36C25019R0093-025.pdf

PDF Posted Dec 6, 2019

Attached to: Community-Based Outpatient Clinic (CBOC) Services to include Primary Care Services in Goshen, IN
Solicitation number: 36C25019R0093
Issued by: Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10

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36C25019R0093 S02- Attachment D24- NIHCS Radiology Protocols.pdf

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NIHCS RADIOLOGY PROTOCOLS

FOR

DIAGNOSTIC	RADIOLOGIC
TECHNOLOGIST	(DRT)

NIHCS

Radiology Diagnostic Radiologic Technologist (DRT) X‐RAY

PROTOCOLS

This	x‐ray	protocol	guide	is	to	assist	DRT	in	performing	radiographic
procedures	with	positioning	and	techniques	under	the	direction	or	indirection	of
the	Radiologist.		Any	policies	&	procedures	or	Standing	Operating	Procedures	(SOP)
should	be	used	to	help	aid	with	radiologic	procedures	at	all	times.

CLINICAL RADIOLOGY PROTOCOLS

BONY THORAX

Chest 2 views PA & LAT (or Single View)

Views:

1.	PA	(or	AP	if	patient	cannot	stand)
2.	LAT

*If

patient

cannot

stand,

conduct

view

wheelchair

secure

stool

and

lat‐

eral

the

receptor

with

wheelchair

arms

removed

and

sponge

back

bring

them

forward.

lateral

cannot

conducted

please

discuss

with

Radiologist

ordering

provider.

*Single

should

done

upright

portable,

wheelchair

stretcher.

only

performing

single

chest

please

document

image

the

SID

used

and

AP.

*Chest

special

views

–

lateral

decubitus,

Lateral

decubitus

Lordotic

views

depending

request.

Areas

covered:

Lungs,

including

both

apices,

air‐filled

trachea,

bronchi,

heart

and

great

vessels,

diaphragm

include

costophrenic

angles,

and

bony

thorax.

SID: 72 inch

Bucky: Upright preferred, but can be supine only if patient is immobile.

Exposure Technique:

	PA	–	117	kVp	@	2.5	mAs
	LAT	–	117	kVp	@	10	mAs
PCXR	(AP)	81	kVp	@	4	mAs

Breath: Inspiration

Markers: Lateral and superior

Shielding: Gonadal

Limited: none

Imaging:

14	x	17	Landscape	(PA),	14	x	17	Portrait	(LAT).
*If	patient	is	thin	can	do	PA	14	X	17	Portrait.

Ribs Both with Chest (Ribs unilateral w/chest)

Views:

1.	PA	chest	(expiration)
2.	AP	ribs	(upper)
3.	AP	ribs	(lower)
4.	RPO	(upper)
5.	RPO	(lower)
6.	LPO	(upper)
7.	LPO	(lower)

*unilateral	ribs	only	image	affected	side	(either	left	or	right)
*PA	chest	not	needed	for	follow‐up	fracture.

Areas

covered:

Ribs

above

and

below

diaphragm,

axillary

margin

ribs

the

side

interest

projected

without

self‐superimposition.

SID: 72 inch PA chest, 40 inch Upper & Lower Ribs

Bucky: PA chest – upright; Ribs – upright or table

Exposure Technique:

PA	chest	117	kVp	@	2.5	mAs
AP	Ribs	(upper)		75	kVp	@	20	mAs
AP	Ribs	(lower)		85	kVp	@	40	mAs
Oblique	(upper)		75	kVp	@	40	mAs
Oblique	(lower)		85	kVp	@	80	mAs

Breath:	PA	chest	–	expiration
				Ribs	(upper)	–	inspiration
				Ribs	(lower)	–	expiration

Markers: Lateral

Shielding: Gonadal

Limited: none

Imaging:

14x17

Landscape

(PA

chest),

portrait

(Ribs

upper

and

upper

oblique),

x12

landscape

(Ribs

lower

and

lower

oblique)

Sternum 2 or more views

Views:

1.	RAO	(oblique	of	15‐20	degrees	done	supine)
2.	Lateral

*RAO done with breathing technique

Areas

covered:

RAO

‐

entire

sternum

superimposed

over

heart

shadow.

Lateral

–

entire

sternum

with

overlap

soft

tissues.

SID: 40 inch

Bucky: RAO – Table, Lateral – Table or Upright

Exposure Technique:

RAO:	70	kVp	@	63	mAs,	3.2	seconds
Lateral:	75	kVp	@	20	mAs

Breath: continuous for RAO, suspended for lateral

Markers: Lateral

Shielding: Gonadal

Limited: none

Imaging:

10x 12 Portrait

Sternoclavicular Joints Min 3 views

Views:

1.	PA
2.	RAO	(slight	rotation	of	10‐15	degrees)
3.	LAO	(slight	rotation	of	10‐15	degrees)

*downside	joint	is	best	visualized.
*both	obliques	are	completed	for	comparison

Areas covered: Joint separation, subluxation, or other pathology of sternoclavicular joints

SID: 40 inch

Bucky: Table (preferred) or Upright

Exposure Technique:

PA	‐	70	kVp	@	10	mAs
OBL	–	70	kVp	@	20	mAs

Breath: suspended

Markers: Lateral

Shielding: gonadal

Limited: none

Imaging:

10 x 12 portrait

Neck Soft Tissue

Views:

1.	LAT
2.	AP

*exposure made during a slow deep inspiration

Areas

covered:

Air‐filled

larynx

and

trachea,

the

region

thyroid

and

thymus

glands

and

upper

esophagus

opacified.

