I. Useful websites
Amion.com — to check your rotation/call schedule
Qgenda — to check attendings schedules
Trojanimaging.com — look up reading room phone numbers, remote access to Keck, useful articles, and lots of other gems!
Myevaluations.com — conference schedule, evaluations
Norris Medical Library — online access to textbooks, journal articles, and much more
Statdx.com — database of radiology information and pathology examples for clinical use
Radprimer.com — question bank for learning
II. Contrast guidelines:
The following are recommended guidelines for administration of intravenous contrast in adults. Each patient referral should be considered on an individual basis within the context of this background information, and strict adherence to these guidelines in all cases is discouraged. Physician judgment is paramount.
A. IV Contrast
We recommend a serum creatinine within 4 weeks for otherwise stable outpatients. For inpatients, a serum creatinine within 7 days (or less as dictated by clinical setting) is advised. Patients receiving chemotherapy, targeted therapy, and immunotherapy and patients undergoing radiation therapy with treatment field including the kidneys should have a serum creatinine after their most recent treatment.
The eGFR screening cutoff to identify patients at increased risk of contrast induced nephropathy (CIN) is eGFR less than 45 ml/min/1.7m2. Iodinated IV contrast should not be given to patients with eGFR < 30 ml/min/1.73m2.
The decision to proceed with contrast administration in patients with an estimated GFR < 45 ml/min/1.7m2 should always be a matter of clinical judgment. If contrast administration is considered essential, IV hydration should be considered.
B. IV Hydration
For inpatients with eGFR less than 45 ml/min/1.7m2, a proposed IV volume expansion protocol (using either isotonic saline or sodium bicarbonate) is 3 cc/kg/hr for 1 hour or 1 cc/kg/hr for 6 hours prior to procedure followed by 1 cc/kg/hr for 6 hours after the procedure. This should be implemented for inpatients after discussion with the referring clinician, with particular attention to volume load and cardiac function.
Due to the logistical complications of performing these hydration protocols in an outpatient setting, the following regimen is suggested for outpatients with eGFR less than 45 ml/min/1.7m2. Oral hydration should be strongly encouraged in all such patients. If the patient can tolerate a hydration bolus, a total IV bolus of 500 - 1000 cc NS should be administered before and after the exam. This should be adjusted according to cardiac status.
In outpatients with BUN/Cr > 20 and no evidence of CHF, then at least 500 cc NS IV bolus should be administered prior to the exam, regardless of eGFR.
Patients on dialysis who have an expectation of renal recovery or those who produce urine and only require intermittent or occasional dialysis are at substantial risk for contrast media-induced nephrotoxicity with further worsening of their renal function. This can jeopardize any chance of reversal of renal impairment or cause marked deleterious consequences to the patient’s quality of life (require more frequent dialysis and hasten complications). In these cases, alternative imaging not requiring contrast media should be strongly considered and consultation with the patient’s nephrologist is recommended. Additionally, the volumes of both oral and IV contrast should be included in the fluid intake of dialysis patients.
In patients with chronic renal failure on maintenance dialysis (anuric), IV contrast is permissible and no evidence exists to support the need for early post-procedural dialysis. In general, the patient should continue with his/her normal dialysis schedule. If a large contrast dose is administered or the patient has heart failure, pre-procedure dialysis may be desirable.
The incidence of lactic acidosis due to metformin is rare, with the actual connection controversial in the medical literature. The following policy is advised:
1. In patients with normal or mild-moderate kidney disease (eGFR ≥ 30 ml/min/1.73m2), there is no need to hold metformin or obtain a follow-up creatinine after an exam with intravascular iodinated contrast.
2. Iodinated IV contrast should not be given to patients with eGFR < 30 ml/min/1.73m2. Consider discussion with the referring physician to reassess if metformin is indicated.
E. Rectal Contrast
A rectal contrast request will be entertained only if the following conditions are met:
1. A surgical resident/fellow has seen the patient AND performed a rectal exam and proctoscopy
2. This physical exam and findings are documented, and the clinician’s pager number/ contact details are indicated in the radiology order.
