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Decontamination in Children

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161. Toxicity, Mushroom (Follow-up)

and renal toxic syndromes. Gut decontamination, including whole-bowel irrigation, may be necessary for amatoxins. Beyond the first postprandial hour, orogastric lavage is not recommended, because of its questionable efficacy. Activated charcoal plays a much more important role in limiting absorption of most toxins and is indicated for all patients with amatoxin mushroom poisoning, regardless of the timing of presentation. When amatoxins are suspected, multiple doses of activated charcoal should (...) be administered repeatedly to interrupt enterohepatic circulation of these toxins. In general, children are more susceptible to volume depletion and mushroom toxicity (mushroom poisoning) than are healthy adults. Elderly patients are more susceptible to volume depletion than are healthy adults. Next: Supportive Measures Once a toxin is absorbed, it may potentially be neutralized in the following ways: Inhibition of tissue uptake of the toxin Inhibition of the metabolic pathways involved in the development

2014 eMedicine.com

163. Cryptosporidiosis (Follow-up)

of diarrhea and can decrease the risk of mortality in malnourished children. [ ] Trials have also demonstrated efficacy in adults. [ , ] Trials of antiparasitic drugs in patients with AIDS and cryptosporidiosis have been disappointing. Nitazoxanide, paromomycin, and azithromycin are partially active. Combination antiretroviral therapy that includes an HIV protease inhibitor is associated with dramatic improvement in many cases. [ , ] Improvement is likely to result from immune reconstitution but may (...) effect on the oocysts, water purification should involve flocculation and filtration (using filters with a pore size of 1-4 μm). Ultraviolet radiation and ozonization are other means of disinfecting contaminated water. Decontamination can also be achieved by bringing water to a boil. Prompt, aggressive measures, including temporary closure of pools, must be carried out in cases of suspected fecal contamination of recreational water. People with diarrhea should not use recreational water, and those

2014 eMedicine.com

164. The Role of Antibiotics in Cutaneous Surgery (Diagnosis)

arthroplasty. [ ] Importantly, note that even with a mupirocin decontamination protocol, the rates of colonization clearance are not 100%. A double-blinded, placebo-controlled trial performed by Harbarth et al demonstrated MRSA eradication at only 44% among the treatment group. [ ] An additional concern is the emergence of strains of S aureus resistant to some of the agents used for decolonization. Resistance to mupirocin has been seen, although rates remain relatively low. Low-level resistance (...) infection. Those at increased risk for MRSA infection include athletes, military personnel, prison inmates, men who have sex with men, intravenous drug users, homeless persons, children in daycare, Native Americans, and Pacific Islanders. Antibiotic coverage should include activity against MRSA. First-line treatment should be trimethoprim-sulfamethoxazole or a tetracycline antibiotic. Inducible lincosamide resistance is becoming more common; therefore, clindamycin should be considered a second-line

2014 eMedicine.com

165. MRSA Skin Infection in Athletes (Diagnosis)

, and sharing of personal items. [ ] Populations reportedly at risk for CA-MRSA outbreaks specifically include military recruits, children in day care, prison inmates, homosexual men, injection drug users, and veterinarians, particularly those who have contact with swine. [ , , ] A study by Jiménez-Truque et al assessed colonization of S. aureus in 377 athletes and trainers and reported that the prevalence ranged from 34% to 62%, and 8% to 29% for MRSA. The study also reported a significantly higher (...) , which may result in cross-resistance to clindamycin Doxycycline: Administer 100 mg PO twice daily; this agent is not recommended for children younger than 8 years Linezolid: Administer 600 mg PO twice daily; note that cost often prohibits the use of this agent Note that ciprofloxacin has a 33% sensitivity in some areas. Therefore, this drug is not recommended due to resistance and reports of clinical failures despite in vitro susceptibility. The susceptibility of CA-MRSA is dependent on local

