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241. A Practical Approach to the Management of Steroid, Chemotherapyvor Transplant Induced Hyperglycaemia or Diabetes in Children and Young People Under 18 years in the Acute or Inpatient Setting

in patients who are not prescribed steroids (46). In glucocorticoid induced hyperglycaemia no paediatric outcome data is available (41,47). In chemotherapy induced hyperglycaemia one study reported in children receiving chemo for ALL, that 6 of 797 had developed DKA, though none required long term insulin therapy (48) and case reports of ketosis and Hyperosmolar coma exist (49,50). In transplant induced hyperglycaemia one study of mortality post liver transplant in children identified 69% of children who (...) status, • family history, The following examinations/ evaluations should take place. • hydration status • fluid balance • features of DKA or HHS. (1,2) Initial investigations should include: • capillary blood ketones • capillary gas • Plasma glucose (avoid sampling from lines delivering glucose infusions) • U+Es, Cr, and • plasma osmolality • HbA1c, Recommendation 11 (Good Practice Point) Type 1 diabetes is the most common form of diabetes and can present incidentally in children on therapy

2020 British Society for Paediatric Endocrinology and Diabetes

242. BSPED Interim Guideline for the Management of Children and Young People under the age of 18 years with Diabetic Ketoacidosis

with DKA. Suspect sepsis if there is fever or hypothermia, hypotension, refractory acidosis or lactic acidosis. A high lactate should increase concern about possible infection or sepsis. C. FULL CLINICAL ASSESSMENT: Assess and record in the notes, so that comparisons can be made by others later, the following - 1. Conscious Level - Institute hourly neurological observations including Glasgow Coma Score (see Appendix 1) whether or not drowsy on admission. If reduced conscious level on admission (...) Examination - looking particularly for evidence of - ? cerebral oedema headache, irritability, slowing pulse, rising blood pressure, reducing conscious level N.B. papilloedema is a late sign. ? ? infection ? ? ? ileus (which is common in DKA) ? ? ? 3. WEIGH THE CHILD. If this is not possible because of the clinical condition, use the most recent clinic weight as a guideline, or an estimated weight from centile charts. Consider where the child or young person should be nursed – Children and young people

2020 British Society for Paediatric Endocrinology and Diabetes

244. Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology position statement on the optimal care of the postarrest patient

active patient cooling, subsequent rewarming, and extended fevercontrol.Thereisnoconsensusregardingwhatconstitutes themagnitudeofneurologicaldysfunctionrequiredtode?nea “comatose”or “unresponsiveness”state.De?nitionsusedinthe primary literature have included “unresponsiveness to verbal commands” 17,18 or a score on the Glasgow Coma Scale of 37.5 C) (Conditional Recommendation; Very Low-Quality Evidence). Values and preferences. Despite the controversy as to whether the presence of fever is a cause (...) ?c agents cannot be recommended. A systematic review of sedation protocols published in TTM trials noted variability in medication preference but identi?ed midazolam and fentanyl as the most commonly used. 105 Shorter-acting medications might allow for a shorter duration of MV and less confounding of the neurologic examination in the OHCA patient after TTM. 108 Propofol and fentanyl were recently reported to be effective in TTM patients 109 and a small randomized trial reported that the use

2017 CPG Infobase

245. Venezuelan equine encephalitis virus infection

infections may result in more serious neurological complications (e.g., seizures and coma), haemorrhage, or death. Overall mortality during outbreaks of VEEV have rarely exceeded 1%. Weaver SC, Paessler S. Alphaviral encephalitides. In: Barrett ADT, Stanberry LR, eds. Vaccines for biodefense and emerging and neglected diseases. San Diego, CA: Elsevier; 2009:340-354. Mortality occurs mainly in children, and is generally attributable to consequences of neurological involvement. Quiroz E, Aguilar PV (...) , Cisneros J, et al. Venezuelan equine encephalitis in Panama: fatal endemic disease and genetic diversity of etiologic viral strains. PLoS Negl Trop Dis. 2009;3:e472. http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0000472 http://www.ncbi.nlm.nih.gov/pubmed/19564908?tool=bestpractice.com History and exam presence of risk factors acute onset of fever headache myalgia arthralgia retro-orbital pain tachypnoea tachycardia chills altered mental status nausea/vomiting seizures GI bleeding

