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Coma Exam

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441. TREKK Series | Pediatric Multisystem Trauma

straight to addressing hypovolemic blood loss with blood directly. To date, there is a paucity of evidence in the pediatrics literature recommending this strategy at this time, but it may be something to consider in the trauma room if obvious bleeding is present. Place IO lines if no IV can be established > 90 seconds or after 2 attempts (1-2 skilled providers). Disability: If the child can’t talk yet, try using the Pediatric Glasgow Coma Scale (see below). A blood glucose should be checked to ensure (...) . Remember to displace the soft tissue when doing these in the femur, either laterally or medially! Pediatric Glasgow Coma Score Remember the Pediatric GCS is age based. This chart was adapted from Rosen’s Emergency Medicine textbook, 8th ed. 1 Radiography in Blunt Pediatric Trauma CXR: Recommended C- spine X-rays or CT imaging of neck: Not warranted for all patients. May be done if not able to clinically clear the C-spine or mechanism. Luckily, C-spine injuries are significantly less common in kids

2016 CandiEM

442. Guidelines on Prevention, Diagnosis and Treatment of Infective Endocarditis Full Text available with Trip Pro

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

443. 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

444. 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

445. 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

447. UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults

in meningococcal disease. Rapidly progressing rash Coma Hypotension and shock Lactate>4 mmol/L Low/normal peripheral white blood cell count Low acute phase reactants Low platelets Coagulopathy Absence of meningitis UK adult meningitis guidelines 7 Please cite this article in press as: McGill F, et al., The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults, J Infect (2016), (...) the Glasgow coma scale (2C). 14. Blood cultures should be taken as soon as possible and within 1 h of arrival at hospital (AR) 15. In patients with suspected meningitis (with no signs of shock or severe sepsis) B LPshouldbeperformedwithin1hofarrivalathos- pital provided that it is safe to do so (1D) B treatment should be commenced immediately af- ter theLPhas been performed, andwithin the?rst hour (1B) B IftheLPcannotbeperformedwithin1htreatment should be commenced immediately after blood cultures have

2016 British Infection Association

448. Extracorporeal Membrane Oxygenation (ECMO)

described as poor did not present enough information to make this determination or did not sufficiently attempt to control for confounding variables in some way. It is also challenging to pool information across comparative observational studies (cohort and case- control study designs) because these studies examined distinct patient populations with different disease entities and variable severities of illness. Another limitation of drawing conclusions across studies is that there is so much variability (...) Cohort studies=3 Cardiopulmonary bypass Medium Inconsistent Direct Imprecise ++ Low Comparable: No survival benefit; shorter length of stay (1 study) Two studies examined heart transplant; one studied heart- lung transplant ECMO ECPR N=1,543 RCT=0 Cohort studies=5 Conventional cardiopulmonary resuscitation Medium Inconsistent Direct Imprecise ++ Low Comparable: Short-term survival benefit is lost in longer- term. One study showed neurologic benefit Only one study reported positive survival benefit

2016 California Technology Assessment Forum

449. Summary of recommendations for the diagnosis and treatment of malaria by the Committee to Advise on Tropical Medicine and Travel (CATMAT)

or complicated malaria requires admission to hospital for regular monitoring of respiratory rate and pattern, coma score, and glucose and urine output, especially if the patient is unconscious. In high levels of parasitemia, exchange transfusion may be beneficial to remove infected red blood cells and toxic mediators from the circulation, and reduce the parasite load . Because of the elevated risk of severe or complicated malaria, those with a diagnosis of Plasmodium falciparum malaria should also (...) for parenteral treatment, for exchange transfusion or for admission to an intensive care unit (ICU). In addition, it is important for monitoring response to treatment. Microscopy, which involves examining thick and thin blood smears, is both rapid and accurate. A Canadian laboratory should be able to confirm the presence of a parasite and, in most cases, identify the species within one to two hours of receiving a blood specimen . However, accurate examination of a blood smear requires considerable training

2014 CPG Infobase

450. Coma in fatal adult human malaria is not caused by cerebral oedema. Full Text available with Trip Pro

Coma in fatal adult human malaria is not caused by cerebral oedema. The role of brain oedema in the pathophysiology of cerebral malaria is controversial. Coma associated with severe Plasmodium falciparum malaria is multifactorial, but associated with histological evidence of parasitized erythrocyte sequestration and resultant microvascular congestion in cerebral vessels. To determine whether these changes cause breakdown of the blood-brain barrier and resultant perivascular or parenchymal (...) cerebral oedema, histology, immunohistochemistry and image analysis were used to define the prevalence of histological patterns of oedema and the expression of specific molecular pathways involved in water balance in the brain in adults with fatal falciparum malaria.The brains of 20 adult Vietnamese patients who died of severe malaria were examined for evidence of disrupted vascular integrity. Immunohistochemistry and image analysis was performed on brainstem sections for activation of the vascular

