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Coma Exam

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361. Does Mannitol Reduce Mortality From Traumatic Brain Injury?

% mannitol vs placebo 1.75 (0.48–6.38) RR, Relative risk; CI, con?dence interval; TBI, traumatic brain injury; GCS, Glasgow Coma Scale; ICP, intracranial pressure. METHODS DATA SOURCES TheauthorssearchedtheCochrane InjuriesGroupSpecializedRegister, CENTRAL,MEDLINE,EMBASE, PubMed,ISIWebofScience,and ConferenceProceedingsCitation IndexfrominceptionuntilApril 2009.Thereferencelistsofrelevant articleswerealsoreviewedandthe ?rstauthorofselectedarticleswas contactedforassistancewith (...) in cerebral blood ?ow and oxygenation. 6 The Brain Trauma Foundation Guidelines Task Force provided a level II recommen- dation (moderate clinical cer- tainty) for administering mannitol in cases of elevated intracranial pressure. 7 A recent survey re- ported that a majority of Canadian emergency physicians in one province use mannitol for pa- tients with severe traumatic brain injury in accordance with physical examination ?ndings or computed tomography evidence ofherniation. 8 Despite mannitol’s long

2016 Annals of Emergency Medicine Systematic Review Snapshots

362. Can Ocular Ultrasonography Be Used to Assess Intracranial Pressure?

tomography: a systematic review and meta-analysis. J Ultrasound Med. 2015;34:1285-1294. 1. Hansen HC, Helmke K. The subarachnoid space surrounding the optic nerves. An ultrasound study of the optic nerve sheath. Surg Radiol Anat. 1996;18: 323-328. 2. Wu EH, Fagan MJ, Reinert SE. Self- con?dence in and perceived utility of the physical examination: a comparison of medical students, residents, and faculty internists. J Gen Intern Med. 2007;22:1725-1730. 3. Helmke K, Hansen HC. Fundamentals of transorbital (...) patients. Ann Emerg Med. 2007;49:508-514. 6. Eisenberg HM, Gary HE Jr, Aldrich EF, et al. InitialCT ?ndingsin753patientswithsevere head injury. A report from the NIH Traumatic Coma Data Bank. J Neurosurg. 1990;73:688-698. 7. KimberlyHH,ShahS,MarillK,etal.Correlation ofopticnervesheathdiameter withdirect measurementofintracranialpressure.Acad EmergMed.2008;15:201-204. 8. Rajajee V, Vanaman M, Fletcher JJ, et al. Optic nerve ultrasound for the detection of raised intracranial pressure. Neurocrit Care

2016 Annals of Emergency Medicine Systematic Review Snapshots

363. ED Patients in Police Custody

instructions should be provided to police personnel to ensure the well-being of the patient. • It is not the role of the ED Staff to act as surrogate Forensic Medical Examiners. Page 3 Scope This guideline has been developed to help medical and nursing staff within Emergency Departments (EDs) manage adult patients (18 or over) who attend whilst in the custody of the police. It includes recommendations on where to treat a patient, the timeliness of management and what information is required (...) observations). Most custody officers or detention officers who are responsible for monitoring detainees in police cells, will have no more than Basic Life Support training. Pulse, blood pressure, neuro-observations (including Glasgow Coma Score), blood glucose and oxygen saturation cannot be monitored regularly in police stations. 30 minute rousing to speech is generally the most intensive monitoring that can be achieved. CCTV or close personal observation is generally used for those at risk of self-harm

