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E/M Medical Decision Making

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8821. Pulmonary Embolism (Overview)

warfarin or low molecular weight heparin upon discharge from the hospital, they must be advised regarding potential interactions between these agents and other medications. For patient education resources, see the patient education articles and . Previous References Amesquita M, Cocchi MN, Donnino MW. Pulmonary Embolism Presenting as Flank Pain: A Case Series. J Emerg Med . 2009 Mar 26. . Carrascosa MF, Batán AM, Novo MF. Delirium and pulmonary embolism in the elderly. Mayo Clin Proc . 2009. 84(1):91-2 (...) vein thrombosis?. J R Soc Med . 1989 Apr. 82(4):203-5. . . Kotsakis A, Cook D, Griffith L, Anton N, Massicotte P, MacFarland K, et al. Clinically important venous thromboembolism in pediatric critical care: a Canadian survey. J Crit Care . 2005 Dec. 20(4):373-80. . Van Ommen CH, Peters M. Acute pulmonary embolism in childhood. Thromb Res . 2006. 118(1):13-25. . Kabrhel C, Varraso R, Goldhaber SZ, Rimm E, Camargo CA Jr. Physical inactivity and idiopathic pulmonary embolism in women: prospective

2014 eMedicine Emergency Medicine

8822. Pregnancy, Ectopic (Overview)

of pregnancies of unknown location. Hum Reprod . 2007 Jun. 22(6):1744-50. . [Guideline] Practice Committee of American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy. Fertil Steril . 2008 Nov. 90(5 Suppl):S206-12. . Ustunyurt E, Duran M, Coskun E, Ustunyurt OB, Simsek H. Role of initial and day 4 human chorionic gonadotropin levels in predicting the outcome of single-dose methotrexate treatment in women with tubal ectopic pregnancy. Arch Gynecol Obstet . 2013 Nov. 288(5):1149-52 (...) level of care. When an ectopic pregnancy is identified, medical or surgical treatment is provided as indicated. Those with ectopic pregnancy who require admission or surgery should be admitted to an obstetrics/gynecology service. Pharmacologic treatment The current standard medical treatment of unruptured ectopic pregnancy consists of the administration of (MTX). [ , , ] This decision to initiate MTX therapy should be made in conjunction with, if not by, the consulting obstetrician/gynecologist

2014 eMedicine Emergency Medicine

8823. Toxicity, Heavy Metals (Overview)

Assistant Professor of Clinical Medicine, Division of Emergency Medicine, Department of Medicine, University of Miami, Leonard M Miller School of Medicine Mark Louden, MD is a member of the following medical societies: Disclosure: Nothing to disclose. Acknowledgements Richard H Sinert, DO Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County (...) reactions in the human body, vitamin B-12 has a cobalt atom at its core, and hemoglobin contains iron. Likewise, copper, manganese, selenium, chromium, and molybdenum are all trace elements that are important in the human diet. Another subset of metals includes those used therapeutically in medicine; aluminum, bismuth, gold, gallium, lithium, and silver are all part of the medical armamentarium. Any of these elements may have pernicious effects if taken in quantity or if the usual mechanisms

2014 eMedicine Emergency Medicine

8824. Toxicity, Calcium Channel Blocker (Overview)

(Phila) . 2011 Nov. 49(9):801-9. . American College of Medical Toxicology. ACMT position statement: interim guidance for the use of lipid resuscitation therapy. J Med Toxicol . 2011 Mar. 7(1):81-2. . Varpula T, Rapola J, Sallisalmi M, Kurola J. Treatment of serious calcium channel blocker overdose with levosimendan, a calcium sensitizer. Anesth Analg . 2009 Mar. 108(3):790-2. . Kolcz J, Pietrzyk J, Januszewska K, Procelewska M, Mroczek T, Malec E. Extracorporeal life support in severe propranolol (...) Medicine, Texas A&M Health Sciences Center; CHRISTUS Spohn Emergency Medicine Residency Program Michael A Miller, MD is a member of the following medical societies: Disclosure: Nothing to disclose. Acknowledgements John G Benitez, MD, MPH Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center John G Benitez, MD, MPH is a member of the following medical societies: , , , , , , and Disclosure: Nothing to disclose

2014 eMedicine Emergency Medicine

8825. Screening and Diagnostic Tests (Overview)

for employment. for: Medscape. Jon Mark Hirshon, MD, MPH, PhD Professor, Department of Emergency Medicine, University of Maryland School of Medicine Jon Mark Hirshon, MD, MPH, PhD is a member of the following medical societies: , , , , Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Pfizer. Chief Editor Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System Robert E O'Connor, MD, MPH (...) with their criterion standard is a decrease in accuracy. How to account for this trade-off between diagnostic accuracy and patient acceptability is the subject of this article. Patient Diagnostic and Screening Decisions In order for patients to make informed decisions regarding diagnostic and screening options when there is more than one option, when no option has a clear advantage, and when the risk-benefit profile may be valued differently, decision aids such as pamphlets, videos, or Web-based tools may be used

