Images Prof Peter Scally. Fig 2. Cross-section of the spinal cord. The only neurons to decussate at (or near) their s pinal cord level are those in the spinothalamic tract. Pyramidal tract \201 bres decussat e in the medulla and the dorsal column \201 bres decussate after the gracile and cuneate nuclei of the medulla. Incomplete spinal cord injuries (see \201 gs 3 \200\2235) and youn ger patients have a better prognosis.353 769 Dorsal column Pyramidal tract Fig 3. Brown \200\223S quard syndrome (OHCM, p710). In this rare injury pattern, there is hemisection of the spinal cord (more often seen after penetrating rather than blunt trauma) , causing ipsilateral loss of dorsal column sensation and motor function below the lesion a nd contralateral loss of spinothalamic sensation from a few levels below the lesion. NB: sp inothalmic tract \201 bres as- cend for a few levels on the same side as cord entry befor e they decussate. Spinothalamic tract a m u a r t d n a s c i d e a p o h t r O Level of spinal cord hemisection Dorsal column Affected area of cord Pyramidal tract Spinothalamic tract Anterior spinal artery Fig 4. Anterior cord syndrome. There is infarction of the spinal cord in the distribution o f the anterior spinal artery, causing complete loss of motor function and pain and temperat ure sensation below the lesion. Vibration and joint position sense are retained. This injur y pat- tern has the worst prognosis of the incomplete injuries. Pyramidal tract Affected area of cord Dorsal column Spinothalamic tract Fig 5. Central cord syndrome. Usually seen after a hyperextension injury in someone with pr e-existing spinal canal stenosis (most often in the cervical region). There is greater loss of motor power in the upper extremities compared to the lower extremities combined with va rying patterns of sensory loss and sphincter dysfunction. Figs 2-5 adapted from Donaghy, M. Oxford Core Texts: Neurology with permission from OUP Cord injury \200\224function and functional anatomy The \200\230tightest \201 t \200\231 between cord and canal is in the thoracic spine; this region also has the poorest blood su pply. These facts explain why thoracic lesions are more likely to be complete than cervical or lumbar lesions. Ischaemic injury often spreads below the level of the mechanical injury . For the segment of the cord involved with injury at a speci \201 c vertebra, see below. Cord compression For causes, see MINIBOX. Root pain (p674) and lower motor neuron signs occ ur at the level of the lesion with upper motor neuron signs and sen- sory changes below the lesion (spastic weakness, brisk re \202 exes, upgoing plantars, loss of co-ordination, jo int position sense, vibration sense, temperature and pain). Cord anatomy (p768) is such tha t dorsal column sensibilities (light touch, joint position sense, vibration sense) are aff ected on the same side as the insult, but spinothalamic tract interruption aff ects pain an d temperature sensation for the opposite side of the body 2 \200\2233 dermatome levels lowe r than the aff ected sensory level. As the cord ends at L1, compression at this vertebral l evel aff ects information in the cord relating to lower dermatomes. To determine the cord l evel aff ected behind a given vertebra, add the number in blue to that of the vertebra conc erned, thus: \200 C2 \200\2237: +1 \200 T1 \200\2236: +2 \200 T7 \200\2239: +3 \200 T10 has L1 and L2 levels behind it \200 T11 has L3 and 4 \200 L1 has sacral and coccyg eal segments. It can be diffi cult to determine the level: MRI will help clarify this. 770 \200 Causes: \200 Bone displacement \200 Disc prolapse \200 Local tumor \200 Abscess \200 Haematoma a m u a r t d n a s c i d e a p o h t r O Lower lumbar problems can cause cauda equina compression ( \200 p675) characterized by musc ular pain, dermatomal sensory changes (if the lowest sacral dermatomes are aff ected the ge nitals are anesthetic), and retention of urine feces. \200\207These signs indicate urge nt neurosurgical referral with imaging eg to con \201 rm or exclude a tumor or extradural abscess. Spinal shock There is anesthesia and \202 accid paralysis of all segments, and m uscles innervated below the level (hence are \202 exia) and there is re- tention of urine. A \200\230stage of reorganization \200\231 then occurs (re \202 ex emptying of bladder a nd rectum; sweating). Later, \202 exion at hip and knee may be in- duced by stimuli (nota bly cold), often with empty- ing of the bladder and rectum (Head and Riddoch \200\231s mass re \202 exes). The legs may become permanently \201 xed in a drawn up position, with do rsi \202 exion of the ankles (spastic paraple- gia in \202 exion). Over months, tendon r e \202 exes return, and proprioceptive stimuli give rise to \200\230mass extension \200 \231. Exact duration is not predictable. Spinal or neurogenic? \200\207NB: don \200\231t confuse spinal shock with neurogenic