Chapter 20
Mobile Bedside Radiography Overview & Specific Hospital Units
Definition & Indication:
Mobile radiography (bedside imaging) is performed on patients who cannot be transported to the main imaging department due to serious injury, illness, or medical condition.
Common operational areas include the Emergency Room (ER), Operating Room (OR), Intensive Care Unit (ICU), Neonatal Intensive Care Unit (NICU), Pediatric Intensive Care Unit (PED/PICU), Post Anesthesia Care Unit (PACU), and individual patient rooms.
Post Anesthesia Care Unit (PACU / PAR):
Also known as Post Anesthesia Recovery (PAR).
Typically located adjacent to the surgical suite.
Special surgical dress is usually not required for radiographers entering this area.
Patients are often not fully responsive and may be connected to ventilators, supplemental oxygen, central venous catheters, and bodily drainage tubes.
Patients are routinely cold due to anesthesia and medication effects; keep them covered.
Common mobile examinations include chest radiographs to evaluate for pneumothorax and verify line placements, as well as bone radiographs to check alignment and artificial joint replacements.
Intensive Care Unit (ICU) & Coronary Care Unit (CCU):
Houses critical patients requiring continuous monitoring of heart rate, cardiac output, blood pressure (via arterial lines), and body temperature.
Chest and abdomen radiographs are most commonly ordered; C-arm fluoroscopy units are occasionally utilized.
Technologist challenges include managing personal anxiety when confronting near-death situations and navigating an assortment of life-sustaining equipment.
Workflow protocol:
Confer with the patient's nurse before beginning any procedure to check limits of movement (e.g., whether the head of the bed can be raised).
Assess the patient and prepare the room before wheeling the mobile X-ray unit inside due to equipment crowding.
Monitoring system precautions:
Monitors utilize visual and auditory signals that can be triggered by patient movement (indicating rapid breathing, line/tube dislodgement, or ventilator disconnection).
If an activated alarm does not terminate within , immediately alert the nurse.
Exercise extreme care with lines and tubes when sliding the Image Receptor (IR) under the patient.
Communication and safety:
Many patients are unresponsive; never assume a patient cannot hear. Always speak directly to the patient as if they are fully conscious.
Warn all room occupants prior to taking an X-ray exposure so non-essential personnel can exit or put on protective lead aprons.
Neonatal Intensive Care Unit (NICU) & Pediatrics (PED / PICU):
Pediatric and neonatal patients require frequent radiographs for respiratory distress syndrome, atelectasis, congenital anomalies, and verification of line/tube placements.
Pediatric patients are extremely radiosensitive; strictly adhere to ALARA principles and precise collimation.
Housing equipment:
Neonates (newborns) are placed in open incubators under radiant warmers or in enclosed incubators/isolettes.
Enclosed isolettes are used more frequently because they provide controlled warmth, moisture, and oxygen while reducing exposure to airborne infections. Keep isolettes closed as much as possible.
Infection control protocol:
Protect patients from acquiring nosocomial infections.
Thoroughly disinfect the mobile unit before entering the unit.
Perform a surgical hand scrub/washing and don a protective gown.
Imaging Technique:
Exposures are made either with the IR placed directly under the infant or via a sliding tray located under the bed; use the sliding tray whenever possible.
Provide lead shielding for neonates and lead aprons for assisting nurses.
Maintain a quiet environment and drive mobile units carefully to avoid colliding with personnel, equipment, or isolettes.
General Patient Interactions & Psychological Considerations
Standard Patient Identification & Preparation Protocol:
Always greet the patient and introduce yourself.
Verify patient identity using two identifiers by checking the wrist band: full name and birthdate.
Inspect and arrange the room prior to bringing equipment to the bedside.
Ask family members to step out of the room during the procedure.
Provide lead aprons to any staff members or individuals remaining inside the room.
The 5 Stages of Grief (DABDA):
Denial: Refusal to accept the reality of the situation or diagnosis.
Anger: Frustration and resentment directed inward or outward.
Bargaining: Attempting to negotiate for more time or a altered outcome.
Depression: Feeling overwhelming sadness, loss, and despair.
Acceptance: Coming to terms with the reality of the condition or loss.
Management of Special Patient Populations:
Intoxicated Patients:
Keep communication simple, concise, and direct.
Do not argue with the patient.
Do not leave the patient unattended.
Obtain additional staff assistance if required.
Agitated or Confused Patients:
Commonly encountered in the ER or mental health units; triggered by alcohol, illicit drugs, or psychotic illness.
If the patient becomes combative, call for immediate assistance (e.g., Code Man / Code ).
Approach the patient from the side rather than face-to-face.
