Chest, Abdomen and Pelvis CT Protocols

Oncology: Hypervascular Mets Chest ADRENAL MASS Protocol Chest CT Low Dose Nodule Evaluation ABDOMEN PELVIS: ROUTINE Chest CT Lung Cancer Screening ABDOMEN PELVIS: TRAUMA Chest CT Routine With Contrast Abdomen Pelvis: FAST ER Protocol: R/O Acute Chest CT Without Routine Appendicitis or Diverticulitis Chest CTA- Pulmonary Embolism Abdomen CTA- Aortic Aneurysm -Pre EVT Chest CTA- Acute Aorta Abdomen CTA- Aortic Aneurysm –Post EVT Chest CTA- Aortic Aneurysm -Pre EVT CT COLONOGRAPHY Chest CTA Aortic Aneurysm- Post EVT CT Enterography Chest CTA- Acute Aorta- Trauma CT UROGRAM Chest CT High Resolution CT UROGRAM LOW DOSE Coronary CTA Screening History Renal Mass

Chest, Abdomen and Pelvis Renal CTA

Retroperitoneal Hemorrhage Chest Abdomen Pelvis: Acute Trauma Oncology: Hepatoma: (Triphasic Liver CT) Abdomen and Pelvis Oncology: Cholangiocarcinoma

CT Cystogram Pancreatic Mass CT

Oncology: Lymphoma CT VENOGRAM PELVIS: Pelvic Venous

Oncology: Hypovascular Mets Congestion

LOWER EXTREMITIES

CT VENOGRAM LOWER EXTREMITY

2 3

Chest

4 Chest CT Low Dose Nodule Evaluation Typical Indications: Follow up pulmonary nodule(s). Normal or nearly normal radiograph Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Lower cervical spine Contrast Y N/A Inspiration through both costophrenic angles Arterial Phase N N/A N/A

Venous Phase N N N/A

Delayed Phase N N/A N/A

Scan Comments: Low dose: reduce mAs appropriate to patients size: consider 100 kVP/mAS modulation per scanner software. Nodules are lesions <3cm. For pulmonary masses (>3cm) or hilar enlargement use Chest CT With Contrast Routine protocol Scan Comments: Low dose: reduce kVP appropriate to patients size: consider 100 kVP for patients less than 200 lbs/90 kgs. If exam is requested because of an “abnormal CXR” please have outside CXR and report available for review. Note: “pulmonary nodules” are lesions <3cm ; pulmonary masses are >3cm. If scan is for pulmonary mass use Chest CT With Contrast Protocol.

Contrast Parameters Parameters Contrast Type None

Contrast Volume N/A

Saline Flush N/A

Injection Rate N/A

Oral Contrast N/A

Oral Contrast Volume N/A

Reconstruction Soft Tissue Bone/ Thin Sag Cor Parameters Lung Data

Slice Thickness x 5mm x 5mm x 2mm 3mm 3mm Recon Spacing 5mm 5mm x x x Phase #1 #1 1mm 3mm 3mm #1) Noncontrast #1 #1 #1

Plane Axial Axial Axial Sag Cor Reconstruction Soft Tissue Lung ST ST ST Algorithm

Send to PACS PACS Hold PACS PACs

6 Chest CT Lung Cancer Screening (USPTF criteria) 1) Adults aged 55-80, with a >30 pack year history of smoking and who currently smoke or have stopped smoking in past 15 years 2) Screening should be discontinued once the individual has not smoked for 15 years or develops a health problem that significantly limits life expectancy or the ability or willingness to have curative lung surgery. Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Lower cervical spine Contrast Y N/A Inspiration thru both costophrenic angles Arterial Phase N N/A N/A

Venous Phase N N/A N/A

Delayed Phase N N/A N/A

Scan Comments: Guidelines for techniques include: For BMI < 30 use kVP of 100; mAS < 40; mA 80; goal CTDIvol < 3 mGy

For BMI > 30 use kVP of 120; mAS < 60; goal CTDIvol < 5 mGy

mAS software modulation with ADIR (Toshiba) or CareDose(Siemens) may alter these parameters. Additional reported risk factors: documented high radon exposure, occupational exposures (silica,cadmium,asbestos,arsenic,beryllium,chromium,diesel fumes,niockel,coal smoke,soot), personal cancer history ( lung cancer, lymphoma, head and neck), COPD or pulmonary fibrosis, family history lung cancer.

Reconstruction Soft Bone/ Thin Sag Cor 3D/Special Parameters Tissue Lung Data Slice Thickness x 1 mm 1 mm 0.5 mm x 2 mm 2 mm NA Recon Spacing 0.3 mm x 2 x 2 Phase mm mm #1) Noncontrast Plane Axial Axial Axial Sag Cor

Reconstruction Algorithm Soft LUNG LUNG LUNG LUNG N/A Tissue

Send to PACS PACS Hold PACS PACs N/A

8 Chest CT Routine With Contrast Typical Indications: Evaluate Infection, known or suspected lung cancer, empyema, evaluate pulmonary mass, hilar enlargement Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non N N/A N/A Contrast Arterial N Use Bolus Inspiration Lower cervical spine Phase Tracking through adrenal glands Venous N N N/A Phase Delayed N N/A N/A Phase

Scan Comments: Nodules are lesions <3cm. For incidental nodules may be able to use Noncontrast CT Nodule protocol. For pulmonary masses (>3cm) or hilar enlargement use Chest CT With Contrast Routine protocol

Contrast Parameters Parameters Contrast Type Per institution Contrast Volume 75-80cc Use 100 cc if combined with abdomen CT Injection Rate 4-5cc/sec Oral Contrast N/A Oral Contrast Volume N/A Contrast Comments: Scan delay: usual 25 seconds; Use Bolus Tracking if available

Reconstruction Soft Bone/ Thin Sag Cor 3D/Special Parameters Tissue Lung Data Slice Thickness x 5mm x 5mm x 2mm x 3mm x 3mm x NA Recon Spacing 5mm 5mm 1mm 3mm 3mm Plane Axial Axial Axial Sag Cor NA

Reconstruction Algorithm Soft Tissue Lung ST ST ST NA

Send to PACS PACS Hold PACS PACS NA

Chest CT Without Routine Typical Indications: Evaluate lung nodule(s) Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Lower cervical spine through both Contrast Y N/A Inspiration costophrenic angles

Arterial Phase N N/A N/A

Venous Phase N N N/A

Delayed N N/A N/A Phase

Scan Comments: Nodules are lesions <3cm. For pulmonary masses (>3cm) or hilar enlargement use Chest CT With Contrast Routine protocol