2017 BMJ Best Practice

246. Hypercalcaemia of malignancy

Jan 27;352(4):373-9. http://www.ncbi.nlm.nih.gov/pubmed/15673803?tool=bestpractice.com Horwitz MJ, Hodak SP, Steward AF. Non-parathyroid hypercalcemia. In: Rosen CJ, ed. Primer on the metabolic bone diseases and disorders of mineral metabolism. 8th ed. Washington, DC: American Society of Bone and Mineral Research; 2013:562-71. History and exam presence of risk factors history of malignancy normal physical exam poor skin turgor and/or dry mucous membranes confusion fatigue constipation loss (...) of appetite nausea polyuria polydipsia bone pain use of hypercalcaemia-inducing medication stupor coma non-metastatic malignancy metastatic skeletal involvement lymphoma Diagnostic investigations total serum calcium serum ionised calcium serum albumin comprehensive metabolic panel resting ECG serum intact parathyroid hormone serum parathyroid hormone-related peptide serum phosphorus serum calcitriol (1,25-dihydroxyvitamin D) serum 25-hydroxyvitamin D skeletal survey chest x-ray Treatment algorithm ACUTE

2017 BMJ Best Practice

247. Salicylate poisoning

. http://informahealthcare.com/doi/full/10.1080/15563650600907140 http://www.ncbi.nlm.nih.gov/pubmed/17364628?tool=bestpractice.com Chronic poisoning tends to occur as a result of repeated exposure to high-dose aspirin or equivalent (150 mg/kg/day). History and exam ingestion of 150 mg/kg or more, or 6.5 g or more, of aspirin or aspirin-equivalent oil of wintergreen ingestion unknown toxin ingestion or exposure self-harm or suicide attempt abnormal behaviour children aged 3 years or younger (...) and adults aged 70 years or older nausea, vomiting, haematemesis, epigastric pain fever and diaphoresis shortness of breath tachypnoea, hyperpnoea, Kussmaul's respirations tinnitus and/or deafness malaise and/or dizziness movement disorders, asterixis, stupor confusion and/or delirium (irritability, hallucinations) coma and/or papilloedema seizures rales plus low oxygen saturation volume depletion skin rash ingestion of 150 mg/kg or more, or 6.5 g or more, of aspirin or aspirin-equivalent ingestion

2017 BMJ Best Practice

248. Psychogenic polydipsia

and/or developmental disability. There may be no physical effects, but hyponatraemia can occur. History and exam presence of risk factors water-seeking and drinking polyuria headache or nausea lethargy or confusion seizures, delirium, or coma mental illness anxious, middle-aged women developmental disability disorders smoking Diagnostic investigations plasma osmolality urine osmolality urine sodium serum sodium 24-hour urine volume urinalysis serum urea water restriction test vasopressin test plasma ADH CXR (...) headache, nausea, cramping, hyporeflexia, dysarthric speech, lethargy, confusion, seizures, and delirium. Coma and even sudden death can ensue as sodium status worsens. Complications of psychogenic polydipsia include incontinence and enuresis, bladder dilation and hydronephrosis, renal and congestive heart failure, and osteoporosis and associated pathological fractures. Diagnosis is one of exclusion. Other medical causes of polydipsia, polyuria, and/or hyponatraemia need to be ruled out. Management

