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NEXUS Criteria for C-Spine Imaging Determines who can be cleared clinically of cervical spine fracture without imaging, by NEXUS study criteria. Focal Neurologic Deficit Present? Midline Spinal Tenderness Present? Altered Level of Consciousness Present? Intoxication Present? Distracting Injury Present? Patient has none of these,If none of the above criteria are present, the C-Spine can be cleared clinically by these criteria. Imaging is not required If any of the above criteria are present, the C-Spine cannot be cleared clinically by these criteria. Imaging is required One easy mnemonic for these criteria is NSAID: Neuro Deficit Spinal Tenderness (Midline) Altered Mental Status/Level of Consciousness Intoxication Distracting Injury Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998 Oct;32(4):461-9. PubMed P...

The classic teaching tells : Esophageal coins appear in the coronal plane, as shown above. Tracheal coins appear in the sagittal plane because of the cartilaginous tracheal rings. Busting the myth :  A case series of 8 pediatric patients were documented with coins positioned in a sagittal plane were actually in the esophagus! This data was collected over 15 years. Age range 3-17 years old Location of coin: 7/8 at level of aortic notch and 1/8 at distal esophagus  The classic teaching likely still holds true most of the time (sagittal coin = tracheal foreign body), but don't rush to immediate judgment. Take a look at the lateral view, and see where the coin is located with respect to the trachea and airway. It may be more posterior, in which case, it's in the esophagus. Reference Schlesinger AE, Crowe JE. Sagittal orientation of ingested coins in the esophagus in children. AJR Am J Roentgenol. 2011 Mar;196(3):670-2.  Pubmed  

In 2003, The Budapest Consensus Group modified the definition and set of clinical criteria for complex regional pain syndrome. THE GENERAL DEFINITION OF THE SYNDROME : Complex regional pain syndrome (CRPS) describes an array of painful conditions that are characterized by a continuing (spontaneous and/or evoked) regional pain that is seemingly disproportionate in time or degree to the usual course of any known trauma or other lesion.  The pain is regional (not in a specific nerve territory or dermatome) and usually has a distal predominance of abnormal sensory, motor, sudomotor, vasomotor and/or trophic findings.  The syndrome shows variable progression over time. THE DIAGNOSTIC CRITERIA: There are two versions of the proposed diagnostic criteria: a clinical version meant to maximize diagnostic sensitivity with adequate specificity, and a research version meant to more equally balance optimal sensitivity and specificity. CLINICAL DIAGNOSTIC CRITERIA FOR CRPS: ...

- One third of asthmatic patients will experience an improvement in their symptoms during pregnancy, one third will suffer a worsening and one third notice no change. - In those that deteriorate, the peak severity is between weeks 24 and 36 after which symptoms improve with attacks being very unusual in labour because of endogenous steroid production. - No adverse outcomes have been demonstrated with the use of inhaled β2 agonists, inhaled steroids, theophyllines or magnesium during pregnancy. Oral steroids do not have convincing evidence of harm and the British Thoracic Society concludes that the detriment to mother and foetus by not adequately treating acute severe asthma outweighs the potential, unproven risk of systemic steroids in pregnancy. - Uncontrolled asthma during pregnancy is associated with hyperemesis, hypertension, pre-eclampsia, premature delivery and low birthweight babies. Emphasis is therefore on maintaining good control with t...

Excessive doses of vasopressor can cause hypertension , but the increase in arterial pressure is  limited by a baroreceptor-mediated reflex decrease  in HR, which is more sensitive in pregnancy  . If the vagus nerve is blocked, this protective reflex is lost and dangerously high pressures can ensue.  Two worrying case reports of hypertensive crises induced in women undergoing spinal anaesthesia for caesarean delivery have been reported. In both, a combination of atropine and vasopressor was given to treat bradycardia associated with hypotension, resulting in severe hypertension and tachycardia.  This caused acute coronary artery dissection in one  and, in the other, a myocardial infarction and pituitary  haemorrhage . These studies suggest that when vagolytics are, quite rightly, given to treat bradycardia associated with hypotension, further vasopressor should be admin...

A 39 -YEAR-OLD WOMAN  on patient-controlled analgesia with morphine after cesarean delivery suddenly developed shortness of breath. On examination, the uvula was notably edematous, pale, and translucent, with no sign of erythema (see figure ). The previous night, when the morphine was started, she had mild pruritus, which responded to treatment with oral diphenhydramine (Benadryl). Given the extent of the uvular edema, emergency intubation was performed, and epinephrine and corticosteroids were given. Q:  Which is the most likely diagnosis at this point? □ Hereditary angioedema □ Infection causing epiglottitis masquerading as uvular swelling □ Opioid-induced uvular hydrops □ Myxedematous infiltration due to hypothyroidism A:  Opioid-induced uvular hydrops is the most likely diagnosis in this case, although it is rare. The most common side effect of opioids is constipation; others include lethargy, delirium, and sedation....

Intravenous administration of recombinant tissue plasminogen activator (rtPA) is currently the only  Food and Drug Administration approved treatment for ischemic stroke. The therapeutic window for IV rtPA in ischemic stroke is 3 h. As per the National Hospital Discharge Survey between 1999 and 2001 out of 1.79 million cases of stroke only 0.6% received rtPA. Intra-arterial (IA) thrombolysis is recommended when a patient misses the window for IV rtPA or has a contraindication for rtPA. Intraarterial thrombolysis is more effective in recanalization because of the delivery of the thrombolytic agent close to the site of occlusion (up to 70% recanalization rate). The therapeutic window for IA therapy extends up to 6h after a stroke. Combined IV rtPA and IA therapy also has been proposed. Mechanical removal of the clot (clot extraction) is another adjunct treatment for reperfusion/ recanalization in st...