F. Oral Contrast
Oral contrast is no longer a routine part of the CT scan at County. Cases that should receive oral contrast include patients with suspected postoperative bowel leak (i.e. patient who had recent bowel surgery and now has fever and elevated white count) and patients not receiving IV contrast due to allergy or renal function. Patients with suspected bowel obstruction do not require oral contrast.
III. Contrast Reaction Protocol
A. Management of Acute Contrast Reaction in Adults
1. Discontinue injection if not completed
2. No treatment needed in most cases
3. Give H1-receptor blocker: Diphenhydramine (Benadryl®) PO/IM/IV 25-50 mg If severe or widely disseminated: Alpha agonist (arteriolar and venous constriction) Epinephrine SC (1:1,000) 0.1-0.3 ml (=0.1-0.3 mg) (if no cardiac contraindications)
B. Facial or Laryngeal Edema
1. Give alpha agonist (arteriolar and venous constriction): Epinephrine SC or IM (1:1,000) 0.1-0.3 ml (=0.1-0.3 mg) or, if hypotension evident, Epinephrine (1:10,000) slowly IV 1 ml (=0.1 mg). Repeat as needed up to a maximum of 1 mg.
2. Give O2 6-10 liters/min (via mask). If not responsive to therapy or if there is obvious acute laryngeal edema, seek appropriate assistance (e.g., cardiopulmonary arrest response team).
1. Give O2 6-10 liters/min (via mask). Monitor: electrocardiogram, O2 saturation (pulse oximeter), and blood pressure.
2. Give beta-agonist inhalers [bronchiolar dilators, such as metaproterenol (Alupent®), terbutaline (Brethaire®), or albuterol (Proventil®)(Ventolin®) 2-3 puffs; repeat prn. If unresponsive to inhalers, use SC, IM or IV epinephrine.
3. Give epinephrine SC or IM (1:1,000) 0.1-0.3 ml (=0.1-0.3 mg) or, if hypotension evident, Epinephrine (1:10,000) slowly IV 1 ml (=0.1 mg). Repeat as needed up to a maximum of 1 mg.
4. Alternatively: Give aminophylline: 6 mg/kg IV in D5W over 10-20 minutes (loading dose), then 0.4-1 mg/kg/hr, as needed (caution: hypotension).
5. Call for assistance (e.g., cardiopulmonary arrest response team) for severe bronchospasm or if O2 saturation < 88% persists.
D. Hypotension with Tachycardia
1. Legs elevated 60° or more (preferred) or Trendelenburg position.
2. Monitor: electrocardiogram, pulse oximeter, blood pressure.
3. Give O2 6-10 liters/min (via mask).
4. Rapid intravenous administration of large volumes of isotonic Ringer’s lactate or normal saline.
5. If poorly responsive: Epinephrine (1:10,000) slowly IV 1 ml (=0.1 mg) (if no cardiac contraindications). Repeat as needed up to a maximum of 1 mg. If still poorly responsive seek appropriate assistance (e.g., cardiopulmonary arrest response team).
E. Hypotension with Bradycardia (Vagal Reaction)
1. Monitor vital signs.
2. Legs elevated 60° or more (preferred) or Trendelenburg position.
3. Secure airway: give O2 6-10 liters/min (via mask).
4. Secure IV access: rapid fluid replacement with Ringer’s lactate or normal saline.
5. Give atropine 0.6-1 mg IV slowly if patient does not respond quickly to steps 2 – 4.
6. Repeat atropine up to a total dose of 0.04 mg/kg (2-3 mg) in adult.
7. Ensure complete resolution of hypotension and bradycardia prior to discharge.
F. Hypertension, Severe
1. Give O2 6-10 liters/min (via mask).
2. Monitor electrocardiogram, pulse oximeter, blood pressure.
3. Give nitroglycerine 0.4-mg tablet, sublingual (may repeat x 3); or, topical 2% ointment, apply 1 in. strip.
4. Transfer to intensive care unit or emergency department.
5. For pheochromocytoma—phentolamine 5 mg IV.
G. Seizures or Convulsions
1. Give O2 6-10 liters/min (via mask).
2. Consider diazepam (Valium®) 5 mg (or more, as appropriate) or midazolam (Versed®) 0.5-1 mg IV.
3. If longer effect needed, obtain consultation; consider phenytoin (Dilantin®) infusion – 15-18 mg/kg at 50 mg/min.
4. Careful monitoring of vital signs required, particularly of pO2 because of risk to respiratory depression with benzodiazepine administration.
