CHAPTER 37

PATIENT RADIATION DOSE MANAGEMENT

• All medical health physics activity is directed in some way toward minimizing the radiation _____ of radiologic personnel
and the radiation _____ to patients during x-ray examination
Answer: exposure; dose

• Radiation exposure of radiologists and radiologic technologists is measured with the use of _____
Answer: Occupational radiation monitors

• Patient dose usually is estimated by conducting simulated x-ray examinations with _____ and _____
Answer: human phantoms and test objects

• If radiation control procedures are adopted, _____ and _____ can be kept acceptably low
Answer: occupational radiation exposure and radiation dose

• What is ALARA?
Answer: As Low As Reasonably Achievable

• What are the three ways for estimating patient radiation dose from diagnostic x-rays?
Answer:
• Entrance Skin Dose
• Gonadal Dose
• Bone marrow Dose

• Most often referred to as patient dose

Answer: Entrance Skin Dose (ESD) or exposure to the entrance surface

• What is the importance of Gonadal dose?

Answer:
Gonadal dose is important because of possible genetic responses to medical x-ray exposure. The dose to the gonads is not difficult to
measure or estimate.

• What is the importance of Bone marrow dose

Answer: Bone marrow dose is important because bone marrow is the target organ believed responsible for radiation-induced leukemia

• Bone marrow dose cannot be measured directly; it is estimated from _____

Answer: Entrance Skin Dose (ESD)

• Patient radiation dose is expressed as

Answer:
• Entrance skin dose
• Gonadal dose
• Bone marrow dose

• In any given x-ray facility, actual doses delivered may be considerably different. Efficiency of _____ and _____ are the most
important variables
Answer:
• Efficiency of x-ray production
• Image receptor speed

• ESD is used widely because it is easy to measure, and reasonably accurate estimates can be made in the absence of _____
Answer: measurements

• Monitor of choice most often used in ESD or patient radiation dose

Answer: Thermoluminescence Dosimeters (TLD)

• What makes TLDs very satisfactory patient radiation monitors?

Answer:

• Size
• Sensitivity
• Accuracy
•
• A small grouping or pack of ___ to ___ TLDs can be taped easily to the patient’s skin in the center of the x-ray field
Answer: 3 to 10

• Because the response of the TLD is proportional to ______ and _____, the TLD can be used to measure all levels
experienced in diagnostic radiology
Answer: exposure and dose

• With proper laboratory technique, the results of such measurements are accurate to within ___%
Answer: 5%

• Two rather straightforward methods for estimating ESD are available in the absence of _____
Answer: patient measurements

• The first method requires the use of a _____ which contains family of curves from which one can estimate the output
intensity of a radiographic unit if the technique is known or assumed
Answer: Nomogram

• The output intensity of different x-ray imaging systems varies widely, so the use of this nomogram method is good only to
perhaps ___%
Answer: 50%

• For the use of this nomogram first requires knowledge of the _____ in the x-ray beam
Answer: total filtration

• Total filtration is usually available from the medical physics report, but if not, ____ mm Al is a good estimate
Answer: 3 mm Al

• What are the two factors of the examination that should be identified in using nomogram
• kVp
• mAs

• In nomogram, a vertical line rising from the value of total filtration should be drawn until it intersects with what factor of the
examination?
Answer: kVp

• From the intersection of the vertical line and kVp, a horizontal line is drawn to the left until it intersects the _____ axis
Answer: mGyt/mAs

• The resultant mGyt/mAs value is the approximate _____ of the radiographic unit
Answer: output intensity

• The resultant mGyt/mAs value should be multiplied with the factor of the examination value to obtain the approximate
patient exposure
Answer: mAs
 • Estimate the ESD from a lateral cervical spine image made at 66 kVp, 150 mAs, with a radiographic unit having 2.5 mm Al
total filtration
Answer: Estimate the intersection between a vertical line rising from 2.5 mm Al and a horizontal line through 66 kVp.
Extend the horizontal line to the y-axis and read 38 μGyt/mAs
38 μGyt/mAs × 150 mAs
= 5700 μGyt
= 5.7 mGyt

