Penetrating Head Injury R Frontal Knife example essay topic

INTRODUCTION Traumatic brain injury (TBI) is a leading cause of death and disability in children and in adults in their most productive years. TBI is a non degenerative, non congenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairments of cognitive, physical, and psychosocial functions with an associated diminished or altered state of consciousness. According to the Australian Bureau of Statistics 2002, Injuries and poisoning are a significant source of preventable illness, disability and mortality in Australia, and place a heavy burden on health services. Injuries (e.g. fractured bones, lacerations, head injuries) and poisoning (e.g. drug overdose) result from events such as car crashes, falls, suicide or attempted suicide, and interpersonal violence.

Such events, and factors involved in them, are known collectively as 'External causes' of injury and poisoning. "Injury, poisoning and certain other consequences of external causes" was recorded as the principal diagnosis for more than 413,735 episodes of inpatient care in Australian hospitals during 1999-2000 (table 9.13). See Appendix 1. Falls are the most common external cause of injuries resulting in admission to a hospital. This is reflected in the draft National Injury Prevention Plan: Priorities for 2001-2003, which nominated falls among persons aged 65 years and older and falls among children under 15 years of age as two of four areas for priority action. The other areas are drowning and near drowning; and poisoning of infants and children less than 5 years of age.

Although the number of deaths from these four types of injuries is relatively small, they account for a large number of hospital admissions. It is reported in the Australian Bureau of Statistics 2002, that suicide and transport accidents presently account for more than half of all injury deaths in Australia. Suicide numbers and rates have risen in recent decades, especially for young and middle-aged men, bringing this topic substantial public and government attention since the mid-1990's. In contrast, the annual number of road deaths has dropped to about half the number in 1970, despite large increases in population and the amount of travel on roads. This decrease is attributable to the range of agencies and programs at Commonwealth and State / Territory level which have had long-standing responsibility for road safety issues, and other aspects of transport safety. According to Sosin D M, Sniezek J E, Waxweiler R J. (1992), many people are left with permanent neurological disabilities as a result of a traumatic brain injury.

The disability involved results in a significant loss of productivity and income potential. It also has a devastating effect on the lives of the individuals and the families touched by these tragedies. Therefore, neuro trauma is a serious public health problem mandating continuing efforts in the areas of prevention and treatment. During the past two decades, understanding of the path physiology of traumatic brain injury has increased remarkably. One central concept is that all neurological damage does not occur immediately at the moment of impact (primary injury), but evolves over the ensuing minutes, hours and days. This secondary brain injury can increase mortality and worsen disability.

Paramedic personnel are often the first healthcare providers for patients with severe head injuries. The treatment of TBI is often begun in the field by paramedic personnel. This care is continued while en route to the hospital. The prehospital assessment and treatment is the critical first link in providing appropriate care for these individuals with severe brain injuries. Paramedic Care Model: Mcdonell A H (1994, ) purports that treating a patient in a pre hospital environment is very different to the controlled environment of the hospitals accident and emergency department.

He developed and describes the three phases of the Paramedic Care Model (PCM): Phase 1: Planning and Scene containment - Dispatch Survey, Arrival survey and the Approach Survey. Phase 2: Assessment and Management: Primary Survey, Chief Complaint Survey, Vital Sign Survey and Secondary Survey. Phase 3: Information Survey, Professional Referral and Evaluation. The Paramedic Care Model is designed to offer medical intervention at time of first contact.

The time of first contact occurs when someone recognizes a need for medical assistance and calls the local emergency number to access help. The caller will usually be routed to a Intergraph worker that will obtain needed information to initiate a response to the scene. The Intergraph worker will also assess the medical situation and offer pre-arrival instructions. These can be as simple as putting pressure on a bleeding site, or as complicated as opening an airway or performing CPR. Once the paramedic arrives on the scene, the arrival survey is completed. This includes collecting visual data.

The arrival survey provides specific information about what might have happened and what is happening now. The first responsibility of the paramedic is to their own safety, the first consideration is to evaluate the danger and or potential dangers. Once this is established the paramedic evaluates bystander behavior, as they often indicate the seriousness of the injury or illness. Surveying the accident scene will frequently provide an indicator of the Mechanism of Injury. From the Mechanism of Injury certain predictable injuries (or pattern of injuries) can be determined. The Pattern of Injury can be helpful in supporting the Paramedic in predicting potential injuries that occur in certain accidents.