2017 BMJ Best Practice

249. Superior vena cava syndrome

, neck, and arms, often with cyanosis, plethora, and distended subcutaneous vessels. Wilson LD, Detterbeck FC, Yahalom J. Clinical practice: superior vena cava syndrome with malignant causes. N Engl J Med. 2007 May 3;356(18):1862-9. http://www.ncbi.nlm.nih.gov/pubmed/17476012?tool=bestpractice.com It can be caused by either intraluminal obstruction of the SVC or extrinsic compression. History and exam presence of risk factors localised oedema of the face and upper extremities dyspnoea facial plethora (...) cough distended neck veins distended chest veins hoarseness of voice lymphadenopathy blurred vision stridor confusion/stupor anorexia weight loss haemoptysis headache chest pain mental changes fever skin rash arthralgia laryngeal oedema cyanosis papilloedema coma smoking multiple pacemaker leads age >50 years radiation Diagnostic investigations chest x-ray chest CT chest MRI ultrasound of upper extremities venography biopsy sputum cytology thoracentesis sputum culture ESR C-reactive protein

2017 BMJ Best Practice

250. Cavernous sinus thrombosis

, ears, teeth, or mouth), affecting the cavernous sinus and its structures. Aseptic CST is usually a thrombotic process that is a result of trauma, iatrogenic injuries, or prothrombotic conditions. History and exam presence of risk factors rapid onset of signs and symptoms (acute septic CST) headache fever peri-orbital oedema chemosis and proptosis lateral gaze palsy ophthalmoplegia profound sepsis (acute septic CST) ptosis and mydriasis papilloedema and/or retinal-vein dilatation decreased corneal (...) reflex hypo- or hyper-aesthesia in the distribution of the ophthalmic and maxillary nerves mental state changes (e.g., confusion, drowsiness, coma) clinically detectable primary infection site meningismus (nuchal rigidity, photophobia, and headache) positive Kernig's or Brudzinski's signs seizures loss of visual acuity recent hx of acute sinusitis hx of facial infections hx of peri-orbital infection hx of otitis media, mastoiditis, or petrositis hx of dental or oral infection hx of sepsis

2017 BMJ Best Practice

251. Thrombotic thrombocytopenic purpura

History and exam non-specific prodrome severe neurological symptoms (coma, focal abnormalities, seizures) mild neurological symptoms (headache, confusion) fever age 30 to 50 years digestive symptoms (nausea, vomiting, diarrhoea, abdominal pain) weakness bleeding symptoms (purpura, ecchymosis, menorrhagia) black ethnicity female gender obesity pregnancy (near term or post-partum period) cancer therapies HIV infection bone marrow transplantation antiplatelet agents quinine Diagnostic investigations (...) are usually non-specific, although half of patients have neurological abnormalities. Pentad of fever, renal failure, haemolytic anaemia, thrombocytopenia, and neurological changes are often seen, although most patients do not have the entire pentad. Examination of the peripheral smear is critical and shows evidence of microangiopathic haemolytic anaemia with fragmented RBCs (schistocytes) and thrombocytopenia. An urgent haematological consultation is recommended for suspected cases. Plasma-exchange

2017 BMJ Best Practice

252. 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

2017 BMJ Best Practice

253. Foreign body aspiration

. Definition Foreign body aspiration is the inhalation of a foreign body into the larynx and respiratory tract. Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001 Mar 1;344(9):665-71. http://www.ncbi.nlm.nih.gov/pubmed/11228282?tool=bestpractice.com [Figure caption and citation for the preceding image starts]: Loquat seed completely occluding the bronchus intermedius From the collection of Dr Septimiu Murgu and Dr Henri Colt; used with permission [Citation ends]. History and exam (...) presence of risk factors choking crisis unilateral decreased breath sounds unilateral wheezing intractable cough fever dyspnoea bilateral wheezing decreased level of consciousness (Glasgow coma score <9) age <4 years age >70 years bulbar dysfunction male gender cerebrovascular disease dementia Diagnostic investigations CXR CT chest bronchoscopy Treatment algorithm ACUTE Contributors Authors Associate Professor of Medicine Section on Pulmonary, Critical Care, Allergy, and Immunologic Disease Wake Forest

