volume 27 • number 6 in this issue - acep · 6/6/2013 · frank lovecchio, do, mph, facep,...

Volume 27 • Number 6

June

2013

In This IssueLesson 11 Imaging in Blunt Cervical Spine Trauma Page 2

Despite the development and validation of the National Emergency X-Radiography Utilization Study and Canadian Cervical Spine decision rules to determine which patients warrant cervical spine imaging after blunt trauma, controversy persists regarding the most efficient and effective screening method for cervical injuries.

Lesson 12 Consent and Capacity Issues in the Emergency Department 1Determining the medical decision-making capacity of patients in the emergency department has presented a significant challenge for emergency physicians. Decision-making capacity is essential in providing informed consent. This article identifies how to ascertain decision-making capacity and informed consent for the often difficult emergency department patient.

ContributorsTimothy Jang, MD, and Amy H Kaji, MD, PhD, wrote “Imaging in Blunt Cervical Spine Trauma ” Dr. Jang is director of Emergency Ultrasonography at Harbor-UCLA Medical Center and an associate professor of clinical medicine at the David Geffen School of Medicine at UCLA, in Los Angeles, California. Dr. Kaji is a physician at Harbor-UCLA Medical Center Department of Emergency Medicine, in Torrance, California.

Daniel A Handel, MD, MPH, FACEP, reviewed “Imaging in Blunt Cervical Spine Trauma.” Dr. Handel is vice chair and director of Clinical Operations and an associate professor in the Department of Emergency Medicine at Oregon Health & Science University, Portland, Oregon.

Amber Bradford-Saffles, DO, FACEP, and Justin J Arambasick, MD, MBA, wrote “Consent and Capacity Issues in the Emergency Department ” Dr. Bradford-Saffles is associate program director at Akron General Medical Center in Akron, Ohio. Dr. Arambasick is an emergency physician in the Department of Emergency Medicine at Akron General Medical Center in , Akron.

Michael S Beeson, MD, MBA, FACEP, reviewed “Consent and Capacity Issues in the Emergency Department.” Dr. Beeson is program director for the Department of Emergency Medicine at Akron General in Akron, Ohio, and professor of clinical emergency medicine at Northeastern Ohio Universities College of Medicine, Rootstown, Ohio.

Frank LoVecchio, DO, MPH, FACEP, reviewed the questions for these lessons. Dr. LoVecchio is research director at the Maricopa Medical Center Emergency Medicine Program and medical director of the Banner Poison Control Center, Phoenix, Arizona, and a professor at Midwestern University/Arizona College of Osteopathic Medicine in Glendale, Arizona.

Louis G Graff IV, MD, FACEP, is Editor-in-Chief of Critical Decisions. Dr. Graff is professor of traumatology and emergency medicine at the University of Connecticut School of Medicine in Farmington, Connecticut.Contributor Disclosures In accordance with the ACCME Standards for Commercial Support and policy of the American College of Emergency Physicians, all individuals with control over CME content (including but not limited to staff, planners, reviewers, and authors) must disclose whether or not they have any relevant financial relationship(s) to learners prior to the start of the activity. These individuals have indicated that they have a relationship which, in the context of their involvement in the CME activity, could be perceived by some as a real or apparent conflict of interest (eg, ownership of stock, grants, honoraria, or consulting fees), but these individuals do not consider that it will influence the CME activity. Sharon E. Mace, MD, FACEP; Masimo, consulting fees; Gebauer, contracted research, non-CME services; Baxter, contracted research; Luitpold, contracted research. Joshua S. Broder, MD, FACEP; GlaxoSmithKline; his wife is employed by GlaxoSmithKline as a research organic chemist. All remaining individuals with control over CME content have no significant financial interests or relationships to disclose.Method of Participation This educational activity consists of two lessons with a posttest, evaluation questions, and a pretest; it should take approximately 5 hours to complete. To complete this educational activity as designed, the participant should, in order, take the pretest (posted online following the previous month’s posttest), review the learning objectives, read the lessons as published in the print or online version, and then complete the online posttest and evaluation questions. Release date June 1, 2013. Expiration date May 31, 2016.Accreditation Statement The American College of Emergency Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The American College of Emergency Physicians designates this enduring material for a maximum of 5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Each issue of Critical Decisions in Emergency Medicine is approved by ACEP for a maximum of 5 ACEP Category I credits. Approved by the AOA for 5 Category 2-B credits. A minimum score of 75% is required.Commercial Support There was no commercial support for this CME activity.Target Audience This educational activity has been developed for emergency physicians.

■ Also in This Issue ∙ The LLSA Literature

Review / Page 10 ∙ The Critical Image

/ Page 16 ∙ The Critical ECG

/ Page 17 ∙ CME Questions

/ Page 18 ∙ The Drug Box / Page 20

■ Next Month ∙ Ectopic Pregnancy ∙ Spontaneous

Pneumothorax

Critical Decisions in Emergency Medicine

2

■ ObjectivesOn completion of this lesson, you should be able to:

1. Describe which trauma patients are at increased risk for spinal cord injury and require imaging.

2. Explain the similarities and differences between the NEXUS and Canadian cervical spine decision rules and their respective test characteristics.

3. Explain the advantages and disadvantages of plain radiography, flexion-extension views, computed tomography, and magnetic resonance imaging.

4. List the potential adverse effects and outcomes of radiation exposure from various imaging modalities.

5. Describe features of spinal cord injury without radiographic abnormality.

6. Discuss diagnostic strategies to evaluate the integrity of the cervical spine in obtunded patients with blunt trauma.

■ From the EM Model18.0 Traumatic Disorders 18.1 Trauma

Timothy Jang, MD, and Amy H. Kaji, MD, PhD

Imaging in Blunt Cervical Spine Trauma

Lesson 11

Seven vertebrae comprise the human cervical spine, and each vertebra is protected by flexible intervertebral disks connected by a network of ligaments. According to the National Spinal Cord Injury Database1:

∙ Motor vehicle collisions account for more than 40% of all spinal injuries, followed by falls, acts of violence, and sporting activities.

∙ More than 80% of spinal cord injuries occur in males.

∙ In the United States, there are an estimated 12,000 new spinal cord injuries annually.

∙ Individuals living with spinal cord injury numbered approximately 265,000 in 2010.

∙ The estimated lifetime costs of caring for those with spinal cord injury depend on the age of the patient at the time of the injury and the level of injury, but the total cost to society from medical expenses and lost productivity is thought to be more than $5 billion per year.

Because of the devastating consequences of failure to recognize a spinal cord injury, diagnostic radiographs were obtained quite liberally prior to the advent of clinical decision rules for spinal imaging after trauma. According to the National Hospital Ambulatory Care Survey,2 less than 5% of cervical spine radiographs demonstrated a fracture, and there was a six-fold range in radiographic ordering rates among emergency physicians.

The National Emergency X-Radiography Utilization Study (NEXUS)3 and the Canadian Cervical Spine (C-spine) decision rules4 were developed to standardize clinical practice when evaluating for spinal injuries. Although the use of diagnostic imaging has decreased, controversy persists regarding the most efficient and effective screening method.

Case Presentations

■ Case OneA 32-year-old woman is brought in

after being involved in a multivehicle, roll-over accident on the interstate. She was a restrained, backseat passenger who was alert on scene but became lethargic and now has sonorous respirations. In the emergency department, vital signs are blood pressure 150/70, heart rate 110, respiratory rate 16, and oxygen saturation 93%. The primary survey reveals a weak gag reflex, sonorous respirations, symmetric breath sounds, and good pulses.

■ Case TwoA 4-year-old boy involved in

the accident described above was restrained in a car seat and arrives via ambulance, crying, without any specific complaints. His vital signs, while crying, are blood pressure 90/50, heart rate 120, respiratory rate 24, and oxygen saturation 97%. His primary survey reveals no deficits.

■ Case ThreeThe 35-year-old male, restrained

driver involved in this accident

June 2013 • Volume 27 • Number 6

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∙ Which patients with blunt trauma warrant cervical spine imaging in the emergency department?

∙ When is computed tomography indicated?

∙ When is magnetic resonance imaging indicated?

∙ When should spinal cord injury without radiographic abnormality (SCIWORA) be suspected and diagnosed?

∙ When are flexion-extension radiographs indicated?

∙ How can an obtunded blunt trauma patient’s cervical spine be cleared?

Critical Decisions

arrives complaining of neck, chest, and back pain. He was ambulatory on the scene. His vital signs in the emergency department are blood pressure 130/60, heart rate 95, respiratory rate 16, and oxygen saturation 96%. The primary survey reveals no deficits. The secondary survey is notable only for midline cervical spine tenderness, bilateral trapezius spasm with decreased range of motion, parasternal chest wall tenderness to palpation, and lumbar paraspinal spasm with tenderness to palpation.

CRITICAL DECISIONWhich patients with blunt trauma warrant cervical spine imaging in the emergency department?

Severe trauma victims who are undergoing computed tomography (CT) imaging to assess for other injuries of the head, chest, or abdomen should also undergo CT of the cervical spine, because this approach is most efficient in terms of both time and costs. Often in such severely injured patients, obtaining

plain cervical spine radiographs (three-view series) results in inadequate views and increased time for repeated attempts to obtain films that are interpretable. In cases of less severe trauma, the history, physical examination, and clinical decision rules may be used to determine whether spinal imaging is necessary and which modality is optimal. In many cases, plain radiographs may be preferred over CT because of the decreased radiation exposure and cost associated with plain radiography. If, however, abnormalities are identified on plain radiographs, or if the plain radiographs are inadequate, or if suspicion for injury persists, CT imaging should be obtained.

Both the NEXUS and Canadian C-spine clinical decision rules, which are used to determine the need for cervical spine imaging in stable, alert trauma patients, have been well studied but should only be applied to the appropriate patient population. For example, both studies excluded

patients who sustained direct blows to the neck and victims of penetrating trauma. Fortunately, cervical spine injuries are uncommon in patients with penetrating trauma who do not manifest neurologic deficits or altered mental status. Conditions considered at greater risk for spinal cord injury are listed in Table 1.

NEXUSNEXUS was derived from a study

of 1,000 consecutive blunt trauma patients who underwent plain radiography of the cervical spine3 and was subsequently validated in a large, multicenter, observational study.5 All blunt trauma patients who underwent cervical spine imaging, either via a three-view cervical spine radiograph or a cervical CT, at any of the 21 participating institutions were included. Of the total 34,069 blunt trauma patients in the study cohort, 818 (2.4%) had a cervical spinal cord injury.