2014 eMedicine.com

166. Digitalis Toxicity (Diagnosis)

tachycardia with heart block and bidirectional ventricular tachycardia are particularly characteristic of severe digitalis toxicity See for more detail. Management Supportive care of digitalis toxicity includes the following: Hydration with IV fluids Oxygenation and support of ventilatory function Discontinuation of the drug, and, sometimes, the correction of electrolyte imbalances GI decontamination Activated charcoal is indicated for acute overdose or accidental ingestion Binding resins (eg (...) the first-line treatment for significant dysrhythmias from digitalis toxicity. Other indications for its use, in the absence of specific contraindications, include the following: Ingestion of massive quantities of digitalis (in children, 4 mg or 0.1 mg/kg; in adults, 10 mg) Serum digoxin level greater than 10 ng/mL in adults at steady state (ie, 6-8 hours after acute ingestion or at baseline in chronic toxicity) Hyperkalemia (serum potassium level greater than 5 mEq/L) Altered mental status attributed

2014 eMedicine.com

167. Viral Hemorrhagic Fevers (Diagnosis)

-ravaged regions. [ ] In the recent Ebola virus disease outbreak in Sierra Leone, it was found that chest pain, symptoms of confusion, coma and viral load greater than 10 6 copies/mL were significantly associated with a poor prognosis. Viral load was the most important factor that affected the survival of patients from the disease. [ ] A total of 278 human cases were confirmed with Rift Valley fever in the recent outbreak in South Africa in 2010-2011, with 25 deaths. Children can develop dengue (...) the detrimental effects of nosocomial transmission and about how such spread can be prevented by implementing infectious disease safety and contact precautions, such as the following: Equipment sterilization Isolation of individuals who are infected Barrier nursing Educate health care workers and others about decontamination procedures, such as the use of hypochlorite or phenolic disinfectants. For patient education resources, see the , as well as . Previous References Racsa LD, Kraft CS, Olinger GG, Hensley

2014 eMedicine.com

168. Brucellosis (Follow-up)

; resistance is not a significant issue in treating brucellosis. [ ] Depending on what other systems are involved, more specialized care may be needed. Transfer to another facility depends on the needs of the patient. Because most patients do not require highly specialized interventions, the need to transfer should not be frequent. Personnel involved in the transfer should maintain respiratory and contact precautions, and the vehicle should be decontaminated after transport as needed. Next: Initial (...) Supportive Care Given that the symptoms generally are vague and the presentation is rarely life-threatening, emergency medical service (EMS) care should focus on stabilization, as needed, and transport. As in the care of any patient with a potentially transmissible disease, appropriate precautions (eg, gloves, mask, and gown) should be used. If a proximate bioterrorist attack is known or strongly suggested at the time of patient contact, appropriate decontamination is warranted. In the event of a covert

2014 eMedicine.com

169. Brucellosis (Follow-up)

; resistance is not a significant issue in treating brucellosis. [ ] Depending on what other systems are involved, more specialized care may be needed. Transfer to another facility depends on the needs of the patient. Because most patients do not require highly specialized interventions, the need to transfer should not be frequent. Personnel involved in the transfer should maintain respiratory and contact precautions, and the vehicle should be decontaminated after transport as needed. Next: Initial (...) Supportive Care Given that the symptoms generally are vague and the presentation is rarely life-threatening, emergency medical service (EMS) care should focus on stabilization, as needed, and transport. As in the care of any patient with a potentially transmissible disease, appropriate precautions (eg, gloves, mask, and gown) should be used. If a proximate bioterrorist attack is known or strongly suggested at the time of patient contact, appropriate decontamination is warranted. In the event of a covert

2014 eMedicine.com

170. Bronchiolitis (Follow-up)

relief but has been associated with longer hospitalization Nebulized hypertonic (3%) saline may improve symptoms of bronchiolitis when length of stay is expected to exceed 3 days Palivizumab prophylaxis should only be administered to selected children (se below) Hand decontamination is indicated to prevent nosocomial spread Infants should not be exposed to passive smoking, and clinicians should inquire about parental smoking and encourage cessation. Breastfeeding is recommended Clinicians should (...) of bronchiolitis, at present, only oxygen appreciably improves the condition of young children with bronchiolitis and many other medical therapies remain controversial. [ ] Bronchodilator therapy to relax bronchial smooth muscle, though commonly used, is not supported as routine practice by convincing evidence. If bronchodilator therapy is started, it may be continued in selected patients who demonstrate clinical improvement. Despite the prominent role that inflammation plays in the pathogenesis of airway

