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Coma Exam

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81. Tide Pod Challenge: Managing caustic laundry pod ingestions

tract injury, with or without clinically obvious signs. 4 A of pediatric laundry pod ingestion cases found that common clinical features included vomiting (56%), coughing or choking (14.6%), drowsiness or lethargy (7.8%) and nausea (4.9%). Severe symptoms included seizures, respiratory arrest, gastric burns, and coma. The differential for laundry pod ingestion is broad, as patients can have increased or decreased temperature and respiratory rate. Common causes on the differentials (...) for these presentations should be explored when reasonable. History should focus on what was specifically ingested by the patient, time since ingestion, whether actions were intentional or unintentional, and whether there were other co-ingestants (e.g. salicylate and acetaminophen in suicide attempts). Physical exam should start by looking for signs of respiratory distress and circulatory shock first. After patients have been deemed stable, the clinician should looks for signs of pharyngeal injury (mucosal burns

2018 CandiEM

82. CRACKCast E144 – High Altitude Medicine

mentation Worsening AMS over hours to days. Consider the ddx. HAPE Insidious onset 2-4 days after arrival at high altitude (but can come on rapidly) Marked dyspnea on exertion, fatigue with minimal-to-moderate effort, prolonged recovery time, and dry cough Cough may become productive; may develop blood Can rapidly progress to hypoxemia, CNS dysfunction, coma and death Exam = tachypnea, tachycardia, rales (patchy), rhonchi, gurgles, cyanosis ● Dyspnea at rest ● Dry cough ● Concurrent AMS symptoms (...) and on awakening or on suddenly becoming upright. HACE ● The symptoms of severe AMS (headache, fatigue, and vomiting) as well as those of HAPE (cough and dyspnea) are often present. ● A taxia, slurred speech, and altered mental status, which can range from mild emotional lability or confusion, to hallucinations and worsening obtundation that may advance to coma and death. Less commonly, generalized seizures and rarely, focal neurologic deficits may occur. Evidence of CNS dysfunction: ● Ataxia ● Altered

2018 CandiEM

83. CRACKCast E145 – Drowning

) Additional workup: ABG Labs with renal function ECG (QTC!) CXR (with repeat testing in a few hours if signs of pulmonary involvement on exam or vital signs) Consider getting that CT head (and maybe Cspine) if the patient is stable to look for any pre-existing bleed, trauma, or cerebral edema (this may help our ICU colleagues prognosticate in 24 hrs) Victims with CNS injury may present with symptoms ranging from mild lethargy to coma with fixed and dilated pupils. CNS injury results from the initial (...) support is essential to optimize the victim’s chance of a favorable outcome from this hypoxic event. Electroencephalography may be indicated in obtunded drowning victims to assess for subclinical seizures. No prognostic scale or clinical presentation accurately predicts long-term neurologic outcome; normal neurologic recovery is documented in patients with prolonged submersions, persistent coma, cardiovascular instability, and fixed and dilated pupils. Hyperventilation, steroids, dehydration

2018 CandiEM

84. Appropriate Use Criteria: Imaging of the Head & Neck

sinus for headache ¾ MRI brain and MRA brain for headache ¾ MRI cervical spine and MRI shoulder for pain indications ¾ MRI lumbar spine and MRI hip for pain indications ¾ MRI or CT of multiple spine levels for pain or radicular indications ¾ MRI foot and MRI ankle for pain indications ¾ Bilateral exams, particularly comparison studies There are certain clinical scenarios where simultaneous ordering of multiple imaging studies is consistent with current literature and/or standards of medical practice (...) the guidelines for specific imaging exams is a determination that the following are true with respect to the imaging request: ? A clinical evaluation has been performed prior to the imaging request (which should include a complete history and physical exam and review of results from relevant laboratory studies, prior imaging and supplementary testing) to identify suspected or established diseases or conditions. ? For suspected diseases or conditions: ? Based on the clinical evaluation, there is a reasonable

2018 AIM Specialty Health

85. Practice Guideline Update Systematic Review Summary: Disorders of Consciousness

, University of Rochester Medical Center, Rochester, NY 8. Indiana University Department of Physical Medicine & Rehabilitation, University of Indiana School of Medicine, Indianapolis, IN 9. Coma Science Group - GIGA Research and Department of Neurology, Sart Tillman Liège University & University Hospital, Liège, Belgium 10. Department Neurology, Uniformed Services University of Health Sciences, Bethesda, MD; Department of Neurology, Johns Hopkins University, Baltimore, MD 11. James A. Haley Veterans (...) Medical Inc. and Enspire DBS, Inc. (Cleveland, Ohio); is listed as inventor for multiple patents held by Cornell University; receives royalties for Plum and Posner’s Stupor and Coma, Oxford University Press; and holds 0.25% stock option in Enspire DBS, Inc (no current value). J. Whyte served on a scientific advisory board for INTRuST; received funding for travel and honoraria from several noncommercial institutions for academic lectures; performs diagnostic behavioral assessments of patients with DoC