SID: 72 inch LAT, 40 inch AP

Bucky: Upright

Exposure Technique:

LAT	–	75	kVp	@	25	mAs
AP	–	75	kVp	@	5	mAs

Breath: continuous (slow deep inspiration)

Markers: Lateral

Shielding: gonadal

Limited: none

Imaging:

10x12 portrait

Abdomen

Abdomen 2 views (or 1 view)

Views:

erect

(Optimally

patient

should

upright

for

least

five

minutes

prior

exposure)

supine

Areas

covered:

Liver,

spleen,

kidneys,

abnormal

masses,

calcifications

accumulations

gas.

Pelvis,

lumbar

spine

and

lower

ribs

are

also

shown.

Air

fluid

levels

and

accumulations

gas

free

intra‐abdominal

air

seen

Erect

and

Decubitus

views.

Mark

images

that

are

upright.

Supine:

include

flank

and

symphysis

pubis.

Some

the

diaphragm

does

need

included

prove

that

the

entire

liver

and

spleen

have

been

visualized.

Upright:

include

flank

and

diaphragm.

center

the

central

ray

above

the

iliac

crest

only

when

using

vertical

plate.

Horizontal

plate

position

include

the

entire

diaphragm.

Image

should

extend

from

the

diaphragm

and

include

both

crest

the

pelvis.

DISTANCE: 40”

BUCKY: YES

FOCAL SPOT: Large

IMAGING PLATE: 14x17 FOV or greater.

CENTRAL

RAY:

Perpendicular

cassette

centered

level

the

iliac

crests

with

bottom

the

cassette

the

pubic

symphysis.

HELPFUL POSITIONING:

1. Be certain to include the entire abdomen (flank to flank). Use two 14x17 cassettes cross

wise

two

14x17

cassettes

lengthwise

across

the

upper

abdomen

and

3rd

14x17

cassette

across

the

lower

abdomen,

necessary.

2. If unable to do upright, do a Left Lateral Decubitus.

*if 1 view is ordered, only supine view is needed

SID:		40	inch
Bucky:		Upright	and	Table,			Decubitus	done	with	grid	holder.
Exposure	Technique
	AP	erect	–	81	kVp	@	40	mAs
	AP	supine	–	81	kVp	@	40	mAs
	LLD	–	81	kVp	@	40	mAs
Breath:		expiration

Shielding: Gonadal

Pelvis 1 view

Views:

1. AP Supine

*done supine unless indicated as weight‐bearing.

Areas	covered:	Pelvic	girdle,	L5,	sacrum	and	coccyx,	femoral	heads,	necks	and
greater	trochanters.

SID: 40 inch

Bucky: table

Exposure Technique

AP – 81 kVp @ 32 mAs

Breath hold: suspended

Markers: Lateral

Shielding: none

Limited: none

Imaging:

14x17 landscape

Sacrum/Coccyx Min 2 Views

Views:

sacrum

15degree

cephalic

angle

coccyx

degree

caudal

angle

LAT

sacrum

and

coccyx

one

film

possible

otherwise

two

exposures

may

necessary.

Areas

Covered:

Sacrum

–

Frontal

view

sacrum

foreshortened,

joints

and

the

L5‐S1

junction.

Coccyx

–

Coccyx

free

self‐superimposition

and

superimposition

symphysis

pubis.

Lateral

‐

L5‐S1,

sacrum,

coccyx

lateral

position.

SID: 40 inch

Bucky: table

Exposure Technique:

AP	–	81	kVp	@	20	mAs
LAT	–	81	kVp	@	40	mAs

Breath hold: suspended

Markers: Lateral

Shielding: none

Limited: none

Imaging:

10x 12 Portrait.

Sacroiliac Joints 3 views

Views:

axial

(30

–

degree

cephalic)

LPO

(25

–

degree

posterior

oblique,

side

interest

elevated)

RPO

(25

–

degree

posterior

oblique,

side

interest

elevated)

*both obliques are done for comparison

Areas	covered:		Sacroiliac	joints,	L5‐S1	junction,	sacrum	and	coccyx,	obliques	show
joints	farthest	from	film

SID: 40 inch

Bucky: Table

Exposure Technique:

AP & OBL – 81 kVp @ 20 mAs

Breath: suspended

Markers: Lateral

Shielding: none

Limited: none

Imaging:

10x12 landscape

CERVICAL SPINE

Cervical Spine 2

2	views:
1.		AP
2.		LAT.
3.	Swimmers	(only	needed	if	C7‐T1	not	seen	on	LAT	projection).

views

with

Obliques:

All

images

views

plus

RPO

LPO

with

patient

degree

oblique.

Posterior

oblique

require

degree

cephalic

angle.

views:

All

images

two

(2)

views

four

(4)

views

plus

additional

two

(2)

views

being

that

Flexion

Extension

Lateral

position.

*for

patients

cervical

collar,

cross

table

lateral

must

completed

and

clear

radiologist

prior

any

further

imaging.

*All

trauma

patients

require

AP,

LAT,

RPO,

LPO,

Open

Mouth

view,

and

(Modified

Fuch’s)

view

DENS

not

seen

open

mouth

view.

Areas

Covered:

Lateral

views

include

cervical

vertebral

bodies,

intervertebral

joint

spaces,

articular

pillars,

spinous

processes

and

zygapophyseal

joints.

views

include

cervical

vertebra

through

include

vertebral

bodies,

space

between

pedicles,

intervertebral

disc

spaces

and

spinous

process.

include

vertebral

body

C2,

lateral

masses

and

zygapophyseal

joints

between

and

C2.

Shielding: Gonadal

Thoracic Spine 2 views (and swimmers)

Views

1.	AP
2.	LAT:		utilize	breathing	technique	to	blur	lung	markings.
3.	Swimmers	(if	C7‐T3	not	visible	on	lateral	view)

*done

supine

*when

patient

cannot

move

into

right

left

lateral,

cross

table

projection

can

performed

Areas	covered:		Thoracic	vertebral	bodies,	intervertebral	joint	spaces,	distance	be‐
tween	pedicles,	spinous	and	transverse	processes,	posterior	ribs	and	costovertebral

articulations.

