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Imaging With Intention: Optimizing Care Through Collaboration in Diagnostic Radiology · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

• 0:00
  I'm Holly Wehmins, and this is Pediatrics Now, brought to you by the Department
• 0:04
  of Pediatrics at UT Health San Antonio and University Health's new Women's and Children's Hospital.
• 0:11
  Today, I'm bringing you Grand Rounds. Let's listen in.
• 0:16
  It's my great pleasure to introduce this morning's Grand Rounds speaker, Dr.
• 0:20
  Shish, who is a pediatric radiologist and physician informatologist at Children's
• 0:25
  Hospital of Colorado in Colorado Springs.
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  After earning her medical degree from the Indiana University School of Medicine,
• 0:33
  she completed Diagnostic Radiology Residency at UT Southwestern and Pediatric
• 0:38
  Radiology Fellowship at Texas Children's Hospital.
• 0:41
  Her clinical and research focus is pediatric bowel ultrasound.
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  She's going to discuss how we optimize pediatric care by collaboration with
• 0:53
  different pediatricians across the school.
• 0:56
  Thank you, Dr. Rashish, for accepting our invitation. I'm looking forward to
• 1:02
  your presentation. Thank you.
• 1:04
  Well, good morning, and thanks so much for having me. Let's jump right in.
• 1:11
  My only disclosure is that this talk contains a couple of AI-generated images,
• 1:15
  so we'll see if you can spot those as we go.
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  I'd like to start by showing you a resource that you can use to help choose
• 1:22
  the best imaging for your patients, and that will lead us into a discussion
• 1:25
  about radiation considerations.
• 1:27
  Then we'll review the imaging modalities, including some tips and tricks on
• 1:31
  how to optimize your imaging orders, as well as some interesting cases.
• 1:35
  And we'll also test your knowledge with a quiz where we will see 10 patients
• 1:39
  over the course of this talk.
• 1:40
  And just a reminder that not all of them will require imaging.
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  We'll wrap up by discussing when to consult a radiologist.
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  The American College of Radiology has created evidence-based guidelines known
• 1:55
  as the Appropriateness Criteria to assist referring clinicians in choosing the
• 1:59
  best imaging exams for patients.
• 2:01
  You can check them out by scanning this QR code on the screen and click Access the Criteria.
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  Now I'll show you how to navigate the Appropriateness Criteria.
• 2:11
  Notice the three tabs across the top.
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  The first way to navigate is by Scenario. Here I've entered pediatric and a
• 2:18
  search term of vomiting, which displays 10 results of clinical scenarios that involve vomiting.
• 2:24
  Next, you can explore by topic. Again, I've entered pediatric,
• 2:28
  and you can see that there are 24 topics that you can browse through.
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  You can also explore by procedure. Here I've entered ultrasound as the modality
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  and right lower quadrant as the anatomy of interest.
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  This narrows it down to a single exam type, and when you click on that,
• 2:44
  it shows a related topic of appendicitis.
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  When you select appendicitis, you'll notice there are five different clinical
• 2:50
  scenarios of a child with suspected acute appendicitis.
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  Notice that if there is low risk of appendicitis, any type of imaging is usually
• 2:59
  not appropriate, as shown in the far right column.
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  If there's intermediate clinical risk, it's usually appropriate to start with an ultrasound.
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  If there's high clinical risk, either an ultrasound, MRI, or CT may be appropriate.
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  Now let's say the ultrasound was equivocal or non-diagnostic because the appendix was not visualized.
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  Then either an MRI or CT would be the appropriate next step.
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  If appendicitis is complicated by an abscess, we usually prefer a CT with contrast.
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  Notice that in all scenarios, a CT without and with contrast is usually not
• 3:36
  appropriate because it's double the radiation dose.
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  Another way to access the appropriateness criteria is to select this link for
• 3:45
  a complete list of topics.
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  Now the tabs across the top are diagnostic and interventional,
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  and I've entered... So we're looking at diagnostic and I've entered pediatric.
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  These are the same topics that we saw before, but here you can see all of the
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  evidence behind each of them.
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  Be aware that the appropriateness criteria have some nuances.
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  They were developed for both adults and children, so not all topics have pediatric-specific
• 4:11
  recommendations, and even the ones that do cannot cover every possible scenario.
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  The availability of different imaging modalities can vary across institutions,
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  multiple sites within the same system, or even the time of day.
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  For example, at most children's hospitals, MRI technologists have to be called
• 4:28
  in from home overnight if an emergent MRI is needed.
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  Imaging protocols can vary across
• 4:34
  institutions or even across different radiologists within the same group.
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  Also, it can take time for the appropriateness criteria to catch up with advances
• 4:43
  in imaging research and technology.
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  You may have noticed these radiation symbols in the charts I showed earlier.
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  This table shows the relative radiation dose indicated by the number of radiation
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  symbols, the range of effective doses that these represent in pediatric patients,
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  and some examples of imaging exams in each category.
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  Ultrasound and MRI have no radiation, whereas X-rays have low radiation,
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  and CTs have higher radiation doses depending on the anatomy and exam type.
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  To put this in perspective, every human on Earth receives about 1.5 mSv per
• 5:19
  year of radiation from the sun, the Earth, and radon in our homes.
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  Another way we get exposed to radiation is by flying in airplanes.
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  A little-known fact is that pilots actually receive the most radiation out of any profession.
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  One of the longest flights in modern aviation is from Melbourne,
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  Australia to London at nearly 23 hours, and the radiation dose from this flight
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  equates to almost a month of living on Earth at sea level.
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  The Royal Children's Hospital of Melbourne looked at the radiation doses of
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  commonly performed x-rays by patient weight and equated that to the number of
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  days of natural background equivalent radiation time as well as the number of
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  hours of international flight time.
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  As you can see, most x-rays carry minimal to low risk of future cancer development.
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  So what can we do? As radiologists, we pledge to image gently,
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  and you can do the same for your patients.
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  This means following a principle known as as low as reasonably achievable.
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  This means that we use the minimum radiation dose needed to answer a clinical question.
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  Unique considerations in the pediatric population include increased radiosensitivity
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  of certain tissues and a longer lifespan for potential radiation-related cancers to occur.
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  These risks must be weighed against the benefits of the diagnostic value of imaging.
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  Choosing Wisely is another campaign that partnered with the AAP to publish a
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  set of guidelines for pediatric imaging.
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  These include not ordering x-rays in children with bronchiolitis,
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  croup, asthma, or first-time wheezing, nor for suspected constipation,
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  and not ordering a head CT for a patient with a febrile seizure.
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  When imaging is indicated, it is important that children are imaged at a dedicated
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  pediatric center whenever possible.
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  Pediatric centers have optimized imaging protocols with appropriate radiation
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  doses for children who would often receive much higher doses at adult facilities.
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  Our technologists image children day in and day out, and they know exactly how
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  to position the patients and acquire the images needed for a diagnostic exam.
