Stu Schroff, MD (PGY 3)
Robert Lieberman, MD, MBA (PGY4)
Aaron Schein, MD (PGY5, Chief Resident)
Andrew Kim, MD (PGY5, Chief Resident)
Sebastian Sugay, MD (PGY5, Chief Resident)
LAC-USC RADIOLOGY
Topics
1.The Department of Radiology
2.Radiology as a Consult Service
3.Risks of Radiation/ALARA
4.Optimal Imaging Strategy
LAC-USC RADIOLOGY
Topics
1.The Department of Radiology
2.Radiology as a Consult Service
3.Risks of Radiation/ALARA
4.Optimal Imaging Strategy
THE FIELD OF RADIOLOGY
“Radiology is a medical specialty
that employs the use of imaging to
both diagnose and treat disease
visualized within the human body.”
- wikipedia
Radiograph of the Left hand of Anna Roentgen
(wife of Wilhelm Roentgen) on November 8, 1895
in Wurzburg, Germany.
DEPARTMENT OF RADIOLOGY

This is an enormously busy hospital





28 percent of trauma victims in the region
39,000 inpatient discharges/year
150,000 emergency department visits/year
1 million ambulatory care visits/year
LAC+USC Medical Center Final Budget FY
2011-2012: $1.189 billion
LAC+USC DEPARTMENT OF RADIOLOGY
2010-2011 Statistics
60,015 CTs
 12,227 MRIs
 18,751 Interventional Procedures
 20,281 Nuclear Medicine Studies
 71,244 Ultrasounds
 239,807 Radiographs

DOR DIVISIONS



We are a subspecialized department
Body imaging (abdomen and pelvis)
 CT, US, MRI, and Plain film/fluoroscopy
(barium studies) are separate reading areas
Cardiothoracic imaging (CXR, CT chest,
cardiac MRI)
DOR DIVISIONS



Neuroradiology (Brain, spine, ENT, angiography)
Musculoskeletal imaging (X-ray, MRI, CT,
arthrograms and biopsies)
Nuclear medicine (PET/CT, cardiac SPECT, bone
scans, V/Q scans…)
DOR DIVISIONS



Pediatric imaging
Women’s imaging (breast imaging, pelvic US and
MRI)
Vascular and Interventional Radiology
(angiography, liver/biliary interventions,
neprhostomies)
 CT and US guided procedures are handled by
the pertinent division, not IR
LAC+USC DEPARTMENT OF RADIOLOGY
MAIN FLOOR
LAC+USC DEPARTMENT OF RADIOLOGY
ED RADIOLOGY
LAC+USC DEPARTMENT OF RADIOLOGY
NUCLEAR MEDICINE
LAC+USC DEPARTMENT OF RADIOLOGY
Hours of Operation, Mon-Fri:
8AM-4PM (Normal workday—
All staff/fellows/residents in house)
4PM-10PM (On call resident and staff/fellow in house)
10PM-8AM (On call resident in house;
staff/fellow at home)
LAC+USC DEPARTMENT OF RADIOLOGY
Hours of Operation, Weekends and Holidays:
8AM-8PM (On call resident and staff/fellow in house)
8PM-8AM (On call resident on call in house;
staff/fellow at home)
www.trojanimaging.com
LAC+USC Radiology Directory
Radread.usc.edu
RADREAD.USC.EDU
WHO TO CALL:
Protocoling studies:
Protocol resident
 Scheduling studies:
Radiology tech
 Interpretation:
Reading room

radread.usc.edu
www.trojanimaging.com
www.amion.com pw: usc rad, dofusc, usc
NON-EMERGENT INTERPRETATIONS
Staging CTs
 “Need a prelim before morning rounds”—There
must be an urgent clinical concern to justify an
overnight prelim
 Old studies
 Didactic