2014 eMedicine.com

171. Meningitis (Diagnosis)

of meningitis. In addition, it is the most common bacterial agent in meningitis associated with basilar skull fracture and CSF leak. It may be associated with other focal infections, such as pneumonia, sinusitis, or endocarditis (as, for example, in Austrian syndrome, which is the triad of pneumococcal meningitis, endocarditis, and pneumonia). S pneumoniae is a common colonizer of the human nasopharynx; it is present in 5-10% of healthy adults and 20-40% of healthy children. It causes meningitis by escaping (...) in epidemics (< 3% of cases). Currently, N meningitidis is the leading cause of bacterial meningitis in children and young adults, accounting for 59% of cases. Risk factors for meningococcal meningitis include the following: Deficiencies in terminal complement components (eg, membrane attack complex, C5-C9), which increases attack rates but is associated with surprisingly lower mortality rates Properdin defects that increase the risk of invasive disease Antecedent viral infection, chronic medical illness

2014 eMedicine.com

172. Lice (Diagnosis)

things with a fine-tooth comb" are part of everyday vocabulary. Louse infestation remains a major problem throughout the world, making the diagnosis and treatment of louse infestation a common task in general medical practice. [ ] Pediculosis capitis results in significant psychological stress in children and adults and missed schooldays in children, particularly in areas with a no-nit policy. [ ] Lice are ectoparasites that live on the body. Lice feed on human blood after piercing the skin (...) are spread by sitting on a toilet seat; pubic lice’s feet are not designed to walk on smooth surfaces such a toilet seats, and the lice cannot live for long away from a warm human body. [ ] Because these organisms are most often spread through close or intimate contact, P pubis infestation is classified as an STD. Condom use does not prevent transmission of P pubis . Upon diagnosis of pubic lice, concern should be raised about the possibility of concomitant STDs. In children, infestation of pubic lice

2014 eMedicine.com

173. Chemotherapy-Induced Oral Mucositis (Diagnosis)

): Scores functional elements only See for more detail. Management The five main approaches to managing oral mucositis are as follows: Oral debridement (eg, brushing, toothettes); mucolytic agents, such as Alkalol, help dislodge dried secretions Oral decontamination, including antibacterial and antifungal rinses Topical and systemic pain management, such as 2% viscous lidocaine, magic mouthwash preparations, and topical morphine solution may be considered [ , ] Prophylaxis, such as ice-chip cryotherapy (...) % of patients who receive myeloablative conditioning regimens (chemotherapy with or without total body irradiation) in preparation for HCT develop oral mucositis; the incidence may be even higher in children. [ ] The incidence is also higher in patients who receive continuous infusion therapy for breast and colon cancer and in those who receive adjuvant therapy for head and neck tumors. However, in patients of the same age with similar diagnoses and treatment regimens and equivalent oral health status

2014 eMedicine.com

174. The Role of Antibiotics in Cutaneous Surgery (Treatment)

arthroplasty. [ ] Importantly, note that even with a mupirocin decontamination protocol, the rates of colonization clearance are not 100%. A double-blinded, placebo-controlled trial performed by Harbarth et al demonstrated MRSA eradication at only 44% among the treatment group. [ ] An additional concern is the emergence of strains of S aureus resistant to some of the agents used for decolonization. Resistance to mupirocin has been seen, although rates remain relatively low. Low-level resistance (...) infection. Those at increased risk for MRSA infection include athletes, military personnel, prison inmates, men who have sex with men, intravenous drug users, homeless persons, children in daycare, Native Americans, and Pacific Islanders. Antibiotic coverage should include activity against MRSA. First-line treatment should be trimethoprim-sulfamethoxazole or a tetracycline antibiotic. Inducible lincosamide resistance is becoming more common; therefore, clindamycin should be considered a second-line

2014 eMedicine.com

176. Brucellosis (Treatment)

; resistance is not a significant issue in treating brucellosis. [ ] Depending on what other systems are involved, more specialized care may be needed. Transfer to another facility depends on the needs of the patient. Because most patients do not require highly specialized interventions, the need to transfer should not be frequent. Personnel involved in the transfer should maintain respiratory and contact precautions, and the vehicle should be decontaminated after transport as needed. Next: Initial (...) Supportive Care Given that the symptoms generally are vague and the presentation is rarely life-threatening, emergency medical service (EMS) care should focus on stabilization, as needed, and transport. As in the care of any patient with a potentially transmissible disease, appropriate precautions (eg, gloves, mask, and gown) should be used. If a proximate bioterrorist attack is known or strongly suggested at the time of patient contact, appropriate decontamination is warranted. In the event of a covert