The Approach Survey commences as the Paramedic moves onto the scene. It is a continuation of the Arrival Survey and requires continuous observation of the scene and the process of questioning of bystanders concerning the condition of the patient. Approaching the scene provides the first opportunity for the paramedic to look at the patient. The presentation of the patient can provide an indication of the patient's condition. Phase 2 of the PCM begins with the Primary Survey. The Primary Survey is the most significant of all the surveys as it deals with conditions that if not managed appropriately can result in death.

The Primary Survey is a combination of rapid assessment and management. The primary survey aims to identify and treat immediately life-threatening injuries. Its basis is the DR A B C of emergency care. This system includes airway control with stabilization of the cervical spine, breathing (work and efficacy), and circulation with control of external bleeding, disability or neurological status, and undressing of the patient while also protecting them from hypothermia. The Chief Complaint Survey is the patients own description of why help was requested, although in some circumstances the patient is unable to provide information. In trauma, additional to the patient's description, the Chief complaint is considered to be the mechanism of injury.

The chief complaint provides the paramedic with an assessment direction by identifying the patients concerns or potential patterns of injury. During the injury process the body is subject to a number of external forces and energies. Kinetic energy is thought to be the type of accident that produces kinetic energy that in turn produces injury. Mcdonell (1994) believes various mechanism of injury show certain consistent injuries. This is described as the pattern of injury; therefore from the mechanism of injury the paramedic can have an idea of the patient's pattern of injury and potential injury. The measurement of vital signs, temperature, pulse, blood pressure and conscious state, provides an overview of the physiological status of the patient.

It includes the Respiratory, Perfusion and Mental Status assessment. As a result of injury or illness, the normal function and balance between organs and body systems are altered as the body struggles to compensate and maintain equilibrium. These changes are reflected in the vital signs survey. Measuring vital signs allows the paramedic to: determine the relative status of vital organs, how the body is responding to Illness or injury (are they getting worse, are they time critical).

Establishes baseline measurements for comparisons with ongoing vital measurement - monitor patient's response to treatment and determines the need for the level of onsite assessment and further diagnostic testing. The concept of time critical is based on the paramedic's judgment whether the patient's management should be on site, a mixture of both onsite and during transport or mostly during transport. Time critical means that there may be potential for an unacceptable risk of deterioration of a patient before tertiary treatment can be reached. Mcdonell A H (1994), states: A patient is considered time critical by: ... being in immediate life threatening condition (Primary Survey). The mechanism of injury and potential resulting patterns of injury (Chief Complaint), The trends of the vital signs with time (Vital Signs Survey). The nature of the actual injuries or illness and its affects on the patient (all surveys, particularly Primary, Vital Signs and Secondary Surveys) and The accessibility of tertiary care...

The Secondary Survey is the final assessment and management phase of the PCM. The Secondary survey is not started until the primary survey is complete: after all immediate life threat is managed and the patient's time critical status is judged. The secondary survey includes a detailed history, and a complete physical examination. During the secondary survey, the patient's A B C should be constantly reevaluated.

The aim of the survey is to determine the patient's main presenting problem, finding other associated problems, management and ongoing assessment. The Secondary Survey consists of 4 areas of examination: Health History, Physical Assessment, Management of Specific problems and Recognition of Patients Problems. Phase 3 of the PCM consists of the Information Survey. The Survey consists of reviewing data collected and the management of the patient. It is then passed on verbally and in written form as a patient care record to the accident and emergency health personnel. Emergency medical care in the field is provided by a wide variety of personnel.

The First Responder or basic paramedic provides patient assessment and non-invasive interventions The Basic Life Support (BSL) Paramedic provides basic life support, manual defibrillation, inhaled analgesia and Intra Muscular Injections. The Advanced Life Support (ALS) Paramedic provides all basic life support plus ALS procedures such as IV therapy, fluid resuscitation, IV Medication such as Adrenaline, Morphine, Maxolon, Laryngeal Mask and chest decompression, and the Mobile Intensive Care Ambulance Paramedic provides all BLS, ALS and Intensive Care procedures such as Endotracheal Intubation, Rapid sequence intubation and sedation, Jugular vein can ulation, intraoesseous infusion, a large range of drugs (including second line), and ongoing infusions (such as adrenaline, salbutamol, lignocaine - sedation midazolam and morphine). MICA paramedics provide intensive care support to ambulance paramedics, and work in additional practices such as air ambulance and on the helicopter. Neuroanatomy and Neurophysiology Review Several aspects of neuroanatomy and neurophysiology require review in a discussion of TBI.

