION

INDICATION:

Reduction (and occasional diagnosis) of ileocolic intussusception

CONTRA-INDICATIONS: Peritonitis

Perforation (free intra-abdominal air) Non-resuscitated child

RISKS / HAZARDS:

Explain success rate (70-80%)

Risk of perforation 1% with possibility of

tension pneumoperitoneum. At higher risk: longer history, poor colour flow in intussusception on US, presence of significant free fluid. Entrapped fluid (? controversial).

PREPARATION:

Referring paediatric surgeon in the room Patient resuscitated; IV line running Diagnostic ultrasound will have been performed

Monitor O2 saturation Large bore IV cannula readily available

MATERIALS: Resus box/trolley in screening room Catheter

Baumanometer with cuff, y-connection and tubing Elastoplast Gauze Linen savers

18G IV cannula in case of pneumo-peritoneum

TECHNIQUE: Tttttt

- Procedure explained and written

consent obtained for laparotomy if necessary.

- Senior referring surgeon to be present during study.

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TECHNIQUE cont. - Insert catheter tip to mid rectum, inflate balloon and tape buttocks well. Do not use jelly, as catheter will fall out.

- Child supine or prone, buttocks taped and

pinched tightly together. - Take exposure (if no recent AXR) of

abdomen to assess small bowel dilatation and exclude perforation.

- Using continuous fluoro of whole abdomen,

screen whilst pumping air at 80mmHg.

- Take image capture when

intussusception encountered. - Continue 3 minutes. Ensure

continuous screening as intussusception reaches caecum to see it reduced.

- Intussusception reduced when gas visualised bubbling into central small bowel loops. Take image capture or exposure if difficult to see.

- May find intussusception mass sticks at ileocaecal valve. Have a short rest and try

again. Use pressures of: 80mmHg for 3 minutes, 100mmHg for 3 minutes,

120mmHg for 3 minutes. If not reduced, surgeons may take child

to theatre or request repeat attempt in 4- 6 hours.

If perforation occurs, stop pumping immediately. Observe child for respiratory distress. Insert IV cannula 2cm above umbilicus and remove central needle.

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AFTERCARE:

Explain 10-15% risk of recurrence in next 48 hours. Patients usually kept NPO 6 hours by surgeons.

Repeat air reduction in the next 4-6 hours is acceptable practice – usually perform the next morning if initial exam done at night.

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MICTURATING CYSTO-URETHROGRAM (MCUG)

INDICATIONS:

(* Refer also to UTI protocol for indications)

Diagnosis of anatomical abnormality and VU reflux - refer to UTI protocol. Potential bladder outflow obstruction or reflux e.g. neuropathic bladder, antenatal hydronephrosis, suspected duplex system ± ureterocele, posterior urethral valves, potential rectovesical fistula i.e. anorectal malformation spectrum? Patent urachus.

CONTRA-INDICATIONS: Active UTI or other sepsis

RISKS / HAZARDS: UTI from catheterisation Septicaemia if performed during active UTI Urethral injury Vaginal injury Prepuce injury

PREPARATION: If structural cardiac disease, give antibiotic prophylaxis; discuss with cardiologists

MATERIALS: Cystogram tray Feeding tube KY jelly® / Remicane® Savlon® Warmed LOCM Saline Linen savers Narrow Micropore® tape Specimen tube and urine dipstix Gloves

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TECHNIQUE: No control film needed. - Dipstick urine prior to procedure. If nitrites or

leucocytes send sample for MC&S, contact doctor and rebook exam.

- Aseptic catheterisation. - Drain bladder into kidney dish. - Connect catheter to contrast and fill bladder

while screening (syringe or gravity) - Allow to void with catheter in situ. NB: Bladder capacity is (approx age + 2) x 30ml or 8ml/kg.

VIEWS: ‘Image capture’ all

BOYS: - Early filling frontal view – to look for filling defects such as ureteroceles and position of feeding tube

- (Frontal) + oblique full bladder views - Oblique voiding view (catheter in situ) - Frontal empty bladder view

GIRLS: - Early filling frontal view - Frontal full bladder - Frontal voiding bladder - Frontal empty bladder view

EITHER SEX: for vesical fistula or patent urachus

Screen whole examination in true lateral position to look for potential fistulae / leaks May then take frontal view to assess full bladder / potential reflux towards end of study.