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  This is even more critical in ultrasound because if the sonographer doesn't
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  know what they're looking at, there's a good chance they won't get the images
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  needed to make the diagnosis.
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  Many pediatric centers have child life specialists who help reduce patient anxiety
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  using distraction techniques, as shown here.
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  Patients imaged at a pediatric center will typically receive subspecialty interpretation
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  by pediatric-trained and certified radiologists.
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  This is critical because children are not just little adults.
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  Another example of a technique utilized by child life specialists is to prepare
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  children for their imaging exams by engaging in medical play.
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  Many pediatric centers have toy MRI machines such as these, where a patient
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  can place a toy or doll into the machine to simulate what their experience will be like.
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  Last but not least, at a pediatric center there's a good chance that the CT
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  or MRI scanner might look like this, which is a lot more fun for kids.
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  Now let's review the imaging modalities.
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  This is one of my favorite photos of an immobilizer device that was used to
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  obtain chest x-rays, and you can tell this is a pretty old picture.
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  X-rays rely on the differential absorption of x-rays by various tissue types to create an image.
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  X-ray is widely available, quick, cheap, and does not require sedation.
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  X-ray has excellent spatial resolution for bony detail, but lacks soft tissue
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  contrast, so sometimes findings can be nonspecific.
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  And, of course, there is some radiation exposure.
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  X-ray is frequently used as first-line imaging for various pediatric conditions,
• 9:05
  especially for things like pneumonia, bowel obstruction, and fractures.
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  Note that constipation is not on this list, as X-rays are not routinely recommended
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  for diagnosis or management.
• 9:17
  I want to share a few tips on ordering X-rays. The first is to order the most
• 9:21
  specific exam, depending on the area of concern.
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  For example, if there's pain near a joint, instead of ordering x-rays of the
• 9:29
  long bones around that joint, it's better to order an x-ray of the joint itself.
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  It does make a difference because joint x-rays include more views than long
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  bone x-rays, and patient positioning for joint x-rays enables us to better evaluate alignment.
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  If there's concern about a specific finger or toe, on a hand or foot x-ray,
• 9:48
  the lateral view often has overlap of all the fingers and all the toes,
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  which can be, not very diagnostic for any given finger or toe.
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  So it's better to order a dedicated finger or toe x-ray that will include a
• 10:02
  specific lateral view of the finger or toe that hurts.
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  And for back pain, scoliosis foams are not optimal because these are low-dose
• 10:12
  exams for evaluating spinal curvature.
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  Dedicated x-rays of a particular region of the spine are better to evaluate
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  for things like fracture or compression deformities.
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  Another tip is that certain x-ray exams are typically of low clinical utility.
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  For example, skull x-rays are rarely helpful. If there's concern for a fracture,
• 10:33
  it's better to just get a CT head, whereas if there's a soft tissue lump or
• 10:37
  bump, start with an ultrasound.
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  X-rays of the nasal bones are challenging to interpret in children due to their
• 10:43
  immature nasal bones, which are normally discontinuous.
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  If there's clinical concern for a fracture, it's best to get a CT of the face.
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  Similarly, for mandibular x-rays, unless it's a displaced fracture,
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  it might be hard to see on an x-ray.
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  Another example is inspiratory and expiratory chest radiographs.
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  I've seen plenty of these that
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  look totally normal or have very subtle asymmetry that's easy to miss.
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  Some pediatric centers now offer low-dose chest CT with direct visualization
• 11:12
  of the airway and esophagus to assess for radiolucent foreign bodies.
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  We'll talk more about this later. And finally, X-rays of the sacrum and coccyx
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  are challenging to interpret due to the immature osseous structures and are
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  unlikely to change management anyway, so just do conservative management.
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  Now let's discuss the radiographic views for a chest X-ray. These can be obtained
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  in two different ways, which are known as PA, posterior-anterior,
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  or AP, anterior-posterior.
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  The difference is the way the patient is positioned between the X-ray tube and the detector.
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  If the x-rays first enter the posterior part of the patient and then come out
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  through the anterior part, that's a PA projection.
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  These are typically performed in outpatients. And if the x-rays go from anterior
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  to posterior through the patient, that's an AP projection, which are often performed in inpatients.
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  Notice what that does to the cardiac shadow. The farther away the heart is from
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  the detector, the more the x-rays fan out before reaching the detector,
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  which leads to magnification of the heart.
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  That is why chest x-rays obtained in an AP projection make the heart look bigger than it actually is.
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  A few tips on how many views to order, depending on the body part.
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  For chest x-rays, inpatients with support devices usually only need one view
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  to determine if the lines and tubes are in satisfactory position,
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  whereas most outpatients with concern for pneumonia will get two views.
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  Due to the shape of the diaphragm, lateral chest x-rays can detect smaller volumes
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  of pleural fluid than frontal chest x-rays.
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  For the abdomen, one view is usually sufficient to assess the bowel gas pattern
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  or the amount of stool, although I know that none of you will order constipation x-rays after this talk.
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  If there is concern for bowel obstruction or pneumoperitoneum,
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  at least two views are needed, and I'll show you why in the next slide.
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  For scoliosis, you can get away with one view if the patient only has scoliosis,
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  but if there's a rotational component or kyphosis, then two views are best.
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  Unless you're an orthopedic surgeon, don't order more than two views for scoliosis.
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  And for extremities, we do two views for most long bones and three views for
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  the joints as well as the hands and feet.
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  This is a 17-year-old who presented with abdominal distension and vomiting.
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  The standard abdomen radiograph is typically done in the supine position.
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  In the supine position, free air collects anteriorly, and it can be subtle if
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  there's only a small amount.
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  One clue is the wriggler sign, which is where you see air on both sides of the bowel wall.
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  However, the finding is much more obvious on the upright view,
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  where free air collects under the diaphragm, or the left lateral decubitus view,
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  where air collects over the liver.
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  These views are much more sensitive for pneumoperitoneum.
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  This 18-year-old young man had a fall while snowboarding with a direct blow to his left shoulder.
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  AP view of the clavicles demonstrates asymmetric left supraclavicular soft tissue
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  swelling, but the fracture is very difficult to visualize.
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  An axial view of the clavicles demonstrates a comminuted fracture of the left
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  distal clavicle with inferior displacement of the fracture fragment.
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  This patient was treated with a sling and repeat radiographs one month later
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  demonstrated healing changes.
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  That case was an example of an imaging principle that we like to call one view
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  is no view, and this set of images is another excellent example of that.
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  All right, it's time for our first quiz. Go ahead and get your phones out if
• 14:42
  you can and scan this QR code.
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  If it asks for your name, it's totally fine to just hit skip.
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  As I mentioned before, we'll be seeing 10 patients over the course of this talk,
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  so keep your phone handy.
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  All right, let's get started with the first one.
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  To make the poll here.
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  Okay, so your first patient is a 5-year-old with first-time wheezing.
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  What type of imaging would you like?
