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61. Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis

). Many reports showed overall rates of uveitis without separately reporting recurrences as opposed to incident episodes (37). The rates were generally lower for adalimumab and infliximab compared to etanercept. For exam- ple, a large observational study demonstrated rates of uveitis (per 100 patient- years) in patients receiving adalimumab, infliximab, and etanercept of 13.6, 27.5, and 60.3, respectively, compared to pretreatment rates of 36.8, 45.5, and 41.6, respectively (38). Adali- mumab

2019 American College of Rheumatology

63. Major Blunt Trauma

® topic on “Head Trauma” [1] should be reviewed for further information. For those who meet criteria for imaging based on mechanism and patients with a Glasgow Coma Score 35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable (...) -FAST) performed by emergency physicians compared to CT. Am J Emerg Med 2018;36:1014-17. 10. Becker A, Lin G, McKenney MG, Marttos A, Schulman CI. Is the FAST exam reliable in severely injured patients? Injury 2010;41:479-83. 11. Abdulrahman Y, Musthafa S, Hakim SY, et al. Utility of extended FAST in blunt chest trauma: is it the time to be used in the ATLS algorithm? World J Surg 2015;39:172-8. 12. Ballard RB, Rozycki GS, Newman PG, et al. An algorithm to reduce the incidence of false-negative FAST

2019 American College of Radiology

64. 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

65. Disseminated intravascular coagulation

/16504043?tool=bestpractice.com 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 (...) 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

2017 BMJ Best Practice

66. Salicylate poisoning

. http://informahealthcare.com/doi/full/10.1080/15563650600907140 http://www.ncbi.nlm.nih.gov/pubmed/17364628?tool=bestpractice.com Chronic poisoning tends to occur as a result of repeated exposure to high-dose aspirin or equivalent (150 mg/kg/day). History and exam ingestion of 150 mg/kg or more, or 6.5 g or more, of aspirin or aspirin-equivalent oil of wintergreen ingestion unknown toxin ingestion or exposure self-harm or suicide attempt abnormal behaviour children aged 3 years or younger (...) and adults aged 70 years or older nausea, vomiting, haematemesis, epigastric pain fever and diaphoresis shortness of breath tachypnoea, hyperpnoea, Kussmaul's respirations tinnitus and/or deafness malaise and/or dizziness movement disorders, asterixis, stupor confusion and/or delirium (irritability, hallucinations) coma and/or papilloedema seizures rales plus low oxygen saturation volume depletion skin rash ingestion of 150 mg/kg or more, or 6.5 g or more, of aspirin or aspirin-equivalent ingestion

2017 BMJ Best Practice

67. Cavernous sinus thrombosis

, ears, teeth, or mouth), affecting the cavernous sinus and its structures. Aseptic CST is usually a thrombotic process that is a result of trauma, iatrogenic injuries, or prothrombotic conditions. History and exam presence of risk factors rapid onset of signs and symptoms (acute septic CST) headache fever peri-orbital oedema chemosis and proptosis lateral gaze palsy ophthalmoplegia profound sepsis (acute septic CST) ptosis and mydriasis papilloedema and/or retinal-vein dilatation decreased corneal (...) reflex hypo- or hyper-aesthesia in the distribution of the ophthalmic and maxillary nerves mental state changes (e.g., confusion, drowsiness, coma) clinically detectable primary infection site meningismus (nuchal rigidity, photophobia, and headache) positive Kernig's or Brudzinski's signs seizures loss of visual acuity recent hx of acute sinusitis hx of facial infections hx of peri-orbital infection hx of otitis media, mastoiditis, or petrositis hx of dental or oral infection hx of sepsis

2017 BMJ Best Practice

68. Psychogenic polydipsia

and/or developmental disability. There may be no physical effects, but hyponatraemia can occur. History and exam presence of risk factors water-seeking and drinking polyuria headache or nausea lethargy or confusion seizures, delirium, or coma mental illness anxious, middle-aged women developmental disability disorders smoking Diagnostic investigations plasma osmolality urine osmolality urine sodium serum sodium 24-hour urine volume urinalysis serum urea water restriction test vasopressin test plasma ADH CXR (...) headache, nausea, cramping, hyporeflexia, dysarthric speech, lethargy, confusion, seizures, and delirium. Coma and even sudden death can ensue as sodium status worsens. Complications of psychogenic polydipsia include incontinence and enuresis, bladder dilation and hydronephrosis, renal and congestive heart failure, and osteoporosis and associated pathological fractures. Diagnosis is one of exclusion. Other medical causes of polydipsia, polyuria, and/or hyponatraemia need to be ruled out. Management