Reconstruction Soft Bone/ Thin Data Sag Cor 3D/Special

Parameters Tissue Lung Slice Thickness x 5mm x 5mm x 2mm x 3mm x 3mm x NA Recon Spacing 5mm 5mm 1mm 3mm 3mm Plane Axial Axial Axial Sag Cor NA Reconstruction Soft Lung ST ST ST NA Algorithm Tissue Send to PACS PACS Hold PACS PACS NA

10 Chest CTA- Pulmonary Embolism Typical Indications: r/o PE; elevated D-Dimer Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Contrast N N/A N/A

Arterial Use Bolus Lung apex thru both Phase Y Inspiration Tracking costophrenic angles

Venous Phase N N N/A

Delayed Phase N N/A N/A

Scan Comments: In Pregnant patients confirm Duplex Venous Exam was NEGATIVE PRIOR to CTA; use low dose protocol; abdominal shielding; informed written consent for radiation during pregnancy; *oral thin barium for “internal shielding” if time permits. No need to breast pump/discard milk recommendations for 24 hours unless patient anxious regarding contrast* Pt info sheet regarding breast feeding available on mxcimaging.com.

Contrast Parameters Parameters Contrast Type Per institution

Contrast Volume 80cc

Injection Rate 4-5cc/sec

Oral Contrast 450 cc thin standard barium PO ideally 20-30 minutes pre for pregnant patients only if time allows

450 cc Oral Contrast Volume

Internal barium shielding provides some protection from scatter Contrast Comments: radiation to pelvis. Mid and lower abdomen pelvis external lead shielding will minimize direct beam radiation to pelvis. CTA has significantly less Fetal dose than standard VQ imaging but has significantly higher Maternal breast dose.

Reconstruction Soft Bone/ Thin Sag Cor 3D/Special Parameters Tissue Lung Data Slice Thickness x 2mm x 5mm x 1mm x 3mm x 3mm x 10 mm thick Recon Spacing 2mm 5mm 0.5mm 3mm 3mm Coronal MIPS (or as thin as scanner config allows) Plane Axial Axial Axial Sag Cor Cor

Reconstruction Soft Tissue Lung ST ST ST ST Algorithm

Send to PACS PACS Hold PACS PACS PACS

12 Chest CTA- Acute Aorta Typical Indications: R/O Acute Aortic Dissection/ Aneurysm, follow up endovascular stent, aortic injury Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Top of Aortic Arch to Contrast N** N/A N/A diaphragm

Arterial Mid cervical spine thru Phase Y-GATED*** Bolus Tracking Inspiration iliac crests*

Venous * If AbdPel CT ordered Phase N N N/A for trauma; pause at diaphragm and continue with 70 sec delay CT of AbdPel Delayed N N/A N/A Phase

Scan Comments: ** For Acute Chest Pain with specific history of “r/o dissection” include NonContrast CT to evaluate for acute intramural hematoma. For routine f/u thoracic aneurysm Noncontrast not needed. Dissections often extend into abdomen or neck- coverage includes expanded FOV*. For acute symptoms add GATING*** to optimally see ascending aorta. Contrast Parameters Parameters Per institution Contrast Type

Contrast Volume 100cc

Injection Rate 4-5cc/sec

Oral Contrast N/A

N/A Oral Contrast Volume

Contrast Comments:

Reconstruction Soft Bone/ Thin Data Sag Cor 3D/Special Parameters Tissue Lung

Slice Thickness x 2mm x 5mm x 1mm x 3mm x 3mm x #3) 3D radial MPR Recon Spacing 2mm 5mm 0.5mm 3mm 3mm #4) 5mm thick Phase #1 #1 #2 #2 MIPs in SAG and #1) Noncontrast #2 #2 COR #2) Arterial Phase Plane Axial Axial Axial Sag Cor 3) Radial Range 4) SAG/COR

Reconstruction Soft Lung ST ST ST ST Algorithm Tissue

Send to PACS PACS 1. To 3D PACS PACs PACs : Reformat server 3Ds AFTER 2. PACS transferring raw data to PACS

14 Chest CTA- Aortic Aneurysm -Pre EVT Typical Indications: f/u known or suspected thoracic aneurysm, preop evaluation stent graft Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non N** N/A N/A Contrast Arterial Use Bolus Mid cervical spine thru Y Inspiration Phase Tracking costophrenic angles Venous Phase N N N/A Delayed Phase N N/A N/A

Contrast Parameters Parameters Contrast Type Per institution Contrast Volume 75-80cc routine 100 cc if combining with abdomen Injection Rate 4-5cc/sec Oral Contrast N/A Oral Contrast Volume N/A Contrast Comments:

Reconstruction Soft Bone/ Thin Sag Cor 3D/Special Parameters Tissue Lung Data

Slice Thickness x 2mm x 5mm x 1mm x 3mm x 3mm x Recon Spacing 2mm 5mm 0.5mm 3mm 3mm #3) 3D radial MPR Phase #1 #1 #2 #2 #2 #4) 5mm thick MIPs in #1) Noncontrast #2 SAG and COR #2) Arterial Phase

Plane Axial Axial Axial Sag Cor 3) Radial Range 4) SAG/COR

Reconstruction Soft Lung ST ST ST ST Algorithm Tissue

1. To

3D PACS : Reformat 3Ds Send to PACS PACS PACS PACS server AFTER transferring raw

2. PACS data to PACS

16 Chest CTA Aortic Aneurysm- Post EVT Typical Indications: f/u thoracic aneurysm stent graft Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Top of Aortic Arch thru Y N/A N/A Contrast domes of diaphragm Mid cervical spine thru Arterial costophrenic angles Phase Use bolus Y Inspiration (if aneurysm extends to tracking abdomen include) Venous N N N/A Phase

Delayed N N/A N/A Phase

Scan Comments: Include entirety of stented region on noncontrast phase. For routine f/u thoracic aneurysm only noncontrast phase not needed. ** For Acute Chest Pain with r/o dissection include NonContrast CT to evaluate for acute intramural hematoma and GATE CTA phase: See CTA Acute Aorta **For POST Endovacular Stent Graft patients add NonContrast phase thru chest/abd stent graft region

Contrast Parameters Parameters Contrast Type Per institution Contrast Volume 80cc

Injection Rate 4cc/sec Oral Contrast N/A Oral Contrast Volume N/A

Reconstruction Soft Bone/ Thin Data Sag Cor Parameters Tissue Lung

Slice Thickness x 2mm x 5mm x 1mm x 3mm x 3mm x Recon Spacing 2mm 5mm 0.5mm 3mm 3mm Phase #1 #1 #2 #2 #1) Noncontrast #2 #2 #2) Arterial Phase