According to Chesnut R M, Marshall L F, Marshall S B (1993), the brain essentially floats within the Cerebral Serous Fluid (CSF); as a result, the brain can undergo significant translation and deformation when the head is subjected to significant forces. In a deceleration injury, in which the head impacts a stationary object such as the windshield of a car, the skull stops moving almost instantly. However, the brain continues to move within the skull toward the direction of the impact for a very brief period after the head has stopped moving. This results in significant forces acting on the brain as it undergoes both translation and deformation. In an acceleration injury, as in a direct blow to the head, the force applied to the skull causes the skull to move away from the applied force. The brain does not move with the skull, and the skull impacts the brain, causing translation and deformation of the brain.

The forces that result from either deceleration or acceleration of the brain can cause injury by direct mechanical effects on the various cellular components of the brain or by shear-type forces on axons. In addition to the translational forces, the brain can experience significant rotational forces, which can also lead to shear injuries. Penetrating objects to the cranium must traverse through the scalp, through the skull bones, and through the dura mater before reaching the brain. Rosenwasser R H, Andrews D W, Jimenez D F (1991), describe the scalp in five different anatomical layers that include the skin (S); the subcutaneous tissue (C); the galea aponeurotic a (A), which is continuous with the musculo aponeurotic system of the frontal is, occipital is, and superficial temporal fascia; underlying loose areolar tissue (L); and the skull periosteum (P). The subcutaneous layer possesses a rich vascular supply that contains an abundant communication of vessels that can result in a significant blood loss when the scalp is lacerated. The relatively poor fixation of the galea to the underlying periosteum of the skull provides little resistance to shear injuries that can result in large scalp flaps or so-called scalping injuries.

This layer also provides little resistance to hematomas or abscess formation, and extensive fluid collections related to the scalp tend to accumulate in the subgaleal plane. The bones of the calvarium have 3 distinct layers in the adult-the hard internal and external tables and the cancellous middle layer, or diplo"e. Although the average thickness is approximately 5 mm, the thickest area is usually the occipital bone and the thinnest is the temporal bone. The calvarium is covered by periosteum on both the outer and inner surfaces.

On the inner surface, it fuses with the dura to become the outer layer of the dura. Rosenwasser R. H et al (1991) report that aesthetically, the frontal bone is the most important because only a small portion of the frontal bone is covered by hair. In addition, it forms the roof and portions of the medial and lateral walls of the orbit. Displaced frontal fractures therefore may cause significant deformities, exophthalmos, or exophthalmos. The frontal bone also contains the frontal sinuses, which are paired cavities located between the inner and outer lamellae of the frontal bone. The lesser thickness of the anterior wall of the frontal sinus makes this area more susceptible to fracture than the adjacent temporal-orbital areas.

The dura mater or pachy meninx is the thickest and most superficial meninx. It consists of 2 layers-a superficial layer that fuses with the periosteum and a deeper layer. In the same region between both layers, large venous compartments or sinuses are present. A laceration through these structures can produce significant blood loss or be responsible for producing epidural or subdural hematomas.

Stab Wounds According to Torner J C, Choi S, Barnes T Y (1999), this group of wounds represents a smaller fraction of penetrating head injuries. The causes may be from knives, nails, spikes, forks, scissors, and other assorted objects. Penetrations most commonly occur in the thin bones of the skull, especially in the orbital surfaces and the squamous portion of the temporal bone. The mechanisms of neuronal and vascular injury caused by cranial stab wounds may differ from those caused by other types of head trauma. Unlike missile injuries, no concentric zone of coagulative necrosis caused by dissipated energy is present. Unlike motor vehicle accidents, no diffuse shearing injury to the brain occurs.

