1. Staff and Patient Radiation Protection In The Cath Lab
Andrés Sinisterra
Assistant Radiation Safety Officer for Medicine

2. Radiation vs. Radioactivity
Energy in transit in the form of high speed particles and electromagnetic waves.
Ionizing Radiation
Radiation with enough energy so that during an interaction with an atom, it can remove tightly bound electrons from their orbits, causing the atom to become charged or ionized.
Radioactivity
Spontaneous transformation of an unstable atom and often results in the emission of radiation. This process is referred to as a transformation, a decay or a disintegration of an atom.

3. External vs. Internal Radiation Exposure
External Exposure – X-rays, Diagnostic Procedures.
Internal Deposition – Contamination from nuclear medicine patient undergoing a diagnostic or therapeutic procedure resulting in an ingestion of radioactive materials by the staff. + =
T E D E

4. Units of Radiation Exposure
Roentgen
Measure of electrical charge produced in air
1,000 mr = 1R
SSD ~3-10 R/min
Measure of energy absorbed, usually in tissue or bone.
200 rad = transient erythema
1 Gray = 100 Rad
Rad (Gray)

5. Units of Radiation Exposure
Rem (Sievert)
Measure of occupational risk (cancer) from radiation exposure
1,000 mrem = 1 Rem
1 Sievert = 100 Rem
1 R = 1 Rad = 1 Rem

6. A wave is a wave & nothing but a wave!

8. X-RAY SOURCE ROTOR ROTATING ANODE FILAMENT TARGET CATHODE TUBE WINDOW
EVACUATED GLASS TUBE

11. Image Quality Vs Exposure

12. Area of Interest Collimation
Calcification of the vas deferens. These bilateral asymmetric calcifications occur in the lower to middle portion of the male pelvis

15. INCIDENT X-RAY
PHOTOELECTRON
Photoelectric effect occurs when an incident x-ray is totally absorbed during the ionization of the inner-shell electron. The incident photon disappears and the k-shell electron, now called a photoelectron, is ejected from the atom.

18. Primary Beam
Scatter Radiation
Leakage Radiation
X-Ray Tube

19. Know Where Your Head Is At……!!!
Caudal

20. Coronal

22. Maximum Scatter plus Leakage
Minimum Scatter

23. Be aware of critically exposed areas
Head
and shoulders
knees
and toes !!!!!

24. 30-cm FOV
Image intensifier
70-cm
SSD
Medium conventional fluoroscopy
Setting C for fluorography
Floor kVp is 110 Dose = 50 rad
55-cm
SSD
Medium conventional fluoroscopy
Setting C for fluorography
Floor kVp is 80 Dose = 140 rad
15-cm air gap
Pail of water 28-cm deep
23-cm FOV
Image intensifier
The effects of an air gap are significant, even if the image is properly collimated
Pail of water 28-cm deep

25. Know Where Your Head Is At……!!!
The greater the distance the greater the scatter

26. Mag Mode (Field-Of-View)
The following Table illustrates the effect of changing Field-Of-View, or magnification modes, for a typical fluoroscopy system
Mag Mode (Field-Of-View)
ESE (R/min)
Increase Factor
Normal (9 inch)
1.2
1.0
Mag 1 (6 inch)
2.9
2.4
Mag 2 (4.5 inch)
5.2
4.3

27. Inverse Square Law (X-Rays & Gamma Rays)
For a point source, the intensity varies inversely as the square of the distance from the source.
Scattered X-rays
X-Ray Tube
1 cm
10,000
2 cm
2,500
5 cm
400
10 cm
100
20 cm 25
Leakage Radiation

28. Basic Radiation Safety Principles
Time
Distance
Shielding
Contamination Control

29. Radiation Exposure and Monitoring
Whole Body Radiation Badge
Worn Underneath Pb Apron
Collar Radiation Badge
Worn Outside Pb Apron At Neck Level
BLACK ICON
RED ICON
Extremity Radiation Badge
Worn on Primary Hand
Closest to Radiation Source

