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Cough fracture

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161. Low Back Pain

scoliosis and/or kyphosis); fracture; neoplasm; metabolic bone disease (osteoporosis, osteomalacia, Paget’s disease) For information on this guideline, see the Background statement, Appendix A – Categorization of Recommendations ( ?, X, ?), Appendix B – Evidence Source, Appendix C – Glossary, and Appendix D – Interventions and Practices Considered. Other appendices in this guideline include: Appendix E – Red and Yellow Flags, Appendix F – Medication Table, Appendix G – Injection Therapies, Appendix H (...) Appendix E for red flag definitions). EO (G2a,b) Evaluate for Fracture ? Order AP and lateral plain film imaging for low back pain when compression or other fracture is suspected. Oblique x-rays should not be done in this circumstance. SR (G2c) + EO (GUC) Imaging to Rule Out Underlying Pathology in the Absence of Radiculopathy ? Only order imaging to clarify anatomy where the results will direct treatment. Imaging is typically not useful except for the following indications: ? MRI indications: ? Major

2017 Accelerating Change Transformation Team

162. Chest pain: What are the signs and symptoms of other causes of chest pain?

(inspiration is inhibited by pain on palpation) on examination. There may also be fever (evidence of sepsis) and jaundice (stone in the bile duct or external compression of the biliary ducts). To confirm a diagnosis of cholecystitis, see the scenario in the CKS topic on . Musculoskeletal causes of chest pain include: Rib fracture History — previous history of trauma or coughing. Symptoms — unilateral, sharp chest pain, worse with inspiration. Signs — bruising and tenderness on palpation over the affected

2017 NICE Clinical Knowledge Summaries

163. Joint NASPGHAN and ESPGHAN guidelines on Gastro-oesophageal Reflux Disease in Children

Barrett esophagus Airway Airway Wheezing Stridor Cough Hoarseness Apnea spells Asthma Recurrent pneumonia associated with aspiration Recurrent otitis media BRUE ¼ brief resolved unexplained event; GERD ¼ gastroesophageal re?ux disease. Ifexcessiveirritabilityandpainisthesinglemanifestation,itisunlikely to be related to GERD. y Typical symptoms of GERD in older children. TABLE 2. ‘‘Red ?ag’’ symptoms and signs that suggest disorders other than gastroesophageal re?ux disease Symptoms and signs Remarks (...) and is complicated by the widespread use of Proton Pump Inhibitors (PPIs). Up to 32% of children presenting solely with extraesophageal symptoms have microscopic esophagitis, and up to 8% of children with these symptoms have eosinophilic esophagitis, only presenting with cough or other respiratory symptoms (47–49). Therefore, the main reason for endoscopy in this population with extraesophageal symptoms is to uncover reflux masqueraders such as eosinophilic esophagitis. Endoscopy can also be used to relieve

2018 British Society of Paediatric Gastroenterology Hepatology and Nutrition

165. CRACKCast E080 – Implantable Cardiac Devices

lose power, versus Mercury-Zinc batteries used to have abrupt and catastrophic unit failure due to sudden power loss. Most common cause of failure is with electrical circuitry eg. a) lead disruption or breakage resulting in failure to pace or sense; or B) partial fracture resulting in a “make or break” contact with intermittent failure to sense or pace Leads can be unipolar versus Bipolar Bipolar leads: has negative (distal) and positive (proximal) electrodes, separated by approximately 1 cm (...) , within the heart Compatible with ICD, but more prone to lead fracture. Over-sensing rarely a problem Unipolar lead has negative electrode contacting endocardium & positive pole is the metallic casing of the pulse generator. Smaller diameter and less prone to lead fracture. Not compatible with ICD as prone to over-sensing Pacemakers can be confusing… but remember it is programmed to do a set amount of things. Think of it as the pacemaker is always listening to the atria and ventricles. If it does