Unless an associated hematoma or infarct is present, cerebral damage caused by stabbing is largely restricted to the wound tract. A narrow elongated defect, or so-called slot fracture, sometimes is produced by a stab wound and is diagnostic when identified. However, in some cases in which skull penetration is proven, no radiological abnormality can be identified. In a series of stab wounds, De Villiers J C (1975) reported a mortality of 17%, mostly related to vascular injury and massive intracerebral hematomas. Stab wounds to the temporal fossa are more likely to result in major neurological deficits because of the thinness of the temporal squama and the shorter distance to the deep brain stem and vascular structures. Patients in whom the penetrating object is left in place have a significantly lower mortality than those in whom the objects are inserted and then removed (26% versus 11% respectively).

Penetrating trauma Penetrating head trauma is a wound in which a projectile splits the cranium but does not exit it. Siccardi D, Cavaliere R, Pau A. (1991), report that in the past 20 years, there has been a dramatic increase in the incidence of penetrating injuries to the brain in the United States. The treatment of penetrating brain injuries involves 2 main aspects. The first is the treatment of the TBI caused by a penetrating object. Penetrating brain injuries, frequently result in severe Inter Cranial Pressure elevations. This aspect of penetrating brain injury treatment is identical to the treatment of closed head injuries.

According to Rosenberg W S, Harsh G R. (1996), the second aspect of penetrating head injury treatment involves debridement and removal of the penetrating objects. Penetrating injuries require careful debridement because these wounds are frequently dirty. When objects penetrate the brain, they introduce pathogens into the brain from the scalp surface and from the surface of the penetrating object. Penetrating injuries may be caused by high-velocity missiles (eg, bullets), penetrating objects (eg, knives, tools), or fragments of bone driven into the brain. Penetrating objects such as knives require removal to prevent further injury and infection.

If the penetrating object either is near or traverses a major vascular structure, an angiogram is necessary to assess for potential vascular injury. When the risk of vascular injury is present, penetrating objects should be removed only after appropriate access has been obtained to ensure that vascular control is easily achieved. Patients who survive penetrating craniocerebral injuries are at risk of experiencing multiple complications, including persistent neurological deficits, infections, epilepsy, cerebrospinal fluid leak, cranial nerve deficits, pseudo aneurysms, and hydrocephalus. Complications of Penetrating Head Injuries Neurological deficits Giannotta S L, Gruen P (1992), report the following complications: Anosmia caused by traumatic injury to the first cranial nerve occurs in 2-38% of patients with TBI. It is more common in those with frontal fractures and in those with posttraumatic rhinorrhea. Posttraumatic anosmia improves slowly, and as many as one third of patients do not show any improvement in olfaction.

Injuries to the fourth cranial nerve, the trochlear nerve, are also quite common. This nerve is often injured in patients with head trauma because it has the longest intracranial course of the cranial nerves. Injury to the trochlear nerve causes a positional diplopia, in which those affected experience diplopia when they look down and toward the eye in which the trochlear nerve is injured. As a result, to compensate, the head is tilted up and away from the side of the injury.

Trochlear nerve injuries resolve fully in approximately two thirds of those with unilateral injury and in one fourth of those with bilateral injuries. According to Giannotta SL, et al (1992), Facial nerve injuries often occur with head injuries in which the temporal bone is fractured. From 10-30% of persons with longitudinal fractures of the temporal bone and 30-50% of those with transverse fractures of the temporal bone have either acute or delayed facial nerve injury? Immediate facial nerve injury suggests direct injury to the nerve, while delayed injury suggests progressive edema within the nerve. In severely injured patients, a delay in the diagnosis of facial nerve injuries occurs frequently because facial nerve function is difficult to assess in obtunded patients.

Cochlear nerve injury (cranial nerve V ) is also a common occurrence in patients with head injury, especially in patients with temporal bone fractures. In addition, vestibular disorders, including vertigo, dizziness, and tinnitus, is extremely common in patients with head injuries. Intracranial infections According to Kaufman H H, Timberlake G, Voelker J (1993), intracranial infections are another potential complication of TBI. In uncomplicated closed head injury, infection is uncommon.

The incidence of infection in penetrating cerebral injuries and open depressed skull fractures increases. These infections can complicate as many as 11% of penetrating craniocerebral injuries. Therefore, prevention and proper management of infectious complications can lead to improved outcome in these patients. Patients can develop meningitis, epidural abscess, subdural empyema's, or brain abscess.

