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+# Standard Operating Procedure: CT Imaging Protocol
+
+| Document ID | SOP-RAD-001 |
+|-------------|-------------|
+| Title | Computed Tomography (CT) Imaging Protocol |
+| Revision | 1.0 |
+| Effective Date | [DATE] |
+| Author | [AUTHOR] |
+| Approved By | [APPROVER] |
+| Department | Radiology/Diagnostic Imaging |
+
+---
+
+## 1. Purpose
+
+To establish standardized procedures for performing computed tomography (CT) examinations to ensure patient safety, optimal image quality, and regulatory compliance with ACR, state, and federal requirements.
+
+## 2. Scope
+
+This procedure applies to all CT examinations including:
+- Non-contrast CT studies
+- Contrast-enhanced CT studies
+- CT angiography (CTA)
+- CT-guided procedures
+- Emergency/trauma CT
+
+## 3. Responsibilities
+
+### 3.1 CT Technologist
+- Screen patients for contraindications
+- Position patient properly
+- Select and execute protocols
+- Assess image quality
+- Monitor patient during examination
+
+### 3.2 Radiologist
+- Approve protocols
+- Supervise contrast administration
+- Interpret studies and generate reports
+- Manage contrast reactions
+
+### 3.3 Radiology Nurse (if applicable)
+- Assess IV access
+- Administer contrast
+- Monitor for reactions
+- Provide patient care
+
+### 3.4 Medical Physicist
+- Establish dose optimization protocols
+- Perform quality control
+- Monitor radiation exposure
+
+## 4. Definitions
+
+| Term | Definition |
+|------|------------|
+| CTDI | CT Dose Index - measure of radiation output |
+| DLP | Dose Length Product - total dose metric |
+| HU | Hounsfield Units - density measurement |
+| kVp | Kilovoltage peak |
+| mAs | Milliampere-seconds |
+| MPR | Multiplanar reconstruction |
+
+## 5. Equipment and Materials
+
+- CT scanner (accredited)
+- Power injector
+- Contrast media (iodinated)
+- IV supplies
+- Emergency equipment and medications
+- Shielding devices
+- Patient monitoring equipment
+
+## 6. Procedure
+
+### 6.1 Pre-Examination
+
+#### 6.1.1 Order Verification
+- [ ] Valid physician order present
+- [ ] Appropriate indication documented
+- [ ] Protocol selection appropriate for indication
+- [ ] Prior imaging reviewed (if available)
+
+#### 6.1.2 Patient Identification
+- Verify using two identifiers
+- Confirm exam matches order
+- Review clinical history
+
+#### 6.1.3 Safety Screening
+
+**For all patients:**
+- [ ] Pregnancy status (women of childbearing age)
+- [ ] Previous CT studies (cumulative dose awareness)
+- [ ] Ability to cooperate with positioning
+- [ ] Metal implants/devices in scan field
+
+**For contrast studies - additional screening:**
+
+| Risk Factor | Check |
+|-------------|-------|
+| Previous contrast reaction | ☐ Yes ☐ No |
+| Allergies (iodine, shellfish) | ☐ Yes ☐ No |
+| Kidney disease/elevated creatinine | ☐ Yes ☐ No |
+| Diabetes (metformin use) | ☐ Yes ☐ No |
+| Thyroid disease | ☐ Yes ☐ No |
+| Multiple myeloma | ☐ Yes ☐ No |
+| Age >70 years | ☐ Yes ☐ No |
+| Dehydration | ☐ Yes ☐ No |
+
+**Renal Function Assessment:**
+| eGFR Level | Risk | Action |
+|------------|------|--------|
+| ≥60 | Low risk | Proceed |
+| 45-59 | Moderate risk | Hydration, consider alternatives |
+| 30-44 | High risk | Alternative imaging preferred, radiologist approval |
+| <30 | Very high risk | Avoid unless emergent, nephrology consult |
+
+#### 6.1.4 Consent
+- Explain procedure and risks
+- Obtain informed consent for contrast (if applicable)
+- Document consent
+
+### 6.2 Patient Preparation
+
+#### 6.2.1 Preparation by Exam Type
+
+| Exam Type | Preparation Required |
+|-----------|---------------------|
+| Head CT | Remove metallic objects from head/neck |
+| Chest CT | Breathing instructions, arms above head |
+| Abdomen/Pelvis CT | Oral contrast (if ordered), full bladder (pelvic) |
+| CT Angiography | IV access, contrast protocol |
+| CT Colonography | Bowel preparation |
+
+#### 6.2.2 IV Access for Contrast
+- Assess vein suitability
+- 20-gauge or larger preferred for power injection
+- Verify patency with saline flush
+- Secure catheter properly
+
+### 6.3 Patient Positioning
+
+#### 6.3.1 Standard Positions
+
+| Body Part | Position | Gantry Entry |
+|-----------|----------|--------------|
+| Head | Supine, neutral | Head first |
+| Neck | Supine, neck extended | Head first |
+| Chest | Supine, arms up | Head or feet first |
+| Abdomen | Supine, arms up | Head first |
+| Pelvis | Supine, arms up | Feet first |
+| Extremity | Per protocol | Varies |
+
+#### 6.3.2 Positioning Considerations
+- Center patient in gantry
+- Use positioning aids as needed
+- Apply shielding where appropriate
+- Ensure patient comfort
+- Remove all artifacts from scan field
