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Defensive Medicine

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5021. Pneumonia, Aspiration (Follow-up)

Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. Paul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, Maricopa Medical Center Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: , , , Disclosure: Nothing to disclose. Chief Editor Guy W Soo (...) ; they are considered a high-risk group. While likely acknowledged, the importance of the swallowing disorder is not well appreciated. Speech therapy can provide some amelioration of risk and is also under used in these patients. Conditions associated with altered or reduced consciousness, including any condition that reduces a patient's gag reflex, ability to maintain an airway, or both, increase the risk of aspiration pneumonia or pneumonitis. Such conditions are as follows: Alcoholism Drug overdose Seizures

2014 eMedicine Emergency Medicine

5022. Personality Disorders (Follow-up)

. The physician need not fear instilling the idea of suicide in a patient who is not already entertaining it. Subsequent inquiry about firearms, lethal medications, and other available means of suicide point to avenues of preventive behavior. [ ] Benzodiazepines, narcotic analgesics, and other drugs with potential for dependency should be used rarely and with great caution. Nearly all personality disorders are marked by impaired impulse control and consequent risk of addictive behavior. Patients (...) of Medicine David Bienenfeld, MD is a member of the following medical societies: , , Disclosure: Nothing to disclose. Chief Editor Iqbal Ahmed, MBBS, FRCPsych(UK) Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine Iqbal Ahmed, MBBS, FRCPsych(UK) is a member of the following

2014 eMedicine Emergency Medicine

5023. Periorbital Infections (Follow-up)

, [ ] or levofloxacin [ ] should be prescribed. The frequency and duration of treatment should be determined based on the severity of the disease process. [ ] Usually, the topical antibiotic is applied 2-4 times daily for 2 weeks. [ ] Posterior blepharitis may be treated with an oral tetracycline; this medication decreases lipase production in staphylococci, preventing plugging of Meibomian glands. Such therapy is limited to patients older than 8 years due to the risk of tooth enamel discoloration. [ ] Alternative (...) and erythema. Acute dacryocystitis. Upper eyelid anatomy. Lower eyelid anatomy. Eye and lacrimal duct, anterior view. of 5 Tables Contributor Information and Disclosures Author Bobak Zonnoor , MD Resident Physician, Department of Emergency Medicine, SUNY Downstate Medical Center, Kings County Hospital Bobak Zonnoor , MD is a member of the following medical societies: Disclosure: Nothing to disclose. Coauthor(s) Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine

2014 eMedicine Emergency Medicine

5024. Pericarditis and Cardiac Tamponade (Follow-up)

, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Verena T Valley, MD Associate Professor, Director of Ultrasound, Department of Emergency Medicine, University of Mississippi School of Medicine; Consulting Staff, Department of Emergency Medicine, Singing River Hospital System, Singing River Hospital, and Ocean Springs Hospital Verena T Valley, MD is a member of the following medical societies: Disclosure: Nothing (...) week, evaluate the clinical response to anti-inflammatory therapy (class I, level B evidence). [ ] Fever above 100.4°F (38°C), subacute onset, immunosuppression, trauma, oral anticoagulation therapy, aspirin or nonsteroidal anti-inflammatory drug (NSAID) treatment failure, myopericarditis, severe pericardial effusion, and cardiac tamponade are considered poor prognostic predictors. [ , , ] Patients without these factors were treated on an outpatient basis without serious complications after a mean

2014 eMedicine Emergency Medicine

5025. Hypothermia (Follow-up)

of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. James Steven Walker, DO, MS Clinical Professor of Surgery, Department of Surgery, University of Oklahoma College of Medicine James Steven Walker, DO, MS is a member of the following medical societies: , , , Disclosure: Nothing to disclose. Chief Editor Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New (...) bretylium in cases of severe hypothermia when spontaneous conversion to ventricular fibrillation is possible. [ , ] This recommendation was due to limited success of such therapy both in controlled animal studies and in anecdotal human reports. According the US Food and Drug Administration, bretylium was withdrawn from the market in 2011. A 2014 review makes no recommendation regarding bretylium or other antidysrhythmics, owing to inadequate evidence. [ ] Cardiac dysrhythmias begin to develop at a core