• 15:09
  No imaging, x-ray 1 view, x-ray 2 views, or 3 views of the chest.
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  All right, looks like we're getting a lot of responses for no imaging.
• 15:23
  Excellent job. So this patient got imaging anyway, and we saw reactive airways
• 15:29
  disease or bronchiolitis.
• 15:33
  Patient 2 is an 18-month-old with upper respiratory symptoms for 6 days,
• 15:38
  fever for 4 days, and tested positive for rhinovirus.
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  What type of imaging would you like? No imaging is an option,
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  or we could get one, two, or three views of the chest.
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  All right, we're getting a variety of responses here.
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  So the correct answer in this case is two views of the chest,
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  and in this patient, you'll see that there is a consolidation in the right upper
• 16:12
  lobe, which is compatible with pneumonia.
• 16:17
  All right, patient three is an eight-year-old with abdominal discomfort,
• 16:21
  vomiting, history of constipation, and palpable left lower quadrant fullness, likely stool.
• 16:30
  This is an actual clinical history that we got.
• 16:36
  So, would you like no imaging or one, two, or three views of the abdomen?
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  Getting some majority responses for no imaging, some with one view,
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  and some people want two views.
• 16:50
  All right, excellent. So the correct answer in this case is no imaging.
• 16:55
  However, as you might imagine, this patient did get imaging.
• 16:58
  And I just wanted to show you the spectrum of stool burden and some of the words
• 17:02
  that we might use to describe it.
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  So a small stool burden means there's really not a whole lot there.
• 17:08
  A normal stool burden would be what I would expect to see if we pull a random
• 17:12
  asymptomatic person off the street and took an x-ray.
• 17:15
  A moderate amount of stool is typically a word that I would use if there is
• 17:21
  a decent amount of stool that I think is slightly greater than physiologic.
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  And a large amount is someone probably needs to do something about that.
• 17:30
  And this is actually our patient in the clinical scenario who had a large stool burden.
• 17:36
  All right, we're going to take a break from the quiz for a while,
• 17:39
  and we're going to come back to it later, so just keep your phones handy.
• 17:44
  The next step when ordering imaging is to enter the clinical history.
• 17:48
  This is super important because without knowing the clinical context,
• 17:51
  the radiologist may come to an incorrect conclusion about the findings.
• 17:55
  This is another saying we have in radiology, which is garbage in, garbage out.
• 18:00
  So what does the radiologist want to know? Some helpful things to include are
• 18:04
  any relevant past medical history, the current signs and symptoms, as well as the duration.
• 18:09
  Whether there's any history of trauma or injury and what happened.
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  Our interpretation of a bone x-ray may be very different depending on whether
• 18:18
  there was an injury or not.
• 18:20
  Also, we want to know the exact anatomic location, especially for the hands
• 18:24
  and feet. This makes it much easier to find subtle fractures.
• 18:29
  And any lab abnormalities, such as the white blood cell count,
• 18:32
  inflammatory markers, liver function tests, etc., which are often more pertinent
• 18:36
  for cross-sectional imaging modalities.
• 18:40
  Here are some examples. Instead of saying pain or trauma, it would be better
• 18:44
  to say an 8-year-old previously healthy child presents after a fall this morning
• 18:48
  with pain and swelling at the second MCP joint.
• 18:52
  Clear communication of clinical details enables radiologists to be more efficient
• 18:56
  and precise while minimizing unnecessary clarifications, follow-up, or additional imaging.
• 19:02
  Additionally, it's important to include presenting signs and symptoms rather
• 19:06
  than simply a differential diagnosis.
• 19:08
  As exams lacking appropriate history, such as rule-out pneumonia,
• 19:12
  may not be reimbursed by insurance companies.
• 19:14
  What would be better here is a four-year-old with history of lymphoma presenting
• 19:19
  with fever and cough for two days.
• 19:23
  Here's an example of a two-year-old who presented with pain.
• 19:26
  This is one of our least favorite indications.
• 19:29
  Without knowing more information, it would be very easy to call this study normal
• 19:33
  and move on to the next case.
• 19:35
  Now let's say we have the same x-rays with this history, two-year-old with pain
• 19:40
  after fall and traveling.
• 19:41
  This enables the radiologist to know exactly where to focus our attention.
• 19:46
  We zoom in on the proximal tibia and notice very subtle cortical irregularity
• 19:50
  at the proximal tibial metafasis consistent with a non-displaced fracture.
• 19:55
  Follow-up radiographs show sclerosis consistent with healing changes.
• 19:59
  The mechanism of injury for trampoline fractures is when a heavier person jumps
• 20:04
  up and the trampoline recoils upward while the child is descending.
• 20:08
  And when the child contacts the trampoline, the excessive load produces this
• 20:11
  characteristic fracture of the proximal tibia.
• 20:16
  X-rays are also great at evaluating radio-opaque foreign bodies,
• 20:20
  meaning ones that are dense or metallic.
• 20:22
  This child went fishing with his dad on Father's Day. This child swallowed a
• 20:26
  steak knife, which was actually detected as an incidental finding, believe it or not.
• 20:30
  And this was an EpiPen that went into a child's thumb.
• 20:35
  This 6-year-old swallowed two coins that are almost perfectly stacked one on
• 20:39
  top of the other in the upper esophagus.
• 20:43
  That is in contrast to a swallowed button battery, which demonstrates a characteristic
• 20:47
  lucent rim on the frontal view and a beveled edge on the lateral view.
• 20:53
  And here's an example of a swallowed button battery that's been there for a
• 20:57
  longer period of time and has begun eroding.
• 20:59
  Notice the irregular appearance around the periphery.
• 21:04
  Here's a side-by-side comparison of a single ingested coin versus an ingested
• 21:09
  button battery. keep those button batteries away from children.
• 21:14
  Moving on to fluoroscopy, this is a device that's still used at some children's
• 21:19
  hospitals for fluoroscopy in infants.
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  The baby is strapped to the board at the head and around the legs,
• 21:25
  and this device can be rotated to position the patient at any 45-degree angle
• 21:29
  to obtain images in frontal, lateral, or oblique views.
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  The x-ray source is above the patient, and the detector is below the table.
• 21:38
  Fluoroscopic images are usually taken by a radiology provider,
• 21:41
  with a technologist assisting with patient positioning and contrast administration.
• 21:46
  Fluoroscopy uses intermittent continuous low-dose x-rays to produce dynamic
• 21:50
  images, allowing for real-time visualization.
• 21:54
  Fluoroscopy is almost always performed with contrast, which can be introduced
• 21:58
  through various routes such as oral, rectal, or intravesical.
• 22:01
  The contrast agent is then imaged as it passes through the anatomy me of interest over time.
• 22:07
  Thus, fluoroscopy is ideal for dynamic imaging of organs that demonstrate movement
• 22:11
  of contrast within them, such as the bowel.
• 22:14
  It does not require sedation, and it can be therapeutic in some instances,
• 22:18
  such as contrast or air enemas, which I'll show you later.
