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341. CrackCAST E129 – Bacteria

CrackCAST E129 – Bacteria CrackCAST E129 - Bacteria - CanadiEM CrackCAST E129 – Bacteria In by Chris Lipp November 23, 2017 This 129th episode of CRACKCast covers Rosen’s 9th edition, Chapter 121, Bacteria. Bacterial infections represent a large proportion of presentations to the emergency department. Here we examine some of the most infrequently seen but extremely dangerous bacterial infections that you must be able to recognize. For more frequent infections, please see their individual (...) Examination – The spatula test involves touching of the oropharynx with a tongue blade. With a negative test result, the patient gags and expels the tongue blade. With a positive test result, the patient has reflex masseter muscle spasm and bites the spatula. This test is 94% sensitive and 100% specific for tetanus. Management Aggressive supportive care Control muscle spasms Avoid unnecessary stimulation / loud noises = these can trigger severe spasms Treat spasms with benzodiazepines Diazepam – widely

2017 CandiEM

342. Treatment for Adults With Schizophrenia

Question 1: Comparative Evidence Regarding Antipsychotic Drugs The findings on antipsychotic drugs came from one systematic review of 138 trials (N=47,189) and 24 additional trials (N=6,672) for SGAs versus SGAs, and one systematic review of 111 trials (N=118,503) and five additional trials (N=1,055) for FGAs versus SGAs. In our review, we examined the prioritized outcomes: measures of functional abilities, quality of life, response and/or remission, mortality, self-harm, core illness symptoms, overall (...) that olanzapine and risperidone were significantly more likely to result in response than quetiapine (low SOE). Other comparisons and meta-regressions examining the influence of study duration, dose-level, populations (either treatment-resistant or first-episode status), and category of response definition did not result in any statistically significant differences between the SGAs (low SOE). Remission was reported too infrequently to assess comparatively, except in the group of studies on patients

2017 Effective Health Care Program (AHRQ)

343. Practical Management of Hyperglycaemic Hyperosmolar State (HHS) in children

) in children 2 Version 2, July 2017 Review 2020 Authors: SM Ng, JA Edge, AE Timmis ssociation of Children’s Diabetes Clinicians Clinicians Patient group This guideline is intended for use in managing Hyperglycaemic Hyperosmolar State (HHS) for all children and young people up to the age of 18 years with diabetes mellitus. 1. Introduction Hyperglycaemic Hyperosmolar State (HHS), previously known as Hyperosmolar Hyperglycaemic Non-Ketotic Coma (HONK), is a triad of severe hyperglycaemia, significant increase (...) in serum osmolality and severe dehydration without marked ketoacidosis. It is a life threatening complication of some forms of uncontrolled diabetes mellitus with significant mortality and morbidity. It is important that HHS is distinguished from Diabetic Ketoacidosis (DKA), which presents with hyperglycaemia, ketosis and acidosis, as the management is significantly different. Both disorders present with dehydration, hyperglycaemia and may show altered levels of mental status or coma. The prevalence

2018 British Society for Paediatric Endocrinology and Diabetes

344. CRACKCast E104 – Delirium and Dementia

disturbances. Here is the big three step approach for us in the ER: Take a full collateral hx and do a physical exam to determine if this is delirium or dementia Rapidly treat any underlying cause of delirium “Establish a supportive environment and employ pharmaceutical adjuncts as needed” [1] List the four key diagnostic criteria for delirium. BOX 94.1 – Diagnostic Criteria for Delirium FOUR KEY CHARACTERISTICS Acute onset with fluctuating course Disturbs attention and awareness (inattention) Disturbed (...) Perception NOT better explained by another neurocognitive disorder Important to note these things on history (collateral hx is crucial): Inattention Short term memory impairment Sleep-wake cycle changes Inquiry about disturbed perceptions – hallucinations or delusions On physical exam: Autonomic system dysfunction: Elevated or decreased: Pulse, RR, temp, BP. Wernicke’s Encephalopathy Ataxia, 6th Cranial Nerve Palsy, and Confusion Remember that magnesium is a cofactor in thiamine utilization!! Replace

