Neonatal Imaging

Radiography in children,

“… the most highly skilled task required of a radiographer. In no other age group does correct diagnosis and treatment depend so much on high-quality films”

 

Hygeine

 Hands – Handwashing, before and after placing hands into the incubator

OBJECTS – Foam pads, image plate etc. Bag them or clean    them before and after placing in the incubator

PATIENT IDENTIFICATION

• AS PER IRME(R) & LOCAL POLICIES
• BE CAREFUL OF WEIGHTS ON INCUBATOR I.D. CARDS…

 

Scattered radiation

 Distance from tube                                    time to receive equiv backgrd dose

50 cm                                                                                                 42 minutes

1M                                                                                                       11 minutes

3m                                                                                                      1 minute

                                               

Exposure 64kV, 1mAs, 100cm, 1cGy cm²

 AGREE HOLDING TECHNIQUES

• BABY’S ARMS ABOVE HEAD ?
• BABY’S ARMS LYING AT SIDES AWAY FROM THE BODY?

WHATEVER IS PREFERRED

– AGREE BEFOREHAND

 

LOOK EXCELLENT CHEST RADIOGRAPHY RESULTS

LOOK                                     =    LORDOSIS

EXCELLENT                        =          EXPOSURE

CHEST                                  =          COLLIMATION

RADIOGRAPHY                 =           ROTATION

RESULTS                             =          RESPIRATION

 

Park Mobile at an Angle to Base of the Incubator

Position the Tube Now – Use a 10% Angle

Ensure Holding PERSON is Protected & Not Pregnant

L – Lordosis

E – Exposure

• Set exposure now before you start positioning – so you do not forget later
• Be aware that the weight written on the card on the incubator might be out of date – babies put on weight fast
• Dr ≥ 3kg 60kV 0.8mAs

1.5–3kg          60kV 0.7mAs

0-1.5kg           60kV 0.63mAs

C – Collimation

• Collimate as tightly as possible using the collimator blades
• Use the lead strips provided on top of incubator
• Ensure a side marker on the L-shaped strip is included

 R – Rotation (1)

• Nurse should hold baby’s head in AP position. Hips and shoulders parallel to image plate
• Baby’s arm lying by sides but angled away from body if possible
• Baby’s legs supported – e.g. by small towel
• Centre to mid-sternum

R – Rotation (2)

• Radiographer to stand at bottom of incubator when exposing– allows easier assessment of rotation
• Note again the caudal angle of the x-ray tube

R – Respiration

• Radiographer watches baby’s breathing closely
• Baby is a tummy breather – when tummy is pushed out, lungs are full
• Expose when tummy is pushed out
• Counting 1-2-3 might help
• If baby is wriggling, wait a  minute – baby might settle

NOT THAT DIFFICULT AFTER ALL

Rotated Images

Why are they bad?

• Alters heart shape and size
• Causes mediastinal distortion
• Shows differences in the degree of lung translucency
• To avoid:
• Ensure head is straight
• Ensure shoulders and hips are level

Lordotic Images

Why are they bad?

• Alters heart shape
• Causes lower lobes of   lungs to be masked by diaphragms
• To Avoid:
• Don’t centre too low -centre to mid-sternum
• Do not have central ray at 90° to the image plate, angle tube or tray
• Be aware that holding baby arms above head can cause back to arch

Be Careful Not To Overangle Caudally

Ventilator Tubing Must Be Clear of Chest

Lateral Decubitus Chest

• Position baby lying on a foam pad facing the x-ray tube
• Holding person holds head and arms with one hand and lower limbs with the other
• Suspicious side up but clinician will usually advise which they wish
• Beware of skin folds

Supine Decubitus Chest

• Again Horizontal Beam to be Used
• Baby to Lie Supine
• Baby Held as for Lateral Decubitus
• Reduce Exposure by Around 4kV!!!