• A straight edge between any _____ and _____ value will cross the ESD scale at the correct mGyt value
Answer: kVp and mAs

• Using the nomogram in Figure 37-2, identify the ESD when a radiographic exposure is made at 66 kVp, 150 mAs.
Answer: The line is drawn as shown and crosses the ESD scale at 10 mGyt

• A third method for estimating ESD requires that one know the _____ intensity for at least one operating condition
Answer: Output

• During the annual or special radiation control survey and calibration of an x-ray imaging system, the medical physicist
measures this output intensity, usually in units of _____ at ______ cm—the approximate source-to-skin distance (SSD)—or
at _____ cm—the source-to-image receptor distance (SID)
Answer: mGyt/mAs at 80 cm or at 100 cm

• At 70 kVp, radiographic output intensity varies from approximately _____ μGyt/mAs at 80 cm SSD
Answer: 20 to 100 μGyt/mAs

• With the calibration value available, one first would make adjustment for a different SSD by applying what law?
Answer: Inverse Square Law

• The output intensity of a radiographic unit is reported as 37 μGya/mAs (3.7 mR/mAs) at 100 cm SID. What is the intensity
at75 cm SSD?
Answer:
2 2
At 75 cm SSD, the intensity will be greater by (100/75) = (1.32) = 1.78
• Gya/mAs × 1.78 = 66 μGya/mAs

• With the ESD, one scales this according to the _____ and _____ of the examination
Answer: kVp and mAs

• _____ varies according to the square of the ratio in terms of the change in kVp
Answer: Output intensity

• Question: The output intensity at 70 kVp and 75 cm SSD is 66 μGya/mAs (6.6 mR/mAs). What is the output intensity at 76
kVp?
Answer: At higher kVp, the output intensity is greater by the square of the ratio of the kVp.
2 2
(76/70) = (1.09) = 1.18
66 μGya/mAs × 1.18 = 78 μGya/mAs

• The final step in estimating ESD is to multiply the output intensity in mGya/mAs by the examination mAs value because
these values are _____
Answer: Proportional

• If the radiographic technique for an intravenous pyelogram calls for 80 mAs, what is the ESD when the output intensity is 78
 μGya/mAs (7.8 mR/mAs)?
Answer: 78 μGya/mAs × 80 mAs = 6240 μGya
= 6.24 mGya

• Why is ESD in fluoroscopy is much more difficult to estimate

Answer: Because the x-ray field moves and sometimes varies in size. If the field were of one size and stationary, ESD would
be directly related to exposure time

• For the average fluoroscopic examination, one can assume an ESD of 40 mGyt/min
Answer: 40 mGyt/min

• A fluoroscopic procedure requires 2.5 min at 90 kVp, 2 mA. What is the approximate ESD?
Answer: ESD = (40 mGyt/min) (2.5 min) = 100 mGyt

• It is the average radiation dose to the entire active bone marrow

Answer: Mean marrow dose

• For instance, if during a particular examination, 50% of the active bone marrow were in the primary beam and received an
average dose of 250 μGyt (25 mrad); the mean marrow dose would be _____
Answer: 125 μGyt (12.5 mrad)

• In children, mean marrow dose levels generally would be _____ because the radiographic techniques used are considerably
less
Answer: lower

• The distribution of active bone marrow in the adult, and gives some clue as to which diagnostic x-ray procedures involve
exposure to large amounts of bone marrow

In the United States, the mean marrow dose from diagnostic x-ray examinations averaged over the entire population is approximately
______. Such a dose never results in the hematologic responses
Answer: 1 mGyt/yr (100 mrad/yr)

• Although the gonad dose from diagnostic x-rays is low for each individual, this may have some significance in terms of
_____ effects
Answer: population

