CathLabHub

CathLabHub complications toolkitcathlabhub.com/toolkit/radiation-skin-injuryIn review, October 24, 2026

Recognize

The signs on the monitor, the image and the patient.

  • MonitorCumulative air kerma over 5 Gy: injury possible; 10 to 15 Gy likely; over 15 Gy a sentinel event 1.
  • MonitorA dose rate over 20 mGy/min 1.
  • PatientErythema, then pain, desquamation or ulceration at the beam entry on the back, weeks after the case 1.
  • ImageLong CTO or complex PCI with steep angles, high magnification and a large patient 1.

Act now

In the order the operator does them. The first three come first, whatever else is happening.

  1. Announce the dose at set intervals, such as every 1 Gy or 30 minutes 1.
  2. Change the beam angle to spread the skin dose 1.
  3. Lower the frame rate to 7.5 fps or less, collimate, raise the table and bring the detector close 1.
  4. Consider stopping and staging when air kerma reaches 7 to 8 Gy 1.
  5. Over 5 Gy: tell the patient and arrange a skin check within a month 1.
  6. Over 10 Gy: a physicist calculates peak skin dose promptly; skin check at 2 to 4 weeks 1.
  7. Over 15 Gy: notify risk management; sentinel event reporting within 24 hours 1.

Equipment

From the complications cart. Linked items open in the equipment directory.

  • Live dose display and a dose alert set in the lab protocolNot in the directory yet.
  • Real time staff dosimetersReduce operator dose by about 30 percent 1.Not in the directory yet.
  • Disposable radiation absorbing drapesOutside the field of view only 1.Not in the directory yet.

Drugs

Adult doses as the cited source gives them. Check your formulary and the label.

  • No drug treatment in the lab; injured skin goes to dermatology or plastic surgery, and a biopsy without the history can cause a nonhealing ulcer 1.

Who to call

The escalation ladder, first call first.

  1. Medical physicist: for air kerma over 10 Gy 1.
  2. Risk management: for a dose over 15 Gy 1.
  3. Dermatology or plastic surgery: for confirmed skin injury 1.

The bailout step by step

Bringing the dose down during a long case 12

  1. Check air kerma and dose rate now.
  2. Fluoroscopy at 7.5 fps or 3.75 fps in thin patients 1.
  3. Store fluoroscopy instead of cine to document balloons and stents; cine is about 10 times the dose 1.
  4. Collimate tightly; use low magnification 1.
  5. Table up, detector down to the patient 1.
  6. Avoid angles over 30 degrees from AP when possible; rotate between working views 1.
  7. Decide on staging at 7 to 8 Gy 1.

Prevent

  • Plan the case; review prior films; know the dose of your room 12.
  • No pedal lag; use markers instead of fluoroscopy to track devices 1.
  • The NCRP sets a substantial radiation dose level that triggers follow up 3.

After care and documentation

  • Record air kerma, dose area product, fluoroscopy time and the beam angles.
  • Follow up over 5 Gy within a month with a documented skin exam of the back 1.
  • Tell the patient what to watch for and whom to call.

Practice

No emergency simulator case for this; every simulator in the app shows fluoroscopy time and dose at the top of the screen. Browse the case library.

References

  1. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 28, Other complications: hypotension, radiation skin injury, contrast induced acute kidney injury.
  2. Hirshfeld JW Jr, et al. 2018 ACC/HRS/NASCI/SCAI/SCCT expert consensus document on optimal use of ionizing radiation in cardiovascular imaging: best practices for safety and effectiveness. J Am Coll Cardiol 2018;71:e283-e351.
  3. National Council on Radiation Protection and Measurements. Radiation dose management for fluoroscopically guided interventional medical procedures. NCRP Report No. 168. Bethesda, MD; 2010.

Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/radiation-skin-injury. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.