Plane Axial Axial Axial Sag Cor

Reconstruction Soft Lung ST ST ST Algorithm Tissue

1. To 3D Send to PACS PACS server PACS PACs 2. PACS

18 Chest CTA- Acute Aorta- Trauma Typical Indications: Severe trauma, Chest pain r/o Acute Aortic Dissection/tear, mediastinal widening Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non N N/A N/A N/A Contrast Arterial *GATED Mid-cervical spine thru Phase Y Use Bolus Inspiration Iliac Crests Tracking Venous N N N/A Phase Delayed Phase N N/A N/A

Scan Comments: *For acute symptoms add GATING to optimally see ascending aorta; Gating improves motion artifact at aortic root and ascending aorta. If using Toshiba Acquillion One may omit gating and use Ultrafast Helical Contrast Parameters Parameters Contrast Type Per institution

Contrast Volume 80cc chest CTA only 100 cc if combined CAP Injection Rate 4-5cc/sec Oral Contrast N/A Oral Contrast Volume N/A Contrast Comments: pancreas/ duodenal/prox SB injury optimally assessed with oral in UGI tract but do not delay scan for oral contrast

Reconstruction Soft Bone/ Thin Data Sag Cor 3D/Special Parameters Tissue Lung

Slice Thickness x 2mm x 5mm x 1mm x 3mm x 3mm x #3) 3D radial Recon Spacing 2mm 5mm 0.5mm 3mm 3mm MPR Phase #1 #1 #2 #2 #4) 5mm thick #1) Noncontrast #2 #2 MIPs in SAG and #2) Arterial Phase COR

Plane Axial Axial Axial Sag Cor 3) Radial Range 4) SAG/COR

Reconstruction Soft Tissue Lung ST ST ST ST Algorithm

Send to PACS PACS 1. To 3D PACS PACS PACS : Reformat server 3Ds AFTER 2. PACS transferring raw data to PACS

20 Chest CT High Resolution Typical Indications: Evaluate interstitial lung disease, emphysema, bronchiectasis, asbestosis Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Y Inspiration Contrast Supine Helical Lung apices to domes N/A Expiration Supine Axial diaphragms Inspiration Prone Axials Arterial N N/A N/A Phase Venous N N N/A Phase Delayed Phase N N/A N/A

Scan Comments: There are three scans in this protocol: supine inspiration helical, supine expiration axials, and prone inspiration axials. Every effort must be made to acquire prone images. Helical first run performed at 5mm x 5mm supine with inspiration. Second acquisiton is Supine Expiration 1.25mm x 10mm and third is Prone Inspiration Axials 1.25mm x 10mm.

Reconstruction Soft Tissue Lung Thin Data Sag/Cor

Parameters Slice Thickness 1) Helical Run 1) 5mm 1) 5mm 1) 2mm 1) 3mm 2) Supine Hi 2) 1.0mm NA Res Axial NA 3) Prone Hi 3) 1.0mm Res Axial Reconstruction Spacing 1) 5mm 1) 5mm 1) 1.0mm 1) 3mm 1) Helical Run 2) 10mm NA 2) Supine Hi Res Axial 3) 10mm NA 3) Prone Hi Res Axial Reconstruction Soft Tissue Bone+ Soft Tissue ST Algorithm Algorithm (Hi-Res Lung) SEND to PACS PACS PACS PACS #1,#2,#3

Coronary CTA Screening History

22 Chest, Abdomen and Pelvis

Chest Abdomen Pelvis: Acute Trauma Typical Indications: Severe trauma, Chest pain r/o Acute Aortic Dissection/tear, mediastinal widening; abdomen pelvis trauma Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non N N/A N/A Contrast ArterialPhase Y GATED Chest CTA Inspiration Mid-cervical spine domes Use Bolus Tracking diaphragms Venous Y Abdomen Inspiration Domes diaphragms to lesser Phase Pelvis trochanters 60-70 seconds Delayed Y 5 -10 minutes Inspiration Kidneys 5 x 5mm Phase Bladder 5 x 5mm

Scan Comments: Clamp foley catheter upon transfer to CT from ER. For acute severe chest trauma add GATING for Chest CTA to optimally see ascending aorta; Pause at diaphragm if needed to achieve portal venous phase 70 second delay thru abdomen/pelvis. If bladder injury is suspected because of multiple pelvic fractures, you should do CT cystogram following the routine abdominal CT. You need to actively distend the bladder in order to exclude bladder injury. Passive filling of the bladder via the I.V. injection is not sufficient to exclude rupture. • Inject 200-300 cc of dilute contrast in bladder via Foley catheter by gravity. Dilute contrast is a 2-3% solution of iodine. (100 cc of Isovue 300 contrast in a 1 liter saline bag.) • The Foley catheter must be placed by the trauma or emergency service, who should have already cleared the patient from possible urethral injury. • Rescan lower abdomen and pelvis. Check for intraperitoneal extravasation along gutters and between bowel loops. Check for extraperitoneal extravasation anterior to the bladder and along the anterior abdominal wall and scrotum. Post-void images are not necessary.

24 Contrast Parameters Parameters Contrast Type Isovue 370 if CTA Isovue 300 if non CTA Contrast Volume 100 cc Injection Rate 4-5cc/sec Oral Contrast N/A Oral Contrast Volume N/A Contrast Comments:

Reconstruction Soft Tissue Bone/ Thin Sag Cor Parameters Lung Data

Slice Thickness x 5mm x 5mm x 2mm 3mm 3mm Recon Spacing 5mm 5mm x x x 1mm 3mm 3mm

Plane AX AX AX SAG COR

Reconstruction Algorithm ST Lung ST ST ST

Send to PACS PACS To 3D PACs PACs Server then PACs

Abdomen and Pelvis

26 CT Cystogram This exam is done specifically to rule out bladder rupture. If bladder injury is suspected because of multiple pelvic fractures or unexplained acites with history of trauma you should do CT cystogram following the routine abdominal CT. You need to actively distend the bladder in order to exclude bladder injury. Passive filling of the bladder via the I.V. injection is not sufficient to exclude rupture. • Inject 200-300 cc of dilute contrast in bladder via Foley catheter by gravity drip 40 cm above table. Dilute contrast = 2-3% solution of iodine. (100 cc of Isovue 300 contrast in a 1 liter saline bag.) • The Foley catheter must be placed by the trauma or emergency service, who should have already cleared the patient from possible urethral injury. • Rescan lower abdomen and pelvis at 5mm x 5mm making sure imaging goes through bottom of symphysis pubis joint. Recon these into ST windows and reformat images to 3mm x3mm SAG and COR planes. Check for intraperitoneal extravasation along gutters and between bowel loops. Check for extraperitoneal extravasation anterior to the bladder and along the anterior abdominal wall and scrotum. Post-void images are usually not necessary.

