1. LAC-USC Radiology 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)

2. LAC-USC Radiology Topics The Department of Radiology
Radiology as a Consult Service
Risks of Radiation/ALARA
Optimal Imaging Strategy

3. LAC-USC Radiology Topics The Department of Radiology
Radiology as a Consult Service
Risks of Radiation/ALARA
Optimal Imaging Strategy

4. 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.

5. 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 : $1.189 billion

6. LAC+USC Department of Radiology
Statistics
60,015 CTs
12,227 MRIs
18,751 Interventional Procedures
20,281 Nuclear Medicine Studies
71,244 Ultrasounds
239,807 Radiographs

7. 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)

8. 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…)

9. 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

10. LAC+USC Department of Radiology Main Floor
Screenshot

11. LAC+USC Department of Radiology ED Radiology

12. LAC+USC Department of Radiology Nuclear Medicine
screenshot

13. 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)

14. 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)

16. LAC+USC Radiology Directory

17. Radread.usc.edu

18. Radread.usc.edu

19. Who to call: Protocoling studies: Protocol resident
Scheduling studies: Radiology tech
Interpretation: Reading room
radread.usc.edu
pw: usc rad, dofusc, usc

20. 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

21. Uploading/Exporting Studies
Mon-Fri 7am-3:30 pm
Tony or Kenny
3F102
(the “bowling alley”)

22. Uploading/Exporting Studies

23. LAC-USC Radiology Topics The Department of Radiology
Radiology as a Consult Service
Risks of Radiation/ALARA
Optimal Imaging Strategy
LAC-USC Radiology

24. Radiology Consult
The more useful information you provide – the more valuable information you will get out of an imaging study.

25. Radiology Consult
The more useful information you provide – the more valuable information you will get out of an imaging study.
Symptom location and duration

26. Radiology Consult
The more useful information you provide – the more valuable information you will get out of an imaging study.
Symptom location and duration
Sidedness!!

27. Radiology Consult
The more useful information you provide – the more valuable information you will get out of an imaging study.
Symptom location and duration
Sidedness!!
Prior pertinent interventions

28. Radiology Consult
The more useful information you provide – the more valuable information you will get out of an imaging study.
Symptom location and duration
Sidedness!!
Prior pertinent interventions
Possible ddx

29. Radiology Consult
The more useful information you provide – the more valuable information you will get out of an imaging study.
Symptom location and duration
Sidedness!!
Prior pertinent interventions
Possible ddx
CONTACT Info

30. Radiology Consult For example…
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

31. Radiology Consult Without History With History:
Impression
Significantly abnormal CXR

32. Radiology Consult
Without History
With History:
Impression
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

33. Radiology Consult Without History With History:
Impression
Significantly abnormal CXR
No radioopaque FB s/p organ harvesting

34. LAC-USC Radiology Topics The Department of Radiology
Radiology as a Consult Service
Risks of Radiation/ALARA
Optimal Imaging Strategy
LAC-USC Radiology

35. First, a note on radiation.
Computed Tomography – An Increasing Source of Radiation Exposure. The New England Journal of Medicine. 2007; 357;

36. Radiation

37. Radiation

38. Radiation
Schaal B. National Academy of the Sciences – What we’ve learned about the Atomic Bomb survivors. 12/8/2010.

39. Radiation
What Are the Risks Associated with Radiation Exposure:

40. Radiation What Are the Risks Associated with Radiation Exposure:
Acute Radiation Syndrome
-Sorenson 2000

41. Radiation What Are the Risks Associated with Radiation Exposure:
Acute Radiation Syndrome
Cancer

42. ALARA
What is ALARA?

43. ALARA
Q:What is a safe dose of radiation?

44. ALARA
Q:What is a safe dose of radiation? A: There is no such thing as a safe dose of radiation.

45. ALARA DECREASED Morbidity/Mortaliy INCREASED Morbidity/Mortality
Diagnosis & Treatment
Cancer

46. ALARA Diagnosis & Treatment DECREASED Morbidity/Mortaliy
INCREASED Morbidity/Mortality
Diagnosis & Treatment
Cancer

47. ALARA ALARA: As Low As Reasonably Acceptable Diagnosis & Treatment
DECREASED Morbidity/Mortaliy
INCREASED Morbidity/Mortality
Diagnosis & Treatment
Cancer
ALARA: As Low As Reasonably Acceptable

48. Why should you care about radiation dosages?
ALARA
Why should you care about radiation dosages?

49. Why should you care about radiation dosages?
ALARA
Why should you care about radiation dosages?
Patient Safety – preventing unnecessary morbidity/mortality

50. Why should you care about radiation dosages?
ALARA
Why should you care about radiation dosages?
Patient Safety – preventing unnecessary morbidity/mortality
Public Perception