2017 BMJ Best Practice

69. Superior vena cava syndrome

, neck, and arms, often with cyanosis, plethora, and distended subcutaneous vessels. Wilson LD, Detterbeck FC, Yahalom J. Clinical practice: superior vena cava syndrome with malignant causes. N Engl J Med. 2007 May 3;356(18):1862-9. http://www.ncbi.nlm.nih.gov/pubmed/17476012?tool=bestpractice.com It can be caused by either intraluminal obstruction of the SVC or extrinsic compression. History and exam presence of risk factors localised oedema of the face and upper extremities dyspnoea facial plethora (...) cough distended neck veins distended chest veins hoarseness of voice lymphadenopathy blurred vision stridor confusion/stupor anorexia weight loss haemoptysis headache chest pain mental changes fever skin rash arthralgia laryngeal oedema cyanosis papilloedema coma smoking multiple pacemaker leads age >50 years radiation Diagnostic investigations chest x-ray chest CT chest MRI ultrasound of upper extremities venography biopsy sputum cytology thoracentesis sputum culture ESR C-reactive protein

2017 BMJ Best Practice

70. 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. http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0000472 http://www.ncbi.nlm.nih.gov/pubmed/19564908?tool=bestpractice.com 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

71. Hypercalcaemia of malignancy

Jan 27;352(4):373-9. http://www.ncbi.nlm.nih.gov/pubmed/15673803?tool=bestpractice.com 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

72. 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

73. 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

2017 BMJ Best Practice

74. 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. http://www.ncbi.nlm.nih.gov/pubmed/11228282?tool=bestpractice.com [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

76. 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

77. Perinatal Mortality Guideline

? Laboratory investigations including serum screening ? Ultrasound(s) ? Past obstetrical history ? Medical history ? ? Laboratory: ? CBC, type/screen* ? Feto-maternal hemorrhage screen* ? Serology for CMV, toxoplasmosis, parvovirus B19, HSV, rubella (if not previously done) ? ? Discuss birth plan. ? ? Vaginal birth is preferable if there is no contraindication. ? ? Consider method of induction in light of clinical circumstances. ? ? Discuss role of autopsy (complete, limited or external exam only (...) ) 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

2017 British Columbia Perinatal Health Program

78. Surveillance of healthcare-associated infections and prevention indicators in European intensive care units: HAI-Net ICU protocol, version 2.2

References 28 Annex 1. Microorganisms code list 29 Annex 2. Extended antimicrobial resistance data for ICU-acquired infections 32 Annex 3. Healthcare-associated infections code list 33 Annex 4. Antimicrobial ATC codes 34 Diagnosis (site) code list for antimicrobial use 39 Annex 5. Risk scores definitions: SAPS II, APACHE II, Glasgow 40 SAPS II score 40 SAPS II weights 41 APACHE II score 41 Glasgow Coma Score 43 Other scoring systems 44 Annex 6. List of HAI outcome indicators 45 Annex 7. Structure (...) include registered nurses involved in bedside patient care. Students are not included. A ‘registered nurse’ is a nurse who has graduated from a college’s nursing program or from a school of nursing and has passed a national licensing exam to obtain a nursing license. Also include ‘agency nurses’, ‘bank nurses’, ‘interim nurses’ or other registered nurses who are not permanently employed for that position in the hospital. Total number of nursing assistant hours in ICU over seven day period: total

2017 European Centre for Disease Prevention and Control - Technical Guidance

79. CRACKCast E159 – Inhaled Toxins

**** Clinical features: Similar to cyanide poisoning and anyone with altered mental status (use the DIMES approach!): CNS: AMS, coma, seizures, CV: abnormal vitals, hypotension, arrest Labs: metabolic acidosis But mild symptoms may occur, so should be thought of with anyone with a benign headache syndrome or viral illness or multiple family members. Headache, N/V Dizziness Myalgia Confusion Normal neuro exam, with perceptual changes. Cherry red skin finding is a myth-unless you work in the morgue Lab (...) (and other noble gases) Nitrous oxide (whipping cream cans) These cause acute effects – due to their displacement of O2 – causing hypoxia and ischemia. Symptoms: tachycardia, tachypnea, dyspnea, cerebral hypoxia (ataxia, dizziness, incoordination, confusion, syncope). Lethargy (cerebral edema) occurs as the FIO2 is < 10%. When removed from the environment, symptoms usually resolve. If they persist: ischemic complications are the cause: seizures, coma due to cerebral edema, or cardiac arrest. Diagnosis

2018 CandiEM

80. 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

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