• 22:22
  Drawbacks include radiation exposure, and fluoroscopy is operator-dependent
• 22:26
  and sensitive to patient cooperation.
• 22:30
  Here are some common indications that we use fluoroscopy to evaluate the GI or GU tract.
• 22:36
  Fluoroscopic exams assessing the upper GI tract typically require fasting or
• 22:40
  pausing enteral nutrition before the exam in order to promote patient participation
• 22:44
  with drinking contrast and to minimize gastric distension.
• 22:48
  Sometimes a fluoroscopic exam, such as the contrast enema or VCUG,
• 22:52
  require catheter insertion into the rectum or urinary bladder, respectively.
• 22:59
  I want to clear up a few misconceptions about fluoroscopy. In the past,
• 23:03
  at least at my institution, we used to say that a patient with dysphagia who
• 23:07
  had never had an upper GI before must have what was called a completion upper
• 23:11
  GI, meaning that we would do an esophagram and then complete the upper GI to
• 23:15
  confirm normal bowel rotation.
• 23:17
  This is no longer recommended as it increases the duration of the exam and the radiation dose.
• 23:23
  If a patient presents with dysphagia, they just need an esophagram,
• 23:27
  but if there's any abdominal pain or vomiting, then we would do an upper GI.
• 23:32
  Another misconception is that we need an upper GI with small bowel follow-through
• 23:35
  to fully evaluate for malrotation, but this is not true.
• 23:40
  An upper GI is sufficient to assess the ligament of trites, and the small bowel
• 23:43
  follow-through is not necessary.
• 23:46
  Here's a side-by-side comparison of an upper GI and an upper GI with a small bowel follow-through.
• 23:52
  With the upper GI alone, we can get by with anywhere between 5 to 60 mLs of
• 23:56
  contrast depending on patient age.
• 23:59
  But a small bowel follow-through, we need much more contrast,
• 24:02
  usually at least 100 to 150 mL.
• 24:06
  In addition to that, the radiation dose is higher with the small bowel follow-through
• 24:10
  because it includes not only the upper GI, but also multiple abdomen x-rays
• 24:15
  taken at various intervals to watch the contrast until it reaches the colon.
• 24:19
  This can take 2 to 4 hours in most patients, but sometimes longer in patients with dysmotility.
• 24:24
  So when outpatients come in for this exam, they're usually spending half a day
• 24:28
  in the radiology department.
• 24:30
  The small bowel follow-through is also generally of low diagnostic utility because
• 24:35
  there are multiple overlapping loops of bowel, such as in this example.
• 24:39
  Also, we don't really know what the normal small bowel transit time is in children.
• 24:43
  So although this exam does produce some quantitative information,
• 24:47
  it may be difficult to understand its significance.
• 24:52
  Another misconception is regarding fluoroscopic enemas. We do not use barium
• 24:56
  for enemas in children, so we don't refer to these as barium enemas.
• 25:00
  Contrast enemas are also generally of low diagnostic utility in the setting
• 25:04
  of chronic constipation, especially
• 25:06
  in older children, because undiagnosed Hirschsprung disease is rare.
• 25:10
  This is the one case I've seen of a 5-year-old with concern for obstruction
• 25:14
  who had a small caliber rectum with mucosal irregularity.
• 25:18
  Biopsy confirmed Hirschsprung's disease, and the patient underwent an ileostomy.
• 25:24
  Moving on to ultrasound. In pediatric radiology, we love ultrasound.
• 25:28
  Ultrasound images are created by the transmission and interaction of sound waves
• 25:32
  with various tissues in the body. Thus, there is no radiation.
• 25:37
  Ultrasound is widely available, and the machines are portable,
• 25:40
  enabling bedside imaging when needed.
• 25:43
  Ultrasound provides real-time dynamic imaging, meaning we can assess in different
• 25:47
  patient positions or with the Valsalba maneuver.
• 25:50
  Ultrasound is cost-effective and does not require sedation.
• 25:54
  Unique considerations include that image quality is operator-dependent and requires
• 25:58
  patient cooperation, as well as that sound waves cannot penetrate through bowel gas or bone.
• 26:06
  As you can see here, there are a plethora of pediatric entities that we can
• 26:10
  evaluate with ultrasound.
• 26:11
  We don't have time to cover all of these, but I do want to highlight one recent
• 26:15
  innovation, which is ultrasound for midgut volvulus.
• 26:20
  In the past, upper GI was the gold standard imaging modality for midgut volvulus,
• 26:24
  as in this case, demonstrating the classic corkscrew sign.
• 26:28
  Many children's hospitals are now moving to ultrasound as the first imaging
• 26:32
  modality, as it is quicker, cheaper, and does not use radiation.
• 26:37
  In this four-day-old male with bilious emesis,
• 26:40
  ultrasound demonstrated a portion of the dilated stomach and proximal duodenum
• 26:44
  with a beaked morphology as it enters a clockwise twist of bowel,
• 26:48
  mesentery, and vessels around the superior mesenteric artery,
• 26:51
  known as the whirlpool sign.
• 26:54
  This patient went directly to the operating room after the ultrasound,
• 26:57
  with interoperative findings of a narrow base mesentery with 540 degree rotation
• 27:02
  of the midgut and complete duodenal obstruction.
• 27:05
  The intestine was viable and the patient underwent a LADS procedure.
• 27:09
  As in this case, ultrasound can prevent the need for upper GI altogether,
• 27:13
  or it can be used in conjunction with upper GI when either modality is inconclusive.
• 27:18
  This is not yet reflected in the ACR appropriateness criteria,
• 27:21
  perhaps because it has been only implemented at a handful of children's hospitals.
• 27:26
  The bottom line is to only order ultrasound if you know the patient will get
• 27:29
  imaged at a facility that routinely performs this exam.
• 27:34
  Ultrasound has a few age cutoffs to be aware of.
• 27:37
  For the spine, posterior element ossification precludes evaluation after about 4-6 months.
• 27:44
  Pyloric stenosis is exceedingly rare after the age of 6 months,
• 27:48
  so we usually don't offer this exam beyond that age.
• 27:51
  For hip dysplasia, imaging too early can create false positives,
• 27:55
  and after 6 months, we recommend pelvis x-rays instead, due to ossification
• 27:59
  of the proximal femoral epiphyses.
• 28:02
  For head ultrasound, dehydration in the newborn causes slit-like ventricles,
• 28:07
  limiting evaluation for intracranial hemorrhage.
• 28:09
  And around one year, the anterior fontanelle starts closing,
• 28:13
  limiting the acoustic window.
• 28:16
  One misconception about ultrasound is that it's not a cross-sectional imaging
• 28:20
  modality, and this is not true.
• 28:22
  Ultrasound images are acquired in multiple imaging planes, most commonly longitudinal
• 28:27
  and transverse, which are analogous to either CT or MRI.
• 28:32
  Another misconception is regarding the order of a complete abdomen ultrasound.
