Body CT Protocoling

Blake Becker, MD

Brandon Kelly, MD

General Considerations

• Who/What/When?
• All residents on body service for month – typically junior levels responsible for protocolling CT studies; senior levels responsible for body MRI
• If there is a question regarding correct study to be order, unsure if order is correct for indication etc., PLEASE ask upper level and/or staff for assistance
• Please have CT list protocolled two weeks out!
• Protocol all studies except those that are ordered as part of PET/CT at JMM
• Spend a little time before and after work day starts and ends (or during down time throughout day) to keep list caught up

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General Considerations con’t

• Why/How?
• Do not assume that the way the study has been ordered by the clinician is the way the study should be protocolled for the stated indication
• Correct protocol imperative not only from a “reader” standpoint (are we able to follow/see what we need with appropriate ancillary info) but also important regarding insurance and billing for the patient getting scan
• How? 🡪 see following slides

1. Click on Protocol Work List

2. Click on CT Body Outpatient Protocol

3. Uncheck Unscheduled

4. Click Run

5. List of studies to be protocolled will appear

6. Click on study (highlighted in blue) then proceed as indicated on following slides 🡪 just because study is ordered a certain way does not always mean this is the way it should be protocolled

7. All studies except those for PET/CT at JMM to be protocolled (see oval above for example of what does NOT need protocolled)

Example: CT C/A/P ordered for follow up of patient with history of RCC

1. How do we know 🡪 once you have clicked on a study to be protocolled, on the left, the relevant information (including why study was ordered) will appear
2. Can find this info under Reason for Exam/Indication or slightly further down under Questions/Reason For Exam (see next slide)

3. What if the reason for exam is blank or does not fit with what is ordered? You will need to go into the patient’s chart and do some digging 🡪 do not just protocol the way that study ordered without assuring it is appropriate

4. If you scroll to bottom, you can see how previous studies were protocolled. Be aware however that these may or may not have been protocolled correctly in the past. Always double check

5. Select the appropriate protocol for the stated reason

6. In the comments please add the FOV that was done on prior scan

7. Click FINALIZE bottom right corner

Special Considerations

• GFR
• Per UMMC policy, HIGH RISK PATIENT 🡪 Estimated GFR < 30: Avoid intravenous contrast
• If the benefits outweigh risks, have conversation with ordering provider
• Ordering provider must place note in EPIC stating benefits outweigh risks if giving IV contrast is deemed most appropriate
• Field of View
• Please add FOV from prior study (if available) in the comments section
• Hypervascular arterial phase (add 40 sec arterial phase)
• Common hypervascular lesions for which this should be added
• Neuroendocrine tumor
• Carcinoid
• RCC (do not need to select if protocolling as Renal Mass; DO add if looking for RCC mets)
• Melanoma
• Angiosarcoma
• Thyroid Carcinoma
• Choriocarcinoma
• Pheochromocytoma

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Special Considerations cont.

• Contrast Allergies
• Allergies can be found on the left side of the protocol list under “Patient Details”
• https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf (refer to for complete details)

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Contrast Reactions cont.

Specific Protocols and Indications

Chest

• Routine Chest w/o contrast
• Indications:
• Follow up pulmonary nodules
• Baseline or follow up low dose screening (please use low dose CT follow up if patient has already undergone baseline low dose CT)

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• Routine Chest w/ contrast
• Indications:
• Primary lung cancer
• Metastases to lung

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Chest Cont.

• PE Chest
• Link to protocol: https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxiYWNrdXB0aGV2aWV3Ym94bmV0fGd4OjZlZDFlODkzYzJlMGNlYTA
• Indications:
• Acute or chronic pulmonary emboli
• High Resolution Chest
• Link to protocol: https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxiYWNrdXB0aGV2aWV3Ym94bmV0fGd4OjQxMGVhM2FmZTBjYjc2ZA
• Please select prone and expiratory phase tabs under technologist instructions
• Indications:
• Interstitial lung disease
• Should not be done out of the ER. On Inpatients in only rare circumstances

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Liver Mass

• Link to what liver mass protocol entails:
• https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxiYWNrdXB0aGV2aWV3Ym94bmV0fGd4OjFiNTdiYjBkYmRiM2E0NmE
• Indications:
• Cirrhosis
• Hepatoma
• Cavernous Hemangioma
• Liver Disease
• Metastatic disease 🡪 if concern for hypervascular met, add hypervascular phase, in general metastatic disease follow up does not need noncontrast portion.

Pancreas Mass

• Link to what pancreas mass protocol entails:
• https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxiYWNrdXB0aGV2aWV3Ym94bmV0fGd4OjcxZWU2ZmM5ZjEwNzdkZjg

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• Indications:
• You guessed it, pancreas mass or pancreatic cystic lesion

Adrenal Mass Protocol

• Link to what protocol entails:
• https://docs.google.com/document/d/14i4XXj3eWifbC3dV_oiyvzxRVRMeaDNxU1Tp9WZ1nEs/edit
• Indications:
• Known Adrenal Mass
• Malignant Hypertension
• Pheochromocytoma
• Adenoma

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• Note 🡪 tech will call you once the non-contrast scan has been completed 🡪 HU over adrenal lesions 🡪 if <10 HU, lesion is lipid rich adenoma, study can be stopped

Renal Protocols

• Renal Stone
• Non contrast CT of abdomen/pelvis
• Indications: urolithiasis, new or known
• Renal Mass
• Link to what protocol entails: https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxiYWNrdXB0aGV2aWV3Ym94bmV0fGd4OjYyYzY0YjRlYmY0ZTUzYmI
• Indications: suspected RCC, oncocytoma or other primary renal lesion

Urinary Tract Protocols

• Urogram
• Link to protocol: https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxiYWNrdXB0aGV2aWV3Ym94bmV0fGd4OjQ0ZTY4MDQ5NzUyNDdkNWY
• Indications:
• Microscopic hematuria
• Transitional Cell Carcinoma of the urinary tract
• TCC of the urinary bladder
• Cystogram
• Indications:
• Urinary bladder rupture
• Post-op urinary bladder injury

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Bowel

• Enterography
• Link to what protocol entails: https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxiYWNrdXB0aGV2aWV3Ym94bmV0fGd4OjYwNjUxYTcyZTk1NmUzY2M
• Indications:
• Inflammatory bowel disease (Crohn’s especially)🡪 prefer MR to assess Crohn’s if patient can tolerate
• Radiation enteritis
• Scleroderma
• Small bowel malignancies
• Polyposis syndromes
• GI Bleeding Protocol
• Link to protocol: https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxiYWNrdXB0aGV2aWV3Ym94bmV0fGd4OjYzNTdhZTdiYmU4OWY3MWM
• Indications:
• Active GI bleeding

Other Non-specific Abdomen/Pelvis Protocols

• Routine Abdomen/Pelvis
• w/ IV contrast +/- Oral contrast depending on indication
• Link to what protocol entails: https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxiYWNrdXB0aGV2aWV3Ym94bmV0fGd4OjczZjZjNzNhYWJlMjJjMGM
• Indications: (not an all-inclusive list)
• Cancer follow (depending on primary site and type)
• Abdominal pain (chronic/acute) – need descriptive history
• Intra-abdominal abscess
• Diverticulitis
• Appendicitis
• Pancreatitis
• Pancreatic Pseudocysts
• Undescended testicle

Final Remarks!!

• If you are unsure if an order is correct for the indication or don’t know how to correctly protocol… ASK (start with upper level, then up chain of command, fellow/staff)

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• You won’t know unless you ask 🡪 more harm to patient if you just protocol in a vacuum