30. Whole Body Radiation Badge Collar Radiation Badge
Worn
Underneath
Pb Apron
Collar Radiation Badge
Worn
Outside
Pb Apron At Neck Level

31. So what’s the big deal where I put my &#@% badges ?
D’OH !
At Thyroid
~45 cm
At Breast
~30 cm

32. Get The Lead Out but Watch Your Back !!
PROTECTIVE EQUIPMENT
Get The Lead Out but Watch Your Back !!

33. As Low As Reasonably Achievable
ALARA Level I
> 10% of the maximum quarterly exposure limit (125 mrem)
ALARA Level II
> 30% of the maximum quarterly exposure limit (375 mrem)

34. ALARA Investigational Level I

36. Reducing Patient Dose During Fluoroscopy (And Yours)
Get off the pedal!! – Fluoro intermittently
Collimate and only expose clinical area
Use larger fields when possible
(Magnification increases patient dose)
Use distance of at least 30 cm for mobile units and 38 cm for fixed installations
Use appropriate mA and KVp

37. Reducing Patient Dose During Fluoroscopy (And Yours)
Remember the egg timer!!!
Be aware of the 5 minute timer (especially in high level mode)
Have sufficient beam filtration
> 90 KVp requires 2.5 mm Al to 3.5 mm 130 KVp
Fluoro only when necessary
Schedule annual QA of equipment

38. Radiation Dose
The amount of energy deposited in any substance by ionizing radiation per unit mass of the substance. It is expressed numerically in rads (traditional units) or grays (SI units).
Absorbed Dose
Dose Equivalent
Deep Dose Equivalent
Eye Dose Equivalent
Shallow Dose Equivalent
Effective Dose Equivalent
Committed Dose Equivalent
Total Effective Dose Equivalent

39. Radiation Dose
Absorbed Dose - The amount of energy deposited in any substance by ionizing radiation per unit mass of the substance. It is expressed numerically in rads (traditional units) or grays (SI units).
Dose Equivalent - The dose equivalent (H) is the product of the absorbed dose in tissue, the quality factor and all other modifying factors at the location of interest. The unit is the rem (R) or the sievert (Sv).

40. Radiation Dose
Deep Dose Equivalent (Hd) - Applies to external whole body exposure, means the dose equivalent at a tissue depth of 1 cm or greater.
Eye Dose Equivalent - The external dose equivalent to the lens of the eye at a tissue depth of 0.3 cm.
Shallow Dose Equivalent (Hg) - Applies to the external exposure of the skin or extremity. The dose equivalent at a tissue depth of cm averaged over an area of 1 cm2.

41. Radiation Dose
Committed Dose Equivalent (HE.50) - The dose equivalent (H) is a given organ or tissue that will be accumulated over 50 years following a single intake of radioactive material.
Effective Dose Equivalent (HE) - The sum of the products of the dose equivalent (HT) to each organ or tissue and the weighting factor (WT) applicable to each of the body organs or tissues that are irradiated (HE = ‡” WTHT).
Total Effective Dose Equivalent - The sum of the deep dose equivalent for external exposures and the committed effective dose equivalent for internal exposures.

42. Radiation Exposure Limits
(State of Connecticut Administrative Regulations Sect )
Type of Exposure
Rem Per Calendar Quarter
Whole body; head and trunk; active blood-forming organs; lens of eyes, or gonads.
Hands and forearms; feet and ankles.
Skin of whole body.
1.25
18.75
7.5
(1,250 mrem)
(5.0 rem/yr)
(18,750 mrem)
(75 rem/yr)
(7,500 mrem)
(30 rem/yr)
Fetus
500 mrem Total Gestation
(0.5 rem)