• 28:37
  This protocol evaluates the
• 28:39
  solid organs shown here, as well as limited images of the aorta and IVC.
• 28:43
  It does not include the bowel, reproductive organs, lymph nodes,
• 28:48
  peritoneal cavity, or abdominal wall.
• 28:50
  So despite its name, this exam is not for screening the whole abdomen.
• 28:55
  To evaluate the bowel, you would order a limited abdomen ultrasound and then
• 28:59
  select from any of the following protocols.
• 29:03
  For vascular assessment, again, it's a limited abdomen ultrasound,
• 29:06
  and we can use this to evaluate for median arcuate ligament syndrome.
• 29:11
  If you're looking for an ascites or an abscess, it would be a limited abdomen
• 29:15
  ultrasound to look for ascites, abscess, or fluid collection.
• 29:18
  And to assess a palpable abnormality of the abdominal wall, we would do a limited
• 29:23
  abdomen ultrasound for soft tissue mass or for a hernia.
• 29:29
  For soft tissue ultrasounds, the history is absolutely critical.
• 29:32
  Things the radiologist want to know include how long has it been present?
• 29:36
  Specifically, has it been present since birth? Then we need to be thinking about
• 29:40
  congenital etiologies.
• 29:42
  Any change in size over time, skin discoloration, discharge, or tenderness.
• 29:47
  It's also helpful to have a clinical photo of the area in the patient's chart.
• 29:51
  Our sonographers routinely obtain these as part of soft tissue exams.
• 29:55
  As in this case of one of my favorite diagnoses, atypical mycobacterial adenitis,
• 30:00
  in which the photo cinches the diagnosis.
• 30:04
  Due to the excellent superficial soft tissue contrast, ultrasound is excellent
• 30:08
  at showing foreign bodies. This teenager fell off a fence.
• 30:12
  X-rays showed subtle soft tissue swelling, but wood is radiolucine.
• 30:17
  Ultrasound nicely shows multiple splinters in the upper arm soft tissues.
• 30:22
  Ultrasound can also assess for ingested foreign material such as bezoars.
• 30:26
  This patient had gastric distension with mottled material on x-ray,
• 30:30
  and ultrasound showed echogenic material in the stomach with posterior acoustic shadowing.
• 30:36
  This is what was removed from the patient in the operating room,
• 30:39
  and it turned out that the patient had been eating carpet fibers.
• 30:43
  Another example of ingested foreign bodies includes water balls.
• 30:47
  This patient swallowed two water bottles that expanded within the bowel in the
• 30:50
  right upper quadrant and pelvis, causing a small bowel obstruction.
• 30:54
  Notice that the intervening loops of bowel are dilated.
• 30:58
  The patient underwent a CT that showed small bowel obstruction with a transition
• 31:02
  point in the pelvis, but the water bottles themselves are invisible on CT due
• 31:06
  to being the same density as the adjacent enteric contents.
• 31:10
  Here is what was removed from this patient in the operating room.
• 31:14
  Also known as Orbeez, these are superabsorbent polymer beads that can expand
• 31:18
  up to 200 times their original size when placed in water and shrink back down
• 31:22
  to their original size outside water, as shown in this home experiment.
• 31:27
  When ingested, ultrasound is the best imaging modality to visualize them as
• 31:31
  they will not be seen on x-ray or CT.
• 31:35
  All right, it's time for our next patient.
• 31:42
  You might have to refresh your browser to see patient four.
• 31:46
  Hopefully everybody can see it. This is a five-month-old with enlarging head
• 31:49
  circumference or macrocephaly. What type of imaging would you like?
• 31:53
  No imaging, an x-ray of the skull, a head, an ultrasound of the intracranial
• 31:59
  structures of the head, or an ultrasound of the soft tissues of the head.
• 32:03
  I see some going for no imaging and some going for the intracranial ultrasound, which is correct.
• 32:09
  This patient had, this was one of the ultrasound images from this patient,
• 32:15
  which is focusing on the extra axial spaces and shows bilateral subdural hemorrhages,
• 32:19
  which raise concern for abusive head trauma.
• 32:21
  This patient was instructed to present to the ED and was admitted for workup,
• 32:25
  including all of the things listed here.
• 32:28
  Based on the CT and MRI images from this patient and all the other workup coming
• 32:33
  back negative, this patient was ultimately diagnosed with minor trauma in the
• 32:37
  setting of benign enlarged subarachnoid spaces and discharged home.
• 32:43
  Our next patient is a 5-month-old, I'm sorry, patient 5 is a 1-month-old with
• 32:48
  projectile vomiting non-bilious Would you like an x-ray, an upper GI,
• 32:52
  a pylorus ultrasound, or a malrotation volvulus ultrasound?
• 32:56
  Looks like everyone is choosing a pylorus ultrasound, which is the correct answer.
• 33:02
  This patient's ultrasound showed findings of hypertrophic pyloric stenosis,
• 33:07
  and here are some of the classic characteristics of this diagnosis.
• 33:13
  Our next patient is a 2-year-old with colicky abdominal pain and current jelly stool.
• 33:18
  We could consider either an x-ray two views or three views of the abdomen,
• 33:23
  a contrast enema, or an intussusception ultrasound. Which one would you like?
• 33:32
  It's like everyone's going for the intussusception ultrasound, which is correct.
• 33:37
  So this patient's ultrasound showed the target sign appearance of an iliocolic intussusception.
• 33:42
  And in case anyone is like me and didn't know what current jelly stool looks
• 33:45
  like, this is actually an image of current jelly.
• 33:49
  And we treat these in radiology with a fluoroscopic air enema,
• 33:53
  as shown here, with insufflation of air through a rectal catheter.
• 33:56
  And here you can see that intussusception, and that is being reduced.
• 34:02
  And when we see air in the small bowel, that's when we know we were successful.
• 34:08
  All right, patient 7 is a 10-year-old with right lower quadrant pain for one
• 34:11
  day, anorexia, nausea, and rebound tenderness.
• 34:16
  Would you like an ultrasound of the appendix, a CT without or with contrast, or an MRI?
• 34:26
  Going for the appendix ultrasound, which is correct.
• 34:31
  These longitudinal views of the appendix show a dilated fluid-filled appendix
• 34:36
  with hyperemia and surrounding echogenic mesenteric fat consistent with inflammatory changes.
• 34:41
  And on the transverse view, the appendix was non-compressible,
• 34:45
  which is an important finding to assess for acute appendicitis.
• 34:49
  Another innovation in ultrasound is contrast-enhanced ultrasound,
• 34:53
  which uses a contrast agent consisting of tiny gas bubbles surrounded by a lipid shell.
• 34:58
  Ultrasound contrast agents can be administered via intravenous or intravesical routes.
• 35:04
  Intravesical administration is used for contrast-enhanced boiding urothonography,
• 35:08
  or SEVIS, as an alternative to fluoroscopic VCUG.
