16 APACHE = Acute Physiology and Chronic Health Evaluation; APC = activated protein C; ARF = acute respiratory failure; BiPAP = bilevel positive airway pressure; CPAP = continuous positive airway pressure; CT = computed tomography; FiO 2 = fractional inspired oxygen; ICU = intensive care unit; NIV = noninvasive ventilation; PaO 2 = arterial oxygen tension. Critical Care February 2005 Vol 9 No 1 Sadler and Williams Cervical spine injuryClearance of potential cervical spine (C-spine) injury in the awake and cooperative patient with no distracting injury is a standardized procedure. The process becomes more problematic in the unconscious patient, leading to delay in C-spine collar removal and consequent complications such as tissue necrosis, raised intracranial pressure, excessive sedation and so on. Two recent reports addressed this issue [1,2].In the first of these [1] a postal questionnaire was sent to 32 neurosurgery and spinal injury departments in the UK, with the aim of determining how they assessed the C-spine in unconscious, adult trauma patients, and at what point immobilization was discontinued. The response rate was 84% (n = 27).The results demonstrated little consistency between units. The majority of the units questioned had no formal protocol for either screening investigations or criteria for discontinuation of C-spine immobilization. All patients underwent at least one plain C-spine X-ray. Out of 27 units, 12 used two X-ray views alone, and only 10 out of 27 units routinely used computed tomography (CT) scanning. One unit used magnetic resonance imaging routinely and two used dynamic fluoroscopy. Following negative imaging of one variety or other, 12 units discontinued immobilization immediately, 10 continued until they were able to clear spines clinically, and the remaining five were prepared to discontinue if the patient's condition required it. Over half of the patients had immobilization discontinued on the basis of plain X-rays alone, despite evidence that plain X-rays have poor diagnostic sensitivity for C-spine fractures [3][4][5] and are inferior to CT.The results suggest that there is often suboptimal and inconsistent investigation, with a subsequent lack of rationale for discontinuation of immobilization. It is suggested that head injured patients receiving a CT scan of the brain should routinely undergo C-spine CT scanning at the same time, and that magnetic resonance imaging and dynamic fluoroscopy are not necessary in these patients.The second article [2], also employing a postal questionnaire (95% response), looked at the major differences between clinicians of differing specialities in the management of potential C-spine injuries in unconscious adult patients. Abstract'Every day' clinical conundrums are all too infrequently addressed in the mainstream literature, but in the past few months two reports attempted to tackle the thorny problem of the occult cervical spine injury on the intensive care unit. Are we approaching the death knell for prone ventilation, and how much more can w...

Tracheostomies have been around for close to 3000 years, so one would hope that the controversies might have been thrashed out by now, but apparently not. Judging by some recent publications it would appear that we still do not know when or how to insert them. Monitoring is fundamental to critical care; two papers describe novel/modified techniques for assessing traumatic brain injury and cardiac output. The intensive care unit imposes a heavy treatment burden, particularly on the elderly. What impact does this have on the lives of the survivors?

Labelling of intravenous (IV) drug infusions in a non-uniform manner often leads to issues of risk of harm to patients and time / financial wasting. Ideally a straightforward, convenient and standardised method of labelling IV drug infusions should significantly reduce these risks. The Association of Anaesthetists of Great Britain and Northern Ireland (AAGBI), in conjunction with the Intensive Care Society, the Royal College of Anaesthetists and the Faculty of Accident and Emergency Medicine has previously published guidelines on syringe labelling in critical care areas in May 2003 1 and June 2004 2. These guidelines are based on a colour-coded labelling system primarily intended for syringes being used to administer drug boluses manually. All drugs with similar clinical actions are labelled in the same colour. This aims to minimise the risk of inadvertently administering a drug with different pharmacological actions in much the same way that gas cylinders in hospital have a colour-coding system. The University Hospitals of Leicester NHS Trust implemented this syringe labelling system across theatres and critical care areas and saw a reduction in drug errors as a result.