Overview. Imaging Indications. Paediatric Radiation Safety 2015/03/12. Paediatric radiation safety General guidelines Protocols
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1 Overview Paediatric radiation safety General guidelines Protocols Paediatric Radiation Safety Paediatric patients are unique Children are more susceptible to radiation induced cancer than adults Younger children are more sensitive Girls more than boys (breast / thyroid) Imaging Indications Radiation - ALARA General Radiation Risk Lowest dose per investigation Sens & Spes Cost Effective 1
2 Radiation effects Body repairs damage Radiation interaction with tissue Formation of free radicals Permanent DNA Alteration (Stochastic effect) ± 350 Chest X-ray No permanent damage DNA Damage Cell death (Deterministic effect) Deterministic = Dose dependant with threshold Hairloss, Burns, infertility, cataracts, etc Stochastic = Potential for cancer / genetic effects. Dose = Risk. No threshold Cancer ± 200 Chest X-ray Relative radiation dose Modality Background equivalent CT 8 months + Interventional 1 6months + ± 500 Chest X-ray Fluoroscopy 10 days + Nuclear medicine 1 day + Radiographs 1 day + Ultrasound / MR None Randall Munroe - 2
3 Relative Risk Activity Death (per million/year) Being a person age 55 years (all causes) 10,000 Smoking a pack of cigarettes daily (all causes) 3,500 Rock climbing for 2 h (accident) 500 Canoeing for 20 h (accident) 200 Motorcycling for 1,000 miles (accident) 200 Travelling 1,500 miles by car (accident) 40 Being a pedestrian (accident) 40 Working 1 week as a fire-fighter (accident) 15 Working 1 week in agriculture (accident) 10 Fishing (drowning) 10 Eating (choking on aspirated food) 8 Skiing for 10 h (accident) 8 Working 1 month in a typical factory (accident) 5 Travelling 5,000 miles by air (accident) 5 Having a chest radiograph (radiation-induced cancer) 1 Visiting Denver for 2 months (cancer from cosmic rays) 1 AAPM Mission Statement Discussion of risks related to radiation dose from medical imaging procedures should be accompanied by acknowledgement of the benefits of the procedures. Risks of medical imaging at effective doses below 50 msv for single procedures or 100 msv for multiple procedures over short time periods are too low to be detectable and may be nonexistent Living in the vicinity of a nuclear power plant (radiationinduced cancer) < How do we reduce radiation? Image appropriately! Best investigation for question Child-size the amount of radiation used Technical stuff your Radiologist need to know about If we CT- Scan Only when necessary Only indicated region Only once Who is responsible for reducing radiation? Radiologist Offer appropriate service Reduce radiation (technical) Offer affordable service Referring clinician Understand modern imaging Imaging educated Cautious of radiation exposure 3
4 Working together Image Gently The Alliance goal is to change practice: to raise awareness of the opportunities to lower radiation dose in the imaging of children SASPI South African Society of Paediatric Imaging ACR American College of Radiology ACR Appropriateness Criteria Practical Points Extremities Comparative views Head and Neck Skull X-rays Convulsions Sinus X-rays Chest Lateral chest X-rays Abdomen Reflux / GORD HPS Intussusception Appendicitis Pelvis DDH Urinary System Urinary tract infection Comparative views Generally not indicated Only on request for subtle or confusing appearances Exceptions Skeletal survey Measurements for Orthopods 4
5 Practical Points Extremities Comparative views Head and Neck Skull X-rays Convulsions Sinus X-rays Chest Lateral chest X-rays Abdomen Reflux / GORD HPS Intussusception Appendicitis Pelvis DDH Urinary System Urinary tract infection Head injury / Skull X-rays Not indicated at institutions with CT facilities If no CT available, may be used in mild head injury visualised fracture = indication for CT May be done as part of skeletal survey in suspected NAI (Leave if doing CT) & surgical follow-up for device implantation CT preferred for head shape abnormalities / craniosynostosis. SASPI ACR 5
6 ACR Head injury Cochlear implant Surgical Cx Minor injury - GCS>13, ϴ Risk Fx No imaging Moderate / Severe GCS <13, ± Risk Fx CT brain pre- contrast (? MRI pre) NAI CT brain pre-contrast / MRI Brain DAI Subacute HI with Neuro Sx MRI brain pre / CT brain pre Craniosynostosis Sinus / Adenoids X-rays Very limited value! Sinus complaints should receive empirical treatment without imaging except Features of complication Surgical planning CT is then indicated Andronikou, S, AND Dekker, G. "Paediatric radiology: what's hot and what's not, Continuing Medical Education [Online],Volume 24Number 6 (23 January 2008) 6
![[Online],Volume](/docs-images/80/81289756/images/7-4.jpg "24Number 6 (23 January")
