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101. CRACKCast E041 – Head Injury

= compressed oculomotor nerve CONTRALATERAL: (+) Babinski’s sign (upward going big toe and outward fanning of the other toes) Contra-lateral hemiparesis, then may progress to bilateral decerebrate posturing As the brainstem becomes compressed: agitation > restlessness > confusion > coma > cushing’s reflex > cardiac collapse Describe the presentation of central herniation. Signs: May be subtle LOC changes → bilateral motor weakness → pinpoint pupils → increased muscle tone and bilateral babinski’s (...) 50-160 mmHg ICP effects are greater than mean systemic venous pressures Goals: to maintain MAP and reduce ICP so that CPP can sustain metabolic needs. So in summary: PCo2 = direct relationship with CBF. So, high pco2 higher ICP. PO2 = inverse relationship with CBF MAP = direct ICP = inverse What are the indications for ICP monitoring? From Severe head injury (GCS <9) Moderate head injury (GCS 9-12) who cannot be monitored with serial neurological exams 4) What is the Canadian CT head

2016 CandiEM

102. Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient

(in-service exam committee). Dr. Patterson disclosed family relationships with makers of healthcare products (he is an employee of the University of Nebraska Medical Center) and disclosed non-governmental research grant funding (Co-PI for a Surviving Sepsis in Resource Limited Environment Grant from European Society of Intensive Care Medicine and Hellman Foundation). Dr. Sands disclosed family relationships with makers of healthcare products, for-profit of healthcare services/products, and with providers (...) the ability of neuromuscular blockade to attenuate the rise in ICP and the fall in cerebral perfusion pressure (CPP) that can accompany tracheal suctioning in brain-injured patients with elevated ICP ( , ). In a prospective crossover study of 18 sedated neurosurgical patients (Glasgow Coma Scale score of < 7), vecuronium and atracurium were equally effective in mitigating cough and changes in ICP and CPP during tracheal suctioning ( ). A smaller study found that the combination of opioids and NMBA therapy

2016 Society of Critical Care Medicine

104. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients

with no prior clinical experience could accurately detect the etiology of systolic murmur 93% of the time and of diastolic murmur 75% of the time with BCU. They contrasted this to the physical exam findings of a fellowship trained cardiologist who could only diagnose these lesions 62% and 16% of the time, respectively. Further studies support the use of hand-carried ultrasound (HCU) to evaluate suspected valvular lesions ( , ). However, a few studies have reported inaccuracies of this method ( ). Martin et

2016 Society of Critical Care Medicine

105. Perinatal substance use: maternal

. They are analgesic and can induce euphoria and in high doses– stupor, coma and respiratory depression. Whereas, opioids include alkaloids derived from the opium poppy as well as synthetic drugs interacting with the same receptors in the brain and include oxycodone, heroin and methadone. They are analgesic and produce euphoria. 12 1.3.1 Pregnancy, fetal and neonatal exposure Table 3. Opioid/opiate exposure potential outcomes–pregnancy, fetal and neonatal Aspect Potential outcomes Pregnancy 13-15 • Stillbirth

2016 Queensland Health

106. 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

107. Management of Concussion-mild Traumatic Brain Injury (mTBI)

category of severity, the higher severity level is assigned) Criteria Mild Moderate Severe Structural imaging Normal Normal or abnormal Normal or abnormal Loss of Consciousness (LOC) 0-30 min >30 min and 24 hours Alteration of consciousness/ mental state (AOC)* up to 24 hours >24 hours; severity based on other criteria Posttraumatic amnesia (PTA) 0-1 day >1 and 7 days Glasgow Coma Scale (GCS) (best available score in first 24 hours)** 13-15 9-12 12 weeks post-injury B. Additional Educational Materials (...) criteria obtained during a history and physical exam (see Algorithms for definition). Symptoms associated with mTBI are identified while conducting the history of present illness. The signs and symptoms associated with mTBI are evaluated through physical examination and history and are treated in accordance with this guideline. This recommendation was not reviewed in the recent literature review; however, the strength of this recommendation is strong. The content of the 2009 mTBI CPG was reviewed

2016 VA/DoD Clinical Practice Guidelines

109. Weakness, head trauma, and an abnormal ECG

Weakness, head trauma, and an abnormal ECG Dr. Smith's ECG Blog: Weakness, head trauma, and an abnormal ECG Sunday, May 27, 2018 Written by Pendell Meyers, with edits by Steve Smith A man in his 50s with history of CAD s/p CABG, CHF, and COPD presented after several falls attributed to acute generalized weakness. Several had reportedly resulted in head trauma. There was a normal neurologic exam. Here is his ECG: What do you think? Sinus rhythm at around 60 bpm. There is STD with "down-up" T (...) ++); and 3-CNS catastrophe (ie, stroke, seizure, coma, tumor, trauma, bleed, etc). Ischemia/Infarction/Conduction defects are other common reasons for seeing a long QT/QU — but these entities will usually be suggested by other associated findings on the ECG. When the ONLY thing wrong with an ECG is a long QT/QU — Think Drugs/Lytes/CNS, or some combination of these as the cause. iii) As per Dr. Meyers — this ECG just “looks” like moderate-to-severe hypokalemia — because of the very long QT/QU with ST