The NEXUS rule stipulates that radiography is unnecessary if patients meet the following five low-risk criteria (Table 2): 1) no midline cervical spine tenderness; 2) normal level of consciousness; 3) not intoxicated; 4) normal neurologic examination; and 5) no painful distracting injuries. An abnormal level of consciousness was defined by a Glasgow Coma Scale (GCS) score less than 15; disorientation to person, place, time, or events; inability to remember three objects at five minutes; and delayed or inappropriate response to external stimuli. However, an episode of loss of consciousness at the time of injury

Table 1 High-risk conditions requiring cervical spine imaging

Advanced arthritis

Any neurologic signs

Cancer, especially with metastatic disease

Degenerative bone disease

Disproportionate pain

Neurologic symptoms

Severe osteoporosis

Upper extremity paresthesias

Table 2 NEXUS low-risk criteria

No midline cervical spine tenderness

Normal level of consciousness, defined as a GCS score of 15, no disorientation, ability to remember three objects after 5 minutes, and/or appropriate response to stimuli

Not intoxicated

Normal neurologic examination results

No painful distracting injuries


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did not preclude the application of NEXUS. Any injury thought to “have the potential to impair the patient’s ability to appreciate other injuries” was the definition for “a painful distracting injury.” Examples of “painful distracting injuries” provided by the NEXUS researchers included long-bone fractures, visceral injury requiring surgical consultation, large lacerations, crush injuries, and large burns.6 Overall, the sensitivity, specificity, and negative predictive value of NEXUS were 99.6%, 12.9%, and 99.9%, respectively.5

Canadian Cervical Spine Rule

Concerned that the low specificity of NEXUS (12.9%) would increase the use of radiography outside of the United States, Canadian researchers developed the Canadian C-spine Rule (CCR). Based on 3 clinical questions and 25 clinical variables associated with spine injury, the CCR involves the following steps4:

1) Radiographic imaging is obtained if:a. patient is aged 65 years or

older;b. there was a dangerous

mechanism of injury: fall from 1 meter (3 feet) or 5 stairs; axial load to the head, such as diving accident; motor vehicle crash at high speed (>100 km/hour [>62 mph]); motorized recreational vehicle accident; ejection from a vehicle; bicycle collision with an immovable object, such as tree or parked car;

c. the patient complains of paresthesias in the extremities.

2) If the patient does not have any of the above characteristics, the clinician next determines if there are any low-risk features that would allow safe assessment of neck range of motion. The low-risk factors are:a. simple rear-end motor

vehicle accident—excludes pushed into oncoming traffic, hit by bus or large truck, vehicle rollover, hit by high speed (>100 km/hour [>62 mph]) vehicle;

b. sitting position in emergency department;

c. ambulatory at any time;d. delayed onset of neck pain;e. absence of midline cervical

spine tenderness.If the patient does not exhibit any

of the low-risk factors, radiographs are obtained.

For patients who exhibit any of the low-risk factors, physicians should assess neck range of motion. If the patient is unable to actively rotate the neck 45° in both directions, the patient requires imaging. In the derivation cohort, the CCR demonstrated a sensitivity of 100% and a specificity of 42.5% for identifying clinically important cervical spine injuries.4 In 2003, the CCR was prospectively studied in nine Canadian tertiary care emergency departments. Of 8,283 patients, 162 had clinically significant injuries, and the sensitivity, specificity, and negative predictive values of the CCR were, respectively, 99.4%, 45.1%, and 100%.7 The CCR investigators reported their rule would have missed 1 patient with a clinically important cervical spine injury, while NEXUS would have missed 16. The CCR has also been validated in larger hospital-based studies and in an out-of-hospital study of paramedics.8

NEXUS versus Canadian Cervical Spine Rule

Whereas both the NEXUS and the CCR have been prospectively validated, controversy persists about which of the two rules is more useful. One Canadian study of NEXUS demonstrated NEXUS to have a lower sensitivity of 90.7% and a higher specificity of 36.8%.7 However, these discrepancies may be due to differences in study design and inclusion criteria. Those under 16 years of age or with a GCS score of less than 15 were excluded in developing the CCR. In contrast, these subjects were included in NEXUS. Additionally, NEXUS investigators excluded all patients in whom radiographs were deemed unnecessary, while they were included in developing the CCR. Thus, the sensitivity and specificity of the CCR may have been inflated because of this selection bias. Finally, since the validation phase of the CCR was performed in the same population of hospitals in which the derivation phase was performed, the CCR may demonstrate improved performance because of clinicians’ familiarity with the rule.9

Radiation Exposure Risk In addition to cost, one of the

reasons for standardizing protocols for cervical spine imaging in blunt trauma is because of increasing concern regarding cancer risks from medical radiation, particularly from CT. The annual number of CT scans

Table 3 Canadian C-spine Rule criteria

Imaging is indicated if: Low-risk factors that obviate imaging:

Age >65 Simple rear-end motor vehicle accident

Fall from >1 meter/3 feet or 5 steps Patient sitting up in the emergency department

Injury causes an axial load to the head Ambulatory at any time

High-speed motor vehicle collision Delayed onset of neck pain

Motorized recreational vehicle injury Absence of midline cervical spine pain

Ejection from vehicle

Bicycle collision with immovable object

Complaint of paresthesias


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performed in the United States is more than 70 million.10 Fifteen percent of the ionizing radiation exposure to the general public comes from artificial sources, and most of this exposure is from medical radiation, largely from diagnostic testing and procedures.11 Relevant studies have demonstrated that among trauma patients, CT accounts for the single largest radiation exposure.12 Based on estimates of cancer risk from computer models and epidemiologic data from survivors of atomic bomb radiation exposure, most studies conclude that there is increased risk of cancer from exposure to radiation from CT. However, because doses from diagnostic examinations are low, cancer risk is difficult to study using epidemiologic methods and difficult to prove. Still, increasing CT examination of the cervical spine following trauma has resulted in a significantly higher radiation dose to the thyroid, lens, and breast.13

Although the radiation dose delivered depends on the patient’s size and the technology used at a particular institution,14 for a typical CT study of the cervical spine or neck, the effective dose, measured in sieverts, is estimated to be 2 millisieverts (mSv). Background radiation is about 1 to 3 mSv per year. Note that the effective dose represents a whole-body equivalent dose that would be expected to produce the same overall cancer risk as non-uniform radiation. In contrast, the effective dose for plain chest radiograph is 0.02 mSv, a chest CT is 8 mSv, and an abdominal CT is 7.5 mSv. To put this in perspective, the seventh Biologic Effects of Ionizing Radiation report (BEIR VII) predicts that for a standardized US population, one radiation-induced cancer can be expected per 1,000 patients receiving a 10-mSv effective dose, and half of these cancers are expected to be fatal.15 Exposure to 100 mSv results in a solid organ cancer or leukemia in 1 per 100 people, while it is estimated that exposure of 2 mSv from a cervical spine CT would result in a

potential lifetime risk of cancer of 1 in 15,000.15

Of particular concern is that children are considerably more sensitive to the carcinogenic effects of ionizing radiation than adults, because children have a longer life expectancy in which to manifest oncogenic risk, and repeated examinations may result in a high cumulative dose.16 In the United States, of approximately 600,000 abdominal and head CT examinations performed per year in patients younger than 15 years, it is estimated that 500 of these individuals may ultimately die from a cancer attributable to the CT radiation.17 There are dose-related increased risks for thyroid, breast, brain, and nonmelanoma skin cancer, as well as leukemia.

CRITICAL DECISIONWhen is computed tomography indicated?

In most patients, plain films are inadequate for neck imaging. In patients whose mechanism of injury was not severe, for whom adequate plain radiographs may be obtained, and for whom CT imaging of the head or other body parts is not planned, plain radiographs may be the first choice for imaging. Some clinicians believe that an excessive number of CT studies are being performed in trauma patients,18 especially in light of the cancer risk from increased radiation exposure with CT.19

The lateral view of the cervical spine is most helpful in diagnosing injuries, detecting 60% to 80% of cervical spine fractures when used alone.20,21 Diagnostic yield increases with the addition of anteroposterior (AP) and odontoid views. Thus, plain cervical spine radiography must include AP, lateral, and odontoid views, and all three views must be evaluated for adequacy and for abnormal findings.22 To ascertain adequacy on the lateral view, the entire cervical spine, from the occipital base to the top of the first thoracic vertebra must be clearly

visible, and on the odontoid view, the dens and both lateral masses must be clearly seen.

In obese and muscular patients, as well as those who have spinal lesions that cause paralysis of the shoulder depressors, the C7 vertebra can be difficult to visualize on plain radiograph. If so, slowly pulling the patient’s hands toward their feet, using steady traction may facilitate better visualization. If this is unsuccessful or difficult to perform because of upper extremity injuries, a transaxillary (or “swimmer’s”) view of the lower cervical vertebrae might be helpful. A CT scan should be obtained if visualization remains inadequate despite these additional maneuvers and views. The NEXUS study found that a technically adequate three-view trauma series fails to diagnose spinal injury in only 0.07% of patients with injuries and in only 0.008% of patients with unstable injures.23

Unfortunately, up to 72% of plain films can be inadequate to visualize the complete cervical spine, necessitating performance of a CT.24 Furthermore, plain radiographs, even when swimmer’s and oblique views are performed, can miss up to 16% of cervical spine fractures in severely injured, obtunded, blunt trauma patients.25,26 Conversely, once a CT is performed, plain radiographs add no further clinically relevant information and should not be obtained.27

CT may be preferable in elderly trauma patients and those who are likely to have abnormal cervical anatomy (patients with rheumatoid arthritis), because radiographs can be difficult to interpret in such cases28 and long-term risks from radiation exposure are of less concern. Plain radiographs often do not provide optimal views of the atlantoaxial joint, and elderly trauma patients are more likely to sustain type II odontoid fractures.29 Similarly, plain radiographs often fail to demonstrate distraction and rotational injuries resulting in atlanto-occipital dislocations.30

Several studies, including a


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systematic review comparing plain radiography and CT in the detection of cervical spinal column injury following blunt trauma, found CT to be superior.31,32 The pooled sensitivity for detecting cervical spine injury was 52% for plain radiography; it was 98% for CT. Patient entry criteria varied widely among the studies included in the review, and heterogeneity tests suggested significant differences among the included studies in how sensitivity of plain radiography was assessed. There was also a relatively high overall prevalence of cervical spinal column injury (5% to 23%). Conclusions drawn from this population, with its higher injury rate, may not apply to more typical trauma populations being screened for cervical injury.