2017 CandiEM

345. CRACKCast E103 – Headache Disorders

) Attributed to ISCHEMIA and SYSTEMIC INFLAMMATION Headache – 70% OF PTS. usually chronic for 2-3 months. Can be anywhwere on the head 40% of pts develop symptoms of PMR Risk for: TIA’s of the eye, peripheral neuropathies, strokes. On exam: Temporal artery: Findings include tenderness, reduced or absent pulsations, erythema, and nodularity or swelling. Visual acuity, visual field testing, and thorough funduscopic examination should be performed. The presence of a relative afferent pupillary defect (Marcus (...) , lacrimation, rhinorrhea. Injected eye. Nasal congestion. Normal neuro exam. Normal vital signs. The most common disorders mimicking tension headache are migraine, IIH, oromandibular dysfunction, cervical spondylosis, sinus or eye disease, and intracranial masses. Subtle indolent infections (such as, cryptococcal meningitis) should be considered in the immunocompromised. Treatment: ● High flow O2 via NRB at 12 L/min ○ Most resolve in 15 mins ● Sumatriptan 6 mg ● Octreotide 100 mcg SC Prventative therapy

2017 CandiEM

346. CRACKCast E102 – Seizures

intervening return to baseline mental status Status epilepticus is divided into two basic categories: Generalized convulsive status epilepticus (GCSE) Non-convulsive status epilepticus (NCSE). GCSE: MEDICAL EMERGENCY Typically tonic-clonic seizures Mortality correlated directly to seizure event NCSE: can be subtle presentation Think about in patients with alteration in mentation (coma to subtle motor signs, such as twitching, blinking, eye deviation, persistent aphasia, or somatosensory aura) EEG (...) epilepticus can mimic Hypoglycemia CNS infection CNS vascular event Drug toxicity Psychiatric disorder Metabolic encephalopathy Migraine Transient global amnesia [4] What factors predict abnormal CT findings in seizure patients? See Box 92.3 – Differential Diagnosis of AMS in Patient Who Has Seized Focal abnormality on neurological examination Malignancy Closed head injury Neurocutaneous disorder Focal onset of seizure Absence of a history of alcohol abuse History of cysticercosis Altered mental status

2017 CandiEM

347. Top 5 Things I’ve Learned About Geriatric Emergency Medicine

a question of being overwhelmed than neglectful. It’s therefore important to maintain a compassionate rather than a judgmental attitude towards caregivers, and to use encounters with family and friends as opportunities to provide guidance, encouragement, and referral to additional supports. For detailed summaries on abuse risk factors, history-taking, and physical exam signs, I recommend Rosen’s outstanding chapter on elder abuse and neglect. 17 4. Don’t call it “failure to cope”. When describing (...) emergency departments: analysis of national US insurance claims data. BMJ . 2017;356:j239. [ ] 23. Huff J. Confusion. In: Marx J, Walls R, eds. Rosen’s Emergency Medicine . Philadelphia: Elsevier/Saunders; 2014:151-155. 24. Huff J. Altered mental status and coma. In: Tintinalli J, Stapczynski J, Ma O, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide . McGraw-Hill; 2016:1. 25. Altered Mental Status. CDEM Curriculum. . Published August 24, 2015. Accessed July 23, 2017. Interests

2017 CandiEM

348. Soft tissue and visceral sarcomas: ESMO-EURACAN Clinical Practice Guidelines for diagnosis, treatment and follow-up

?cans, and in retroperitoneal tumours, where the performance is identical to MRI. Ultrasound may be the ?rst exam, but it should be followed by CT or MRI. Following appropriate imaging assessment, the standard approach to diagnosis consists of multiple core needle biopsies, possibly by using 14–16 G needles. However, an excisional biopsy may be the most practical option for 5cm lesions [II, B] [11–13]. RT is not given in the case of a currently unusual, truly compartmental resection of a tumour