Sensitivity: SnOUT: If a test has a high sensitivity and the elicited test is negative, you have essentially ruled OUT the disease.   How accurately the test picks up patients WITH disease Specificity: SpIN: If a test has a high specificity and the test is positive, you have essentially ruled IN the disease.  How accurately the test picks up patients WITHOUT disease  Likelihood Ratio (LR): Compares results of patients with disease vs patients without disease More accurate than sensitivity and specificity Helps you derive the post-test probability Takes sensitivity and specificity into account simultaneously  When LR >1 it means the probability of disease increases  When LR <1 it means the probability of disease decreases  When LR = 1, the probability of disease is unchanged  Before ordering a test, eliciting a symptom, or finding a sign, ask yourself: How will the absence or presence of this factor change my post-test proba...

There is no clear evidence of superiority of either mannitol or hypertonic saline at reducing intracranial pressure. One small trial suggested  mannitol was better , others have  favored hypertonic saline . The absolute differences of effects between agents have been quite small in these studies. If a ventricular drain is placed, CSF can be removed and intracranial pressure can be measured directly; this invasive approach carries a slight infection risk and has not been shown to improve outcomes. If a direct-pressure monitoring device is not in place, the goal of hyperosmolar therapy is to either: Increase the serum osmolarity initially to a target of  300-320 mOsm/L . Calculate osmolarity by (2 x Na) + (glucose / 18) + (BUN / 3), or use an  osmolarity calculator ,  or your lab’s true measured osmolality. Increase serum sodium to  145-150 mmol/L . Both these methods work whether using mannitol (an osmotic diuretic that causes generalized dehy...

Raised intracranial pressure (ICP) appears to be quite lethal: in traumatic brain injury patients, those with ICP > 40 mm Hg had a mortality of 56%, compared to 18% for those with ICP < 20 mm Hg. Most traumatic brain injuries causing long-term disability also initially presented with raised intracranial pressure. As volume increases inside the skull, intracranial pressure exponentially rises after it passes an inflection point of ~20-25 mm Hg. As ICP passes 50-60 mm Hg and approaches arterial pressure, global brain ischemia and eventual brain death result. The brain is 80% water, so using hyperosmolar agents to create an osmolar gradient between the inside of the brain and the systemic circulation has strong theoretical appeal. Hypertonic saline and mannitol are effective because they do not cross the blood-brain barrier (much), and thereby draw cerebrospinal fluid out of the cranium and fluid out of the injured brain, reducing pressure and further injury. In brain i...

In current international guidelines, intraaortic balloon counterpulsation is considered to be a class I treatment for cardiogenic shock complicating acute myocardial infarction. However, evidence is based mainly on registry data, and there is a paucity of randomized clinical trials. METHODS In this randomized, prospective, open-label, multicenter trial, we randomly assigned 600 patients with cardiogenic shock complicating acute myocardial infarction to intraaortic balloon counterpulsation (IABP group, 301 patients) or no intraaortic balloon counterpulsation (control group, 299 patients). All patients were expected to undergo early revascularization (by means of percutaneous coronary intervention or bypass surgery) and to receive the best available medical therapy. The primary efficacy end point was 30-day all-cause mortality. Safety assessments included major bleeding, peripheral ischemic complications, sepsis, and stroke. RESULTS A total of 300 patients in the IABP g...

Subdural intracranial hematoma is a very rare consequence of accidental dural puncture.  The bleeding results from cerebrospinal fluid loss (cerebral hypotension) related to traction on the intracranial bridging veins. Postdural puncture headache may complicate the diagnosis.  Atypical headache (absence of postural component, persistence for more than 7 days, unresponsiveness to analgesics), signs of increased  intracranial pressure, or mass effect on brain parenchyma (vomiting, seizures, altered level of consciousness,focal motor and sensory  deficits) should lead to consideration of subdural intracranial hematoma. Presence of semilunar extraparenchymal liquid over the convexity on computed tomography (more sensitive in acute situations) or magnetic resonance imaging (more sensitive in older “denser” hematomas) scans confirms the diagnosis (arrows). In view of the small size of the hematomas, in our case con...

Over 4800 separate substances have been found in cigarette smoke, and the health risks of cigarette smoking are well documented.  Cigarette smoke may interfere with both the action and metabolism of a wide range of medications, some of which are relevant to anesthetic practice. Central to this is the cytochrome P450 multi-enzyme system of which there are around 30 CYP enzymes responsible for drug metabolism. Polycyclic aromatic hydrocarbons (PACs) in cigarette smoke react with these enzymes, in general inducing them, thus affecting the metabolism of a number of drugs including paracetamol, codeine and theophylline. It is only the last whose dose is significantly affected.  In addition, PACs also have an effect on a membrane bound glycoprotein called uridine diphosphate-glucuronotransferase (UGT). UGT partially metabolises codeine and morphine as well as being involved in the glucuronidation of a number of drugs including NSAIDs, amytriptyline and temazepam. It has consi...