CT appears to outperform plain radiography as a screening test for patients at high risk of cervical spine injury and thus should be the initial study obtained in patients with altered mental status or severe nonspinal injury. One research group found CT to be more cost-effective than plain radiography among patients whose probability of cervical spine injury is more than 5%.33 Subsequently, Hanson et al developed and validated a clinical decision rule using three injury mechanisms and three clinical parameters to identify high-risk patients whose injuries warrant imaging of the cervical spine with CT.34 The three injury mechanisms are high-speed (≥56 kph [35 mph] combined impact) motor vehicle crash, a death at the scene of the motor vehicle crash, and a fall from height (≥3 m [10 ft]). The three clinical parameters are significant closed-head injury or intracranial hemorrhage seen on CT, neurologic symptoms or signs referred to the cervical spine, and pelvic or multiple extremity fractures. For patients who have sustained injury from a severe mechanism, practice guidelines from the Eastern Association for the Surgery of Trauma (EAST) recommend that CT from the occiput to the first thoracic vertebra, including

sagittal and coronal reconstructions, be used as the primary method of screening for cervical trauma.35

However, there is insufficient evidence to support replacing plain radiograph with CT for the initial screening of patients at lower risk for cervical spine injury.

In addition to improved accuracy in high-risk patients, CT scanning may be more efficient than plain radiographs.36,37 CT enables clinicians to assess for nonspinal injuries simultaneously and rapidly, and one retrospective review demonstrated that assessment with magnetic resonance imaging (MRI) was unnecessary in blunt trauma patients with a normal motor examination and a normal cervical spine CT.38

The primary disadvantage of CT is increased radiation exposure. Compared with plain radiography of the cervical spine, there is a tenfold increase in the radiation dose to the skin (28 vs 2.89 mGy) and a 14-fold increase in the dose to the thyroid (26 vs 1.8 mGy) among those studied with CT.39,40 CT images of the cervical spine may also be limited in patients with severe degenerative disease, and although CT detects 97% to 100% of all fractures, its accuracy in the detection of purely ligamentous injuries is not well studied.41

CRITICAL DECISIONWhen is magnetic resonance imaging indicated?

MRI has become an indispensable adjunct in evaluating trauma patients with neurologic deficits. MRI is less sensitive than CT for fractures of the posterior elements of the spine and injuries to the craniocervical junction,41,42 but best delineates the integrity of the spinal cord and nerve roots, intervertebral discs, surrounding soft tissue, ligamentous structures, and vertebral arteries.43 MRI is useful in discriminating between neurologic deficits caused by extrinsic compression versus those caused by hemorrhage, edema, or injury to the cord itself. Additionally, it can help clinicians diagnose the

causes of delayed and progressive neurologic deterioration in spinal injury, predict the outcome of spinal cord injury without radiographic abnormality (SCIWORA), and determine the acuity of bony injuries. MRI and magnetic resonance arteriography (MRA) also have an important role in the assessment of vertebral or carotid artery injury of the neck, which can be associated with cervical spine injury.44 Vascular injury of the neck should be suspected if there is: 1) severe blunt force to the neck; 2) significant hyperextension or hyperflexion injury; 3) unexplained neurologic deficits; 4) fracture of the skull base; 5) fracture of the cervical vertebra adjacent to or involving the vertebral arteries; 6) penetrating injury adjacent to vascular structures; and 7) severe facial fractures.45,46

The disadvantage of MRI is that it is not always available depending on the time of day and institutional capability, potentially causing delays in clearing the cervical spine. There are risks associated with secondary brain injury and aspiration from prolonged cervical collar use.47 Furthermore, often the MRI suite will be located in a separate geographic location, and there are risks associated with the transport of sick patients.48 Finally, monitors, and other devices (eg, pacemakers) must be compatible with the MRI machine.

CRITICAL DECISIONWhen should SCIWORA be suspected and diagnosed?

Cervical spinal subluxation can occur when the ligamentous complexes rupture without an associated bony injury. Such injuries often begin posteriorly in the nuchal ligament and proceed anteriorly to involve other ligaments. The CT scan or a plain lateral radiograph can show widening of both the interspinous and intervertebral spaces. Degenerative changes of the spinal column and spinal stenosis can be risk factors for ligamentous injury.49

Defined as neurologic deficits


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without evidence of bony injury on a complete, technically adequate, plain radiograph series or a CT scan, SCIWORA is seldom associated with permanent neurologic injury in adults.50 SCIWORA is thought by some to occur primarily in children; however, with the increased use of MRI, SCIWORA among adults is being reported at higher rates than previously suspected.51,52

Reported rates of SCIWORA vary widely, from 3.3% to 32.2%.49,51,53 The reasons for this variation may be because of a difference in the definition of SCIWORA; some define SCIWORA as any spinal cord injury not seen on plain radiograph or CT, and others think SCIWORA should refer only to patients with a clinical spinal cord injury and no neuroimaging abnormality, including on MRI.

CRITICAL DECISIONWhen are flexion-extension radiographs indicated?

Flexion-extension (F/E) radiographs have been used when there is concern for ligamentous injury to detect ligamentous and disc injuries despite negative imaging, although some question the technique’s safety.54 F/E views involve using fluoroscopy and still images with at least 30° of neck excursion in each direction. The patient is instructed to perform the movements slowly and to stop if pain or neurologic symptoms develop. Instability of the cervical spine is suggested by any of the following findings on F/E views: 1) more than 3.5 mm of horizontal displacement between adjacent disks; 2) displaced apophyseal joints; 3) widened disk spaces; 4) more than 30% loss of disk height; and 5) presence of a pre-vertebral hematoma.55 However, the incidence of an unstable cervical spine injury evident only on F/E radiographs is low, and the safety of the procedure is uncertain, even in the stable, alert trauma patient.56 A subgroup analysis of the NEXUS study found that of the 818 patients

found to have a cervical spine injury, 86 (10.5%) underwent F/E imaging. Two patients had sustained bony injuries and four patients had subluxation injuries detected with F/E views, but all others had injuries apparent on routine plain radiographs.57

Furthermore, obtaining adequate F/E views is problematic. In one retrospective case series of 311 patients assessed with F/E imaging, only 31% of studies were deemed adequate.58 Other studies have similarly demonstrated limitations due to inadequate visualization in up to 33% of patients.59,60 Several observational studies suggest that F/E views are inadequate and inaccurate for cervical spine imaging in obtunded patients with blunt trauma,41 because of poor visualization61 and high false-positive62,63 and false-negative rates.64

CRITICAL DECISIONHow can an obtunded blunt trauma patient’s cervical spine be cleared?

The optimal method of clearing the cervical spine in obtunded, blunt trauma patients remains unclear and controversial. As highlighted above, although CT identifies most bony vertebral injuries, it is less sensitive than MRI for ligamentous and spinal cord injuries. Various studies have thus been performed to determine whether CT alone is sufficient or whether MRI is necessary to clear the cervical spine in obtunded patients with blunt trauma.

One study of 115 obtunded blunt trauma patients undergoing both CT and MRI demonstrated that, although six new injuries were identified by MRI, no findings changed management and none required continued cervical collar use. By eliminating MRI in this cohort, health care costs would have decreased by over $250,000.65 Similarly, another study of 367 obtunded blunt trauma patients demonstrated that initial CT identified all unstable cervical spine injuries and the decision to obtain subsequent imaging delayed spine

clearance by a mean of 2.6 days.66 In a retrospective analysis of 180 patients who had undergone contemporaneous cervical spine CT and MRI, where the sagittal and coronal reconstructions of CT were normal, the MRI identified lesions in 38 patients, but none of these patients had unstable injuries, and no patients required surgery.67 Finally, another study of 366 obtunded patients with blunt trauma who had normal findings on multi-detector CT demonstrated a negative predictive value of 98.9% (362 of 366 patients) for ligamentous injury and 100% for unstable cervical spine injuries when compared to followup MRI.68

In contrast, a more recent study by Menaker et al refutes the finding that CT alone is sufficient to evaluate the cervical spine in patients with unreliable examinations.69 Of 213 total patients with unreliable examinations, 24.4% had abnormal MRIs, 15 of whom required operative repair and 23 of whom required extended cervical collar use. In a prior study, the same authors had demonstrated that MRI changed the management of 7.9% of patients who had an admission CT with no acute injury.70

At present, information is insufficient to determine whether MRI is indicated when the patient’s examination is unreliable.71 Indicative of this controversy, after a literature review, the Eastern Association for the Surgery of Trauma (EAST) management guidelines committee did not make firm recommendations regarding cervical spine clearance in the obtunded patient without gross neurologic deficit.35

Case Resolutions

■ Case OneIn the case of the woman who

became increasingly obtunded following a motor vehicle crash, the emergency physician ordered CT of the head and cervical spine as indicated by both the NEXUS guidelines and CCR but they did not reveal any acute injuries. The


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patient was kept in cervical spine immobilization and an MRI was ordered, which was normal. The patient was admitted for serial examinations and had a normal mental status the following morning without any neck pain.

■ Case TwoThe child was able to be clinically

assessed after his fears were allayed by the presence of family who arrived

in the emergency department. He was then cleared clinically without any exposure to radiation. On one-week followup, there were no complications, and the child was doing well.

■ Case ThreeIn the case of the driver with

midline cervical spine tenderness, the emergency physician ordered plain film cervical spine imaging because the patient did not meet NEXUS or CCR low-risk criteria. The radiographs did not reveal any fractures, but the patient had persistent pain on examination so a CT of the cervical spine was ordered, which also did not demonstrate a fracture. The patient was discharged in a cervical collar and, on repeat examination in one week, did not have any problems and was cleared clinically.

Summary In trauma from a low-risk

mechanism of injury, the history, physical examination, and clinical decision rules may be used to determine if spinal imaging is necessary. Because both NEXUS and the CCR are validated and sensitive, either rule may be used. For patients who have sustained major trauma and are undergoing CT scan of other body parts to assess for injury or are otherwise at high risk for cervical spinal cord injury, CT scan of the cervical spine is the optimal imaging modality. Selection of the imaging study (plain radiographs, CT, MRI) depends on several factors, including clinician judgment, hospital resources, and patient age, size, and comorbidities (eg, degenerative osteoarthritis). Flexion-extension imaging should not be used to assess for ligamentous injury or SCIWORA of the cervical spine in an obtunded patient. Although controversial, MRI for the unreliable, obtunded patient is probably indicated if the patient’s mental status does not improve.

References1. NSCISC National Spinal Cord Injury Statistical Center.

National spinal cord injury database. Updated 2012. Available online at: https://www.nscisc.uab.edu/nscisc-database.aspx. Accessed April 8, 2013.