• 35:12
  In some cases, such as for liver lesion characterization, contrast ultrasound
• 35:16
  can replace the need for CT or MRI without radiation or sedation and at lower cost.
• 35:22
  There are also a variety of emerging uses for contrast ultrasound that are not
• 35:26
  yet FDA approved. Let's see an example of a SEVIS exam.
• 35:31
  This 26-day-old female had a prenatal history of a duplex kidney.
• 35:35
  The ultrasound image on the left demonstrates a duplex collecting system with
• 35:39
  urinary tract dilation involving the upper and lower moieties.
• 35:42
  On the right is a dual-screen contrast ultrasound image demonstrating reflux
• 35:47
  of contrast instilled into the bladder into the lower moiety but not the upper moiety.
• 35:53
  Findings are consistent with the Weigert-Meyer rule, which states that the upper
• 35:56
  moiety obstructs and the lower moiety refluxes.
• 36:01
  When comparing fluoroscopic VCUG with contrast ultrasound, both exams require
• 36:05
  bladder catheterization, but ultrasound is more optimized for patient and family
• 36:09
  comfort, does not have radiation, and is also lower cost.
• 36:13
  Additionally, it is more sensitive for detecting reflux because it's easier
• 36:17
  to see even a few refluxing micro-bubbles with contrast ultrasound versus contrast
• 36:22
  diluted in urine on a fluoroscopic VCUG.
• 36:28
  Okay, it's time for our next patient. This is a five-year-old with urinary urgency
• 36:32
  and history of previous UTI.
• 36:38
  You may need to refresh your browser window again if you're not seeing patient eight.
• 36:43
  Okay, so would you like no imaging, ultrasound of the kidneys,
• 36:48
  an ultrasound contrast enhanced boiding urosinography, or a fluoroscopic VCUG?
• 36:55
  All right, we've got some takers for SEVIS. That's awesome.
• 37:02
  Any other thoughts?
• 37:11
  Okay, renal ultrasound, very nice,
• 37:17
  So this patient actually did not really require any imaging due to it being
• 37:22
  a first-time UTI This patient, of course, got a renal ultrasound anyway and
• 37:27
  what we are seeing here are just the normal kidneys.
• 37:31
  In contrast to our next patient, which is a three-year-old with recurrent pyelonephritis,
• 37:36
  and this patient has had no prior imaging, so which one of these would you start with?
• 37:41
  No imaging, renal ultrasound, SEVIS, or fluoroscopic VCUG?
• 37:49
  Got some takers for renal ultrasound,
• 37:53
  which is the correct answer. So this patient had a renal ultrasound to start
• 37:59
  with, and it showed pyelonephritis, which is this area of increased echogenicity
• 38:04
  and decreased vascularity in the upper pole of the left kidney.
• 38:08
  Keep in mind that pyelonephritis is a clinical diagnosis, and even a normal
• 38:12
  renal ultrasound does not exclude this diagnosis.
• 38:16
  This patient then went on to have a fluoroscopic VCUG showing left grade 3 and
• 38:21
  right grade 2 vesco-ureteral reflux. These are images before voiding and after voiding.
• 38:30
  Alright, moving on to CT. So ED providers may consider CT to be the donut of
• 38:35
  truth, but this image may show you why our jobs have not been replaced by AI yet.
• 38:41
  So the benefits of CT are that it is widely available, quick,
• 38:46
  usually does not require sedation, and has excellent spatial resolution.
• 38:50
  Drawbacks include radiation exposure, imaging at a single time point,
• 38:54
  and IV catheter placement for contrast-enhanced CT exams.
• 38:59
  Most pediatric CT exams are limited to a single acquisition to minimize radiation.
• 39:04
  For this reason, CT is either performed with contrast or without contrast, not both.
• 39:11
  Multiphase CT, consisting of multiple acquisitions in various phases of contrast,
• 39:17
  is rarely performed in children due to multiple times the radiation dose.
• 39:21
  Most clinical questions can be answered with a single phase,
• 39:24
  and a second acquisition is usually not helpful, with few exceptions.
• 39:28
  Here are some common indications for CT without contrast and CT with contrast.
• 39:33
  I would like to highlight a new CT protocol that's being implemented at some
• 39:37
  children's hospitals for airway and esophageal foreign bodies.
• 39:42
  A little over a third of patients with an airway foreign body will have a normal radiograph.
• 39:46
  In fact, one study found that the diagnostic ability of chest X-ray for airway
• 39:51
  foreign bodies was no better than chance.
• 39:53
  As you can see here, CT has very high sensitivity and specificity for airway
• 39:58
  foreign bodies as well as esophageal foreign bodies.
• 40:02
  Here's an example. This 9-year-old girl with history of trisomy 21 presented
• 40:07
  with coughing, hypoxia, retractions, and decreased breath sounds on the left
• 40:11
  after eating popcorn at school three days prior.
• 40:14
  Given concern for an aspirated radiolucent foreign body, a low-dose chest CT was performed.
• 40:20
  These coronal CT images demonstrate a rounded hyperdense object within the left mainstem bronchus.
• 40:26
  This minimum intensity projection image enables visualization of nearly the
• 40:31
  entire central bronchial tree in a single image and nicely demonstrates the filling defect here.
• 40:37
  There were also patchy right lower lobe opacities suggestive of aspiration or pneumonia.
• 40:42
  Interoperative image from flexible bronchoscopy demonstrates an obstructing
• 40:46
  popcorn kernel that was removed.
• 40:50
  This case illustrates that foreign bodies can present with a more indolent history.
• 40:55
  This three-year-old girl presented with history of abrupt-onset higher-pitched
• 40:59
  voice a year and a half prior, with progressive dysphagia and unilateral vocal cord paresis.
• 41:05
  MRI, with contrast, showed a linear non-enhancing structure with an adjacent fluid collection.
• 41:12
  On CT, the foreign body appears hyperdense, with surrounding inflammatory changes.
• 41:18
  After multiple attempts, finally an ELSA crown sticker was removed that had
• 41:21
  been embedded within the esophageal wall.
• 41:26
  When it comes to imaging the abdomen, Marie Kondo says that this CT with contrast
• 41:30
  sparks joy, whereas this one without contrast does not spark joy,
• 41:33
  and I would have to agree.
• 41:35
  And as Dr. Glockenflecken would say, just give the contrast.
• 41:41
  In terms of oral contrast, it's generally preferred since most children lack
• 41:45
  the mesenteric fat that separates intra-abdominal structures in adults.
• 41:49
  Thus, enteric contrast can help us distinguish with fluid collections from fluid-filled bowel loops.
• 41:54
  Enteric contrast is also helpful
• 41:56
  in the post-operative setting if there is concern for a bowel leak.
• 41:59
  However, if the patient is unable to drink contrast and has no other form of
• 42:03
  enteral access, usually we will just do the exam without enteric contrast.
• 42:08
  There are also some situations where enteric contrast can get in our way,
• 42:12
  such as with a CT angiogram to look for a GI bleed.