shock : the latter is BP \200\201 tachycardia, without caused by impairment of the descending spi nal sympathetic pathways. Paraplegia/quadriplegia levels (See also p716 for testing motor nerves) Levels \202 uctua te (as does interpretation), so examine often: Raises elbow to horizontal: deltoid C5 Flexes hip: iliopsoas Flexes forearm: biceps Extends forearm: triceps Flexes wrist and \201 ngers L2 C6 Extends knee: quadriceps C7 Dorsi \202 exes ankle: tibialis anterior C8 Extends great t oe: Extensor hallucis L3 L4 L5 longus Spreads \201 ngers T1 Plantar \202 exes ankle: gastrocnemius S1 771 Restoring lost function: is it possible? The following is not a list of well-tried treatmen t options: the \201 eld is too new. Here we present a way of thinking about cord injury, and preparing our minds for discussions with experts. Most patients prioritize their wishes for restora- tion of functions in this order: bowel and bladder control; sexual function; hand function; breathing. Options might be: \200 Glutamate receptor blockers to limit sec ondary injury (p767). \200 Anti-apoptotic agents, eg NT-3 (neurotrophin-3), BDNF (brain-d erived neuro- trophic factor), and ICE-protease (interleukin-1 \200 -converting enzyme) inh ibi- tors. a m u a r t d n a s c i d e a p o h t r O Chemical prevention of action potential dissipation from demyelinated ar- eas agents to remyelinate axons. \200 Blocking natural inhibitors of regeneration, eg IN-1 (inhibitor n eutralizing antibody). Promotion of axonal regeneration \200\224eg BDNF & NT-3, (see above). Note that guidance of axons must be arranged, eg via guidance molecules such as netrins, cell adhesion molecules , and speci \201 c matrix proteins. Replacement of lost cells (cloned embryonic stem cells are one option; use of endogenous progenitor cells is another option). Often these options seem a long way off , but note that only 10% of damaged neurones need t o be replaced to enable useful locomotion.354,355 Segment injury \200\224a guide to possible subsequent function: C4 Can use electric chairs with chin control; type with mouthstick; use a \200\230Pos- sum \200\231 environmental control system to turn on lights & open doors. C5 With special devices, he can feed, wash face, comb hair, and help with dress- ing the up per body. He may be able to push a wheelchair along the \202 at, if pushing gloves are wo rn, and there are capstan rims on the wheels. The NHS will supply an electric wheelchair (i ndoor use only). Unable to transfer from wheelchair to toilet. C6 Still needs a strap to aid feeding and washing. Dresses top half of body; helps dress lower half. Can drive with hand controls. C7 Can transfer, dress, feed himself. C8 Independent wheelchair life. Spinal cord injury: genitourinary aspects One major problem is urinary incontinence and re \202 ex detrusor activity (after acontractility in the period of spinal shock) and the pre sence of residual urine. This predisposes to infection and ureteric re \202 ux. These are major causes of renal failure, morbidity, and mortality. Methods of bladder drainage Manage ment in the \201 rst few days typically requires an indwelling urethral catheter. This sh ould be secured with a waist band to prevent urethral traction. By the \201 rst weeks aft er cord injury use su- prapubic or clean intermittent urethral catheterization356 (OHCM \201 g 3, p777) with a 12 or 14 FG Nelaton catheter. Culture the urine every week, and ai m to eradicate infection (particularly important with Proteus which induces stones in infec ted alkaline urine). In some patients it may be possible to induce void- ing by tapping the suprapubic area for 20sec. Initially, catheterization is still necessary to drain the res idual urine, but when this is <80mL (on 3 consecutive occasions), discontinue the catheter. If this does not occur, and particularly if the detrusor is non-contractile (conus medulla ris or cauda equina injury), intermittent self-catheterization (eg with a silver catheter i n women) may be used, as soon as the patient can sit. If re \202 ex voiding occurs, propan theline 15 \200\22330mg/8 \200\22312h PO 1h AC may reduce detrusor activity and obviate the need for wearing drainage devices continuously. It may also help reduce hyperhidro- sis.35 7 The elderly may require an indwelling silicone catheter, with 6-weekly changes. Weekly wa shouts (eg Suby-G ) may prevent stones. Aim for an out- put of >3L/day. Use clamps to achi eve volumes of 300mL. Arti \201 cial sphincters are available for acontractile bladders. C omplications Genitourinary complications are among the commonest causes for rehospitalizati on in spinal cord injury patients, so eff ective manage- ment, involvement and education ar e vital.358 Urinary infection: Historically used to be a serious cause of mortality (along with infected skin ulceration).359 It may be prevented by a high \202 uid intake, en- sur ing eff