2. Centers for Disease Control and Prevention. Ambulatory health care data. Available online at: http://www.cdc.gov/nchs/ahcd.htm. Accessed April 8, 2013.

3. Hoffman JR, Schriger DL, Mower W, et al. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med. 1992;21(12):1454-1460.

4. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841-1848.

5. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343(2):94-99.

6. 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;32(4):461-469.

7. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-2518.

8. Vaillancourt C, Stiell IG, Beaudoin T, et al. The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Ann Emerg Med. 2009;54(5):663-671.e1.

9. Yealy DM, Auble TE. Choosing between clinical prediction rules. N Engl J Med. 2003;349(26):2553-2555.

10. Brenner DJ. Slowing the increase in the population dose resulting from CT scans. Radiat Res. 2010;174(6):809-815.

11. Ron E. Cancer risks from medical radiation. Health Phys. 2003;85(1): 47-59.

12. Hui CM, MacGregor JH, Tien HC, Kortbeek JB. Radiation dose from initial trauma assessment and resuscitation: review of the literature. Can J Surg. 2009;52(2):147-152.

13. Chan PN, Antonio GE, Griffith JF, et al. Computed tomography for cervical spine trauma. The impact of MDCT on fracture detection and dose deposition. Emerg Radiol. 2005;11(5):286-290.

14. Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009;169(22):2078-2086.

15. Griffey RT, Sodickson A. Cumulative radiation exposure and cancer risk estimates in emergency department patients undergoing repeat or multiple CT. AJR Am J Roentogenol. 2009;192(4):887-892.

16. Kleinerman RA. Cancer risks following diagnostic and therapeutic radiation exposure in children. Pediatr Radiol. 2006;36 Suppl 2:121-125.

17. Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR AM J Roentogenol. 2001;176(2):289-296.

18. Kaups KL, Davis JW, Parks SN. Routinely repeated computed tomography after blunt head trauma: does it benefit patients? J Trauma. 2004;56(3):475-480.

19. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med. 2007;357(22):2277-2284.

20. West OC, Anbari MM, Pilgram TK, Wilson AJ. Acute cervical spine trauma: diagnostic performance of single-view versus three-view radiographic screening. Radiology. 1997;204(3):819-823.

21. Crim JR, Moore K, Brodke D. Clearance of the cervical spine in multitrauma patients: the role of advanced imaging. Semin Ultrasound CT MR. 2001;22(4):283-305.

22. Petri R, Gimbel R. Evaluation of the patient with spinal trauma and back pain: an evidence based approach. Emerg Med Clin North Am. 1999;17(1):25-39, vii-viii.

23. Mower WR, Hoffman JR, Pollack CV Jr, et al. Use of plain radiography to screen for cervical spine injuries. Ann Emerg Med. 2001;38(1):1-7.

Pearls ∙ After a high-risk mechanism of

injury, it is prudent to assume that the patient has sustained a spinal column injury.

∙ Either the NEXUS or CCR decision rules may be used to determine the need for radiographic imaging in the awake, alert, evaluable trauma patient.

∙ In a patient who is alert and evaluable and has sustained trauma from a low-risk mechanism of injury, plain radiographs may be preferred over CT, in light of the cost and risk of radiation exposure.

∙ If CT imaging of other body parts is being performed and the patient requires radiographic clearance of the cervical spine, CT of the cervical spine may be preferred over plain radiographs.

Pitfalls ∙ Accepting radiographs that

are inadequate to evaluate for spinal column injury.

∙ Using flexion-extension radiographs to clear the cervical spine in an obtunded patient.

∙ Failing to obtain specialty consultation when there is a fracture, instability, or neurologic deficit.


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24. Gale SC, Gracias VH, Reilly PM, Schwab CW. The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. J Trauma. 2005;59(5):1121-1125.

25. Widder S, Doig C, Burrowes P, et al. Prospective evaluation of computed tomographic scanning for the spinal clearance of obtunded trauma patients: preliminary results. J Trauma. 2004;56(6):1179-1184.

26. Ajani AE, Cooper DJ, Scheinkestel CD, et al. Optimal assessment of cervical spine trauma in critically ill patients: a prospective evaluation. Anaesth Intensive Care. 1998;26(5):487-491.

27. Mathen R, Inaba K, Munera F, et al. Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients. J Trauma. 2007;62(6):1427-1431.

28. Greenbaum J, Walters N, Levy PD. An evidenced-based approach to radiographic assessment of cervical spine injuries in the emergency department. J Emerg Med. 2009;36(1):64-71.

29. Watanabe M, Sakai D, Yamamoto Y, et al. Upper cervical spine injuries: age-specific clinical features. J Orthop Sci. 2010;15(4):485-492.

30. Govender S, Vlok GJ, Fisher-Jeffes N, Du Preez CP. Traumatic dislocation of the atlanto-occipital joint. J Bone Joint Surg Br. 2003;85(6):875-878.

31. Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. J Trauma. 2005;58(5):902-905.

32. Bailitz J, Starr F, Beecroft M, et al. CT should replace three-view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison. J Trauma. 2009;66(6):1605-1609.

33. Blackmore CC, Ramsey SD, Mann FA, Deyo RA. Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis. Radiology. 1999;212(1):117-125.

34. Hanson JA, Blackmore CC, Mann FA, Wilson AJ. Cervical spine injury: a clinical decision rule to identify high-risk patients for helical CT screening. AJR Am J Roentgenol. 2000;174(3):713-717.

35. Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. J Trauma. 2009;67(3):651-659.

36. Daffner RH. Cervical radiography for trauma patients: a time-effective technique? AJR Am J Roentgenol. 2000;175(5):1309-1311.

37. Daffner RH. Helical CT of the cervical spine for trauma patients: a time study. AJR Am J Roentgenol. 2001;177(3):677-679.

38. Schuster R, Waxman K, Sanchez B, et al. Magnetic resonance imaging is not needed to clear cervical spines in blunt trauma patients with normal computed tomographic results and no motor deficits. Arch Surg. 2005;140(8):762-766.

39. Adelgais KM, Grossman DC, Langer SG, Mann FA. Use of helical computed tomography for imaging the pediatric cervical spine. Acad Emerg Med. 2004;11(3):228-236.

40. Rybicki F, Nawfel RD, Judy PF, et al. Skin and thyroid dosimetry in cervical spine screening: two methods for evaluation and a comparison between a helical CT and radiographic trauma series. AJR Am J Roentgenol. 2002;179(4):933-937.

41. Crim JR, Moore K, Brodke D. Clearance of the cervical spine in multitrauma patients: the role of advanced imaging. Semin Ultrasound CT MR. 2001;22(4):283-305.

42. Holmes JF, Mirvis SE, Panacek EA, et al. Variability in computed tomography and magnetic resonance imaging in patients with cervical spine injuries. J Trauma. 2002;53(3):524-529.

43. Cohen WA, Giauque AP, Hallam DK, et al. Evidence-based approach to use of MR imaging in acute spinal trauma. Eur J Radiol. 2003;48(1):49-60.

44. Cothren CC, Moore EE, Biffl WL, et al. Cervical spine fracture patterns predictive of blunt vertebral artery injury. J Trauma. 2003;55(5):811-813.

45. Biffl WL, Moore EE, Offner PJ, Burch JM. Blunt carotid and vertebral arterial injuries. World J Surg. 2001;25(8):1036-1043.

46. Malhotra AK, Camacho M, Ivatury RR, et al. Computed tomographic angiography for the diagnosis of blunt carotid/vertebral artery injury: a note of caution. Ann Surg. 2007;246(4):632-642.

47. Dunham CM, Brocker BP, Collier BD, Gemmel DJ. Risks associated with magnetic resonance imaging and cervical collar in comatose, blunt trauma patients with negative comprehensive cervical spine computed tomography and no apparent spinal deficit. Crit Care. 2008;12(4):R89.

48. Cooper DJ, Ackland HM. Clearing the cervical spine in unconscious head injured patients—the evidence. Crit Care Resusc. 2005;7(3):181-184.

49. Kato H, Kimura A, Sasaki R, et al. Cervical spinal cord injury without bony injury: a multicenter retrospective study of emergency and critical care centers in Japan. J Trauma. 2008;65(2):373-379.

50. Kothari P, Freeman B, Grevitt M, Kerslake R. Injury to the spinal cord without radiological abnormality (SCIWORA) in adults. J Bone Joint Surg Br. 2000;82(7):1034-1037.

51. Kasimatis GB, Panagiotopoulos E, Megas P, et al. The adult spinal cord injury without radiographic abnormalities syndrome: magnetic resonance imaging and clinical findings in adults with spinal cord injuries having normal radiographs and computed tomography studies. J Trauma. 2008;65(1):86-93.

52. Tewari MK, Gifti DS, Singh P, et al. Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging: analysis of 40 patients. Surg Neurol. 2005;63(3):204-209.

53. Hendey GW, Wolfson AB, Mower WR, et al. Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma. J Trauma. 2002;53(1):1-4.

54. Harrison JL, Ostlere SJ. Diagnosing purely ligamentous injuries of the cervical spine in the unconscious trauma patient. Br J Radiol. 2004;77(916):276-278.

55. Bagley LJ. Imaging of spinal trauma. Radiol Clin North Am. 2006;44(1):1-12,vii.

56. Sliker CW, Mirvis SE, Shanmuganathan K. Assessing cervical spine stability in obtunded blunt trauma patients: review of medical literature. Radiology. 2005;234(3):733-739.

57. Pollack CV Jr, Hendey GW, Martin DR, et al. Use of flexion-extension radiographs of the cervical spine in blunt trauma. Ann Emerg Med. 2001;38(1):8-11.

58. Khan SN, Erickson G, Sena MJ, Gupta MC. Use of flexion and extension radiographs of the cervical spine to rule out acute instability in patients with negative computed tomography scans. J Orthop Trauma. 2011;25(1):51-56.

59. Wang JC, Hatch JD, Sandhu HS, Delamarter RB. Cervical flexion and extension radiographs in acutely injured patients. Clin Orthop Relat Res. 1999;(365):111-116.

60. Insko EK, Gracias VH, Gupta R, et al. Utility of flexion and extension radiographs of the cervical spine in the acute evaluation of blunt trauma. J Trauma. 2002;53(3):426-429.

61. Griffiths HJ, Wagner J, Anglen J, et al. The use of forced flexion/extension views in the obtunded trauma patient. Skeletal Radiol. 2002;31(10):587-591.

