PB-322 Radiologic Technology One

1. 1 PB-322 Radiologic Technology One Week One Sequence of Radiography And Basic Cervical Radiography

2. 2 What is expected this quarter? There will be four examinations this quarter. Midterm and Final Laboratory Examinations Midterm and Final Lecture Examinations There are four series of phantom x-rays that must be completed this quarter. The Laboratory Final serves as the clinic entrance examination for positioning.

3. 3 Website : http://w3.palmer.edu/russell.wilson Lecture presentations are available on my website as well as other important information. The need to take notes during the lecture is minimized by the website. Lecture exams will have questions covering material in the textbook not mentioned in lecture. You are responsible for all material in the first three chapters of the text. Review the introductory presentation on the website. We do not have lecture time to cover this material in lecture.

4. 4 1.1 Basic Radiographic Room Tube stand allows vertical and horizontal movement of tube. Tube can be angled Collimator restricts beam Wall Bucky holds cassette.

5. 5 Complete X-ray Room The Non-Bucky Film holder allows non-grid films that reduce exposure. The radiographic table makes imaging unstable or handicapped patients safer.

6. 6 Modern control panel Located behind shielded barrier. Controls for kVp and mAs. Selection of focal spot. Exposure buttons located so operator must be behind barrier.

7. 7 Cassettes Black border Kodak Lanex Regular Cassettes are 400 speed and used for spine and general radiography. Grey Border Kodak Lanex Fine Cassettes or Extremity Cassettes are 80 speed and used for non-Bucky small extremity films.

8. 8 Nolan Filtration System Additional aluminum filters are added to compensate for varying body thickness. The filters will reduce exposure in the area that they are placed. The objective is to equalize the exposure on the film. The thoracic region is where most filtration is required.

9. 9 Compensating Filters This rack contains compensating filters and shields. Top row holds numbered point filters Bottom row holds cervical thoracic filters and shields. Shields contain lead that will block the x-ray at the tube.

10. 10 Tube controls Buttons to release the horizontal and vertical locks to move tube stand. Button to turn on collimator light. Tube angle indicator Knobs to collimate beam.

11. 11 Basic Patient Positions: A-P Anterior-Posterior Facing toward Tube Back touching Bucky Marker �R� or �L� facing forward. One of the required views

12. 12 Basic Positions: P-A Posterior-Anterior Facing the Bucky Back toward tube. Markers �R� or �L� Pronated or facing toward film. Either A-P or P-A is a required view.

13. 13 Basic Positions: Posterior Oblique Facing toward tube Patient turned 40 to 45 degrees from A-P. Markers: �R� or �L� indicate the side closest to the Bucky. Must be placed on the anatomical side. Anterior to Spine

14. 14 Basic Positions: Anterior Oblique Facing toward Bucky Back toward Tube Patient turned 40 to 45 degrees from P-A. Marker: �R� or �L� pronated indicating the side closest to Bucky. Must be behind the spine.

15. 15 Basic Positions: Lateral Mid coronal plane is perpendicular to film. Make sure feet are parallel. Markers used to indicate the side closest to the film.

16. 16 Basic Positions: Recumbent Can be any of the basic view such as: A-P P-A Oblique Lateral All marker rule apply

17. 17 Basic Positions: Decubitus Taken to see air or fluid levels. Patient must stay on side for 5 to 10 minutes. Markers: �R� or �L� to indicate side down. Arrow to indicate side up.

18. 18 Anatomical Markers 1. Identify the side of patient closest to film. Lateral & Oblique Views. 2. Faces the same way as patient. Easy to read for A-P views. Pronated for P-A views. 3. Identify the right or left side of patient on A-P or P-A views.

19. 19 Tube Angle: Caudal Tube angled toward the feet. Decrease SID by one inch for every five degrees of tube angle. Directs Beam through angled body part.

20. 20 Tube Angle: Cephalad Tube angled toward head. Reduce SID one inch for every five degrees of tube angle. Used to get angled body parts perpendicular to film.

21. 21 Tube Angulation Erect Radiography requires adding or subtracting the required angle from 90 degrees. Cephalad angles: Add required angle to 90 degrees. Caudal angles: Subtract required angle from 90 degrees.