2018 European Society for Medical Oncology

349. Prevention, Diagnosis & Management of infective endocarditis

or fastidious microorganisms, and perform the appropriate microbiological tests (refer Table 3.2 and Figure 3a).16 • Histopathological examination (HPE) of cardiac tissue/vegetations obtained during surgery is of diagnostic value and is recommended. • A transthoracic echocardiogram (TTE) should be obtained without delay if the diagnosis of IE is suspected. • Echocardiogram findings should be interpreted in the context of the clinical scenario and repeated if the clinical suspicion of IE persists despite (...) a negative initial echocardiogram. • Transoesophageal echocardiogram (TOE/TEE) should be done if initial TTE examination is negative, in patients with strong clinical suspicion of IE, in those with prosthetic valves/cardiac material and in those with high-risk features (refer Figure 3b). • Echocardiography plays a crucial role in the diagnosis of IE, monitoring for complications and progression of valvular dysfunction, assessing the outcome of surgical repair and in the follow-up after completion

2017 Ministry of Health, Malaysia

350. Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplase in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Full Text available with Trip Pro

stroke unit. The recommended monitoring includes blood pressure measurement and neurological examination every 15 minutes for the first 2 hours after the alteplase infusion, then every 30 minutes for the next 6 hours, and then every hour for the next 16 hours. Because an excessively high blood pressure may increase hemorrhagic complications, a blood pressure goal of <180/105 mm Hg is recommended for 24 hours after the infusion. In addition, an emergent brain computed tomography (CT) is recommended (...) the risk of hematoma expansion against the risk of stroke recurrence. Timing of Postthrombolytic ICH In early large trials of thrombolysis for myocardial ischemia, sICH occurred within 12 hours after thrombolytic therapy in 65% of patients, within 12 to 24 hours in 17%, within 24 to 48 hours in 9%, and after 48 hours in 9%. In acute ischemic stroke, several studies have examined sICH timing but with variable time thresholds, thereby limiting comparability. , , , One recent review of stroke clinical

2017 American Heart Association

351. Heart Disease and Stroke Statistics 2017 Update: A Report From the American Heart Association Full Text available with Trip Pro

the National Health and Nutrition Examination Survey (NHANES) 1999 to 2000 to NHANES 2011 to 2012 show that the use of cho- lesterol-lowering treatment has increased substan- tially among adults, from 8% in 1999 to 2000 to 18% in 2011 to 2012. During this period, the use of statins increased from 7% to 17%. • From 1988 to 1994 to 2013 to 2014, mean serum total cholesterol for adolescents 12 to 19 years of age has decreased across all subgroups of race and sex. High Blood Pressure (Chapter 9) • The age (...) adults Disease Prevalence Prevalence is an estimate of how many people have a condition at a given point or period in time. The NCHS/ CDC conducts health examination and health interview surveys that provide estimates of the prevalence of dis- eases and risk factors. In this Update, the health inter- view part of the NHANES is used for the prevalence of CVDs. NHANES is used more than the NHIS because in NHANES, AP is based on the Rose Questionnaire; esti- mates are made regularly for HF; hypertension

2017 American Heart Association

352. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease

and Evidence Review? ? ? ? ? ? ? ? ? e728 1?2? Organization of the Writing Committee ? ? ? ? ? ? e730 1?3? Document Review and Approval ? ? ? ? ? ? ? ? ? ? ? e730 1?4? Scope of Guideline ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? e731 2? Clinical Assessment for PAD ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? e733 2?1? History and Physical Examination: Recommendations ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? e733 3? Diagnostic Testing for the Patient With Suspected Lower Extremity PAD (Claudication or CLI (...) of vertebral artery steal), no further imaging or intervention is warranted. Recommendations for History and Physical Examination (Continued) COR LOE Recommendations Table 4. Patients at Increased Risk of PAD Age =65 y Age 50–64 y, with risk factors for atherosclerosis (eg, diabetes mellitus, history of smoking, hyperlipidemia, hypertension) or family history of PAD 63 Age 1.40). 27,67–69,72 See Online Data Supplement 4. Standardized reporting improves communication among healthcare providers. Calculated