UPLOADING/EXPORTING STUDIES
Mon-Fri 7am-3:30 pm
Tony or Kenny
323-409-7253
3F102
(the “bowling alley”)
UPLOADING/EXPORTING STUDIES
LAC-USC RADIOLOGY
Topics
1.The
Department of Radiology
2.Radiology as a Consult Service
3.Risks of Radiation/ALARA
4.Optimal Imaging Strategy
RADIOLOGY CONSULT
The more useful information you provide – the
more valuable information you will get out of
an imaging study.
RADIOLOGY CONSULT
The more useful information you provide – the
more valuable information you will get out of
an imaging study.
1. Symptom location and duration
RADIOLOGY CONSULT
The more useful information you provide – the
more valuable information you will get out of
an imaging study.
1. Symptom location and duration
2. Sidedness!!
RADIOLOGY CONSULT
The more useful information you provide – the
more valuable information you will get out of
an imaging study.
1. Symptom location and duration
2. Sidedness!!
3. Prior pertinent interventions
RADIOLOGY CONSULT
The more useful information you provide – the
more valuable information you will get out of
an imaging study.
1. Symptom location and duration
2. Sidedness!!
3. Prior pertinent interventions
4. Possible ddx
RADIOLOGY CONSULT
The more useful information you provide – the
more valuable information you will get out of
an imaging study.
1. Symptom location and duration
2. Sidedness!!
3. Prior pertinent interventions
4. Possible ddx
5. CONTACT Info
RADIOLOGY CONSULT
For example…
1.
2.
3.
Ordering Dx: 34yo M h/o Crohn’s s/p partial SB
resxn new RLQ abd pain x 1day
Chief Complaint: Abscess, SBO, perf.
Physican #: Reliable physician #, team VOIP
preferred
Radiology Consult
Without History
Impression
Significantly
abnormal CXR
With History:
Radiology Consult
Without History
Impression
With History:
Significantly
abnormal CXR
Actual history: 19yo M organ
donor s/p organ harvesting
with abnormal counts in the
OR looking for foreign body
per protocol
Radiology Consult
Impression
Without History
With History:
Significantly
abnormal CXR
No
radioopaque
FB s/p organ
harvesting
LAC-USC RADIOLOGY
Topics
1.The
Department of Radiology
2.Radiology as a Consult Service
3.Risks of Radiation/ALARA
4.Optimal Imaging Strategy
Radiation
First, a note on radiation.
Computed Tomography – An Increasing Source of Radiation Exposure. The New England
Journal of Medicine. 2007; 357;2277-84.
Radiation
Radiation
Radiation
Schaal B. National Academy of the Sciences – What we’ve learned about the Atomic Bomb
survivors. 12/8/2010.
Radiation
What Are the Risks Associated with Radiation
Exposure:
Radiation
What Are the Risks Associated with Radiation
Exposure:
1. Acute Radiation Syndrome
-Sorenson 2000
Radiation
What Are the Risks Associated with Radiation
Exposure:
1. Acute Radiation Syndrome
2. Cancer
ALARA
What is ALARA?
ALARA
Q:What is a safe
dose of radiation?
ALARA
Q:What is a safe dose of
radiation?
A: There is no such thing
as a safe dose of
radiation.
ALARA
INCREASED MORBIDITY/MORTALITY
DECREASED MORBIDITY/MORTALIY
Diagnosis &
Treatment
Cancer
www.acr.org
ALARA
INCREASED MORBIDITY/MORTALITY
DECREASED MORBIDITY/MORTALIY
Diagnosis &
Treatment
Cancer
www.acr.org
ALARA
INCREASED MORBIDITY/MORTALITY
DECREASED MORBIDITY/MORTALIY
Diagnosis &
Treatment
Cancer
ALARA: As Low As
Reasonably Acceptable
www.acr.org
ALARA
Why should you care about radiation
dosages?
ALARA
Why should you care about radiation
dosages?
1. Patient Safety – preventing unnecessary
morbidity/mortality
ALARA
Why should you care about radiation
dosages?
1. Patient Safety – preventing unnecessary
morbidity/mortality
2. Public Perception
ALARA – PUBLIC PERCEPTION
ALARA – PUBLIC PERCEPTION
ALARA – PUBLIC PERCEPTION
ALARA
Why should you care about radiation
dosages?
1. Patient Safety – preventing unnecessary
morbidity/mortality
2. Public Perception
3. Reimbursement
LAC-USC RADIOLOGY
Topics
1.The
Department of Radiology
2.Radiology as a Consult Service
3.Risks of Radiation/ALARA
4.Optimal Imaging Strategy
IMAGING STRATEGY