SID: 40 inch

Bucky: table

Exposure technique:

AP	–	75	kVp	@	20	mAs
LAT	–	81	kVp	@	80	mAs,	1.0	sec	breathing	technique
Swimmers	–	75	kVp	@	100	mAs

Breath: suspended on AP & swimmers, continuous on LAT

Markers: Lateral

Limited: none

Imaging:

14x17 portrait, 10 x 12 portrait (swimmers)

Lumbar Spine

views;

LAT

Coned

down

L5‐S1

(SPOT

‐

LAT

image)*

*Complete

SPOT

image

only

L5‐S1

not

visible

and

always

female

patients.

4	views;
All	images	in	2	views	plus
4.		RPO	&	LPO	with	patient	in	45	degree	oblique

6	views;
All	images	in	2	&	4	views	plus
5.		Flexion	&	Extension	in	Lateral	position

*done

supine

*when

patient

cannot

position

into

either

left

right

lateral,

cross‐table

lateral

can

done.

Areas	covered:		Lumbar	vertebral	bodies,	intervertebral	joints,	spinous	and	trans‐
verse	processes,	laminae,	SI	joints	and	sacrum.		Oblique	views	also	include
zygapophyseal	joints;	“scotty	dogs”	should	be	visualized	on	good	oblique.

SID: 40 inch

Bucky: table

Exposure	technique:
	AP:		81	kVp	@	32	mAs
	OBL:	81	kVp	@	45	mAs
	LAT:	90	kVp	@	80	mAs
	Spot:	90	kVp	@	120	mAs

Breath: expiration

Markers: Lateral

Shielding: gonadal

Limited: AP & LAT

Imaging: 14x17 portrait, 8x10 portrait for L5‐S1 spot film

Spine Entire AP & LAT

Views:

1.		AP	Cervical	Spine
2.		LAT	Cervical	Spine
3.		Odontoid
4.		Swimmers
5.		AP	Thoracic	Spine
6.		LAT	Thoracic	Spine
7.		AP	Lumbar	Spine
8.		LAT	Lumbar	Spine
9.		Coned	down	L5‐S1	(SPOT	‐	LAT	image)*
*Complete	the	SPOT	image	only	if	L5‐S1	not	visible.

Areas Covered: Entire Spine in AP & LAT projections from C1 through SI joints

SID – 72 inch C‐spine LAT, all others 40 inch

Exposure Technique:

See C, T & L‐spine pages for appropriate techniques.

Breath: suspended, breathing technique on T‐spine Lateral

Markers: Lateral

Shielding: Gonadal

Limited: none

Imaging:

10 x12 c‐spine, all others 14 x 17 landscapes

Upper Extremities

Shoulder 2 or more views

Views:

1.	AP	(Neutral)
2.	AP	(Grashey)
3.	Axillary

C&P and limited: Perform AP (Neutral) & AP (Grashey).

not

able

obtain

axillary

perform

Scapular

“Y”

view.

for

Ortho

protocol,

perform

1‐3

and

add

additional

Y‐View

Axillary.

*If

fracture

suspected

NOT

rotate

the

arm,

leave

the

neutral

position

and

con‐

duct

limited.

*Modifier

must

include

one

the

following

(Left,

Right)

Area	Covered:		Glenohumeral	Joint,	Acromioclavicular	Joint,	Sternoclavicular	Joint,
Coracoid	Process,	Lateral	2/3rd	Clavicle,	Superior	Scapula,	Proximal	third	of

Humerus

Bucky:

Upright

Table

for

views,

Grashey

views.

Axillary

can

done

table

top

Bucky

Exposure Technique:

AP:

kVp

mAs

Axillary:

kVp

mAs

view:

kVp

mAs

SID: 40 Inches

Markers:	Lateral	and	Superior
Shielding:	Gonadal
Respiration:	Suspend
Limited	–	2	views	(AP	Neutral)	&	(AP	Grashey).

Imaging:

10 x12 Landscape

Clavicle

Views:

1.	AP	Clavicle
2.	AP	Clavicle	(30	degrees	Cephalic)

*Modifier must include one of the following (Left, Right)

Area	Covered:	Entire	clavicle,	acromioclavicular	joint,	sternoclavicular	joint,	acro‐
mion	process

Bucky: Upright or Table

Exposure Technique:

AP	Clavicle	‐	66	kVp	@	16	mAs
AP	Clavicle	(30	degrees	Cephalic)	–	66	kVp	@	16	mAs

SID: 40 Inches

Markers: Lateral and Superior

Shielding: Gonadal

Respiration: Inspiration

Limited – none

Imaging:

10 x12 Landscape

Acromioclavicular Joints (Both)

Views:

1.	AP	Both	without	Weights
2.	AP	Both	with	Weights

*Modifier:

Both

*Get

all

one

image

all

possible.

unable,

then

total

films

will

needed.

*Place

weight

unaffected

hand

first,

then

place

weight

affected

just

prior

taking

image

Area Covered: AC Joints, entire clavicles, sternoclavicular joints.

Bucky: Upright

Exposure Technique:

without

weights

‐

kVp

mAs

with

weights

‐

kVp

mAs

kVp

mAs

(40

inch

SID)

SID: 72 Inches (or 40 inches if AC joints done individually).

Markers: Lateral and Superior

Shielding: Gonadal

Respiration: Suspended

Limited – none

Imaging:

14 x 17 Landscape

Scapula

Views:

1.	AP
2.	LAT	(Y	View)

*Modifier must include one of the following (Left, Right)

Area	Covered:
		AP	Scapula	–	Scapula	free	from	superimposition
		LAT	Scapula	–	Entire	Scapula	visualized	in	lateral	position.