2011 Malaria journal

451. Prognostic factors among children with acute encephalitis/encephalopathy associated with viral and other pathogens. (Abstract)

Prognostic factors among children with acute encephalitis/encephalopathy associated with viral and other pathogens. Acute encephalitis/encephalopathy (AE) associated with viral and other pathogens leads to neurological sequelae and mortality. Knowing the prognostic factors is therefore important for immediate interventions. We examined early-phase unfavorable prognostic factors among children with AE using a nationwide database.We performed a retrospective cohort study using the Diagnosis (...) pathogens, and interventions within 2 days of admission adjusting for within-hospital clustering.This study included 9,386 children with AE (median age of 3 years). A total of 241 (2.6%) in-hospital deaths occurred, and 2,027 (21.6%) patients had the composite unfavorable outcome. Significant unfavorable prognostic factors were age of 12 to 18 years, congenital anomalies, epilepsy, and Japan Coma Scale score of 100 to 300 at admission (i.e., worse levels of consciousness). In contrast, herpes simplex

2020 Clinical Infectious Diseases

452. Cobra snakebite mimicking brain death treated with a novel combination of polyvalent snake antivenom and anticholinesterase: Case report. (Abstract)

Cobra snakebite mimicking brain death treated with a novel combination of polyvalent snake antivenom and anticholinesterase: Case report. In toxicology literature, snake bites were the second toxicology-relevant cause mimicking brain death. A 57-year-old woman with history of cobra snake bite. On examination, the brain stem reflexes were absent with Glasgow coma score of 3. The patient accomplished full neurological recovery after using a novel combination of Polyvalent Snake Antivenom (PSA

2020 American Journal of Emergency Medicine

453. Time trends in deaths before age 50 years in people with type 1 diabetes: a nationwide analysis from Scotland 2004-2017. Full Text available with Trip Pro

Time trends in deaths before age 50 years in people with type 1 diabetes: a nationwide analysis from Scotland 2004-2017. We aimed to examine whether crude mortality and mortality relative to the general population below 50 years of age have improved in recent years in those with type 1 diabetes.Individuals with type 1 diabetes aged below 50 and at least 1 year old at any time between 2004 and 2017 in Scotland were identified using the national register. Death data were obtained by linkage (...) in men and 4.09 and 4.16 in women for 2004 and 2017, respectively. Diabetic ketoacidosis or coma (DKAoC) accounted for 22% of deaths and the rate did not decline significantly (IRR 0.975 [95% CI 0.94, 1.011], p = 0.168); 79.3% of DKAoC deaths occurred out of hospital. Circulatory diseases accounted for 27% of deaths and did decline significantly (IRR 0.946 [95% CI 0.914, 0.979], p = 0.002).Absolute mortality has fallen, but the relative impact of type 1 diabetes on mortality below 50 years has

2020 Diabetologia

454. Prognostic Accuracy of Soluble Triggering Receptor Expressed on Myeloid Cells (sTREM-1)-based Algorithms in Febrile Adults Presenting to Tanzanian Outpatient Clinics. Full Text available with Trip Pro

[CRP]) activation pathways were determined in consecutive adults with acute fever (≥38°C) at presentation to outpatient clinics in Dar es Salaam, Tanzania. We evaluated the accuracy of these mediators in predicting all-cause mortality and examined whether markers could improve the prognostic accuracy of clinical scoring systems, including the quick sequential organ failure assessment (qSOFA) and Glasgow coma scale (GCS).Of 507 febrile adults, 32 died (6.3%) within 28 days of presentation. We found

2020 Clinical Infectious Diseases

455. Clinical Predictors of Intracranial Bleeding in Older Adults Who Have Fallen: A Cohort Study. (Abstract)

bleeding: new abnormalities on neurologic examination (odds ratio [OR] = 4.4; 95% CI = 2.4-8.1), bruise or laceration on the head (OR = 4.3; 95% CI = 2.7-7.0), chronic kidney disease (OR = 2.4; 95% CI = 1.3-4.6), and reduced Glasgow Coma Scale from normal (OR = 1.9; 95% CI = 1.0-3.4).The incidence of intracranial bleeding in our study was 5.0%. We found significant associations between intracranial bleeding and four simple clinical variables. We did not find significant associations between