7 Adenoid hypertrophy Adenoid hypertrophy? 3yr 5m Sinuses SASPI CT Sinuses Andronikou, S, AND Dekker, G. "Paediatric radiology: what's hot and what's not, Continuing Medical Education [Online],Volume 24Number 6 (23 January 2008) 7
8 ACR Sinusitis Uncomplicated acute sinusitis NO IMAGING Persistent, recurrent or chronic sinusitis CT Sinuses pre-contrast Complicated sinusitis (Orbital / Intracranial) CT brain and sinuses with contrast (? MRI with contrast) Convulsions Modality differs between ages Correlating clinical history of vital importance. ACR - Convulsions Practical Points Neonatal Ultrasound head ± MRI (HIE) Simple Febrile No Imaging Complex febrile ± MRI (No CT) Seizure Post Traumatic CT Brain ± MRI Partial MRI Brain Neuro normal? MRI Generalised Neuro Abnormal MRI ± CT Extremities Comparative views Head and Neck Skull X-rays Convulsions Sinus X-rays Chest Lateral chest X-rays Abdomen Reflux / GORD HPS Intussusception Appendicitis Pelvis DDH Urinary System Urinary tract infection 8
!["Paediatric radiology: what's hot and what's not, Continuing Medical Education [Online],Volume 24Number 6 (23 January 2008) Practical Points Bowel imaging Extremities](/docs-images/80/81289756/images/9-1.jpg "Comparative views Head and Neck Skull X-rays Convulsions Sinus X-rays Chest Lateral chest X-rays Abdomen Reflux / GORD HPS Intussusception Appendicitis Pelvis DDH Urinary")
9 Lateral Chest X-ray Not routinely used in USA / UK Valuable in SA for detecting TB lymph adenopathy CT more accurate, but not feasible to perform in every case of suspected TB Andronikou, S, AND Dekker, G. "Paediatric radiology: what's hot and what's not, Continuing Medical Education [Online],Volume 24Number 6 (23 January 2008) Practical Points Bowel imaging Extremities Comparative views Head and Neck Skull X-rays Convulsions Sinus X-rays Chest Lateral chest X-rays Abdomen Reflux / GORD HPS Intussusception Appendicitis Pelvis DDH Urinary System Urinary tract infection X-ray evaluation very limited Only absolute x-ray indication Obstruction / Perforation Positioning of lines 9
10 Bowel imaging Non-specific abdo pain? Constipation Very limited value! Reflux / GORD Barium swallow limited value early Physiological reflux /? When abnormal Hypertrophic pylorus stenosis Ultrasound first line Barium studies only in difficult / equivocal cases Hypertrophic Pyloric Stenosis Bowel imaging Reflux / GORD Barium swallow limited value early Physiological reflux /? When abnormal Hypertrophic pylorus stenosis Ultrasound first line Barium studies only in difficult / equivocal cases Intussusception Ultrasound first line Barium studies only in difficult / equivocal cases 10
11 Intussusception Bowel Imaging - Appendicitis X-ray Rarely helpful may show focal ileus which is non-specific Ultrasound is still first line investigation Can be difficult due to location, bowel gas, etc. Abnormal ultrasound = Appendicitis Normal ultrasound Normal Appendicitis Can demonstrate mesenterial glands / Adenitis CT as next line investigation Single venous phase +- oral / rectal contrast Andronikou, S, AND Dekker, G. "Paediatric radiology: what's hot and what's not, Continuing Medical Education [Online],Volume 24Number 6 (23 January 2008) Appendicitis - US Appendicitis 11
12 Appendicitis Intussusception Appendicitis?Pre /? Post Practical Points Extremities Comparative views Head and Neck Skull X-rays Convulsions Sinus X-rays Chest Lateral chest X-rays Abdomen Reflux / GORD HPS Intussusception Appendicitis Pelvis DDH Urinary System Urinary tract infection 12
!["Paediatric radiology: what's hot and what's not, Continuing Medical Education [Online],Volume 24Number 6 (23 January 2008) Practical Points Urinary tract infection Extremities Comparative views Head](/docs-images/80/81289756/images/13-1.jpg "and Neck Skull X-rays Convulsions Sinus X-rays Chest Lateral chest X-rays Abdomen Reflux / GORD HPS Intussusception Appendicitis Pelvis DDH Urinary System Urinary tract infection Ultrasound is")
13 Pelvic X-rays DDH Limited value for DDH Ultrasound preferred Bony lesions, Perthe s and SUFE possible with X-rays, but MRI more sensitive Coronal ultrasound of the hip Andronikou, S, AND Dekker, G. "Paediatric radiology: what's hot and what's not, Continuing Medical Education [Online],Volume 24Number 6 (23 January 2008) Practical Points Urinary tract infection Extremities Comparative views Head and Neck Skull X-rays Convulsions Sinus X-rays Chest Lateral chest X-rays Abdomen Reflux / GORD HPS Intussusception Appendicitis Pelvis DDH Urinary System Urinary tract infection Ultrasound is mainstay of UTI imaging IVP should not be used Nuclear medicine / MAG3 study for obstructive uropathy ACR Ultrasound always first VCUG only really appropriate if US abnormal / poor response on Rx / urine retention / recurrent febrile UTI s 13
14 Summary Questions / Comments Radiation Dose & Risk Radiation reduction Appropriate imaging for the clinical question 14
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