Oncology: Lymphoma Typical Indications: staging; r/o mets Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non N N/A N/A Contrast Arterial N N/A N/A Phase Venous Y 60-70 SECS Inspiration Domes diaphragms Phase thru lesser trochanters Delayed N < 40 yo Delayed Inspiration Kidneys 5x5 Phase Y > 40 yo kidneys/bladder Bladder 5x5 after 5minutes for age >40, trauma, or hematuria

Scan Comments: Contrast Parameters Parameters Contrast Type Isovue 300 Contrast Volume 100cc Injection Rate 3-4cc/sec Oral Contrast Per institution protocol

Oral Contrast Volume Per institution Contrast Comments:

Reconstruction Soft Bone/ Thin Sag Cor 3D/Special Parameters Tissue Lung Data

Slice Thickness x 5mm 5mm 2mm 3mm 3mm NA Recon Spacing 5mm 5mm 1mm 3mm 3mm

Plane AX AX AX NA COR NA

Reconstruction ST LUNG ST NA ST NA Algorithm

Send to PACS PACS HOLD PACs PACS NA

Oncology: Hypovascular Mets Typical Indications: routine staging breast, ovarian, lung, colon Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non N N/A N/A Contrast

Arterial N N/A N/A Phase Venous Y 60-70 SECS Inspiration Domes diaphragms Phase thru lesser trochanters* Delayed N < 40 yo Delayed Inspiration Kidneys 5x5 Phase Y > 40 yo kidneys/bladder Bladder 5x5 after 5 minutes for age >40, trauma, or hematuria

Scan Comments: *Include pelvis during PVP if pelvis CT ordered. Contrast Parameters Parameters Contrast Type Isovue 300 Contrast Volume 75-80 cc routine use 100cc if scanning combined C-A-P Injection Rate 3-4cc/sec Oral Contrast Per institution Oral Contrast Volume Per institution Contrast Comments:

Reconstruction Soft Bone/ Thin Sag Cor 3D/Special Parameters Tissue Lung Data

Slice Thickness x 5mm x 5mm x 2mm x 3mm x 3mm x NA Recon Spacing 5mm 5mm 1mm 3mm 3mm

Plane AX AX AX NA COR NA

Reconstruction ST LUNG ST NA ST NA Algorithm

Send to PACS PACS HOLD PACs PACS NA

Oncology: Hypervascular Mets Typical Indications: Staging: neuroendocrine tumor: islet cell tumor/carcinoid, renal carcinoma, thyroid, choriocarcinoma, hepatoma, melanoma, sarcoma; leiomyosarcoma Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Y N/A Inspiration Liver thru Pancreas Contrast Arterial Use Bolus Tracking Phase Y arterial phase Inspiration Liver (25-30 SECS) Venous Domes diaphragms thru Y 60-70 SECS Inspiration Phase lesser trochanters Delayed Delayed kidneys/bladder Phase N < 40 yo after 5 minutes for age Kidneys 5x5 Inspiration Y > 40 yo >40, trauma, or Bladder 5x5 hematuria Contrast Parameters Parameters Contrast Type Per insitution Contrast Volume 100cc Injection Rate 4-5cc/sec

Oral Contrast Per Institution

Per Institution Oral Contrast Volume Contrast Comments:

Reconstruction Soft Bone/ Thin Sag Cor 3D/Special Parameters Tissue Lung Data

Slice Thickness x 5mm x 5mm x 2mm x 3mm x 3mm x NA Recon Spacing 5mm 5mm 1mm 3mm 3mm

Plane AX AX AX NA COR NA

Reconstruction ST LUNG ST NA ST NA Algorithm

Send to PACS PACS HOLD PACs PACS NA

ADRENAL MASS Protocol Typical Indications: adrenal mass, biochemical evidence adrenal lesion, elevated catecholamines/metanephrines; r/o pheochromocytoma Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Highest dome Contrast Y N/A Inspiration diaphragm thru kidneys

Arterial N/A N/A Phase N

Venous Y* 60 seconds** Inspiration Same as noncontrast; Phase Scan thru pelvis if indication PHEO Delayed Y* 15 minutes Inspiration Highest dome Phase diaphragm thru kidneys

Scan Comments: *If noncontrast images demonstrate adrenal lesion <4cm and with HU < 10 contrast images may not be needed. If the noncontrast images demonstrate a homogeneous lesion that is less than 10 HU and less than 4cm the lesion is highly likely to be an adrenal adenoma and no further imaging is necessary. Therefore, the radiologist should check the noncontrast images prior to proceeding with the remainder of the study unless evaluation of the entire abdomen and pelvis was requested for other reasons. Relative Washout values >40% most c/w benign adenoma (RW= EAV-DAV/EAV). **Literature specifies 60 sec scan comparison to 15 minute scan: please do not fudge these scan times. If scanning for Pheochromocytoma: will need pelvis CT. Contrast Parameters Parameters IV Contrast Per Institution

Contrast Volume 75-80 cc

Injection Rate 3-4cc/sec

Oral Contrast Use H20 Protocol

Oral Volume 400 cc H20 pre 400 cc H20 on table Contrast Comments

Reconstruction Soft Bone/ Thin Sag Cor 3D/Special Parameters Tissue Lung Data

Slice Thickness x 3mm 5mm 2mm 3mm 3mm NA Recon Spacing 3mm 5mm 1mm 3mm 3mm

Plane AX AX AX NA COR NA

Reconstruction ST LUNG ST NA ST NA Algorithm

Send to PACS PACS HOLD PACs PACS NA

ABDOMEN PELVIS: ROUTINE Typical Indications: abdominal pain, mass, r/o abscess, appendicitis, diverticulitis, FUO, acute pancreatitis Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Contrast N N/A N/A

Arterial N/A N/A Phase N

Venous Y Bolus Tracking (60- Inspiration Domes diaphragms Phase 70 SECS) thru lesser trochanters

Delayed No < 40 yo Delayed Inspiration Kidneys 5x5 Phase Yes > 40 yo kidneys/bladder Bladder 5x5 after 5-10minutes for age >40, trauma, or hematuria

Scan Comments: Acute Pancreatitis: work-up should be done as routine abdomen. Noncontrast CT only need if concern for pancreatic hemorrhage. Contrast: For Pancreatitis cases OPACIFICATION AND DISTENTION OF DUODENUM IS VERY HELPFUL- drink additional oral contrast immediately before scan and consider placing patient right side down for 2-3minutes prior to scanning to mobilize contrast into duodenum. Contrast Parameters Parameters

