Harbor:STAT MRI

Ordering

• The decision to order a STAT MRI will be made after discussion with an attending physician AND for which MRI results will alter the current treatment plan (including admit vs discharge decisions - Drs. Lewis, Mahajan, & Munn 4/2018); external services may be consulted, but their "permission" is not necessary to order the study
• Once the MRI is ordered

1. Call the MRI building 212-5939 from 7a-7p, Monday to Friday; Rosalinda on-site manager
2. After hours, contact the MRI tech at 218.2379 (rings 6x, VM has back-up numbers)

• • Expected response time is 1 hour from contact to arrival (Trauma Criteria - CD 11-46, ACS COT VRC)

• The tech will need the following information from the ED attending:
  • Patient's name, MRUN, DOB, the type of MRI (you may want to discuss with the radiology resident to ensure the optimal type of scan +/- if contrast is needed), and suspected diagnosis
  • Does the patient have a pacemaker?
  • Past surgical history
  • Does the patient have any electronic implants?
  • Does the patient have any retained metallic fragments in the eyes (or anywhere else)?
  • Are the patient labs (creatinine) in the computer?
  • Patient's weight for dosing purposes
• The patient's nurse should complete the MRI safety form: https://emedharbor.labiomed.org/private/Contact%20Info/ED%20Documents/HUCLA%20Safety%20Screening%20Form%20English%20and%20Spanish%2011-2018.pdf

• Policy 367B: Priority for the portable MRI will be given to the following groups of patients:

1. Emergency Department patients
2. Acute Trauma or ICU patients
3. Any Pediatric or Adult patient (including outpatients) requiring sedation or Anesthesiology support for monitoring or provision of sedation
4. Inpatients with potentially treatable neurological or neurosurgical emergencies

• WITH one of the following documented indications:

1. Acute spinal cord injury
2. Suspected spinal instability
3. Suspected spinal compression or ischemia
4. Concern for epidural abscess or discitis
5. Suspected acute/subacute myelopathy or focal neurological deficit
6. Concern for acute/subacute cauda equina/conus medullaris syndrome
7. Acute stroke symptoms with non-diagnostic head CT
8. Suspected meningitis, encephalitis, or CNS vasculitis
9. Concern for CNS tumor or abscess with acute change in neurological status
10. Evaluation for cerebral hemorrhage
11. Emergent arterial imaging (aortic dissection, aneurysm leak, etc.) when contraindication to IV CT contrast
12. Pregnant female with equivocal physical examination and ultrasound for appendicitis
13. Urgent Magnetic Resonance Cholangiopancreatopgraphy (MRCP)
14. Assessment of VP shunt malfunction

• Limitations:
  • 350 lb weight limit
  • 15 inches high, 21 inches wide
  • MRI lift 1000 lbs total for gurney, staff, equipment, etc.

Transport to MRI (Policy 367B)

• • Mobile Unit
    • CODE BLUE
      • Hospital gurney will be left on the lift while patient is getting scanned if ambulatory patient and they will be transferred from MRI table to gurney for transport to ED
      • If critical/ICU patient, gurney will not stay on the lift during the scan; in case of code, the MRI table will be used to transport the patient to the ED
      • CODE BLUE Team should receive the patient at the loading dock, move patient to the ED, and ED team assists with resuscitation
      • Move to trauma bay for resuscitation and use paper code sheet, quick reg all patients (outpatient, inpatient)
      • Patients who are admitted as inpatient and in an inpatient bed will be re-registered using the same MRN and an ED FIN will be created. The inpatient FIN will stay active and the ED FIN will be used for the stay in the ED and discharged when the patient is stable enough for transfer and the inpatient FIN will be used when the patient returns upstairs.
    • TRANSPORT
      • Ambulatory patients may be taken to MRI via wheelchair or gurney
      • Need for physician accompaniment determined by R2 and above (discuss with ED Attending)
      • R1 or above to assure maintenance of spinal precautions at times of transport only; need not stay during entire study
      • RN will assist with transport of adult patients to MRI but only needs to be present during MRI if sedation is occurring
      • RN will remain with ALL pediatric patients during the entirety of the MRI regardless of need for sedation
      • ED Physician proximity in the AED meets the requirement for physician presence during the administration of IV contrast
    • SEDATION
      • Anxiolysis to be provided by anesthesia (attending, resident, or CRNA)- Anesthesia attending must be present for pediatric sedations
        • Place order in ORCHID “Request for Out of OR Anesthesia”; if issues, call Operating Room Scheduling Center at x6439 during regular hours and OR Front Desk x2797 after-hours
        • Anesthesiologist running the board Spectralink x23337 can also assist
        • Assessment by anesthesia will occur in the ED room as well as post-MRI sedation monitoring/recovery
        • Sedation is defined as IV pushes, and excludes IV drips maintained at a stable rate or oral anxiolytics(Policy 367b, Section IV)
      • If patient is unstable, must be accompanied by physician (R2 and above) AND nurse