2014 eMedicine Emergency Medicine

8826. Sarcoidosis (Overview)

, Akira M, Kitaichi M, et al. A case of combined sarcoidosis and usual interstitial pneumonia. Intern Med . 2012. 51(14):1893-7. . Chapelon-Abric C, de Zuttere D, Duhaut P, Veyssier P, Wechsler B, Huong DL, et al. Cardiac sarcoidosis: a retrospective study of 41 cases. Medicine (Baltimore) . 2004 Nov. 83(6):315-34. . Media Gallery Stage II sarcoidosis. Courtesy of Anthony Notino, MD, New York Hospital, Department of Radiology, Cornell Medical Center. Stage II sarcoidosis. Courtesy of Anthony Notino (...) Disclosure: Received salary from Medscape for employment. for: Medscape. Gino A Farina, MD, FACEP, FAAEM Professor of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine at Hofstra University; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: , , Disclosure: Nothing to disclose. Chief Editor Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal

2014 eMedicine Emergency Medicine

8827. Thrombolytic Therapy (Overview)

are being adhered and aggregated. Aspirin, glycoprotein (GP) IIb/IIIa inhibitors, and clopidogrel have an inhibitory effect on platelet activation and aggregation. Plasminogen gathers in the fibrin matrix. Fibrin-bound plasminogen will be converted by thrombolytic drugs to plasmin, the rate-limiting step in thrombolysis. It should be kept in mind that the thrombolysis process works best on recently formed thrombi. Older thrombi have extensive fibrin polymerization that makes them more resistant (...) to treat a single patient. Urokinase is also commercially available in a form produced by tissue culture, and recombinant DNA techniques have been developed for urokinase production in E coli cultures. Urokinase was withheld from the market for some years because of manufacturer issues with the FDA but has since been reintroduced. The package insert was revised and now carries indications only for massive PE and PE accompanied by unstable hemodynamics. During the period when urokinase was not available

2014 eMedicine Emergency Medicine

8828. Hypertensive Emergencies (Overview)

Medicine, Harvard Medical School Gary Setnik, MD is a member of the following medical societies: , , Disclosure: Medical Director for: SironaHealth. Chief Editor Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Sanz Laniado Medical Center, Netanya, Israel Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: , , , , , , , , , Disclosure: Nothing to disclose. Additional Contributors Robin R (...) of therapeutic interventions, and making disposition decisions. Acutely lowering BP in the ED for clinical situations other than those listed below is controversial and generally should be avoided. In pediatric hypertension, in the absence of hypertensive target organ damage, diet and exercise are used to treat stage I hypertension, followed by the addition of drug therapy if the initial strategy is unsuccessful. [ ] In the presence of stage I hypertension with end-organ damage and stage II hypertension

2014 eMedicine Emergency Medicine

8829. Personality Disorders (Overview)

Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: , , , and Disclosure: Nothing to disclose. Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine Barry E Brenner, MD, PhD, FACEP is a member of the following (...) autonomic activity in antisocial personality disorder. This may underlie the low arousal, poor fear conditioning, and decision-making deficits described in antisocial personality disorder. [ ] Borderline personality disorder Psychosocial formulations point to the high prevalence of early abuse (sexual, physical, and emotional) in these patients, and the borderline syndrome is often formulated as a variant of posttraumatic stress disorder. Mood disorders in first-degree relatives are strongly linked

2014 eMedicine Emergency Medicine

8830. Pediatrics, Sudden Infant Death Syndrome (Overview)

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

8831. Gastroenteritis (Overview)

):e0165441. . Ruiz-Palacios GM, Perez-Schael I, Velazquez FR, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med . 2006 Jan 5. 354(1):11-22. . Esan OB, Pearce M, van Hecke O, et al. Factors associated with sequelae of Campylobacter and non-typhoidal Salmonella infections: a systematic review. EBioMedicine . 2017 Feb. 15:100-11. . Geurts D, de Vos-Kerkhof E, Polinder S, et al. Implementation of clinical decision support in young children with acute (...) Author Arthur Diskin, MD Vice-President, Global Chief Medical Officer, Royal Caribbean Cruise Lines; Voluntary Associate Professor, University of Miami, Leonard M Miller School of Medicine Arthur Diskin, MD is a member of the following medical societies: Disclosure: Nothing to disclose. Coauthor(s) Lillian Gutierrez-Alvarez, MPH Public Health Analyst, Medical and Public Health Department, Royal Caribbean Cruises, Ltd Lillian Gutierrez-Alvarez, MPH is a member of the following medical societies

