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E/M Medical Decision Making

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8961. External Pacemakers (Follow-up)

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

8962. Dislocation, Ankle (Follow-up)

=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvODIzMDg3LXRyZWF0bWVudA== processing > Ankle Dislocation in Emergency Medicine Treatment & Management Updated: Apr 28, 2016 Author: James E Keany, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH Share Email Print Feedback Close Sections Sections Ankle Dislocation in Emergency Medicine Treatment Prehospital Care Prehospital personnel should immobilize the joint following standard procedure for any extremity injury. If neurovascular compromise is identified in the field by examination, revealing a cold, discolored (...) , and pulseless or insensate foot, the joint should be realigned unless transport time is brief. This is accomplished by in-line traction with countertraction. Traction or splinting should be maintained en route to the hospital (see ). Intravenous opioids should be administered to make the patient comfortable and especially if traction is applied to reduce the dislocation en route. If intravenous opioids are unavailable, intravenous benzodiazepine medications can be used as an alternative. Next: Emergency

2014 eMedicine Emergency Medicine

8963. Diabetes Mellitus, Type 2 (Follow-up)

profile. Careful study is needed when making a decision regarding reduced dosing frequency. A rapid-acting inhaled insulin powder (Afrezza) for types 1 and 2 diabetes mellitus was approved by the FDA in June 2014. Approval was based on a study involving over 3,000 patients over a 24-week period. In persons with type 1 diabetes, the inhaled insulin was found to be noninferior to standard injectable insulin when used in conjunction with basal insulin at reducing hemoglobin A1c. In persons with type 2 (...) professionals with expertise in diabetes, working in collaboration with the patient and family. [ ] Management includes the following: Appropriate goal setting Dietary and exercise modifications Medications Appropriate self-monitoring of blood glucose (SMBG) Regular monitoring for complications Laboratory assessment Ideally, blood glucose should be maintained at near-normal levels (preprandial levels of 90-130 mg/dL and hemoglobin A1C [HbA1c] levels < 7%). However, focus on glucose alone does not provide

2014 eMedicine Emergency Medicine

8964. Depression and Suicide (Follow-up)

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. Acknowledgements Robert Harwood, MD, MPH, FACEP, FAAEM Program Director, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College (...) with the public or clients, and had high levels of stress and low levels of physical activity. [ ] The medical profession has the highest risk of death by suicide of any profession or occupation for several reasons (see . In all populations, the existence of depression coupled with knowledge of and access to lethal means dramatically increases the risk for suicide. In addition to medicine, other high control and highly regulated professions such as law enforcement, military, and the legal profession may

2014 eMedicine Emergency Medicine

8965. Abdominal Trauma, Penetrating (Follow-up)

stabilizing surgical intervention. Obviously, if no surgeon is available, transfer may be the only course of action. Practitioners must be cognizant of Emergency Medical Treatment and Active Labor Act (EMTALA)/Consolidated Omnibus Budget Reconciliation Act (COBRA) violations and document accordingly (see ). This legislation was enacted with the intention of removing economic considerations from important medical decisions in the ED. Previous Next: Initial Emergency Department Care A team leader should (...) ) Katie Jo Stanton-Maxey, MD Assistant Professor, Department of Surgery, Indiana University School of Medicine Katie Jo Stanton-Maxey, MD is a member of the following medical societies: Disclosure: Nothing to disclose. H Scott Bjerke, MD, FACS Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Professor, Department of Surgery, Kansas City University of Medicine

2014 eMedicine Emergency Medicine

8966. Abortion, Incomplete (Follow-up)

with clinical presentation (spotting vs bleeding) to aid in making clinical decisions. This endovaginal ultrasonogram reveals an irregular gestational sac with an amorphic fetal pole. No fetal cardiac activity was noted. This image represents a missed miscarriage or fetal demise. of 6 Tables Contributor Information and Disclosures Author Slava V Gaufberg, MD Assistant Professor of Medicine, Harvard Medical School; Director of Transitional Residency Training Program, Cambridge Health Alliance Slava V (...) , Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial). BMJ . 2006 May 27. 332(7552):1235-40. . Dempsey A, Davis A. Medical management of early pregnancy failure: how to treat and what to expect. Semin Reprod Med . 2008 Sep. 26(5):401-10. . Coomarasamy A, Williams H, Truchanowicz E, et al. A Randomized Trial of Progesterone in Women with Recurrent Miscarriages. N Engl J Med

2014 eMedicine Emergency Medicine

8967. Abortion, Complete (Follow-up)

with clinical presentation (spotting vs bleeding) to aid in making clinical decisions. This endovaginal ultrasonogram reveals an irregular gestational sac with an amorphic fetal pole. No fetal cardiac activity was noted. This image represents a missed miscarriage or fetal demise. of 6 Tables Contributor Information and Disclosures Author Slava V Gaufberg, MD Assistant Professor of Medicine, Harvard Medical School; Director of Transitional Residency Training Program, Cambridge Health Alliance Slava V (...) , Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial). BMJ . 2006 May 27. 332(7552):1235-40. . Dempsey A, Davis A. Medical management of early pregnancy failure: how to treat and what to expect. Semin Reprod Med . 2008 Sep. 26(5):401-10. . Coomarasamy A, Williams H, Truchanowicz E, et al. A Randomized Trial of Progesterone in Women with Recurrent Miscarriages. N Engl J Med