51. ALARA – Public Perception

52. ALARA – Public Perception

53. ALARA – Public Perception

54. Why should you care about radiation dosages?
ALARA
Why should you care about radiation dosages?
Patient Safety – preventing unnecessary morbidity/mortality
Public Perception
Reimbursement

55. LAC-USC Radiology Topics The Department of Radiology
Radiology as a Consult Service
Risks of Radiation/ALARA
Optimal Imaging Strategy
LAC-USC Radiology

56. 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
Discuss difference between Radiology and Pathology

57. CT with Contrast
When should you order IV contrast?

58. CT with Contrast When should you order IV contrast?
If you are looking for:
Infection

59. CT with Contrast When should you order IV contrast?
If you are looking for:
Infection
Abscess

60. CT with Contrast When should you order IV contrast?
If you are looking for:
Infection
Abscess
Neoplasm

61. CT with Contrast When should you order IV contrast?
If you are looking for:
Infection
Abscess
Neoplasm
You do not know what you are looking for.

62. CT without Contrast
When should you avoid IV contrast?

63. CT without Contrast When should you avoid IV contrast?
Looking for Ca++ - (eg: Kidney stones)

64. CT without Contrast When should you avoid IV contrast?
Looking for Ca++
Looking for acute intracranial hemorrhage

65. Radiology Consult 62yo F with sudden onset of severe headache
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

66. Radiology Consult 62yo F with sudden onset of severe headache
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

67. CT without Contrast When should you avoid IV contrast?
Looking for Ca++
Looking for acute intracranial hemorrhage
Patient has prior history of anaphylaxis to IV contrast

68. CT without Contrast When should you avoid IV contrast?
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

69. Contrast Creatinine GFR Risk Factors* Guidelines <1.3 >60
Acceptable for most situations
Hydration
30-60
None
Present
N-acetylcysteine (Mucomyst) PO 600mg BID the day before and day of IV contrast load(*controversial)
>1.9
<30 -
IV contrast should be avoided
*Risk Factors for Renal disease:
Diabetes Mellitus
Dehydration
Cardiovascular disease and the use of diuretics
Age > 70yrs
Multiple Myeloma
Hypertension

70. Contrast Creatinine GFR Risk Factors* Guidelines <1.3 >60
Acceptable for most situations
Hydration
30-60
None
Present
N-acetylcysteine (Mucomyst) PO 600mg BID the day before and day of IV contrast load(*controversial)
>1.9
<30 -
IV contrast should be avoided
*Risk Factors for Renal disease:
Diabetes Mellitus
Dehydration
Cardiovascular disease and the use of diuretics
Age > 70yrs
Multiple Myeloma
Hypertension

71. Contrast Dialysis Dependent Patients:
Contrast agents are not protein-bound and have relatively low molecular weights and readily cleared by dialysis.

72. 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

73. Contrast Prior Contrast Reactions to IV contrast Anaphylaxis:
avoid IV contrast
PO contrast is OK

74. Contrast Prior Contrast Reactions to IV contrast Anaphylaxis:
avoid IV contrast
PO contrast is OK
Mild reactions:
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.

75. MRI with IV Contrast (Gadolinium)
When should you order IV contrast with MRI?
If you are looking for:
Infection
Abscess
Neoplasm

76. MRI IV Contrast (Gadolinium)
Creatinine
GFR
Risk Factors*
Guidelines
<1.3
>60
Acceptable for most situations
Hydration
30-60
None
>1.9
<30 -
IV contrast should be avoided
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] Available at Accessed 07/12/2012.

77. Radiology Consult
62yo immunocompromised HIV+ female with sudden onset of severe headache
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

78. ACR Appropriateness Criteria
What do you do if you have NO idea what study to order?

79. Ordering Imaging Studies
What do you do if you have NO idea what study to order?
ACR Appropriateness Criteria

80. ACR Appropriateness Criteria www.acr.org/ac

81. ACR Appropriateness Criteria www.acr.org/ac

82. ACR Appropriateness Criteria www.acr.org/ac

83. ACR Appropriateness Criteria www.acr.org/ac

84. Radiology Consult
62yo immunocompromised HIV+ female with sudden onset of severe headache
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

85. Radiology Consult
62yo immunocompromised HIV+ female with sudden onset of severe headache
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

86. Radiology Consult
32yo pregnant female with sudden onset of severe headache
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

87. ACR Appropriateness Criteria www.acr.org/ac

88. Radiology Consult
32yo pregnant female with sudden onset of severe headache
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

89. Radiology Consult
32yo pregnant female with sudden onset of severe headache
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

90. Ordering Imaging Studies
What do you do if you have NO idea what study to order?
ACR Appropriateness Criteria
Call Radiology

91. Ordering Imaging Studies
What do you do if you have NO idea what study to order?
ACR Appropriateness Criteria
Call Radiology

92. LAC-USC Radiology
Thank you.
Questions?