Exam Intelligence

Image via Wikipedia

Clearing the C-spine in unconscious or obtunded patients has bugged (and buggered) trauma teams around the world for decades. Several guidlines have been published over the years on how to manage patients with potential C-spine injuries following blunt trauma (incidence about 5%, apparently). Unfortunately none of them is universally applicable.

The Eastern Association for Surgery in Trauma (EAST) has published guidelines for clearing the C-spine in awake/compliant patients on clinical grounds (without radiology), and these could previously be seen at the EAST website. However, since it appears to have been infected with a spyware virus (according to my Sophos and AVG scanners!), so rather than go through the front portal of the site, see them instead by following these direct links:

• 1998 EAST Guidelines
• 2000 Update to EAST Guidelines

The National Emergency X-Radiography Utilization Study (NEXUS) Low Risk Criteria for C-Spine Injury and the Canadian C-spine rules also exist, and you can read about both of these in an article from the NEJM (free access) here., and also an article here.

One of the greatest difficulties, and most difficult questions to answer is: once there have been x-rays and possibly CT, or even MRI, when do we take the collar off? A recent article in the Continuing Education in Anaesthesia, Critical Care & Pain [2008 8(4):117-120] tries to put us out of our misery by publishing a suggested flow chart for clearing the c-spine in an unconscious patient, and also shoves it right up on the agenda for SAQ/Viva potential.

It is difficult to decide what kind of question might come out of this, but potentially:

• Describe potential causes of neurological defecit in a patient who has fallen from more than 10 metres (30 feet)?
• How would you assess the cervical spine for injury in a patient with a Glasgow Coma Scale score of 10 or less?

Alternatively:

• What are the advantages and disadvantages of spinal immobilisation in an unconscious patient?
• How can you determine the requirement for continued immobilisation?

This is a common problem that we will all see and have to deal with, and therefore is fair game…

Physics, Pharmacology and Physiology for Anaesthetists: Key Concepts for the FRCA
by Matthew E. Cross and Emma V. E. Plunkett (ISBN-13: 978-0521700443; Publisher: Cambridge University Press).

This is a brand new book, published in March of this year, and is, quite frankly, a breath of fresh air.

During my Primary and Finals revision I moaned about how difficult a certain other physics book was for me to deal with. It is full of explanations that to me, who enjoys pure physics and science as well as its application, were just not all there, and obscured some of the concepts rather than simplified them. This book is the one I would have hoped to write if I was going to write one.

The explanations are clear. The concepts are simply explained. They even go into detail about how to remember what a particular curve should look like, and how to draw it from scratch.

Whilst it doesn’t cover everything, it does strike me that it will make it simpler to learn and understand other concepts which are NOT covered in the book. (It is called “Key Concepts”…. - Ed.)

Having looked through this book only briefly (no review copy available for us you see (not well established enough!), I think it is almost certainly a “must have” for anyone who is not happy and confident with core physics, pharmacology and physiology concepts and drawing simple diagrams for the exam in each of those fields. It’s not fancy with multi-coloured drawings and photos, but that’s why it works so well.

If you want to see what it looks like, click on the link at the start of this review, and you’ll be able to do a “search inside” at Amazon so you can take a look at it.

This is definitely a “Recommended Buy” from me.