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Coma Exam

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282. CRACKCast E154 – Hallucinogens

, dopamine receptors, and NMDA receptors. Diagnosis and management are based primarily on the history and physical examination, with hallmarks of therapy including supportive care, a calm quiet environment, and sedation with benzodiazepines such as diazepam or lorazepam. Severely agitated patients may benefit from butyrophenone antipsychotic agents such as haloperidol and droperidol. Screening tests for drugs of abuse are of limited value in the acute management of intoxicated patients. Novel synthetic (...) AND EXCITED DELIRIUM AGGRESSIVELY Chemical sedation with Benzos or haloperidol / droperidol (if you have it) Cool, tx hypoglycemia Intubate and paralyse if needed Watch for rhabdo etc Watch for Torsades with intoxication plus tx Priorities: SAFETY – patient and staff Chemical sedation IM benzo’s (e.g. Midazolam 0.2 mg/kg IM = usually 10 mg) Assessment Glucose, FULL set of vital signs Full physical examination IV access and oxygenation via NRB (doubles as a spit mask) Chemical sedation Benzo’s** – Diazepam

2018 CandiEM

283. Tide Pod Challenge: Managing caustic laundry pod ingestions

tract injury, with or without clinically obvious signs. 4 A of pediatric laundry pod ingestion cases found that common clinical features included vomiting (56%), coughing or choking (14.6%), drowsiness or lethargy (7.8%) and nausea (4.9%). Severe symptoms included seizures, respiratory arrest, gastric burns, and coma. The differential for laundry pod ingestion is broad, as patients can have increased or decreased temperature and respiratory rate. Common causes on the differentials (...) for these presentations should be explored when reasonable. History should focus on what was specifically ingested by the patient, time since ingestion, whether actions were intentional or unintentional, and whether there were other co-ingestants (e.g. salicylate and acetaminophen in suicide attempts). Physical exam should start by looking for signs of respiratory distress and circulatory shock first. After patients have been deemed stable, the clinician should looks for signs of pharyngeal injury (mucosal burns

2018 CandiEM

284. CRACKCast E170 – Paediatric Respiratory Emergencies: Disease of the Lungs

, neurologic alterations that predispose to aspiration (eg, coma, seizures, cerebral palsy, general anesthesia), and alterations in quality of secreted mucus (cystic fibrosis [CF]). Bacterial pneumonia and mycoplasma infections are usually transmitted person to person by droplet aspiration Sometimes bacteria can cause pneumonia through hematogenous spread; Viruses such as varicella, CMV, herpes simplex, Epstein-Barr, measles, and rubella also may infect the lungs through hematogenous spread 1) Name 8 non (...) and generally seen in children older than 2 to 3 years. Fever is often absent, and the examination findings are remarkably normal between paroxysms. The paroxysmal stage lasts 2 to 4 weeks Convalescent stage Gradually resolving symptoms; 2-4 weeks 3) How is whooping cough managed? Ideally infectious spread from mildly symptomatic/asymptomatic adults to children is prevented through vaccination! Treatment: Erythromycin, azithromycin, or trimethoprim-sulfamethoxazole. Given the association of erythromycin

2018 CandiEM

285. Imaging Guidelines

a primary adjunct to rapidly diagnose immediate life-threatening injuries. Computed tomography (CT) and magnetic resonance imaging (MRI) later became additional imaging modalities important for injury diagnosis and management. By the early 90s, bedside abdominal examination with Focused Assessment with Sonography in Trauma (FAST) largely replaced diagnostic peritoneal lavage as the primary imaging modality for rapid assessment of intra-abdominal hemorrhage in unstable trauma patients. This guideline (...) for pneumothorax and hemothorax. 1 Extremity radiographs remain an important secondary adjunct for diagnosis of extremity orthopaedic injury. A best practice is interpretation of all radiographs concurrent with the trauma evaluation to facilitate timely treatment interventions. Computed Tomography Imaging Multi-detector computed tomographic (MDCT) imaging is now well established as the imaging modality of choice in hemodynamically stable patients following the secondary survey exam. Oral contrast