• 42:15
  If there is enteric contrast in the bowel lumen, it can obscure IV contrast
• 42:19
  that extravasates into the bowel.
• 42:22
  Additionally, when we're specifically evaluating the bowel wall,
• 42:25
  such as in the setting of IBD, it's helpful to distend the bowel with a different
• 42:29
  type of contrast agent that has a lower density similar to water.
• 42:36
  Okay.
• 42:38
  If you refresh your browser, you'll see patient 10, which is a 14-year-old girl
• 42:43
  who fell 7 feet from monkey bars and presents with hematuria.
• 42:47
  Would you like an x-ray of the
• 42:49
  abdomen, a renal ultrasound, a CT without contrast, or a CT with contrast?
• 43:00
  So far, I'm seeing responses for CT abdomen with contrast, which is correct.
• 43:05
  This patient sustained a grade 5 left renal injury or shattered kidney with
• 43:11
  likely active bleeding at the margins of the lacerated and devascularized segments
• 43:15
  and associated perinephric and retroperitoneal hematoma.
• 43:20
  She also had a grade 2 laceration of the inferior pole of the spleen.
• 43:26
  Ultrasound is not recommended as first-line imaging in trauma.
• 43:29
  This patient did receive an ultrasound three days later to follow her findings in the left kidney.
• 43:35
  And you can see here that there are areas of the kidney that don't demonstrate vascularity.
• 43:41
  However, it is much more obvious and better evaluated on CT.
• 43:44
  And the image on the right shows the perinepharic hematoma.
• 43:50
  Moving on to MRI, these scanners generate images through a powerful magnetic
• 43:55
  field, which also poses safety risks as seen here, where projectile objects
• 43:59
  can become pinned to the scanner.
• 44:02
  MRI is particularly valuable in children for whom minimizing radiation exposure is critical.
• 44:07
  MRI has excellent soft tissue and bone contrast resolution and includes customizable
• 44:13
  protocols and sequences, such as dynamic post-contrast imaging in the arterial,
• 44:18
  venous, and delayed phases.
• 44:19
  Drawbacks include less availability, higher cost, usually longer scan times
• 44:25
  that may require sedation, and IV catheter placement.
• 44:29
  Artifacts can also be seen in MRI due to various factors including motion,
• 44:33
  electrical interference, or certain materials in the body such as metal,
• 44:37
  gas, or surgical changes.
• 44:39
  Metal suppression techniques can be applied in patients with orthopedic hardware
• 44:43
  to improve image quality.
• 44:44
  If the degree of artifact precludes diagnostic evaluation of the anatomy of
• 44:49
  interest, it is not worth performing
• 44:51
  the MRI, which may be the case with dental braces and brain MRI.
• 44:57
  The benefits of MRI must be weighed against the risks of sedation,
• 45:00
  which may be necessary in certain patient populations.
• 45:04
  Infants can often be imaged without sedation using a feed-and-swaddle technique.
• 45:07
  Older children are often successful without sedation with the help of child
• 45:12
  life specialists or distraction techniques like music, movies,
• 45:15
  or even virtual reality goggles during the exam.
• 45:18
  Rapid MRI is an approach that limits scan time sufficiently to avoid sedation.
• 45:24
  This is often used for brain imaging, musculoskeletal infections,
• 45:27
  and even acute abdominal pain at some children's hospitals.
• 45:32
  Implanted devices and other metallic materials, such as those listed here,
• 45:36
  pose an increased risk as a result of interaction with the electromagnetic field,
• 45:41
  which can lead to severe injury.
• 45:43
  Implanted devices are assessed by MRI technologists to determine whether they
• 45:47
  are safe, conditional, or unsafe.
• 45:50
  Conditional devices have a prescribed set of parameters that must be followed
• 45:54
  per manufacturer instructions.
• 45:57
  Ferromagnetic materials can become magnetized and have the potential for movement within the body.
• 46:02
  These considerations are especially critical in patients who are unable to communicate
• 46:06
  or sedated patients who cannot respond to painful stimuli.
• 46:11
  This chart shows common indications for performing MRI without contrast versus with contrast.
• 46:16
  When contrast is used in MRI, images are always acquired before and after contrast
• 46:22
  administration, without and with.
• 46:25
  Gadolinium-based contrast agents are used in MRI to enhance imaging of infection,
• 46:30
  inflammation, tumor, or vascular structures.
• 46:34
  Standard gadolinium agents are excreted by the kidneys, whereas hepatobiliary
• 46:38
  contrast agents are excreted by both the biliary system and the kidneys,
• 46:42
  which is why they are preferred for liver lesion characterization in children.
• 46:47
  Here's an example. This 12-year-old girl hit a tree while skiing and then sustained
• 46:52
  a second injury to the same area while sledding.
• 46:54
  She presented to the ED with a contusion over the left superior iliac crest
• 46:58
  and extensive bruising.
• 47:00
  Contrast-enhanced CT demonstrated a large soft tissue hematoma in the left flank,
• 47:05
  as well as an incidental liver lesion.
• 47:08
  The patient underwent incision and drainage of the hematoma,
• 47:11
  and two months later, an MRI was performed with EOVS contrast for liver lesion characterization.
• 47:16
  The lesion demonstrates early arterial hyperenhancement and retains contrast
• 47:21
  on 20-minute delayed images during the hepatobiliary phase, indicating that
• 47:26
  this lesion contains functioning hepatocytes.
• 47:28
  There's also a central non-enhancing scar, and these findings are compatible
• 47:33
  with focal nodular hyperplasia, or FNH.
• 47:41
  Finally, I'll briefly touch on nuclear medicine. Some of the benefits include
• 47:45
  functional and metabolic imaging, and nuclear medicine can detect abnormal activity
• 47:50
  before structural changes are visible on other imaging modalities such as CT or MRI.
• 47:55
  Nuclear medicine can also be used for therapy.
• 47:58
  Drawbacks include less widely available radiation exposure, IV placement for
• 48:03
  radiotracer administration, long scan times, and low spatial resolution.
• 48:08
  For nuclear medicine, we give a radiopharmaceutical as our contrast agent,
• 48:12
  which includes a radioactive compound linked to a targeting molecule that will
• 48:17
  bind to a molecule of interest,
• 48:22
  including cancer cells in some instances.
• 48:27
  These are some indications for nuclear medicine scans that we perform in children.
• 48:35
  Here's an example of a common type of nuclear medicine exam.
• 48:39
  This 18-year-old young woman underwent MIBG therapy for refractory neuroblastoma.
• 48:44
  Whole-body planar images obtained seven days after treatment demonstrate numerous
• 48:49
  foci of osseous metastatic disease involving the calvarium, left scapula,
• 48:54
  left rib, pelvis, bilateral proximal femurs, and spine.
• 48:59
  SPECT images fused with a contrast-enhanced CT enable improved anatomic localization
• 49:04
  of the areas of MIBG uptake, including the left 5th rib and spine.