ective bladder emptying, and acidi \201 cation of the urine (eg ascorbic acid 1g/6 h PO). Detrusor-sphincter dyssynergia: The external urethral sphincter fails to relax or ac tively contracts during detrusor contraction. There is poor bladder emp- tying and vesicour eteric re \202 ux, predisposing to pyelonephritis, hydronephro- sis, and renal failure. It is wise to do U&E, creatinine, and IVU as early baseline tests. Treatment: Endoscopic exte rnal sphincterotomy. Autonomic dysre \202 exia: In those with lesions above the sympatheti c out \202 ow (ie above T6) bladder distension (eg with a blocked catheter) may result in sympathetic overactivity below the level of the lesion. There is vasoconstric- tion and hyp ertension (may cause strokes/seizures/intra-cranial hemorrhage and death). The patient may have a headache, a feeling of anxiety, sweaty/ blotchy skin above the lesion with pale, dry skin below the levely of lesion. The carotid baroreceptors are stimulated causing re \202 ex vagal bradycardia, but the signals which would normally produce relieving vasodilatatio n are unable to pass down the cord. Other stimuli which may produce this eff ect include UT I, calculi, constipation, labor, ejaculation, and bladder or colonic irrigation.360 Treatme nt: 361 Remove the cause; put in an upright position and loosen tight clothing. Give nifedi pine (10mg \200\224bite the capsule) with glyceryl trinitrate 0.5mg (not if patient has use d sildena \201 l in the prior 24h). Captopril may also be useful in the acute management. Prazosin may be useful in its prevention. On-demand urination There have been encouraging t rials in those with ASIA- A lesions (p767) of the Brindley \200\223Finetech Vocare implanta ble bladder system which activates anterior sacral nerve roots to regulate bladder and larg e bow- el and urethral/anal contraction. This leads to cost savings (fewer catheters), fewe r UTIs, and a better life.355 772 a m u a r t d n a s c i d e a p o h t r O 773 Sexual function \200\207Sexual counseling is an integral part of rehabilitation. It is imp ortant in itself, but we should recognize that sexuality interacts with important determina nts of our patient \200\231s quality of life, eg levels of dependency, aggression, self-est eem, and autonomy.362 a m u a r t d n a s c i d e a p o h t r O We should enlist expert help, but we can all counter myths that disabled men cannot sexuall y satisfy able-bodied women; and that the cord-injured cannot have intercourse. Don \200 \231t be shy and don \200\231t be shocked: for help with dis- cussing sexual issues, see p3 28. \200\207Given a knowing and patient partner, most persons with spinal injury can enjoy a satisfying sex life.363,364 Be aware that sexuality encompasses more than physical attractiveness and penile \200\223va ginal intercourse. With spinal cord injury, use of sexual imagery and concentration on body areas that retain sensation have especial impor- tance, as does a certain inventiveness an d readiness to experiment.365 When helping these patients it is important to distinguish sexual drive and sexual satisfac tion from fertility and parenting needs. Both need addressing in a systematic way within th e broader contexts of psychosocial, emotional, and relationship aspects \200\224and also in terms of cognitive-genital dissociation, per- ceived sexual disenfranchisement, and sexual rediscovery. Cognitive-genital dissociation may take various forms, eg indicating that for some, sexual activ- ity is more like watching a graphic movie than engaging in a physical experi- ence.366 It is equally important to assess the partner \200\231s needs and response s to the injury. This takes time.367 Do not concentrate on physical aspects alone: nevertheless it may be helpful to familiarize yourself with some statistics, and to emphasize that individu- als vary. In some studies, locomotor impairment and dysre \202 exia were more frequently given as causes of reduced s exual pleasure than speci \201 c sexual dysfunctions.365 In women, only 17% with complete lower motor neuron dysfunction aff ect- ing the S2 \200 \223S5 spinal segments can achieve orgasm, compared with 59% of women with other levels and degrees of injury. In men with lesions between T6 and L5, 75% can expect improvement in erections with use of sildena \201 l.368,369 Fertility issues in men center around performance and sperm quality, which may be reduced b y scrotal hyperthermia, retrograde ejaculation, prostatic \202 u- id stasis, and testicul ar denervation. Electro-ejaculation and intracytoplasmic sperm injection have a useful role (p293). In women, pregnancy rates vary from 10% to 60%.370 Autonomic dysre- \202 exia is serious risk, especially in lesions at or above the level of T6. Pregnancy and childbirth can be s uccessful and rewarding for all involved when careful planning and communication take place \200\224eg incorporating child