22. 22 1.3 Elements of Technique Chart mAs: Product of mA and time. Determines the number or quantity of photons. Establishes the density of the film. kVp: Quality of beam. Controls the contrast of the image. Patient size in centimeters: Determines the mAs and added filters used to equalize exposure. Focal spot size: Controls geometric resolution

23. 23 1.3 Fixed kVp Technique Charts Consistent image contrast Proper penetration of body part. More image latitude: less retakes. Use of higher kVp will reduce the ionization in body tissue. Reduction in patient exposure.

24. 24 Complete Technique Charts Chart should be located in the control booth and easy to read. This will help avoid technique errors. They will work fine for 85% of the patients.

25. 25 Technique Adjustment for Contrast Rule of �Tens or 15%� Increase kVp by 10 or 15% and reduce mAs 50% Decrease kVp by 10 or 15% and double mAs Change kVp by 8% and adjust mAs by 25% If the film is underexposed increase the kVp 15% and leave the mAs alone if patient is unstable. If the film is overexposed, reduce kVp 15% if it lacks contrast and patient is stable.

26. 26 Technique Adjustment for Contrast The 15% rule can be used to adjust the technical factors for different patient body habitus or disease processes. Elderly patients often have osteoporosis and muscle loss making them easier to penetrate. This calls for a reduction in kVp to avoid over penetration.

27. 27 Technique Adjustment for Contrast Extremely muscular patient need an increase in kVp to avoid under penetration and a light film. Osteopenic patient require a reduction in kVp by 4 to 10 kVp. Frail and osteopenic patient require a reduction in both mAs and kVp. Children require a 30% reduction in mAs.

28. 28 Technique Adjustment for Density The 30 � 50 Rule is most commonly used to adjust the technical factors for over or under exposure. If the film is very light or underexposed, double the mAs if the patient is stable. If it is dark or overexposed, cut the mAs in half. If it is slightly under or over exposed adjust the mAs 30%.

29. 29 1.2 Collimation A key factor in patient exposure. Reduces radiation to the area of interest. Reduces scatter radiation that improves contrast.

30. 30 Collimation Rules Collimation must be at a minimum slightly less than film size. Or To the area of clinical interest. Whichever is smaller. Need three borders.

31. 31 1.4 Dark room Painted a light color. Should have good safe light. Sink with eye wash. Space to store fresh processing chemicals. Work counter with I.D. Camera.

32. 32 Darkroom: Film Bin Light tight container for storage of unexposed film. Small film in front.. Larger film in back. Never opened in light or with darkroom door open.

33. 33 Darkroom: I.D. Camera Used to print patient information from flash card on film. Card goes under clip to hold it in place. Film goes next to clip to align information in I.D. Block of film.

34. 34 Darkroom: Film Processor Kodak M-35 processor Fresh Chemical storage Hazardous Waste storage Film fed into processor on feed tray.

35. 35 Darkroom: Film Processor Developer is not considered hazardous waste. Fresh Fixer is not considered hazardous waste. Used fixer is hazardous waste due to silver.

36. 36 Darkroom: Film Processor Chemicals in secondary containment. Air tight containers to keep fresh and reduce fumes. Always wear eye protection and gloves when handling chemicals.

37. 37 Darkroom: Film Processor With automatic processing you should not need to become in contact with the processing chemicals. Only when a film is lost or jammed in the processor will we open the processor.

38. 38 Processing Chemicals Chemical Safety Developer contains Hydroquinone and Sodium Bisulfate. Both are hazardous. Hydroquinone can be absorbed through the skin. Gloves must be used when in contact with developer.

39. 39 Processing Chemicals Chemical Safety Fixer contains Ammonium Thiosulfate and Sodium Thiosulfate. Since it removes the unexposed silver from the film, it becomes hazardous waste when used. Fresh Fixer is not hazardous waste.

40. 40 Processing Chemicals Chemical Safety Eye Protection and gloves must be used when working on the processor. Eye Wash facilities should be provided in case of accidental exposure to the chemicals.

41. 41 3.2 Sequence of Steps for Taking Radiographs 1. Introduce yourself to patient. Explain what your are going to do. 2. Determine that a female patient of child bearing age is not pregnant. Have the patient the sign the release from liability. Give the gowning instructions consistent for the views being taken.