2017 American Heart Association

353. 2015 Revised Utstein-Style Recommended Guidelines for Uniform Reporting of Data From Drowning-Related Resuscitation: An ILCOR Advisory Statement Full Text available with Trip Pro

or ECG Ventricular fibrillationVentricular tachycardiaPulseless electrical activityAsystoleOther Vital signs Supplementary Devices are necessary to measure vital signs Heart rateBlood pressureTemperatureSp o 2 Pulmonary status Supplementary Assess severity of lung injury Normal lung examination; patient is coughing; unilateral rales; bilateral rales Type of water/liquid (eg, salt/fresh/chemical/other ) Supplementary In what type of liquid did the drowning occur? Fresh water, salt water, water (...) , was resuscitation attempted before arrival of EMS? was EMS called? was an EMS vehicle dispatched? was cyanosis present? These elements have either been replaced with updated elements or are considered unreliable (eg, cyanosis could be a result of hypoxia or submersion in cold water). ABC indicates alert, blunted, coma; AVPU, alert, responds to verbal stimuli, responds to painful stimuli, unresponsive; CPR, cardiopulmonary resuscitation; EMS, emergency medical services; GCS, Glasgow Coma Scale; and Y/N/U, yes

2017 American Heart Association

354. Management of Brain Arteriovenous Malformations: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Full Text available with Trip Pro

and bAVM hemorrhagic groups. The authors noted that independent predictors of death at 1 year were primary ICH (OR, 21; 95% CI, 4–104) and increasing ICH volume (OR, 1.03; 95% CI, 1.01–1.05) and independent predictors of death or dependence at 1 year were primary ICH (OR, 11; 95% CI, 2–62) and Glasgow Coma Scale score on admission (OR, 0.79; 95% CI, 0.67–0.93). More recently, Appelboom et al examined the utility of a historical ICH scale and a new bAVM-based scale, shifted in age and hemorrhagic volume (...) (0.9–1.75) 1.0 (0.4 -1.6) 2.4 (1.4–3.4 ) 1.8 (1.6–2.0 ) 1.4 (0.6–2.1) 1.0 (0.8–1.2) bAVMs indicates brain arteriovenous malformations; and CI, confidence interval. Boldface type indicates statistical significance. Unruptured bAVMs Many observational cohorts have examined the natural history of bAVMs. Ondra et al and Hernesniemi et al followed up 160 and 238 patients for a mean of 23.7 and 13.4 years, yielding the often-cited 2% to 4% annual risk of hemorrhage. In a meta-analysis of 3923 patients

2017 American Heart Association

355. Poststroke Fatigue: Emerging Evidence and Approaches to Management: A Scientific Statement for Healthcare Professionals From the American Heart Association

absent in patients with continuous-flow LVADs, it is important to understand the differences in the physical examination and in methods that can help rescuers determine if an unresponsive or mentally altered patient is, in fact, in cardiac arrest or circulatory collapse. Pulsatile-Flow LVADS Most early generations of LVADs had pulsatile pumps, which filled and emptied a volume-displacement chamber sequentially, generating pulsatile flow similar to the native heart. Given the advantages of continuous (...) on the pump preload. The pumps maintain decompression of the LV by pumping more quickly when preload increases and pumping less quickly when preload decreases. The native heart continues to contract in patients with a continuous-flow device, but the filling and emptying of the device is not synchronous with the heart. Because the flow from pulsatile-flow LVADs mimics that of the native heart, these patients have a detectable pulse on physical examination that reflects forward cardiac output and perfusion

2017 American Heart Association

356. Cardiopulmonary Resuscitation in Adults and Children With Mechanical Circulatory Support: A Scientific Statement From the American Heart Association

to understand the differences in the physical examination and in methods that can help rescuers determine if an unresponsive or mentally altered patient is, in fact, in cardiac arrest or circulatory collapse. Pulsatile-Flow LVADS Most early generations of LVADs had pulsatile pumps, which filled and emptied a volume-displacement chamber sequentially, generating pulsatile flow similar to the native heart. Given the advantages of continuous-flow devices, intracorporeal pulsatile devices are no longer available (...) when preload increases and pumping less quickly when preload decreases. The native heart continues to contract in patients with a continuous-flow device, but the filling and emptying of the device is not synchronous with the heart. Because the flow from pulsatile-flow LVADs mimics that of the native heart, these patients have a detectable pulse on physical examination that reflects forward cardiac output and perfusion. However, because a pulsatile-flow device fills and empties asynchronously