SID: 40 Inches

Bucky: Upright or Table

Exposure Technique:

AP	Scapula	‐	66	kVp	@	16	mAs
LAT	(Y	View)	‐	80	kVp	@	20	mAs

Markers: Lateral and Superior

Shielding: gonadal

Respiration: Suspended or Breath gently.

Limited – none

Imaging:

Portrait 10x12

Humerus 2 or more views

Views:

1.	AP	–	(shoulder	joint	and	elbow)
2.	LAT	–	(shoulder	joint	and	elbow)

*Modifier must include one of the following (Left, Right)

Area Covered: Entire humerus

SID: 40 Inches

Bucky: Yes

Exposure Technique:

AP/Lateral – 70 kVp @ 4 mAs

Markers: Distal and Lateral

Shielding: Gonadal

Respiration: Suspend

Limited – none

Imaging:

Portrait 14x17

Elbow 3 or more views

Views:

AP	external	oblique
LAT	(superimpose	epicondyles)

Special	Notes:
		*	Modifier	must	include	one	of	the	following	(Left,	Right)
		*	3	views	standard	protocol.

Area Covered: Distal Humerus, Elbow joint space, proximal Radius and Ulna.

SID: 40 Inches

Bucky: none

Exposure Technique:

Lateral –60 kVp @ 1.6 mAs

Markers: Distal and Lateral

Shielding: Gonadal

Respiration: none

Limited: 2 views mainly used for C&P.

Imaging:

10 x12 portrait

Forearm 2 views

Views:

LAT

Special	Notes:
		*Modifier	must	include	one	of	the	following	(Left,	Right)

Area Covered: Radius, Ulna, Carpals, distal Humerus

Bucky: none

Exposure Technique:

Lateral – 60 kVp @ 1.6 mAs

SID: 40 Inches

Markers: Distal and Lateral

Shielding: Gonadal

Respiration: None

Imaging:

14 x 17 portraits

Wrist 3 or more views

Views:

PA Oblique

LAT

*Modifier

must

include

one

the

following

(Left,

Right)

*For

requested

scaphoid

view,

evert

hand

toward

ulnar

side,

angle

10‐15

degrees

proximally.

views

standard

protocol.

Area

Covered:

Mid

and

proximal

Metacarpals,

Carpals,

distal

Radius

and

Ulna,

and

associated

joints,

including

all

soft

tissue.

Bucky: none

Exposure Technique:

‐

kVp

1.25

mAs

Obl

–60

kVp

1.25

mAs

Lateral

–

kVp

1.5

mAs

SID: 40 Inches

Markers: Distal and Lateral

Shielding: Gonadal

Respiration: None

Limited: 2 views mainly used for C&P.

Imaging:

8 x10 portrait

Hand 3 or more views

Views:

oblique

–

(Replace

with

ball

catcher

views

for

Rheumatoid

work

up)

LAT

Notes:

*Modifier	must	include	one	of	the	following	(Left,	Right).
*	Standard	Protocol	is	3	views.

Area Covered: Phalanges, metacarpals, carpals and all joints of the hand.

Bucky: none

Exposure Technique:

			PA	‐	60	kVp	@	1.25	mAs
OBL	–	60	kVp	@	1.25mAs
LAT	–	60	kVp	@	1.5	mAs

SID: 40 Inches

Markers: Distal and Lateral

Shielding: Gonadal

Respiration: None

Limited: 2 views mainly used for C&P.

Imaging:

8x10 portrait

Finger(s) 2 or more views

1.	PA
2.	PA	oblique
3.	LAT

*Modifier must include one of the following (Left, Right)

Area

Covered:

Phalages

affected

digit

and

distal

half

adjoining

metacarpal.

For

the

Thumb

include

distal

and

proximal

Phalanx,

carpometacarpal

joint,

metacarpal,

and

trapezium.

Notes:

Standard protocol is 3 views.

Bucky: none

Exposure Technique:

PA	‐	60	kVp	@	1.0	mAs
OBL	–	60	kVp	@1.0	mAs
LAT	–	60	kVp	@	1.0	mAs

SID: 40 Inches

Markers: Distal and Lateral

Shielding: Gonadal

Respiration: none

Limited: 2 views mainly used for C&P.

Imaging:

8 x10 portrait

LOWER EXTREMITIES

Hip Both

Views:

1.	AP	Pelvis
2.	LAT/Oblique	(Frog)	(Left)
3.	LAT/Oblique	(Frog)	(Right)

Special

Notes:

*If

suspected

hip

fracture

use

horizontal

beam

lateral

(Shoot

Through

tech‐

nique).

not

touch

toes

together.

*If

provider

orders

pelvis

along

with

bilateral

hips,

please

discontinue

the

pelvis

and

include

with

the

hip

x‐rays

‐

this

new

CPT

code

requirement.

*When

moving

patient

with

known

fracture,

the

legs

should

immobilized.

*Remember

image

entire

joint

replacement

hardware

(If

applicable).

*If

routine

with

suspected

fracture

spread

feet

apart

and

have

patient

touch

toes

together.

This

will

rotate

the

Greater

Trochanters

outward.

*Heels

out

and

toes

touching

for

Pelvis.

(Ask

patient

alright

tape

together).

*Include

pubic

symphysis

least

one

the

images.

Area

Covered:

acetabulum,

femoral

heads,

necks

and

greater

trochanters

and

associ‐

ated

parts

the

ilium,

ischium

and

pubis.