2016 Royal College of Emergency Medicine

364. Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury

have ex- perienced a concussive event for mental health, cognitive impairment, and other potential coinciding diagnoses and refer for additional evaluation and services as indicated. F For patients not deemed appropriate for a comprehen- sive physical therapy examination (ie, those who present with severe mental health concerns or health conditions that re- quire medical clearance prior to comprehensive physical exam- ination), physical therapists should provide education regarding concussion (...) Impairment/Function-Based Diagnosis CPG16 Screening and Diagnosis CPG18 Examination CPG21 Interventions CPG30 DECISION TREE CPG36 AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS ...CPG40 REFERENCES CPG42 APPENDICES (ONLINE) CPG50 REVIEWERS: Roy D. Altman, MD • Paul Beattie, PT , PhD • Kate E. Berz, DO • Bradley Bley, DO, FAAP , RMSK, CSCS Amy Cecchini, DPT , MS • John Dewitt, DPT • Amanda Ferland, DPT • Isabelle Gagnon, PT , PhD • Kathleen Gill-Body, DPT , MS, NCS, FAPTA Sandra Kaplan, PT , PhD • John J. Leddy

2020 The Orthopaedic Section of the American Physical Therapy Association (APTA), Inc.

365. Fexeric - ferric citrate coordination complex

, decreased muscular control, prostration, urination, bowel obstruction, gastroenteritis (including diarrhea and vomiting leading to dehydration, haemoconcentration and electrolyte imbalance), rapid and shallow respiration, convulsions, coma, respiratory failure and cardiac arrest. Post-mortem examination reveals congestion and hemorrhagic necrosis of the GIT. Citric acid has a low acute toxicity when administered orally to mice (LD50=5.4 g/kg) and rats (LD 50 =3 to 12 g/kg); these doses are associated

2015 European Medicines Agency - EPARs

366. Kyprolis - carfilzomib

of 5 daily doses (TR-0021-171). After both single and QDx5 administration, dose- dependent inhibition in proteasome activity was observed in all tissues examined, with the exception of brain, where there was no inhibition of proteasome activity. After five daily doses ofPR-171, proteasome inhibition increased in whole blood, PBMCs, heart and lung, where a statistically significant increase in proteasome inhibition was noted. Recovery occurred in all tissues, except whole blood, with a t1/2 of ~ 24 (...) seen. Carfilzomib did not markedly affect male CYP1A, female CYP2C and male or female CYP3A enzyme expression at the concentrations examined (TR-0197-171). In contrast, carfilzomib may decrease female CYP1A and increase male CYP2C enzyme expression. Additionally, a dose-dependent decrease in total hepatic CYP content was observed in female monkeys treated with carfilzomib. Study (TR-0087-171) was conducted to investigate whether carfilzomib is a substrate and/or an inhibitor of P-gp using the Caco

2015 European Medicines Agency - EPARs

367. Ionsys - fentanyl

of these studies is acceptable. Concomitant use of other CNS depressants, including other opioids, sedatives or hypnotics, general anaesthetics, phenothiazines, tranquillisers, skeletal muscle relaxants, sedating antihistamines and alcoholic beverages are noted to produce additive depressant effects. Hypoventilation, hypotension and profound sedation or coma may occur. Use of fentanyl with monoamine oxidase (MAO) inhibitors within 14 days is not recommended due to Medicinal product no longer authorised (...) however are based upon the techniques used by Janssen Research for the initial studies with fentanyl. In addition the applicant has described methodology used to quantify fentanyl in the mouse dermal repeat-dose toxicity studies. Fentanyl absorption has been described from both a transdermal and intravenous perspective. The transdermal data are obviously more relevant for this product and this was examined using hairless rat skin preparations, examining the influence of iontophoresis on increasing

2015 European Medicines Agency - EPARs

368. Ebymect - dapagliflozin / metformin

on the medicinal product, with a view to examining subsequent applications relating to other medicinal products possessing the same qualitative and quantitative composition in terms of active substances and the same pharmaceutical form. 2.2. Quality aspects Since this application is an informed consent of the Xigduo, the quality data in support of the Ebymect application are identical to the up-to-date quality data of the Xigduo dossier, which has been assessed and approved (including all post-marketing (...) associated with hypoxia. Diagnosis The risk of lactic acidosis must be considered in the event of non-specific signs such as muscle cramps with digestive disorders, abdominal pain and severe asthenia. Lactic acidosis is characterised by acidotic dyspnoea, abdominal pain and hypothermia followed by coma. Diagnostic laboratory findings are decreased blood pH, plasma lactate levels above 5 mmol/L, and an increased anion gap and lactate/pyruvate ratio. If metabolic acidosis is suspected, treatment