care issues into the rehabilitation process.371 Cord injury \200\224OT, physio, and nursing aspects The occupational therapist (OT) is a ke y person in maximizing the levels of achievement outlined above. She is also in a position to arrange a home visit with a member of the spinal injuries team, and a community liaison nurse or social worker. The aim is to construct a plan with local social services and the l o- cal domiciliary OT, so that the patient \200\231s (and his family \200\231s) hopes can b e realized to the fullest extent. She can arrange the necessary home modi \201 cations, an d give invaluable advice about the level of independence which is realistic to strive for. As ever, the aims of the OT extend into augmenting self-esteem, and helping the patient com e to terms with loss of role, and loss of con \201 dence, and to mitigate the eff ects of disability by arranging for as much purposeful activity as possible, in the realms of both work and leisure. She will also be able to make plans for acquiring of social skills to ass ist the patient in his new way of life. Nursing & physiotherapy \200 The chest: Regular p hysio with coughing and breathing exercises prevents sputum retention and pneumonia which a re like- ly to follow diaphragmatic partial paralysis (eg C3 \200\2234 dislocation). If the lesion is above T10 segmental level, there is no eff ective coughing. \200 The straight lift: (for transferring patients) One attendant supports the head with both hands under the neck so that the head lies on the arms. 3 lifters standing on the same side insert their a rms under the patient, one at a time, starting at the top. After the lift, withdraw in the reverse order. 774 a m u a r t d n a s c i d e a p o h t r O The log-roll: (learn from observation; see \201 g 1, p799) 3 lifters stand on the same si de of the patient. The one near the head has both arms under the patient \200\231s trunk an d over the patient \200\231s further arm; the 2nd has one arm under the legs and the other arm holds the patient \200\231s iliac crest. The 3rd lifter supports the calves. A 4th pers on controls the head and neck, and gives the command to turn. The patient is then gently ro lled laterally, with pillows to support the lum- bar curve and to keep the position stable. Posture: Place joints in a full range of positions. Avoid hyperextensions. Keep the feet \202 exed at 90 with a pillow between soles and bed-end. Bowels: From the second day of injury gentle manual evacuation using plenty of lubricant is needed. A \202 atus tube may be helpful in relieving distension once the ileus of spinal shock has passed. Irrigation may improve quality of life.372 \200 Wheelchairs: The patie nt should be kept sitting erect; adjust the footplates so that the thighs are supported on the wheelchair cushion and there is no undue pressure on the sacrum. \200\207Regular relie f of pressure on sacral and ischial areas is vital. Independence in transferring to bed or toilet will be a suitable aim for some patients with paraplegia. Expert skill is needed in assigning the correct wheelchair for any particular patient. Standing and walking: Using a \200\230tilt table \200\231, or the Oswestry standing frame with trunk support straps, the tetraplegic patient can become upright. If the injury level is at L2 \200\2234, below-knee calipers and crutches enable walking to take place. If the l esion is at T1 \200\2238, \200\230swing to gait \200\231 may be possible. The crutches are placed a short distance in front of the feet. By leaning on them and pushing down with the shoulders, both legs can be lifted and moved forwards together. The goal is to promote re- establishment of functional connections in neuronal networks and shaping the motor patterns that they generate.373 \200 Sport: Consider archery, darts, snooker, table tennis, and s wimming for those with paraplegia. Many other sports may also be suitable. There are intere sting and important factors to consider such as the optimal heart rate (eg with le- sions a bove T4 there is severely diminished cardiac acceleration, and a maximal rate of 130bpm) a nd the reduction in bone density below the lesion.374 Personal qualities in therapists are almost as important as exact anatomic lesion. There may be big mood swings from euphoria to despair as the patient accustoms himself to his loss and his new body image. This page intentionally left blank \200\234I seemed to have been asleep nearly all of my life. \200\235 \200\234 But when did you wake up? \200\235 \200\234I don \200\231t know that I ever did, or ever have. \200 \235 Sons & Lovers, 274 Vegetative states \200\230Persistent vegetative state \200\231 aims to describe the behav- iour of severely brain damaged people who show sleep \200\223 awake behavior, but in whom there is absent cognition and awareness. Making the diagnosis Persistent vegetative states are rare, and liable to