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Coma Exam

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321. 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

322. 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

323. 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. [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

324. 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

325. 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? 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

326. 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. 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

327. Hypercalcaemia of malignancy

Jan 27;352(4):373-9. 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

328. 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

329. Sex differences in Japanese patients with ruptured aortic aneurysms Full Text available with Trip Pro

in Japan. Methods: We identified patients hospitalized in certified teaching hospitals in Japan with rAA between April 1, 2012, and March 31, 2015. Patients' characteristics and in-hospital outcomes were compared between men and women. The Barthel index was used for evaluating functional status at discharge by examining the ability to perform basic daily activities. Results: Of 7086 eligible patients, 32.3% (2291/7086) were women. Women were older than men (81.9 years vs 76.1 years; P < .001), had (...) higher prevalence of coma at admission (33.2% vs 25.2%; P < .001), and were less likely to undergo emergency operation including endovascular aneurysm repair (35.7% vs 51.1%; P < .001). The unadjusted mortality rate (62.5% vs 52.0%; P < .001) and Barthel index at discharge (78.7 vs 86.1; P < .001) were significantly worse in women than in men. However, multilevel mixed-effect logistic regression analyses showed that female sex itself was not an independent predictor for in-hospital death (odds ratio

2020 EvidenceUpdates

330. Assessment, diagnosis and interventions for autism spectrum disorders

and 3). Siblings of individuals with ASD also have an increased risk (RR 13.40, CI 6.93 to 25.92). 5 Secondary screening is dependent on an awareness that a child is at higher risk of ASD and the application of sound clinical knowledge and skills. Several structured instruments for use in secondary screening have been examined in a number of studies using relatively small cohorts. 36-42 With all these instruments, the findings of the studies have not been replicated outwith the study settings. See

2016 SIGN

331. Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project. (Abstract)

/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent (...) , and neurosurgery.Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed.Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD

2020 JAMA

332. Clinical practice guideline for the rehabilitation of adults with moderate to severe TBI - section 1: components of the optimal TBI rehabilitation system

· Etiology of TBI · Severity of TBI · Glasgow Coma Scale · Duration of post-traumatic amnesia · Others (INESSS-ONF, 2015) A 1.11 In order to support the continuous quality improvement of their services, traumatic brain injury rehabilitation programs should monitor key aspects of their processes and efficiency, including but not limited to: · Injury onset days to start of rehabilitation · Length of stay in rehabilitation · Intensity of services · Measures of functional change progression (ex. FIM, FAM (...) . (INESSS-ONF, 2015) Note: The interdisciplinary team may include the following core professionals: intensivist, neurologist, neurosurgeon, physiatrist, clinical nutritionist, respiratory therapist, physiotherapist, occupational therapist, neuropsychologist, social worker and speech- language pathologist, etc., as appropriate. B 1.2 Where individuals remain in a coma or minimally conscious state following traumatic brain injury, a period of treatment/management in a specialized tertiary centre should

2016 CPG Infobase

333. The AutoPulse non-invasive cardiac support pump for cardiopulmonary resuscitation

is not to replace manual CPR, but to be used as a support to manual CPR. It can provide consistent CPR over long periods of time and would be used to reduce the impact of rescuer fatigue while also allowing the rescuer to attend to other patient needs. The AutoPulse can also be used to maintain CPR when there is a need to move a patient, either to conduct further examinations or to seek more specialist care. The AutoPulse is promoted by the manufacturer only for use in cases where manual CPR would normally (...) or death from other causes. An overall performance category score of 1 indicates good overall performance; 2, moderate overall disability; 3, severe overall disability; 4, coma/vegetative state; and 5, brain death: certified brain dead or dead by traditional criteria. T T able 4 Summary of the Hallstrom et able 4 Summary of the Hallstrom et al. (2006) trial al. (2006) trial AutoPulse AutoPulse CPR CPR Manual Manual CPR CPR Analysis Analysis Randomised n=554 n=517 Primary outcome: Survival to 4 hours

2015 National Institute for Health and Clinical Excellence - Advice

334. Hypnotics

risk of Alzheimer's disease. The study suggests that taking benzodiazepines for more than 3 months and the use of agents with longer half-lives strengthen the association, but potential biases in the study limit the conclusions that can be drawn. Another observational study discussed in NICE's medicines evidence commentary on psychotropic drugs and risk of motor vehicle accidents examined the relationship between exposure to psychotropic drugs and motor vehicle accidents and found (...) and Drug administration announced new labelling requirements for prescription opioids (indicated for pain or cough) and benzodiazepines. These concern the serious risks of respiratory depression, coma and death associated with the combined use of certain opioids and benzodiazepines. The European Economic Area subsequently made similar labelling variations, and in February 2018, the Co-ordination Group for Mutual Recognition and Decentralised Procedure (CMDh) agreed on a proposed text warning about