+
+### 6.4 Protocol Selection and Parameters
+
+#### 6.4.1 Dose Optimization Principles
+- ALARA (As Low As Reasonably Achievable)
+- Use automatic exposure control (AEC)
+- Size-appropriate protocols
+- Limit scan range to clinical question
+
+#### 6.4.2 Standard Protocol Parameters
+
+| Protocol | kVp | mAs | Slice Thickness | Pitch |
+|----------|-----|-----|-----------------|-------|
+| Head routine | 120 | Auto | 5mm | N/A (axial) |
+| Chest routine | 120 | Auto | 5mm/1.25mm | 1.0-1.5 |
+| Abdomen routine | 120 | Auto | 5mm/2.5mm | 1.0-1.5 |
+| CT Angiography | 100-120 | Auto | 0.625-1.25mm | 0.8-1.0 |
+| Low-dose chest | 100-120 | Reduced | 1.25mm | 1.0-1.5 |
+
+#### 6.4.3 Pediatric Considerations
+- Reduce kVp and mAs based on weight/age
+- Use pediatric-specific protocols
+- Apply "Image Gently" principles
+- Minimize number of phases
+
+### 6.5 Contrast Administration
+
+#### 6.5.1 Contrast Selection
+
+| Indication | Contrast Type | Concentration |
+|------------|---------------|---------------|
+| Routine enhanced | Low-osmolar | 300-350 mgI/mL |
+| CT Angiography | Low-osmolar | 350-370 mgI/mL |
+| High-risk patients | Iso-osmolar | 270-320 mgI/mL |
+
+#### 6.5.2 Contrast Volume and Rate
+
+| Exam Type | Volume | Rate |
+|-----------|--------|------|
+| Head with contrast | 100 mL | 1-2 mL/sec |
+| Chest with contrast | 100-125 mL | 2-3 mL/sec |
+| Abdomen with contrast | 100-150 mL | 2-3 mL/sec |
+| CT Angiography | 75-125 mL | 4-5 mL/sec |
+
+#### 6.5.3 Timing Methods
+- Fixed delay (empiric)
+- Bolus tracking (threshold trigger)
+- Test bolus (timing determination)
+
+### 6.6 Image Acquisition
+
+1. **Scout/Topogram**
+   - Acquire scout images
+   - Verify positioning and coverage
+   - Set scan range
+
+2. **Pre-Contrast (if applicable)**
+   - Acquire non-contrast images
+   - Assess for baseline findings
+
+3. **Contrast Injection (if applicable)**
+   - Verify IV patency
+   - Program injector parameters
+   - Monitor injection
+
+4. **Post-Contrast Acquisition**
+   - Acquire at appropriate phase(s)
+   - Arterial: 25-35 seconds
+   - Portal venous: 60-70 seconds
+   - Delayed: 3-5 minutes (as needed)
+
+5. **Image Review**
+   - Review images for quality
+   - Assess for artifacts
+   - Repeat if technically inadequate
+
+### 6.7 Post-Examination
+
+#### 6.7.1 Patient Care After Contrast
+- Monitor for 15-30 minutes
+- Assess IV site
+- Provide hydration instructions
+- Advise on potential delayed reactions
+- Metformin patients: follow institutional protocol
+
+#### 6.7.2 Documentation
+- Complete FRM-RAD-001 CT Procedure Log
+- Document dose metrics (CTDIvol, DLP)
+- Record contrast details
+- Note any adverse events
+- Submit images to PACS
+
+### 6.8 Image Post-Processing
+
+| Reconstruction | Application |
+|----------------|-------------|
+| Soft tissue | Routine interpretation |
+| Bone | Skeletal evaluation |
+| Lung | Pulmonary parenchyma |
+| 3D/MPR | Vascular, complex anatomy |
+| MIP | Angiography |
+
+## 7. Contrast Reaction Management
+
+### 7.1 Reaction Classification
+
+| Severity | Symptoms | Action |
+|----------|----------|--------|
+| Mild | Nausea, urticaria (limited), warmth | Observe, treat symptoms |
+| Moderate | Extensive urticaria, bronchospasm, hypotension | Medical treatment, monitor |
+| Severe | Anaphylaxis, cardiac arrest, seizure | Emergency response, call code |
+
+### 7.2 Emergency Equipment
+Available in CT suite:
+- Oxygen and suction
+- Emergency medications (epinephrine, diphenhydramine, etc.)
+- IV fluids
+- Defibrillator/AED
+- Crash cart
+
+## 8. Radiation Safety
+
+### 8.1 Dose Monitoring
+- Record CTDIvol and DLP for each exam
+- Compare to diagnostic reference levels
+- Investigate outliers
+
+### 8.2 Diagnostic Reference Levels
+
+| Exam | CTDIvol (mGy) | DLP (mGy·cm) |
+|------|---------------|--------------|
+| Head | 60 | 1000 |
+| Chest | 15 | 400 |
+| Abdomen | 20 | 700 |
+| Abdomen/Pelvis | 20 | 900 |
+
+## 9. Quality Control
+
+| Activity | Frequency |
+|----------|-----------|
+| Daily warm-up and calibration | Daily |
+| Water phantom QC | Daily/Weekly |
+| CT number accuracy | Weekly |
+| Spatial resolution | Monthly |
+| Physicist review | Annually |
+
+## 10. Documentation
+
+- FRM-RAD-001 CT Procedure Log
+- FRM-RAD-002 Contrast Administration Record
+- FRM-RAD-003 Adverse Reaction Report
+- Dose reports
+- QC logs
+
+## 11. References
+
+- ACR Practice Parameter for CT
+- ACR Manual on Contrast Media
+- Image Gently Campaign
+- AAPM CT Protocols
+- State radiation regulations
+
+---
+
+## Revision History
+
+| Rev | Date | Description | Author |
+|-----|------|-------------|--------|
+| 1.0 | [DATE] | Initial release | [AUTHOR] |