A Radiologist is always available if you are uncertain about the most appropriate imaging modality or you have urgent requests, however non-urgent requests should be discussed in business hours (8.30-5pm, Monday to Friday)
The radiology request card should contain the relevant history as well as the clinical suspicion.
All patients should have adequate assessment and management before being sent for investigations. A nurse should be available at all times for patients having radiology investigations and medical escort is required for potentially/ unstable patients.
- look for widened prevertebral shadow (normal prevertebral width equal to vertebral body width at C4 level) or neck flexion
- Inhaled foreign body:
if clinical suspicion that FB in neck or upper resp tract signs
rarely, a sharp FB may have perforated ST and imaging of the neck may be indicated
See acute upper airway obstruction
Chest xray (frontal view)
Infection - to exclude pneumonia
Inhaled foreign body
Pneumothorax - full inspiratory films adequate
Asthma/ Bronchiolitis - Consider only if:
Clinical cardiomegaly or heart
Heart murmurs - If careful examination suggests innocent murmur, no need for urgent CXR - but arrange appropriate follow up.
Hypertension - CXR is seldom useful.
Neonates (<6 wks):
Limb xrays & other imaging
Comparative and Stress Views - rarely necessary and should not be routinely taken. However may be useful for complex fractures (after consultation) if initial xrays unclear (eg elbow)
Xray of the suspected fracture as well as the joints
above and below if signs and symptoms suggest bone injury. If in doubt about the site of injury, seek senior help rather than xraying the entire limb.
If a fracture is clinically suspected but xrays
normal, discuss with consultant and if in doubt treat as if fracture present.
Non accidental injury (to be seen by registrar or
See Non-accidental injury
Acutely painful hip
Plain xrays (AP and frog-leg lateral) will demonstrate slipped upper femoral epiphyses, Perthe's and fractures.
USS/ bone scan may be indicated depending on clinical findings (discuss with specialty team or treating consultant).
See limping or non-weight bearing child
Acutely swollen joint
See acutely swollen joint
See Bone and joint infection
See Bone and joint infection
Suspected bowel obstruction/ perforation
See ingested foreign body
Suspected Abdominal Mass
Blunt abdominal trauma
If unsure whether AXR would be helpful - ask consultant or registrar for advice
AXR not indicated for:
Vague central abdominal pain
Chronic constipation, encopresis or enuresis (in the Emerg. Dept setting)
Abdominal & pelvic ultrasounds
If an urgent ultrasound is necessary, the patient should be discussed with the surgeon &/or the treating consultant.
Ultrasound by experienced operators is the diagnostic modality of choice for intussusception.
However these patients are potentially unstable and should only be sent for ultrasound after appropriate resuscitation including an IV, and treatment as well as notifying the surgeons and the treating consultant
Suspected pyloric stenosis
See pyloric stenosis
or iliac or pelvic pain in the pubertal
female with possible ovarian pathology (requires full bladder), or if potential renal tract obstruction, early ultrasound recommended.
Abdominal ultrasound is a useful tool for many other abdominal pain presentations however urgency of the request should be proportional to the symptoms.
Urinary tract imaging
See urinary tract infection
Intracranial and skull imaging
Specific Indications for Skull Xrays (SXR):
Only indicated in well-appearing children
There are no other routine indications for skull XRay and any such requests should be discussed with the treating consultant.
Specific Indications for CT Brain:
Useful for rapid diagnosis of suspected intracranial injuries and is the preferred investigation if clinical evidence of intracranial injury.
Clinical deterioration is usually an indication for repeat CT examination.
See Head injury
Depressed conscious level of unknown cause
Clinical evaluation is the most important factor in determining the need for imaging.
CT scan indications:
Abnormal neurological signs.
Unexplained decrease in visual acuity.
Headaches with seizures.
Marked change in behaviour.
Symptoms of raised intracranial pressure.
Increasing frequency of unexplained headaches or new onset of severe or persistent headache
Persistent abnormal neurological signs/impaired conscious state.
Focal neurological signs or EEG findings.
Failure to respond to anticonvulsant therapy.
See afebrile seizures
Abnormal Size / Shape Of Skull
Clinical examination is usually sufficient to diagnose abnormality of the skull.
Large head - rapidly enlarging head needs imaging-US or CT scan.
Small head - nearly always pathological secondary to abnormal brain growth. Evaluate with CT or MRI scan, which is usually best organised via the managing outpatient physician
Specific Indications for cranial ultrasound:
Neurological concerns in neonates/ infants
Any investigations other than plain xrays should be
ordered in consultation with the treating consultant &/or the
appropriate specialty team.
NB. Down syndrome children have increased risk of C1-2 instability.
Specific indications in Trauma:
A normal Spinal Xray series or CT scan will not allow
clearance of the neck in the unconscious or uncooperative
See cervical spine assessment
Children poorly localise the level of the injury, therefore imaging the full length of thoraco-lumbar spine may be necessary (discuss with treating consultant).
If neurological signs present do a CT or MRI scan after consultation with Neurosurgery.
Specific Non-trauma indications:
Potential cord compression
Suspected focal vertebral pathology