Epilepsy Annegers JF, Hauser WA, Coan SP (1998), suggest that the incidence of posttraumatic epilepsy varies widely, depending on the type and severity of the injury. Posttraumatic seizures are a frequent complication of TBI and are divided into 3 categories. Early seizures occur within 24 hours of the initial injury, intermediate seizures occur 1-7 days following injury, and late seizures occur more than 7 days after the initial injury. Posttraumatic seizures are very common in those with a penetrating cerebral injury, and late seizures occur in as many as half of these patients.

Cerebrospinal fluid leak Chesnut RM et al (1993), report that head trauma is the most common cause of CSF leak. Meningitis occurs in approximately 20% of acute (within 1 wk) posttraumatic leaks and 57% of delayed posttraumatic leaks. The use of prophylactic antibiotics administration for CSF leak has been demonstrated to lead to serious infections, including drug-resistant meningitis. Vascular injuries may result from direct injury of the vessels by the penetrating object, blast effect at the time of trauma, or by skull fractures or bone fragments producing vascular occlusion. Direct vascular injuries sustained at the time of head injury initially may be clinically silent and may remain so for weeks, months, or years.

In addition, delayed posttraumatic pseudo aneurysms can appear weeks to months after the injury. Cranial nerve deficits According to Rosenberg W S et al (1996), patients who experience an injury to the temporal area and / or have a fracture of the temporal bone are especially at risk for carotid artery injury as well as injury to the facial nerve. Vascular injuries Sosin D M, Sniezek J E, Waxweiler R J (1995), report that vascular injuries are uncommon sequelae of This. Arterial injuries that may occur following head trauma include arterial transactions, thrombo embolic phenomena, posttraumatic aneurysms, dissections, and carotid-cavernous fistulae. Brain death Sosin D M, et al (1995), suggests brain death can result from either massive initial injury or as the result of prolonged severe elevations of ICP. Brain death is defined as the absence of brain function.

Patient Case Study Due to confidentiality the patients name and any identifying data has been removed. Dispatch Survey: Initial Information: Possible murder, woman found by neighbours with knife in her head. Given as signal 1. Address: 33 View Rd Timbuktu. Arrival Survey: Police in attendance, unit in back yard.

No apparent dangers to paramedics or patient. Approach Survey Homicide Team in attendance. They provided the following information. The woman's name was Jane Doe, a 48 year old woman who was well known to police. They believed the injury was self inflicted and that she had a history of same.

The neighbours had found the woman lying on the bathroom floor and contacted police. On entry patient was found in the supine position on the bathroom floor with a bread knife embedded approximately 10 cm in to the skull. Primary Survey On examination the patient was conscious but appeared floridly psychotic, talking about fairies and politicians. She complained of a headache and nausea. 1548 hrs: O 2 commenced at 8 lpm. P - 100 Blood Pressure - 90 p Respirations - 25 Respiratory effort - Normal.

Skin - Temperature: Cold. Colour: Pale. Moist: Dry. Pain - not assessed. Glasgow Coma Scale: opening Eye - 4 Best verbal response - 4 Best Motor - 6 Pupils - R) P R. L) P R Chief Complaint Survey According to the patient she drove the bread knife into her head by banging the handle against the wall. The incident happened 24 hours ago.

As she was banging her head she lost her balance and fell and was unable to get up. The Mechanism of Injury was stabbing by a bread knife. Expected pattern of injury: traumatic brain injury Focal neurologic deficits are quite common following TBI. Cranial nerves are affected often because of their anatomic location at the base of the brain.

When the brain shifts within the skull as it undergoes either acceleration or deceleration forces, significant force is often placed on the entire brain and the cranial nerves. The cranial nerves are tethered at their exit sites from the skull, and, as a result, they may be stretched when the brain shifts as a result of acceleration or deceleration forces. In addition, the cranial nerves are very susceptible to injury as they course through narrow bony canals and grooves. The cranial nerves that are injured most commonly in patients with TBI are cranial nerves I, IV, VII, and V. DR ABC completed.

NO obvious dangers GCS was 14. Pulse weak. Past History; According to the Homicide Squad the patient has a history of Psychiatric illness and was well known to the police. Patient denied same and stated that she had never been unwell, but considering that she presented as floridly psychotic she was not seen as a good historian. No known allergies. Presenting History: 48 divorced woman found by neighbours with a bread knife protruding from her head.