2015 National Institute for Health and Clinical Excellence - Advice

335. CATMAT statement on disseminated strongyloidiasis: prevention, assessment and management guidelines

in a Strongyloides-endemic area who undergo iatrogenic immunosuppression or have intercurrent human T-lymphotropic virus (HTLV-1) infection. Diagnosis of strongyloidiasis is based on serologic testing and/or examination of stools and other clinical specimens for larvae. Referral to a tropical medicine specialist with expertise in the management of strongyloidiasis is recommended for suspected and confirmed cases. A diagnosis and treatment algorithm for strongyloidiasis has been developed as a reference tool (...) screening decisions. Due to the low sensitivity of stool examination for ova and parasites (O&P) arising from low larval burden and intermittent shedding in the stool, serologic testing is the diagnostic method of choice in the patient suspected to have simple intestinal strongyloidiasis. It is important to note that sensitivity of serology may be reduced in the patient with immunosuppression, especially due to HTLV-1 infection or hematologic malignancy and associated chemotherapy (18,19

2016 CPG Infobase

336. The Association of Coloproctology of Great Britain and Ireland Consensus Guidelines in Surgery for Inflammatory Bowel Disease Full Text available with Trip Pro

with 37 000 patients undergoing cancer surgery . The strongest predictors of thromboembolic complications after surgery for IBD were stoma formation, with an adjusted OR of 1.95 (95% CI: 1.34–2.84), preoperative steroid administration [adjusted OR 1.57 (95% CI: 1.19–2.08)], ileoanal pouch formation [adjusted OR 2.66 (95% CI: 1.65–4.29)] and longer length of stay [adjusted OR 1.89 (95% CI: 1.41–2.52)] . In a large population‐based study examining venous thromboembolism after colectomy for a variety (...) trials as major research gaps . The latter concern is partly met by the ongoing PISA trial in fistulating perianal Crohn's disease that offers randomization among three arms of (i) standard care with long‐term seton placement and oral immunosuppression, (ii) biological therapy with timed seton removal and (iii) seton drainage with limited biological therapy and then advancement flap . A recent randomized trial has been published examining stem cell therapy in fistulizing perianal Crohn's disease

2018 Association of Coloproctology of Great Britain and Ireland

337. BHIVA guidelines for the management of tuberculosis in adults living with HIV

advantage of rifabutin is that it allows the co- administration of (ritonavir-boosted) PIs (see Section 10 and Appendix 7). Corticosteroids should be used as an adjunct to TB therapy to reduce the immune/inflammatory response to M. tuberculosis in those with meningitis. An RCT of individuals with TB meningitis showed a 31% reduction in mortality among those who received adjunctive dexamethasone during the induction phase [12]. Participants with grade 2/3 disease (Glasgow coma scale score 2 months

2018 British HIV Association

338. 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

339. Bone sarcomas: ESMO?PaedCan?EURACAN: Clinical Practice Guidelines for diagnosis, treatment and follow-up

the periosteum, but they are often later signs. The differential diagnosis of a bone sar- coma includes osteomyelitis, benign tumours and bone metasta- ses, all of which outnumber primary bone sarcomas [10–12]. The diagnosis can be strongly oriented by patient age. For patients 60%. In general, ChT is administered before and after surgery, although a formal proof that giving ChT preoperatively improves survival is lacking. The extent of histological response to preoperative ChT predicts sur- vival [25–27 (...) in the ?nal pathological examination. If en bloc R0 resection is not feasible, the patient is inoperable or surgical sequelae are not accepted by the patient, de?nitive RT Annals of Oncology Clinical Practice Guidelines Volume 29 | Supplement 4 | October 2018 doi:10.1093/annonc/mdy310 | iv87 Downloaded from by guest on 26 March 2019alone (without debulking) is an alternative [V, C]. Particle ther- apy (high-dose protons

2018 European Society for Medical Oncology

340. Near Infrared Spectroscopy for Detecting Brain Hematoma

involves conducting a physical exam to evaluate the extent of injuries, including impaired consciousness as measured by the Glasgow Coma Scale (GCS), and considering baseline risk factors for intracranial hemorrhage, a potential complication of head injury. Identifying patients with moderate-severe injuries in need of transport and head imaging is usually straightforward. However, determining which patients with mild injuries need further evaluation can be more challenging as many elderly patients have (...) pre-existing dementia or other cognitive disorders that impair the physical exam and GCS assessment, as well as higher baseline risk for intracranial hemorrhage due to use of anticoagulants. A further challenge in evaluating patients with possible head injury after falls is that a subset of patients who initially have a normal exam will develop delayed intracranial hemorrhage and could worsen quickly. For these reasons, guidelines on management of mild head injury including those by the American

2017 Veterans Affairs Evidence-based Synthesis Program Reports

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