Case 1:
29 year-old male with PMHx significant for Obesity who presents to the ED with complaints of fever, chills, generalized muscle aches, shortness of breath and a nonproductive cough. States symptoms have been present for approximately 5 days.
Vitals: BP: 138/72 HR: 107 SpO2: 88% on 10 LPM RR: 38 Temp: 38.90 PMHx: Obesity
Ht: 5’7”
Wt: 153 kg
12. Who is at fault?
Academic Emergency Medicine, Volume: 22, Issue: 4, Pages: 390-398, First published: 23 March 2015, DOI: (10.1111/acem.12625)
13. Who is at fault?
Academic Emergency Medicine, Volume: 22, Issue: 4, Pages: 390-398, First published: 23 March 2015, DOI: (10.1111/acem.12625)
ME
Y’ALL
21. Lancet 2012; 380: 499–505
Of 10,000 people age 0 to 20 CT scanned
Leukemia (1 scan): 0.83 excess cases
Brain tumors (2-3 scans): 0.32 excess cases
22. Retrospective cohort study: 178,604 children
3x risk of
Leukemia for cumulative doses ~50 mGy
Brain cancer for ~ 60 mGy
23. Absolute vs relative risk: 3x small = still small!
1 excess leukemia and 1 excess brain tumor per
10,000 in first 10 yrs after pediatric head CT
24. BEIR-VII Lifetime Attributable Risk (LAR)
of radiation-induced cancer above baseline
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
0 10 20 30 40 50 60 70 80
Age at Exposure
LAR
(%
per
100
mSv) Female Cancer Incidence
Male Cancer Incidence
Sodickson, Baeyens, Prevedello, et. al. RecurrentCT, Cumulative Radiation Exposure, and Associated Radiation-Induced Cancer Risk from CT of Adults, Radiology. 2009;251(1)
25. Who are we worried about?
31,462 patients
33% > 5 exams
5% > 22 exams
1% > 38 exams
Mean 6.1 exams
Max 132 exams
Sodickson, Baeyens, Prevedello, et. al. RecurrentCT, Cumulative Radiation Exposure, and Associated Radiation-Induced Cancer Risk from CT of Adults, Radiology. 2009;251(1)
asodickson@bwh.harvard.edu
26. Sodickson, Baeyens, Prevedello, et. al. RecurrentCT, Cumulative Radiation Exposure, and Associated Radiation-Induced Cancer Risk from CT of Adults, Radiology. 2009;251(1)
Incremental risks vs benefits (indications)
asodickson@bwh.harvard.edu
27. Sodickson, Baeyens, Prevedello, et. al. RecurrentCT, Cumulative Radiation Exposure, and Associated Radiation-Induced Cancer Risk from CT of Adults, Radiology. 2009;251(1)
Incremental risks vs benefits (indications)
asodickson@bwh.harvard.edu
Patient FP - Cumulative Exposure and LAR
at 1 X, 1/2 X, 1/4 X Projected CT Rates
0
250
500
750
1000
1250
1500
1750
2000
2250
2500
2750
3000
3250
3500
3750
4000
25 30 35 40 45 50 55 60 65 70 75 80
Age
Cumulative
Exposure
(mSv)
0
5
10
15
20
25
%
Lifetime
Attributable
Risk
(LAR)
above
baseline
31. Do we hurt kidneys?
Contrast CT scan à acute kidney injury (AKI)
contrast is
associated
with AKI
contrast not
associated
with AKI
Aycock RD et al. Acute kidney injury after computed tomography: A meta-analysis. Ann Emerg Med 2017 Aug
32. Do we hurt kidneys?
Contrast CT scan à renal replacement therary
(dialysis or similar)
contrast is
associated
with RRT
contrast not
associated
with RRT
Aycock RD et al. Acute kidney injury after computed tomography: A meta-analysis. Ann Emerg Med 2017 Aug
33. Do we hurt kidneys?
Contrast CT scan à death
contrast is
associated
with death
contrast not
associated
with death
Aycock RD et al. Acute kidney injury after computed tomography: A meta-analysis. Ann Emerg Med 2017 Aug
34. Do we hurt kidneys?
Contrast CT scan à death
contrast is
associated
with death
contrast not
associated
with death
Aycock RD et al. Acute kidney injury after computed tomography: A meta-analysis. Ann Emerg Med 2017 Aug
50. Why do we over-test?
Academic Emergency Medicine, Volume: 22, Issue: 4, Pages: 390-398, First published: 23 March 2015, DOI: (10.1111/acem.12625)
51. What do we think would reduce
over testing?
Academic Emergency Medicine, Volume: 22, Issue: 4, Pages: 390-398, First published: 23 March 2015, DOI: (10.1111/acem.12625)
67. In review
More care ≠ better
49.999% of us are worse than average
CT scans add up. Not your fault.
68. In review
Contrast not so bad in our setting.
Incidentalomas and ultrasound.
Spending less money may be costly.
Malpractice reform only a little helpful
Culture matters.