Approximately 5-10% of unconscious patients who present to the ED as the result of a motor vehicle accident or fall have a major injury to the cervical spine. Most cervical spine fractures occur predominantly at 2 levels. One third of injuries occur at the level of C2, and one half of injuries occur at the level of C6 or C7. Most fatal cervical spine injuries occur in upper cervical levels, either at craniocervical junction C1 or C2.
Cervical spine injuries are best classified according to several mechanisms of injury. These include flexion, flexion-rotation, extension, extension-rotation, vertical compression, lateral flexion, and imprecisely understood mechanisms that may result in odontoid fractures and atlanto-occipital dislocation.
When a cervical spine injury is suspected, minimize neck movement during transport to the treating facility. Ideally, transport the patient on a backboard with a semirigid collar, with the neck stabilized on the sides of the head with sand bags or foam blocks taped from side to side (of the board), across the forehead.
If spinal malalignment is identified, place the patient in skeletal traction with tongs as soon as possible , even if no evidence of neurologic deficit exists.


Diagnosing Low Back Pain

Posted by e-Medical PPT

Low back pain is a common musculoskeletal disorder affecting 80% of people at some point in their lives.It can be either acute, subacute or chronic in duration. Lower back pain may be classified by the duration of symptoms as acute (less than 4 weeks), sub acute (4–12 weeks), chronic (more than 12 weeks).The majority of lower back pain stem from benign musculoskeletal problems, and are referred to as non specific low back pain; this type may be due to muscle or soft tissues sprain or strain,particularly in instances where pain arose suddenly during physical loading of the back, with the pain lateral to the spine. Over 99% of back pain instances fall within this category.The full differential diagnosis includes many other less common conditions.
    * Mechanical:
          o Osteoarthritis     
          o Degenerative discs
          o Scheuermann's kyphosis
          o Spinal disc herniation ("slipped disc")
          o Spinal stenosis
          o Spondylolisthesis and other congenital abnormalities
          o Fractures      
    * Inflammatory:
          o Seronegative spondylarthritides (e.g. ankylosing spondylitis)
          o Rheumatoid arthritis
          o Infection - epidural abscess or osteomyelitis
    * Neoplastic:
          o Bone tumors (primary or metastatic)
          o Intradural spinal tumors
    * Metabolic:
          o Osteoporotic fractures
          o Osteomalacia
    * Psychosomatic
          o Tension myositis syndrome
    * Paget's disease
    * Referred pain:
          o Pelvic/abdominal disease
          o Prostate Cancer       


Advanced Trauma Life Support

Posted by e-Medical PPT

Advanced Trauma Life Support (ATLS) is a training program for doctors and paramedics in the management of acute trauma cases, developed by the American College of Surgeons.Originally designed for emergency situations where only one doctor and one nurse are present, ATLS is now widely accepted as the standard of care for initial assessment and treatment in trauma centers.
A - Airway Maintenance with Cervical Spine Protection
The first stage of the primary survey is to assess the airway. If the patient is able to talk, the airway is likely to be clear. If the patient is unconscious, he/she may not be able to maintain his/her own airway. The airway can be opened using a chin lift or jaw thrust.
B - Breathing and Ventilation
The chest must be examined by inspection, palpation, percussion and auscultation. Subcutaneous emphysema and tracheal deviation must be identified if present.The aim is to identify and manage six life threatening thoracic conditions as Airway Obstruction, Tension Pneumothorax, Massive Haemothorax, Open Pneumothorax, Flail chest segment with Pulmonary Contusion and Cardiac Temponade.
C - Circulation with Hemorrhage Control
Hemorrhage is the predominant cause of preventable post-injury deaths.Hypovolemic shock is caused by significant blood loss. Two large-bore intravenous lines are established and crystalloid solution given. If the patient does not respond to this, type-specific blood, or O-negative if this is not available, should be given.
D - Disability (Neurologic Evaluation)
During the primary survey a basic neurological assessment is made, known by the mnenomic AVPU.
E - Exposure / Environmental control
The patient should be completely undressed, usually by cutting off the garments. It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department. Intravenous fluids should be warmed and a warm environment maintained. Patient privacy should be maintained.


Epidemiology of Malignant Mesothelioma
Peak Asbestos Consumption in Australia in 1975 (90% in asbestos cement industry)
First documented MPM case in Australia in 1947
The incidence of mesothelioma is expected to increase and peak between 2015 and 2020
The median latency period from first exposure to clinical manifestation is around 40 years
Genetic predisposition for MPM is likely

Diagnosis
Mesothelin is a cell surface glycoprotein, expressed on normal mesothelial cells and > 90% of mesotheliomas (binds to CA125)
Soluble mesothelin-related proteins in serum
Osteopontin
Cell surface glycoprotein, binding to integrin and CD 44 receptors
Elevated serum levels of Osteopontin in MPM compared with controls Pass et al, NEJM 2005
Immunohistochemistry +
Osteopontin expression in other tumours

Chemotherapy Spectrum
Anthracyclines (Doxorubicin)
Taxanes (Paclitaxel)
Vinca Alkaloids (Vinorelbine)
Antimetabolites: Edatrexate, Gemcitabine, Pemetrexed & Raltitrexed
Combinations: Cisplatin, Carboplatin


Malignant Mesothelioma

Posted by e-Medical PPT

Mesothelioma is an insidious neoplasm arising from the mesothelial surfaces of the pleural and peritoneal cavities, the tunica vaginalis, or the pericardium.
Causes
The vast majority of mesothelioma cases are attributed to asbestos exposure. 
Less common causes of mesothelioma include:
Radiation therapy
Erionite fibers (genetic susceptibility)
Collapsotherapy (the induction of artificial pneumothorax or pneumoperitoneum for treatment of tuberculosis)
The DNA tumor virus SV40

Industries with High Incidence of Mesothelioma
Construction (carpenters, plumbers, electricians, insulators)
Ship and boat building
Manufacture of cement products
Manufacture of non-metallic mineral products (including asbestos)
Glass products manufacturing
Generation of electricity
Brick and ceramic products manufacturing

No chemotherapy regimen for mesothelioma has proven curative , but several regimes are valuable for palliation. These treatments not only decrease tumor burden but also improve symptoms such as pain, breathlessness and chest wall masses. Untill 5 years ago, comprehensive reviews of chemotherapy and mesothelioma were unable to recommend any particular therapy as a standard of care because of the low RR. Two therapeutic regimens  have since proven to be of value.

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