Contrast Type Per institution

Contrast Volume 100cc

Injection Rate 3-4cc/sec

Per insitution Oral Contrast

Per institution Oral Contrast Volume

Contrast Comments:

Reconstruction Soft Bone/ Thin Sag Cor 3D/Special Parameters Tissue Lung Data

Slice Thickness x 5mm x 5mm x 2mm x 3mm x 3mm x NA Recon Spacing 5mm 5mm 1mm 3mm 3mm

Plane AX AX AX SAG COR NA

Reconstruction ST LUNG ST SAG ST NA Algorithm

Send to PACS PACS HOLD PACs PACS NA

ABDOMEN PELVIS: TRAUMA Typical Indications: ACUTE TRAUMA Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Contrast N N/A N/A

Arterial N/A N/A Phase N

Venous Y 60-70 SECS Inspiration Domes diaphragms thru Phase lesser trochanters

Delayed Y 5-10 minutes Inspiration Kidneys 5x5 Phase Bladder 5x5

Scan Comments: Clamp foley if present prior to scan. If multiple pelvic fractures and or bladder injury suspected will need to do a CT Cystogram (See Cystogram Protocol) to actively distend bladder (passive filling via IV is not sufficient). ALL SERIOUS TRAUMA PATIENTS INCLUDE PELVIS CT: Abdomen CT only is not option for serious trauma unless discussed and approved by radiologist.

Contrast Parameters Parameters

Contrast Type Per insitution

Contrast Volume 100cc

Injection Rate 3cc-4cc/sec

No Oral Contrast Delay for Severe Trauma Oral Contrast If NG Tube already present: Isovue 370/H20 (33cc/900cc) on way to CT for indication upper abd trauma

Oral Contrast Volume If NG Tube already present: 400cc Isovue 370/H20 ABD PEL CT: TRAUMA (mix 33ccIsovue/900ccH20) on the way to CT for indication upper Contrast Comments: abd pancreas/ duodenal/prox SB injury optimally assessed with oral in UGI tract but do not delay scan for oral contrast.

Reconstruction Soft Bone/ Thin Sag Cor 3D/Special Parameters Tissue Lung Data

Slice Thickness x 5mm x 5mm x 2mm x 3mm x 3mm x NA Recon Spacing 5mm 5mm 1mm 3mm 3mm

Plane AX AX AX SAG COR NA

Reconstruction ST LUNG ST ST ST NA Algorithm

Send to PACS PACS HOLD PACs PACS NA

Abdomen Pelvis: FAST ER Protocol: R/O Acute Appendicitis or Diverticulitis ** For ER Patients with BMI >30 and Age >16 ** THIS IS NOT FOR ABSCESS:: INTR-ABDOMINAL ABSCESS EVALUATION NEEDS ORAL CONTRAST Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Contrast N N/A N/A

Arterial N N/A N/A Phase Venous Y 60-70 SECS Inspiration Domes diaphragms thru Phase lesser trochanters Delayed N N/A N/A Phase

Scan Comments: This is a limited scan focused to exclude acute cases of typical appendicitis in obese adults. If there is clinical suspicion for Abdominal Abscess then ORAL contrast is needed Atypical presentations including prolonged symptoms or signs suggesting abscess are optimally imaged with oral contrast. Thin patients with BMI <30 and/or <16 years old use AbdPelvis CT: Routine. NOTE: Oral Contrast is critically important in thin patients and children to successfully exclude appendicitis. Contrast Parameters Parameters Contrast Type Per Institution Contrast Volume 100cc Injection Rate 3-4cc/sec Oral Contrast None Oral Contrast Volume N/A Contrast Comments:

Reconstruction Soft Bone/ Thin Sag Cor 3D/Special Parameters Tissue Lung Data

Slice Thickness x 5mm x 5mm x 2mm x 3mm x 3mm x NA Recon Spacing 5mm 5mm 1mm 3mm 3mm

Plane AX AX AX NA COR NA

Reconstruction ST LUNG ST NA ST NA Algorithm

Send to PACS PACS HOLD PACs PACS NA

Abdomen CTA- Aortic Aneurysm -Pre EVT Typical Indications: f/u known or suspected abdominal aneurysm, preop evaluation stent graft Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non N** N/A N/A Dome Diaphragms to Contrast iliac crests Arterial Y Use Bolus Inspiration Domes Diaphragms thru Phase Tracking lesser trochanters Venous N N N/A Phase Delayed N N/A N/A Phase

Scan Comments: For routine f/u abdominal aneurysm or initial preop evaluation Noncontrast phase not needed. ** For Acute Abdominal Pain with r/o dissection include NonContrast CT to evaluate for acute intramural hematoma: **For POST Endovacular Stent Graft patients add NonContrast phase thru chest/abd stent graft region: See Abdomen Aorta CTA Post EVT protocol Contrast Parameters Parameters Contrast Type Per Institution Contrast Volume 75-80cc routine 100 cc if combining with chest Injection Rate 4-5cc/sec Oral Contrast N/A Oral Contrast Volume DO NOT GIVE ORAL CONTRAST; if scout shows barium consider delaying exam for elective cases

Reconstruction Soft Bone/ Thin Data Sag Cor 3D/Special Parameters Tissue Lung

Slice Thickness x 2mm x 5mm x 1mm x 3mm 3mm x #3) 3D radial MPR Recon Spacing 2mm 5mm 0.5mm x 3mm #4) 5mm thick 3mm MIPs in SAG and COR

Plane Axial Axial Axial Sag Cor 3) Radial Range 4) SAG/COR

Reconstruction Soft Tissue Lung ST ST ST ST Algorithm

Send to PACS PACS 1. To 3D PACS PACs PACs : Reformat server 3Ds AFTER 2. PACS transferring raw data to PACS

Abdomen CTA- Aortic Aneurysm –Post EVT Typical Indications: f/u known or suspected thoracic aneurysm, preop evaluation stent graft Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Y** N/A N/A Domes diaphragms Contrast thru symphysis Arterial Y Use Bolus Inspiration Domes diaphragms Phase Tracking thru lesser trochanters Venous N N N/A Phase Delayed N N/A N/A Phase

Scan Comments: For routine f/u thoracic aneurysm noncontrast not needed. ** For Acute Chest Pain with r/o dissection include NonContrast CT to evaluate for acute intramural hematoma: See CTA Acute Aorta **For POST Endovacular Stent Graft patients add NonContrast phase thru chest/abd stent graft region Contrast Parameters Parameters Contrast Type Per insitution Contrast Volume 75-80cc routine 100 cc if combining with chest CTA Injection Rate 4-5cc/sec Oral Contrast N/A Oral Contrast Volume N/A Contrast Comments: DO NOT GIVE ORAL CONTRAST; if scout shows barium consider delaying exam for elective cases