Bucky: Table

Exposure Technique:

AP	PELVIS	‐	80	kVp	@	40	mAs
LAT/OBL	–	77	kVp	@	14	mAs

SID: 40 Inches

Markers: Distal and Lateral

Shielding: Shielding may get in way of anatomy

Respiration: Suspend

Limited –none

Imaging:

Landscape 14 X17, Portrait (LAT) 10x12

Hip Unilateral 2 views

Views:

1.	AP	Hip	(Affective	Side)
2.	LAT/Oblique	(Frog)	(Affected	Side)

*If

suspected

hip

fracture

use

horizontal

beam

lateral

(Shoot

Through

technique)

not

touch

toes

together.

*When

moving

patient

with

known

fracture,

the

legs

should

immobilized.

*Remember

image

entire

joint

replacement

hardware

(If

applicable).

*modifier

must

include

one

the

following

(Left,

Right)

*If

routine

with

suspected

fracture

spread

feet

apart

and

have

patient

touch

toes

together

‐

This

will

rotate

the

Greater

Trochanters

outward.

Area Covered: Acetabulum, femoral head, neck and greater trochanter

Bucky: Table

Exposure Technique:

		AP	HIP	‐	77	kVp	@	14	mAs
LAT/OBL	–	77	kVp	@14	mAs

SID: 40 Inches

Markers: Distal and Lateral

Shielding: Shielding may get in way of anatomy

Respiration: Suspend

Limited: None

Imaging:

Portrait 10x12

Femur 2 views

Views:

1.	AP	(include	the	hip	and	knee	–two	separate	cassettes	needed).
2.	LAT	(include	the	hip	and	knee	–two	separate	cassettes	needed).

*	If	suspected	hip	fracture	use	a	cross
table	horizontal	beam
*	Modifier	must	include	either	a	Left,	or	Right.

Area Covered: entire femur from hip joint to knee joint

Bucky: Table

Exposure Technique:

AP/LAT	(hip)	–	77	kVp	@	14	mAs
AP/LAT	(knee)	77	kVp	@	2.5	mAs

SID: 40 inches

Markers: Distal and Lateral

Shielding: Gonadal

Respiration: suspended

Limited – none

Imaging:

Portrait 14x17, 10x12

Knee (3 views)

Views:

Routine	Knee	(3	views)
1.		AP	(weight	bearing)
2.		LAT	(weight	bearing)
3.		Sunrise	(supine)

Knee	(4	views)
Trauma	Knee	(4	views)
Trauma	knee	–	Initial	trauma	within	30	days	or	less
1. AP	(supine)
2. Medial	oblique	(supine)
3. Sunrise	(supine)
4. Lateral	(cross‐table,	lateral)	gentle	flexion

Knee	(4	views)
Trauma	Knee	(4	views)
Trauma	knee	order	after	30	days	up	to	6	months
1.	AP	(supine)
2.	Medial	oblique	(supine)
3.	Sunrise	(supine)
4.	Lateral	(supine)	gentle	flexion

Limited: 2 views mainly used for C&P.

1.	AP	(weight	bearing)
2.	LAT	(weight	bearing)

Notes:

*Modifier

must

include

one

the

following

(left,

right)

Areas

Covered:

Distal

femur,

proximal

tibia

and

fibula,

patella

and

knee

joint.

Standard

protocol

views

unless

trauma

then

views.

SID:	40	inches
Bucky:		Upright	&	table
Exposure	Technique

	AP	&	LAT:	77	kVp	@	2.5	mAs
	Sunrise:		70	kVp	@	3.2	mAs
Breath	Hold:		None
Markers:	Lateral
Shielding:		Gonadal	(Ages	newborn	to	age	50)

Imaging:

Portrait 10x12

Knee Both Standing (ORTHO PROTOCOL)

*Must have additional orders in addition to this order*

View:

			Orders	needed:
1. AP	both	knees	(weight	bearing)
2. Left	Knee	2	view	(Lateral	weight	bearing,	sunrise	supine)
3. Right	Knee	2	view	(Lateral	weight	bearing,	sunrise	supine)

Another

order

should

present

also

have

knee

two

(2)

view

order

“left”,

and

knee

two

(2)

view

order

“right.”

(1)

view

standing

knee

should

never

performed

itself.

All

views

are

done

weight

bearing

except

for

sunrise

views.

Views completed:

1. Both	AP	weight	bearing	knees	together	(1	view	standing)
2. Left	knee	lateral	&	sunrise	(Lateral	weight	bearing,	sunrise	supine)
3. Right	knee	lateral	&	sunrise	(Lateral	weight	bearing,	sunrise	supine)

*Lateral knee views to angle tube even‐though patient is standing.

Area

covered:

Both

knee

position

include

distal

femur,

proximal

tibia

and

fibula,

patella

and

knee

joint.

Exposure Technique:

AP – 77 kVp @ 2.5 mAs

Breath: none

Bucky: Upright

SID: 40 inches

Markers: Lateral

Shielding: Gonadal

Limited: none

Imaging:

Landscape 14x17

Tibia & Fibula 2 views

View:

		1.	AP
2.	LAT

*Modifier must include either a Left or Right

Areas covered: Entire Tibia/Fibula to include ankle and knee joints

SID

–

40+

inch

(distance

may

have

greater

than

40”

include

entire

tib/fib

plus

joints

diagonal

film).

Exposure Technique

AP & LAT: 66 KVp @ 3.2 mAs

Bucky: none

Breath Hold: Suspended

Markers: Lateral and Superior

Shielding: Gonadal

Limited: none

Imaging:

portrait 14 x 17 on an angle

Ankle 3 or more views

Views:

1.	AP
2.	AP	Mortise	(internally	rotate	foot	&	ankle	15	–	20	degrees)
3.	LAT

*Supine	unless	indicated	weight	bearing	views
*Modifier	must	include	either,	Left,	Right	or	Weight	Bearing.
*Standard	protocol	is	3	views.