• It is the gonad dose that, if received by every member of the population, would produce the total genetic effect on the
population as the sum of the individual doses actually received
Answer: Genetically significant dose (GSD)

• The population gonad dose of importance is the _____, the radiation dose to the population gene pool. Thus, it is a weighted-
average gonad dose. It takes into account those persons who are irradiated and those who are not, with averaging of the
results.
Answer: GSD

• The GSD can be estimated only through

Answer: large-scale epidemiologic studies

• Genetically Significant Dose is expressed as

ΣDNxP
GSD =
ΣNTP
where Σ is the mathematical symbol meaning to sum or add values,
D is the average gonad dose per examination,
NX signifies the number of persons receiving x-ray examinations,
NT is the total number of persons in the population, and
P (progeny) is the expected future number of children per person.

• For computational purposes, therefore, what are the factors to be considered in GSD
Answer:
•
• Age
•
• Sex
• expected number of children for each person examined with x-rays

• GSD also acknowledges the various types of examinations and the _____ per examination type.
Answer: Gonadal dose

• It is defined as any radiation dose that is not required for the patient’s well-being or for proper management and care.
Answer: Unnecessary patient radiation dose

• An ESD of approximately _____ is normal

Answer: 8 mGya/view (800 mR/view)

• Grid ratios of _____ and _____ are most popular

Answer: 4:1 and 5:1

• The contrast enhancement produced by the use of such grids is significant, but so is the increase in patient dose
Answer: patient dose

• Patient dose is increased by approximately _____ times with the use of such grids compared with the nongrid technique
Answer: two times

• Because of the _____ energies used in mammography, the dose falls off very rapidly as the x-ray beam penetrates the breast
Answer: low x-ray energies

• If the ESD for a craniocaudad view mammography is 8 mGya (800 mR), the dose to the midline of the breast may be only
1.0 mGyt (100 mrad) Fortunately, it is known that the risk of an adverse biologic response from mammography is _____
Answer: small

• Certainly, it is nothing about which a patient should be concerned. Any possible response, however, is related to the average
radiation dose to ______ tissue, and not to skin exposure
Answer: glandular tissue

• Glandular dose (Dg) varies in a complicated way, with variations noted in x-ray beam _____ and _____
Answer: quantity and quality

• Glandular dose is approximately _____% of the ESE

Answer: 15%

• _____ can be estimated by approximating that the contribution from each view will be 15% of the ESD.
Answer: Total Dg
 • The total Dg would be the sum of (0.15 × 8 = 1.2 mGyt) as the contribution from each of the craniocaudad and mediolateral
oblique views. The total Dg would, therefore, be _____
Answer: 2.4 mGyt

• Glandular dose should not exceed ___ mGyt/view with contact mammography and ___ mGyt/view with a grid.
Answer: 1 mGyt/view; 3 mGyt/view

• For screening programs, no more than _____ views per breast are advisable.
Answer: two

• Digital mammography should result in _____ Dg than that attained with screen-film mammography
Answer: lower

• On the basis of skin dose, CT results in a _____ dose than other diagnostic x-ray procedures
Answer: higher

• The skin dose delivered by a series of contiguous CT slices is much _____ than that delivered by a single radiographic view.
Answer: higher

• Because of increasing use of multislice helical CT, CT must be considered a _____ procedure
Answer: high-dose

• The CT tissue dose is approximately equal to the average _____ dose

Answer: fluoroscopic

• CT images the patient with a fine, _____ beam of x-rays

Answer: collimated

• The CT dose is approximately _____% of the ESD for body CT

Answer: 50%

• Radiographic and fluoroscopic doses are _____ at the surface and very _____ at the exit surface
Answer: high; low

• Part of the dose efficiency of CT is attributable to the precise ______ of the x-ray beam
Answer: collimation

• Scatter radiation increases _____ and reduces _____

Answer: patient dose; radiographic contrast

• Because CT uses narrow, well-collimated x-ray beams, _____ is reduced significantly, and _____ is improved significantly
Answer: scatter radiation; contrast resolution