2017 BMJ Best Practice

254. Hepatic encephalopathy

Hepatic encephalopathy Hepatic encephalopathy - Symptoms, diagnosis and treatment | BMJ Best Practice You'll need a subscription to access all of BMJ Best Practice Search  Hepatic encephalopathy Last reviewed: February 2019 Last updated: December 2017 Summary A neuropsychiatric syndrome caused by acute or chronic hepatic insufficiency. Symptoms vary in severity from a mild alteration in mental state to coma but are often reversible with treatment. Causation is thought to be multi-factorial (...) in cognition that cannot be better accounted for by a pre-existing or evolving dementia' that develops over a short period of time and fluctuates in severity. Minimal HE comprises those patients who have no recognisable clinical symptoms of brain dysfunction. Therefore, the prerequisite for the diagnosis of minimal HE is the careful exclusion of clinical symptoms. History and exam presence of risk factors mood disturbances sleep disturbances motor disturbances advanced neurological deficits palmar erythema

2017 BMJ Best Practice

255. Disseminated intravascular coagulation

can include epistaxis, gingival bleeding, haematuria, oliguria, cough, dyspnoea, fever, delirium, and coma. Physical examination may reveal petechiae, ecchymosis, gangrene, mental disorientation, hypoxia, hypotension, and GI bleeding. Diagnosis is based on presence of ≥1 known underlying conditions causing DIC plus abnormal global coagulation tests: decreased platelet count, increased prothrombin time, elevated fibrin-related maker (D-dimer/fibrin degradation products), and decreased fibrinogen (...) /16504043?tool=bestpractice.com History and exam presence of underlying disorders oliguria, hypotension, or tachycardia purpura fulminans, gangrene, or acral cyanosis delirium or coma petechiae, ecchymosis, oozing, or haematuria major trauma/burn/organ destruction or sepsis/severe infection severe obstetric disorders or complications solid tumours and haematological malignancies severe toxic or immunological reactions major vascular disorders (large aortic aneurysms or giant haemangiomas) Diagnostic

2017 BMJ Best Practice

259. Scleroderma Morphea

Clinical scores 14 Radiologic examination 15 Technical outcome measures 16 Differential diagnoses 16 Specifics of juvenile localized scleroderma 16 Treatment 17 Topical therapy 18 Systemic therapy 19 UV phototherapy 21 Physiotherapy 23 Surgical therapy 23 References 29 II Scleromyxedema 38 Introduction 38 Epidemiology 38 Pathogenesis 38 Clinical manifestation 38 Cutaneous manifestations 39 Extracutaneous manifestations 39 Associated disorders 41 Clinical course 41 Diagnostic procedures 42 (...) disorders 117 Clinical course 118 Diagnostic procedures 119 Histopathology 119 Diagnostic criteria 119 Patient history 120 Physical examination 120 Skin biopsy 120 Complementary investigations 120 Additional tests 121 Differential diagnosis 121 Treatment 123 Prognosis and follow-up 124 Summary and recommendation 125 References 129 7 List of abbreviations ACA Anti-centromere antibodies ACE Angiotensin-converting enzyme ACR American College of Rheumatology ANA Antinuclear antibodies CARRA Childhood

2018 European Dermatology Forum

260. Guideline for concussion/mild traumatic brain injury & persistent symptoms - Diagnosis/Assessment of Concussion/mTBI

an object, including sport and recreational injury. 2 Patients may present in a post-traumatic amnestic (PTA) state, where they may have a Glasgow Coma Scale (GCS) score of 15/15; however, they may be variably oriented and not able to form continuous memories. The purpose of the initial medical assessment is to establish the diagnosis of concussion/mTBI by ruling out more severe forms of TBI, cervical spine injuries and medical and neurological conditions that can present with concussion-like symptoms (...) a history, examination and cognitive screen for post-concussive symptoms, and review of mental health (see Table ). Adapted from the Motor Accidents Authority NSW, Guidelines for Mild Traumatic Brain Injury following a Closed Head Injury (MAA, NSW, 2008). 1.3 A The need for early neuroimaging should be determined according to the Canadian CT Head Rule (see Figure ). For patients who fulfill these criteria, CT scanning is the most appropriate investigation for the exclusion of neurosurgically significant

2018 Ontario Neurotrauma Foundation

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