Areas

covered:

Ankle

joint,

distal

tibia

and

fibula

and

proximal

talus.

Lateral

view

must

also

include

complete

talus

and

calcaneus.

SID: 40 inches

Exposure Technique

60 kVp @ 2.0 mAs

Breath Hold: none

Markers: Lateral and Superior

Shielding: Gonadal

Limited: 2 views mainly used for C&P. AP & Lateral

Imaging:

8x10 Portrait.

Foot 3 or more views

Views:

(Angle

tube

degrees

toward

heel)

oblique

(rotate

foot

medially

place

plantar

surface

degrees

plane

film.

3. LAT

*Supine	unless	indicating	Weight	Bearing
*Modifier	must	include	Left,	or	Right	or	Weight	Bearing
*Standard	is	3	views.

Areas

covered:

AP:

Phalanges,

metatarsals,

cuniforms,

cuboid,

and

navicular

Obl:

Phalanges,

metatarsals,

cuboid,

3rd

cuneiform,

navicular

and

distal

calcaneous

with

associated

intertarsal

spaces.

LAT:

Tarsals

are

partially

superimposed.

Ankle

joint

and

subtalar

joint

are

seen

partially

superimposed,

metatarsals

and

phalanges

are

superimposed.

SID: 40 inch

Exposure Technique:

60 kVp @ 1.25 mAs

Breath Hold: none

Shielding: Gonadal

Markers: Lateral and Superior

Limited: 2 views mainly used for C&P. AP & Lateral

Imaging:

Portrait 10x12

Heel 2 views

Views:

Axial

(Angle

Degrees

cephalic

long

axis

foot)

Lateral

*Modifier must include either Left or Right.

Areas covered: Calcaneus, talus and talcalcaneal joint.

SID: 40 inch

Exposure Technique:

Axial	‐	70kVp	@	3.2	mAs
Lateral	‐	60	kVp	@	2.8	mAs

Breath Hold: none

Shielding: Gonadal

Markers: Lateral and Superior

Limited – none

Imaging:

8 x 10 portrait

Toe(s) 2 or more views

Views:

1.	AP
2.	AP	Oblique
3.	Lateral

*modifier

must

include

either

Left

Right

*Great

Toe

(1st):

include

views,

all

other

toes

only

two

views

needed.

*tape

can

used

separate

the

toes.

*Standard

Protocol

views.

Areas Covered: Distal metatarsal to distal phalanges

SID: 40 inch

Exposure Technique:

AP & LAT: 60 kVp @ 1.0 mAs

Breath hold: none

Markers: Lateral

Shielding: Gonadal

Limited: 2 views mainly used for C&P. AP & Lateral

Imaging:

8x10 landscape

CRANIUM

Skull 3 views, 4 or more views

Views:

Towne

–

degree

caudal

OML

with

OML

perpendicular

film.

Caldwell

–

degree

angle,

OML

perpendicular

film

Lateral

(for

views

add

both

Laterals)

*usually	done	as	upright	but	can	be	done	supine.
*Standard	is	3	views.

Areas

covered:

Towne:

Occipital

bone,

petrous

pyramids,

and

foramen

magnum

with

dorsum

sellae

and

posterior

clinoids

its

shadow.

Caldwell:

Greater

and

lesser

sphenoid

wings,

frontal

bone,

superior

orbital

fissures,

frontal

and

ethmoid

sinuses,

foramen

rotundum,

orbital

margin,

and

cristi

galli

Lateral:

Lateral

cranium

closest

film,

sella

tursica,

and

posterior

clinoids,

dorsum

sellae,

and

greater

and

lesser

wings

sphenoid.

SID: 40 inch

Bucky: Upright or Table

Exposure technique

AP,	PA	–	75	kVp	@	20	mAs
LAT	–	75	kVp	@	10	mAs

Breath: suspended

Markers: Lateral

Shielding: Gonadal

Limited: 2 views mainly used for C&P. AP Towne & Lateral

Imaging: 10x 12 Landscape

Facial Bones 3 views

Views:

1.	PA	Waters
2.	PA	Caldwell
3.	Lateral	(affected	side)
4.	SMV	Zygomatic	arches

*can be done upright or supine.

Areas

covered:

Waters:

Inferior

orbital

rim,

maxillae,

nasal

septum,

zygomatic

bones,

zygomatic

arches

and

nasal

spine

Caldwell:

Orbital

rim,

maxillae,

nasal

septum,

zygomatic

bones,

and

nasal

spine.

Lateral:

Superimposed

facial

bones,

greater

wings

the

sphenoid,

orbital

roofs,

sella

turcica,

zygoma

and

mandible

SMV:

Bilateral

zygomatic

arches

*Standard

Protocol

views.

SID: 40 inch

Bucky: upright or table

Exposure Technique

PA	Waters	and	Caldwell	75	kVp	@	20	mAs
Lateral	and	SMV	75	kVp	@	10	mAs

Breath: suspended

Markers: Lateral

Shielding: Gonadal

Limited: 2 views mainly used for C&P. PA Waters and Lateral

Imaging:

10x12 Portrait.

Sinus 3 or more views

Views:

1.	PA	Caldwell
2.	PA	Waters
3.	Lateral	(affected	side	if	available)

*All images to be done upright for air/fluid levels

Areas	covered: Caldwell:		Orbital	rim,	maxillae,	nasal	septum,	zygomatic	bones,
and	anterior	nasal	spine.
	Waters:		Inferior	orbital	rim,	maxillae,	nasal	septum,	zygomatic	bones,	zygo‐
matic	arches	and	anterior	nasal	spine
	Lateral:		Superimposed	facial	bones,	greater	wings	of	the	sphenoid,	orbital
roofs,	sella	turcica,	zygoma	and	mandible
*Standard	Protocol	is	3	views.