62. Freedman I, van Gelderen D, Cooper DJ, et al. Cervical spine assessment in the unconscious trauma patient: a major trauma service’s experience with passive flexion-extension radiography. J Trauma. 2005;58(6):1183-1188.

63. Goodnight TJ, Helmer SD, Dort JM, et al. A comparison of flexion and extension radiographs with computed tomography of the cervical spine in blunt trauma. Am Surg. 2008;74(9):855-857.

64. Padayachee L, Cooper DJ, Irons S, et al. Cervical spine clearance in unconscious traumatic brain injury patients: dynamic flexion-extension fluoroscopy versus computed tomography with three-dimensional reconstruction. J Trauma. 2006;60(2):341-345.

65. Como JJ, Thompson MA, Anderson JS, et al. Is magnetic resonance imaging essential in clearing the cervical spine in obtunded patients with blunt trauma? J Trauma. 2007;63(3):544-549.

66. Harris TJ, Blackmore CC, Mirza SK, Jurkovich GJ. Clearing the cervical spine in obtunded patients. Spine. 2008;33(14):1547-1553.

67. Tomycz ND, Chew BG, Chang YF, et al. MRI is unnecessary to clear the cervical spine in obtunded/comatose trauma patients: the four year experience of a level I trauma center. J Trauma. 2008;64(5):1258-1263.

68. Hogan GJ, Mirvis SE, Shanmuganathan K, Scalea TM. Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: is MR imaging needed when multi-detector row CT findings are normal? Radiology. 2005;237(1):106-113.

69. Menaker J, Stein DM, Philip AS, Scalea TM. 40-slice multidetector CT: is MRI still necessary for cervical spine clearance after blunt trauma? Am Surg. 2010;76(2):157-163.

70. Menaker J, Philip A, Boswell S, Scalea TM. Computed tomography alone for cervical spine clearance in the unreliable patient – are we there yet? J Trauma. 2008;64(4):898-903.

71. Anderson PA, Gugala Z, Lindsey RW, et al. Clearing the cervical spine in the blunt trauma patient. J Am Acad Orthop Surg. 2010;18(3):149-159.


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The LLSA Literature Review“The LLSA Literature Review” summarizes articles from ABEM’s “2014 Lifelong Learning and Self-Assessment Reading List.” These articles are available online in the ACEP LLSA Resource Center (www.acep.org/llsa) and on the ABEM Web site.

Article 2

DrowningReviewed by J. Stephen Bohan, MS, MD, FACEP; Harvard Affiliated Emergency Medicine Residency; Brigham and Women’s Hospital

Szpilman D, Bierens J, Handley A, Orlowski J. Drowning. N Engl J Med. 2012;366(22):2102-2110.

Drowning occurs most commonly in those younger than 14 years and is associated, in this group, with a deficit in supervision. In older persons, drowning is associated with alcohol, poor education, rural residence, and those without experience in water. Adjusted for exposure to hazard, drowning is 15 times more common than having an automobile accident. Patients with epilepsy are particularly prone to drown.

Recent standardized terminology eschews all terms except “fatal drowning,” or “nonfatal drowning” if there is evidence of respiratory impairment. If there is no respiratory impairment, this is termed a “rescue event.” Also standardized is a patient grading system (grade 1 being benign, and grade 6 indicating a high fatality rate). All patients save those determined to be grade 1 should be considered for admission.

Aspirated water, saltwater or not, disrupts the alveolar-capillary membrane and results in a severe hemorrhagic pulmonary edema. This and subsequent death occur in seconds to minutes because there is severe oxygen deficit in the brain, unless there is significant hypothermia which reduces the oxygen demand by the brain. The rate of cerebral oxygen consumption falls by about 5% for each drop of 1°C below 37°C. In areas where lifeguards are present, less than 6% of those rescued require medical attention, with 0.5% requiring cardiopulmonary resuscitation (CPR).

When providing CPR, ventilation should take precedence over chest compression because the defect is primarily in oxygenation and ventilation. Rescue breaths (start with five and then continue with two per cycle) can be administered by a skilled rescue person while still in the water, whereas chest compressions cannot. Efforts to expel water only delay ventilation. CPR is continued on the shore. Early

intubation by EMS or in the emergency department should be considered as standard for most patients in classes 2 through 6. Such patients should be warmed and taken to the ICU where, ironically, hypothermia should be induced.

Injuries to the cervical spine occur in less than 1 out of 100, and severe electrolyte disturbance is rare.

It is thought that 85% of drownings could have been prevented.

Highlights ∙ Common terminology will facilitate research.

∙ Attention to the victim’s airway and the use of rescue breaths are paramount.

∙ The victim is not dead unless “warm and dead.”


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Consent and Capacity Issues in the Emergency DepartmentLesson 12

Amber Bradford-Saffles, DO, FACEP, and Justin J. Arambasick, MD, MBA

■ ObjectivesOn completion of this lesson, you should be able to:

1. Describe the differences in competence and decision-making capacity.

2. Assess a patient’s decision-making capacity.

3. Explain the CURVES mnemonic and its use.

4. Discuss the principles of informed consent.

5. Identify ethical decision-making models that can be useful in difficult ethical situations.

6. Identify documentation practices to avoid legal consequences in a patient leaving against medical advice.

7. Identify situations in which a patient is able to refuse care.

8. Identify situations in which emergency treatment is acceptable without informed consent.

■ From the EM Model20.0 Other Core Competencies of the Practice of Emergency Medicine 20.4 Systems-based Practice 20.4.5 Regulatory/Legal

The evaluation of a patient’s medical decision-making capability in the emergency department has presented a significant challenge for physicians, midlevel providers, and nurses. Determining a patient’s decision-making capacity is an essential component of informed consent. Capacity may be assessed simply from a brief conversation with the patient, but this strategy is not possible with all patients. Patients with compromised mental capacity (ie, acute mental or physical illness, substance abuse, delirium, stroke, or traumatic brain injury) make it difficult for emergency physicians to balance the patients’ right to provide adequate informed consent with patient safety and the provision of emergent patient care.

Case Presentations

■ Case OneA 76-year-old man presents with

one week of increasing shortness of breath, productive cough, and fever. On examination, the patient appears to be in respiratory distress. His respiratory rate is 29 with accessory muscle usage; other vital signs are blood pressure 120/85, heart rate 105, and temperature 38°C (100.4°F). There is wheezing and rhonchi bilaterally, and a chest radiograph shows bilateral opacities. The patient appears to have an imminent life-threatening pneumonia. The patient refuses to be intubated. He states that he wants to go home and die.

■ Case TwoA 29-year-old man is brought in by

friends after he ingested an unknown substance at a party. On arrival, the patient is unresponsive to verbal or noxious stimuli. Traditional drug reversal therapies are ineffective, and the patient’s pulse oximetry is 80%. As preparations are made for intubation, the patient momentarily regains consciousness and says, “You will not put that tube in me!” Then he passes out again, and his oxygen saturation continues to drop.

■ Case ThreeA 32-year-old woman is

transported to the emergency department following a high-speed motor vehicle collision during which a large rod impaled her thigh. She is unconscious and was intubated at the scene. There is obvious pelvic instability on examination. Her fiancé and parents arrive, and the parents say that their daughter is a devout Jehovah’s Witness, and they refuse all blood products, claiming that this is what she would want. Hemoglobin comes back at 4.5, and there is continued bleeding despite all efforts. The fiancé insists that blood products be used to save her.

CRITICAL DECISIONWhat is the difference between capacity and competence?

The various legal and medical terms related to informed consent can be confusing. Consent in the medical context is defined as a patient’s willing participation in a medical therapy after achieving an


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Critical Decisions

Table 1 The four functional abilities of decision-making capacity

Ability to communicate

Ability to understand information

Ability to understand the situation

Ability to manipulate information

Table 2 CURVES mnemonic for emergency assessment of decision-making capacity. The first four elements of the mnemonic are for evaluation of the patient; the last two assess whether treatment can proceed without consent.

Choose/Communicate—patient able to make/communicate choice

Understand—patient understands benefits, risks, alternatives

Reason—patient makes logical, rational choice

Value—patient choice consistent with patient’s values

Emergency—patient has an impending risk

Surrogate—surrogate unavailable

∙ What is the difference between capacity and competence?

∙ How can a patient’s decision-making capacity be assessed?

∙ What tools can help physicians assess decision-making capacity in an emergent situation?

∙ What are the criteria governing a valid informed consent?

∙ Under what circumstances must a patient’s refusal of care be acceded to?

∙ Are there ethical decision-making models available for the situation?

∙ What documentation can shield physicians from potential legal consequences when a patient leaves AMA?

∙ When is emergency treatment acceptable without informed consent?

understanding of what is involved.1 Competence and decision-making capacity are components of consent. Competence is defined as sufficient understanding and memory to comprehend in a general way the situation in which one finds oneself and the nature, purpose, and consequence of any act or transaction into which one proposes to enter. Capacity in this setting is defined as a legal qualification or an ability to grasp and analyze ideas and cope with problems. The terms “decision-making capacity” and “competence” are often used interchangeably. In the medical community, this may refer to a patient’s ability to make a clinical judgment as determined by the treating physician while in the legal community this may refer to a judicial determination as to whether a patient can make legally effective decisions in other areas. Due to the medical nature of this paper the term “decision-making capacity” will be used.

CRITICAL DECISIONHow can a patient’s decision-making capacity be assessed?

Decision-making capacity is a medical term describing a patient’s ability to make informed decisions about his or her health care at a particular point in time.2 From a legal perspective, capacity comprises four functional abilities (Table 1). First is the ability to communicate choices. Patients must be able to inform the health care provider whether they would prefer receiving a medication by mouth or

intravenously. Some patients cannot verbally communicate but may be able to nod a head or squeeze a hand in order to communicate. Second is the ability to understand relevant information. To continue the previous example, a patient must be able to understand that this oral medication is less effective than the intravenous medication. Next is an ability to understand the situation and its consequences. The patient must be able to understand that taking the less effective medication could cause a slower recovery. Lastly is the ability to manipulate information rationally.3 The patient must be able to balance his desire to get well quickly with his fear of needles.

CRITICAL DECISIONWhat tools can help physicians assess decision-making capacity in an emergent situation?

Multiple decision-making tools exist for assessing decision-making capacity. The MacArthur Competence Assessment Tool (MacCAT-T) is a structured interview customized

to the current condition of the patient, the treatment benefits with alternatives, and the recommended treatment option.4 At the end, the physician assesses the patient’s understanding of the situation and the patient’s ability to make an informed choice. The Hopkins Competency Assessment Test (HCAT) requires the health care professional to read aloud an essay about informed consent and advanced directives. This may be repeated up to three times with different versions to adjust for levels of education or understanding.4,5 After reading the essay, the health care provider assesses the patient’s


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understanding through a six-question quiz. Both of these tools have been proved useful in nonemergent settings, but they are not easily adapted to an emergency situation.