misdiagnosis by non-specialist neurologists and neurosur- geons \200\224it requires careful repeated assessment and taking into account ob- servations made by family and carers. \200\207The harder you look, the more likely you are to \201 nd s igns of active cognition, so negating the diagnosis of a vegetative state. The patient in a vegetative state (VS) \200\234appears at times to be wakeful, with cycles of eye closure and eye opening resembling those of sleep and wak- ing \200\235. But they lack signs of awa reness \200\224there is no evidence they can perceive the environment or their own body.375 Persistent vegetative state refers to a VS which has continued for more than 4 weeks. Perm anent vegetative state refers a VS that has lasted 12 months following a traumatic brain in jury, or 6 months following other causes of brain injury. Patients that show awareness are said to be in a minimally conscious state rather than a vegetative state. Investigations In addition to history and neurological examination, there are a number of methods that can b e used to aid the decision as to whether there is cognitive brain function present: eg soma tosensory evoked potentials (SSEPs) and electroencephalography (EEG). However, the problem is that these tests not only have to be 100% speci \201 c (an impossibility) but they also need to be able to predict return of cognitive function, and not just its presence. To mak e matters even more complicated, pharmacological and metabolic chang- es can also interfere with the accuracy of such tests.376 One review has quoted that with the absence of somatos ensory evoked potentials in patients with hypoxic ischaemic encephalopathy, the chances of waking are less than 1%.377 Another method of showing awareness and cognition is by demonst rating communication, eg by following a simple request to press a buzzer or to look at a na med object. These switches are particularly suited to those who can only manage a tiny amou nt of voluntary movement. Other ways of commu- nicating include listener scanning: the ther apist goes through A \200\223Z slowly, and the patient buzzes when the required letter is r eached. It may take weeks or months to establish that the patient can communicate. Rancho s cale assess- ment establishes the level of cognition \200\224from confused-and-inappropriat e (level 5) to purposeful-and-appropriate (level 8). 776 Causes: \200 Trauma \200 Anoxia \200 Vascular causes \200 Encephalitis a m u a r t d n a s c i d e a p o h t r O fMRI has shown that some patients with the diagnosis of a vegetative state can have pattern s of brain activity detectable which are suggestive of higher mental activity thus indicati ng a degree of consciouness of self and environ- ment.378 Whether this makes an ethically s igni \201 cant diff erence in the manage- ment of such patients is unresolved.379 Manageme nt Seek expert rehabilitative help. While waiting for any recov- ery, aim to provide vigoro us nursing care to maintain nutrition, and to pre- vent pressure sores, and tracheostomy an d muscle contracture complications. No drugs are known to help, although there is anecdotal evidence that bro- mocriptine may do so. Randomized trials indicate that multimodal stimul a- tion (arousal programs) help. These programs involve stimulation of all senses every 15m in for up to 11h per day. Once it is agreed that there will be no recovery (the diffi cult issue), discus- sions on w ithdrawing active treatment and nutrition raise big ethical ques- tions \200\224which are o nly partly mitigated if the patient has an advance direc- tive (an unlikely event). Ethicis ts, medical specialists, nurses, physiotherapists, judges, and the family must all be allow ed to have their say. None is infallible. NB: also see Death: diagnosis and management, OHC M, p6. 777 Muddled over death, brain death and persistent vegetative states? When the Buddha was ailin g, he was at \201 rst mispronounced dead by Ananda, his attendant for 25 years. Ananda wa s then \200\230corrected \200\231 by a top monk who stated that the Buddha had entered a d eep yogic trance in which no vital signs could be discerned (as might occur in hypothermia) .380 How do you tell? First, recognize that death is a process, and in some instances (such as hypothermia) all processes are suspended \200\224so not even death can unfold (or it ma y unfold slowly). Next, accept that absent brainstem re \202 exes is a only a useful short - hand for death of the brainstem \200\224which itself is only a shorthand for brain death (functions remain, such as thermoregulation and production of CNS hor- mones, etc). And dea th of the brain is just a useful shorthand for death itself. According to ancient Buddhist authorities, death occurs when the body is bereft of vitality (ayu), heat (usma), and senti ency (vi ana). In many ways the senior monk was right. First know your patient, and take into account past his- tory1 and the current medical and moral context in which the diagno sis of brain death or persistent vegetative states is being made. Then ask a colleague, and keep an open mind \200\224especially when organ donation is contemplated.2 a m u a r t d n a s c i d e a p o h t r O 1 Contexts such as barbiturate poisoning and Bickerstaff \200\231s brainstem encephalitis can give a brain- death picture \200\224but are reversible (worryingly so \200\224more for ethicists than the patient). 