SID: 40 inch

Bucky: Upright

Exposure	Technique
	PA	Waters	and	Caldwell:		75	kVp	@	20	mAs
	Lateral:		75	kVp	@	10	mAs

Breath: suspended

Markers: Lateral

Shielding: gonadal

Limited: 2 views mainly used for C&P. PA Caldwell & Lateral

Imaging:

10x12 Portrait

Nasal Bones min 3 views

Views:

1.	PA	Waters
2.	Both	Laterals

*general	done	upright,	but	can	be	done	supine
*both	laterals	done	for	comparison
*Standard	Protocol	is	3	views.

Areas

covered:

Waters:

bony

nasal

septum.

Lateral:

nasal

bone

and

soft

tissue

nose

structures

SID: 40 inch

Bucky: upright or table

Exposure Technique:

Waters:	75	kVp	@	20	mAs
Lateral:	75	kVp	@	5	mAs

Breath: suspended

Markers: Lateral

Shielding: gonadal

Limited: 2 views mainly used for C&P. PA Waters and LAT

Imaging:

8x10 Portrait

Orbits Foreign Body

Views:

1.	PA	Caldwell	(30	degree	caudal	angle	with	eyes	looking	up)
2.	PA	Caldwell	(30	degree	caudal	angle	with	eyes	looking	down)

*Ensure

petrous

ridges

located

below

lower

orbital

rim

*cone

over

the

orbits,

not

include

entire

skull.

*all

images

must

approved

radiologist

prior

patient

leaving

department.

Radiologist

present

review

images

–

send

NTP

STAT

using

portal

then

call

NTP

support

get

read.

Check

for

report

then

let

patient

go.

*Standard

Protocol

views.

Areas

covered:

PA:

Petrous

ridges

located

below

orbital

rim,

rotation

cranium

Lateral:

superimposed

orbital

roofs,

rotation

sella

turcica

SID: 40 inch

Exposure Technique:

PA	Caldwell:	70	kVp	@	20	mAs
Lateral:		70	kVp	@10	mAs

Bucky: Upright

Breath: suspended

Markers: Lateral

Shielding: Gonadal

Limited: none

Imaging:

10x12 portrait

Orbits Min 4 views

Views:

1.	PA	modified	Waters
2.	Both	Laterals
3.	Both	Rhese

*patient

done

erect

condition

allows

*Standard

Protocol

views.

*This

protocol

mainly

used

for

trauma

view

orbital

rim

canal.

pre

MRI

screening

order

should

“orbits

foreign

body.”

Areas	covered:	PA:		Floor	of	orbits	and	inferior	orbital	rim.
			Rhese:		Cross	section	of	each	optical	canal

SID: 40 inch

Bucky: Upright or Table

Exposure Techniques:

PA	&	Rhese	–	70	kVp	@	20	mAs
Lateral	‐		70	kVp	@10	mAs

Breath: suspended

Markers: lateral

Shielding: Gonadal

Limited: none

Imaging:

10x12 portrait

Mandible less than 4 views

Views:

1.	AP	Towne	(35	‐40	degree	caudal)
2.	PA
3.	Both	Obliques	(25	degree	cephalic,	both	obliques	done)

Areas	covered:		AP	Towne:		condyloid	processes	of	mandible	and	temporomandibu‐
lar	fossae
PA:		mandibular	rami	and	lateral	portion	of	body
Oblique:	mandibular	rami,	body	of	mentum	of	mandible	positioned	closest
to	film

*Standard protocol is 4 views.

SID: 40 inch

Bucky: Upright or Table

Exposure Technique

AP	&	PA:		75	kVp	@	20	mAs
Oblique:		75	kVp	@	32	mAs

Breath: suspended

Markers: Lateral

Shielding: gonadal

Limited: 2 views mainly used for C&P. PA & Obliques

Imaging:

10 x 12 portrait

TM Joints Both O & C Mouth

Views:

1.	AP	Axial	(Towne,	35	degree	caudal)
2.	Axiolateral	(Schuller	method,	head	lateral	position,	25‐30	degree	caudal,	open
and	closed	both	sides)

*both	right	and	left	sides	done	for	comparison.
Standard	Protocol	is	5	views.

Areas	covered:	AP	Axial:		condyloid	processes	of	mandible	and	temporomandibular
fossae.		Axiolateral:		Temporomandibular	joint	closest	to	film

SID: 40 inch

Bucky: Upright or Table

Exposure Technique

AP	Axial:	75	kVp	@20	mAs
Axiolateral:		75	kVp	@	20	mAs

Breath: suspended

Markers: Lateral

Shielding: Gonadal

Limited: none

Imaging:

10x 12 portrait

OTHER

Bone Survey

Views:

1.	AP	Townes	(skull)
2.	LAT	Skull
3.	LAT	Cervical	Spine
4.	LAT	Thoracic	Spine
5.	LAT	Lumbar	Spine
6.	AP	Ribs
7.	AP	Pelvis
8.	AP	Humerus	(both)
9.	AP	Femurs	(both)

*generally	done	for	patients	with	metastatic	disease
*swimmers	view	to	be	done	if	C7‐T3	cannot	be	seen.
*Standard	protocol	is	11	views.

Areas covered: See appropriate pages for each body part listed above.

SID: 72 inch LAT Cervical Spine, 40 inch all others

Exposure Technique:

See appropriate pages for each body part listed above.

Breath: suspended, breathing for LAT thoracic spine

Markers: Lateral

Shielding: gonadal

Limited: none

Imaging:

10 x12 skull, LAT c‐spine, 14 x17 all others

FLUORO

ESOPHAGUS

Prep: NPO after mid‐night

NO KUB (Scout)

No post films unless Radiologist indicates

Areas covered: Radiologist protocol

SID: 40”

Exposure Technique:

UGI

Prep: NPO after mid‐night

KUB (Scout)

Barium (blue) (add water to top & shake) with straw inserted through top

Small cup of water approximately six (6) to eight (8) table spoons (tbs)

Crystal

tablets

(one

small

packet)

another

cup.