2015 European Medicines Agency - EPARs

369. Praxbind - idarucizumab

to idarucizumab have not been identified. However, DNA banking samples are collected in the ongoing study 1321.3. These will be stored by the applicant for up to 15 years and may be analysed at a later time to identify potential genetic factors that could influence therapeutic outcome or adverse reactions. This was endorsed. PK-PD results: Linear and nonlinear (Emax) mixed effects models were used to examine the PK/PD relationship of dabigatran analyte concentration and ECT, dTT, TT, and aPTT and to identify

2015 European Medicines Agency - EPARs

370. Ravicti - glycerol phenylbutyrate

, hyperventilation, posturing, coma) as well as more subtle (e.g., loss of appetite, headache, cyclical vomiting, somnolence, lethargy, fatigue, Assessment report EMA/676925/2015 Page 10/89 disorientation, behavioural abnormalities, sleep disorders, delusions, hallucinations, psychosis, headaches, nausea, vomiting) manifestations are nonspecific, long delays in diagnosis are common (Rüegger, 2014, Nassogne, 2005). Some critically ill infants are misdiagnosed, for example, with sepsis, resulting in delayed (...) inability to synthesize urea can result in dramatic hyperammonaemia leading to coma and death shortly after birth, whereas less severe defects in urea formation are typically associated with lesser degrees of hyperammonaemia and often present somewhat later in life. UCD management is aimed at prompt diagnosis and reducing production of ammonia through dietary protein restriction and, for patients in whom dietary measures are insufficient, control of blood ammonia through the use of waste nitrogen

2015 European Medicines Agency - EPARs

372. Addyi - Flibanserin

with a strong CYP3A4 inhibitor (ketoconazole) ? Concern with flibanserin being a P-gp inhibitor given the increase in digoxin level when co-administered with flibanserin The second CR letter requests that the Applicant conduct additional pharmacokinetic investigations to examine whether additional enzymes, such as CYP2C9 or CYP2C19, contribute to the metabolism of flibanserin. The letter also recommended a driving simulation study to assess the potential for impaired next-day driving. The applicant

2015 FDA - Drug Approval Package

373. Post-Resuscitation Therapy in Adult Advanced Life Support

element, and supplementary tests should be considered in the context of the clinical examination. The most reliable combination and timing for assessments have not been fully determined. 3 Recommendations address prognostication of comatose post-cardiac arrest patients treated with hypothermic TTM and patients not treated with hypothermic TTM. This approach was chosen because hypothermic TTM may alter the natural history of coma and may delay recovery of CNS function. Patients may be exposed to large (...) of neurological recovery during or immediately after a cardiac arrest. After cessation of sedation (and/or induced hypothermia) the probability of awakening decreases with each day of coma. ANZCOR Guideline 11.7 January 2016 Page 13 of 17 Recommendation Relying on the neurologic exam during cardiac arrest to predict outcome is not recommended and should not be used. 4 [Class A, Expert consensus opinion] 3 Prognostication for comatose cardiac arrest victims treated with TTM Recommendations ANZCOR suggest

2016 Australian Resuscitation Council

374. Acute Coronary Syndromes: Reperfusion Strategy

performing immediate angiography and if necessary PCI in patients with ST elevation or new left bundle branch block on the standard 12 lead electrocardiograph who respond to cardio-pulmonary resuscitation with spontaneous return of circulation after cardiac arrest 32-35 (LOE II) (CoSTR 2015, strong recommendation, low-quality evidence) 14 . Coma is common and should not be a contraindication to angiography and PCI. We suggest immediate angiography and if necessary PCI in selected patients who do not have (...) -low-quality evidence) 14 . 2.6 Facilitated PCI Facilitated PCI refers to the routine use of fibrinolysis prior to PPCI. The strategy of facilitated PCI compared with PPCI is not recommended in STEMI. ANZCOR Guideline 14.3 January 2016 Page 5 of 10 A number of studies have examined the strategy of facilitated PCI and they have shown no benefit of PPCI and some studies have shown poor outcomes with routine PCI shortly after fibrinolysis 69,70 . (LOE II) (strong recommendation, moderate-quality

