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Coma Exam

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181. Syndrome of inappropriate antidiuretic hormone

excessive arginine vasopressin (AVP) release. Severe neurological symptoms, such as altered mental status, seizure, and coma, may result from SIADH and these are always treated with hypertonic saline, with close monitoring to avoid overcorrection of serum sodium. Central pontine myelinolysis (osmotic demyelination syndrome) may occur with rapid correction of serum sodium in excess of 12 mmol/L/day (12 mEq/L/day). Vasopressin receptor antagonists (vaptans) are a new class of medicines that compete (...) insufficiency, and appropriate release of AVP secondary to extracellular volume depletion (hypovolaemia, due to gastrointestinal or renal loss) or intravascular volume depletion (hypervolaemia due to congestive heart failure, cirrhosis of the liver, or nephrotic syndrome) must be ruled out in order to diagnose SIADH. History and exam presence of risk factors absence of hypovolaemia absence of hypervolaemia absence of signs of adrenal insufficiency or hypothyroidism nausea vomiting altered mental status

2018 BMJ Best Practice

182. Assessment of syncope

Guidelines, and the Heart Rhythm Society. Circulation. 2017 Aug 1;136(5):e60-122. https://www.ahajournals.org/doi/abs/10.1161/CIR.0000000000000499 http://www.ncbi.nlm.nih.gov/pubmed/28280231?tool=bestpractice.com It has many causes, and is distinct from vertigo, seizures, coma, falls, psychogenic pseudosyncope, drop attacks, transient ischaemic attacks, and states of altered consciousness. Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACCF scientific statement on the evaluation of syncope: from (...) with or without heart disease. J Am Coll Cardiol. 2001 Jun 1;37(7):1921-8. https://www.sciencedirect.com/science/article/pii/S0735109701012414?via%3Dihub http://www.ncbi.nlm.nih.gov/pubmed/11401133?tool=bestpractice.com Linzer M, Yang EH, Estes NA 3rd, et al. Diagnosing syncope. Part 1: Value of history, physical examination, and electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians. Ann Intern Med. 1997 Jun 15;126(12):989-96. http://www.ncbi.nlm.nih.gov/pubmed

2018 BMJ Best Practice

183. Hyperosmolar hyperglycaemic state

, weakness, weight loss, tachycardia, dry mucous membranes, poor skin turgor, hypotension, and, in severe cases, shock. Altered sensorium (lethargy, disorientation, stupor) is common and correlates best with effective serum osmolality. Coma is rare and, if seen, is usually associated with a serum osmolality >340 mmol/kg (>340 mOsm/kg) Treatment includes correction of fluid deficit and electrolyte abnormalities, and intravenous insulin. Definition Hyperosmolar hyperglycaemic state (HHS), also known as non (...) ?tool=bestpractice.com History and exam altered mental status polyuria polydipsia weight loss weakness dry mucous membranes poor skin turgor tachycardia hypotension seizures hypothermia shock abdominal pain focal neurological signs infection inadequate insulin or oral antidiabetic therapy acute illness in a known patient with diabetes nursing home residents postoperative state precipitating medications total parenteral nutrition (TPN) Cushing's syndrome hyperthyroidism acromegaly Diagnostic

2018 BMJ Best Practice

184. Paracetamol overdose

gastrointestinal symptoms at initial presentation. Untreated paracetamol poisoning may cause varying degrees of liver injury over the 2 to 4 days following ingestion, including fulminant hepatic failure. Rarely, massive overdose may initially present with coma and severe metabolic acidosis. Presentation with coma may also occur if a combination preparation of paracetamol and opioid is taken in overdose, or after an overdose of multiple drugs. Hepatotoxicity is extremely rare in patients treated (...) . The definition of hepatotoxicity after paracetamol overdose is a serum AST concentration at least 1000 IU/L. Paracetamol is known as acetaminophen in some countries. History and exam attempted self-harm repeated non-prescription analgesic use for pain relief asymptomatic presentation nausea, vomiting, or abdominal pain right upper quadrant pain and tenderness jaundice confusion, decreased consciousness level, and/or asterixis history of self-harm history of frequent or repeated use of medications for pain