Important

for

patient

not

burp.

Radiologist

give

patient

with

instructions.

Wash cloth to wipe patient’s mouth if barium gets on lips or face.

Radiologist and Technologist completes study based on Radiologist protocol

No post films unless Radiology indicates

UGI / SMALL BOWEL FOLLOW THROUGH

Prep: NPO after mid‐night

KUB (Scout)

Barium (blue) (add water & shake) with straw inserted through top (No Gastro)

Small cup of water approximately six (6) to eight (8) table spoons (tbs)

Crystal

tablets

(one

small

packet)

another

cup.

Important

for

patient

not

burp.

Radiologist

mix

water

and

crystals

then

hand

patient

with

instructions.

Wash cloth to wipe patient’s mouth if barium gets on lips or face.

Radiologist and Technologist completes study based on Radiologist protocol

Ask Radiologist for any follow‐up if post films needed.

BARIUM ENEMA (BE)

Prep: Provider to order cleaning of colon prep, NPO after mid‐night

KUB (Scout)

BE bag and tip

Towel

Radiologist and Technologist completes study based on Radiologist protocol

Ask Radiologist for any follow‐up if post films needed.

SPEECH (THERAPY) STUDIES

Prep: Prep will be given by speech therapist

All supplies set up by Speech Therapist.

Radiologist and Speech Therapist to complete study.

Fluoro to be done in real time and captured.

Technologist to complete procedure and send to IntelliSpace PACS.

No post images.

NIHCS	EXPOSURE	TECHNIQUE	CHART	(AVG	SIZE	PT)
Protocol	Technique	Chart
		kVp mAs COMMENTS

CHEST PA 117 2.5

CHEST LAT 117 10

CHEST AP PORTABLE 81 4 no grid

RIBS AP 75 20

RIBS AP LOWER 85 40

RIBS OBLIQUE 75 40

RIBS OBLIQUE LOWER 85 80

STERNUM RAO 70 63 1.0 sec ‐ DR; 3.2 sec ‐ CR

STERNUM LAT 75 20

STERNOCLAV PA 70 10

STERNOCLAV OBL 70 20

NECK SOFT TISSUE AP 75 5

NECK SOFT TISSUE LAT 75 25

ABDOMEN ERECT 81 40

ABDOMEN SUPINE 81 40

ABDOMEN LLD 81 40

PELVIS 81 32

SACRUM/COCCYX AP 81 20

SACRUM/COCCYX LAT 81 40

SI JOINTS AP 81 20

SI JOINTS OBL 81 20

CERVICAL SPINE AP 75 5

CERVICAL SPINE ODON‐

TIOD 75 10

CERVICAL SPINE LATERAL 75 40

CERVICAL SPINE OBLIQUE 75 40

CERVICAL SPINE SWIM‐

MERS 75 100

THORACIC SPINE AP 75 20

THORACIC SPINE LAT 81 80 1.0 sec ‐ DR; 3.2 sec ‐ CR

LUMBAR SPINE AP 81 32

LUMBAR SPINE OBLIQUE 81 45

LUMBAR SPINE LAT 90 80

LUMBAR SPINE L5‐S1 90 120

kVp mAs COMMENTS

SHOULDER AP 66 16

SHOULDER AXILLARY 66 16 w/grid; no grid ‐ 70 @ 5

SHOULDER Y VIEW 80 20

CLAVICAL AP/AXIAL 66 16

AC JOINTS 70 25

72 inch SID; 70 @ 10 ‐ 40in

SID

SCAPULA AP 66 16

SCAPULA Y VIEW 80 20

HUMERUS AP/LAT 70 4

ELBOW AP/LAT 60 1.6

FOREARM AP/LAT 60 1.6

WRIST AP/LAT 60 1.25

HAND AP/LAT 60 1.25

FINGER AP LAT 60 1

HIP AP/FROG 77 14

FEMUR 77 10

KNEE AP/LAT 77 2.5

KNEE SUNRISE 70 3.2

TIB/FIB AP/LAT 66 3.2

ANKLE AP/LAT 60 2

FOOT AP/LAT 60 1.25

CALCANEOUS AXIAL 70 3.2

CALCANEOUS LAT 60 2.8

TOES AP/LAT 60 1

kVp mAs COMMENTS

SKULL AP/PA 75 20

SKULL LAT 75 10

FACIAL BONES PA/AP 75 20

FACIAL BONES LAT 75 10

SINUS PA 75 20

SINUS LAT 75 10

NASAL BONES PA 75 20

NASAL BONES LAT 75 5

ORBITS PA 70 20

ORBITS LAT 70 10

MANDIBLE PA/AP 75 20

MANDIBLE OBL 75 32

TMJ PA/AP 75 20

TMJ OBL 75 20

* No AEC for distal extremities

Notes:

If adult body part is larger than 10cm a grid should be used

If using more than 90 kVp a grid should be used to reduce scatter.

A best practice in digital radiography is the consistent use of lead anatomic side markers captured on the original image during the x‐ray exposure.

All techniques given are approximate, and should not be taken as the only tech-nique that will give the desired results. Please use caution when setting tech-niques look at your patient size and body habitus then, set the technique accord-ingly.

Reference for Positioning:

Textbook	of	Radiographic	Positioning	and	Related	Anatomy,	Sixth	Edition.	Authors	:	Kenneth
L.	Bontrager,	and	John	P.	Lampignano.	Copyright	2005	by	Mosby,	Inc.

File details come from the government source that posted it. Updated Dec 6, 2019.