2 Patients who have \200\230con \201 rmed \200\231 brain dea th and who are suitable for organ donation would be heart- beating donors. However, organ r etrieval is never straightforward, and so the Maastricht criteria exist for the categorizat ion of non-heart-beating organ donors: 1 Dead on arrival at hospital; 2 Unsuccessful resusc itation; 3 Awaiting cardiac arrest (eg after withdrawal of treatment); 4 Cardiac arrest aft er con- \201 rmation of brainstem death.381 Does he need a radiograph? The aim is to provide information that will alter management, wi thout expos- ing patients to unnecessary radiation. The following is based on the advice of the UK Royal College of Radiologists, and other bodies. Twisting injury of foot or ankle A n ankle radiograph is indicated if patients cannot bear weight; or if there is tenderness o n the posterior edge of either the lateral or medial malleolus. A foot radiograph is requir ed if there is pain in the midfoot, tenderness at the base of the 5th metatarsal or over th e navicu- lar. \200\224but all rules have exceptions, and, on occasion, we \200\231ve all s een patients walk on a fractured ankle.1 Injury to the cervical spine: The consequences of a missed cervical spine in- jury are disastrous, and so c-spine radiography is always perfo rmed for major trauma. But in patients who have been subjected to less violent trauma, what can be used as a guide to requesting imaging? Until you become more experi- enced in these situations, liaison with a senior colleague is wise. Nonetheless, in the presence of NSAID : \200 Neurological exam reveals a focal de \201 cit. \200 Spine exam reveals tenderne ss (posterior midline). \200 Alteration in consciousness. \200 Intoxication. \200 Dis tracting injury \200\224i.e. long bone fracture, clavicle fracture, chest trauma etc. \200 request imaging.382 Based on the NEXUS criteria for imaging of c-spine blunt injury, all t hese factors are important, though may have the drawback of a low sensitivity if applied as the sole criteria for imaging.383,384 The Canadian C-spine rules are more speci \201 c bu t more complicated. High risk factors (dan- gerous mechanism, age >65, focal neurology) man date a radiograph. Absence of these allows consideration of low risk factors (simple rear e nd RTA, sitting up in A&E, ambulatory at any time, delayed onset of pain, absence of midlin e C-spine tenderness) \200\224the presence of any one allows clinical examination of the ne ck: if the patient can rotate their neck 45 left and right they do not need a radiograph. 385 \200\230Possible \200\231 neck injury in minor head injury A radiograph is not indicat ed if fully conscious and there are no symptoms or signs related to the neck. Nose injury I maging in A&E is not indicated in simple nasal injury. Rib injury Only a posteroanterior CX R is indicated if you suspect a pneumotho- rax; rib views are not needed in uncomplicated b lunt injury. Lumbar spine pain Avoid early radiographs (in 1st 6 weeks) if there are no fac tors suggesting serious disease, eg trauma, focal neurology, fever, weight \200\201, anemia , ESR \200\200 (so do blood tests \201 rst). Each examination=2.2mSv=40 CXRs. The Sievert (Sv) is the SI unit of radiation absorbed by biological tissues \200\224see OHCM p733. Thi s dose may be expected to cause 16 malignancies/yr in the UK at current rates of exposure. It is impossible to protect the ovaries. Abdominal pain Plain \201 lms are rarely needed; request only an erect chest \201 lm in suspected gastrointestinal perforation. Erect abd ominal \201 lms are generally not indicated in most patients with abdominal pain. Foreign bodies Always do radiography if the presence of glass is possible (glass is usually radiop aque). Ultrasound can also be used in foreign body detection and to guide removal, especial ly for those that are not radio-opaque (eg splinters). NB: lumbar spine radiographs deliver a signi \201 cant dose of radiation to the go- nads \200\224similarly for skull and facia l radiographs to the eyes (lens cataracts are the risk). These guidelines yield substantial savings in costs and in patients \200\231 waiting times, without compromising patient care . 