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Background. If conversion of labor epidural analgesia to cesarean delivery anesthesia fails, the anesthesiologist can be confronted with a challenging clinical dilemma. Optimal management of a failed epidural top up continues to be debated in the absence of best practice guidelines. Method. All members of the Obstetric Anaesthetists’ Association in the United Kingdom were emailed an online survey in May 2017. It obtained information on factors influencing the decision to utilize an existing labor epidural for cesarean section and, if epidural top up resulted in no objective sensory block, bilateral T10 sensory block, or unilateral T6 sensory block, factors influencing the management and selection of anesthetic technique. Differences in management options between respondents were compared using the chi-squared test. Results. We received 710 survey questionnaires with an overall response rate of 41%. Most respondents (89%) would consider topping up an existing labor epidural for a category-one cesarean section. In evaluating whether or not to top up an existing labor epidural, the factors influencing decision-making were how effective the epidural had been for labor pain (99%), category of cesarean section (73%), and dermatomal level of blockade (61%). In the setting of a failed epidural top up, the most influential factors determining further anesthetic management were the category of cesarean section (92%), dermatomal level of blockade (78%), and the assessment of maternal airway. Spinal anesthesia was commonly preferred if an epidural top up resulted in no objective sensory block (74%), bilateral T10 sensory block (57%), or unilateral T6 sensory block (45%). If the sensory block level was higher or unilateral, then a lower dose of intrathecal local anesthetic was selected and alternative options such as combined-spinal epidural and general anesthesia were increasingly favored. Discussion. Our survey revealed variations in the clinical management of a failed epidural top up for cesarean delivery, suggesting guidelines to aid decision-making are needed.

Background: Rugby League is a high-intensity collision sport that carries a risk of concussion. Youth athletes are considered to be more vulnerable and take longer to recover from concussion than adult athletes. Purpose: To review head impact events in elite level junior representative rugby league and to verify and analyze x-patchTM recorded impacts via video analysis.Study Design: Observational case series.Methods: The x-patchTM was used on twenty-one adolescent players (thirteen forwards and eight backs) during a 2017 junior representative rugby league competition. Game day footage, recorded by a trained videographer from a single camera, was synchronized with accelerometer timestamps. Impacts were double verified by video review. Impact rates, playing characteristics, and game play situations were described.Results: The x-patchTM recorded 624 impacts 20g between game start and finish, of which 564 (90.4%) were verified on video. Upon video review, 413 (73.2%) of all verified impacts 20g where determined to be direct head impacts. Direct head impacts 20g occurred at a rate of 5.2 impacts per game hour; 7.6 for forwards and 3.0 for backs (range=0-18.2). A defender’s arm directly impacting the head of the ball carrier was the most common event, accounting for 21.3% (n=120) of all impacts, and 46.7% of all “hit-up” impacts. There were no medically diagnosed concussions during the competition.Conclusion: The majority (90.4%) of impacts 20g recorded by the x-patchTM sensor were verified by video. Double verification of direct head impacts in addition to cross-verification of sensor recorded impacts using a secondary source such as synchronized video review can be used to ensure accuracy and validation of data.

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