Indications for Imaging:

Screening—No clinical signs of disease
 e.g.
Mammography, liver screening in patients with known
chronic liver disease, certain high risk groups…

Diagnosis following clinical workup
 Imaging
should be targeted based on the clinical suspicion
 There should be a working differential diagnosis before
imaging

Treatment Planning
 Only
when the imaging findings will dictate a change in
management
CT with Contrast
When should you order IV contrast?
CT with Contrast
When should you order IV contrast?
1. If you are looking for:
1.
Infection
CT with Contrast
When should you order IV contrast?
1. If you are looking for:
1.
2.
Infection
Abscess
CT with Contrast
When should you order IV contrast?
1. If you are looking for:
1.
2.
3.
Infection
Abscess
Neoplasm
CT with Contrast
When should you order IV contrast?
1. If you are looking for:
1.
2.
3.
4.
Infection
Abscess
Neoplasm
You do not know what you are looking for.
CT without Contrast
When should you avoid IV contrast?
CT without Contrast
When should you avoid IV contrast?
1.
Looking for Ca++ - (eg: Kidney stones)
CT without Contrast
When should you avoid IV contrast?
1.
2.
Looking for Ca++
Looking for acute intracranial hemorrhage
Radiology Consult
62yo F with sudden onset of severe headache
1.
2.
3.
4.
5.
6.
CT head without contrast
CTA head with contrast
MRA head and neck
MRI head without contrast
MRI head with and without contrast
CT head with AND without contrast
Radiology Consult
62yo F with sudden onset of severe headache
1.
2.
3.
4.
5.
6.
CT head without contrast
CTA head with contrast
MRA head and neck
MRI head without contrast
MRI head with and without contrast
CT head with AND without contrast
CT without Contrast
When should you avoid IV contrast?
1.
2.
3.
Looking for Ca++
Looking for acute intracranial hemorrhage
Patient has prior history of anaphylaxis to IV
contrast
CT without Contrast
When should you avoid IV contrast?
1.
2.
3.
4.
Looking for Ca++
Looking for acute intracranial hemorrhage
Patient has prior history of anaphylaxis to IV
contrast
Patient is at risk of Contrast Induced
Nephropathy
Contrast
Creatinine
GFR
Risk
Factors*
Guidelines
<1.3
>60
1.3-1.9
3060
None
Hydration
1.3-1.9
3060
Present
Hydration
N-acetylcysteine (Mucomyst) PO 600mg BID the day
before and day of IV contrast load(*controversial)
>1.9
<30
-
IV contrast should be avoided
 Acceptable for most situations
 Hydration
*Risk Factors for Renal disease:
1. Diabetes Mellitus
2. Dehydration
3. Cardiovascular disease and the use of diuretics
4. Age > 70yrs
5. Multiple Myeloma
6. Hypertension
Contrast
Creatinine
GFR
Risk
Factors*
Guidelines
<1.3
>60
1.3-1.9
3060
None
Hydration
1.3-1.9
3060
Present
Hydration
N-acetylcysteine (Mucomyst) PO 600mg BID the day
before and day of IV contrast load(*controversial)
>1.9
<30
-
IV contrast should be avoided
 Acceptable for most situations
 Hydration
*Risk Factors for Renal disease:
1. Diabetes Mellitus
2. Dehydration
3. Cardiovascular disease and the use of diuretics
4. Age > 70yrs
5. Multiple Myeloma
6. Hypertension
Contrast
Dialysis Dependent Patients:
 Contrast agents are not protein-bound and
have relatively low molecular weights and
readily cleared by dialysis.
Contrast
Dialysis Dependent Patients:
 Contrast agents are not protein-bound and
have relatively low molecular weights and
readily cleared by dialysis.
 Dialysis should be scheduled within 24 hrs of
intravenous contrast load