2017 American Heart Association

357. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association Full Text available with Trip Pro

; SBP, systolic blood pressure; and SHOCK, Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. * In setting of MI complicated by predominantly LV dysfunction. † In setting of acute MI. Historical Perspectives Before the routine use of early revascularization, MI-associated CS had an in-hospital mortality exceeding 80%. A registry trial of 250 patients with acute MI described the association between bedside physical examination (Killip classification) for the assessment

2017 American Heart Association

358. Venous Thromboembolism Prophylaxis, Pediatric Trauma Patients - Joint between EAST and PTS

; Petrillo, Toni M. MD; Faustino, E. Vincent S. MD, MHS Objectives The primary objective of this guideline was to evaluate whether pharmacologic or mechanical prophylaxis reduces the incidence of VTE in children hospitalized after trauma and whether active surveillance with ultrasound (versus daily physical examination alone) results in earlier detection of VTE in this population. Our PICO (population [P], intervention [I], comparator [C], and outcome [O]) questions were as follows: PICO Question 1 (...) with ultrasound be performed (I), compared with daily physical examination alone (C), to detect VTE earlier (O)? A secondary objective was to evaluate putative risk factors for VTE in children hospitalized after trauma. The findings for this question were incorporated in PICO Question 1. Inclusion Criteria for this Review Study Types We included case series, cross-sectional studies, case-control studies, cohort studies, and randomized controlled trials. Original studies from meta-analyses and reviews were

2017 Eastern Association for the Surgery of Trauma

359. Damage control resuscitation in patients with severe traumatic hemorrhage

severely injured patients. The landmark publication by Borgman et al. [18] examining the role of a more balanced transfusion strategy in combat casualties demonstrated improved survival. Numerous subsequent reports have suggested that early transfusion of PLAS and RBC in a balanced ratio of 1:1 to 1:1.5 is associated with lower mortality and less MSOF in patients who receive an MT. [47][77] Some have suggested the mortality may increase in a U-shaped curve as the ratio approaches 1:1, [50][78][79 (...) in Afghanistan reported in MATTERs and MATTERs II. [24][61] The CRASH-2 and MATTERs studies include patients with significant disparities in mechanism and injury severity. In CRASH-2, 68% of patients had a blunt mechanism of injury compared to MATTERs, which reported only patients injured by gunshot wound (30%) or explosion (70%). In CRASH-2, injury severity was not reported; however, only 18% had a Glasgow Coma Scale score of 8 or less compared to 29% in MATTERs. Additionally, less than half of CRASH-2

2017 Eastern Association for the Surgery of Trauma

360. Management of brain arteriovenous malformations

year were primary ICH (OR, 11; 95% CI, 2–62) and Glasgow Coma Scale score on admission (OR, 0.79; 95% CI, 0.67–0.93). More recently, Appelboom et al examined the utility of a historical ICH scale and a new bAVM-based scale, shifted in age and hemorrhagic volume, in their ability to predict poor (modified Rankin Scale score ≥3) clinical outcomes. The authors reported good agreement between the scales and increased specificity of the novel scale to predict outcome (87.9% versus 68.2%; P <0.001 (...) observational cohorts have examined the natural history of bAVMs. Ondra et al and Hernesniemi et al followed up 160 and 238 patients for a mean of 23.7 and 13.4 years, yielding the often-cited 2% to 4% annual risk of hemorrhage. In a meta-analysis of 3923 patients, Gross and Du reported overall (3.0%) ICH rates and those in the setting of no (2.2%) and prior (4.5%) rupture. The authors noted prior hemorrhage (hazard ratio [HR], 3.2; 95% CI, 2.1–4.3), deep AVM location (HR, 2.4; 95% CI, 1.4–3.4), exclusively

2017 American Academy of Neurology

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