42. 42 Gowning Instructions Cervical Region : Remove everything from the waist up and put gown on with opening to the back. Remove any necklaces, ear rings or dentures and any other items that contain metal in the skull or neck area. Watch & rings may be left on.

43. 43 Gowning Instructions Thorax & Chest Remove everything from the waist up and shoes. Remove bra. Put gown on with the opening towards the back.

44. 44 Gowning Instructions Lumbar spine or Full spine Remove all clothing except for underpants. Remove shoes but leave socks on Remove any removable jewelry. Put gown on with the opening towards the back.

45. 45 Asking about Pregnancy �It has been reported that the safest time to take x-rays of females of childbearing age is within ten to fourteen days of the onset of menses. Are we within that time frame? If not is there any change that you could be pregnant? Please sign this form that states that to the best of your knowledge, you are not pregnant and the start of the last menses.�

46. 46 Sequence of Steps for Taking Radiographs 3. Take all measurements needed for the study being taken. Record measurements on the request form. Locate the radiation protection being used for the first film. 4. Using the technique chart, determine and set the technique for the first film.

47. 47 Sequence of Steps for Taking Radiographs 5. Position tube, film and patient. A. Set the SID and tube angle for first film. B. Place film in Bucky or Non-Bucky film holder. Set I.D. Blocker and anatomical marker the the correct location for the view. C. Position patient in correct position for the view.

48. 48 Anatomical Markers 1. Identify the side of patient closest to film. Lateral & Oblique Views. 2. Faces the same way as patient. Easy to read for A-P views. Pronated for P-A views. 3. Identify the right or left side of patient on A-P or P-A views.

49. 49 Sequence of Steps for Taking Radiographs D. Center horizontal central ray to patient and film to the central ray. Or Set film to patient and center central ray to film. E. Push film into Bucky. F. Fine tune positioning of vertical central ray. Check all planes and object to film distance.

50. 50 Sequence of Steps for Taking Radiographs 6. Collimation to area of clinical interest or slightly less than film size. Which ever is smaller. 7. Step into the control booth. Ask patient to remain still and give the breathing instructions required for the view. 8. Watch the patient while preparing the rotor and make the exposure.

51. 51 Breathing Instructions Suspended respiration:� Don�t breathe move or swallow.� Cervical spine A-P and Obliques Inspiration:�Hold very still. Take a very deep breath and hold your breath in.� Thoracic spine, upper ribs & chest views Expiration:� Hold very still. Take a small breath in and blow it all the way out and hold it out. Lateral c-spine and all views below diaphragms.

52. 52 Sequence of Steps for Taking Radiographs 9. Tell the patient to breathe and relax. Set the technical factors for the next view. 10. Proceed with the positioning for the next view Steps 5 through 9 until the exam is completed. 11. Carefully process all films.

53. 53 Landmarks for Cervical Spine and Skull Radiography.

54. 54 Chapter 5 Cervical Spine Radiography All cervical spine views are routinely taken on 8� x 10� Regular Speed Cassettes. The lateral can be taken on a 10 X 12 for anterior weight bearing patients. The I.D. is placed down at PCCW because we use a smaller film size than at other schools. Upper cervical views are not taught in this class but are covered in the elective upper cervical course.

55. 55 Acanthameatal Line This is the most important base line for cervical positioning. It runs from the base of the nose to the EAM. It is parallel to the floor and perpendicular to the film for all views except the Fuchs Projection, Pillars and Flexion and Extension Lateral Views.

56. 56 Cervical Spine Variations Different schools will perform cervical spine exams differently. Some places will take the lateral in the Bucky instead of Non-Bucky. The Oblique and Lateral Views can be taken at 40� though 72� SIDs with changes to the technical factors.

57. 57 The Palmer West Way The way we perform cervical spine exams will provide consistent superior image quality and relatively low patient exposure. The use of the Non-Bucky Film Holder significantly reduces patient exposure. Employing just 40� and 72� SID simplifies the learning process.

58. 58 5.2 A-P Open Mouth Used to visualize the top two cervical vertebra. Common view of all cervical spine series. Most challenging of all routine cervical spine views.