Reconstruction Soft Bone/ Thin Data Sag Cor 3D/Special Parameters Tissue Lung

Slice Thickness x 2mm x 5mm x 1mm x 3mm x 3mm x #3) 3D radial MPR Recon Spacing 2mm 5mm 0.5mm 3mm 3mm #4) 5mm thick MIPs in SAG and COR

Plane Axial Axial Axial Sag Cor 3) Radial Range 4) SAG/COR

Reconstruction Soft Lung ST ST ST ST Algorithm Tissue

Send to PACS PACS 1. To 3D PACS PACs PACs : Reformat server 3Ds AFTER 2. PACS transferring raw data to PACS

CT COLONOGRAPHY Indications: Screening or Diagnostic Acquisition Phase Scan Respiration Anatomical Included Delay Phase Coverage Phase Non Y Domes diaphragms thru Contrast Sup + Prone N/A Inspiration lesser trochanters Arterial Phase N/A N/A N/A

Venous Phase N/A N/A N/A

Delayed Phase N/A N/A N/A

Scan Comments: Scan acquisitions in both Supine and Prone position Contrast Parameters Parameters Contrast Type Air per rectum Contrast Volume 50 puffs hand mechanical Scout after insufflation to assess air adequacy Saline Flush N/A

Injection Rate N/A

Oral Contrast Tagitol Oral prep protocol Oral Contrast Volume Tagitol V 3 bottles @ 20 ml each at 0800, 1200, 1700 day before See Virtual Colonography Prep Protocol: For Screening use Contrast Comments: Tagitol Oral Prep; For Diagnostic Cases coming from Incomplete Endoscopy may scan immediately without Tagitol prep

Reconstruction Parameters Soft Tissue Lung Thin Data Slice Thickness 5mm 5mm 0.5mm Reconstruction Spacing 5mm 5mm 0.5mm Reconstruction Algorithm Soft Tissue Lung Soft Tissue B30f B80f B30f Window and Level 400/40 1500/-500 400/40 Supine and Prone Axial 5x5 mm in Soft Tissue to PACS Reconstruction Comments: Lung 5 x 5 mm Recons to PACS Sag/Cor recons 3 x 3 Soft Tissue to PACS Supine and Prone Thin Data Sets to 3D Server (Terarecon) Only

46 Insufflation Technique 1. Left down decubitus. Inflate balloon in rectum; pull back to create seal at anorectal junction; tape catheter to cheeks; Turn on CO2 with maximum pressure (the machine’s computer starts at a low pressure and gradually increases it, no need to do this manually). Inflate first 1000 mL in LLD position. Roll patient to supine for 2nd 1000 mL. When pressure equilibriates to 25 mm and/or 2000 mL is reached then do supine scout. Do not turn off the gas. Check the scout. If the patient is full of stool find out if they took the prep, and if not send them home to reprep. If there is a nondistended segment, try rolling the patient so that segment is UP (air rises). Make sure tip is still in the rectum. Re-scout. If still not well distended, try hand insufflation (locate plastic bag in the tubing between pump and patient; occlude tubing between bag and patient; bag fills with gas; occlude tubing between bag and pump; squeeze contents of bag into patient. Repeat sequence of maneuvers several times. Pump will shut off automatically at 4 liters. If this happens, turn it back on. Repeat scout. Scan. Check axial images for non-distended segments. Make a note of them. Turn patient prone. DO NOT TURN OFF THE GAS. Place boosters underneath thighs and chest. If pump turns off by itself put it back on. Wait a minute or two. Rescan. If there is a non-distended segment repeat procedure above. Scan. Check axial images for non-distended segments. If there is an area nondistended on both supine and prone do a third scan (after additional insufflation) in a decubitus or oblique with the collapsed segment up. 2. Alternate method of manual insufflation- cut tubing with scissors between bag and patient; attach blue puffer bulb and insufflate room air. About 10 puffs should do if there is CO2 in there already. This may overcome ileocecal reflux or slight rectal sphincter incompetence. A complete exam can be done if the pump breask or you run out of CO2 using 50 bulb squeezes supine, then additional 10 after position change. 3. If gas escapes: use large bore tip with a big balloon

CT Enterography Typical Indications: Suspected or known Crohn’s, small bowel tumor, GI bleeding, malabsorption.. THIS IS NOT FOR ISCHEMIA- see CTA Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Contrast N N/A N/A Arterial Y* for occult GI Use Inspritation Mid liver to bottom of Phase bleeding/tumor Bolus Tracking ischial tuberosities Enteric Phase Y* 20 SECS after Inspiration Mid liver to bottom of (Crohn’s) arterial phase ischial tuberosities (50 seconds total) Delayed No for Crohn’s 90 SECS after Inspiration Mid liver to bottom of Phase Yes for Occult GI arterial phase ischial tuberosities Bleed/Tumor

Scan Comments: Biphasic and Triphasic scanning in young patients requires special consideration of lowering scan dose: 1) Scan range is directly related to the total radiation dose ; therefore, if the primary focus is imaging of the small bowel, coverage can be reduced to exclude the lung bases, breast tissue, and top of the liver. Imaging should be performed through the perineum, since perianal fistulas can be an essential diagnostic clue in Crohn colitis and may not be recognized clinically. 2) Dose reduction and improved lesion detection with lower kVP to 80-100 in normal to thin patients. Mucosal hyperenhancement and mural stratification of inflamed bowel are more pronounced at lower tube potentials, thus improving the conspicuity of abnormal segments. A potential radiation dose savings of 16%–30% can be achieved by reducing the kilovolt peak to 80 or 100 kVp.

From: July 2013 RadioGraphics, 33, 1109- 1124. Crohn disease or other diffuse bowel pathology: Enteric phase study only (approximately 50 seconds after start of injection) is sufficient. For occult GI bleeding and search for GI malignancy: arterial, enteric, and delayed scans are usually needed. Before giving IV contrast perform a low mA single slice through mid abdomen or topogram and check if there is adequate bowel distention. (Make sure most of Volumen is not in stomach) Pts need to be NPO 6hours except meds and oral contrast protocol. If patient cannot drink contrast NG tube required. Follow Volumen Protocol.