2018 Dr Smith's ECG Blog

112. Paediatric trauma protocols

radiation burden. ? An example of a suitable contrast and timings calculator is included (see the Camp Bastion contrast wheel, Appendix 2). ? A hand injection of contrast is appropriate in very small children and babies. ? There are no mechanisms of injury which mandate abdominal CT as an isolated factor. Decisions to perform abdominal CT should be made on the basis of the clinical history and examination. 29 ? Where there is an isolated head injury, a reduced Glasgow Coma Scale (GCS) score should (...) the Manchester Royal Infirmary. BET 4: is physical exam and laboratory data sufficient to exclude intra-abdominal injury in the paediatric trauma patient? Emerg Med J 2012; 29(3): 258–260. 27. Eppich WJ, Zonfrillo MR. Emergency department evaluation and management of blunt abdominal trauma in children. Curr Opin Pediatr 2007; 19(3): 265–269. 28. Taylor GA. Imaging of pediatric blunt abdominal trauma: what have we learned in the past decade? Radiology 1995; 195(3): 600–601. 29. Neish AS, Taylor GA, Lund DP

2014 Royal College of Radiologists

113. Diagnosis and Management of Acute Pulmonary Embolism

embolism. a Low or intermediate clinical probability, or PE unlikely, depending on the studies. ESC Guidelines 3042 Downloaded from by guest on 02 April 2019The incidental discovery of clinically unsuspected PE on CT is an in- creasingly frequent problem, arising in 1–2% of all thoracic CT exam- inations, most often in patients with cancer, but also among those with paroxysmal atrial ?brillation or heart failure and history of atrial

2014 European Society of Cardiology

114. Patient Dignity (Formerly: Patient Modesty): Volume 94

of the patient on the belt (entry into the doctor's office, for example) through to the 10 minute history taking and onward to the exam room with its structural and other attending issues of privacy and then perhaps a procedure with the attending assistants and so forth. The "conveyor belt", as in the NEJM article is there starting up actually even before the patient arrived at the major hospital to "prepare" for the "endpoint". The "belt" is for efficiency and meeting some goals set by the profession (...) to financial aspects of medical care but the other misbehaviors toward their patients. What do you think? ..Maurice. At , Anonymous said... Not much preservation of patient dignity at this facility: REL At , said... This Comment was attempted to be posted today on Volume 86 of course closed to further comments but I thought it was worthy of publishing it here on Volume 94. ..Maurice. At Wednesday

2019 Bioethics Discussion Blog

115. Patient Dignity (Formerly: Patient Modesty): Volume 93

and wasn't bothered by it but this being her 1st job it was notable to her. On the touch issue, I'm fine with handshakes, touching my shoulder, or similar normal social interaction type stuff, but I do want healthcare staff to tell me or ask me as appropriate before they touch me for medical exam purposes. At , said... Biker, elements of human dignity are present and should be aware to the medical staff whether or not the patient is fully under general anesthesia. I can present here an example (...) gynecological procedures on women. Before that time, only midwives examined women intimately. I have this very picture on an article I wrote about . Misty At , Anonymous said... Misty On your site regarding your illustration “ what to expect during a pelvic exam”, it would be beneficial to readers that female patients can additionally request drapes to cover their inner and outer thighs for more privacy. Many more proactive facilitiesare doing just this to enhance the patient experience. Again, thank you

2019 Bioethics Discussion Blog

116. Clinical guidance for responding to suffering in adults with cancer

follow-up care. 8, 13, 43 Understanding the possible emotional and spiritual responses that patients may have at different stages of cancer can help healthcare professionals anticipate when individual patients are likely to need more support. 9 For exam- ple, studies have shown that acknowledging a terminal prognosis earlier rather than later ultimately contributes to relief of suffering. 4 The recognition of death can offer a shift in perspective from small concerns to a deep appre- ciation of life

2014 Cancer Australia

117. Delirium

oximetry — to identify fever, hypoperfusion, hyperglycaemia, hypoglycaemia, or hypoxia. Carry out a general examination to identify such as: Respiratory conditions, for example chest infection, pulmonary embolus, heart failure, or chronic obstructive pulmonary disease. Cardiovascular conditions, for example myocardial infarction and heart failure. Abdominal conditions, for example acute abdomen, constipation, faecal loading (carry out a rectal exam if possible if impaction is suspected), urinary

2017 NICE Clinical Knowledge Summaries

119. Cervical Spine Collar Clearance in the Obtunded Adult Blunt Trauma Patient

reassessment, cervical collar complication (e.g., pressure ulcer), and time to cervical collar clearance. The term obtunded required an operationalized definition using the terms Glasgow Coma Scale , altered , intoxicated , intubated , unconscious , and/or u nreliable exam . Unstable injuries were identified primarily using the system delineated by White and Punjabi and the three-column model of Denis. [9–11] C-spine instability required either a fracture or fractures involving contiguous columns or levels (...) Eligibility Our PICO question and protocol were registered with the PROSPERO international prospective register of systematic reviews [7][8] on August 23, 2013 (Registration Number: CRD42013005461) and last revised on June 18, 2014. Inclusion criteria consisted of adult blunt trauma patients 16 years or older, who underwent C-spine CT with axial thickness of less than 3 mm and who were obtunded with any author-specified definition of this term (Glasgow Coma Scale [GCS] score < 15, unconscious, intubated

2015 Eastern Association for the Surgery of Trauma

120. Management of Orthopaedic Trauma

tissue damage within six hours of impaired perfusion.  Caution regarding the estimation of elapsed time is important, as the time of precise onset is often uncertain. z Compartment syndrome is a dynamic process and, in patients with high-risk injuries, an evaluation should occur every one to two hours for a 24 to 48 hour period.  Sequential physical examinations should be performed for individuals at risk for compartment syndrome, as a single exam at one point in time is unreliable. z The most (...) clinical exam may benefit from measurement of intracompartmental pressures. A gradient of 48 hours after admission are reviewed by the trauma PIPS or equivalent committee in the hospital, unless a specific contraindication is documented in the medical record. Geriatric Hip Fractures z All geriatric (=65 years of age) patients with hip fractures and multiple co-morbidities are evaluated by a multidisciplinary team, including, at minimum, personnel with expertise in the care of the geriatric patients. z

2015 American College of Surgeons

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