Explain every action clearly before touching the patient.
If the patient refuses the procedure, stop and notify the nurse.
Trauma Care & Emergency Principles
Trauma Overview:
Trauma is the leading cause of death among all individuals under the age of \text{ years}.
Common mechanisms of injury include assaults (beatings, stabbings, gunshot wounds), Motor Vehicle Accidents/Collisions (MVA/MVC), pedestrian accidents, motorcycle accidents, falls from heights, blunt trauma, choking, industrial accidents, suicides, drowning, smoke inhalation, and sports injuries.
Typical Emergency Trauma Team Members:
ER Physician
General Surgeon
\text{ or more} ER Nurses
Radiologic Technologist
Respiratory Therapist
Phlebotomist
Anesthesiologist
Admitting Clerk
House Supervisor
Basic Rules for Trauma Radiography:
Assess the situation quickly and develop a clear action plan.
Determine patient mobility and explain the procedure thoroughly to the patient.
Predetermine and gather all necessary equipment and accessories before starting (lead aprons, grids, IR markers).
Obtain at least two projections taken at angles to each other for every body part examined.
Ensure Central Ray (CR) and Image Receptor (IR) alignment are precise and closely match routine positioning by adapting angles to the patient's condition.
Include all relevant anatomy of interest on the radiograph.
For long bone radiography, include the joint nearest the injury site and, if possible, the joint farthest from the trauma.
Provide protective lead apparel for any personnel assisting with patient care in the exposure room.
General Guidelines for Handling Traumatic Injuries:
MOST IMPORTANT RULE: DO NO ADDITIONAL HARM TO THE PATIENT!
Never remove dressings, splints, or immobilization devices without explicit physician orders.
Do not move patients who arrive on stretchers or backboards until instructed to do so by a physician.
If a patient is wearing a cervical collar (C-collar), never move the head or neck, and never remove the collar until the cervical spine has been cleared by a physician. Assume a spinal injury exists until proven otherwise.
Request assistance to maintain an adequate number of staff for safe patient transfers.
Do not disturb impaled objects; stabilize and support them so they do not shift during image acquisition.
Do not remove pneumatic antishock garments.
Keep oxygen equipment, suction devices, and emesis basins accessible and ready for immediate use.
Work quickly, efficiently, and accurately to minimize examination time.
Traumatic Specific Injuries & Clinical Signs
Head Injuries:
Always assume a concurrent cervical spine injury exists when evaluating head injuries.
Open Head Injury: Injury causing a break or penetration in the skull or meninges. The brain is rendered vulnerable to structural damage and infection due to the disruption of its protective casing.
Closed Head Injury: Blunt force trauma where brain swelling occurs within the intact skull; increased intracranial pressure can cause extensive brain tissue damage.
Basal Skull Fractures: Fractures occurring at the base of the skull, frequently accompanied by facial bone fractures. Can tear the dura mater (the outermost membrane lining the brain and spinal cord), causing cerebrospinal fluid (CSF) leakage.
Signs & Symptoms of Closed Head Injury: Varying levels of consciousness, loss of reflexes, periods of lucidity followed by unconsciousness (lucidity refers to clearness of mind, rationality, and good sense), altered vital signs, headache, dizziness, giddiness, gait abnormalities, unequal pupil dilation, seizures, vomiting, and hemiparesis (paralysis affecting one side of the body).
Signs & Symptoms of Open Head Injury: Abrasions, contusions, or lacerations of the scalp; observable break or penetration in the skull/meninges; CSF leakage from the nose (rhinorrhea), ears (otorrhea), or as a postnasal drip; presence of the "Halo sign" (a ring of blood on a sheet or dressing surrounded by a yellowish stain indicating CSF leakage); altered consciousness; hearing loss; periorbital ecchymosis ("raccoon's eyes"); facial nerve palsy.
Facial Injuries:
Assume concurrent skull and cervical spine injuries are present.
Signs & Symptoms: Facial misalignment, localized pain, ecchymosis of the floor of the mouth (oozing of blood from damaged vessels into subcutaneous tissue forming a discolored area), inability to close the jaw, edema, abnormal face/jaw movement, nosebleeds (epistaxis), paresthesia (abnormal sensations such as burning, itching, tickling, or tingling), presence of the "Halo" sign (indicating basal skull fracture with CSF leak), and potential respiratory distress in unconscious patients.
Spinal Cord Injuries:
Handling: Always use the Log Roll technique during positioning to maintain strict straight-line alignment of the head, neck, and torso.
Complete Transection of the Spinal Cord:
Flaccid paralysis.
Complete loss of all sensation below the level of injury.