AFTERCARE: Clean and dry patient. Warn carer that any residual contrast is sticky. Advise to contact doctor if child unwell or pyrexial in next 48 hours and explain recently had MCUG.

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2.3 INTRAVENOUS UROGRAPHY (IVU)

INDICATIONS: Consider MRU for all IVU requests

Demonstration of pelvicalyceal and ureteric anatomy, often for a suspected duplex system. Not part of UTI assessment.

CONTRA-INDICATIONS: Contrast allergy Absent venous access

RISKS / HAZARDS: Contrast allergy Extravasation of contrast

PREPARATION: Resus box / trolley in room O2 saturation Remove radio-opaque clothing from renal tract area Venous access to large vein e.g. antecubital fossa Obtain weight (kg) of patient

MATERIALS: Butterfly / IV cannula Skin prep, swabs, micropore Tourniquet LOCM 300 3ml/kg in 20ml syringes 10ml saline flush

TECHNIQUE and VIEWS: - Inject contrast bolus fast - Single, full-length, 7-minute film - No abdominal compression - Consider prone view to demonstrate full length

ureter

AFTERCARE: Remove venous access. Resume normal activities.

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2.4 COMPUTED TOMOGRAPHY (CT)

Weight and age-based exposure factors for CT in children

Exam kV mAs

Chest: Under 15 kg 100 20

15-24 kg 100 25 25-34 kg 100 35 35-44 kg 100 55 45-54 kg 100 75

Over 54 kg 100 100

Abdomen:

Under 15 kg 100 20 15-24 kg 100 35 25-34 kg 100 55 35-44 kg 100 85 45-54 kg 100 120

Over 54 kg 100 160

HRCT Chest:

Under 35 kg 120 25­55 35-54 kg 120 55

Over 54 kg 120 65

Chest Angiogram:

Under 15 kg 100 20 15-24 kg 100 25 25-34 kg 100 35 35-44 kg 100 40 45-54 kg 100 50 55-80 kg 100 60 Over 80 kg 100 80

Extremities: Elbow down or knee down

< 15 kg 120 21

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15-34 kg 120 35 35-54 kg 120 55

3D pelvis < 15 kg 120 21

15-34 kg 120 35 35-54 kg 120 70

Spine: Cervical spine

Under 15 kg 120 26 15-24 kg 120 55 25-34 kg 120 90 35-44 kg 120 130 45-54 kg 120 200

Heads: Brain:

Neonate 120 70 0-6mnth 120 90

6mnth - 3yrs 120 Base 150, cerebrum 130 3yrs - 6yrs 120 Base 220, cerebrum 180 6yrs -10yrs 120 Base 240, cerebrum 200 >10 yrs yrs 120 Base 240, cerebrum 200 Hydrocephalus:

0-6mnth 120 90 6mnth - 3 yrs 120 150 3yrs - 6 yrs 120 180 6yrs - 10 yrs 120 200

>10 yrs yrs 120 230 Sinuses:

< 3yrs 120 40 >3 yrs 120 60

IAM’s All ages 120 100

Orbits: < 3yrs 120 60

>3 yrs 120 90

Low dose 3D for surface shaded display on bone

120 30

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General rules for CT scanning in children

Children: less than 13 years of age (older = adolescents)

All requests should be agreed upon by a radiologist – say ‘no’ to unnecessary procedures

Offer alternative modalities like MRI or U/S

Scan only once – no multiphase, no pre contrast (use only post contrast, except trauma

head)

CT brain other than trauma – do post contrast only

Chest CT scan field: end at diaphragms, NOT adrenals

Wilms tumours – always do chest CT as well

Chest requests – do Combi-Scan (this is at finest slice thickness post contrast; get

reconstructed in soft tissue, lung and HR)

Put child in the centre of gantry

Use low dose scanogram

Decrease mAs. Decrease kV. Increase pitch.

MDCT – use one long study rather than 2 sections to decrease penumbra effects

Rules of thumb:

Jelco needle

Yellow -> flow rate = 1 ml/sec

Blue -> flow rate = 1 ml/sec

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Oral contrast

Mix 6 – 10 ml Omnipaque 300 with 500 ml water and give over 2 hours

Literature advises to give over an hour, but also advises to be careful about anaesthetic

requirements (NPO). No oral contrast in trauma!