2016 Australian Resuscitation Council

376. Guidelines on Prevention, Diagnosis and Treatment of Infective Endocarditis (Full text)

is suspected. TOE must be performed in case of negative TTE when there is a high index of suspicion for IE, particularly when TTE is of suboptimal quality. TOE should also be performed in patients with positive TTE to rule out local complications. The indications of echocardiographic examination for diagnosis and follow-up of patients with suspected IE are summarized in Table and Figure . In patients with S. aureus bacteraemia, echocardiography is justified in view of the frequency of IE in this setting (...) echocardiographic findings of IE. In cases with an initially negative examination, repeat TTE/TOE must be performed 5–7 days later if the clinical level of suspicion is still high, or even earlier in the case of S. aureus infection. Other imaging techniques should also be used in this situation (see section 5.5). Finally, follow-up echocardiography to monitor complications and response to treatment is mandatory ( Figure ). Real-time three-dimensional (3D) TOE allows the analysis of 3D volumes of cardiac

2015 European Society of Cardiology PubMed abstract

377. Public health guidance on varicella vaccination in the European Union

of infection and (potentially) the boosting of immunity to zoster [265,267]. A few models also took into account potential waning of vaccine protection. New information on parameters related to the vaccine or to the mechanisms of HZ development may result in additional costs. For example, additional costs could arise if new findings would result in a need to protect more adults (or adults at high risk, e.g. vaccinated women of childbearing age) after childhood vaccination. Studies examining varicella

2015 European Centre for Disease Prevention and Control - Public Health Guidance

378. Diabetes - type 2

with diabetes, on the register, in whom the last IFCC-HbA1c is 64 mmol/mol or less in the preceding 12 months 8 43–83% DM009. The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months 10 52–92% DM012. The percentage of patients with diabetes, on the register, with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk

2019 NICE Clinical Knowledge Summaries

379. Heart failure - chronic

nocturnal dyspnoea). Fluid retention (ankle swelling, bloated feeling, abdominal swelling, or weight gain). Fatigue, decreased exercise tolerance, or increased recovery time after exercise. Light headedness or history of syncope. Ask about risk factors: Coronary artery disease including previous history of myocardial infarction, hypertension, atrial fibrillation, and diabetes mellitus. Drugs, including alcohol. Family history of heart failure or sudden cardiac death under the age of 40 years. Examine (...) calcium-channel blockers, nonsteroidal anti-inflammatory drugs). Hypoalbuminaemia (from renal or hepatic disease). Pelvic tumour. Other conditions such as: Obesity. Severe anaemia or thyroid disease. Bilateral renal artery stenosis. Basis for recommendation Basis for recommendation This information is taken from the textbooks Macleod's clinical examination [ ] and Clinical medicine [ ], and the National Institute for Health and Clinical Excellence (NICE) Chronic heart failure diagnosis and management

2019 NICE Clinical Knowledge Summaries

380. Hypercalcaemia

, or pathological fractures in malignancy). See the CKS topic on for more information. Neuromuscular and neuropsychiatric Drowsiness, delirium, coma. See the CKS topic on for more information. Fatigue, lethargy, muscle weakness, insomnia. See the CKS topics on and for more information. Impaired concentration and memory, confusion. See the CKS topic on for more information. Depression, anxiety, irritability, psychosis. See the CKS topics on , , and for more information. Neurological signs (for example upper (...) fractures, renal stones, or malignancy. Any past history of radiotherapy to the head and neck. Any family history of hypercalaemia (for example due to genetic forms of primary hyperparathyroidism, or familial hypocalciuric hypercalcaemia). Any , supplements, or over-the-counter preparations that may be causative or contributory. Examine the person: Assess hydration status — people with hypercalcaemia are often dehydrated due to nephrogenic diabetes insipidus due to reduced oral intake resulting from

2019 NICE Clinical Knowledge Summaries

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