2014 eMedicine Emergency Medicine

5026. Pediatrics, Urinary Tract Infections and Pyelonephritis (Follow-up)

, however. Previous antibiotic exposure (ie, for otitis media) has been found to be associated with drug-resistant UTIs and should be kept in mind when choosing empiric therapy. [ ] The choice of outpatient versus inpatient care can often be guided by practical considerations. Outpatient care is reasonable if the following criteria are met: A caregiver with appropriate observational and coping skills Telephone and automobile at home The ability to return within 24 hours The patient has no need (...) with such findings are usually hospitalized and receive parenteral antibiotic therapy (see Table 3, below). However, clinical judgment may indicate that home treatment is appropriate. Parenteral antibiotics may be used with daily follow-up until the patient is afebrile for 24 hours. Complete 10-14 days of therapy with an oral antibiotic that is active against the infecting bacteria. Table 3. Antibiotic Agents for Parenteral Treatment of a Urinary Tract Infection Drug Dosage and Route Comment Ceftriaxone 50-75 mg

2014 eMedicine Emergency Medicine

5027. Polymyalgia Rheumatica (Diagnosis)

in this article are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the US Government. Additionally, this publication does not imply the Federal or Department of Defense endorsement of any product. Past Contributors Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center Michael S Beeson, MD, MBA, FACEP is a member (...) Be Enhanced by Amino Bisphosphonates. J Rheumatol . 2018 Nov 1. . González-Gay MA, García-Porrúa C, Vázquez-Caruncho M, Dababneh A, Hajeer A, Ollier WE. The spectrum of polymyalgia rheumatica in northwestern Spain: incidence and analysis of variables associated with relapse in a 10 year study. J Rheumatol . 1999 Jun. 26(6):1326-32. . González-Gay MA, Pina T, Prieto-Peña D, Calderon-Goercke M, Blanco R, Castañeda S. Drug therapies for polymyalgia rheumatica: a pharmacotherapeutic update. Expert Opin

2014 eMedicine Emergency Medicine

5028. Pneumonia, Viral (Diagnosis)

with bacterial pneumonia—making diagnosis on purely clinical grounds difficult or impossible. [ ] A number of rapid tests to determine viral etiologies have now been developed, and their use in the emergency department (ED) has allowed bedside diagnosis of the etiology of viral pneumonia. An accurate and early etiologic diagnosis is important because specific therapies are used against certain viruses (see Treatment and Management). Even with currently available tests, however, in some series a causative (...) of host defenses and may foster bacterial infection of normally sterile areas, including the lower respiratory tract. This impairment of host defenses may explain why as many as 53% of outpatients with bacterial pneumonia have a concurrent viral infection. Adenoviruses Little is known regarding mechanisms of pathogenicity of adenoviruses. Studies in children have identified increased production of cytokines, particularly tumor necrosis factor-alpha (TNF-α), interleukin 6 (IL-6), and interleukin 8 (IL

2014 eMedicine Emergency Medicine

5029. Pneumonia, Bacterial (Diagnosis)

examination Histologic inflammatory lung changes vary according to whether the patient has lobar pneumonia, bronchopneumonia, or interstitial pneumonia. [ ] See for more detail. Management The mainstay of drug therapy for bacterial pneumonia is antibiotic treatment. First-line antimicrobials for S pneumoniae , the most prevalent cause of bacterial pneumonia, are, for the penicillin-susceptible form of the bacterium, penicillin G and amoxicillin. For the penicillin-resistant form of S pneumoniae , first (...) , MD Resident Physician, Department of Internal Medicine, Olive View-UCLA Medical Center Disclosure: Nothing to disclose. Coauthor(s) Annie Harrington, MD Fellow in Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center

2014 eMedicine Emergency Medicine

5030. Pneumonia, Aspiration (Diagnosis)

Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. Paul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, Maricopa Medical Center Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: , , , Disclosure: Nothing to disclose. Chief Editor Guy W Soo (...) ; they are considered a high-risk group. While likely acknowledged, the importance of the swallowing disorder is not well appreciated. Speech therapy can provide some amelioration of risk and is also under used in these patients. Conditions associated with altered or reduced consciousness, including any condition that reduces a patient's gag reflex, ability to maintain an airway, or both, increase the risk of aspiration pneumonia or pneumonitis. Such conditions are as follows: Alcoholism Drug overdose Seizures