48 Contrast Parameters Parameters

Contrast Type Isovue 300

Contrast Volume 100cc

Injection Rate 4-5cc/sec

Oral Contrast Volumen

See Volumen protocol Oral Contrast Volume

For Gastric Mass/Ulcer Contrast Comments: evaluation use H2O water protocol  Scan Supine and have rad review need on while patient table to assess need for Prone images Reconstruction Soft Thin Bone/ Lung Sag Cor Parameters Tissue Data Slice Thickness x 3mm x 5mm x 1mm x 3mm 3mm Recon Spacing 3mm 5mm 0.5mm x x 3mm 3mm Plane Axial Axial Axial Sag Cor

Reconstruction Algorithm Soft Tissue Lung ST ST ST

Send to PACS PACS 1. To 3D PACS PACs server 2. PACS

50 CT UROGRAM Typical Indications: hematuria; bladder mass; see Renal Mass Protocol for known renal mass Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Contrast Y N/A Inspiration Kidneys thru lesser trochanters Arterial Phase/Early Y Approx 30 secs Inspiration Kidneys Corticomedullary Phase

Venous Phase/ Domes diaphragms Nephrographic Y 80-90 seconds Inspiration thru lesser trochanters Phase

Delayed Phase/ Y* 8-10 minutes Inspiration Kidneys thru lesser Urographic Phase trochanters

Scan Comments: Patients should be well hydrated for exam. *For Renal Mass protocol only do NonContrast, Arterial, and Nephrographic Phases ( no urographic phase). If obstructing renal stone identified on noncontrast contact Radiologist- may be able to omit other phases Contrast Parameters Parameters

Contrast Type Per Institution

Contrast Volume 100cc

Injection Rate 4-5 cc/sec

Oral Contrast H20

Oral Contrast Volume 800cc

400 cc H20 20 minutes Contrast Comments: prior to scan 400 cc H20 on table

Reconstruction Soft Tissue B Thin Sag Cor Parameters o Data n e/ Lu n g

Slice Thickness x 5mm 5 2mm 3mm 3mm Recon Spacing 5mm m 1mm 3mm 3mm m 5 m m Plane AX A AX NA COR X

Reconstruction ST L ST NA ST Algorithm U N G

Send to PACS P HOL PACs PACS A D CS

52 CT UROGRAM LOW DOSE

CT LOW DOSE UROGRAM- TRIPHASIC INJECTION

Typical Indications: “hematuria; bladder mass”

Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Contrast Y N/A Inspiration Kidneys thru lesser trochanters Combined Nephrographic/ Y 1)30cc @ Inspiration Domes thru Urographic Phase 2cc/sec bottom of Then NS flush symphysis 200cc pubis joint @1.5cc/sec Pause 10 mins 2) 55cc @ 1.5cc/sec Pause 20 secs 3)65cc @ 3 cc/sec

Reconstruction Soft Tissue Lung Thin Data Parameters 5mm 5mm 2mm Slice Thickness

5mm 5mm 2mm Reconstruction Spacing

Soft Tissue Lung ST Reconstruction Algorithm B30f B80f

400/40 1500/-500 400/40 Window and Level

54 Renal Mass Typical Indications: abnormal renal ultrasound/suspected renal mass Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Y N/A Inspiration Kidneys 5 x 5mm Contrast Corticomedullary Top of Liver to bottom Phase Y 30-40 secs Inspiration of Kidneys 5 x 5mm Nephrographic Y 90 secs Inspiration Top of Liver to Lesser Phase Trochanters DelayedPhase N N/A N/A N/A

Scan Comments:

Contrast Parameters Parameters Contrast Type Per institution

Contrast Volume 100cc Injection Rate 3cc-4cc/sec

Oral Contrast H20 Oral Contrast protocol 400 ml H20 20 minutes prior to scan Contrast Comment 400 ml H20 on table

Reconstruction Soft Tissue Bone/ Thin Sag Cor Parameters Lung Data

Slice Thickness x 5mm x 5mm x 2mm 3mm 3mm Recon Spacing 5mm 5mm x x x 1mm 3mm 3mm

Plane AX AX AX NA COR

Reconstruction Algorithm ST LUNG ST NA ST

Send to PACS PACS HOLD PACs PACS

56 Renal CTA Typical Indications: r/o renal artery stenosis Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non N N/A N/A N/A Contrast Arterial Y Use Bolus Inspiration Dome diaphragm thru Phase Tracking iliac crests Venous N N N/A Phase Delayed N N/A N/A Phase

Contrast Parameters Parameters Contrast Type Per institution Contrast Volume 80cc

Injection Rate 4-5cc/sec Oral Contrast N/A

Oral Contrast Volume N/A

Contrast Comments:

Reconstruction Soft Bone/ Thin Sag Cor 3D/Special Parameters Tissue Lung Data

Slice Thickness x 3mm x 5mm x 1mm x 3mm x 3mm x 1) 3D radial MPR Recon Spacing 3mm 5mm 0.5mm 3mm 3mm 2) 5mm thick MIPs in SAG and COR

Plane Axial Axial Axial Sag Cor 1) Radial Range 2) SAG/COR

Reconstruction Soft Tissue Lung ST ST ST ST Algorithm

To 3D PACs : Reformat server 3Ds AFTER Send to PACS PACS PACS PACs then to transferring raw PACS data to PACS

58 Retroperitoneal Hemorrhage Typical Indications: post heart cath r/o bleeding, unexplained drop in Hg/Hct, r/o acute bleeding Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Y N/A Inspiration Domes diaphragms thru Contrast lesser trochanters 5 x 5mm Arterial N* Bolus Tracking Inspiration Phase Venous N N N/A Phase Delayed N* N/A N/A Phase

Scan Comments: Consider IV contrast if Noncontrast Positive and/or if needed to detect acute vascular extravasation (especially immediately post heart cath, recent biopsy, or trauma) If extravasation seen on initial scan call radiologist and consider delayed scans thru area of extravasation depending on patient condition Contrast Parameters Parameters Contrast Type Per Institution Contrast Volume 100cc Injection Rate 4-5cc/sec Oral Contrast None Oral Contrast Volume N/A Contrast Comments

Reconstruction Soft Bone/ Thin Data Sag Cor 3D/Special Parameters Tissue Lung

Slice Thickness x 5mm x 5mm x 1mm x 3mm x 3mm x NA Recon Spacing 5mm 5mm 0.5mm 3mm 3mm

Plane Axial Axial Axial Sag Cor NA

Reconstruction Soft Tissue Lung ST ST ST NA Algorithm

Send to PACS PACS Hold PACS PACs NA

60 Oncology: Hepatoma: (Triphasic Liver CT) Typical Indications: Staging: Hepatoma; Hepatocellular CA; h/o liver cirrhoiss r/o HCC screening for hepatoma Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Y N/A Inspiration Liver Contrast Arterial Y Use arterial Inspiration Liver Phase bolus tracking software Venous Y 60-70 SECS Inspiration Domes diaphragms Phase thru lesser trochanters Delayed Y 3minutes Inspiration Liver Phase/Equilibrium Phase

