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brain injury

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982. Hypertension in Pregnancy

is a multisystem disease, with variable progression leading to signs and symptoms requiring imminent treatment. Pre-eclampsia is associated with generalized vasospasm and progressive involvement of essential organs such as the kidney, liver, brain, and haematological systems. Maternal endothelial cell damage associated with the release of substances from the poorly perfused placenta initiates a dysfunctional cascade of coagulation, vasoconstriction and intravascular fluid redistribution that results (...) in the clinical syndrome of pre-eclampsia/eclampsia. The following diagram models the pathogenesis of pre- eclampsia (Figure 1). 5.1 PLACENTAL INVOLVEMENT When inadequate fetal vascular development, recurrent ischemia-reperfusion injury, and vasospasm affect the uteroplacental bed, fetoplacental demands outstrip the maternal circulatory supply. The fetus then becomes growth restricted and at increased risk of stillbirth and neonatal death. The incidence of IUGR in the context of pre-eclampsia ranges from 30

2006 British Columbia Perinatal Health Program

983. Practice Parameters for the Treatment of Narcolepsy and other Hypersomnias of Central Origin

Practice Parameters for the Treatment of Narcolepsy and other Hypersomnias of Central Origin SLEEP , Vol. 30, No. 12, 2007 1705 IntroductIon EXCESSIVE DAYTIME SLEEPINESS HAS A SIGNIFICANT DETRIMENTAL IMPACT ON PSYCHOLOGICAL, SOCIAL AND VOCATIONAL FUNCTION AND PERSONAL SAFETY , thus adversely affecting quality of life. Sleepiness is an important public health issue among individuals who work in fields where the lack of attention can result in injury to self or others such as transportation

2007 American Academy of Sleep Medicine

984. Reassessment: neuroimaging in the emergency patient presenting with seizure

, in how many subjects neuroimaging disclosed a new structural lesion that would likely lead to surgery or an urgent change in management, such as the finding of a brain tumor in a patient with first seizure, a finding which would reasonably be expected to prompt an urgent intervention, either by ER physicians or a consultant. The list of specific abnormalities that were included as leading to a change in acute or urgent management were as follows: traumatic brain injury including depressed skull (...) of the results of a neuroimaging study? Evidence. Five Class III studies addressed this question ( ). These studies included 98 to 875 patients, and 34 to 56% had abnormal CT scans including brain atrophy. Overall, CT scans in the emergency department for adult presenting with seizure resulted in a change of acute management in 9 to 17% of patients. Frequent CT abnormalities that changed acute management were traumatic brain injury, subdural hematomas, nontraumatic bleeding, cerebrovascular accidents, tumors

2007 American Academy of Neurology

985. Prediction of outcome in comatose survivors after cardiopulmonary resuscitation

swelling. Further injury results from increased intracranial pressure (ICP) and reduced cerebral perfusion pressure. ICP >20 mm Hg in comatose patients has been associated with poor outcome in one class IV study. Two class IV studies have suggested prognostic value of brain oxygenation (using oximetric jugular catheters). One class IV study suggested the oxygen glucose index predicted recovery of consciousness (appendix E-5). Conclusions. The prognostic usefulness of monitoring of brain oxygenation (...) and ICP is inconclusive. Recommendations. There are inadequate data to support or refute the prognostic value of ICP monitoring (recommendation level U). Are neuroimaging studies indicative of outcome? Evidence. A noncontrast CT scan is often used to exclude a primary catastrophic brain injury that could result in cardiac arrest and coma. CT scans performed soon after primary cardiac arrest are typically normal, but diffuse brain swelling may occur as early as 3 days after CPR. On CT, an inversed gray

2006 American Academy of Neurology

986. APA Consensus Guideline on Perioperative Fluid Management in Children

to loss of weight. Intravascular volume is often well preserved during the initial stages. iv. Management of hypernatraemic dehydration consists of initial volume replacement with 0.9% sodium chloride given in boluses of 20ml/kg to restore normovolaemia. Complete correction should be done very slowly over at least 48 hours to prevent cerebral oedema, seizures and brain injury. The serum Na should be corrected at a rate of no more that 12mmol/kg/day with 0.45% sodium chloride or 0.9% sodium chloride (...) list and particularly if it is judged that the situation will be compounded by a delay in returning to oral fluids post-operatively, then it may be prudent to give an intravenous bolus during surgery. APA CONSENSUS GUIDELINE ON PERIOPERATIVE FLUID MANAGEMENT IN CHILDREN v 1.1 September 2007 © APAGBI Review Date August 2010 Please feedback comments to mary.cunliffe@rlc.nhs.uk 28 REFERENCES Arieff AI, Ayus JC, Fraser CL (1992). Hyponatraemia and death or permanent brain damage in healthy children