2018 American College of Surgeons

286. Stroke Prevention in Patients With Atrial Fibrillation: A Systematic Review Update

. Left ventricular systolic dysfunction, heart failure, and stroke risk 47 Table 20. Mini-Mental Status Examination and stroke risk 47 vii Table 21. C-statistics from studies comparing stroke risk scores of interest 48 Table 22. Strength of evidence domains for prediction of thromboembolic risk 57 Table 23. Description and interpretation of included bleeding risk scores 60 Table 24. Summary of results for studies evaluating BRI among patients on warfarin 62 Table 25. Summary of results for studies

2018 Effective Health Care Program (AHRQ)

287. CRACKCast E162 – Opioids

‐0.8 mg/hr (25‐50 mL/hr). Also, if 10-15 mg of naloxone doesn’t work, you definitely should be broadening your ddx and look for other causes of respiratory depression and coma. Don’t forget there are other routes: intranasal and nebulized! Intranasal naloxone has proved a viable, alternative to intravenous administration, especially for prehospital providers. Both 0.4 mg/mL and 1 mg/mL solutions of naloxone, delivered into each nare using an atomizer device, have been used. Nebulized naloxone—2 mg (...) is emerging from CNS depression, respiratory efforts can be made against a floppy glottis and cause greatly elevated negative pressures that suck water out of pulmonary vasculature and into the airspaces (capillary leak). One of those patients who needs a good clinical exam, CXR, and supportive care (may need NIPPV) 5) Difference between a “body packer” and “body stuffer”? Packers: pre-meditated ingestion of well-packaged, high concentrated goods for the purpose of trafficking. Often packing lethal doses

2018 CandiEM

288. ILCOR Scientific Knowledge Gaps and Clinical Research Priorities for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: A Consensus Statement Full Text available with Trip Pro

temperatures of 32°C, 33°C, and 34°C after ROSC for adults with OHCA and initial shockable rhythm. It is challenging to design a prospective clinical trial examining a goal-directed strategy that optimizes only 1 physiological parameter. One study currently underway in Belgium is the NEUROPROTECT trial (Neuroprotective Goal Directed Hemodynamic Optimization in Post-Cardiac Arrest Patients; NCT02541591). NEUROPROTECT is an adult prospective randomized study comparing a hemodynamic optimization strategy (...) prognosis: clinical examination, neurophysiological studies, blood biomarkers, and imaging studies. , There were specific knowledge gaps about prognostic tests and global concerns related to the design of prognosis studies. First, understanding how sedative drugs and neuromuscular blocking drugs alter prognostic testing requires prospective studies on drug pharmacokinetics and pharmacodynamics in postcardiac arrest patients, especially those treated with temperatures below normal. Next, studies

2018 American Heart Association

289. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease Full Text available with Trip Pro

surgery) or could be used as a bridge to other therapy, such as heart transplantation. 7,8 The purpose of this consensus statement is to high- light the unique aspects of cardiac resuscitation in chil- dren with congenital and acquired heart disease and to provide evidence-based recommendations for modify- ing resuscitation for this high-risk patient population to improve survival. The management of specific phases of cardiac arrest (prearrest, arrest, and postarrest stabiliza- tion) is examined (...) of trends and changes in continuously measured hemodynamic variables (eg, invasive systemic arterial and central venous pressures [CVPs], heart rate), physical examination, and specific laboratory tests. Lab- oratory data that can reveal inadequate cardiac output include direct or estimated measurements of Svo 2 , arte- rial blood gas analysis, and serum lactate assessment. The ECG can document the presence of ischemia or arrhythmias that can cause or result from low cardiac output. Echocardiography can

