The utility of magnetic resonance imaging in addition to computed tomography scans in the evaluation of cervical spine injuries: a study of obtunded blunt trauma patients.

PURPOSE: Evidence guiding the use of CT and MRI scans in blunt trauma patients who are obtunded remains controversial. This study aims to determine and predict if computed tomography (CT) scans alone can be performed without risking oversight of substantial injuries found on follow-up magnetic resonance imaging (MRI). METHODS: This is a retrospective cohort study of 63 blunt trauma patients with a Glasgow Coma Scale of < 8. Data were collated from electronic medical records and included patient demographics, premorbid mobility, mechanism of injury, suspected level of injury and neurological examination findings. Patients were urgently evaluated using CT scans, followed by non-contrast MRI scans within 48 h of admission. The accuracy of CT scan was evaluated using MRI as a reference. Adjusted multivariable analysis was also performed to identify predictors for findings detected on MRI but not on CT. RESULTS: The mean age of patients was 42.3 years and 90.5% were males. CT scans had a high specificity of 100% and sensitivity of 87.2%. Predictors of MRI abnormalities include females, patients with relatively milder mechanisms of injury, patients with suspected thoracic spine injury, and CT scan findings of facet dislocation and intracranial haemorrhage. There was no predictor for spinal cord oedema. CONCLUSIONS: MRI should be performed in the presence of the aforementioned predictive factors and in the presence of neurological deficits. Otherwise, patients can be treated medically without the fear of missing a substantial cervical injury.

Use of Activated Recombinant Factor VII in Severe Bleeding - Evidence for Efficacy and Safety in Trauma, Postpartum Hemorrhage, Cardiac Surgery, and Gastrointestinal Bleeding.

BACKGROUND: Uncontrolled bleeding continues to be a major cause of mortality in trauma, cardiac surgery, postpartum hemorrhage and liver failure. The aim of this paper is to assess the evidence supporting the efficacy of activated recombinant factor VII (rFVIIa) administration in these settings. METHODS: Electronic literature search. RESULTS: Numerous retrospective trials have mostly shown a decrease in blood transfusion requirements with no increase in thromboembolic events (TEE), but major limitations in trial design make generalization difficult. In most retrospective reports rFVIIa has been administered as a last-ditch attempt to control bleeding, when acidosis, hypothermia and coagulation factor depletion may not allow optimal rFVIIa effect. Prospective randomized controlled trials have not shown any effect of rFVIIa on mortality or TEE, although some have shown a reduction in RBC requirement. CONCLUSION: Stipulated transfusion protocols in prospective trials have reduced anticipated mortality among controls and make future trials for mortality effect unlikely in view of large sample size requirements. Establishment of these protocols and rapid hemostasis are likely to have greater benefits than administration of a single agent.

Experiential learning improves the learning and retention of endotracheal intubation.

CONTEXT: Simulators provide an effective platform for the learning of clinical motor skills such as endotracheal intubation, although the optimal learning technique remains unidentified. We hypothesised that, for novices, experiential learning would improve the learning and retention of endotracheal intubation compared with guided learning. METHODS: Year 4 medical students were randomised to either guided or experiential learning. Students in the guided group were taught using the conventional step-by-step technique. Students in the experiential group had to work out the correct technique for intubation on their own. Both groups had further opportunities to intubate manikins and patients during their postings. The students were recalled 3, 6, 9 and 12 months later, and their intubation skills assessed in four major categories: equipment preparation; intubation technique; successful intubation, and placement confirmation. RESULTS: A total of 210 students (107 guided, 103 experiential) participated in the study. At 3 months, 64.5% of the students in the experiential group successfully intubated the manikin, compared with 36.9% in the guided group (P < 0.001). The experiential group also had higher overall scores, signifying quality of intubation attempts, at 3 months (79% versus 70%; P < 0.001). Success rates and overall scores for both groups were comparable at 6 and 9 months, but were better in the experiential group at 12 months. Success rates improved with time, reaching 86% at 12 months. CONCLUSIONS: Novices learned and retained the skill of endotracheal intubation better with experiential learning. This study suggests that experiential learning should be adopted for the teaching of endotracheal intubation and that refresher tuition at 3-monthly intervals will prevent the decay of this skill in infrequent users.

Sevoflurane Output in the Isoflurane/Halothane Diamedica Draw-over Vaporiser.

INTRODUCTION: Draw-over anaesthesia remains an attractive option for conduct of anaesthesia in austere conditions. The Diamedica Draw-over Vaporiser (DDV) is a modern draw-over vaporiser and has separate models for isoflurane/halothane and sevoflurane. MATERIALS AND METHODS: A laboratory study was done to measure sevoflurane output in an isoflurane/ halothane DDV. We did 3 series of experiments with the isoflurane/halothane DDV. We measured anaesthetic agent output in both push-over and draw-over setups, and at minute ventilation of 6 L/min and 3 L/min. Series 1 experiment was done with isoflurane in the DDV at ambient temperature of 20°C. Series 2 experiment was done with sevoflurane in the DDV at ambient temperature of 20°C. Series 3 experiment was done with sevoflurane in the DDV and with the DDV placed in a water bath of 40°C. RESULTS: The sevoflurane output was found to be two-thirds of the isoflurane/ halothane DDV dial setting at ambient temperature of 20°C. With the DDV in a 40°C water bath, the sevoflurane output was found to be about the isoflurane/ halothane DDV dial settings. CONCLUSION: In our experiment, we show that it is possible to use sevoflurane in an isoflurane/halothane DDV.

A 5-year profile of trauma admissions to the surgical intensive care unit of a tertiary hospital in Singapore.

INTRODUCTION: This retrospective pilot study provides information on trauma admissions to the Surgical Intensive Care Unit (SICU) of a tertiary hospital in Singapore. The aim was to use the data collected to generate awareness and interest in this area. The authors also wish to use the information to advocate subsequent in-depth collection and analysis of data and the development of a Trauma Registry. As this was a pilot study, the data collected were by no means exhaustive and only descriptive analysis was applied. MATERIALS AND METHODS: Trauma admissions to the SICU for the period between January 2001 and December 2005 were identified from the admissions logbook maintained in the unit. The physical case-notes or electronic-records for the identified cases were retrieved and the relevant data and parameters were entered into the data collection sheet. Descriptive analysis was applied to the data collected. RESULTS: A total of 503 cases over the 5-year period fulfilled our criteria. Motor vehicle accidents were the greatest contributor of trauma admissions to the SICU (53%). The length of stay (LOS) in the unit ranged from 1 to 59 days. The anatomical area most frequently injured was the head (68%). Out of the 132 mortalities, male patients accounted for 84%. Two-thirds (67%) of injury-related mortality occurred in young patients aged less than 45 years. Motor vehicle accidents accounted for nearly half (47%) of injury-related mortality. Motorcyclists accounted for almost half (46%) of motor vehicle accident deaths. CONCLUSION: The preponderance of young people involved in motor vehicle accidents with head injuries has a large impact on society and on the hospital workload. The authors hope that this pilot study will generate awareness and interest in the area of trauma injuries. They recommend that a nationwide trauma registry be established to look closer into this "disease", as other developed countries have done.