Body CT Protocols General tips:

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1 Body CT Protocols General tips: -Check the list of protocol types on Intrad -Look at prior studies for help -Look up clinical info in Epic or Powerchart -Call ordering clinician if you have unanswered questions -Always ask for help from upper levels and attendings -If you want to change a non-contrast study to a contrast study, you must discuss it with the ordering physician first in case they had a specific reason not to (allergy, renal failure etc) -Look up ordering physicians specialties (in webpaging or directory), since they will usually be proficient at ordering studies related to their field (e.g. Urologist and stone protocol vs. Triphasic; hepatologist and Liver Triphasic vs. regular AP etc.).

2 This is the sheet where you actually write the protocol (in this example, where they wrote Urogram and initialed below). In the protocol area, you indicate whether the study is to have IV, PO or Rectal contrast. These must be circled. - Make sure your initials are LEGIBLE - VERY IMPORTANT: You must make sure to evaluate the actual physician order and relevant clinical history or Reason for exam, do not protocol just by looking at what Appointment Type is ordered. - This is the sheet where you actually write the protocol (in this example, where they wrote Urogram and initialed below). In the protocol area, you indicate whether the study is to have IV, PO or Rectal contrast. These must be circled. - Make sure your initials are LEGIBLE - VERY IMPORTANT: You must make sure to evaluate the actual physician order and relevant clinical history or Reason for exam, do not protocol just by looking at what Appointment Type is ordered.

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4 Outpatient RadNet Requisition: -The procedure requested here is usually correct (for example, if it says enterography or some other specific protocol, it is usually correct). If it says W/WO contrast investigate further to see if both a pre and post contrast study is needed (see info for page 3) -The Reason for Exams is extremely useful as the ordering physician (or their staff) enters text here. Always look at this to determine what exam should be done and if the correct exam was ordered. -The third circle for Contrast is also useful as it specified if the patient can receive contrast. If the clinician says Do Not Give Contrast and you feel it is needed, you must contact them before making any changes.

5 -Possibly the most important sheet for protocoling: The actual patient s order -The first circle at the top of the page is usually the correct protocol. If it indicates a specific protocol (basically anything other than just Abdomen and Pelvis such as Enterography, Triphasic Pancreas, Aorta Endograft etc), this is usually correct and what the clinician wants. However, if it says something like W&W/O DYE investigate further as some clinicians order this as default when it should just be W dye. Studies that sometimes need W&WO are usually urologic (urograms, triphasic kidneys), vascular (aorta), triphasic studies of the liver or pancreas, and a few other very specific studies such as a GI bleeding study. -The second circle is usually a list of the patient s diagnoses, some of which may be relevant to the exam being ordered -The last circle at the bottom is the most important since this is where the ordering clinician (or his staff) type in the reason for the exam and relevant clinical history.

6 These are just general guidelines on how to use the numerous sheets you re given for protocoling, which can get pretty complicated. Remember, if you re confused or have a question, ask someone who knows. -PO contrast: usually barium (default); if concern for leak, use oral omnipaque (similar to gastrograffin); if enterography study, pancreas triphasic or GI bleed study, use VoluMen (built into protocol) -Rectal contrast: usually done for post-surgical patients with anastomoses (not recent surgery as the rectal tube could damage the anastomosis). These are often ordered by Dr. Stryker and will sometimes be referred to as Triple Contrast (IV, PO and Rectal) -Regarding triphasic studies (kidney, liver, pancreas): if the patient has a known mass that has already been worked up or resected, they may only need a regular CT with IV/PO for staging/recurrence unless the ordering physician specifically ordered a triphasic. In this case, look at any prior studies and call the clinician if you have questions on whether a triphasic is necessary. Tips on Specific Protocols: CT Chest: Routine chest that can be done with or without IV. If it s just to follow-up a pulmonary nodule, no contrast is needed. Hi-res CT Chest: hi-resolution CT (regular chest, hi-res, expiratory) without IV contrast performed for interstitial lung disease or fibrosis, often in patients with sarcoid or connective tissue disorders. CTA Chest PE: evaluate for PE, w IV contrast CTA Chest/A/P Aorta: Pre and post IV contrast to evaluate for aneurysm or dissection. If the order mentions ECG gating or is regarding an ascending aneurysm that may require gating, the cardiovascular imaging fellows will protocol it. CTA Chest/A/P Post-Op Endograft: These are pre, post and delayed CTA Aorta studies in patients with endografts from vascular surgery. There is also a pre-op protocol. CT AP w IV and PO: This is the routine study we do for general complaints such as abdominal pain. CT Enterography: This is a special abdominal CT using IV contrast and oral Volumen (negative oral contrast) that is usually done for patients with (or if concerned for) inflammatory bowel disease. CT Liver Triphasic: Triphasic liver CT (pre-contrast, and arterial and venous postcontrast) performed for liver masses with IV and oral contrast. This is sometimes ordered for the IR radioembolization patients, in which case it is usually IV only. CT Cholangiocarcinoma: Liver triphasic with delayed images. Performed with IV and PO.

7 CT Pancreas Triphasic: Performed for patients with pancreatic masses and sometimes pancreatitis/pseudocysts. Performed with IV and PO (volumen) CT Kidney Donor: performed for kidney donors to evaluate anatomy and vasculature Urologic: -CT Stone Protocol: This is done to look for urologic stones and is without IV or PO contrast. Order this if the clinician specifies without contrast and is following up known calculi or only wants to exclude calculi and not other pathology (tumor, pyelo, etc). -CT Urogram: This consists of pre contrast imaging of the abdomen and pelvis followed by post contrast imaging of the abdomen and pelvis. A split contrast bolus is used so that the post contrast imaging will have excreted contrast in the renal collecting systems/ureters/bladder and enhancement of the cortex is during nephrographic phase (essentially combining nephrographic and excretory phases). If for any reason pre s are required to be checked before infusing, then order this and specify Check Pre s. Do not routinely request check pre's in the outpatient setting unless requested by the clinician or if there is a special clinical situation like appendicitis versus kidney stone. -CT Triphasic Kidney: This is done for patients with painless hematuria to look for stones and urologic tumors etc. This includes pre, nephrographic and excretory phases of the kidneys and imaging of the pelvis pre and during excretory phases. It involves approximately 20-25% more radiation than a CT Urogram. Any Age Patient reason for exam is stones Protocol is CT Urogram or CT Stone, depending on orders Any Age Patient reason for exam is renal mass (solid or cystic) Protocol is Triphasic Kidney Patients UNDER 40 years of Age reason for exam is hematuria Protocol is CT Urogram Patients Age 40 and OVER reason for exam is hematuria Protocol is Triphasic Kidney

8 Call ordering physician if order is uncertain General Protocoling Guidelines: OUTPATIENTS BODY, NEURO, MSK cases to be protocolled by 1pm for the next day INPATIENTS (see attached example) RadNet orders printed to CT control area with specific information designated in Comments or Relevant Clinical Hx section (see circled areas) Tech will protocol exams unless unclear reason or special protocol requested ER PATIENTS (see attached example)

9 RadNet orders printed in ERCT control area with specific information designated in Comments or Relevant Clinical Hx section (see circled areas) Tech will protocol exams unless unclear reason or special protocol requested Non-emergent cases requested (ie Triphasic Studies, CAPs, Enterography studies) to be approved by a Radiologist. They will be scanned as Inpatients, this requires you to speak with the ER service to understand to place future order for patient to get scanned when admitted.

10 Inpatient Order:

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