2018 American Heart Association

291. All-Terrain Vehicle Injuries, Prevention of

mandating use were developed. A query of MEDLINE, PubMed, Cochrane Library, and Embase for all-terrain vehicle injury was performed. Letters to the editor, case reports, book chapters, and review articles were excluded. Grading of Recommendations Assessment, Development, and Evaluation methodology was used to perform a systematic review and create recommendations. RESULTS Twenty-eight studies were included. Helmet use reduced traumatic brain injury (TBI). However, studies examining whether legislation (...) of safety measures and legislation on ATV-related injury prevention. Objectives The objective of this systematic review was to assess the scientific evidence on ATV-related injury prevention strategies for riders. While there are myriad studies examining injury patterns, far fewer focus on injury prevention. For this study, we used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, which has been previously validated. [ ] The GRADE approach dictates a priori

2018 Eastern Association for the Surgery of Trauma

292. CRACKCast Episode 185 – Alcohol Related Disease

CRACKCast Episode 185 – Alcohol Related Disease CRACKCast Episode 185 - Alcohol Related Disease - CanadiEM CRACKCast Episode 185 – Alcohol Related Disease In by Chris Lipp June 11, 2018 This episode of CRACKCast covers Rosen’s Chapter 142 (9th Edition), Alcohol Related Disease. This chapter covers the spectrum of alcohol use, including effects of mild, moderate, and severe use disorders, including prevention, screening, diagnosis and management. We also examine the wide variety of complications (...) are found on the GABA receptor complex. Chronic ethanol use induces an insensitivity to GABA such that more inhibitor is required to maintain a constant inhibitory tone. As alcohol tolerance develops, the individual retains arousal at alcohol concentrations which would normally produce lethargy or even coma in relatively alcohol naïve individuals. Cessation of alcohol or a reduction from chronically elevated concentrations results in decreased inhibitory tone. Excitatory amino acids — Glutamate is one

2018 CandiEM

293. Physiologic Predictors of Severe Injury: Systematic Review

about the level of trauma care needed. Key Messages • Studies examined individual measures and combinations for trauma triage, including systolic blood pressure, heart rate, shock index, lactate, base deficit, respiratory rate, oxygen saturation, and need for airway support. • Included measures have: o Low sensitivities, so normal values on the physiologic measure (a negative test) cannot be used with confidence to determine that patients are not seriously injured. o High specificities, meaning (...) was for the Glasgow Coma Scale, age, and arterial pressure (GAP) combination measure (AUROC, 0.96; estimate based on emergency department data). All of the measures had low sensitivities and comparatively high specificities (e.g., sensitivities ranging from 13% to 74% and specificities ranging from 62% to 96% for out- of-hospital pooled estimates). Conclusions. Physiologic measures usable in triaging trauma patients have been evaluated in multiple studies; however, their predictive utilities are moderate and far

2018 Effective Health Care Program (AHRQ)

294. Screening of fetal aneuploidies whereby non-invasive prenatal test (NIPT)

. The comparator, chosen by application of EUnetHTA criteria [1], is first-trimester serum screening (pregnancy-associated plasma protein A (PAPP-A) and ß subunit of human chorionic gonadotropin (ß-hCG)) and/or an ultrasound scan to measure fetal nuchal translucency (NT) or fetal crown-rump length (CRL) and maternal age. Fetal karyotyping or birth outcomes determined through clinical examination or follow-up of the newborn are considered the reference standards. The effectiveness of the screening processes (...) ). The EC declaration can be done by a declaration of conformity of full quality assurance (Annex IV) or by EC-type examination (Annex V) couplet with EC verification or EC declaration of conformity (production quality assurance) (Annex VI). For all other trisomy determinations, companies are required to comply only with the general requirements for in vitro medical devices (Annex III). Information regarding CE marking is lacking for many of the existing providers or laboratories. Table 4 summarises

2018 EUnetHTA

296. Continuous glucose monitoring (CGM real-time) and flash glucose monitoring (FGM) as personal, standalone systems in patients with diabetes mellitus treated with insulin

and consistent management approach. They should cover these basic principles of diabetes management [16]: • Interventions to promote and support healthy lifestyles, including healthy diet, physical activity, avoidance of tobacco use, and harmful use of alcohol. • Medication for blood glucose control – insulin or oral hypo-glycaemic agents as required. • Medication to control cardiovascular disease risk. • Regular exams for early detection of complications: comprehensive eye examination, measurement of urine (...) , ongoing, and organized care delivered by a team of skilled healthcare providers. The majority of care can be provided at the primary care level with basic interventions involving medication, health education and counselling, and consistent follow-up. A periodic referral for spe- cialist care is required in order to perform more complicated interventions (for example, compre- hensive eye examinations, laser and surgical treatment of eye complications, complex kidney function tests, and tests