Chest & Abdomen 1 Image

Note the ECG leads are all moved to the lateral chest and abdomen walls

• • Note also the “rugby- ball” shape of baby – be careful not to over collimate the diaphragm area laterally.Neonatal ImagingRadiography in children,“… the most highly skilled task required of a radiographer. In no other age group does correct diagnosis and treatment depend so much on high-quality films” 

    Hygeine

     Hands – Handwashing, before and after placing hands into the incubator

    OBJECTS – Foam pads, image plate etc. Bag them or clean    them before and after placing in the incubator

    PATIENT IDENTIFICATION

    • AS PER IRME(R) & LOCAL POLICIES
    • BE CAREFUL OF WEIGHTS ON INCUBATOR I.D. CARDS…

     

    Scattered radiation

     Distance from tube                                    time to receive equiv backgrd dose

    50 cm                                                                                                 42 minutes

    1M                                                                                                       11 minutes

    3m                                                                                                      1 minute

                                                   

    Exposure 64kV, 1mAs, 100cm, 1cGy cm²

     Lines

    Endotracheal tubes (ETT

    nasogastric line (NGT)

    Electrocardiography (ECG)

    umbilical venous catheter (UVC)

    Umbilical artery catheters (UAC)

 

 

Rankin scale          Stroke protocol 

 

A Thrombolysis Stroke is a blood clot blocking the blood supply to part of the brain. This clot can lead to some permanent damage. Six months after a stroke about half of all patients will still have disability, with some fatalities. Medicines like Alteplase are used in frontline treatment of thrombolysis stroke. These treatments improve blood supply to the brain and improve chances of a better recovery. Research suggests treatment has to be given as soon as possible and no later than 4./5hrs of onset of the stroke.

Benefits:

Reverse the effect

Reducesthe amount of disability

One person in ten or 10% treated with Alteplase will make a better recovery.

Alteplase appears to increase the number of people who are able to manage without help.

To confirm a stroke from a transient ischaemic attack (TIA) doctors follow a strict protocol listed below to determine which route to take:

Side effects

Serious side effects from a risk of bleeding from the first day after treatment.

Some bleeding risks are minor (EG: bleeding from injection site).

Most severe bleeding in the brain making the stroke worse.

Small number (3 in 100) will be fatal.

This bleeding can also occur naturally without receiving Alteplase.

 

 

Sudden onset of focal neurological deficit If subacute onset, look for typical syndrome Seizure (e.g. limb twitching) at onset makes ischaemic

stroke less likely but does occur.  It is more common in intracerebral haemorrhage. Loss of consiousness is unusual in stroke.  Look for signs of brainstem dysfunction. For diagnostic scores e.g. ROSIER

Ongoing symptoms and less than 3 hours from symptom onset? IF SO, STOP HERE, DO NOT GIVE ASPIRIN, and start THROMBOLYSIS PROTOCOL

NHS Fife Stroke Thrombolysis pathway & Protocol

There is an (in hours) and (out of hours) pathway in place.

Timescale starts when patient arrive with CT request in place within 5 mins of patient arrival. Ideally patient is in CT scanner 15mins after arrival, with 15 mins CT to treatment.

Patient assessed using the ROSIER guide and stroke team and CT advised.

ROSIER score is a measurement of consciousness, seizure activity, speech, weakness in the face, arm and leg. This is measured using a +1/0 scale. The score determines the likeliness of a stroke or Tran ischemic Attack (TIA).

Once a patient has agreed to Treatment, the clock is stopped at the onset of treatment. Optimal timescale is arrival to treatment within 30 minutes.

Treatment is done by IV bolus and infusion doses of Alteplase based on patient weight.  Alteplase is a fibrinolytic drug that acts as thrombolytic by activating plasminogen to form plasmin, which degrades fibrin and so breaks up thrombi.(NICE guidelines).This is done over an hour and the patient monitored over the next 24hrs.

Overview

Strokes

9000 per year

1000 eligable for IV+PA injections

300 severe due to large artery occlusion

Intracranial stent

STEMI

cagnard LINNC 2015

Jeffery L Saver neurosurgeon – Rankin Scale (time of onset)

Aspect score

CT perfusion

 

Ineligible for TPA

Time from wake up – 76hr stroke

Time = brain quality

Role of the acute stroke is:

Exclude contraindications/haemorrhage

Establish diagnosis

Other pathologies SAH SDH Abscess

 

CT pitfalls

Inaccurate at early stages

Insensitive for small lesions

Insensitive for old bleeds

Insensitive for posterior fossa

However enough to exclude

Hyperacute 0-6hrs

Late 6-12hrs

 

Hyperdense artery sign

Insular ribbon sign

Odema takes hrs

CT fogging?????