2017 CandiEM

166. CRACKCast E075 – Upper Respiratory Tract Infections

? What are the typical pathogens? A healthy sinus – is sterile; with free air exchange and mucous drainage Ostial obstruction leads to sinusitis: Due to: Viral / allergic / ciliary paralysis (smokers) Leads to bacteria introduction by coughing, nose blowing → then overgrowth and infection Other causes of obstruction: Immunocompromised Septal deviation Nasal polyps Tumors Trauma Rhinitis medicamentosa Barotrauma foreign bodies Cocaine abuse NG tubes Pathogens: Pneumoniae Non-typable H.influenzae M (...) . catarrhalis Pseudomonas Strep. Staph. Fungi [9] Describe the management of acute rhinosinusitis and list 6 predisposing factors Risk Factors: immunocompromised status nasal septal deviation and other structural abnormalities nasal polyps tumors trauma and fractures, rhinitis medicamentosa (rebound rhinitis from overuse of decongestants) rhinitis secondary to toxic mucosal exposure barotrauma foreign bodies nasal cocaine abuse instrumentation (including nasogastric and nasotracheal intubation) *Goal

2017 CandiEM

168. CRACKCast E071 – Ophthalmology Part A

– to reduce aqueous humour production – Methazolamide 50mg PO instead of acetazolamide of the patient has sickle cell disease If IOP>30 (emergency)- Constrict pupil (Pilocarpine 4% 1 drop, then repeat in 15 minutes) – Establish an osmotic gradient (Mannitol 2g/kg IV) Decrease IOP (other treatments)- Head of bed at 30 degrees – Anti-emetics for prevention of N/V and prevent coughing – Analgesics Decrease inflammation:- Prednisolone 1% 1 drop q 15 minutes Just to recap: Timolol Pilocarpine Acetazolamide (...) / Brainstem Tumour- N 24) Describe the findings in CN III, IV, and VI palsies + list 2 causes for each Disorders of EOM Report DIPLOPIA LR – 6 (lateral movement) SO – 4 (contralateral down and in) CN 3 all the rest Monocular Less severe Causes Refractive errors Dislocated lens Iridodialysis Feigned Binocular *** Disappears with either eye covered*** Causes: Hematoma Orbital floor fractures Abscess ****#1 cause: palsy of cranial nerve 3,4, or 6*** Usually decreased LOC, focal findings 3rd nerve palsy

2017 CandiEM

169. CRACKCast E123 – Selected Oncologic Emergencies

the mitral valve opens. This represents diastole. This can then be correlated to the RV free wall and seeing whether there is a “dip” which represents collapse of the RV during diastole. This may be hard to visualize, so check out the on this! [10] Describe the presentation and management of hypercalcemia. Presentation Nonspecific presentation Stones – Nephrolithiasis Bones – Bony pain, pathological fracture Abdominal Groans – Anorexia, Consiptation, Abdominal Pain Psychiatric Moans – Altered LOC (...) ., in patients with multiple myeloma) interfere with platelet function. The other symptoms of HVS are due to sludging effects. [15] Describe the clinical presentation of superior vena cava syndrome. Results from external or internal compression of the SVC Upper extremity, chest or face edema or erythema +/- dyspnea, chest pain, cough Physical exam shows elevated venous return pressures – e.g., JVD, cyanosis to upper trunk Can attempt Pemberton’s sign: facial redness caused by elevating the arms above

2017 CandiEM

170. CRACKCast E099 – Urological Disorders

as for ciprofloxacin Trimethoprim-sulfamethoxazole 160/800 mg bid 10–14 days Nausea, vomiting, anorexia, hypersensitivity reactions In places with >10% fluoroquinolone resistance: give 1 g ceftriaxone followed by 10-14 days of an oral cephalosporin Complicated Cefepime 1–2 g every 12 hours Abdominal pain, muscle cramps, nausea, vomiting Ceftriaxone 1 g every 24 hours Fever, cough, sore throat, fatigue Piperacillin-tazobactam 3.375 g every 6 hours Diarrhea, nausea, vomiting, rash Aztreonam 1 g every 8–12 hours (...) Cough, abdominal pain, nausea, vomiting Ciprofloxacin 400 mg every 12 hours GI disturbance, headache, dizziness, tremors, restlessness, confusion, rash, Candida infections Levofloxacin 500 mg every 24 hours Same as for ciprofloxacin [6] What are safe antibiotic options for bacteriuria in pregnancy? How is pyelonephritis managed in pregnancy? A couple key points about the pregnant patient with a UTI: Bacteriuria in pregnancy – gets treated even if the patient is asymptomatic If the patient

