PEDS - ON CALL
INSTRUCTIONS
Perform emergent fluoro if requested, with discussion with covering attending as needed
Pediatric fluoro + Neonate/infant US requests: Please call the on call Pediatric Radiology attending (usually email is forwarded from Dr Rosenberg to MSW chiefs/residents) for further instructions; further evaluation/care may require transfer to MSH.
If you get a request for this (usually MSW), get the information about the baby, callback number, NICU attending name and phone number -discuss the case with peds attending on call to see if it needs to be done emergently
If peds attending agrees for study to be done emergently and you are not at MSW, need to call in the MWeve/backup resident, get in touch with Xray tech and tell them we need to do an emergent fluoro study, have NICU team bring down patient
when patient on table, perform the upper GI with peds attending either on facetime or immediately available to review images (do not send the patient back upstairs or out of the room until confirmed that study is done by peds attending)
Do not transfer pediatric patients for UGI studies from MSW to MSH without the consultation of the MSH pediatric radiology attending on call
INTUSSUSCEPTION
INTUSSUSCEPTION
If there's high clinical suspicion for an intussusception, ultrasound is the best diagnostic test. Supine and left lateral abdominal X-rays can be obtained to exclude ileocolic intussusception and free intraperitoneal air. Radiographic assessment does not exclude a smallbowel-small bowel intussusception.
If the there's an ileocolic intussusception detected on ultrasound, 2 view X ray should be obtained to exclude free intraperitoneal air prior to attempt a reduction via air enema.
See attached document
RESOURCES
Message from Dr Rosenberg regarding afterhour coverage/ED XR
The Pediatric Radiology Team reads the Pediatric Radiology cases for multiple sites in the Mount Sinai Network. We are providing final reads for Plain Film Radiography, Ultrasound, Body CT and Body MRI for all the Network sites (major hospitals, out-patient centers, and urgent care centers) except when a private practice facility specifically prefers otherwise for particular aspects of their practice. In addition, a Pediatric Radiologist is scheduled to be on site at PACC (Phillips Ambulatory Care Center) 2 days a month during which fluoroscopic procedures and hip & spine sonography will be included in the Pediatric imaging armamentarium.
We follow the same guidelines for reviewing and finalizing cases that are used at MSH during routine working hours (8:30 am – 5 pm) and during evenings and weekends. During non-routine working hours, the Radiology Residents prelim the cases and we finalize them the following morning. Although the Pediatric Radiologists provide 24/7 coverage for emergencies, the policy is that the in-house Radiology Residents consult with the in-house or virtual evening and night Attending Radiologist as needed. If there is a need for escalating the consultation, the Resident calls the Ped Rad Doc on call. In house attending coverage during non-routine working hours is limited to MSH for emergencies such as pneumatic reduction of intussusception. Supervision of Residents at MSH and MSW performing UGIs ordered for babies suspected of having malrotation is provided virtually with/without facetime as needed.
Pediatric Fluoroscopic Exam
(Quick Reference)
(Quick Reference)
Infant UGI
Refer to handout
1. Preparation: NPO for 3 hours
2. Materials:
a. Chux under patient
b. 4 oz bottle and nipple, or patient's regular bottle and nipple
c. Routine single contrast liquid barium or aqueous contrast (Omnipaque 180 in infant) (aqueous contrast preferred in patients who may potentially go to the OR)
3. Shield table
4. Infant restraining device
5. Film sequence
a. Preliminary AP supine chest/abdomen on one film. Obtain left lateral decubitus radiograph of abdomen as needed.
b. Fluoroscopic portion of examination:
i. Minimize radiation exposure by using “pulsed” fluoro, keeping the tower as close to the patient as possible, collimating as tightly as possible, and using a “tap” fluoro technique. Take advantage of the last image hold feature to examine the image without prolonged exposure!
ii. Minimize radiation exposure by obtaining saved spot images and reserve actual spot filming for images in which it is determined that more definition is necessary to maximize detail as well as to clarify confusing fluoroscopic findings.
a. To evaluate the esophagus:
i. Place infant into straight left lateral decubitus position.*
ii. Observe and image first swallow in the left lateral projection.
1. Evaluate the swallowing mechanism.
2. Look for evidence of nasopharyngeal reflux, laryngeal penetration, and tracheal aspiration
iii. Evaluate esophageal peristalsis.
iv. Look for position of esophagus, vascular rings, strictures, varices, mucosal abnormalities, hiatal hernia.
v. Turn infant into supine position and evaluate esophagus
vi. Do not allow the patient to drink too much contrast as the overdistended contrast filled stomach may obscure the C-loop and interfere with the evaluation for malrotation!!!!!
* Please note that if you begin the examination with the patient in a right lateral decubitus position that you must be very careful not to miss imaging the C-loop and the duodenal-jejunal junction, as gravity will hasten it to fill out more quickly in this position.
b. To evaluate for malrotation (must call pediatric radiologist on call to review the history and the preliminary scout films:
i. Turn the baby RPO or, if necessary, prone oblique with right side down, in relationship to the table.
ii. As soon as the first and second parts of the duodenum are visualized, turn the infant into an absolutely straight supine AP position and obtain an image of the entire C-loop including the region of the ligament of Treitz. The duodenal-jejunal junction should be to the left of the spine at the level of the duodenal bulb, at about the level of L1.
iii. Be sure to open up the shutters over the lower chest so you can see the cardiac silhouette and the rib case in order to be certain that the baby is absolutely straight, as patient rotation can lead to an error in assessing the position of the duodenal-jejunal junction (ligament of Treitz).
c. To further evaluate for hiatal hernia:
Obtain images of the esophagus either supine or LPO to the table with the infant crying (induce Valsalva maneuver by removing bottle as infant is drinking or the pacifier) and with infant calm (pacifier may be used).
e. To evaluate the stomach and duodenum:
Obtain prone barium/air contrast spots of the fundus, prone obliques of the barium filled duodenum, supine and oblique air filled gastric antrum and duodenal bulb and loop.
f. To evaluate for gastroesophageal reflux (GER):
Remove the baby from the immobilization board and have the accompanying person hold the baby and feed him/her (without fluoroscopic observation) an equivalent amount of his/her usual feeding. The infant should be burped and then put back on the fluoroscopic table for assessment of GER with the infant in various positions and document presence and extent of reflux, if present.
g. Overhead films:
i. At the discretion of the radiologist (e.g. supine chest/abdomen)
h. When infant has enteric tube and cannot drink by mouth:
i. Fill 60 cc syringe with routine single contrast barium that is compatible with the baby’s enteric tube. Do not administer more contrast than required to answer the question at hand or an amount equivalent to the amount usually offered to the baby during a feeding.
ii. Begin with the infant in a prone oblique position with the right side down and obtain images of the gastric antrum and descending duodenum, a supine view of C-loop, and contrast and air-filled views of the stomach and duodenum.
iii. Check for GER after the stomach is filled to the amount of the infant's usual feeding.
iv. Overhead films at the discretion of the radiologist: (e.g. supine chest/abdomen)