2018 American Academy of Neurology

86. When and how to treat hyponatremia in the ED

”. No further details are available. Her medications include L-thyroxine, a statin and a thiazide diuretic. Vitals are normal. On exam, Marjorie is weak and is unable to sit up without assistance. Strength testing reveals bilateral weakness in the arms and legs. A walk test is not attempted. No focal neurological deficits are noted. Cardiac, respiratory, and abdominal exams are normal. Investigations are ordered and results reviewed. Electrolytes : sodium 110 mmol/L , potassium 3.4 mmol/L, chloride 76 mmol (...) be classified as acute (having developed over <48 hours) or chronic. 1 However, although there is some correlation between duration and severity, recent treatment algorithms classify hyponatremia by severity of symptoms. which more appropriately guides treatment in most cases 4 (see Treatment below). Severe : cardiorespiratory arrest, seizures, coma, deep somnolence Moderate : nausea, confusion, headache, vomiting In adults, the most common causes of hyponatremia include thiazide use, SIADH, primary

2018 CandiEM

87. Imaging Guidelines

for pneumothorax and hemothorax. 1 Extremity radiographs remain an important secondary adjunct for diagnosis of extremity orthopaedic injury. A best practice is interpretation of all radiographs concurrent with the trauma evaluation to facilitate timely treatment interventions. Computed Tomography Imaging Multi-detector computed tomographic (MDCT) imaging is now well established as the imaging modality of choice in hemodynamically stable patients following the secondary survey exam. Oral contrast (...) imaging technology continues to rapidly evolve. Trauma centers and referring facilities need to continuously re-evaluate their protocols and capability to ensure imaging technology meets their needs. A radiologist liaison for Table 1. Components of Enhanced Radiologic Reports for Trauma Injuries Element Description Clinical history Mechanism of injury Glasgow Coma Scale score, if applicable Abnormal physical and clinical findings, any deformities Specific clinical questions or concerns Relevant

2018 American College of Surgeons

88. Continuous glucose monitoring (CGM real-time) and flash glucose monitoring (FGM) as personal, standalone systems in patients with diabetes mellitus treated with insulin

of the heart and arteries in the limbs). All cases of acute cardiovascular disease, diabetic coma, kidney failure, and infected foot ulcers should be managed in a hospital. Patient education is an important component of diabetes management since the effectiveness of diabetes management ultimately depends on patient compliance with recommendations and treat- ment [16]. National guidelines and management protocols developed for (or adapted to) individual settings are useful tools in achieving a standardized (...) and consistent management approach. They should cover these basic principles of diabetes management [16]: • Interventions to promote and support healthy lifestyles, including healthy diet, physical activity, avoidance of tobacco use, and harmful use of alcohol. • Medication for blood glucose control – insulin or oral hypo-glycaemic agents as required. • Medication to control cardiovascular disease risk. • Regular exams for early detection of complications: comprehensive eye examination, measurement of urine

2018 EUnetHTA

89. CRACKCast E103 – Headache Disorders

, 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 (...) for Cerebral Aneurysms and SAH Grade 0 = Unruputured aneurysm Grade 1 = Asymptomatic or minimal headache and slight nuchal rigidity Grade 2 = Moderate or severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy Grade 3 = Drowsiness, confusion, or mild focal deficit Grade 4 = Stupor, moderate to severe hemiparesis Grade 5 = Deep coma, decerebrate posturing, moribund appearance Prognosis 1-2 = good px 3 = risk for rapid deterioration 4-5 = poor px 10) Describe a diagnostic

2017 CandiEM

90. Near Infrared Spectroscopy for Detecting Brain Hematoma

are unknown and patients cannot provide additional history or participate in the physical exam due to pre-existing dementia or other cognitive disorders. Mild head injury management guidelines commonly recommend head computed tomography (CT) for all patients ≥ 65 years old. However, most patients with mild head injuries who undergo head CT have normal findings, raising concern about the overuse of head CT and implications for patient safety due to radiation exposure. Near infrared spectroscopy (NIRS (...) characteristics such as age, risk factors for intracranial hemorrhage, including use of anticoagulants, and degree of injury after falls including GCS (Glasgow Coma Scale) scores; Ensure blinding of radiologists reading CTs to NIRS results; and Include only completed NIRS scans in results, thereby limiting the potential for over-reporting of false negatives. Note The Office of Community Engagement's Center for Compassionate Innovation (CCI) requested this evidence brief on the use of NIRS to evaluate patients