778 \200 a m u a r t d n a s c i d e a p o h t r O 1 Ottawa rules: www.bmj.com/cgi/content/full/326/7386/417. If the rule says \200\230don \200\231t x-ray \200\231 it will be right in 98.6% of cases assuming a # prevalence of 15%. Speci \201 city ( \200\230do x-ray \200\231 and # is present) is worse.386 779 Does he need a CT? Quick, accurate, and available: good reasons to think of CT as 1st-line imaging for trauma patients. But there are caveats, as any radiologist who has seen images arriving at their workstation monitor, only to have to comment that the patient \200\231s h eart has stopped, will tell you. The appropriateness of scanning in an acute trauma must be decided on the balance of risk and bene \201 t to the patient. It is not that radiologist s don \200\231t want sick patients in their depart- ment; radiology departments just aren \200\231t the best place to be if you are very sick. \200\207Ensure that the patient is ha emodynamically stable before moving them to the relatively resource-poor radiology departme nt. Some centers have tried to overcome this problem by bringing CT to the emergency depart ment, imag- ing patients as they come through the door, and while CT may well become the ne w stethoscope, this approach will also have its faults. Remember that: Radiation can do har m: It cannot be used limitlessly (OHCM p733). Imaging is just a snapshot: A \200\230normal \200\231 scan mustn \200\231t allow for complacency in patient ob- servation. \200\207Alw ays be on the lookout for clinical deterioration requiring prompt intervention. Imaging tak es time: Transfers and interpretation take the long- est: CT itself may only take 20s. This is time that the patient is at risk and also time delaying de \201 nitive management. For this reason, you may be paradoxi- cally encouraged to request more imaging (eg including C -spine), given that having to come back to the department for a second scan doubles the ris k. The Canadian CT head rule CT is only required for minor head injury if one of the follow ing is present:387 \200 Glasgow coma scale <15 at 2h post-injury. \200 Suspected open o r depressed skull fracture. \200 Signs of basal skull fracture: haematotympanum (blood in middle ear/tym- panic cavity) raccoon eyes, CSF otorrhoea/rhinorrhoea, Battle \200\231s si gn, p728). a m u a r t d n a s c i d e a p o h t r O Age >65 \200 Vomiting >2 times \200 Amnesia before impact of >30min. \200 Dangerous m echanism (pedestrian struck by car; car occupant ejected, fall from a height of >1m, or downstairs). The NICE guidelines on head injury adds post-traumatic seizure, coagulopa- thy and focal ne urological deficit as indications for a CT head.388 CT of the cervical spine CT assessment of the cervical spine is quick and ef- fective. Meta-analysis suggests that CT be used as t he \201 rst line investigation in those with a depressed mental status, though not as a m atter of course for less severe injury, in which plain radiography should still be used.389 It also has cost-bene \201 t implications.217 It is indicated if an injury is seen on the plain \201 lm series and if there is inadequate visualization (C7/T1 can be diffi cult t o image in full with plain X-ray.) A similar approach applies for other spinal injuries, bu t remember that MRI will be needed to assess the vital soft tissue structures. CT of the ch est Evidence of traumatic injury on CXR that warrants further imaging: \200 Haemothorax \200 Pneumothorax \200 Widened mediastinum (all diffi cult to spot on a supine \201 lm ) \200 Pneumomediastinum \200 Posterior rib fractures \200 Frac- tures of ribs 1 or 2 \200 Pulmonary contusion. CT of the abdomen and pelvis Usually done together. Indication s may in- clude: \200 Free \202 uid noted on FAST scan (p727), but beware US algorithms for as- sessment in blunt abdominal trauma)223 \200 Suspicion of retroperitoneal haemor- rhage (shock but not cause found) \200 Renal trauma (macroscopic haematuria, microscopic haematuria + shock). CT of the appendicular skeleton Part of pre-operative planning for co mplex injury patterns. \200\207Remember to think of patterns of injury: eg rib fractures w ith bilateral pulmo- nary contusions have a high coincidence of intra-abdominal injury Appropriate use of Emergency Departments From our point of view, the ideal scenario is to h ave a pristine, ever-ready but empty trauma department with the doctors and nurses educatin g themselves (etcetera) in the coff ee room, occasionally being called out by paramedics to save a few lives in a brief display of energy and technical brilliance. This is not how th e public sees our role. If in shock, having just run over a hedge- hog, some people feel th ey need attention now. All Emergency Departments are abused \200\224because it is always do ctors who de \201 ne what abuse is. Thus up to 70% of users have been deemed inappropriate in some studies. This \201 g- ure dwindles towards nothingness if abuse is de \201 ned as those consultations where all 3 parties to the visit, on re \202 ection, concur that it was inappropri- ate: the doctor, the patient family, and the patient \200\231s GP (who may have sent them). Overcrowding and \200\230exit-block \200\231390 This is a major probl em in Emergency De- partments the world over \200\224partly re \202 ecting centrally deter mined reductions in acute bed provision and availability, and partly re \202 ecting access problems for populations seeking prompt help with immediate (and, sometimes, chron- ic) pr oblems. If the inpatient side of a hospital is full, patients will stack up in Emergency De partments, awaiting admission. If overcrowding is cumulative, ambulances may be redirected to other hospitals (adding to delay and danger) and patients with genuine needs may, catast rophically, decide they cannot wait any more hours for help. How to cope with inappropriate attendance \200 Triage by a trained nurse is one way to reduce inappropriate attendance. (In the UK, triage is mandatory.) Is this condition life-threatening, urgent, or semi-urge nt or is delay acceptable? These are the chief categories. If the most urgent patients are seen \201 rst, patients who do not really need to be in the department can wait for ages, and many will begin to drift away. Note that if long waits become essential because of dea ling with life-threatening conditions, this should be explained to patients (under the term s of the UK health charter \200\224and as a matter of common courtesy). 780 a m u a r t d n a s c i d e a p o h t r O Another way to reduce unnecessary spending is to have primary care fa- cilities within the Emergency Department, or, more radically, to have GPs as the casualty offi cers \200\224bec ause they use resources more sparingly and are used to dealing with mismatches between pati ent \200\231s expectations and reality. Is this expectation borne out in practice? In one c areful randomized study of patient-contacts with the Emergency Department in Dublin (N=4684 ), GPs treating people with semi-urgent problems investigated less (by 20%), referred to ot her hospital services less (by 39%), admitted fewer patients (45%) and prescribed more ofte n (43%): there were no diff erences in meas- ures of outcome.391 It is not clear whether th e more economical style of the GPs was to do with being a GP, or because these doctors were older and more experienced than their emergency department counterparts.1 Risk management strategy when overwhelmed by the work to be done: \200 Prioritize the wai ting tasks and then concentrate on the task in hand. \200 At times you may feel you are w orking at a pace that is faster than is com- fortable. This is part of \200\230continuous learning \200\231, and as you get better this un- ease will abate. Look on it as practice f or emergency situations where quick decisions are vital. Working faster need not mean makin g more errors. Have good techniques of clinical decision-making, which you continue to re- \201 ne. Start with something like the system on p532. Keep the goal in mind: What to do for the best for this patient. 1 UK GPs are an established part of the team at the front line seeing patients in Emergency Departments: they join the growing team of emergency nurse practitioners, junior doctors, and consultants (eg in a \200\230meet & greet \200\231 capacity) to tackle the turnover of patients with more minor injuries and ailments. Medical specialists (eg dedicated emergenc y pediatricians) are also increasingly involved. 781 Another busy shift? In the middle of any horrendous Emergency Department shift, you may be forgiven for wondering what on earth is happening outside to prompt such a heave in the num ber of attendances. Rumors circulate that sunshine means that children are out in force at the local playgrounds, or rain means that old ladies will be slipping up on the kerb. Perha ps late on a Friday night you despair at the number of alcohol-related incidents? Similarly , you hear that because the Grand National is on, the shift is going to be a quiet one \200 until the race \201 nishes and people are out spending their winnings (or drowning their losses). Factors that have been suggested to be correlated with an increase in the a m u a r t d n a s c i d e a p o h t r O number of Emergency Department attendances include: \200 Warm, dry and sunny weather cond itions.392 \200 Season, especially winter for the over-65s and the under 1s.393,394 \200 Local music festivals (despite on-site facilities).395 \200 An at-home winning national sports side (sadly, for assault).396 \200 Major natural disasters (eg a hurricane, thoug h with an understandable reduction on the day of the disaster).397 \200 And yes \200 Mond ays.394 Other studies have suggested that attendances may be reduced by major televised sporting events.398,399 It is a complicated mix which depends on where in the world you are work- ing and it is not always clear whether these factors are delaying, precipitating, or causative (though logic may point the \201 nger of causality).1