43. Radiation Exposure Limits
(USNRC 10CFR20 - § )
Type of Exposure
Rem Per Calendar Year
The total effective dose equivalent.
5.0
(0.05 Sv)
The sum of the deep-dose equivalent
and the committed dose equivalent to
any individual organ or tissue other
than the lens of the eye 50
(0.5 Sv)

44. Radiation Exposure Limits
(USNRC 10CFR20 - § )
Type of Exposure
Rem Per Calendar Year
An eye dose equivalent
and A shallow dose equivalent to the skin or to any extremity.
15 rem ( 0.15 Sv )
50 rem ( 0.50 Sv )
In Utero exposure to the Fetus
0.5 rem Total Gestation
(500 mrem & <50/mo)

45. Conditions For Exceeding Quarterly Doses To Whole Body
Total Dose For Any Quarter
< 3.0 rem
Total Whole Body Dose
<= 5 (N-18) rem
All Previous Whole Body Doses
Plus
N = Your Age In Years
Prior Dose Must Be On a Clear Record
! ! ! ! ALARA PROGRAM EXISTS ! ! ! !

46. Confidential Declaration of Pregnancy
NRC requires a signed declaration of pregnancy for occupational workers to limit exposures to 500 mrem/9months or 50 mrem in any one month.

47. A question of risk

48. Radiation Exposures From ?
Smoking a pack and a half of cigarettes a day will add about 1,300 mrem/year to one's effective dose
Flying from New York to London results in the absorption of an extra
2-3 mrem of cosmic radiation
6-8 mrem from NY to Japan

49. Risks which Increase Chance of Death by 1 in 1 million a
a B.L. Cohen and I.S. Lee, “Catalog of Risks Extended and Updated”, Health Physics, Vol. 61, Sept

50. Estimated Loss of Life Expectancy from Health Risks
Health Risk Average Days of Life Expectancy Lost
Smoking 20 cigarettes/day (6.5 years)
Overweight (by 20%) (2.7 years)
All accidents combined (1.2 years)
Auto accidents
Alcohol consumption
Home accidents
Drowning
Natural background radiation 8
Medical diagnostic x-rays 6
All catastrophes (fire, flood, etc.) 3.5
1,000 mrem (1 rem) occupational radiation dose 1
1,000 mrem (1 rem)/yr for 30 years 30
Note: Average U.S. occupational radiation dose is estimated at rem/year.

51. PROGRAM FOR IMPLEMENTING PATIENT INFORMED CONSENT
AND
FOLLOW UP REGARDING HIGH DOSE SPECIAL
X-RAY PROCEDURES

52. Purpose:
There are certain x-ray guided procedures that could result in the delivery of a radiation dose to an area of a patient’s skin of sufficient magnitude to produce clinical symptoms.
This program was developed to inform patients of this potential risk prior to such procedures, determine if a procedure may lead to a large skin dose and to follow up with the patient if there is a possibility of a skin reaction.

53. Policy:
This program is applicable to following x-ray guided procedures:
Percutaneous Transluminal Angioplasty
Radiofrequency Cardiac Catheter Ablation
Vascular Embolization
Stent and Filter Placement
Thrombolytic & Fibrinolytic Procedures
Percutaneous Transhepatic Cholangiography and/or Biliary Drainage

54. Policy (continued): Endoscopic Retrograde Cholangiopancreatography
Transjugular Intrahepatic Portosystemic Shunt
Percutaneous Nephrostomy
Urinary/Biliary Stone Removal Or
Any other x-ray guided procedure that could
expose the same area of the skin for more
than 30 minutes

55. Policy (continued):
For such cases, the patient must be informed in writing prior to the procedure of the risks associated with large x-ray skin doses.
Appropriate follow up must be made, if after completion of a procedure, a large skin dose is possible.

56. Policy (continued):
Connective tissue diseases (e.g. scleroderma, lupus erythematosus, mixed connective tissue disease), diabetes mellitus, hyperthyroidism and the homozygous form of ataxia telangiectasia have been associated with an increased sensitivity to radiation.  Some chemotherapy agents are also known to increase radiation effects. 
To avoid injuries when using an oblique or lateral beam projection, the patient's arm must be secured away from the primary beam.  Direct exposure of the female breast, especially entrance-beam exposure, must also be avoided.