2014 eMedicine Emergency Medicine

8832. Grief Support in the ED (Overview)

of residents. Acad Emerg Med . 2005 Apr. 12(4):296-301. . Edlich RF, Kubler-Ross E. On death and dying in the emergency department. J Emerg Med . 1992 Mar-Apr. 10(2):225-9. . Olsen JC, Buenefe ML, Falco WD. Death in the emergency department. Ann Emerg Med . 1998 Jun. 31(6):758-65. . Benenson RS, Pollack ML. Evaluation of emergency medicine resident death notification skills by direct observation. Acad Emerg Med . 2003 Mar. 10(3):219-23. . Dosanjh S, Barnes J, Bhandari M. Barriers to breaking bad news among (...) MA. The presence of a family witness impacts physician performance during simulated medical codes. Crit Care Med . 2009 Jun. 37(6):1956-60. . Compton S, Levy P, Griffin M, Waselewsky D, Mango L, Zalenski R. Family-witnessed resuscitation: bereavement outcomes in an urban environment. J Palliat Med . 2011 Jun. 14(6):715-21. . Jabre P, Belpomme V, Azoulay E, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med . 2013 Mar 14. 368(11):1008-18. . Sacchetti A, Paston C, Carraccio C

2014 eMedicine Emergency Medicine

8833. Hazmat (Overview)

and the EMS system. The ideal situation is to have the HAZMAT team is made up of specially trained members of the fire department who also are cross-trained as paramedics or emergency medical technicians (EMTs). However, smaller communities commonly do not have this luxury. Especially in situations in which the HAZMAT team is not trained in prehospital care, involving medical control physicians and poison control centers in patient care decisions is essential. Goals in managing a HAZMAT incident The goals (...) physician and the site commander must make decisions on an individual basis. Transportation Placing a contaminated patient in an ambulance is strongly discouraged. This is a closed environment and presents increased risk to those in the ambulance. This action also results in the contamination of the ambulance and its equipment. No further use of the ambulance is allowed until it can be decontaminated appropriately. Ambulances usually are resources that most communities cannot spare. Transportation prior

2014 eMedicine Emergency Medicine

8834. Fracture, Scapular (Overview)

fractures for clinical research and surgical decision making. [ , ] Previous Next: Epidemiology Scapular fractures occur infrequently and account for approximately 1% of all fractures and 3% to 5% of shoulder girdle injuries. [ , ] Morbidity and mortality result primarily from associated injuries. Traditional wisdom holds that scapular fractures serve as markers of increased morbidity and mortality in patients with blunt trauma. One retrospective study comparing patients with scapular fractures due (...) . . Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole PA. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma . 2006 Mar. 20(3):230-3. . Cole PA, Freeman G, Dubin JR. Scapula fractures. Curr Rev Musculoskelet Med . 2013 Mar. 6 (1):79-87. . Stephens NG, Morgan AS, Corvo P, Bernstein BA. Significance of scapular fracture in the blunt-trauma patient. Ann Emerg Med . 1995 Oct. 26(4):439-42. . Baldwin KD, Ohman-Strickland P, Mehta S, Hume E. Scapula fractures

2014 eMedicine Emergency Medicine

8835. Fracture, Wrist (Overview)

, et al. The Amsterdam wrist rules: the multicenter prospective derivation and external validation of a clinical decision rule for the use of radiography in acute wrist trauma. BMC Musculoskelet Disord . 2015 Dec 18. 16:389. . Brants A, IJsseldijk MA. A pilot study to identify clinical predictors for wrist fractures in adult patients with acute wrist injury. Int J Emerg Med . 2015. 8:2. . Behzadi C, Karul M, Henes FO, Laqmani A, Catala-Lehnen P, Lehmann W, et al. Comparison of conventional (...) J, Ruiz E, Krome R. Emergency Medicine: A Comprehensive Study Guide . 4th ed. McGraw-Hill Publishing; 1996. Jain R, Jain N, Sheikh T, Yadav C. Early scaphoid fractures are better diagnosed with ultrasonography than X-rays: A prospective study over 114 patients. Chin J Traumatol . 2018 Jan 31. . Media Gallery Lateral radiograph of the wrist illustrating volar dislocation of the lunate. During a soccer game, a 12-year-old boy fractured his wrist when falling on an outstretched hand. The fracture