2018 BMJ Best Practice

185. West Nile virus

. No vaccine or specific antiviral treatment is available. Definition An infection caused by West Nile virus (WNV), a flavivirus of the family Flaviviridae, that is transmitted to humans by mosquito bites or through contact with infected blood. The majority of cases are asymptomatic, but infection can cause a self-limited influenza-like illness (West Nile fever or WNF) or, rarely, West Nile neuroinvasive disease (WNND). Kunjin virus is a subtype of West Nile virus endemic to Oceania. History and exam fever (...) of sudden onset malaise myalgia arthralgia pharyngitis anorexia abdominal pain visual disturbances headache rash lymphadenopathy conjunctival injection multi-focal chorioretinal lesions chorioretinitis and inflammatory vitritis seizures respiratory distress jaundice epigastric tenderness mild confusion disorientation stupor/coma neck stiffness Kernig's sign Brudzinski's sign muscle paralysis parkinsonism ataxia myoclonus tremors nausea/vomiting generalised muscle weakness splenomegaly retinal

2018 BMJ Best Practice

186. Overview of substance use disorders and overdose

cause coma and respiratory depression. Acute management consists of maintaining airway, respiration, and haemodynamic support while excluding other diagnoses. Assisted ventilation may be necessary. Death is uncommon. Tricyclic antidepressants have a narrow therapeutic index and therefore become potent cardiovascular and CNS toxins in moderate doses. Best markers for suspected overdose are a history of depression, suicidality, and overdose, with a sudden deterioration in mental status and vital signs (...) presentation. Initial presentation with coma and severe metabolic acidosis is rare. Alcohol dependence is a chronic, relapsing disorder that results from a variety of genetic, psychosocial, and environmental factors. Swift RM. Drug therapy for alcohol dependence. N Engl J Med. 1999 May 13;340(19):1482-90. http://www.ncbi.nlm.nih.gov/pubmed/10320388?tool=bestpractice.com It is characterised by increased tolerance to the effects of alcohol, the presence of characteristic withdrawal signs and symptoms

2018 BMJ Best Practice

187. Assessment of syncope

Guidelines, and the Heart Rhythm Society. Circulation. 2017 Aug 1;136(5):e60-122. https://www.ahajournals.org/doi/abs/10.1161/CIR.0000000000000499 http://www.ncbi.nlm.nih.gov/pubmed/28280231?tool=bestpractice.com It has many causes, and is distinct from vertigo, seizures, coma, falls, psychogenic pseudosyncope, drop attacks, transient ischaemic attacks, and states of altered consciousness. Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACCF scientific statement on the evaluation of syncope: from (...) with or without heart disease. J Am Coll Cardiol. 2001 Jun 1;37(7):1921-8. https://www.sciencedirect.com/science/article/pii/S0735109701012414?via%3Dihub http://www.ncbi.nlm.nih.gov/pubmed/11401133?tool=bestpractice.com Linzer M, Yang EH, Estes NA 3rd, et al. Diagnosing syncope. Part 1: Value of history, physical examination, and electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians. Ann Intern Med. 1997 Jun 15;126(12):989-96. http://www.ncbi.nlm.nih.gov/pubmed

2018 BMJ Best Practice

188. Acute aspiration

:818-826. http://www.ncbi.nlm.nih.gov/pubmed/21263315?tool=bestpractice.com This topic does not discuss the inhalation of foreign bodies. History and exam presence of risk factors intractable cough fever dyspnoea wheezing crackles decreased level of consciousness (Glasgow coma scale score <9) increased severity of illness general anaesthesia age >70 years male sex head trauma cerebrovascular disease endotracheal or tracheostomy tube dysphagia airway difficulties barium meal gastro-oesophageal (...) examination before feeding. Anaesthesia-related aspiration of gastric contents can be prevented by identifying patients susceptible to vomiting and reflux, minimising gastric contents before surgery, minimising emetic stimuli, and avoiding complete loss of protective reflexes from over-sedation. Antibiotics are not indicated early after aspiration of gastric contents, but they should be considered if the pneumonitis does not resolve after 48 hours. Patients with neurological deficits, infants, older

2018 BMJ Best Practice

189. Ischaemic stroke

=bestpractice.com This replaced the former definition of focal neurological impairment lasting less than 24 hours. History and exam vision loss or visual field deficit weakness aphasia impaired co-ordination (ataxia) history of transient ischaemic attack (TIA) sudden onset of symptoms negative symptoms (i.e., loss of function) altered sensation headache diplopia sensory loss dysarthria gaze paresis arrhythmias, murmurs, or pulmonary oedema vertigo/dizziness nausea and/or vomiting neck or facial pain miosis (...) , ptosis, and facial anhidrosis (hemilateral) altered level of consciousness/coma confusion older age family history of stroke history of ischaemic stroke hypertension smoking diabetes mellitus atrial fibrillation comorbid cardiac conditions carotid artery stenosis sickle cell disease dyslipidaemia people with lower levels of education African-American or Hispanic ancestry poor diet and nutrition physical inactivity obesity alcohol abuse oestrogen-containing therapy illicit drug use migraine