59. Radiation Biology

60. Radiosensitivity of Cells 1
As cells mature they become less sensitive to radiation
As metabolic rate increases cells become more sensitive to radiation
As reproductive rate increases cells become more sensitive to radiation
Cell types that are most sensitive to radiation include lymphocytes and stem cells
Cell types that are least sensitive to radiation include muscle and ganglion cells
1 Adapted from The 1906 Law of Bergonie and Tribondeau

61. Various degrees of sensitivity to radiation exist due to the type of tissue which receives the exposure
Radiosensitive
Radioresistant
Breast tissue
Heart tissue
Bone marrow cells
Large arteries
Mucosa lining of small intestines
Large veins
Sebaceous (fat) glands of skin
Mature blood cells
Immune response cells
Neurons
All stem cell populations
Muscle cells
Lymphocytes

62. Radiation Induced Skin Injuries
SKIN EFFECT
Single-Dose Threshold rad (Gy)
Time to Onset
Early transient erythema
200 (2)
Hours
Main Erythema
600 (6)
~10 d
Temporary epilation
300 (3)
~3 wk
Permanent epilation
700 (7)
Dry desquamation
1400 (14)
~4 wk
Moist desquamation
1800 (18)
Secondary ulceration
2400 (24)
>6 wk
Late erythema
1500 (15)
~6 – 10 wk
Ischemic dermal necrosis
>10 wk
Dermal atrophy (1st phase)
1000 (10)
>14 wk
Dermal atrophy (2nd phase)
>1 yr
Induration (Invasive Fibrosis)
Telangiectasia
d: day(s); wk: week(s); yr: year(s)

63. Stochastic Effects (by chance)
Health effects that occur randomly. Effects that occur by chance, generally occurring without a threshold level of dose, whose probability is proportional to the dose and whose severity is independent of the dose. .
(examples: cancer incidence and genetic effects)

64. Stochastic Effects (by chance)
1,000,000 persons buy a lottery ticket for $1,00 each.
999,999 persons will not get the large prize. Only one will win the BIG ONE.
Return on scratch tickets is not certain.

65. Nonstochastic (Deterministic) Effects
Health effects that can be induced upon reaching an apparent threshold, and their severity varies with the radiation dose.
examples:
cataract in the lens of the eye, non- malignant damage to the skin

66. Nonstochastic (Deterministic) Effects
100 persons invest $1,000 at 5% interest
Each person will receive $1,050.00
Return is certain

67. So....., how really dangerous is this so called “RADIATION??”

68. Radiation Injuries - Cases

69. Industrial Radiation Accident

70. An example of a skin injury attributable to x-rays from fluoroscopy is shown in Figure 2.
This case, patient A in Table 2, is that of a 40-year-old male who underwent coronary angiography, coronary angioplasty and a second angiography procedure due to complications, followed by a coronary artery by-pass graft, all on March 29, 1990.
Source:
Thomas B. Shope, Ph.D. (HFZ-140) FDA/Center for Devices and Radiological Health

71. Figure 2(a).
Condition of patient's back six to eight weeks following multiple coronary angiography and angioplasty procedures
Source:
Thomas B. Shope, Ph.D. (HFZ-140) FDA/Center for Devices and Radiological Health

72. Figure 2(b).
Appearance of skin injury approximately 16 to 21 weeks following the procedures with small ulcerated area present.
Source:
Thomas B. Shope, Ph.D. (HFZ-140) FDA/Center for Devices and Radiological Health

73. Figure 2(c).
Appearance of skin injury approximately 18 to 21 months following procedures, evidencing tissue necrosis.
Source:
Thomas B. Shope, Ph.D. (HFZ-140) FDA/Center for Devices and Radiological Health