One tool that may be of use in an emergent setting, due to its ease of recall and application, is the CURVES assessment tool2 (Table 2). CURVES is a mnemonic for choose/communicate, understand, reason, value, emergency, surrogate. Choose and Communicate: Is the patient able to make and communicate a choice? Understand: Is the patient able to understand benefits, risks, and alternatives? Reason: Can the patient make a logical rational choice? Value: Is the choice made known to be consistent with the patient’s values? Emergency: Is there an impending risk to the patient? Surrogate: Is there a decision maker available?6 The first four letters of this mnemonic evaluate the decision-making capacity of the patient, while the last two evaluate whether emergency treatment can be provided without informed consent. This tool is useful as a quick reminder of the aspects necessary in the assessment of capacity and acute treatment in an emergent situation.

CRITICAL DECISIONWhat are the criteria governing a valid informed consent?

In order for informed consent to be valid, four principles must be followed during the discussion with the patient, as follows: ∙ The patient must exhibit sufficient

mental capacity (ie, have the ability to communicate choices, understand relevant information, appreciate the situation and its consequences, and manipulate information rationally).

∙ The patient must be given sufficient information about the choice to enable an informed decision to be made. For example, a patient must not be informed only about a procedure’s benefits, but also be told about potential negative consequences and risks of the procedure.

∙ The patient must be able to make the decision freely, without coercion.7 For example, a health care professional might be very knowledgeable and comfortable with a certain type of procedure, although a different one might be more beneficial for the patient. In cases such as this, it is vital that the health care provider not coerce the patient into agreeing to the physician’s preferred procedure.

∙ The decision must be stable over time. This means that the decision was not made in haste, and that, if asked again, the patient is likely to make the same decision. This principle becomes more important as the stakes become higher (ie, if a decision carries the potential for significant morbidity or mortality).

CRITICAL DECISIONUnder what circumstances must a patient’s refusal of care be acceded to?

A patient, at any time, can refuse treatment of any type, an admission, a test, or a procedure, as long as the patient has decision-making capacity. It is important for the physician to establish decision-making capacity during the initial patient evaluation to prevent questioning whether a patient is of sound mind when the patient refuses a recommended treatment.

If, however, a patient does refuse a recommended intervention, there are a few strategies that might cause the patient to give consent. Ways that have been used to alleviate such problems include establishing patient trust, attempting to negotiate in order to have time for the patient to reflect on the decision, and using a family member to help the patient fully understand the risks and benefits of the treatment. In one study, factors that correlate most highly with patient’s trust in physicians were communication, level of interpersonal treatment, and knowledge of the patient.8

A patient with identified decision-making capacity can leave against medical advice (AMA) at any time. Information on this topic in the

emergency medicine literature is minimal. A study looking at patients leaving AMA from the general medicine service estimated an AMA rate of 1% to 2%.9 Factors associated with patients’ leaving AMA include substance abuse, being uninsured, being on Medicaid, younger age, being male, admission through the emergency department, admission with a substance abuse–related diagnosis, and previous AMA discharge.10-12 In general, AMA discharge rates tend to be higher at urban rather than suburban hospitals and higher at community hospitals than teaching hospitals. At hospitals serving disadvantaged inner-city populations, as many as 6% of general medical patients and 13% of patients with HIV/AIDS leave AMA.13,14

CRITICAL DECISIONAre there ethical decision-making models available for the situation?

In one such model, referred to as the “Four Boxes” developed by Jonsen, Siegler, and Winslade, the authors state that to make any ethical decision four factors must be considered.15 These factors are patient preferences, medical indications, quality of life, and contextual features. The idea of patient preferences is based on the belief that the wishes of patients should be followed, and physicians should provide treatment that meets a patient’s goals. The idea of medical indications is consideration of what is needed to evaluate and treat the medical problem. Quality of life is the goal of medical intervention to improve the quality of the patient’s life. Quality of life must be defined from the patient’s point of view, not the health care provider’s. Lastly, contextual features analyze the other considerations involved in a specific situation such as the law, wishes of the family, socioeconomic considerations, and the effect a decision will have on others. It is helpful to have a model for ethical decisions, just as health care providers have models to make other clinical decisions. A work tool like this is


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Table 3 Three criteria for treating without informed consent. All three criteria must be met.

Patient lacks adequate decision-making capacity

No legal document or surrogate decision maker is present

Situation is a true emergency with threat to life or limb

useful to help avoid overlooking any pertinent aspect of the situation and aids in the organization of the health care provider’s thought process. Like many models, this may provide too much detail to be useful in the emergency department.

The Iserson model is a tool designed for the emergency setting16: ∙ If there is a rule (law, policy,

precedent) that is close enough to apply to the dilemma at hand, follow it.

∙ If no rule clearly applies, is there an option that can buy time and does not pose additional risk to the patient? If so, take it and use that time (as much as you have) to pursue other data gathering or consultation.

∙ If action cannot be delayed, use a practiced reasoning technique to arrive at an outcome.Lastly, if a resolution still has not

been reached, then there are three rules that can be applied to help make any ethical decision. Iserson refers to these three rules as the Golden Rule test.16

∙ Impartiality—the concept of placing the decision maker in the position of the patient by asking, “Would you be willing to have this action performed if you were in the patient’s place?”

∙ Universalizability—the concept of repetition; “Would you be willing to use the same solution in all similar cases?”

∙ Interpersonal justifiability—the concept of support; “Would you be willing to defend this decision to others or to share the decision in public?”

CRITICAL DECISIONWhat documentation can shield physicians from potential legal consequences when a patient leaves AMA?

Patients leaving AMA present serious legal risk. Documentation that the patient has good decision-making capacity is beneficial, along with documentation that the risks and benefits of the recommended intervention have been discussed with the patient. In a review of four legal cases on this topic, documentation of the patient’s leaving AMA with capacity was helpful to the treating physician’s case but the plaintiff ’s inability to show negligence on the side of the physician ultimately was the deciding factor.17

When documenting, a variety of different points should be addressed within the statement. A thorough document would include the patient’s mental capacity to make the AMA decision and the physician’s discussion of why it is important for the patient to stay in the hospital and all possible serious risks of leaving AMA. These risks should be specific to the patient’s medical condition. Document the exact words the physician said to the patient. It is also important to document the physician’s efforts to get the patient to stay and instructions to the patient that they may return at any time. If possible, also document with which family members the physician discussed the issue. Nurses should also document efforts that were made to get the patient to stay.18

The following is an example of documentation including the points above. “Patient has decided to leave AMA. The patient had a normal mental status examination and understands his/her condition and the risks of leaving (include specific details), including permanent disability and/or death. The patient has had an opportunity to ask questions about his/her medical condition. The patient has been informed that he/she may return for care at any time and has been referred

to his/her own physician.”

CRITICAL DECISIONWhen is emergency treatment acceptable without informed consent?

Another problem facing emergency practitioners is when to treat a patient without consent. Patients who have not given consent may be treated if all three of the following criteria (Table 3) are met: ∙ The first criterion is that adequate

decision-making capacity is not present.

∙ Next, the situation must be a true emergency, posing a serious and immediate threat to the patient’s life or limb.

∙ Lastly, there must be no legal document or surrogate readily available and no time to obtain an ethics consultation.19

Case Resolutions

■ Case OneIn the case of the elderly man

with pneumonia who refused to be intubated, the physician explained the situation to the patient and the patient repeated the information in his own words, indicating that he understood. His family reported that the patient had a living will in which intubation is not allowed. Family members were sure that he did not want that. The patient acknowledged his options and was able to repeat in his own words that he knew without further treatment he would die. Thus, all four functional abilities of confirming decision-making capacity were present. Despite the medical emergency, the patient demonstrated decision-making capacity that was confirmed by the family. Comfort care was offered to the patient and family in the hospital. The patient died six hours later.

■ Case Two

The young man who was unconscious following an unknown ingestion was unable to communicate, did not have a gag reflex, and had equal but minimally reactive pupils.


15

Pearls ∙ Decision-making capacity is a medical evaluation made

by the treating physician, not by a court of law.

∙ The mnemonic CURVES (choose and communicate, understand, reason, value, emergency, surrogate) can be a useful tool in the assessment of capacity in an emergent situation.

∙ Informed consent must demonstrate four points, as follows: the patient has sufficient mental capacity, the patient is given sufficient information, the patient is able to make the decision freely, without coercion, and the decision is stable over time.

∙ In order to treat patients without informed consent, three criteria must be met: decision-making capacity is not present; the situation is a true emergency, presenting a serious threat to life or limb; and there is no legal document or surrogate readily available and no time to obtain an ethics consultation.

Pitfalls ∙ Trying to evaluate competence in the emergency department;

competence refers to a judicial determination about whether a patient can make legally binding decisions in other areas.

∙ Focusing on determining a patient’s decision-making capacity at the expense of patient safety or care.

∙ Assuming that documenting a patient’s decisions-making capacity is sufficient to protect the physician from the legal risks of a patient’s leaving AMA; adding a documented discussion of the risks and benefits of the recommended course of action offers greater protection.

Furthermore, he had no immediate access to legal documentation and no family was noted on arrival. The patient was in an immediately life-threatening situation. The physician was unable to ascertain whether the patient had decision-making capacity. All three principles of treating without informed consent were present. The patient was intubated, treated, and admitted to the ICU.

■ Case ThreeThis 32-year-old woman who

was in a motor vehicle collision was unable to communicate with the emergency physician and had no known documentation available. The parents, who were still the known legal surrogates of the patient since she is unmarried, refused blood products for her and said that she would do the same because of her beliefs as a Jehovah’s Witness. With this patient, although the first two guidelines of treating without consent are met, the last principle is not

met; legal surrogates were available, and they stated the patient’s known wishes. In this case, the parents’ decision not to give blood products was respected.

SummaryIn the emergency department,

decision-making capacity can be extremely difficult to ascertain. The use of multiple medical and legal terms can often be confusing to the patient. The term medical decision-making capacity is the term that the emergency physician must be able to identify and ascertain in order to provide informed consent. Multiple tools have been developed in order to help the physician deterine whether a patient is medically competent. The CURVES mnemonic for choose and communicate, understand, reason, value, emergency, and surrogate is an easy-to-remember and helpful tool. Establishing that a patient has decision-making capacity is necessary for providing informed consent.