2014 eMedicine.com

177. Burn Wound Infections (Treatment)

the rate of burn wound infections, although it does not affect mortality. [ ] In nonsurgical patients, systemic antibiotic prophylaxis does not affect the incidence of burn wound infection or sepsis. [ ] Treatment of airway colonization is not recommended, as local airway antibiotic prophylaxis does not influence sepsis or mortality rates. [ ] Furthermore, selective decontamination of the digestive tract with nonabsorbable antibiotics plus cefotaxime significantly increases the risk of MRSA infection (...) injury, decreased healing time and hospital length of stay was noted. [ ] A meta-analysis in the use of recombinant growth hormone (rhGH) in burn patients could not find any study reporting burn wound infection as an outcome. It was observed that, among both children and adults with burns larger than 40% TBSA, rhGH hastened burn wound healing and reduced length of hospital stay. An increased risk for hyperglycemia was observed; nonetheless, rhGH treatment did not affect mortality. [ ] Patients

2014 eMedicine.com

178. Cryptosporidiosis (Treatment)

of diarrhea and can decrease the risk of mortality in malnourished children. [ ] Trials have also demonstrated efficacy in adults. [ , ] Trials of antiparasitic drugs in patients with AIDS and cryptosporidiosis have been disappointing. Nitazoxanide, paromomycin, and azithromycin are partially active. Combination antiretroviral therapy that includes an HIV protease inhibitor is associated with dramatic improvement in many cases. [ , ] Improvement is likely to result from immune reconstitution but may (...) effect on the oocysts, water purification should involve flocculation and filtration (using filters with a pore size of 1-4 μm). Ultraviolet radiation and ozonization are other means of disinfecting contaminated water. Decontamination can also be achieved by bringing water to a boil. Prompt, aggressive measures, including temporary closure of pools, must be carried out in cases of suspected fecal contamination of recreational water. People with diarrhea should not use recreational water, and those

2014 eMedicine.com

179. Anthrax (Treatment)

IgG1 kappa monoclonal antibody. [ ] Human anthrax immune globulin (Anthrasil) is indicated for treatment of inhalational anthrax in adults and children in combination with antibiotic therapy. [ ] The indication for anthrax vaccine adsorbed (BioThrax) was expanded in November 2015 to include postexposure use following suspected or confirmed B anthracis exposure in combination with antimicrobial therapy. It was originally approved for pre-exposure prophylaxis in high-risk individuals (...) outlined as recommended by the CDC, IDSA, and AAP (see table below). Table 3. CDC Expert Panel Recommendations for Treatment of Cutaneous Anthrax Nonpregnant adults Pregnant/lactating women Children Recommended therapy [ ] : Treatment duration, 7-10 days Ciprofloxacin 500 mg every 12 hours Ciprofloxacin 500 mg every 12 hours Ciprofloxacin 30 mg/kg/day divided every 12 hours (max dose, 500 mg/dose) Doxycycline 100 mg every 12 hours Amoxicillin 75 mg/kg/day divided every 8 hours (max dose, 1 g/dose

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2014 eMedicine.com

180. Burns, Chemical (Treatment)

, then this should be started immediately. Immediate removal of caustic substances in the eye is critical. [ ] Next: Emergency Department Care The first priority in treatment is to ensure complete removal of the offending agent. Thorough decontamination is key. Adequate irrigation is difficult to define and depends on the amount of exposure and the agent involved. Using litmus paper to measure the pH of the affected area or the irrigating solution is helpful. Complete removal and neutralization of concentrated (...) burns require the same fluid therapy as that for thermal burns. [ ] See . After initial decontamination, the full extent of the injury must be ascertained and the patient must be treated as a typical burn patient. Based on the degree of injury, ensure adequate fluid resuscitation and take precautions to prevent complications (eg, hypothermia, infection, rhabdomyolysis). Special situations Elemental metals The elemental forms of lithium, potassium, sodium, and magnesium react with water

2014 eMedicine.com

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