74. Close-up view of lesion shown in 2(c).
Figure 2(d).
Close-up view of lesion shown in 2(c).
Source:
Thomas B. Shope, Ph.D. (HFZ-140) FDA/Center for Devices and Radiological Health

75. Appearance of patient's back following skin grafting procedure.
Figure 2(e).
Appearance of patient's back following skin grafting procedure.
Source:
Thomas B. Shope, Ph.D. (HFZ-140) FDA/Center for Devices and Radiological Health

76. Transjugular Intrahepatic Portosystemic Shunt
6 month
23 month
10 month
22 month
This patient received 3 TIPS procedures within a week
7.5 month
Source:
Koening, Wagner, et al., University of Texas Health Science Center

77. Radiofrequency Cardiac Catheter Ablation
Tissue necrosis 5 months after procedure, and deep ulceration with exposure of the humerus at 6.5 months
Source:
Koening, Wagner, et al., University of Texas Health Science Center

78. Radiation-sensitive patients
Both patients with Discoid Lupus Erythematosis received skin doses believed insufficient to cause such effects in normal skin.
Reproduced with permission from Gironet et al, 1998, Ann Dermatol Venerol, 125,
Reproduced with permission from Wagner et al, 1999, Radiology, 213,
Courtesy of IAEA
In right photo, G = graft, R = rib

79. Lessons from injured patients
Case #1:Electrophysiological and ablation procedure
Three attempts in 4 months, each with more than 100 minutes of fluoroscopy.
After first attempt erythema observed by patient, but not recognized as due to procedure.
Erythemas on back healed. Arm lesion required grafting.
Material used here previously copyrighted by Louis K Wagner 2004 or Partners in Radiation Management LTD Company 2004 and used here by permission.
Courtesy of IAEA

80. Lessons from injured patients
If cause of initial erythemas was correctly identified, injury would likely have been avoided because failures of initial ablations would not have been blamed on faulty equipment.
Erythemas on back healed. Arm lesion required grafting.
Material used here previously copyrighted by Louis K Wagner 2004 or Partners in Radiation Management LTD Company 2004 and used here by permission.
Courtesy of IAEA

81. Lessons from injured patients
Case #2:
PTCA and stent placement of RCA. Involved 63 minutes of fluoroscopy and nearly 5000 frames of cine in LAO orientation with cranial tilt.
Lesion required grafting.
Material used here previously copyrighted by Louis K Wagner 2004 or Partners in Radiation Management LTD Company 2004 and used here by permission.
Courtesy of IAEA

82. Lessons from injured patients
Case #2:
Dose buildup due to long fluoroscopy and fluorography with steep angle through thick chested patient not recognized
Lesion required grafting.
Material used here previously copyrighted by Louis K Wagner 2004 or Partners in Radiation Management LTD Company 2004 and used here by permission.
Courtesy of IAEA

83. Lessons from injured patients
Case #2:
Cause of injury initially misidentified as pressure wound due to defibrillator pad.
Lesion required grafting.
Material used here previously copyrighted by Louis K Wagner 2004 or Partners in Radiation Management LTD Company 2004 and used here by permission.

84. Lessons from injured patients
Case #3:
PTCA : 51 minutes high-dose fluoroscopy, 74 seconds cine in 141 kg man. Dose estimated retrospectively at 22 Gy.
Lesion required grafting.
Courtesy of IAEA

85. Lessons from injured patients
Case #3:
Cumulative buildup of dose for steeply angled high-dose beam through large patient not recognized
Lesion required grafting.
Courtesy of IAEA

86. If you use too much radiation … you will get your ass in trouble
RULE 1
Courtesy of IAEA

87. Excess radiation can sneak up on you and catch you unaware RULE 2
A fluoroscope can be
a dangerous beast
Courtesy of IAEA

88. Use all protective measures at your disposal to minimize risk
Rule 3
Use all protective measures at your disposal to minimize risk

89. The End