Informed consent requires capacity, full information disclosure, and no coercion. A patient once identified as having decision-making capacity at any time can refuse any treatment. Lastly, the decision to treat a patient without informed consent requires that three conditions be met—the patient does not have decision-making capacity, it is a true emergency, and there is no quick access to documentation or a surrogate decision maker.

References1. Moskop JC. Informed consent and refusal of

treatment: challenges for emergency physicians. Emerg Med Clin North Am. 2006;24(3):605-618.

2. Chow GV, Czarny MJ, Hughes MT, Carrese JA. CURVES: a mnemonic for determining medical decision-making capacity and providing emergency treatment in the acute setting. Chest. 2010;137(2):421-427.

3. Miller SS, Marin DB. Assessing capacity. Emerg Med Clin North Am. 2000;18(2):233-242, viii.

4. Grisso T, Appelbaum PS, Hill-Fotouhi C. The MacCAT-T: a clinical tool to assess patients’ capacities to make treatment decisions. Psychiatr Serv. 1997;48(11):1415-1419.

5. Janofsky JS, McCarthy RJ, Folstein MF. The Hopkins Competency Assessment Test: a brief method for evaluating patients’ capacity to give informed consent. Hosp Community Psychiatry. 1992;43(2):132-136.

6. Curtis JR. Life and death decisions in the middle of the night: teaching the assessment of decision-making capacity. Chest. 2010;137(2):248-250.

7. Magauran BG Jr. Risk management for the emergency physician: competency and decision-making capacity, informed consent, and refusal of care against medical advice. Emerg Med Clin North Am. 2009;27(4):605-614, viii.

8. Pearson SD, Raeke LH. Patients’ trust in physicians: many theories, few measures, and little data. J Gen Intern Med. 2000;15(7):509–513.

9. Alfandre DJ. “I’m going home”: discharges against medical advice. Mayo Clin Proc. 2009;84(3):255-260.

10. Smith DB, Telles JL. Discharges against medical advice at regional acute care hospitals. Am J Public Health. 1991;81(2):212-215.

11. Jeremiah J, O’Sullivan P, Stein MD. Who leaves against medical advice? J Gen Intern Med. 1995;10(7):403-405.

12. Weingart SN, Davis RB, Phillips RS. Patients discharged against medical advice from a general medicine service. J Gen Intern Med. 1998;13(8):568-571.

13. Hwang SW, Li J, Gupta R, et al. What happens to patients who leave hospital against medical advice? CMAJ. 2003;168:417-420.

14. Anis AH, Sun H, Guh DP, et al. Leaving hospital against medical advice among HIV-positive patients. CMAJ. 2002;167(6):633-637.

15. Jonsen AR, Siegler M, Winslade WJ (eds). In: Clinical Ethics. 3rd ed. McGraw-Hill, Inc: New York, NY; 1992.

16. Iserson KV, Sanders AB, Mathieu DR, Buchanan AE (eds). In: Ethics in Emergency Medicine. Williams and Wilkins: Baltimore, Maryland; 1986

17. Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51(7):899-902.

18. Hill HF III. Leaving against medical advice. In: Henry GL, Sullivan DJ, eds. Emergency Department Risk Management, A Comprehensive Review. Dallas, TX: American College of Emergency Physicians. 1991:315-320.

19. Derse AR. What part of “no” don’t you understand? Patient refusal of recommended treatment in the emergency department. Mt Sinai J Med. 2005;72(4):221-227.


16

The Critical Image

The image appears to indicate dextrocardia and a left-sided liver. The physician noted this and the history of recurrent otitis media and suspected Kartagener syndrome, a rare autosomal-recessive genetic disorder of ciliary motility affecting fewer than 200,000 people in the United States. The syndrome is associated with situs inversus in about 50% of cases. Patients with this condition present with chronic recurrent rhinosinusitis, otitis media, and pneumonia, and may develop bronchiectasis caused by pseudomonal infection.1 While an astute observation, the physician’s conclusion was the result of a mislabeled image in this case.

Mislabeling of images and mistaken use of the wrong image can lead to dangerous clinical scenarios, ranging from unnecessary additional testing to wrong patient, wrong side, or wrong site interventions.

In one study, errors occurred in labeling of 2.4% of plain radiographs. Though the percentage of errors is low, the large volume of radiographs ordered can result in a significant number of erroneously labeled images. In this study, 62 errors occurred in 2,536 images during a 2-week period – an average of more than 4 per day.2 The most common errors included incorrect left-right markers, false patient demographic information, and incorrect date.

∙ Always confirm the patient identity by a unique identifier such as medical record number. Patient names may not be unique and should not be relied on.

∙ Always confirm the date and time of the image to avoid use of old imaging data for clinical decision making.

∙ Always consider imaging findings in the clinical scenario and reassess unexpected imaging findings. In this case, the patient’s cardiac examination was normal, and dextrocardia was not expected.

Bedside ultrasound was performed and showed the heart to be normal in orientation. A repeat chest radiograph confirmed normal anatomy. The patient was recognized to have a probably viral illness and improved after a period of observation.1. Skeik N, Jabr FI. Kartagener syndrome. Int J Gen Med. 2011;4:41-43.

2. Aakre KT, Johnson CD. Plain-radiographic image labeling: a process to improve clinical outcomes. J Am Coll Radiol. 2006;3:949-953.

Feature Editor: Joshua S. Broder, MD, FACEP. See also Diagnostic Imaging for the Emergency Physician (winner of the 2011 Prose Award in Clinical Medicine, the American Publishers Award for Professional and Scholarly Excellence) by Dr. Broder, available from the ACEP Bookstore, www.acep.org/bookstore.

A full-term, 18-month-old male patient with up-to-date immunizations, presenting from a clinic with respiratory distress and two to three days of cough The parents report subjective fever and decreased oral intake and urine output. The patient was reportedly hypoxic at the clinic. The parents also note a history of multiple otitis media episodes. The patient’s vital signs are heart rate 130, respiratory rate 28, rectal temperature 38.6°C, and oxygen saturation of 97% on room air. The physical examination is normal except for tachypnea and intercostal retractions.

A chest radiograph was obtained (below). The physician reviewed the image and concluded that, given the radiographic appearance and history of multiple otitis media infections, underlying ciliary dysmotility might be present, with increased infection risk and a need for empiric antibiotics.

Marker indicates left side of patient

Cardiac apex points to right, consistent with dextrocardia

Left diaphragm is elevated and soft tissue density in left upper quadrant is consistent with liver


17

The Critical ECG

Sinus rhythm, rate 82, right atrial enlargement, nonspecific T-wave flattening in inferior leads, abnormal precordial T-wave balance. The normal ECG has an inverted, flat, or small upright T wave in lead V1. The T wave usually is upright in lead V2 and becomes larger in the other precordial leads in normal ECGs. In this case, however, the T wave in lead V1 is not only upright, but it is larger than the T waves in the lateral leads. Marriott has referred to this abnormality as “abnormal T-wave balance.”1 Marriott and others2,3 have suggested that when the T wave in lead V1 is upright and large (more specifically, when the T wave in lead V1 is larger than the T wave in lead V6), it suggests underlying cardiac disease. This patient did prove to have a 90% obstructing lesion of the left anterior descending artery. 1. Marriott HJ. Emergency Electrocardiography. Naples, FL: Trinity Press; 1997:28-36.

2. Barthwal SP, Agarwal R, Sarkari NB, et al. Diagnostic significance of T I<T III and TV1>TV6 signs in ischaemic heart disease. J Assoc Phys India. 1993;41:26-27.

3. Manno BV, Hakki AH, Iskandrian AS, Hare T. Significance of the upright T wave in precordial lead V1 in adults with coronary artery disease. J Am Coll Cardiol. 1983;1:1213-1215.

Feature Editor: Amal Mattu, MD, FACEP. From: Mattu A, Brady W. ECGs for the Emergency Physician. London: BMJ Publishing; 2003:124,149. Available at www.acep.org/bookstore. Reprinted with permission.

A 46-year-old woman with chest and upper abdominal pain.


18

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1 Credits™, and 5 AOA Category 2-B credits for answering the following questions. To receive your certificate, go to www.acep.org/newcriticaldecisionstesting and submit your answers online. On achieving a score of 75% or better, you will receive a printable CME certificate. You may submit the answers to these questions at any time within 3 years of the publication date. You will be given appropriate credit for all tests you complete and submit within this time. Answers to this month’s questions will be published in next month’s issue.

CME Questions

1. Which of the following patients can be cleared clinically using the NEXUS criteria?A. A 24-year-old woman who is alert and who has no complaints

of pain or tenderness on examinationB. A 45-year-old intoxicated man who had a fall from standingC. A 55-year-old woman with a femur fracture after a high-speed

motor vehicle crashD. A 65-year-old man who complains of paresthesias in both of

his arms

2. Which of the following is the leading cause of spinal column injuries in adults?A. FallsB. Motor vehicle crashesC. Penetrating traumaD. Sports injuries

3. Which of the following patients would be most likely to have a cervical vascular injury?A. A patient who has a facial lacerationB. A patient who has sustained a severe hyperflexion or

hyperextension injuryC. A patient who hit his head on a cabinetD. A patient who was punched in the stomach

4. All other things being equal, which of the following trauma patients is at lowest risk for spinal column injury and may not require imaging?A. A patient with advanced arthritisB. A patient with history of cancerC. A patient with severe degenerative bone diseaseD. A young patient with a short neck

5. In the first step of applying the Canadian C-spine rule, which of the following trauma patients would require imaging?A. A patient 55 years oldB. A patient 75 years oldC. A patient injured falling off of one step (<1 foot)D. A patient injured in a low-speed motor vehicle crash

6. Ordering plain radiographs of the cervical spine should be considered before ordering computed tomography (CT) of the cervical spine in which of the following patients?A. Elderly patients with osteoporosis and arthritisB. Patients undergoing chest radiograph for blunt traumaC. Patients who require CT of the headD. Young, healthy adults who do not require CT imaging for other

causes

7. Magnetic resonance imaging (MRI) of the cervical spine is indicated in which of the following cases?A. All patients with neurologic deficitsB. Only if a fracture is seen on plain film or CTC. Only in patients with neurologic deficits and no radiographic

evidence of fracturesD. Only in pediatric trauma

8. Plain radiographs of the cervical spine are inadequate in what percentage of cases?A. In about 10% of casesB. In about 25% of casesC. In about 50% of casesD. In about 75% of cases

9. In the Canadian C-spine rule, which of the following qualifies as a low-risk mechanism of injury?A. Fall from three stairsB. Motor vehicle accident at speed of more than 65 mphC. Motorcycle accidentD. Rollover motor vehicle accident