5. Consider using cardiopulmonary arrest response team for intubation if needed.
H. Pulmonary Edema
1. Elevate torso; rotating tourniquets (venous compression).
2. Give O2 6-10 liters/min (via mask).
3. Give diuretics – furosemide (Lasix®) 20-40 mg IV, slow push.
4. Consider giving morphine (1-3 mg IV).
5. Transfer to intensive care unit or emergency department.
6. Corticosteroids optional.
(Abbreviations: IM= intramuscular IV=intravenous SC=subcutaneous PO=orally)
IV. LAC+USC DEPARTMENT OF RADIOLOGY CTPA PROTOCOL ALGORITHM
A. NON-PREGNANT ADULTS
1) Assessment of vital signs including pulse oximetry, chest radiography, and ECG.
2) Calculation of Wells score by either the ordering physician or protocoling resident. If the Wells score is calculated by the ordering physician, then the specific criteria which generated the score should be documented, if possible.
3) If Wells score > 4, CTPA is automatically approved.
4) If Wells score ≤ 4, a D-dimer level will be requested, unless already obtained.
5) If D-dimer > 249 ng/mL, CTPA is automatically approved.
6) If D-dimer is < 249 ng/mL, the study can still be performed, but only after approval by an attending-level physician (if this is a clinician, the name needs to be documented).
Well's Criteria for Pulmonary Embolism:
Clinical Signs and Symptoms of DVT? (3 points)
PE is #1 Diagnosis, or Equally Likely (3 points)
Heart Rate > 100 (1.5 points)
Immobilization at least 3 days, or Surgery in the Previous 4 weeks (1.5 points)
Previous, objectively diagnosed PE or DVT (1.5 points)
Hemoptysis (1 point)
Malignancy with treatment within 6 mo, or palliative (1 point)
B. PREGNANT PATIENTS (positive pregnancy test):
See algorithm at the right.
V. Reading and Resource List Recommendations
There are tons of additional resources out there that are not listed here, so take these with a grain of salt. Below are just some of the traditional choices. We recommend that you supplement your reading during rotations with Radprimer practice questions to keep yourself engaged.
A. General (can use during all rotations)
1. Core Radiology Mandell — Provides a solid foundation for almost all of your rotations. Add to it or make notes in it as you go if you can.
2. Brant & Helms — The old-school foundational book that has been replaced by Core Radiology as the go-to source in many institutions. Still has a lot of great information in certain subjects.
1. Headneckbrainspine.com — great website for anatomy and cases
2. Neuroradiology Companion Castillo
3. Brain Imaging: Case Review Loevner
4. Spine Imaging: Case Review Bowen
1. Chest Radiology: The Essentials (Collins)
2. Felson’s Principles of Chest Roentgenology (Goodman)
3. High Resolution CT of the Lung (Webb)
1. Fundamentals of Body CT (Webb)
2. Mayo Clinic Gastrointestinal Radiology Review (Johnson)
3. Dynamic Radiology of the Abdomen (Meyers)
4. Gastrointestinal Imaging: Case Review (Halpert)
1. Textbook of Uroradiology (Dunnick)
2. Genitourinary Imaging: Case Review (Zagoria)
1. Ultrasound: The Requisites (Middleton)
2. General and Vascular Ultrasound: Case Review (Middelton)
G. Women’s Imaging
2. Breast Imaging Companion (Cardenosa)
3. Breast Imaging: Case Review (Conant)
4. Dr. Walker’s HSG Powerpoint — file is saved to the desktop of computer in the chest reading room
1. Fundamentals of Body CT (Webb)
2. The Radiology of Emergency Medicine (Harris)
3. Primer of Diagnostic Imaging (Weislleder)
1. Fundamentals of Pediatric Radiology (Donnelly)
2. Pediatric Imaging: Case Review (Huisman)
3. Pediatric Radiology: The Requisites (Blickman)
1. Musculoskeletal Imaging chapter in Brant and Helms
2. Musculoskeletal Imaging: Case Review (Yu)
3. Musculoskeletal Imaging: A Teaching File (Chew)
4. Musculoskeletal Imaging: The Requisites (Manaster)
5. Musculoskeletal Imaging: Musculoskeletal MRI (Helms/Kaplan)
K. Nuclear Medicine
1. Essentials of Nuclear Medicine (Mettler)
2. Nuclear Medicine: The Requisites (Thrall)
L. Vascular and Intervention
1. Vascular and Interventional Radiology (Valji)
2. Vascular and Interventional Imaging: Case Review (Saad)
VI. Quick and Dirty Tips for Inpatient Orders and Protocolling
● Body CT order approval for Inpatients and the ED is based on Order Right scores. Orders with score > 4 are automatically approved and should be performed. Only studies with score < 4, or without a score, require Radiologist approval.