59. 59 A-P Open Mouth View Measure: A-P at C-4 Film: 8� X 10� I.D. down Portrait Requires very precise positioning. Routine: No tube angle Protection: Full or half apron.

60. 60 APOM positioning Acanthiomeatal line perpendicular to film. Mastoid tips and upper incisors perpendicular to film. HR: 1� below upper incisors. VR: mid sagittal with no head rotation.

61. 61 APOM positioning Center film to horizontal central ray Collimate to 5� x 5� Breathing Instructions: Don�t breathe move or swallow or phonate �AH� Make exposure. Have patient breathe and relax.

62. 62 The A-P Open Mouth Film The should be no rotation. The Mastoid tips and upper incisors aligned. Dental caps are blocking view of dens.

63. 63 5.3 APOM Images Analysis A slight miss alignment of of the teeth and mastoid tips will mess up the view. 1/16� equals 1/8� on the film or enough the cause a retake. Anterior W/B or reverse cervical curve will affect positioning. Usually will need 5 degree cephalad tilt.

64. 64 The A-P Open Mouth Film The should be no rotation. The Mastoid tips and upper incisors aligned. Dental caps are blocking view of dens.

65. 65 APOM Anterior Weight Bearing Without a tube angle, teeth will block view of dens. This view is adequate due to the use of a five degree cephalad tube angulation. Look at the lateral before doing APOM.

66. 66 APOM Teeth Block View The teeth are lower than the mastoid tips. The teeth block the view. Raise head to improve image. If anterior w/b, angle tube.

67. 67 APOM with tube angle This is the same patient with a 5� cephalad tube angle. Take lateral view 1st to check gravitational line before taking the APOM.

68. 68 APOM Teeth Blocking View The incisors are below the mastoid tips. This causes the teeth to cover the dens. Slightly raising the head back until the mastoid tips and teeth are perpendicular to film will solve problem.

69. 69 APOM Base Of Skull Blocks View The Mastoid Tips are well below the upper incisors. If patient is told to open mouth as far as possible without monitoring acanthiomeatal line, this will be the result.

70. 70 APOM Image Critique Poor quality due to: Head rotated to right. Teeth not aligned with upper incisors because head is extended back too far. Solution: Lower head and check for rotation when positioning.

71. 71 5.4 Fuchs Projection Supplementary View when the A-P Open Mouth view does not demonstrate dens.

72. 72 Fuchs Projection Measure: A-P at C-4 Protection: Full or Half Apron SID: 40� No tube angle Film: 8� x 10� Regular with I.D. down Portrait

73. 73 Fuchs Projection Head extended back until the Mentameatal line is perpendicular to film. EAM and Chin perpendicular to film. Horizontal C R: just below mandible Vertical C R: Mid sagittal plane

74. 74 Fuchs Projection Film centered to Horizontal CR Film pushed into Bucky Collimation : 5� x 5� Breathing Instructions Suspended respiration �Don�t breathe, move or swallow.� Make exposure.

75. 75 Fuchs Image Should see the dens within the foramen magnum. The view will not help evaluate any other upper cervical structures. There should be no rotation..

76. 76 Use of the Fuchs Projection This is a lateral cervical spine on a very anterior weight-bearing patient.

77. 77 Use of the Fuchs Projection Two attempts were made to see the dens on the A-P Open Mouth with the customary tube angle used on the anterior weight bearing patient.

78. 78 Use of the Fuchs Projection The Fuchs projection gave us our only view of the dens.

79. 79 5.5 A-P Cervical Spine One of the required views of all cervical spine series. Tube must be angled cephalad to open the disc spaces.

80. 80 A-P Cervical spine Measure: A-P at C-4 Protection: Half or Full Coat Apron SID: 40� Bucky Tube angle: 15 � to 20 �cephalad Film: 8� x 10� I.D. down Portrait

81. 81 A-P Cervical spine Head extended until acanthiomeatal line is perpendicular to film. Horizontal Central Ray: at level of C-4 Vertical Central Ray: mid sagittal with no rotation

82. 82 A-P Cervical spine Center film to Horizontal Central Ray and push Bucky tray in. Collimation side to side: Skin of neck Collimation top to bottom: EAM to T-2

83. 83 A-P Cervical spine Breathing instructions: �Don�t breathe, move or swallow.� Suspended respiration. Make exposure After exposure: �Breathe and relax.�

84. 84 A-P Cervical Spine Image Mandible and base of skull should be superimposed. Sternoclavicular joints should be equal distance from T-spine. No evidence of rotation.