1 0 - 6 months 20 ml every 1/2 hour x 4 80 ml max

2 6 months - 2 years 50 ml every 1/2 hour x 4 200 ml max

3 3 - 6 years 80 ml every 1/2 hour x 4 320 ml max

4 7 - 13 years 100 ml every 1/2 hour x 4 400 ml max

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BRAIN CT

Indication Trauma

For all other, consider MRI

Trauma Other

Contrast Non No Pre C/ only Post C

Dose n/a 1 ml/kg

Range vertex to below foramen magnum Vertex to below foramen magnum

Slice 1 mm or less recon 5 mm 1 mm or less recon 4 mm

Tilt Avoid eyes in scan plane Tilt gantry or patient’s head

Avoid eyes in scan plane Tilt gantry or patient’s head

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PARANASAL SINUSES CT

Indication

(A) Only after trial of therapy if planning endoscopic surgery

(B) Complicated Sinusitis – Orbital Cellulitis /Intracranial extension?

(C) No role for plain radiographs

(D) Do NOT image children under 4 years, particularly not under 2 years

(A) After trial of therapy prior to surgery

(B) Complicated Sinusitis – Orbital Cellulitis /Intracranial extension?

Contrast Non C Post C ONLY

2 ml/kg

No Delay

Slice 1 mm or less 1 mm or less

COR recons bone window

COR recons bone W sinuses

AX / COR soft tissue W sinus and orbits

Ax Brain 5 mm recon

Range Above orbits to below hard palate

Vertex to below foramen magnum

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NECK / C-SPINE CT

Indication Trauma / Abscess(retropharyngeal)

Masses / Cyst / Abscess - Consider MRI

Trauma Masses

Contrast Non C trauma Post contrast ONLY

Post C only for abscess 2ml/kg

2 ml/kg

Delay 30 sec Delay 30 sec

Slice 1 mm or less 1 mm or less

SAG/COR recons SAG/COR recons

Range Trauma: BOS to T1 Abscess: BOS to top of aortic arch

BOS to top of aortic arch

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CHEST (COMBI-SCAN) CT

Indication Any request for High Resolution CT (HRCT) or other pulmonary disease - DO THE SAME STUDY

Contrast No Pre C / only Post C (even for HRCT)

2ml/kg

(A) Delay 20-30 sec or (B) ROI aorta

Slice 1 mm or less

(A) Soft tissue window recon in 5 mm

(B) Lung window recon in 5mm

(C) HR recon with bone filter in 5 mm with 10 mm gap

Range Do NOT scan through adrenals routinely

Scan to below diaphragm except for sequestration / Scimitar syndrome - scan lower

If mosaic pattern, do expiratory views (left and right side down, each 3 select slices HRCT separately non C at end)

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CHEST AND ABDOMEN CT

Indication Trauma / infection / vascular

Lymphoma - consider MRI

Wilms tumor - consider MRI (reserve CT for chest only)

Contrast Post C only - single phase only

Volume 2 ml/kg

Delay 45 sec

Slice 1 mm or less

Range Customise - usually end at crests or include pelvis for sepsis

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ABDOMEN CT

Indication Trauma

Sepsis - Appendicitis

Vascular

Masses - consider MRI

Renal pathology - consider MRI

Contrast Post C ONLY - single phase only

Volume 2 ml/kg

Delay 45 - 50 sec / ROI ? Portal vein

ORAL: No oral C for trauma

Use diluted Omnipaque

See rules of thumb above for instructions for oral contrast

Slice 1 mm or less

Range Customise (Diaphragm to crests / diaphragm to pubis)

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BONY PELVIS HIPS CT

Indication Hip dysplasia

Femoral head abnormality

Bone tumours

Masses - consider MRI

Contrast Non

Slice 1 mm or less

Range Customise

CT ANGIOGRAM

Indication Vascular lesion / anomaly

Contrast 3 ml/kg

Use ROI

Slice 1 mm or less

Range Customise for coverage

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2.5 MAGNETIC RESONANCE IMAGING (MRI)