● Viewing orders: Only use "LAC Radiology" filter for Department (use "all sections" and "all subsections" for the other two filters)
● Click on "unapproved requests" — these are studies pending approval
● Right click on any column title, such as "Patient Name" and click "Customize" -- you can put the columns in an order that makes sense to you. We recommend having the requested date, accession #, pt name, pt type, allergies, procedure name, reason for exam, reason for exam-DCP, and nurse unit immediately visible; you can move all the other columns to the right.
● Click on the "Patient Type" column to sort by patient type
● Now all the inpatients are bunched together in a digestable group, and just focus on the CT requests needing approval (beware, especially early in the year: sometimes procedures are ordered as “IR…” instead of “CT…”)
● To make things even prettier, you can assign colors. Go to View-->Customize-->Color Settings. Then select the following:
● Column: patient type
● Column value: inpatient
● Color setting: your preference
● Repeat as needed for Emergency patients, outpatients, etc.
● If you want to see if a study has been protocoled and it's not on your list, go to the "Exam" tab (you were under "Unapproved Requests" until now) and sort by name. Right click any column to customize your columns again (make sure vetting status, patient name, MRN are visible) and you can quickly see if a study has been approved/canceled/modified/etc.
● To make sure your list auto-refreshes, go to: View-->Options-->Interval options, make sure it says 5 minutes!
VII. Procedures while on CT and US
When getting a request for a procedure, first look up the pertinent clinical history, imaging, coagulation status and other pertinent info. Any requests for procedures must be presented to an attending for approval. For CT procedures, everything above the diaphragm is staffed by CTI attending, anything below goes to your body CT attending. If study is approved, make sure the patient is consentable, NPO (not necessary for some minor procedures), off anticoagulants, and that coags and platelets are within acceptable limits. Then tell the techs/front desk when you want them to call for the patient. When the patient arrives, consent them for the procedure (iMed consent is on the hospital’s home website). If doing biopsies, make sure the samples are dropped off in pathology lab. You are responsible for dictating procedures that you are in.
A. Pathology stuff for biopsies: After biopsy, put in orders in Powerchart:
1. "Pathology Tissue Request", and
2. "Cytology Non-Gyn Request" (if applicable)
B. Orders for microbiology:
1. “Wound culture”: for AEROBIC culture of anything (yes, this doesn't make sense!)
2. C AFB, C Fungal, C anaerobic — for other cultures
The labels should print out and should be kept with the sample. The first time you do these orders, it’s not a bad idea to have either your senior resident or the pathology fellow/resident double-check your work as errors can be easy to make.
1. Unofficial Resident-to-Resident Guide by former residents: Stu, Alok, and Kristina.
2. Dr. Frank Chen’s contrast guidelines.
3. Inpatient Body Protocoling / Procedure tips by Nasim and Felix.
4. Compiled and put together by your friendly 2016-17 chiefs: Nasim, Navid, & Hussan.
5. Updated and hosted online in 2018 by Tim.