Absence of visceral sensations below the level of injury.
Inability to perspire (sweat) below the level of injury.
Bowel and bladder incontinence.
Partial Transection of the Spinal Cord:
Asymmetrical flaccid paralysis below the level of injury.
Asymmetrical loss of tendon reflexes.
Retention of some sensation (such as pain, temperature, pressure, and touch).
More stable blood pressure control.
Retention of some visceral sensations.
Ability to perspire remains intact unilaterally (on one side).
Possible priapism (abnormal, sustained erections) in male patients.
Spinal Injury Terminology:
Paraplegia: Paralysis affecting the lower portion of the body and both lower extremities.
Hemi Paraplegia: Paralysis affecting the lower half of one side of the body or one lower extremity.
Quadriplegia: Paralysis affecting all four extremities and usually the trunk. Higher injury levels correspond to greater loss of arm function. Injuries above require a mechanical ventilator to sustain life due to spinal canal damage disrupting respiratory control.
Flaccid Paralysis: Paralysis characterized by a complete loss of muscle tone, absence or reduction of deep tendon reflexes, muscle atrophy, and tissue degeneration.
Fractures, Cast Care, Orthopedic Traction, & Abdominal Emergencies
Fractures:
Classification: Open (compound, skin broken) or Closed (simple, skin intact).
Clinical Signs: Severe localized pain, swelling, complete or partial functional loss, physical deformity of the limb, grating sound or sensation during movement (crepitus), discoloration of surrounding cutaneous tissue (closed fractures), excessive external bleeding (open fractures), and potential signs/symptoms of circulatory shock.
Handling Guidelines: Support the injured body part at both ends (proximal and distal to the fracture site) with extreme care when moving. Rib fractures carry a high risk of causing pneumothorax or hemothorax.
Cast Care & Monitoring:
Handling: Never grasp a wet or dry cast with fingers; slide opened, flattened hands underneath to support it. Always support the cast at both adjacent joints.
Circulation and Nerve Compression Assessment: Assess distal extremities every for:
Pain: Sudden or worsening pain may signal nerve damage or tissue ischemia.
Coldness: Distal digits (fingers or toes) should feel warm to the touch.
Numbness: Indicates the cast is excessively tight; sign of nerve compression.
Burning or Tingling: Signifies circulatory impairment or nerve pressure.
Swelling (Edema): Can restrict flow within the cast, compounding nerve compression and circulatory deficits.
Skin Color Changes: Skin must remain pink and warm; pale or cyanotic (blue) skin indicates vascular compromise.
Motor & Vascular Loss: Inability to move digits, or diminished/absent arterial pulses.
Orthopedic Traction:
Definition: A mechanical system utilizing suspended weights to provide continuous, constant traction (pulling force) on a specific part of the body.
Current Clinical Usage: Typically utilized temporarily until muscle spasms subside and definitive surgical bone repair can be completed.
Technologist Rules: NEVER release, remove, alter, or bump traction weights or apparatus.
Acute Abdominal Distress:
Etiology: Internal hemorrhage, acute appendicitis, bleeding peptic ulcers, ectopic pregnancy, cholecystitis, pancreatitis, or mechanical bowel obstruction.
Clinical Symptoms: Severe abdominal pain, superficial abrasions or lacerations, rigid or board-like abdomen, intense nausea, vomiting, and extreme thirst.
Imaging & Management Protocols:
Perform required radiographs efficiently and rapidly with minimal patient movement (patients are frequently routed directly to the OR).
Transport patients exclusively by cart.
If the patient cannot tolerate standing for upright films, employ horizontal beam decubitus projections.
Request assistance if the patient is too ill to assist with repositioning.
Keep an emesis basin immediately at hand.
Do NOT give the patient anything to eat or drink (NPO).
Continuously observe for systemic signs and symptoms of shock.
Specialized Equipment, Tubes, Lines, & Drains
Special Beds, Mattresses, and Thermal Care:
Immobile patients or those with severe circulatory impairments may be placed on specialized beds (e.g., air, sand, rocking, wave floatation, or bead mattresses).
Imaging Rule: Beds featuring rocking motions or alternating pressure waves MUST be turned off during X-ray exposures to prevent motion blurriness. Consult the nursing staff if unfamiliar with bed controls.
Thermal Equipment: Mylar warming or cooling blankets/pads require placing the X-ray cassette between the patient and the Mylar pad. "Bair Hugger" blanket warmers allow radiographs to be taken directly through them without removal.
Patient Monitoring & Best Practices:
Observe patient physical status prior to procedure initiation; reassess vital signs and condition every .
Promptly notify the emergency team/physician of any acute physical changes.