85. 85 5.6 Posterior Oblique Cervical Spine Part of the complete cervical spine series. Always done in pairs Marks must note the side closest to the film. Markers in front of the body of the vertebra.

86. 86 Posterior Cervical Oblique Measure: A-P at C-4 Protection: Half apron SID: 40� Tube Angle: 15 �to 20� cephalad Film: 8� x 10� Regular speed I.D. down Portrait

87. 87 Posterior Cervical Oblique Patient turned 40 to 45� from A-P. Marker to side closest to film. Acanthiomeatal line perpendicular to film. Head turned to true lateral.

88. 88 Posterior Cervical Oblique Horizontal central ray: At level of C-4 Vertical central ray: through EAM with skull lateral. One inch anterior with head not turned. Center film to horizontal central ray.

89. 89 Posterior Cervical Oblique Push film into Bucky. Collimation Top to Bottom: EAM to T-1 Collimation Side to Side: Skin of neck. Breathing Instructions: Suspended respiration �Don�t breath move or swallow� Make exposure. Tell patient to relax

90. 90 Posterior Oblique Cervical Films Disc spaces should be open. Mandible should be clear of spine. RPO shows left foramina (furthest away from film) LPO show right foramina

91. 91 Posterior Oblique Cervical Films If body of vertebra is too large, patient was not turned 40 to 45 degrees. If body too small, patient was turned too far. IVF�s must be open !!

92. 92 5.7 Anterior Cervical Oblique Lack of vertical tube travel may require the patient to be seated. When seated use the lower Bucky tray slots. Because of opposite tube angle from A-P, not the routine oblique.

93. 93 Anterior Cervical Oblique Measure: A-P at C-4 Protection: Half Apron SID: 40� Tube angle: 15�to 20� caudal Film: 8� x 10� regular cassette I.D. down Portrait

94. 94 Anterior Cervical Oblique Patient faces Bucky. Turn patient 40 to 45� from P-A. Tall patient is seated. Skull turned lateral with acanthiomeatal line perpendicular to film. Marker pronated and to the side closest to the Bucky.

95. 95 Anterior Cervical Oblique Horizontal central ray: level of C-4 Vertical central ray: through EAM. Film centered to horizontal central ray. Collimation Side to side: skin of neck Collimation Top to Bottom: EAM to T-2

96. 96 Anterior Cervical Oblique Breathing Instructions: �Don�t breathe, move or swallow� Suspended respiration Make exposure Have patient breathe and relax.

97. 97 Anterior Cervical Oblique Film The IVF�s must be open. Disc spaces must be open. RAO will demonstrate the right foramina (side closest to film) LAO will demonstrate the left foramina

98. 98 C-spine Problems The angles of the mandible should be superimposed. The I.D. is in the wrong location.

99. 99 Poor Gowning: Ear Ring A single ear ring on a lateral cervical spine view.

100. 100 Poor Gowning: Pins in Hair Bobby pins can ruin cervical or skull radiographs.

101. 101 Poor Gowning: Hair in Pony Tail Most bands used for pigtails or ponytails have have metal clips. There appears to be an ear ring also.

102. 102 Poor Gowning: Wet Hair The patient�s hair is wet. Combined with the ponytail resulted in significant artifacts.

103. 103 Poor Gowning: Mousse This patient had dreadlocks with lots of mousse in the hair.

104. 104 Poor Gowning: Mousse The A-P c-spine was repeated with the hair in pigtails.

105. 105 Poor Gowning: Bra The complete study of a brassiere. P-A & Lateral Views

106. 106 Cervical Spine Positioning Errors Horizontal CR too low so the EAM and part of upper c-spine missed. EAM must be in collimation and film properly centered to avoid missing anatomy.

107. 107 Cervical Spine Positioning Errors I.D. in wrong location so it blocks part of C-1. Note that the oblique view provides a good look at C-7 & T-1.

108. 108 End of Lecture Return to Winter 2008 Index Return to PB-322 Home Page