MRI Acronyms Philips GE Siemens

SE SE SE

SE (MultiEcho, MS) MEMP& CSMEMP SE (MultiEcho, MS)

Spin Echo MSE VMP&CSVEMP RASE

TSE / FSE FSE

LASE POMP TSE HASTE

Inversion Recovery IR IR IR

IR in MS Mode MPIR IR in MS Mode

STIR STIR STIR

IR-TSE IRS-FSE IR-TSE

FFE / FE T1-FFE

GRASSE, GRE SPGR

FISP, GRE FLASH

Gradient Echo T2 -FFE SSFP PSIF

Balanced FFE(BFFE) / CBASS

FIESTA True FISP

TFE Rapid SPGR TurboFlash

TFE FGRE MP RAGE

3D-TFE

Fast Scan Techniques Keyhole

GRASE TGSE

EPI EPI EPI

TSE FSE TSE

Phase Imaging Phase Imaging Phase Imaging Phase Imaging

38

Reduced Imaging HalfScan / PCS Half NEX Half Fourier

RFOV RFOV RFOV

Saturation Bands REST, PreSAT SAT PreSat

FC, MAST GMN, FC

Motion Compensation PEAR SMART

EXORCIST, RSPE

GMR ROPE

RC, RT RSPE

Fat, water and background suppression

SPIR,FATSAT CHEMSAT FATSAT

ProSet

Inflow, TOF TOF TOF

PCA PC PC

Multichunk MOTSA MOTSA

MR Angio TONE Ramped RF TONE

MTC MTC MTS

CVP

39

MRI BRAIN

STANDARD BRAIN: 3D T1 FFE Sagittal: anatomy, myelination T2 Axial FLAIR Axial DWI/ADC (T2 Coronal - venous sinuses)

NEONATES: + GE + MRS of BG for HIE

SEIZURE: + STIR IR Cor 2mm (angled 90 degrees at hippocampus)

VASCULAR MALFORMATION (haemorrhage):

+ GE/ T2 FFE + MRA / MRV + Post Gad T1 - 3 Planes

NEOPLASM/ SPACE-OCCUPYING LESION:

+ MRS + Post Gad T1 - 3 Planes + Post Gad T1 spinal cord (posterior fossa ) (+ DTI) (+ MRA/ MRV)

INFECTION: + MRS + Post Gad Ax/ Sag

Acute Demyelinating Encephalomyelitis (ADEM):

+ T2/ 3D T2 Sag brain (corpus callosum/cord) + T1 Sag cord + T2 Sag cord / (T2 Ax) + T1 post Gad cord (+ MRS)

LEUKOENCEPHALOPATHY: (+ MRS) (+ Post Gad) (+T2 Sag brain) - ? MS

STROKE: + MRA + MRV + MRS (lactate)

40

HYDROCEPHALUS: + High res T2 Sag / 3D T2 (CSF flow) + CSF flow

TRAUMA /

DIFFUSE AXONAL INJURY:

+ GE/ T2 FFE + T2 Sag brain (corpus callosum)

NEUROFIBROMATOSIS: T2 TSE Ax FLAIR Ax T1 SE Sag STIR Ax Post Gad - 3 Planes

NF SCREENING: FLAIR Ax T2 TSE Ax T1 SE Sag T1 SPIR Ax T2 SPIR Sag-Obl (both eyes) STIR long TE

TUBEROUS SCLEROSIS: T2 TSE Ax FLAIR Ax T1 SE Ax Post Gad - 3 Planes

STURGE WEBER: T2 TSE Ax T1 SE Ax T1 SE Sag SWI FFE Ax T1 Post Gad Ax T1 Post Gad Cor

FAST BRAIN:

T2 TSE Ax

T1 SE Ax

FLAIR Ax

Post Gad - 3 Planes

41

MRI PITUITARY

PITUITARY: FLAIR Ax T1 SE Sag T1 SE Cor T2 TSE Cor T2 TSE Sag T1 Post Gad Sag T1 Post Gad Cor T1 Post Gad brain

MRI ORBITS

ORBITS:

T2 SPIR Ax

T2 SPIR Sag-Obl

T1 SPIR Sag-Obl

T2 TSE spir Cor

T1 SPIR Post Gad Sag-Obl

T1 SPIR Post Gad Ax

STIR long TE

MRI INTERNAL AUDITORY MEATI

IAM’S:

T2 3D FSE Ax

T2 3D FSE Cor

FLAIR Ax

T1 3D FFE Post Gad Ax

T1 Post Gad Ax

42

MRI NON-ACCIDENTAL INJURY

NON-ACCIDENTAL INJURY: Standard brain T2 FFE Ax DWI T2 whole spine Sag T1 whole spine Sag

MRI FACE AND NECK

GENERAL:

T2 SPAIR Ax T2 SPAIR Cor T1 SE Ax T1 SPIR Post Gad Cor T1 SPIR Post Gad Ax

ENCEPHALOCOELE/MIDLINE FACIAL LESIONS:

T1 and T2 Sag (thin slices tip of nose to back of crista galli) 2 or 3mm T1 SE Cor 3mm (nose to brainstem) T1 and T2 Ax 3mm (floor anterior cranial fossa to hard palate) DWI to exclude epidermoid FLAIR Ax (Brain) T2 TSE Ax (Brain ) +/- Contrast

VASCULAR / LYMPHATIC MALFORMATION:

T2 SPAIR Ax T2 SPAIR Cor T1 SE Ax T2 FFE Ax +/- MRA T1 SPIR Post planes

43

MRI ABDOMEN

ABDOMEN BREATHING:

COR BFFE T1 FB Cor T2 FB Cor STIR FB Cor T1 FB Ax T2 FB Ax STIR Ax T1 SPIR Post Gad Ax T1 SPIR Post Gad Cor

ABDOMEN FFE BHOLD:

S4TW HR IP S4DUAL FE HR Ax S3 T1 WATTS HR Ax

LIVER:

T2 TSE BH Cor COR BFFE Cor T1 Tfe IP FB Ax T1 Tfe OP FB Ax Dynamic Post Gad 4D THRIVE BA Ax Post Gad THRIVE BH Ax Post Gad

MRCP (Red Cross Hospital):

COR BFFE Cor TRA BFFE Ax T1 TFE IP FB Ax T1 TFE OP FB Ax Ssh MRCP Ssh MRCPRAD SMRCP 3D SVISTA 3DT2

44

MRCP EXTRAS:

COR BFFE T1 FB Ax T1 BH Ax T2 FB Ax T2 BH Ax T2 FB spir Ax T1 FB CR Cor T1 BH CR Cor T2 FB CR Cor T2 BH Cor MRCP Radial MRCP 3D Cor

MRCP FLEX COIL:

T2 SPAIR Ax T2 SPAIR Cor SMRCP 3D SSH MRCP SSH MRCPRAD

RENAL SCAN NON- CONTRAST:

COR BFFE Cor T1 TFE 3D Cor COR BFFE Sag COR BFFE Ax T2 TSE Ax T1 TSE Ax T2 TSE Ax

MRU PROTOCOL SBC:

T2 SPAIR FB Ax T1 TFe IP Cor T2 SPAIR Cor 3D HR MRU Cor THRIVE PRE Cor THRIVE DYN Cor

45

MRU PROTOCOL FLEX- L:

T2 SPAIR Ax T1 TFE IP FB Ax T1 TFE IP FB Cor T2 SPAIR Cor T2 TSE Cor 3D HR MRU Cor THRIVE PRE Cor THRIVE DYN Cor

ADRENALS:

COR BFFE Cor COR BFFE Ax T1 TFE IP FB Ax T1 TFE OP FB Ax T1 TSE Ax

DYNAMIC SCAN: WAVE BH pre Ax 2D BOLUSTRAK BT WAVE BH Ax WAVE BH Ax WAVE BH Ax

46

MRI PELVIS

FEMALE PELVIS:

T1 TSE Sag T1 TSE Ax T2 TSE Sag T2 TSE Ax T2 TSE Cor T1 TSE Post Gad - 3 Planes

PERI-ANAL:

T1 TSE Cor T2 TSE Cor T1 TSE Ax T2 TSE Ax STIR Ax T1 TSE Post Gad Ax T1 TSE Post Gad Cor

47

MRI ONCOLOGY

LYMPHOMA:

T1 TFE IP FB Ax DWIBS SBC T2 SPAIR Ax T2 SPAIR Cor T1 TSE Post Gad Ax T2 SPAIR Ax T2 SPAIR Cor

ABDOMINAL MASS:

T2 SPAIR Ax T2 SPAIR Cor T2 SPAIR Cor T2 SPAIR Ax T1 TFE Ax COR B-FFE Cor S BTFE M2D Cor S BTFE M2D Ax DWIBS SBC T1 TFE IP Post Gad Ax DYNAMIC Post Gad Ax

PELVIC MASS: STIR BH Cor T2 SPAIR Ax T2 SPAIR Sag T2 SPAIR Cor T1 Ax T1 SPIR Post Gad Ax T1 SPIR Post Gad Sag

GASTRIC MASS: T2 ABDO 10mm Ax T2 ABDO 5mm Cor T2 ABDO 3mm Ax T2 ABDO 3mm Cor

GASTRIC MASS > 2 YRS: T2 ABDO 3mm Cor T2 ABDO 3mm Ax T2 ABDO 3mm Cor

48

MRI SPINE

CERVICAL SPINE: T2 TSE Sag T1 TSE Sag BFFE Ax T1 TFE 3D Ax T2 DRIVE 3D Ax MYELO RADIAL STIR TSE Sag

THORACIC SPINE: T1 TSE Sag T2 TSE Sag STIR TSE Sag BFFE Ax T1 TFE 3D Ax

LUMBAR SPINE: T1 TSE Sag T2 TSE Sag BFFE Ax T1 TFE 3D Ax T1 DRIVE 3D Ax MYELO RADIAL STIR long TE Sag +/- PROSET Cor

LUMBAR SPINE (DISCS): T1 TSE Sag T2 TSE Sag T1 3D FFE Ax T2 DRIVE 3D Ax

BRAIN & TOTAL SPINE (dual coil):

Brain T1 SE Sag T2 TSE Ax FLAIR Ax Post Gad 3 Planes Spine T2 TSE Sag T1 TSE Sag T1 TSE Post Gad Sag

49

TOTAL SPINE (spine coil or nv top on + spine or nv top off + spine):

T2 TSE Sag T1 TSE Sag T2 TSE Cor

COMP/SPINE (PAED SPINE COIL):

T1 TSE Sag T2 TSE Sag STIR Sag T1 TSE Sag sm fov T2 TSE PEDI Ax cord T1 TSE Ax conus STIR Ax T11 TSE PEDI Cor [cord] T2 TSE PEDI Cor[cord] Post Gad T1 TSE Sag [cord] Post Gad T1 TSE Ax [conus]

COMP/SPINE (SENSE SPINE COIL):

T1 TSE Sag T2 TSE Sag STIR Sag T2 TSE Ax [cord] T1 TSE Ax [conus] STIR Ax T1 TSE Cor [cord] T2 TSE Cor [cord] Post Gad T1TSE Sag Post Gad T1 TSE Ax

TRAUMA BRAIN & SPINE:

Spine T1 TSE Sag T2 TSE Sag STIR Sag PDW TSE Sag T1 TFE 3D Ax T2 DRIVE 3D Ax T2 FFE Ax Brain FLAIR Ax DWI

50

DYSRAPHISM / TETHERED CORD < 2YRS:

T2 TSE Sag T1 TSE Sag T1 TFE 3D Ax T2 BFFE Sag

TETHERED CORD >2YRS: T2 TSE Sag T1 TSE Sag T1 TFE Sag T2 TSE Cor

SYRINX: T2 TSE Sag T1 TSE Sag T2 DRIVE 3D Ax Post Gad T1 TSE Ax Post Gad T1 TFE Ax Standard Brain T1 SE Sag T2 TSE Ax FLAIR Ax T2 FFE Ax

INFECTION / TUMOUR: T2 TSE Sag T1 TSE Sag T1 TFE Ax T2 DRIVE 3D Ax T1 TFE 3D Ax Po STIR Cor Pelvis STIR Cor Abdo STIR Cor Thorax STIR Cor Head

GUILLAIN-BARRÉ: T2 TSE Sag T1 TSE Sag Post Gad T1 TSE Sag Post Gad T1 TFE 3D Ax Post Gad T1 TFE 3D Sag