2018 BMJ Best Practice

190. Overview of acid-base and electrolyte disorders

bicarbonate retention and loss, respectively; metabolic acidosis and alkalosis are accompanied by compensatory hyperventilation and hypoventilation, respectively. Mixed metabolic disorders can occur (e.g., diabetic ketoacidosis complicated by vomiting), and evaluation depends on clinical history and examination, assessment of anion gap, serum electrolytes, and arterial blood gases. These disorders can be effectively evaluated by a stepwise pathophysiological approach. Berend K, de Vries AP, Gans RO (...) , pseudohypoparathyroidism, vitamin D deficiency, magnesium imbalance, hyperphosphataemia, hungry bone syndrome, acute pancreatitis, extensive osteoblastic skeletal metastases, chelating agents (e.g., citrate, EDTA, lactate, foscarnet), drug-induced, and use of gadolinium-based magnetic resonance imaging (MRI) contrast agents. It is also seen in critically ill patients. Symptoms from calcium elevation are typically not found unless the calcium is above 3 mmol/L (12 mg/dL). Severe hypercalcaemia symptoms and coma

2018 BMJ Best Practice

191. Sepsis: recognition, diagnosis and early management

a delay in assessment or treatment. 1.3.6 Measure oxygen saturation in community settings if equipment is available and taking a measurement does not cause a delay in assessment or treatment.10 SEPSIS: RECOGNITION, DIAGNOSIS AND EARLY MANAGEMENT www.bpac.org.nz/guidelines/4 This is a bpac nz contextualisation of NICE Guideline NG51 © NICE 2015 1.3.7 Examine people with suspected sepsis for mottled or ashen appearance, cyanosis of the skin, lips or tongue, non-blanching rash of the skin, any breach (...) of skin integrity (for example, cuts, burns or skin infections) or other rash indicating potential infection. 1.3.8 Ask the person, parent or carer about frequency of urination in the past 18 hours. 1.4 Stratifying risk of severe illness or death from sepsis 1.4.1 Use the person’s history and physical examination results to grade risk of severe illness or death from sepsis using criteria based on age (see tables 1, 2 and 3). Adults, children and young people aged 12 years and over Table 1 Risk

2018 Best Practice Advocacy Centre New Zealand

192. Bariatric surgery: an HTA report on the efficacy, safety and cost-effectiveness

review 69 4.3.3 Discussion 70 4.4 CLINICAL EFFECTIVENESS IN PATIENTS WITH DIABETES AND A BMI 2 SD from the median BMI for that age). 6 From a population point of view, obesity and overweight categories have been defined by examining longitudinal data that associate a given weight with future health effects or risks. 4, 5 22 Bariatric Surgery KCE Report 316 BMI is a surrogate measure for evaluating obesity as it neither takes into account body composition (relative amounts of fat mass/muscle/bone

2019 Belgian Health Care Knowledge Centre

194. Fourth Universal Definition of Myocardial Infarction Full Text available with Trip Pro

definitions of myocardial injury and myocardial infarction: summary CABG = coronary artery bypass grafting; cTn = cardiac troponin; ECG = electrocardiogram; MI = myocardial infarction; PCI = percutaneous coronary intervention; URL = upper reference limit. CABG = coronary artery bypass grafting; cTn = cardiac troponin; ECG = electrocardiogram; MI = myocardial infarction; PCI = percutaneous coronary intervention; URL = upper reference limit. 3 Introduction In the late 19th century, post-mortem examinations (...) be identified by post-mortem examination in humans; this is in contrast to animal models, in which biochemical evidence of myocardial cell death due to apoptosis can be detected within 10 min of induced myocardial ischaemia in association with myocyte death. Experimentally, necrosis progresses from the subendocardium to the subepicardium over several hours. The time course may be prolonged by increased collateral flow, reduced determinants of myocardial oxygen consumption, and intermittent occlusion

2018 European Society of Cardiology

196. Hepatitis

have questions please contact us via jon.brassey@tripdatabase.com Top results for hepatitis 1. Patient Awareness of Need for Hepatitis A Vaccination (Prophylaxis) Before International Travel. INTRODUCTION: Although hepatitis A virus (HAV) infection is preventable through vaccination, cases associated with international travel continue to occur. The purpose of this study was to examine the frequency of international travel and countries visited among persons infected with HAV and assess reasons why (...) travelers had not received hepatitis A vaccine before traveling. METHODS: Using data from (...) sentinel surveillance for HAV infection in seven US counties during 1996 to 2006, we examined the role of international travel in hepatitis A incidence and the reasons for patients not being vaccinated. RESULTS: Of 2,002 hepatitis A patients for whom travel history was available, 300 (15%) reported traveling outside of the United States. Compared to non-travelers, travelers were more likely to be female [odds