2007 Association of Paediatric Anaesthetists of Great Britain and Ireland

987. Cardiac - recognition of life extinct by ambulance clinicians

such measures. The views of an attending General Practitioner (GP) or relevant third party should be considered. CONDITIONS UNEQUIVOCALLY ASSOCIATED WITH DEATH WHERE RESUSCITATION SHOULD NOT BE ATTEMPTED All the conditions, listed below, are unequivocally associated with death in ALL age groups (see below for further details): 1. massive cranial and cerebral destruction 2. hemicorporectomy 3. massive truncal injury incompatible with life including decapitation 4. decomposition/putrefaction 5. incineration 6 (...) . hypostasis 7. rigor mortis In the newborn, fetal maceration is a contraindication to attempted resuscitation. FURTHER DETAILS Decapitation: Self evidently incompatible with life. Massive cranial and cerebral destruction: Where the injuries are considered by the ambulance clinician to be incompatible with life. Hemicorporectomy (or similar massive injury): Where the injuries are considered by the ambulance clinician to be incompatible with life. Decomposition/putrefaction: Where tissue damage indicates

2007 Joint Royal Colleges Ambulance Liaison Committee

988. Drugs - Morphine Sulphate Oral Solution

actually improve respiratory status. Patients with other respiratory problems e.g. asthma, COPD. Head injury. Agitation following head injury may be due to acute brain injury, hypoxia or pain. The decision to administer analgesia to agitated head injured patients is a clinical one. It is essential however, that any such patient who receives analgesia is closely monitored as opiates may cause disproportionate respiratory depression and hence increase intracranial pressure. Acute alcohol intoxication (...) under 1 year of age. Respiratory depression (Adult <10 breaths per minute, Child <20 breaths per minute) or inadequate tidal volume. Hypotension (actual, not estimated, systolic blood pressure <90mmHg in adults, <80mmHg in school children, <70mmHg in pre-school children). Head injury with significantly impaired consciousness (Glasgow Coma Score <12). Phaeochromocytoma (tumour on the adrenal gland). This is a rare condition which is usually unknown to the patient or has been identi?ed and treated

2007 Joint Royal Colleges Ambulance Liaison Committee

989. Assault/Abuse - safeguarding children

their legs through the bars of the cot. Babies rarely fracture their skull after a fall from a bed or a chair. Fractures in non-mobile infants should be assessed by an experienced paediatrician to exclude non-accidental injury. Safeguarding Children Page 6 of 14 October 2006 Treatment and Management of Assault Treatment & Management of AssaultShaking injuries When small babies are shaken violently their head and limb movements cannot be controlled, and this results in severe brain damage from haemorrhage (...) and responsibility to investigate allegations or suspicions about child abuse. The Ambulance Service must refer all such concerns to social services. However, in circumstances where the child could be described as at immediate risk, cases should be referred to the Police. Children with signi?cant injury should be taken to hospital without delay. To help clinicians recognise where children are at risk, a set of recognition of abuse notes are attached (refer to Appendix 1). OBJECTIVES 1. To ensure all staff

2007 Joint Royal Colleges Ambulance Liaison Committee

990. Trauma - neck and back trauma

-spine immobilization. Journal of Emergency Medicine 1996;14(5):553-559. 14 McGuire RA, Neville S, Green BA, Watts C. Spinal instability and the log-rolling maneuver. J Trauma 1987;27(5):525-31. 15 Kennedy F , Gonzalez P , Dang C, Fleming A, Sterling- Scott R. The Glasgow Coma Scale and prognosis in gunshot wounds to the brain. J Trauma 1993;35(1):75-7. 16 Kaups KL, Davis JW. Patients with Gunshot Wounds to the Head Do Not Require Cervical Spine Immobilization and Evaluation Journal of Trauma- Injury (...) Trauma - neck and back trauma INTRODUCTION Spinal cord injury (SCI) most commonly affects young and ?t people and will continue to affect them to a varying degree for the rest of their lives. In the extreme, SCI may prove immediately fatal where the upper cervical cord is damaged, paralysing the diaphragm and respiratory muscles. Partial cord damage, however, may solely affect individual sensory or motor nerve tracts producing varying long-term disability. It is important to note