2017 CandiEM

171. CRACKCast E022 – Red and Painful Eye

to perceive light V: Visual field testing Confrontational field testing (not accurate for small field cuts) But this rarely changes the ED management E: External examination Of both external eyes and surrounding structures (facial bone fracture, etc.) Globe position: exop/enophthalmos (proptosis) Conjugate gaze Periorbital soft tissues, bones, sensation i. Examination of upper a lower eyelids, including eversion*** Ensure no foreign body ii. Assess adjacent structures E: Extraocular muscle movement Assess (...) penetration Leaking aqueous fluid is detected by diluted fluorescein. The fluorescein strip MUST BE HELD DIRECTLY OVER THE SUSPECTED AREA OF CORNEAL DISRUPTION Ancillary testing: ESR and CRP – may help in cases where temporal arteritis is suspected ○ **however TA can occur with NORMAL levels of ESR and CRP** CT orbits and facial bones to rule out free air, FB’s, fractures, Ultrasound – good at detecting foreign bodies, but CT is better at delineating the damage caused by intraocular foreign bodies 1

2017 CandiEM

173. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians.

) for which important revised regulatory and/or warning information has been released. : A U.S. Food and Drug Administration (FDA) review has found that the growing combined used of opioid medicines with benzodiazepines or other drugs that depress the central nervous system (CNS) has resulted in serious side effects, including slowed or difficult breathing and deaths. FDA is adding Boxed Warnings to the drug labeling of prescription opioid pain and prescription opioid cough medicines and benzodiazepines (...) and searched . Study Selection Two investigators independently reviewed abstracts and full-text articles against prespecified eligibility criteria. The population was adults with nonradicular or radicular low back pain of any duration (categorized as acute [<4 weeks], subacute [4 to 12 weeks], and chronic [≥12 weeks]). Excluded conditions were low back pain due to cancer, infection, inflammatory arthropathy, high-velocity trauma, or fracture; low back pain during pregnancy; and presence of severe

2017 National Guideline Clearinghouse (partial archive)

174. Role of bone-modifying agents in metastatic breast cancer: an American Society of Clinical Oncology-Cancer Care Ontario focused guideline update.

, adjunct therapies, radiotherapy, surgery, systemic anticancer therapy, and referral to supportive care and pain management) Skeletal-related events (SREs) (fracture, radiation, surgery to bone or spinal cord compression, hypercalcemia) Skeletal morbidity rates (SMRs) Pain Analgesic use Adverse events Quality of life Searches of Electronic Databases Guideline Update Process The Update Committee conducted a search of the PubMed database to identify systematic reviews, meta-analyses, and randomized (...) ), the comparisons between dosing the bone-modifying agents (BMAs) every 4 weeks or every 12 weeks showed a similar rate of skeletal complications as measured by proportion of skeletal-related events (SREs) or skeletal morbidity rates (SMRs) between the 4-week and 12-week dosing study arms. SREs are defined as fracture, radiation, or surgery to bone or spinal cord compression. One of the studies also included hypercalcemia as an SRE. SMR is defined as the number of SREs over time. In one study, the most common

2017 National Guideline Clearinghouse (partial archive)

175. Complex regional pain syndrome/reflex sympathetic dystrophy medical treatment guideline.

: Vitamin C Some Evidence Vitamin C 500 mg to 2 grams taken for 50 days after a wrist fracture may help to prevent CRPS (Design: Randomized clinical trial ). Evidence Statements Regarding CRPS-Specific Medications: Ketamine Hydrochloride Some Evidence In CRPS I patients, low dose daily infusions of ketamine can provide pain relief compared to placebo. The relief, however, faded within a few weeks (Design: Randomized clinical trial ). Refer to the Division's for a list of drug classes to address