American College of Radiology Appropriateness Criteria for MRI

numbers below in parenthesis - ranked 0-10, with 10 most appropriate study

• Emergent (to Portable MRI Trailer)
  • Neurology
    • Stroke within therapeutic window with negative head CT (9)
      • MRI brain w/o contrast
      • Consider MRA
    • Vertigo with concern for posterior fossa infarct (9)
      • MRI brain w/o contrast
    • New myelopathy or plexopathy (9)
      • MRI spine w/o contrast
    • Venous sinus thrombosis (if CT Venogram is contra-indicated); (9)
      • MRV brain with and w/o contrast
  • Trauma
    • Traumatic cord injury/cord syndrome (9)
      • MRI spine w/o contrast
    • Spinal cord compression/ischemia
      • MRI spine w/o contrast
  • Neurosurgery
    • Cauda Equina Syndrome or suspected spinal tumor with motor loss (9)
      • MRI spine w/o contrast
      • MRI spine with contrast if infection suspected
    • Epidural abscess/hematoma or discitis (8)
      • MRI spine with and w/o contrast
    • Non-traumatic SAH with contra-indication to IV contrast to assess for aneurysm (8)
      • MRI brain w/o contrast + MRA brain w/o contrast (8)
    • Intracranial AVM with intraparenchymal hemorrhage (when CTA contra-indicated)
      • MRI brain with and w/o contrast + MRA brain w/o contrast
    • Concern for subdural empyema/intracranial abscess (8)
      •  MRI brain with and w/o contrast
    • Brain tumor with acute change in mental status (8)
      • MRI with and w/o contrast
    • Spinal tumor with acute change in neurological status
      • MRI with and w/o contrast
  • Surgery
    • Emergent arterial imaging with contra-indication to IV contrast (carotid, vertebral, or aortic dissections/aneurismal leaks); (8)
    • MRA head and neck with and w/o contrast
  • Pediatrics
    • Assessment of VP Shunt malfunction
      • MRI brain w/o contrast (T1/T2)
• Urgent (to Portable MRI trailer)
  • Neuro
    • Suspected meningitis/encephalitis (unable to perform LP); (8)
    • MRI brain with and w/o contrast
  • Trauma
    • Spinal instability due to ligamentous injury (9)
      • MRI spine w/o contrast
    • Concern for spinal fracture with equivocal CT (9)
      • MRI spine w/o contrast
    • Suspicion of diffuse axonal injury (8)
      • MRI brain w/o contrast
  • Neurosurgery
    • CT equivocal for intracranial hemorrhage
      • MRI brain w/o contrast
    • Post-op intracranial surgery to evaluate for abscess
      • MRI brain with and w/o contrast
    • Concern for posterior fossa mass (8)
      • MRI brain with and w/o contrast
  • Surgery
    • Pregnant female with equivocal exam/US for appendicitis (vs. enroll in CODA/empiric antibiotic treatment); (7)
      • MRI Abdomen/pelvis w/o contrast
  • Pediatrics
    • Concern for Septic Hip/Joint (7)
      • MRI pelvic w/o contrast
  • GI
    • MRCP
  • Pulmonology
    • PE in pregnancy (if CTA or VQ contra-indicated or not feasible); (3)
    • MRA chest with and w/o contrast
  • OB
    • Stable patients with equivocal US/HCG where outpatient evaluation is not feasible (extenuating circumstances) or concern for ctopic/heterotopic pregnancy
      • MRI pelvis w/o contrast
• Urgent (to MRI building)
  • Neurology
    • Stroke outside therapeutic window (8)
      • MRI brain w/o contrast
    • Opthalmoplegia (9)
      • MRI brain and orbits with and w/o contrast
    • Concern for Multiple Sclerosis (8)
      • MRI brain/spine with and w/o contrast
  • Neurosurgery
    • Concern for pituitary apoplexy (8)
      • MRI brain with and w/o contrast with multiplanar thin sellar imaging
    • Post-op brain tumor to evaluate for residual tumor
      • MRI brain with and w/o contrast
    • Spinal compression fractures (7)
    • MRI spine w/o contrast
  • Ortho
    • Osteomyelitis (9)
      • MRI with and w/o contrast
    • Concern for hip fracture with negative CT (9)
      •  MRI w/o contrast
    • Septic arthritis (unable to perform arthrocentesis)
      • MRI with and w/o contrast (T1/T2)
  • Pediatrics
    • Slowly progressive vision loss (8)
      • MRI brain and orbits with and w/o contrast
  • Medicine
    • Evaluate for brain metastasis with equivocal CT (9)
      • MRI brain with and w/o contrast
    • Concern for Primary CNS lymphoma (9)
      • MRI brain with and w/o contrast
    • Concern for opportunistic CNS infection (9)
      • MRI brain with and w/o contrast
• Outpatient (to MRI building)
  • Any stable patient not requiring sedation
  • All outpatient imaging orders
  • Ortho
    • Ligamentous injuries of the extremities
      • MRI w/o contrast

Chappell, Wu, 2/2017