Trauma patients must NEVER be left unattended under any circumstances.
Best Practices (ASRT Guidelines):
Immobilization: Maintain immobilizers until ordered removed by a physician; apply proper stabilization to prevent motion artifacts.
Anticipation: Prepare for follow-up views based on initial findings.
Attention to Detail: Closely monitor fluctuating clinical status.
Scope of Practice: Adhere strictly to institutional trauma protocols and the ASRT Code of Ethics.
Radiation Protection: Maximize distance, utilize optimal shielding, and minimize exposure time.
Chest Tubes & Water-Sealed Drainage Systems:
Indication: Used to treat pneumothorax (air in pleural space), hemothorax (blood in pleural space), or pleural effusion (fluid accumulation). The drainage system re-establishes normal negative intrapleural pressure, allowing the lung to re-expand.
System Management:
Chest tubes (CT) connect directly to a water-seal drainage system (e.g., ATRU).
Keep the water-seal unit below the level of the patient's chest at all times.
Verify with the nurse whether the patient can be temporarily disconnected from suction for imaging.
Precautions & Monitoring:
Inspect tubing regularly for kinks; verify all connection points are secure.
Keep sterile chest tube dressings and tape readily accessible at the bedside in case of accidental dislodgement.
DO NOT clamp the chest tube.
Do not pull, tension, or jerk the tubing.
Monitor the patient continuously for tachypnea, cyanosis, shortness of breath (SOB), chest pressure, and continuous bubbling in the water-seal chamber (which signals a system air leak).
Tissue Drains:
Indication: Inserted at or near surgical wound/operative sites when large volumes of fluid drainage are anticipated.
Management: Apply strict aseptic precautions to prevent infection and avoid accidental drain dislodgement.
Types:
Penrose Drain: Soft, pliable rubber tube that drains directly onto an external surgical dressing.
Jackson-Pratt (JP) & Hemovac Drains: Plastic drainage tubes connected to closed, flexible suction containers that maintain low negative pressure.
Nasogastric (NG) & Nasoenteric (NE) Tubes:
Composition: Made of polyurethane, silicone, or flexible rubber.
Insertion Route: Passed through the nasopharynx or oral cavity into the stomach, duodenum, or jejunum.
Clinical Uses: Diagnostic studies, administration of enteral nutrition/medications, and therapeutic decompression/treatment of gastrointestinal obstruction or bleeding.
Precautions:
Tube placement must be verified (radiographically or via institutional protocol) prior to administering feedings, medications, or contrast media.
Confirm suction can be safely interrupted before transferring a patient on active NG suction.
Tube Classifications & Names:
Dobbhoff: Nasogastric (NG) enteral feeding tube.
Frederick Miller, Miller-Abbott, Harris, Cantor: Nasoenteric/Nasojejunal (NE/NJ) tubes.
Levin & Salem-Sump: Decompression and suction tubes.
Gastrostomy Tube (G-Tube):
Definition: Surgical creation of a direct external opening into the stomach cavity.
Purpose: Long-term enteral feeding and medication administration.
Care: Exercise care during positioning to avoid tension or dislodgement of the site.
Central Venous Catheters (CVC):
Clinical Uses: Intravenous medication administration, chemotherapy, blood transfusions, total parenteral nutrition (TPN), and long-term vascular access.
Specific Types: Hickman, Trifusion, Port-a-cath, PICC (Peripherally Inserted Central Catheter), and Groshong.
Care: Maintain strict sterile precautions to prevent systemic infections and guard against catheter dislodgement.
Pacemakers:
Definition: An electromechanical device implanted to regulate cardiac rhythm by delivering controlled electrical pulses to the heart muscle, replacing natural nerve conduction impulses.
Components: Includes a pulse generator and electrical leads routed directly into the heart chambers.
Tracheostomy:
Definition: A surgically created opening in the anterior trachea to establish an open airway; may be temporary or permanent.
Care Guidelines:
Patients with newly created tracheostomies are unable to speak.
A nurse must accompany tracheostomy patients during transport and imaging procedures.
Ensure operational suction equipment and oxygen sources are immediately available at the bedside.
NEVER loosen or undo the ties holding the tracheostomy tube in place.
Mechanical Ventilation & Endotracheal (ET) Tubes:
Airway Access: Ventilated patients possess either an Endotracheal (ET) tube or a tracheostomy.
Protocol: The nurse must remain at the bedside during mobile imaging procedures. Exercise extreme caution to avoid dislodging the tube.
Imaging Frequency: Daily portable chest radiographs (CXR) are routinely ordered to verify correct ET tube tip positioning above the carina.