2014 eMedicine Emergency Medicine

8836. Fracture, Foot (Overview)

Ankle Surg . 2017 May 31. . Bishop JA, Braun HJ, Hunt KJ. Operative Versus Nonoperative Treatment of Jones Fractures: A Decision Analysis Model. Am J Orthop (Belle Mead NJ) . 2016 Mar-Apr. 45 (3):E69-76. . Hunt KJ, Goeb Y, Esparza R, Malone M, Shultz R, Matheson G. Site-Specific Loading at the Fifth Metatarsal Base in Rehabilitative Devices: Implications for Jones Fracture Treatment. PM R . 2014 May 28. . Lau S, Bozin M, Thillainadesan T. Lisfranc fracture dislocation: a review of a commonly missed (...) ) view is shown here. An added oblique view of this same patient with a navicular fracture was performed in the ED to help verify the absence of other significant fractures. Obtaining views that are not part of the routine foot series can be helpful and should be added when needed. of 12 Tables Contributor Information and Disclosures Author Robert Silbergleit, MD Professor, Department of Emergency Medicine, University of Michigan Medical School Robert Silbergleit, MD is a member of the following

2014 eMedicine Emergency Medicine

8837. Meningitis (Overview)

Headache Neck stiffness Other symptoms can include nausea, vomiting, photalgia (photophobia), sleepiness, confusion, irritability, delirium, and coma. Patients with viral meningitis may have a history of preceding systemic symptoms (eg, myalgias, fatigue, or anorexia). The history should also address the following: Epidemiologic factors and predisposing risks Exposure to a patients or animals with a similar illness Previous medical treatment and existing conditions Geographic location and travel (...) and Medication.) The specific infectious agents that are involved in bacterial meningitis vary among different patient age groups, and the inflammation may evolve into the following conditions: Ventriculitis Empyema Cerebritis Abscess formation Meningitis can also be also classified more specifically according to its etiology. Numerous infectious and noninfectious causes of meningitis have been identified. Examples of common noninfectious causes include medications (eg, nonsteroidal anti-inflammatory drugs

2014 eMedicine Emergency Medicine

8838. Molluscum Contagiosum (Overview)

Dermatology, Department of Dermatology, Northwestern University, The Feinberg School of Medicine; Medical Director for Dermatologic Research, Director of Dermatologic, Laser and Cosmetic Surgery, Oak Dermatology Ashish C Bhatia, MD, FAAD, FACMS is a member of the following medical societies: , , , , , Disclosure: Nothing to disclose. Chief Editor Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine Dirk M (...) ; Director of Dermatologic Surgery and Dermatology, The Dermatology Institute of DuPage Medical Group Ashish C Bhatia, MD, FAAD is a member of the following medical societies: , , , , , , and Disclosure: Nothing to disclose. David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic David F Butler, MD is a member of the following medical societies

2014 eMedicine Emergency Medicine

8839. Knee Injury, Soft Tissue (Overview)

Kardon, MD, FACEP Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center Eric M Kardon, MD, FACEP is a member of the following medical societies: , , Disclosure: Nothing to disclose. Acknowledgements June E Sanson CNRP, MSN Nurse Practitioner, Take Care Health Systems Disclosure: Nothing to disclose. Tom Scaletta, MD President, Smart-ER (http://smart-er.net); Chair, Department of Emergency Medicine, Edward (...) ; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. Chief Editor Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine Trevor John Mills, MD, MPH is a member of the following medical societies: , Disclosure: Nothing to disclose. Additional Contributors Eric M

2014 eMedicine Emergency Medicine

8840. External Pacemakers (Overview)

processing > Pacemakers and Implantable Cardioverter-Defibrillators Updated: Feb 13, 2017 Author: Daniel M Beyerbach, MD, PhD; Chief Editor: Jeffrey N Rottman, MD Share Email Print Feedback Close Sections Sections Pacemakers and Implantable Cardioverter-Defibrillators Overview Practice Essentials An implantable cardioverter-defibrillator (ICD) is a specialized device designed to directly treat many dysrhythmias, and it is specifically designed to address ventricular tachyarrhythmias. ICDs have (...) dysfunction (sick sinus syndrome) Symptomatic chronotropic incompetence Symptomatic sinus bradycardia due to necessary drug therapy for other medical conditions, such as atrial fibrillation or coronary artery disease Symptomatic AV block Symptomatic bradycardia due to complete heart block or second-degree AV block or when ventricular arrhythmias are presumed to arise from AV block Symptomatic bradycardia due to complete heart block or second-degree AV block that is due to necessary drug therapy

2014 eMedicine Emergency Medicine

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