2018 Trip Latest and Greatest

197. Traumatic brain injury

of traumatic brain injury , acute Last reviewed: August 2018 Last updated: June 2018 Summary Definitions Head injury is defined as any trauma to the head, with or without injury to the brain . The head injury can be described as minimal, minor, moderate, or severe, based (...) on symptoms after the injury . Patients with minimal head injury are those with trauma to the head and no loss of consciousness, a normal Glasgow Coma Scale (GCS) score, and no symptoms of head injury . Minor head injury patients (...) , nutritional status, complications and clinical outcomes of patients with severe traumatic brain injury (STBI). Methods A prospective randomized control trial was carried out from January 2009 to May 2012 in Neurological Intensive Care Unit (NICU). Patients of STBI who met the enrolment criteria (Glasgow Coma Scale score 6~8; Nutritional Risk Screening ≥3) were randomly divided 2017 11. Mindfulness-based stress reduction (MBSR) improves long-term mental fatigue after stroke or traumatic brain injury

2018 Trip Latest and Greatest

198. Phenytoin

S, Barnett CC, Bensard DD, Burlew CC, Biffl WL, Stoval RT (...) , Johnson JL Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary This study examined the clinical and economic impact of levetiracetam, compared with phenytoin , to prevent (...) Apr;17(4):573-9 4231236 Ataxia chemically induced Cerebellar Diseases chemically induced Coma chemically induced Digoxin adverse effects (...) Humans Male Middle Aged Phenytoin adverse effects PMC1699756 1970 4 4 1970 4 4 0 1 1970 4 4 0 0 ppublish 5440585 PMC1699756 1970 19. The use of Levetiracetam and Phenytoin for Seizure Prophylaxis in the Setting of Severe Traumatic Brain Injury "The use of Levetiracetam and Phenytoin for Seizure Prophylaxis in the " by Gregg V. Kosloff > > > > Title Author

2018 Trip Latest and Greatest

199. Caplacizumab (Cablivi) - thrombotic thrombocytopenic purpura (aTTP)

toxicity study. Caplacizumab PK/TK after repeated administration and the formation of anti-drug antibodies (ADAs) was mainly investigated in toxicity studies conducted in guinea pig and Cynomolgus monkey. The distribution of caplacizumab radioactively labelled with 125 I was examined in mice. Methods The concentration of caplacizumab in guinea pig and Cynomolgus monkey plasm was determined by an ELISA-based method. In short, caplacizumab in the samples was captured in microtiter plates using a bivalent (...) in cross-reactive species and the detection of caplacizumab in the urine of treated Cynomolgus monkeys. 2.3.3. Toxicology The toxicity of caplacizumab was examined in compliance with ICH S6(R1). The toxicology of caplacizumab was evaluated in single and repeat-dose toxicity studies in both rodent (guinea pig) and non-rodent species (Cynomolgus monkey). All single and repeat dose toxicity studies were conducted in compliance with Good Laboratory Practice (GLP). Toxicokinetic investigations were

2018 European Medicines Agency - EPARs

200. What Physiologic Parameters Are Indicative of Severe Injury in Trauma?

(Table). The combination of Glasgow Coma Scale (GCS) score, age, and arterial pressure (also known as GAP) demonstrated the best performance (AUROC 0.96). Moderate risk of bias was present in 103 studies, with 10 at low risk and 25 at high risk of bias.Biasissuesincluded study participation (sampling and recruitment), attrition (lost to follow-up), and lack of adequate control for con- founders. Strength of evidence assessments was mostly low because of inconsistency of re- sults across studies (...) parameter demonstrated suf?- cient sensitivity alone to exclude serious injury, although speci?c- ities were generally high for most parameters examined, including systolic blood pressure less than 90 mm Hg, pulse rate greater than 110 beats/min, shock index greaterthan1,andrespiratoryrate less than 10 or greater than 29 breaths/min. Shock index, lactate level, and respiratory rate demon- strated fair AUROC values (0.61 to 0.77), although the authors of the included studies did not iden- tify optimal

2018 Annals of Emergency Medicine Systematic Review Snapshots

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