2018 EUnetHTA

297. Diagnosis and management of primary central nervous system diffuse large B?cell lymphoma Full Text available with Trip Pro

that slit lamp examination and ophthalmoscopy are followed, if necessary, by vitreous biopsy. Vitreous biopsy should be combined with a sub‐retinal aspirate or chorioretinal biopsy, particularly for those with visible sub‐retinal deposits, as vitrectomy specimens have diagnostic failure rates up to 30% (Coupland et al , ). Contrast‐enhanced MRI of the brain is the neuroimaging modality of choice for both diagnosis and response assessment (Coulon et al , ; Abrey et al , ; Ferreri, ). A diagnosis of PCNSL (...) or suspected PCNSL (Abrey et al , ) are summarised in Table . Table 1. Pre‐treatment investigations and staging for primary central nervous system lymphoma Histology Imaging Clinical evaluation Laboratory evaluation CSF analysis a Unless contraindicated. Essential Tissue diagnosis: Gadolinium‐enhanced MRI brain and spine a Unless contraindicated. Physical examination including full neurological assessment Renal and liver function Stereotactic or surgical biopsy Vitrectomy specimen (if PIOL suspected) CSF

2018 British Committee for Standards in Haematology

298. Perinatal Mortality Guideline

) and alternatives such as imaging. ? ? Discuss role of placental pathology. ? ? Offer grief support using appropriate resources. 2. At the Time of Delivery ? ? Examination of the stillborn: external exam by care giver, or specialist if available. ? ? Gross examination of placenta: weight, appearance, cord length and appearance, coiling ratio, particularly if placental pathology will not be done. ? ? Obtain informed consent/refusal for autopsy. ? ? Submit placenta for pathology. ? ? Cytogenetic studies (...) OF STILLBIRTH . . . . . . . . . 7 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Overview: Considerations in Stillbirth Evaluation and Care Checklist 9 Laboratory Investigations in Stillbirth . . . . . . . . . . . . . . . . . . . 10 Clinical External Examination of the Stillborn at the Time of Delivery 11 Stillbirth Autopsy and Request: Information for Practitioners . . . . . 13 Stillbirth Autopsy Information for Parents . . . . . . . . . . . . . . . . 17 Clinical

2017 British Columbia Perinatal Health Program

299. Management of acute (fulminant) liver failure

), and may need renal replacement therapy (RRT) to treat the acidosis. In these cases, othercompoundingaetiologiesshouldalsobesoughtsuchassal- icylate, tricyclic or methanol ingestion. The clinical evolution of POD is often that of rapidly progres- sive multi-organ failure (MOF) and HE, which may progress from a mild grade 1 to grade 4 coma over a period of hours. Patients who do not meetcriteria for emergency LTx have a good progno- sis, and those whomeetthe criteriamaystill have a survival rate of20–40 (...) for underlying malig- nancies are necessary [34,95]. Wilson disease. The classic presentation of acute Wilson dis- ease includes HE in young patients ( 30, head in neutral position and intubate, ventilate and sedate if progresses to >3 coma. Low threshold for empirical start of antibiotics if hemodynamic deterioration and/or increasing encephalopathy with in?ammatory phenotype In case of evolving HE intubation and sedation prior to the transfer Ensure volume replete and normalize biochemical variables (Na

2017 European Association for the Study of the Liver

300. Sepsis: recognition, diagnosis and early management

, are available. 1.3.5 Only measure blood pressure in children under 12 years in community settings if facilities to measure blood pressure, including a correctly-sized cuff, are available and taking a measurement does not cause 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. 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

2016 National Institute for Health and Clinical Excellence - Clinical Guidelines

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