CASE STUDY

CASE ONE

A mother brings her six-year-old
son to your emergency department.
He was practising his “Power
Ranger” moves in the family’s
split-level living room and leapt
from the upper to the lower level,
landing heavily on his feet. He
complains of neck pain but no
other symptoms.
What features are present on
inspection?
He has a torticollis, and is in some
degree of pain.
What immobilisation is
indicated?
This child would not fit into a collar.
Forcing the issue would create further
pain and distress and may exacerbate
an injury. He should be allowed to
adopt a position of comfort, with
padded support if necessary, and
given simple analgesia as required.
What imaging is indicated?
X-rays are indicated as an initial investigation,
but should be interpreted
with care, with recognition that in
this age-group plain X-rays are
known to be poorly sensitive.
What is the injury?
X-rays showed an anterior subluxation
of C2 on C3. In this particular
case, injury was missed on two presentations,
as the treating doctor interpreted
the X-rays as normal and
assumed a “muscular strain”. Relying
on negative X-rays in this age
group is a classical error – the
history and examination (inspection)
give the diagnosis.
Neck pain after play mishap
X-rays are indicated for the boy but
should be interpreted with care.

CERVICAL SPINE CLEARING

1. The awake, alert patient, with no other
significant injuries.
Bony and ligamentous
injury to the cervical spine and its supporting
structures is intrinsically painful and also
causes pain because of secondary muscle
spasm. Patients in this category can tell you
where it hurts, and are able to respond adequately
to examination.
If these features are present, the neck can
be cleared clinically:
■ No midline cervical tenderness
■ No focal neurological deficit
■ Normal alertness
■ No intoxication
■ No painful distracting injury
■ 50% or greater active range of movement
in all planes.
If any of the first five features are present,
standard plain three-view X-rays are indicated.
These three views should include a
lateral view (to include all seven cervical
vertebrae and enough of the first dorsal vertebra
to demonstrate alignment), an anterior-
posterior projection, and an openmouth
odontoid view.

2. The mentally obtunded patient.

Thisgroup is the most difficult to assess accurately.
They may be affected by intoxicants,
head injury, hypoxia, shock or pain, or by a
combination of these factors. They need careful
clinical assessment and imaging, and are
at high risk of having a spinal injury and it
may be masked.
X-rays are often of sub-standard quality
in this group for several reasons, including
poor co-operation leading to difficulty visualising
C7-T1 junction and difficulty
getting the open mouth “peg view”. Plain
X-rays of good quality, which include the
C7/T1 junction and the odontoid peg/C1/occipital
junctions, are needed to clear the neck
for most patients and swimmer’s views
and/or obliques may be needed.
Those patients with a significant head
injury, requiring CT scanning of the brain,
should also have CT scanning of the craniocervical
junction and often the rest of the
neck as well. Patients with other significant
injuries, whether spinal, chest, abdomen or
pelvic, often require CT scanning, and clearance
of the cervical spine using CT should
be done then.
3. The patient who clearly has a spinal
injury.

This is the easiest group for decisionmaking!
They may have evidence of a spinal
cord injury, or displaced fracture on plain
X-rays, or other myelopathic or radiculopathic
symptoms or signs that will require
specialist consultation. They need transfer
for detailed imaging such as CT and/or MRI,
as well as treatment.
4. The patient with other injuries requiring
transfer to a higher-level facility. Plain Xrays
should be performed and the need for
continued immobilisation discussed with
the referral centre.

Non-ulcer dyspepsia

Functional or non-ulcer dyspepsia is defined as at least three
months of dyspepsia in which no definite biochemical or
structural cause can be found to explain symptoms. There
is no confirmatory test and the diagnosis can only be made
after exclusion of the aforementioned structural causes.
A diagnosis of non-NSAID, non-H pylori ulcer should
only be entertained after:
■ exclusion of surreptitious NSAID use
■ careful exclusion of H pylori infection by several
biopsies
■ use of more than one H pylori diagnostic test
■ exclusion of confounders that would alter the sensitivity
of these tests, such as concurrent proton pump inhibitor
(PPI) use, recent antibiotic therapy or gastrointestinal
bleed.
Management involves 4-8 weeks of PPI therapy.
Although rare, exclusion of gastric carcinoma and other
upper gastrointestinal malignancies is important in those
with “alarm symptoms”, which the American Gastroenterological
Association guidelines summarise as:
■ age older than 55 years with new-onset dyspepsia
■ family history of upper gastrointestinal cancer
■ unintended weight loss
■ gastrointestinal bleeding
■ progressive dysphagia
■ odynophagia
■ unexplained iron-deficiency anemia
■ persistent vomiting
■ palpable lymphadenopathy
■ jaundice.
However, the presence of alarm symptoms has been
found to have poor predictive value for malignancy – rather
they alert the practitioner to the need for early endoscopy
to avoid the risk of missing a neoplastic process.
Functional dyspepsia can be difficult to manage. There
is evidence showing a small benefit with H pylori eradication
and PPI therapy. Although impaired gastric emptying
is noted in 25-40% of patients with functional dyspepsia,
there is inadequate evidence for the efficacy of
prokinetic therapy.
Despite its similarities to irritable bowel syndrome in
pathophysiology, there is also inadequate evidence to support
routine use of anti-depressants and psychological
therapies, although these should be considered as alternatives
for refractory patients. Counselling and reassurance
is essential.

EPIGASTRIC PAIN

peptic ulcer disease
(5-15%)
■ gastro-oesophageal reflux
disease (5-15%)
■ gastric or oesophageal
cancer (<2%)
■ gallstones/biliary pain
■ chronic pancreatitis/
pancreatic cancer
■ coeliac disease
■ lactose intolerance
■ medications – digoxin,
theophylline, erythromycin,
potassium supplements,
corticosteroids and NSAIDs
■ infiltrative diseases of
the stomach – eosinophillic
gastritis, Crohn’s disease,
sarcoidosis
■ metabolic causes –
hypothyroidism,
hypercalcaemia,
hyperkaelemia, heavy
metals
■ hepatoma and
steatohepatitis
■ intestinal angina
■ abdominal wall pain
■ Zollinger-Ellison syndrome
■ diabetic radiculopathy
Functional dyspepsia
(up to 60%)
■ caffeine, alcohol and
smoking can exacerbate
symptoms

PERINATAL DEPRESIION

■ Women often don’t recognise
themselves as being depressed
– they hide their symptoms or
present as the baby having the
problem.
■ When symptoms (anxiety,
lowered mood, tearfulness,
fears of not being able to cope
or being a bad mother) are
recurrent, severe or continue for
more than two weeks, the diagnosis
of depression or anxiety
disorder must be considered.
■ In PND many anxieties arise
from the lack a balanced
perspective. Cognitive behavioural
therapy is well suited to
address these issues.
■ Maternal depression is associated
with poor developmental
outcomes for children with
implications for the child’s
education and the potential for
mental illness as adults.
■ Mothers’ groups can be
beneficial if they are specifically
for women with PND but general
mothers groups can alienate
women if they feel different to
the other “coping” mothers.
■ Early detection and treatment
of PND may lead to remission
of symptoms and improvement
for mother, child and family
members, but it does not
guarantee a good outcome.
For some women, mother-infant
or long-term therapy is needed