10. The cumulative lifetime risk of cancer following CT examination of the cervical spine is: A. 1:100B. 1:5,000C. 1:15,000D. 1:100,000

11. Which of the following patients should be considered to lack adequate decision-making capacity?A. An adult patient who is functionally illiterate and cannot read

the consent formB. A patient who does not speak English and communicates with

the help of his bilingual daughterC. A patient who is angry at waiting for hours in the emergency

department and wants to leaveD. An unconscious patient who arrives via EMS after a motor

vehicle crash

12. Which of the following conditions calls into question a patient’s ability to give informed consent?A. Patient has been provided with relevant informationB. Patient has a history of psychosisC. Patient is not coerced in any wayD. Patient’s decisions are consistent with previous decisions


19

Answer key for May 2013, Volume 27, Number 5

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20A C C D A C A A D A B C B B C D D B A C

13. If a patient is refusing treatment, which of the following is an acceptable way to proceed?A. Discuss with the patient the reasons for refusing the treatment,

clarifying any misunderstandingB. Establish trust with the next of kin and ignore the patientC. Inform the patient that he is making the wrong decisionD. Move forward with your treatment plan, because you know

what is best for the patient

14. Which of the following characteristics is associated with patients who leave AMA?A. Being addicted to hydrocodoneB. Being femaleC. Being on MedicareD. Having health insurance

15. Which of the following criteria must be met in order for a physician to be justified in treating a patient without informed consent?A. Adequate decision making capacity is presentB. A legal document is readily availableC. The patient’s life is at risk without treatmentD. A surrogate decision maker is available

16. In the evaluation of medical decision-making capacity in the emergency department which of the following is correct?A. Competence is an evaluation made by the treating emergency

physicianB. Decision-making capacity is an evaluation made in a court of

lawC. Decision-making capacity is not needed for informed consentD. Determining a patient’s decision-making capacity must not

compromise patient safety or care

17. An 88-year-old woman is brought in by ambulance after being involved in a motor vehicle accident. She is unconscious and was intubated at the scene. The husband arrives and says that his wife would not want to be intubated for any reason; he says that they had discussed this issue and she was very clear about her wishes. What should the emergency physician do?A. Ask security to remove the husband from the roomB. Discuss other options for ventilation (BiPAP, CPAP, bag mask)

with the husbandC. Ignore the husband since the patient is already intubatedD. State that this is a medical emergency and, since the patient

cannot speak for herself, intubation continues

18. A 35-year-old, combative, obviously intoxicated man is brought in by paramedics; he is drooling, with obvious respiratory distress. Pulse oximetry shows that his oxygen saturation is low. All attempts to communicate with him have failed, and there are no family members present. Paramedics report that during transport the patient screamed that he did not want anyone doing anything to him at the hospital. What is the correct treatment for this patient?A. Give only supportive treatmentB. Intubate and give all treatments medically necessaryC. Obey the patient’s wishes and do not start any treatmentD. Take time to contact family before starting any treatment

19. A 28-year-old woman is brought in; she is intubated and unresponsive, and the cause is unknown. Soon after, her parents and her husband arrive. The parents demand that the ventilator be discontinued, saying that they spoke to the daughter about these matters and that it was what she wanted. The husband demands that the care be continued and states that he is the appointed medical power of attorney. How should the emergency physician proceed?A. Listen to neither and do what is medically best for the patientB. Listen to the husband because he is the legal surrogate for the

patientC. Listen to the parents because they state they understand what

the daughter wantsD. Obey the parents’ wishes

20. Which of the follow demonstrates the documentation of a patient leaving AMA that offers emergency physicians the best protection from later legal action?A. Documentation that the patient has good decision-making

capacityB. Documentation that the patient has good decision-making

capacity and that risks and benefits were discussed with the patient

C. Documentation that a discussion of risks and benefits took place

D. Having the patient sign the AMA form

NONPROFITU.S. POSTAGE

P A I DDALLAS, TXPERMIT NO.

1586


Critical Decisions in Emergency Medicine is the official CME publication of the American College of Emergency Physicians. Additional volumes are available to keep emergency medicine professionals up-to-date on relevant clinical issues.

Editor-in-ChiefLouis G. Graff IV, MD, FACEP Professor of Traumatology and Emergency Medicine, Professor of Clinical Medicine, University of Connecticut School of Medicine; Farmington, Connecticut

Section EditorJ. Stephen Bohan, MS, MD, FACEP Executive Vice Chairman and Clinical Director, Department of Emergency Medicine, Brigham & Women’s Hospital; Instructor, Harvard Medical School, Boston, Massachusetts

Feature EditorsMichael S. Beeson, MD, MBA, FACEP Program Director, Department of Emergency Medicine, Akron General, Akron, Ohio; Professor, Clinical Emergency Medicine, Northeastern Ohio Universities College of Medicine, Rootstown, Ohio

Joshua S. Broder, MD, FACEP Associate Clinical Professor of Surgery, Residency Program Director, Division of Emergency Medicine, Duke University Medical Center, Durham, North Carolina

Amal Mattu, MD, FACEP Professor and Vice Chair, Department of Emergency Medicine, Director, Faculty Development and Emergency Cardiology Fellowships, University of Maryland School of Medicine, Baltimore, Maryland

Robert C. Solomon, MD, FACEP Core faculty, Emergency Medicine Residency, Allegheny General Hospital, Pittsburgh, Pennsylvania; Assistant Professor (adjunct) Emergency Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania

Associate EditorsDaniel A. Handel, MD, MPH, FACEP Vice Chair and Director of Clinical Operations; Associate Professor, Department of Emergency Medicine; Oregon Health & Science University, Portland, Oregon

Frank LoVecchio, DO, MPH, FACEP Research Director, Maricopa Medical Center Emergency Medicine Program; Medical Director, Banner Poison Control Center, Phoenix, Arizona; Professor, Midwestern University/Arizona College of Osteopathic Medicine, Glendale, Arizona

Sharon E. Mace, MD, FACEP Associate Professor, Department of Emergency Medicine, Ohio State University School of Medicine; Faculty, MetroHealth Medical Center/Cleveland Clinic Foundation Emergency Medicine Residency Program; Director, Pediatric Education/Quality Improvement and Observation Unit, Cleveland Clinic Foundation, Cleveland, Ohio

Lynn P. Roppolo, MD, FACEP Associate Emergency Medicine Residency Director, Associate Professor of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas

Robert A. Rosen, MD, FACEP Medical Director, Culpeper Regional Hospital, Culpeper, Virginia; Associate Professor, Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia

George Sternbach, MD, FACEP Clinical Professor of Surgery (Emergency Medicine), Stanford University Medical Center, Stanford, California

Kathleen Wittels, MD Instructor, Harvard Medical School, Boston, Massachusetts

Editorial StaffMary Anne Mitchell, ELS, Managing EditorMike Goodwin, Creative Services ManagerJessica Hamilton, Educational Products AssistantLexi Schwartz, Subscriptions CoordinatorMarta Foster, Director, Educational Products

Critical Decisions in Emergency Medicine is a trademark owned and published monthly by the American College of Emergency Physicians, PO Box 619911, Dallas, TX 75261-9911. Send address changes and comments to Critical Decisions in Emergency Medicine, PO Box 619911, Dallas, TX 75261-9911, or to [email protected]; call toll free 800-798-1822, or 972-550-0911.Copyright 2013 © by the American College of Emergency Physicians. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, including storage and retrieval systems, without permission in writing from the Publisher. Printed in the USA.The American College of Emergency Physicians (ACEP) makes every effort to ensure that contributors to its publications are knowledgeable subject matter experts. Readers are nevertheless advised that the statements and opinions expressed in this publication are provided as the contributors’ recommendations at the time of publication and should not be construed as official College policy. ACEP recognizes the complexity of emergency medicine and makes no representation that this publication serves as an authoritative resource for the prevention, diagnosis, treatment, or intervention for any medical condition, nor should it be the basis for the definition of, or standard of care that should be practiced by all health care providers at any particular time or place. Drugs are generally referred to by generic names. In some instances, brand names are added for easier recognition. Device manufacturer information is provided according to style conventions of the American Medical Association. ACEP received no commercial support for this publication. To the fullest extent permitted by law, and without limitation, ACEP expressly disclaims all liability for errors or omissions contained within this publication, and for damages of any kind or nature, arising out of use, reference to, reliance on, or performance of such information.ISSN 2325-0186 (Print) ISSN 2325-8365 (Online)

The Drug BoxKetofol (ketamine/propofol combination)By Jacob Zimmerman, PharmD; Akron General Medical Center

Administering ketamine and propofol in combination has been shown to be safe and effective for procedural sedation and analgesia in the emergency department. The benefit of using the combination is that the agents may offset each other’s negative effects, decreasing the likelihood of adverse reaction. Additionally, using the combination allows sedation to be achieved with lower total doses of each drug, which decreases the time to recovery.

Mechanism of action Ketamine: noncompetitive NMDA receptor antagonist that blocks glutamate. Has analgesic, amnestic, and anesthetic propertiesPropofol: short acting general anesthetic. It is believed to work through agonism of GABAA receptors. Has no analgesic properties

Indications Ketamine: General anesthesia, procedural sedationOff-label: Analgesia, rapid sequence intubationPropofol: General and monitored anesthesia, sedation for a mechanically ventilated patientOff-label: Procedural sedation, intubationThe ketamine/propofol combination is not an FDA-approved mixture for any indication.

Dosing There is no ketofol preparation commercially available. The combination should be mixed at the time of use. One studied combination is a 1:1 mixture of ketamine, 10 mg/mL, and propofol, 10 mg/mL.1 In the event that ketamine is not available in a 10 mg/mL concentration, it can be diluted to this concentration with normal saline.An appropriate initial dose would be 0.5 mg/kg IV, repeated every 30 to 60 seconds until the desired level of sedation is achieved. Doses required to achieve adequate sedation can vary by patient.

Side effects Side effects of either agent can present during treatment. See individual agents for further information.

Contraindications/precautions

Ketamine: should be avoided if an increase in blood pressure could be hazardousPropofol: allergies to eggs or soy

1. William EV, Andolfatto G. A prospective evaluation of “ketofol” (ketamine/propofol combination) for procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2007;49(1):23-30.

Feature Editors: Michael S. Beeson, MD, MBA, FACEP; Steven Warrington, MD

volume 27 • number 6 in this issue - acep · 6/6/2013 · frank lovecchio, do, mph, facep,...

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