Contrast
Prior Contrast Reactions to IV contrast
1. Anaphylaxis:
1.
2.
avoid IV contrast
PO contrast is OK
Contrast
Prior Contrast Reactions to IV contrast
1. Anaphylaxis:
1.
2.
2.
avoid IV contrast
PO contrast is OK
Mild reactions:
1.
2.
Prednisone 50mg PO x 3doses given 13hrs, 7hrs,
and 1hr prior to IV contrast load.
Benadryl 50mg PO x 1 dose 1hr prior to IV contrast
load.
MRI with IV Contrast (Gadolinium)
When should you order IV contrast with MRI?
1. If you are looking for:
1.
2.
3.
Infection
Abscess
Neoplasm
MRI IV Contrast (Gadolinium)
Creatinine
GFR
Risk
Factors*
Guidelines
<1.3
>60
1.3-1.9
3060
None
Hydration
>1.9
<30
-
IV contrast should be avoided
 Acceptable for most situations
 Hydration
Nephrogenic systemic fibrosis (NSF)
• First case 1997, first described in 2000
• Resembles scleroderma/connective tissue disease
• Systemic disorder, no consistently effective treatment
• Very rare, and happens only in patients with CKD
• Higher stage of CKD  Higher risk of NSF
Cowper SE. Nephrogenic Systemic Fibrosis [ICNSFR Website]. 2001-2012. Available
at http://www.icnsfr.org. Accessed 07/12/2012.
Radiology Consult
62yo immunocompromised HIV+ female with
sudden onset of severe headache
1.
2.
3.
4.
5.
6.
CT head without contrast
CTA head with contrast
MRA head and neck
MRI head without contrast
MRI head with and without contrast
CT head with AND without contrast
ACR Appropriateness Criteria
What do you do if you have NO idea what
study to order?
ORDERING IMAGING STUDIES
What do you do if you have NO idea what study to order?
1.
ACR Appropriateness Criteria
ACR APPROPRIATENESS CRITERIA
WWW.ACR.ORG/AC
ACR APPROPRIATENESS CRITERIA
WWW.ACR.ORG/AC
ACR APPROPRIATENESS CRITERIA
WWW.ACR.ORG/AC
ACR APPROPRIATENESS CRITERIA
WWW.ACR.ORG/AC
Radiology Consult
62yo immunocompromised HIV+ female with
sudden onset of severe headache
1.
2.
3.
4.
5.
6.
CT head without contrast
CTA head with contrast
MRA head and neck
MRI head without contrast
MRI head with and without contrast
CT head with AND without contrast
Radiology Consult
62yo immunocompromised HIV+ female with
sudden onset of severe headache
1.
2.
3.
4.
5.
6.
CT head without contrast
CTA head with contrast
MRA head and neck
MRI head without contrast
MRI head with and without contrast
CT head with AND without contrast
Radiology Consult
32yo pregnant female with sudden onset of
severe headache
1.
2.
3.
4.
5.
6.
CT head without contrast
CTA head with contrast
MRA head and neck
MRI head without contrast
MRI head with and without contrast
CT head with AND without contrast
ACR APPROPRIATENESS CRITERIA
WWW.ACR.ORG/AC
Radiology Consult
32yo pregnant female with sudden onset of
severe headache
1.
2.
3.
4.
5.
6.
CT head without contrast
CTA head with contrast
MRA head and neck
MRI head without contrast
MRI head with and without contrast
CT head with AND without contrast
Radiology Consult
32yo pregnant female with sudden onset of
severe headache
1.
2.
3.
4.
5.
6.
CT head without contrast
CTA head with contrast
MRA head and neck
MRI head without contrast
MRI head with and without contrast
CT head with AND without contrast
ORDERING IMAGING STUDIES
What do you do if you have NO idea what study to order?
1.
2.
ACR Appropriateness Criteria
Call Radiology
ORDERING IMAGING STUDIES
What do you do if you have NO idea what study to order?
1.
2.
ACR Appropriateness Criteria
Call Radiology
LAC-USC RADIOLOGY
Thank you.
Questions?