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)

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

LAC-USC Radiology Topics The Department of Radiology Radiology as a Consult Service Risks of Radiation/ALARA 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 Screenshot

LAC+USC Department of Radiology ED Radiology

LAC+USC Department of Radiology Nuclear Medicine screenshot

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

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. Symptom location and duration

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!!

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

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

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

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

Radiology Consult Without History With History: Impression Significantly abnormal CXR

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

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

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

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: Acute Radiation Syndrome -Sorenson 2000

Radiation What Are the Risks Associated with Radiation Exposure: Acute Radiation Syndrome 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 DECREASED Morbidity/Mortaliy INCREASED Morbidity/Mortality Diagnosis & Treatment Cancer www.acr.org

ALARA Diagnosis & Treatment DECREASED Morbidity/Mortaliy INCREASED Morbidity/Mortality Diagnosis & Treatment Cancer www.acr.org

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

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

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

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

ALARA – Public Perception

ALARA – Public Perception

ALARA – Public Perception

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

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

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

CT with Contrast When should you order IV contrast?

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

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

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

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.

CT without Contrast When should you avoid IV contrast?

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

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

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

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

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

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

Contrast Creatinine GFR Risk Factors* Guidelines <1.3 >60 Acceptable for most situations Hydration 1.3-1.9 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

Contrast Creatinine GFR Risk Factors* Guidelines <1.3 >60 Acceptable for most situations Hydration 1.3-1.9 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

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 Anaphylaxis: avoid IV contrast PO contrast is OK

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.

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

MRI IV Contrast (Gadolinium) Creatinine GFR Risk Factors* Guidelines <1.3 >60 Acceptable for most situations Hydration 1.3-1.9 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]. 2001-2012. Available at http://www.icnsfr.org. Accessed 07/12/2012.

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

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? 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 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 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 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 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 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? ACR Appropriateness Criteria Call Radiology

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

LAC-USC Radiology Thank you. Questions?