2017 National Guideline Clearinghouse (partial archive)

177. Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians Full Text available with Trip Pro

Lower BP Targets in Older Adults Studies showed mixed findings for withdrawal due to adverse events. Treatment to lower BP targets increased withdrawals due to adverse events in 4 out of 10 trials (RR, 44% to 100%); cough and hypotension were the most frequently reported adverse events ( , , , , , , , , , ). Low-quality evidence showed an increased risk for syncope associated with treatment to lower BP targets (achieved SBP range, 121.5 to 143 mm Hg) (RR, 1.52 [CI, 1.22 to 2.07]) ( , , ). Low (...) -quality evidence showed no difference in renal outcomes (including end-stage renal disease) for treatment to higher versus lower BP targets ( , , , , , , , , ). Moderate-quality evidence showed no differences between treatment to higher versus lower BP targets in the degree of cognitive decline or dementia ( , , ), fractures ( , ), or quality of life ( , ). Low-quality evidence showed no difference for treatment to higher versus lower BP targets on functional status ( ) or the risk for falls

2017 American College of Physicians

178. Imaging Program Guidelines: Pediatric Imaging

lesions ? osseous assessment of the calvarium, skull base and maxillofacial bones, including detection of calvarial and facial bone fractures Common Diagnostic Indications This section begins with general pediatric indications for CT Head, followed by neurologic signs and symptoms and vascular indications. General Head/Brain Abnormal imaging findings Follow up of abnormal or indeterminate findings on a prior imaging study when required to direct treatment Ataxia, congenital or hereditary Examples (...) is present: ? Non-accidental injury (NAI) ? Trauma associated with any of the following features: ? Altered mental status ? Change in behavior ? Vomiting ? Loss of consciousness ? History of high risk MVA or other mechanism of injury ? Scalp hematoma if less than 2 years of age ? Evidence of basilar skull fracture Note: This indication does not apply to patients with bleeding diathesis or intracranial shunts. Tumor (benign or malignant) ? Diagnosis of suspected tumor when supported by the clinical

2017 AIM Specialty Health

179. Shaken baby syndrome or non-accidental head injury caused by shaking

muscle lesions are an additional sign suggestive of shaking, but are not always present. They are significantly associated with the presence of diffuse cerebral hypoxic-ischaemic lesions. ? Bone lesions: all traumatic injuries may be and should alert (fractures, periosteal appositions and calluses reflecting an old fracture, etc.) to the possibility of non-accidental trauma; some lesions are particularly common in case of abuse, such as rib fractures and metaphyseal corner fractures. These fractures (...) . ? If the diagnosis remains uncertain and in case of spinal fracture, a complete spinal examination (sagittal and axial T1 and T2 sequences) must also be carried out ? Other examinations required: ? full blood count, haematocrit, blood electrolytes, lactate assay, haemostasis assessment (FBC, platelets, PT [prothombin time], aPTT [activated partial thromboplastin time], fibrinogen, Von Willebrand factor [RCo and Ag] FVIII, FIX, FXI), transaminase and lipase assay. ? X-rays of the entire skeleton which should

2017 HAS Guidelines

180. Pharmacological Management of Hypertension

(2017) Increased withdrawals due to adverse events with higher vs. lower BP targets Increased cough, hypotension, and risk for syncope with treating to lower vs. higher BP targets No difference between higher and lower BP targets for renal outcomes, cognitive outcomes, or falls and fractures Adverse Effects Some of the adverse effects associated with antihypertensive medications include (but are not limited to) the following: Thiazide-type diuretics: electrolyte disturbances, gastrointestinal (...) hypotension), ACEIs (adverse effects include cough and hyperkalemia), ARBs (adverse effects include dizziness, cough, and hyperkalemia), CCBs (adverse effects include dizziness, headache, edema, and constipation), and beta-blockers (adverse effects include fatigue and sexual dysfunction). Most of the included studies measured seated BP after 5 minutes of rest and used multiple readings. Clinicians should ensure that they are accurately measuring BP before beginning or changing treatment of hypertension

2017 National Guideline Clearinghouse (partial archive)

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