• The precise collimation used in CT means that only a well-defined volume of tissue is _____ for each image
Answer: irradiated

• If a series of adjacent images is performed with an automatically indexed patient couch, the couch movement must be
precise. If the couch moves _____ between images, some tissue will be missed. If it moves _____, some tissue in each image
will be doubled-exposed
Answer: too much; too little

• It is essential that CT collimators be monitored periodically for proper _____

Answer: adjustment
 • Multislice helical CT results in _____ patient radiation dose than step-and-shoot CT because fewer tails are seen on the dose
profile for a given volume of tissue
Answer: lower

• The dose profile tail is called a

Answer: penumbra

• Typical CT doses range from_____ during head imaging and from _____ during body imaging
These values are only approximate and vary widely depending on the type of CT imaging system and the examination technique used
Answer: 30 to 50 mGyt (3000 to 5000 mrad); 20 to 40 mGyt (2000 to 4000 mrad)

• The effective dose for each examination is approximately _____

Answer: 10 mSv (1000 mrem)

• A 64-slice CT imaging system will result in a _____ patient dose than fewer slices because a lower contribution is made from
the penumbra for the same volume of tissue
Answer: low

• Additional patient dose saving occurs when the same beam width is imaged with combined pixel rows because the ____ can
be reduced without compromising image noise and therefore contrast resolution
Answer: mA

• Patient radiation dose is ____ with higher multislice computed tomography because the beam penumbra is less for a given
imaged anatomy
Answer: lower

• When two detector rows are combined for the same beam width, patient dose will be _____
Answer: lower

• A reduction in the noise or beam width, while other factors remain constant, _____ patient dose.
Answer: increases

• Who has considerable control over many sources of unnecessary patient radiation dose?
Answer: Radiologic Technologist

• Routine x-ray examinations should not be performed when there is no precise _____
Answer: medical indication

• What x-ray examination should not be performed for routine hospital admission when no clinical indication of chest disease
is found
Answer: Chest x-ray examination

• Among patients who might be candidates for such chest x-ray examination are those admitted to the _____
Answer: pulmonary service

• When such an examination is conducted on an asymptomatic patient, it should not include ______, especially ______
examination
Answer: x-ray examination; fluoroscopic examination

• In the typical busy hospital facility, the rate of repeat examinations should not normally exceed _____%
Answer: 5%

• Examinations with the highest repeat rates include

Answer:
• lumbar spine
• thoracic spine
 • chest
• abdomen

• It should never be necessary to repeat a

Answer: digital radiographic examination

• Two causes of repeat examinations resulting in an image that is too light or too dark are primarily responsible for repeats
Answer: improper positioning & poor radiographic technique

• Motion and improper collimation are responsible for some _____

Answer: repeats

• Infrequent errors that contribute to repeat examinations include

Answer:
• dirty screens
• use of improperly loaded cassettes
• light leaks
• chemical fog
• artifacts caused by a dirty processor
• wrong projection
• improper patient preparation
• grid errors
• multiple exposures

• In general, the use of high-kVp technique results in _____ patient dose

Answer: reduced

• Increasing the kVp is always associated with a reduction in ______ to obtain an acceptable radiographic optical density; this,
in turn, results in reduced patient radiation dose
Answer: mAs

• Dose reduction occurs because the patient dose is linearly related to the _____ but is related to approximately the square of
the _____
Answer: mAs; kVp

• What examination does the area of radiography for which high-kVp technique is widely accepted
Answer: Chest x-ray examination

• A lateral skull radiograph is obtained at 64 kVp, 80 mAs, and results in an ESD of 4 mGy (400 mR). If the tube potential is
a
increased to 74 kVp (15% increase) and the mAs is reduced by half, to 40 mAs, the optical density will remain the same.
What will be the new ESD?
Answer:

• Increasing _____ even slightly may result in images with contrast that is too low for proper interpretation by the radiologist
Answer: kVp

• Digital radiography can be conducted at _____ kVp, resulting in lower patient dose
Answer: high kVp

• With the use of collimation, not only is _____, but _____ is improved with enhanced contrast resolution because scatter
radiation also is _____
Answer: patient effective dose; image quality; reduced

• It is screen speed rather than film speed that principally controls ______
Answer: patient dose
 • What screen-film combination consistent with the nature of the examination should be used?
Answer: fastest-speed screen-film combination

Rare Earth and other fast screens should be used when possible

• _____-speed systems are used now for general radiography.