2014 eMedicine Emergency Medicine

5031. Plant Poisoning, Resins (Diagnosis)

. Hemlock. Photo by Cornell University Poisonous Plants Informational Database. Throughout human history, plants have played pivotal roles as medicines and poisons. Our medical predecessors may not have known the exact mechanisms involved, but they did recognize various plants as instrumental for medical treatment and as instruments of murder. With current technology, we finally are able to peer into plants and see their vast arsenal of chemicals, including glycosides, alkaloids, oxalates, and resins (...) caused fatalities worldwide after both intentional and unintentional ingestions. [ ] When considering poisoning by plant resin, always be aware of possible co-intoxicants, which may blur the clinical picture. Such co-intoxicants include pharmaceutical and illicit drugs, herbicides, fungicides, insecticides, fertilizers, and artificial plant hormones. Examples of unintentional toxic plant ingestion include the following: Hikers who mistake poisonous plants for nutritious ones Herbalists who seek

2014 eMedicine Emergency Medicine

5032. Pediatrics, Respiratory Distress Syndrome (Diagnosis)

, University of Toronto Faculty of Medicine; Associate Clinical Professor of Pediatrics, McMaster University School of Medicine, Canada Lennox H Huang, MD, FAAP is a member of the following medical societies: , , , , Disclosure: Nothing to disclose. Specialty Editor Board Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Nothing to disclose. Grace M Young, MD Associate Professor, Department (...) Disclosure: Nothing to disclose. Coauthor(s) Dale W Steele, MD, MS Professor of Emergency Medicine, Pediatrics, and Health Services, Policy, and Practice, Warren Alpert Medical School of Brown University; Attending Physician, Department of Pediatric Emergency Medicine, Rhode Island Hospital Dale W Steele, MD, MS is a member of the following medical societies: , , Disclosure: Nothing to disclose. G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care

2014 eMedicine Emergency Medicine

5033. Pediatrics, Pertussis (Diagnosis)

of the following medical societies: , , , and Disclosure: Nothing to disclose. Garry Wilkes MBBS, FACEM, Director of Emergency Medicine, Calvary Hospital, Canberra, ACT; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia Disclosure: Nothing to disclose. Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Nothing (...) Assistant Professor, Departments of Internal Medicine and Emergency Medicine, Via Christ Regional Medical Center Bryon K McNeil, MD is a member of the following medical societies: , Disclosure: Nothing to disclose. Stephen C Aronoff, MD Waldo E Nelson Chair and Professor, Department of Pediatrics, Temple University School of Medicine Stephen C Aronoff, MD is a member of the following medical societies: , Disclosure: Nothing to disclose. Chief Editor Russell W Steele, MD Clinical Professor, Tulane

2014 eMedicine Emergency Medicine

5034. Pediatrics, Pneumonia (Diagnosis)

the . Also, see the patient education articles , , and . Previous References Boggs W. Point-of-Care Ultrasound Diagnoses Pneumonia in Children. Medscape Medical News. December 10, 2012. Available at . Accessed: January 9, 2013. Shah VP, Tunik MG, Tsung JW. Prospective Evaluation of Point-of-Care Ultrasonography for the Diagnosis of Pneumonia in Children and Young Adults. Arch Pediatr Adolesc Med . 2012 Dec 10. 1-7. . Metinko AP. Neonatal pulmonary host defense mechanisms. Polin RA, Fox WW, eds. Fetal (...) with uncomplicated community-acquired pneumonia. Second- or third-generation cephalosporins and macrolide antibiotics such as azithromycin are acceptable alternatives. Combination therapy (ampicillin and either gentamicin or cefotaxime) is typically used in the initial treatment of newborns and young infants. Hospitalized patients can also usually be treated with a narrow-spectrum penicillin such as ampicillin. The choice of agent and dosing may vary based on local resistance rates (high rates of intermediate

2014 eMedicine Emergency Medicine

5035. Shock, Septic (Diagnosis)

defined, but it may involve systemic inflammation from either infectious or noninfectious causes, [ ] as well as a combination of the effects of hypoxemia, hypotension, hemorrhage, and medications such as sedatives and analgesics. [ , ] Previous Next: Etiology of Septic Shock Regarding the causes of septic shock, most patients who develop sepsis and septic shock have underlying circumstances that interfere with local or systemic host defense mechanisms. Sepsis is seen most frequently in elderly (...) of sepsis and are as follows: Head and neck infections – Severe headache, neck stiffness, altered mental status, earache, sore throat, sinus pain/tenderness, cervical/submandibular lymphadenopathy Chest and pulmonary infections – Cough (especially if productive), pleuritic chest pain, dyspnea, dullness on percussion, bronchial breath sounds, localized rales, any evidence of consolidation Cardiac infections – Any new murmur, especially in patients with a history of injection or IV drug use Abdominal