Scan Comments: This is the standard triphasic liver CT. Contrast Parameters Parameters Contrast Type Per institution Contrast Volume 100cc Injection Rate 4cc/sec Oral Contrast H20 Protocol Oral Contrast Volume 400 cc H20 PO 20 minutes prior to scan 400c H20 PO on table Contrast Comments:

Reconstruction Soft Bone/ Thin Data Sag Cor 3D/Special Parameters Tissue Lung

Slice Thickness x 5mm x 5mm x 1mm x 3mm x 3mm x NA Recon Spacing 5mm 5mm 0.5mm 3mm 3mm

Plane Axial Axial Axial Sag Cor NA

Reconstruction Soft Tissue Lung ST ST ST NA Algorithm

Send to PACS PACS Hold PACS PACs NA

62 Oncology: Cholangiocarcinoma Typical Indications: Staging: cholangiocarinoma, bile duct tumor Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non N N/A N/A Contrast Arterial Y 25-30 SECS Inspiration Liver Phase Venous Y 60-70 SECS Inspiration Domes diaphragms Phase thru lesser trochanters* Delayed Y 8 minutes Inspiration Liver Phase

Scan Comments: * Include pelvis during PVP if ordered Contrast Parameters Parameters Contrast Type Per institution Contrast Volume 75- 80 cc routine 100cc if combined with CAP Injection Rate 4cc/sec

Oral Contrast Per institution

Oral Contrast Volume Per institution

Contrast Comments: May use 800 cc H20 as alternative to positive oral contrast if only scanning liver

Reconstruction Soft Bone/ Thin Data Sag Cor 3D/Special Parameters Tissue Lung

Slice Thickness x 5mm x 5mm x 1mm x 3mm x 3mm x NA Recon Spacing 5mm 5mm 0.5mm 3mm 3mm

Plane Axial Axial Axial Sag Cor NA

Reconstruction Soft Tissue Lung ST ST ST NA Algorithm

Send to PACS PACS Hold PACS PACs NA

64 Pancreatic Mass CT Typical Indications: Evaluate Pancreatic Mass (For evaluation standard pancreatitis use Routine Abdomen Pelvis CT) Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Y N/A Inspiration Liver through pancreas Contrast Arterial Y Use bolus tracking Inspiration Liver through pancreas Phase software Venous Y 60-70 SECS Inspiration Domes diaphragms Phase thru lesser trochanters

Scan Comments: Acute Pancreatitis: work-up should be done as Routine Abdomen-pelvis. For Pancreas cases OPACIFICATION AND DISTENTION OF DUODENUM IS VERY IMPORTANT- drink additional oral contrast immediately before scan and consider placing patient right side down for 2-3minutes prior to scanning to mobilize contrast into duodenum. Venous phase through pelvis if pelvis CT ordered. Contrast Parameters Parameters Contrast Type Per Institution Contrast Volume 75-80cc routine 100 cc if combined with CAP Injection Rate 4cc/sec Oral Contrast Per institution

Oral Contrast Volume Contrast Comments: Be sure to give extra oral contrast immediately prior to scanning to distend stomach/ duodenum. Check for adequacy of duodenal contrast on un-enhanced series

Reconstruction Soft Bone/ Thin Data Sag Cor 3D/Special Parameters Tissue Lung

Slice Thickness x 3mm x 3mm x 1mm x 3mm x 3mm x NA Recon Spacing 3mm 3mm 0.5mm 3mm 3mm

Plane Axial Axial Axial Sag Cor NA

Reconstruction Soft Lung ST ST ST NA Algorithm Tissue

Send to PACS PACS Hold PACS PACs NA

66 CT VENOGRAM PELVIS: Pelvic Venous Congestion Typical Indications: Evaluate Ovarian Vein Reflux/ Pelvic Venous Congestion ; pelvic varicosities, exclude pelvic vein or lower extremity deep venous thrombosis :

Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Contrast N N/A N/A N/A

Arterial N/A Phase N N/A N/A

Venous Top of Kidneys to Phase Y 3MINS QUIET below Lesser Trochanters Delayed Phase N N/A N/A N/A

Scan Comments: MAY BE ABLE TO DECREASE KVP TO 100 OR 80 IN SMALL PTS

Contrast Parameters Parameters Isovue 370 Contrast Type

Contrast Volume 100CC

Injection Rate 2CC/sec CONTRAST 2CC/SEC SALINE FLUSH X 30 CC

Oral Contrast N/A

N/A Oral Contrast Volume

Contrast Comments: SCAN DELAY 3 MINUTES

Reconstruction Soft Bone/ Thin Sag Cor 3D/Special Parameters Tissue Lung Data

Slice Thickness x 1MM X N/A 0.75MM X 3mm x 3mm x SEND Recon Spacing 1MM 1MM 3mm 3mm THINSTO PACS FOR MD RECONS

Plane Axial N/A Axial Sag Cor AX

Reconstruction Soft Tissue N/A ST ST ST ST Algorithm

Send to PACS N/A TO TERA PACS PACs DONE BY MD

68 LOWER EXTREMITIES

CT VENOGRAM LOWER EXTREMITY Typical Indications: Evaluate Venous varicosities, exclude pelvic vein or lower extremity deep venous thrombosis :

Acquisition Phase Scan Respiration Anatomical Phase Included Delay Phase Coverage Non Contrast N N/A N/A N/A

Arterial N/A Phase N N/A N/A

Venous TOP OF L4 TO FEET Phase Y 3MINS QUIET

Delayed Phase N N/A N/A N/A

Scan Comments: IF PATIENT IS BEING SCANNED TO RULE OUT OVARIAN VEIN REFLUX, PELVIC VENOUS CONGESTION PLEASE SEE OVARIAN VEIN REFLUX/ PLEVIC VENOUS CONGESTION PROTOCOL. MAY BE ABLE TO DECREASE KVP TO 100 OR 80 IN SMALL PTS

Contrast Parameters Parameters Isovue 370 Contrast Type

Contrast Volume 100CC

Injection Rate 2CC/sec CONTRAST 2CC/SEC SALINE FLUSH X 30 CC

Oral Contrast N/A

N/A Oral Contrast Volume

Contrast Comments: SCAN DELAY 3 MINUTES

Reconstruction Soft Bone/ Thin Sag Cor 3D/Special Parameters Tissue Lung Data

Slice Thickness x 1MM X N/A 0.75MM X 3mm x 3mm x SEND Recon Spacing 1MM 1MM 3mm 3mm THINSTO PACS FOR MD RECONS

Plane Axial N/A Axial Sag Cor AX

Reconstruction Soft Tissue N/A ST ST ST ST Algorithm

Send to PACS N/A TO TERA PACS PACs DONE BY MD