SCOLIOSIS: T2 TSE Sag T2 TSE Cor T1 FFE 3D Ax T2 DRIVE

51

MR ANGIOGRAMS (MRA)

CAROTID ADULT: SURVEY PCA Sag SURVEY M2 D1 Ax S3D CAROTIDS Cor 2D BOLUSTRAK BT S3D CAROTIDS Cor

PERIPHERALS: MOBI FLEX Lower Leg MOBI FLEX Upper Leg MOBI FLEX Pelvis 2 BOLUSTRAK MOB. FLEX Pelvis MOBI.FLEX Upper Leg MOBI FLEX Lower Leg

BRAIN ANGIO: T1 SE Sag T2 TSE Ax FLAIR Ax 3DI ANGIO VEN 3D PCA

MRA ABDOMEN (TRIGGERED): T2 TSE Ax T2 TSE Cor 3D RENALS 2D BOLUSTRAK 3D RENALS S3D RENALS T1 TSE SPIR Ax

MRA ABDOMEN (BREATH-HOLD):

BTFFE BH sense Ax BTFFE BH sense Cor S3D RENALS 2D BOLUSTRAK bt S3D RENALS S3D RENALS T1 TSE SPIR Ax

52

WHOLE BODY MRI

TOTAL BODY (STIR)COR:

STIR COR PELVIS /ABDO / THORAX / HEAD (4 sequences)

TOTAL BODY DWIBS:

DWIBS LOWER / MIDDLE / UPPER / NECK (4 sequences)

53

2.6 URINARY TRACT INFECTION

ULTRASOUND FOR ALL (INCLUDING COLOUR

DOPPLER)

NORMAL

DMSA in 4-6

months / MAG 3 STOP

HYDRONEPHROSIS

MAG 3

(obstruction and

level)

MCUG

(exclude PUV, reflux)

IF > 2 MONTHS

UTI PROTOCOL

IF < 2 MONTHS

22monthsMONTH

S

HIGH RISK KIDNEYS

(PYELONEOPHRITIS) OR

RECURRENT UTI

54

2.7 SINUS DISEASE

55

2.8 SEDATION

SEDATION GUIDELINES FOR CT / MRI:

Children over 6 years of age may not require sedation or anaesthesia for MRI if accompanied by a parent

IMPORTANT TO BE SAFE

Must have trained paediatric nurse administering sedation

Monitoring equipment must be well-maintained and appropriate, i.e. O2 saturation monitor and capnograph

Monitoring for sedation must be before, during and after procedure

Well-maintained and age-appropriate resuscitation equipment must be in the room

Trained emergency staff must be readily available

Oral sedation is currently performed with Chloral Hydrate 75mg/kg (up to 20kg patient weight) and can be increased to 100mg/kg (after 1 hour)

Anaesthetist-led sedation / anaesthesia may be with any method with which they are familiar

INDICATIONS FOR GENERAL ANAESTHESIA:

Failed oral sedation

Long procedures

Airway / possible anaesthetic risk

Sick patient from ICU

Clinicians request

HRCT in younger child

56

Chloral Hydrate Dosage Regimen

CHLORAL HYDRATE 500 mg/5ml

500 mg/kg 75mg/kg 100 mg/kg

kg mgs mls Mgs mls mgs mls

1 50 0.5 75 0.75 100 1

2 100 1 150 1.5 200 2

3 150 1.5 200 2 300 3

4 200 2 300 3 400 4

5 250 2.5 350 3.5 500 5

6 300 3 450 4.5 600 6

7 350 3.5 500 5 700 7

8 400 4 600 6 800 8

9 450 4.5 650 6.5 900 9

10 500 5 750 7.5 1000 10

11 550 5.5 800 8 1100 11

12 600 6 900 9 1200 12

13 650 6.5 950 9.5 1300 13

14 700 7 1050 10.5 1400 14

15 750 7.5 1100 11 1500 15

16 800 8 1200 12 1600 16

17 850 8.8 1250 12.5 1700 17

18 900 9 1350 13.5 1800 18

19 950 9.5 1400 14 1900 19

20 1000 10 1500 15 2000 20

21 1050 1.5 1550 15.5 2100 21

22 1100 11 1650 16.5 2200 22

57

{end}