Answer: 400-speed systems

Digital radiographic (DR) image receptors are inherently faster than screen-film. Patient dose should be lower with the use of DR
because of increased speed and increased kVp accompanied by reduced mAs.

• The partial-body nature of the x-ray examination is controlled by

Answer:
• proper beam collimation
• the use of specific area shielding

• Use of _____ is indicated when a particularly sensitive tissue or organ is in or near the useful beam
Answer: specific area shielding

• What parts of the body that are frequently shielded from the primary radiation beam?
Answer:
• lens of the eye
• breasts
• gonads

• Two types of specific area shielding devices are used

• contact shield
• shadow shield

• The lens shield is what type of specific area shielding device?

Answer: contact shield

• Contact shielding device is positioned directly on the _____

Answer: patient

• Gonad shields can be what type of specific area shielding device?

Answer: Either contact shield or shadow shield

• Shields that are recommended for use during scoliosis examinations

Answer: Breast shields

• Breast shields are what type of specific area shielding device?

Answer: contact shields

• Scoliosis examinations often consist of an anterior-posterior (AP) projection, which subjects juvenile ______ to primary
beam x-irradiation
Answer: breasts

• The posterior-anterior (PA) projection is equally satisfactory because _____ is of little importance
Answer: magnification

• The PA projection results in a breast dose of only approximately ___% of the AP projection
Answer: 1%
 • Improper positioning of the shadow shield can result in a _____ examination and _____ patient dose
Answer: repeat; increased

• Shadow shield suspended above the beam-defining system casts a _____ over the gonads
Answer: shadow

• _____ shields are particularly useful during surgery for which sterile procedure is required.
Answer: Shadow shield

• The severity of the potential response to radiation exposure in utero is both _____ related and _____ related
Answer: time; dose

• The period most sensitive to radiation exposure occurs before _____

Answer: birth

• Fetus is _____ sensitive early in pregnancy than late in pregnancy

Answer: more

• The_____ the radiation dose, the more severe will be the radiation response
Answer: higher

• What is the most likely biologic response to irradiation during the first 2 weeks of pregnancy
Answer: Resorption of the embryo, and therefore no pregnancy

• The time from approximately the second week to the tenth week of pregnancy is called the
Answer: period of major organogenesis

• During organogenesis, the major organ systems of the fetus are developing. If the radiation dose is sufficiently high, what
may result?
Answer: Congenital abnormalities

• Early in organogenesis, the most likely congenital abnormalities are associated with _____ deformities
Answer: Skeletal deformities

• Later in this period, _____ deficiencies are more likely to occur

Answer: neurological deficiencies

• If a response occurs after diagnostic irradiation during the latter two trimesters, the principal response would be the
appearance of _____ disease during childhood
Answer: malignant

• If the state of pregnancy is known, then under some circumstances, the radiologic examination should ____ conducted
Answer: not be

• When a pregnant patient must be examined, the examination should be done with precisely collimated beams and carefully
positioned _____. The use of _____-kVp technique is most appropriate in such situations
Answer: protective shields; high

• What is the most direct way to institute to ensure against the irradiation of an unsuspected pregnancy?
Answer: Elective booking

This requires that the clinician, radiologist, or radiologic technologist determine the time of the patient’s previous menstrual cycle

• X-ray examinations in which the fetus is not in or near the primary beam may be allowed, but they should be accompanied by
_____ shielding
Answer: pelvic shielding