Crit Care Resusc
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Cervical spine injury occurs in 5-10% of patients with traumatic brain injury (TBI) and the consequences of missing significant cervical injuries in unconscious blunt trauma patients are potentially devastating. An adequate cervical spine clearance protocol for unconscious patients must avoid missed injuries, but must also avoid unnecessary cervical immobilisation and the associated morbidity. Existing protocols include various combinations of plain X-rays, helical CT, dynamic flexion-extension X-rays and MRI. ⋯ Nevertheless, recently at The Alfred Hospital, extremely high-risk TBI patients have had unstable cervical injuries detected solely by MRI. Current generation multi-slice CT with reconstructions may obviate the need for MRI even in these patients. The current Alfred Hospital cervical clearance protocol for unconscious patients, and the evolutionary steps in its development, will be discussed.
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Stroke is a medical emergency as it is the third commonest cause of death and the most important cause of acquired severe disability in adults. Stroke services, funding and research have lagged behind cardiac medicine but evidence is now available to support a much more interventional approach to the assessment and management of patients with ischaemic stroke. Randomised controlled trials and meta-analyses of the most important interventions are the main sources of evidence for this review. ⋯ Patients not eligible for thrombolysis should receive aspirin and specialised care in a stroke unit. Many other treatments have been evaluated for acute ischaemic stroke of which some have been shown to be ineffective such as haemodilution or anticoagulation, whilst other interventions have not been adequately investigated such as neuroprotection and blood pressure lowering strategies. There is now good evidence to support a much more active assessment and treatment of patients with stroke but it is recognised that stroke services still need substantial development to maximise the benefits from the current proven interventions.
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In 2004, two large randomised multi-centre Australian clinical trials provided new information concerning optimal resuscitation for patients with traumatic brain injury (TBI). One examined hypertonic saline (HTS) and the other, albumin versus saline.( )For the first time in a randomised trial, hypertonic saline was tested for pre-hospital resuscitation of hypotensive patients with traumatic brain injury, and for the first time a resuscitation fluid trial measured long term neurological function as the primary outcome. Despite many potential advantages which may have much greater relevance in the hospital setting, in the paramedic based VICn trauma system, HTS did not improve neurological outcome compared to conventional pre-hospital fluid protocols. ⋯ Intriguingly however, the SAFE study also reported that within a subgroup of 492 patients with TBI, 28 day survival was superior in patients receiving saline. This subgroup result was not considered definitive, but a post hoc examination of the TBI patients currently in progress by the SAFE investigators, is expected to provide further guidance for clinicians. In the meanwhile, and until more high quality data is available, many clinicians are likely to prefer crystalloid resuscitation for trauma patients, and especially for trauma patients with brain injury.
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The authors conducted a postal survey to establish what the current sedative and analgesic practice in selected Australian intensive care units was. ⋯ Despite recent recommendations for daily interruption of sedative agents and the use of a sedation scale, this was not the most common practice in Australian intensive care units. Most units used continuous infusions of midazolam and morphine for sedation/analgesia.
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Ion selective electrodes (ISE) measure electrolytes by two different technologies, direct and indirect. We wished to investigate the effect of total plasma protein concentration on the plasma sodium, potassium and chloride measurements by indirect ISE compared with measurements by direct ISE. ⋯ The plasma sodium, potassium and chloride measurements are effected by changes in plasma protein concentration when measured by indirect ISE systems. Clinicians must be aware that differences exist between the ISE technologies and in border-line clinical situations, the direct ISE systems provide a more accurate estimate of plasma sodium, potassium, chloride, anion gap, osmolality and strong ion difference calculations, and should be used for clinical decision-making.