• 49:09
  The primary tumor arises from the right adrenal gland and extends across midline,
• 49:14
  but was not MIBG-avid at the time of this scan.
• 49:19
  Here's a summary of all the imaging modalities that we've discussed today,
• 49:22
  and we'll wrap up with a couple of clinical scenarios.
• 49:28
  For a newborn or infant with vomiting, the first step is to determine whether
• 49:32
  the emesis is truly bilious or not.
• 49:34
  For non-bilious projectile vomiting, we would want to start with a pyloric ultrasound.
• 49:39
  For bilious emesis, at my institution we start with ultrasound and then move
• 49:44
  on to upper GI if the ultrasound is equivocal.
• 49:47
  For patients with delayed meconium passage, if an abdominal x-ray shows distal
• 49:51
  bowel obstruction, we would do a contrast enema to assess for Hirschbaum disease,
• 49:56
  which can present with bilious or non-bilious emesis.
• 50:01
  For an older child with acute abdominal pain, we usually start with ultrasound
• 50:05
  and then consider CT or MRI if the ultrasound is equivocal.
• 50:10
  If the patient has a history of abdominal surgery or abnormal bowel sounds with
• 50:14
  abdominal distension, we would usually start with an x-ray and then go on to CT if needed.
• 50:22
  To summarize, here are some situations where it may be helpful to consult with a radiologist.
• 50:28
  The best thing to do is to start with the patient's information,
• 50:31
  such as the medical record number, so that the radiologist can review the patient's
• 50:35
  prior imaging and other information in the chart during the discussion.
• 50:40
  Some questions to ask the radiologist might be, what imaging modality should
• 50:43
  I order for a particular clinical question?
• 50:46
  Does the patient need contrast for this imaging exam?
• 50:49
  Should I order an upper GI with small bowel follow-through? Half joking,
• 50:53
  but I would much rather get this phone call rather than having to track down
• 50:56
  a provider later to clarify the order.
• 51:00
  Another reason to call a radiologist would be to clarify the report findings,
• 51:04
  differential diagnosis, or recommendations.
• 51:07
  Also, we can sometimes help determine the next best step after imaging.
• 51:13
  To learn more, check out this paper that was recently published in Pediatrics in Review.
• 51:20
  Thank you. Thank you, Dr. Shish, for that wonderful presentation on how we collaborate
• 51:25
  with radiologists to get the best patient care.
• 51:29
  Let's see if anybody has any questions or comments, either in the chat box or
• 51:34
  they can raise their hand and ask the questions.
• 51:46
  Dr. Williams, go ahead and please ask your question. Good morning.
• 51:50
  Thank you for that excellent presentation.
• 51:53
  So, it seems
• 51:57
  to me that there's this trust relationship between the radiology department
• 52:05
  or radiologists and the practitioner in that you have to trust the radiologist is up to date,
• 52:14
  the equipment's up to date, it's oriented toward children.
• 52:17
  And not everybody's at a children's hospital or within distance of a children's hospital.
• 52:24
  And but even if you are, there are things that unless you're in the intensive
• 52:31
  care setting, you're probably not going to see very often.
• 52:36
  So remembering which or knowing what just changed in radiology.
• 52:42
  So which test to order is not very practical.
• 52:46
  So it seems to me that that's where either AI could be helpful or to say this
• 52:55
  is what probably should be ordered or better than that to, as you suggested,
• 53:00
  give a good history and have the radiologist suggest, oh, this is what we need here.
• 53:07
  If this is what you're looking for, these are our thoughts. So if you'd please comment on that.
• 53:14
  Yeah, you're exactly right. And there's a lot to unpack in that question.
• 53:18
  I think, you know, providing the best history that you can is the first step.
• 53:26
  Certainly, when we receive imaging orders that don't make sense,
• 53:31
  we will look at the history that's provided.
• 53:33
  And if we need more information, we'll delve into the patient's chart to figure
• 53:38
  out as much as we can, which can be challenging if the patient was seen at another institution.
• 53:44
  We may not have all the information.
• 53:46
  And those are the instances where we may sometimes reach out to you and get
• 53:51
  more information about what's going on with the patient.
• 53:54
  And then we can have a conversation about what would be the best imaging test
• 53:57
  to help answer the clinical question.
• 54:01
  The appropriateness criteria can be helpful if you don't have a radiologist
• 54:04
  handy to speak with, but we are always welcome to receive calls as well from any type of clinician.
• 54:13
  We do welcome that, and we're always happy to chat about patients over the phone.
• 54:18
  It's oftentimes the best way to really have that conversation,
• 54:22
  learn what's going on with the patient, what diagnoses you're concerned about,
• 54:25
  and kind of go from there.
• 54:27
  In the future, I do hope that there will be some AI built into our electronic
• 54:33
  medical records that may be able to suggest the best imaging study.
• 54:38
  That is still in the works.
• 54:42
  Thank you so much. Any other questions, comment from Dr. Shish?
• 54:57
  This is a question by Dr. Perlman. Why is CT with and without contrast even offered as an order?
• 55:04
  That's a great question.
• 55:07
  I kind of wish that it wasn't. But, you know, in the adult setting,
• 55:13
  there are reasons to get a CT without and with contrast.
• 55:16
  An example might be aortic injury, where it is helpful to have that non-contrast
• 55:23
  CT acquisition first before giving contrast so that we can see if there's an intramural hematoma.
• 55:30
  That can be more challenging to visualize after contrast is given.
• 55:35
  Those types of injuries are very rare in children. The other thing that we have
• 55:39
  in children is, well, for all patients,
• 55:42
  is that, you know, an innovation in CT that's come out in the last handful of
• 55:47
  years is it's called dual energy CT.
• 55:51
  And so some of our CT scanners are now sophisticated enough that they can generate
• 55:56
  a virtual non-contrast image.
• 55:58
  So that can be helpful in certain
• 56:01
  cases for example if there's
• 56:04
  concern for both a renal stone as well
• 56:07
  as pyelonephritis we can just do a single acquisition with IB contrast and then
• 56:13
  the CT scanner generates a virtual non-contrast because the CT scanner can actually
• 56:18
  distinguish between the density of a stone versus the density of the contrast
• 56:23
  which is harder to distinguish with our
• 56:26
  eyes, but when we get those virtual non-contrast images, we can see that a lot better.
• 56:32
  And so oftentimes the virtual non-contrast image can be used in place of without
• 56:39
  and with contrast, especially in children where we're trying to minimize the radiation dose.
• 56:43
  So to answer your question, I'm not really sure why it's still available as
• 56:48
  an order. I think it would be used very, very infrequently in children.
• 56:52
  And so if we do see that order come through, we will oftentimes be reaching out.
• 57:00
  Thank you so much for listening to that fascinating talk. I'm Holly Wehmut. I'll see you next week.
• 57:07
  Don't forget to click on the link in this podcast for free credit that may include
• 57:10
  CME, MOC, or ethics credit.