2007 Joint Royal Colleges Ambulance Liaison Committee

991. Trauma - limb trauma

Trauma - limb trauma INTRODUCTION There is one fundamental rule to apply to these cases and that is NOT to let limb injuries, however dramatic in appearance, distract the clinician from less visible but life-threatening problems such as airway obstruction, compromised breathing, poor perfusion and spinal injury. HISTORY Obtain a history of how the injury was sustained, in particular factors indicating the forces involved. ASSESSMENT However dramatic limb injuries appear, ALWAYS exclude (...) the presence of other TIME CRITICAL injuries by using the PRIMARY SURVEY. Assess and correct de?cits with: ? AIRWAY ? BREATHING ? CIRCULATION ? DISABILITY (mini neurological examination) Evaluate whether the patient is TIME CRITICAL or NON-TIME CRITICAL following criteria as per trauma emergencies guideline. In TIME CRITICAL patients, evidence suggests that haemorrhage control, spinal immobilisation if indicated (refer to neck and back trauma guideline) and rigid splinting are suf?cient treatment

2007 Joint Royal Colleges Ambulance Liaison Committee

992. Medical Emergencies - headache

), head injury (refer to head trauma guideline) and glycaemic emergency (refer to glycaemic emergencies guideline). ? Is the headache severe? Is it the most severe ever experienced by this patient? Is this an unfamiliar type of headache? ? Has the patient had this type of headache before? ? Is the headache progressive and escalating in severity? ? Was it a sudden onset? ? Is there loss of function or sensation? ? Is there any impairment of consciousness? ? Any visual symptoms or associated vomiting (...) recovery. These patients should not be left at home and require full hospital assessment. Neck stiffness may also be a sign of SAH. Cerebral haemorrhage (bleeding into the brain itself) often causes a similar acute picture in older patients. Migraine Commonly causes recurrent one-sided headache, often accompanied by nausea or vomiting and blurring distortion of vision. There is frequently a previous history of migraine or similar pattern of headaches but this does not exclude the possibility

2007 Joint Royal Colleges Ambulance Liaison Committee

993. Trauma - head trauma

Trauma - head trauma INTRODUCTION Head injury is estimated to be the cause of 1,000,000 hospital presentations each year in the UK, with an incidence of severe brain injury of between 10 and 15 per 100,000 population. 1 It may be an isolated injury or be part of multi-system traumatic injury. There is a signi?cant association with cervical spinal injury in those with a depressed level of consciousness. 2 Little can be done for primary brain injury, i.e. damage that occurs to the brain (...) at the time of injury. Injury prevention strategies such as the wearing of motorcycle helmets or use of vehicle restraint systems (e.g. seatbelts and airbags) are the only viable means of reducing these injuries. 3,4 Secondary brain injury is that which occurs following the primary event as a result of hypoxia, hypercarbia and hypoperfusion. The reduced level of consciousness may lead to airway obstruction or inadequate ventilation with consequent decreased oxygenation and increased levels of carbon

2007 Joint Royal Colleges Ambulance Liaison Committee

994. Specific Treatment Options - convulsions in adults

accompany a full epileptic convulsion (tonic/clonic). Febrile The other most common Convulsions: ambulance emergency involving convulsions is febrile convulsions. These tend to occur in children. Cardiac Arrest: REMEMBER, as a convulsion occurs, the brain is acutely starved of oxygen (O2). A convulsion may be the presenting sign of circulatory arrest at the onset of sudden CARDIAC ARREST. Always take a de?brillator to patients who are convulsing. Hypoglycaemia: Convulsions may be a presenting sign (...) , are they on medication, and are they taking it? Have they had convulsions recently? Has the adult patient been unwell at present? Have they had a high temperature? Is the patient DIABETIC (could this be secondary to hypoglycaemia)? Is the patient pregnant or delivered in the last 48- hours? – could this be due to eclampsia? (refer to pregnancy induced hypertension (including eclampsia) guideline). Is there any history of head injury? Is there any evidence of alcoholism or drug usage? Convulsions are more common

2007 Joint Royal Colleges Ambulance Liaison Committee

995. Drugs - Thrombolytics (Reteplase, Tenecteplase)

no recent blood loss (except for normal menstruation) and is not taking warfarin (anticoagulant) therapy? 16. Can you con?rm that the patient has not had any surgical operation, tooth extractions, signi?cant trauma, or head injury within the last 4 weeks? 17. Can you con?rm that the patient has not been treated recently for any other serious head or brain condition? (This is intended to exclude patients with cerebral tumours). 18. Can you con?rm that the patient is not being treated for liver failure