2017 Veterans Affairs - R&D

91. CRACKCast E123 – Selected Oncologic Emergencies

exam including anorectal area, indwelling lines, head/neck area for sinusitis [4] What are high risk and low risk criteria for febrile neutropenia? Scoring systems MASCC or CISNE scoring systems A recent retrospective cohort study by ) showed CISNE has higher specificity for identifying low risk patients who can be managed with oral antibiotics and close f/u within 2-3 days to recheck fever and neutrophil count (98% vs 54% specificity) MASCC CISNE Symptom severity / burden of illness Hypotension BP (...) ) Acute Lymphocytic Leukemia 2) CNS tumors 3) Other cancer patients receiving high dose corticosteroids Therefore, a patient with febrile neutropenia in true septic shock in a coma with a distended abdomen should receive a regimen like Meropenem, Vancomycin, Ciprofloxacin, Acyclovir +/- Metronidazole. Would definitely want your ID consultants involved in a (rare) case like this! N.B., the above recommendations are a compilation of the IDSA 2010 Guidelines, the BC Cancer Agency Guidelines, Rosen’s 9th

2017 CandiEM

92. 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

93. 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

95. Post-Resuscitation Therapy in Adult Advanced Life Support

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 (...) for transport to a specialist cardiac arrest center as part of wider regional system of care for management of patients with OHCA. Prognostication and cardiac arrest 22. Relying on the neurologic exam during or immediately after cardiac arrest to predict outcome is not recommended and should not be used. Prognostication with TTM 23. ANZCOR suggest against the use of clinical criteria alone before 72 hours after ROSC to estimate prognosis. ANZCOR Guideline 11.7 January 2016 Page 3 of 17 24. ANZCOR suggests

2016 Australian Resuscitation Council

96. 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

97. Management of Toxicities from Immunotherapy: ESMO Clinical Practice Guidelines

diseases, baseline laboratory tests and radiological exams (Supplementary Table S1, available at Annals ofOncology online) [mostly computed tomography (CT) scans of the chest, abdomen/pelvis and often brain magnetic resonance imaging (MRI)]. Patients with a history of autoimmune disease, or who are being actively treated for an autoimmune disease, are at risk for worsening of their autoimmune disease while on im- mune checkpoint blockade [16]. Similarly, patients that have had irAEs on ipilimumab

2017 European Society for Medical Oncology

98. CRACKCast E044 – Neck Trauma

or weak pulse Shock Diagnostic strategies Key debate is whether physical exam is sensitive enough to diagnose significant injury Thought to be able to identify vascular and esophageal injuries Use hard and soft signs as a guide Soft signs present indicate that surgical repair is less likely needed 3) Describe an approach to managing acute neck trauma in the ER Management: Stable patients Transport to trauma centre Basic wound compression and occlusion (to prevent air embolus) Neurologic deficits (...) is needed – as physical exam will miss injuries. The absence of hard AND soft signs of neck trauma Blunt trauma: ½ of patients with dissections are asymptomatic Delayed presentation presents at TIA/Cerebral ischemia – ⅓ present after 24 hrs These are some of the most under-reported injuries due to their insidious presentation and catastrophic neurologic outcome Horner’s syndrome Symptoms: Carotid artery = contralateral sensory/motor deficits Vertebral arteries = ataxia, emesis, visual field defects

2016 CandiEM

99. CRACKCast E009 – Adult Resuscitation

pneumothorax treat anaphylaxis control the airway Brain arrest / Cognitive arrest You show up to a code or patient is wheeled in who is comatose, but breathing and a pulse… (more in Episode 17 – Coma) Bottom line you think of something affecting both hemispheres using an approach like DIMS: Drugs Infection Metabolic Structural Approach this similarly to the post-ROSC patient and you won’t miss much. 3) Describe your approach to the post-cardiac arrest patient One great approach to the post arrest patient (...) is from Dr. David Sweet (Emergency Physician/ Intensivist at Vancouver General Hospital) His memory aid for the post arrest patient is: 1:2:2:3 1: one full set of vitals including glucose 2: two machines that you should call for ASAP – ECG and CXR 2: two bloods: full cardiac labs (CBC, troponin, lytes etc.) and an ABG 3: three basics: take a history, do a physical exam, and look at the old charts 4) Sleuthing out why the patient arrested: an approach to the history and physical History family

2016 CandiEM

100. CRACKCast E010 – Pediatric Resuscitation

normal at the time of ED presentation (50% of the time) but any non-hospital person who witnessed choking or cyanosis should be taken seriously ED evaluation depends on hx and physical exam investigations +/-: CBC, glucose, lytes, urine/blood cultures tox screen, ECG +-CT, CXR, children < 60 days should undergo thorough screening for infection with//without pediatrics assessment EMRAP Claudius and Keens suggests kids <1 month be admitted outcome: variable depending on etiology one retrospective (...) avoid the insult that caused asphyxia or ischemia gates around swimming pools, seat belts recognize and treat shock early 2) no flow untreated cardiac arrest: recognize ASAP 3) low flow (aka CPR phase) do CPR 4) post-resuscitation: complex number of factors involved post arrest brain injury coma, seizures, myoclonus, spectrum: full function–> brain death probably best to keep temp <36 degrees (based on adult studies in post VF arrests) and prevent fever post arrest myocardial dysfunction consider

2016 CandiEM

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