2014 eMedicine Emergency Medicine

5036. Scorpion Envenomation (Diagnosis)

from: BTG International Inc. Specialty Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. Chief Editor Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New Mexico Health Sciences Center Joe Alcock, MD, MS is a member of the following medical societies: Disclosure (...) . Furthermore, patients in rural areas tend to fare worse than patients in urban areas because of the delay in getting medical help due to a longer travel time to medical centers and the lack of advanced medical treatments. [ ] Fortunately, better public education, improved control of the scorpion population, increased supportive therapies, more technologically advanced intensive care units and advances in immunotherapy have combined to produce a substantial decrease in mortality from these envenomations

2014 eMedicine Emergency Medicine

5037. Periorbital Infections (Diagnosis)

Information and Disclosures Author Bobak Zonnoor , MD Resident Physician, Department of Emergency Medicine, SUNY Downstate Medical Center, Kings County Hospital Bobak Zonnoor , MD is a member of the following medical societies: Disclosure: Nothing to disclose. Coauthor(s) Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department (...) of Emergency Medicine, Kings County Hospital Center Richard H Sinert, DO is a member of the following medical societies: , Disclosure: Nothing to disclose. Zach Kassutto, MD, FAAP Director, Pediatric Emergency Medicine, Capital Health System; Associate Professor of Pediatrics and Emergency Medicine, Drexel University College of Medicine; Attending Physician, St Christopher's Hospital for Children Zach Kassutto, MD, FAAP is a member of the following medical societies: Disclosure: Nothing to disclose

2014 eMedicine Emergency Medicine

5038. Pediatrics, Sudden Infant Death Syndrome (Diagnosis)

a thorough investigation of the scene, interview of caregivers, and a complete forensic autopsy. Development of Emergency Department guidelines for the reporting and evaluation of SUID, in collaboration with the local medical examiner and child death review teams, will enable ED practitioners to collect important information in a compassionate manner that will be valuable to the investigating personnel. The image below illustrates the incidence of SIDS in the United States, 1985-2008. Depiction (...) to suggest another cause of death. [ ] To confirm the diagnosis of SIDS, a complete forensic autopsy needs to be performed, using information gathered from the scene investigation, interview of caregivers and review of medical and social history. After a thorough case investigation, some of these SUIDs may be explained. Poisoning, metabolic disorders, hyper- or hypothermia, child abuse and neglect resulting in homicide, and suffocation are all explainable, but much less common, causes of SUID

2014 eMedicine Emergency Medicine

5039. Pediatrics, Urinary Tract Infections and Pyelonephritis (Diagnosis)

: , , , and Disclosure: Nothing to disclose. Stephen L Thornton, MD Assistant Professor of Emergency Medicine, University of Kansas Hospital Stephen L Thornton, MD is a member of the following medical societies: and Disclosure: Nothing to disclose. Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Nothing to disclose. Grace M Young, MD Associate Professor, Department of Pediatrics, University of Maryland (...) factors: Alteration of the periurethral flora by antibiotic therapy Anatomic anomaly Bowel and bladder dysfunction Constipation Children who receive antibiotics (eg, amoxicillin, cephalexin) for other infections are at increased risk for UTI. These agents may alter gastrointestinal (GI) and periurethral flora, disturbing the urinary tract's natural defense against colonization by pathogenic bacteria. Prolonged retention of urine may permit incubation of bacteria in the bladder. Voiding dysfunction

2014 eMedicine Emergency Medicine

5040. Pericarditis and Cardiac Tamponade (Diagnosis)

for suspected infectious etiologies and testing for tuberculosis exposure (ie, PPD or interferon-gamma release assays) may be helpful. See for more detail. Management Treatment for specific causes of pericarditis is directed according to the underlying cause. For patients with idiopathic or viral pericarditis, therapy is directed at symptom relief. Pharmacologic treatment Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstays of therapy. NSAID agents have a similar efficacy, with relief (...) to other medical management. Patients with effusions larger than 250 mL, effusions in which size increases despite intensive dialysis for 10-14 days, or effusions with evidence of tamponade are candidates for pericardiocentesis. Pericardial window placement is used for effusive pericarditis therapy. In critically ill patients, a balloon catheter may be used to create a pericardial window, in which only 9 cm 2 or less of pericardium is resected. Consider subxiphoid pericardiotomy for large effusions

2014 eMedicine Emergency Medicine

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