2007 Joint Royal Colleges Ambulance Liaison Committee

996. Paediatric - trauma emergencies in children (overview)

? a GCS of <8 is the de?nition of coma, however a GCS of <12 in a child post-trauma that is not rapidly returning to normal mandates meticulous airway management, optimising of the ventilation and cerebral perfusion and a formal investigation of brain injury using a computerised tomography (CT) scan.Trauma Emergencies in Children – overview Page 4 of 5 October 2006 Paediatric Guidelines Paediatric Guidelines Neck: ? it is often impractical to clinically clear a cervical spine of a child in the pre (...) differences as the assessment progresses through the airway, breathing, circulation and disability areas. Children can physiologically compensate very well and so can conceal serious injury unless a high index of suspicion is retained. Agitation and/or confusion may indicate primary brain injury, but could just as readily be due to inadequate ventilation and cerebral perfusion. DEFG (DON’T EVER FORGET GLUCOSE) in terms of assessment of an altered mental state. Key Points – Trauma Emergencies in Children

2007 Joint Royal Colleges Ambulance Liaison Committee

997. Recommendations for standards of monitoring during anaesthesia and recovery : fourth edition

Patient. Wallace PGM, in Intensive Care Medicine (Bion J ed), London, BMJ Books, 1999: 404-13. 17 Recommendations for the Safe Transfer of Patients with Brain Injury. Neuroanaesthesia Society of Great Britain and Ireland & Association of Anaesthetists of Great Britain and Ireland, London, 2006. 1321 portland place, London w1b 1pY Tel: 020 7631 1650 Fax: 020 7631 4352 Email: info@aagbi.org www.aagbi.org (...) , monitoring, e.g. vascular or intracranial pressures, cardiac output, or biochemical variables. Specific devices designed to monitor loss of consciousness using adaptations of either surface EEG monitoring or auditory evoked potentials have become available. However, their routine use has yet to be fully considered as part of our recommended minimum monitoring standards. The American Society of Anesthesiologists (ASA) recently published a report from a task force set up to assess the use of brain function

2007 Association of Anaesthetists of GB and Ireland

998. Trauma emergencies in children ? overview

? a GCS of <8 is the de?nition of coma, however a GCS of <12 in a child post-trauma that is not rapidly returning to normal mandates meticulous airway management, optimising of the ventilation and cerebral perfusion and a formal investigation of brain injury using a computerised tomography (CT) scan.Trauma Emergencies in Children – overview Page 4 of 5 October 2006 Paediatric Guidelines Paediatric Guidelines Neck: ? it is often impractical to clinically clear a cervical spine of a child in the pre (...) differences as the assessment progresses through the airway, breathing, circulation and disability areas. Children can physiologically compensate very well and so can conceal serious injury unless a high index of suspicion is retained. Agitation and/or confusion may indicate primary brain injury, but could just as readily be due to inadequate ventilation and cerebral perfusion. DEFG (DON’T EVER FORGET GLUCOSE) in terms of assessment of an altered mental state. Key Points – Trauma Emergencies in Children

2006 Joint Royal Colleges Ambulance Liaison Committee

999. Convulsions in adults

convulsion (tonic/clonic). Febrile The other most common Convulsions: ambulance emergency involving convulsions is febrile convulsions. These tend to occur in children. Cardiac Arrest: REMEMBER, as a convulsion occurs, the brain is acutely starved of oxygen (O2). A convulsion may be the presenting sign of circulatory arrest at the onset of sudden CARDIAC ARREST. Always take a de?brillator to patients who are convulsing. Hypoglycaemia: Convulsions may be a presenting sign of HYPOGLYCAEMIA and should (...) , and are they taking it? Have they had convulsions recently? Has the adult patient been unwell at present? Have they had a high temperature? Is the patient DIABETIC (could this be secondary to hypoglycaemia)? Is the patient pregnant or delivered in the last 48- hours? – could this be due to eclampsia? (refer to pregnancy induced hypertension (including eclampsia) guideline). Is there any history of head injury? Is there any evidence of alcoholism or drug usage? Convulsions are more common in alcoholics

2006 Joint Royal Colleges Ambulance Liaison Committee

1000. Headache

Headache Medical Emergencies in Adults INTRODUCTION Headache is a common presenting problem met by emergency ambulance crews. Its origins may be simple, and require no more than simple painkillers, or be potentially TIME CRITICAL, caused by meningitis or subarachnoid haemorrhage. HISTORY Take a full history and determine the most probable causes of the headache (see additional information). Exclude history of stroke (refer to stroke/transient ischaemic attack guideline), head injury (refer (...) . These patients should not be left at home and require full hospital assessment. Neck stiffness may also be a sign of SAH. Cerebral haemorrhage (bleeding into the brain itself) often causes a similar acute picture in older patients. Migraine Commonly causes recurrent one-sided headache, often accompanied by nausea or vomiting and blurring distortion of vision. There is frequently a previous history of migraine or similar pattern of headaches but this does not exclude the possibility of a serious bleed

2006 Joint Royal Colleges Ambulance Liaison Committee

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