2020 Journal of the American Geriatrics Society

456. Cerebral Venous Thrombosis and Subdural Collection in a Comatose Patient: Do Not Forget Intracranial Hypotension. A Case Report. (Abstract)

are a rare presentation. Diagnosis of IH is based on the association of clinical history, evocative symptomatology, and cerebral imaging. CVT occurs in 1-2% of IH cases and the association between IH, CVT, and subdural hemorrhage is rare. MRI is probably the key imaging examination. In the present case, epidural patch was performed after confounding factors for coma had been treated. Benefit of anticoagulation had to be balanced in this case with potential hemorrhagic complications, especially within (...) Cerebral Venous Thrombosis and Subdural Collection in a Comatose Patient: Do Not Forget Intracranial Hypotension. A Case Report. The typical sign of intracranial hypotension (IH) is postural headache. However, IH can be associated with a large diversity of clinical or radiological signs leading to difficult diagnosis especially in case of coma. The association of cerebral venous thrombosis (CVT) and subdural hemorrhage is rare but should suggest the diagnosis of IH.Case report.We report here

2020 Headache

457. Transcutaneous Carbon Dioxide Monitoring During Apnea Testing for Determination of Neurologic Death in Children: A Retrospective Case Series. (Abstract)

Transcutaneous Carbon Dioxide Monitoring During Apnea Testing for Determination of Neurologic Death in Children: A Retrospective Case Series. Determination of neurologic death in children is a clinical diagnosis based on absence of neurologic function with irreversible coma and apnea. Apnea testing during determination of neurologic death assesses spontaneous respiration when PaCO2 increases to greater than or equal to 60 and greater than or equal to 20 mm Hg above pre-apneic baseline (...) paired transcutaneous carbon dioxide and PaCO2 values obtained during determination of neurologic death. Primary analyses included Pearson correlation coefficient, Bland-Altman bias and limits of agreement, and comparative statistics. Descriptive data included demographics, admission diagnoses, hemodynamics, Vasoactive Inotropic Scores, and arterial blood gas measurement. Eight children underwent 15 determination of neurologic death examinations resulting in 31 paired transcutaneous carbon dioxide

2020 Pediatric Critical Care Medicine

458. Understanding Characteristics of Acute Brain Injury in Adult Extracorporeal Membrane Oxygenation: An Autopsy Study. (Abstract)

and microscopic examinations from January 2009 to December 2018 from a single tertiary center.Twenty-five patients (median age 53 yr) had postmortem brain autopsy.Description and analysis of neuropathologic findings.Of 25, 22 had venoarterial extracorporeal membrane oxygenation (88%) (nine cardiac arrest; 13 cardiogenic shock) and three had venovenous extracorporeal membrane oxygenation cannulation (12%). The median extracorporeal membrane oxygenation support time was 96 hours (interquartile range, 26-181 hr (...) ). Extracorporeal membrane oxygenation duration, cannulation methods, hemoglobin level, coma, renal impairment, and hepatic impairment were not associated with acute brain injury.In the population who underwent postmortem neuropathologic evaluation, 68% of extracorporeal membrane oxygenation nonsurvivors developed acute brain injury. Hypoxic-ischemic brain injury was the most common type of injury suggesting that patients sustained acute brain injury as a consequence of cardiogenic shock and cardiac arrest

2020 Critical Care Medicine

459. Habituation of auditory startle reflex is a new sign of minimally conscious state. Full Text available with Trip Pro

Habituation of auditory startle reflex is a new sign of minimally conscious state. Neurological examination of non-communicating patients relies on a few decisive items that enable the crucial distinction between vegetative state (VS)-also coined unresponsive wakefulness syndrome (UWS)-and minimally conscious state. Over the past 10 years, this distinction has proven its diagnostic value as well as its important prognostic value on consciousness recovery. However, clinicians are currently (...) limited by three factors: (i) the current behavioural repertoire of minimally conscious state items is limited and restricted to a few cognitive domains in the goldstandard revised version of the Coma Recovery Scale; (ii) a proportion of ∼15-20% clinically VS/UWS patients are actually in a richer state than VS/UWS as evidenced by functional brain imaging; and (iii) the neurophysiological and cognitive interpretation of each minimally conscious state item is still unclear and debated. In the current

2020 Brain

460. Predictors of New-Onset Physical Restraint Use in Critically Ill Adults. (Abstract)

care medical center in the United States. Use of physical restraints was determined via daily in-person assessments and medical record review. Mixed-effects logistic regression analysis was used to examine factors associated with new-onset use of physical restraints, adjusting for covariates and within-subject correlation among intensive care unit days.Of 145 patients who were free of physical restraints within 48 hours of intensive care unit admission, 24 (16.6%) had restraints newly applied (...) during their stay. In adjusted models, delirium (odds ratio [OR], 5.09; 95% CI, 1.83-14.14), endotracheal tube presence (OR, 3.47; 95% CI, 1.22-9.86), and benzodiazepine administration (OR, 3.17; 95% CI, 1.28-7.81) significantly increased the odds of next-day use of physical restraints. Tracheostomy was associated with significantly lowered odds of next-day restraint use (OR, 0.13; 95% CI, 0.02-0.73). Compared with patients with a target sedation level, patients who were in a coma (OR, 2.56; 95% CI

2020 American Journal of Critical Care

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