According to the patient she had driven the bread knife into her head by banging the handle against the wall, 24 hours ago. She lost her balance and fell to the floor and was unable to get up. The patient was found by neighbours, who then contacted the police and ambulance. She complained of headache and nausea.

Medications: The patient denied being prescribed any medication. Allergies: None known at this time. Handed over to Mobile Intensive Care Ambulance crew at 1550 hours. Secondary Survey On examination: GCS - 14, E 4, V 4 M 6. Tachycardia, Radial BP 90 Skin cold pink dry.

Monitor Sinus Tachycardia Head: Penetrating Head Injury R) Frontal Knife, in situ. C / O headache Chest: A / E L = R Decrease at bases. Abdomen: Soft non -tender, C / O nausea. Pelvis: NAD. Extremities: R) Normal movement.

L) Abnormal Flexion L) arm. Unable to move L) arm or Leg. Incontinent of urine and faeces. Denied any illicit / prescribed medications ingestion. 1555 hrs: Pad and Bandage to immobilize knife.

16600 hrs: Cervical Collar to stabilize head. 1602 hrs: I. V access 18 g R) foot Reflux Valve. Normal Saline flush. 1606 hrs: I. V access 18 g R) ACF 3 way tap. 1606 hrs: Hartmann's 1000 mls TIVO. 1610 hrs: Maxolon 10 mg I.V. 1610 hrs: Transport Hospital notification.

Signal 2. On arrival at Accident and Emergency: MR 114. BP 90. GCS 14. Information Survey: 48 year old woman found by neighbours this afternoon with a penetrating head injury. Patient stated that she drove the knife into her head 24 hours ago.

Complaining of headache and nausea. Pulse: 110, Blood Pressure: 90 P, Respiration: 25, GCS: 14. Left sided weakness. I. V access in R) foot and R) ACF. Hartmann's 100 mls commenced at 1606 hrs. Maxolon 10 mg given I. V at 1610 for nausea.

Final assessment: Penetrating head injury. Clinical Practice Guidelines used: Clinical Approach CPG: A 0201 Time Critical Guidelines CPG: A 0101. Perfusion Status Assessment CPG: A 0102. Respiratory Status assessment.

CPG: A 0103. Conscious State Assessment (Glasgow Coma Score) CPG: A 0104. Mental Status Assessment. CPG: A 0202. Compound Sodium Lactate "Hartmann's Solution". CPG: D 005.

Metoclopramide "Maxolon". CPG: D 019. Conclusion Ideally, care of the head-injured patient should be provided as rapidly as possible to establish an airway and administer oxygen. Early recognition of the initial signs and symptoms of TBI have a significant impact on the outcome of these patients. In addition to initial treatment, EMS providers must be aware of interventions aimed at minimizing a secondary injury.

Appropriate prehospital emergency medical care can help minimize the impact of secondary injury in patients who have sustained TBI. As discussed in the essay TBI is a major contributor to death and ongoing disability in our society. As paramedics we are often the first medical personal on the scene and are the critical first link in providing appropriate care for these individuals with severe brain injuries. Research for the paper proved difficult in the respect of obtaining current Australian Statistics. The United States is advanced in their research on TBI and Australia needs to obtain evidence based research to further our role as leaders in prehospital trauma care. According to Sackett DL, Rosenberg WMC, Gray JAM, Richardson WS (1996) Evidence Based Medicine has been defined as: ... an approach to practicing medicine in which the clinician is aware of the evidence in support of clinical practice, and the strength of that evidence...

Evidence-Based Medicine has been described as a process of life-long, problem-based learning. The process involves: Converting information needs into focused questions, proficiently tracking down the best evidence with which to answer the question, critically appraising the evidence for validity and clinical value, applying the results in clinical practice and evaluating performance of the evidence in clinical application. Paramedics need tools to be able to apply research in a practical way. Bridging the gap between theory and practice requires both a means to translate research findings into the language and action of practice, and the opportunity to elicit sustained changes based on these findings (FoNS 1996). A number of mechanisms exist which may enable this process to take place: Clinical practice guidelines based on sound evidence about best practice. The setting of clinical standards on the basis of such guidance and effective care planning to facilitate application of guidelines and the meeting of standards in practice.

The current Cpg met the needs of the patient but as with all guidelines require constant appraisal and upgrade.

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