Radiation exposure among patients with the highest CT scan utilization in the emergency department.

The risk of cancer from computed tomography (CT) scan radiation is a rising concern in the medical field. Our objectives were to determine how many patients received more than ten CT scans in an academic emergency department (ED) over the course of 7 years and to quantify their radiation exposure and lifetime attributable risk of cancer. An electronic chart review was performed at our urban academic institution with an annual census of 110,000 patients. All patients who underwent a CT scan performed during ED management between the dates of January 2001 and December 2007 were identified. Specific predetermined data elements (e.g., subject demographics, type of CT scan) were extracted by two researchers blinded to hypothesis, using a preformatted data form. After identifying patients with more than ten CTs performed during the study period, radiation exposure was calculated based on accepted and reported radiation doses for the respective anatomic CTs, and lifetime attributable cancer risk was calculated based on the seventh report of the Biological Effects of Ionizing Radiation (BEIR VII) projections. Over the 7-year study period, 24,393 patients received 34,671 CT scans. The vast majority of patients (17,909) received a single CT. Twenty-six (0.1 %) patients received more than ten CTs totaling 374 scans with an average radiation exposure of 83.4 mSv. The maximum lifetime attributable risk for any individual in this cohort was 1.7 % above the baseline cancer risk. Among those undergoing CT imaging in our ED, high-exposure patients (greater than ten scans) constituted a significant minority, while more than one in four patients underwent more than one CT scan during the study period. While the presumed overall risk of radiation-induced cancer continues to be low, it is important for the emergency physician to use clinical knowledge as well as concern for the patient when utilizing radiographic imaging. Increasing attributable cancer risk may have important public health implications in the future, regardless of the low individual risk.

Etomidate Use Is Associated With Less Hypotension Than Ketamine for Emergency Department Sepsis Intubations: A NEAR Cohort Study.

OBJECTIVE: The objectives of this study were 1) to describe the current use of etomidate and other induction agents in patients with sepsis and 2) to compare adverse events between etomidate and ketamine in sepsis. METHODS: This was an observational cohort study of the prospective National Emergency Airway Registry (NEAR) data set. Descriptive statistics were used to report the distribution of induction agents used in patients with sepsis. Adverse events were compared using bivariate analysis, and a sensitivity analysis was conducted using a propensity score-adjusted analysis of etomidate versus ketamine. RESULTS: A total of 531 patients were intubated for sepsis, and the majority (71%) were intubated with etomidate as the initial induction agent. Etomidate was less frequently used in sepsis patients than nonsepsis patients (71% vs. 85%, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.4 to 0.5). Sepsis patients had a greater risk of adverse events, and vasopressor therapy was required for 25% of patients after intubation. Postprocedure hypotension was higher between those intubated for sepsis with ketamine versus etomidate (74% vs. 50%, OR = 2.9, 95% CI = 1.9 to 4.5). After confounding by indication in the propensity score-adjusted analysis was accounted for, ketamine was associated with more postprocedure hypotension (OR = 2.7, 95% CI = 1.1 to 6.7). No difference in emergency department deaths was observed. CONCLUSIONS: Etomidate is used less frequently in sepsis patients than nonsepsis patients, with ketamine being the most frequently used alternative. Ketamine was associated with more postprocedural hypotension than etomidate. Future clinical trials are needed to determine the optimal induction agent in patients with sepsis.