Steven Aaron Ross, M.D. Pediatric Radiologist El Paso Imaging Consultants El Paso Children s Hospital
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1 Steven Aaron Ross, M.D. Pediatric Radiologist El Paso Imaging Consultants El Paso Children s Hospital
2 I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. From the Hippocratic Oath Association of American Physicians and Surgeons
3 Describe risks of CT radiation. Describe benefits of CT in pediatric trauma. Describe risk/benefit analysis. Describe current recommendations. Discuss if we should communicate the risks to parents/patients?
4 Deterministic Threshold exists Cataracts, skin/soft tissue burns, epilation. Stochastic No threshold linear dose effect. Cancer, teratogenesis. Hormesis Theory that low-level radiation is protective against cancer.
5 Based on current understanding of radiation, how would you best describe the risk of cancer from being in the room when an x-ray is taken? A-There is no risk since the amount of radiation does not meet the stochastic threshold. B-There is minimal risk from minimal exposure to radiation. C-There is risk to the patient but not to people nearby. D-The risk of cancer from radiation is often understated.
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7 Based on current understanding of radiation, how would you best describe the risk of cancer from being in the room when an x-ray is taken? A-There is no risk since the amount of radiation does not meet the stochastic threshold. B-There is minimal risk from minimal exposure to radiation. C-There is risk to the patient but not to people nearby. D-The risk of cancer from radiation is often understated.
8 The risk is theoretical due to limitations in research. Studies are all based on data from atomic bombs, workers in nuclear industry, and accidental exposures. Assumptions include: Type of radiation Extrapolation. Organ sensitivities.
9 We discuss (and consent patients for) certain risks involved with procedures (e.g. infection, bleeding, death) These are not risks, they are known potential outcomes. Outcomes have a definable incidence in a population. Incidence of medical radiation induced cancer cannot be defined.
10 The mortality/morbidity reduction obtained through CT identification of disease. Difficult, if not impossible, to measure. Risk cannot be measured. Benefit is extremely difficult to measure. Risk-Benefit analysis is generally subjective. Analysis can become semi-quantitative through extrapolation/comparison.
11 2006, Nat l Council on Radiation Exposure & Measurements
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13 Study Type Flight (NY to London) PA CXR Abdominal CT Barium Enema Neonatal abdominal CT Dose (mgy or msv)
14 Risk of developing cancer (lifetime) Male: 1 in 2 (44.1%) Female 1 in 3 (37.6%) Risk of dying from cancer (lifetime) Male 1 in 4 (23.2%) Female 1 in 5 (37.6%) _or_dying_from_cancer.asp
15 McCollough CH, et al. AJR 2009
16 Toshiba America Medical Systems, Inc.
17 Brenner DJ, et al. AJR 2001
18 Children have longer life expectancy. Children are more radiosensitive than adults. Size of patient creates higher doses for same CT settings. Children, in general, receive a higher dose than necessary.
19 Cause of Death Deaths per 1,000 Cancer 228 MVA 11.9 Radon 3-21 Arsenic in water 1-13 Abdominal CT 0.5 Pedestrian accident 1.6 Drowning 0.9 Lightning strike 0.013
20 1 in 175,223,510. Roughly equivalent to being hit by lightning while being eaten by a shark living through it then having it happen again.
21 Lifetime risk of dying from cancer in the U.S. is about 22%. There is no statistical evidence of increased fatal cancer risk for radiation doses below 100 msv. In order to ensure public health, we assume a risk exists, even at low doses. Current theories place risk of fatal cancer at % for a CT (~1 in 1500 as compared to the background risk of 1 in 4.5).
22 How have the risks of developing cancer from CT radiation been calculated? A-They have not been calculated or estimated. B-Calculation is based on retrospective studies from patients with medical radiation doses. C-Calculation is based on cohort studies. D-Risks are estimated by extrapolation from nuclear bomb and nuclear accident survivors.
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24 How have the risks of developing cancer from CT radiation been calculated? A-They have not been calculated or estimated. B-Calculation is based on retrospective studies from patients with medical radiation doses. C-Calculation is based on cohort studies. D-Risks are estimated by extrapolation from nuclear bomb and nuclear accident survivors.
25 Immeasurable. CT has revolutionized the diagnosis and treatment of nearly every human pathologic condition. CT has an even more important place in Trauma. CT has resulted in the avoidance of countless surgeries. CT SAVES LIVES No one has estimated how many!
26 Judicious use of CT Adjust parameters Weight based settings, automated exposure control Variable dosing methods Indication specific protocols. Shielding Breast, eyes, thyroid. Image processing Exam alternatives.
27 What is the best way to reduce the risks from CT? A-Judicious use of CT. B-Adjust parameters for child size. C-Shielding. D-All of the above.
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29 What is the best way to reduce the risks from CT? A-Judicious use of CT. B-Adjust parameters for child size. C-Shielding. D-All of the above.
30 Ultrasound No radiation No sedation Vascularity, cyst? MRI No radiation Often sedation Better contrast resolution, less spatial resolution.
31 What indication would be the MOST appropriate for CT? A-16 yo with cyst on arm. B-2 yo with head injury and scalp swelling. C-3 yo with insidiously enlarging abdomen. D-15 yo with blunt force trauma to abdomen.
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33 What indication would be the MOST appropriate for CT? A-16 yo with cyst on arm. B-2 yo with head injury and scalp swelling. C-3 yo with insidiously enlarging abdomen. D-15 yo with blunt force trauma to abdomen.
34 PECARN (Pediatric Emergency Care Applied Research Network) Kuppermann et. al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009: Oct 3; 374(9696):
35 Largest study ever on pediatric head injury. Validated in multiple settings with sensitivity of 100% for ci-tbi. Outperformed CHALICE and CATCH in 2 studies. Specificity (55%-62%). Used to identify pts who DON T need CT. Low rates of citbi and even lower rate of TBI that required neurosurgical intervention. Large confidence intervals for sensitivity.
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38 Informed consent? Do you need to? Informed choice
39 Karsli T, et al. Pediatr Radiol 2009
40 Larson DB, et al. AJR 2007
41 Do I have to consent patients for CT? A-Image Gently alliance states NO. B-NRC guidelines state YES. C-It is up to the clinician and radiologist. D-In TX and NM patients must be consented for medical radiation.
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43 Do I have to consent patients for CT? A-Image Gently alliance states NO. B-NRC guidelines state YES. C-It is up to the clinician and radiologist. D-In TX and NM patients must be consented for medical radiation.
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