2014 eMedicine Emergency Medicine

8968. Yellow Fever (Diagnosis)

: , , , , , and Disclosure: Nothing to disclose. Aleksandr Gleyzer, MD, FAAEM Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Attending Physician, Department of Emergency Medicine, Kings County Medical Center and Brooklyn Veterans Affairs Medical Center Aleksandr Gleyzer, MD, FAAEM is a member of the following medical societies: and Disclosure: Nothing to disclose. Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School (...) of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio Thomas E Herchline, MD is a member of the following medical societies: , , and Disclosure: Nothing to disclose. Emily Nichols, MD Clinical Assistant Instructor, State University of New York Downstate Medical Center, Kings County Hospital Center Emily Nichols, MD is a member of the following medical societies: , , , and Disclosure: Nothing to disclose. Mark L Plaster, MD, JD Executive Editor, Emergency Physicians Monthly Mark

2014 eMedicine Emergency Medicine

8969. Abdominal Pain in Elderly Persons (Follow-up)

of an elderly patient with abdominal pain should be the exception rather than the rule. Previous References Esses D, Birnbaum A, Bijur P, et al. Ability of CT to alter decision making in elderly patients with acute abdominal pain. Am J Emerg Med . 2004 Jul. 22(4):270-2. . Hustey FM, Meldon SW, Banet GA, et al. The use of abdominal computed tomography in older ED patients with acute abdominal pain. Am J Emerg Med . 2005 May. 23(3):259-65. . Lewis LM, Banet GA, Blanda M, et al. Etiology and clinical course (...) Center at El Paso; Medical Director, Department of Emergency Medicine, Thomason Hospital E David Bryan, MD is a member of the following medical societies: , Disclosure: Nothing to disclose. 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 Barry E Brenner, MD, PhD, FACEP Professor

2014 eMedicine Emergency Medicine

8970. Urinary Tract Infection, Female (Diagnosis)

, Winthrop-University Hospital Burke A Cunha, MD is a member of the following medical societies: , , Disclosure: Nothing to disclose. Jeffrey M Tessier, MD Assistant Professor, Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University School of Medicine Jeffrey M Tessier, MD is a member of the following medical societies: Disclosure: Nothing to disclose. Chief Editor Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart (...) : , , , , and Disclosure: Sepracor None None Allison M Loynd, DO Resident Physician, Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Receiving Hospital Allison M Loynd, DO is a member of the following medical societies: , , and Disclosure: Nothing to disclose. Mark Jeffrey Noble, MD Consulting Staff, Urologic Institute, Cleveland Clinic Foundation Mark Jeffrey Noble, MD is a member of the following medical societies: , , , , , Society of University Urologists, and Disclosure

2014 eMedicine Emergency Medicine

8971. Toxicity, Heavy Metals (Diagnosis)

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

8972. Acute Coronary Syndrome (Follow-up)

with suspected acute coronary syndrome. Am J Emerg Med . 2010 Feb. 28(2):170-6. . Katritsis DG, Siontis GC, Kastrati A, van't Hof AW, Neumann FJ, Siontis KC, et al. Optimal timing of coronary angiography and potential intervention in non-ST-elevation acute coronary syndromes. Eur Heart J . 2011 Jan. 32(1):32-40. . Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making (...) delay and its impact on time to treatment in ST-elevation myocardial infarction. Am J Emerg Med . 2011 May. 29(4):396-400. . Wood S. STEMI in Women: Same Plaques, Same Stent Outcomes: OCTAVIA. Medscape Medical News. Available at . Accessed: May 27, 2014. Than M, Cullen L, Reid CM, Lim SH, Aldous S, Ardagh MW, et al. A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study. Lancet . 2011 Mar 26. 377(9771

2014 eMedicine Emergency Medicine

8973. Neck Trauma (Treatment)

emergency medicine, surgery, and anesthesiology. Intubating a patient with penetrating neck trauma may incite gagging or coughing, potentially dislodging a clot and setting off massive bleeding from a previously injured blood vessel. Additionally, existent bleeding and edema rapidly distort the surrounding anatomy, making oral intubation difficult, if not impossible. Nevertheless, assessment of the airway takes priority over all other actions, including those procedures that risk exacerbating hemorrhage (...) in the aerodigestive tract, hemoptysis, and/or hematemesis New-onset bruit Previous Next: Medical Care Observe patients with all but the most trivial of neck wounds for delayed onset of symptoms. Platysma violation usually justifies admission for 24 hours of observation to avoid missing occult injuries, particularly vascular and esophageal wounds. Decisions regarding the need to admit a patient with blunt neck trauma are based on the presence or absence of signs and symptoms as well as the patient's underlying

2014 eMedicine Emergency Medicine

8974. Pacemaker and Automatic Internal Cardiac Defibrillator (Treatment)

=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTYyMjQ1LW92ZXJ2aWV3 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

8975. Myocardial Infarction (Treatment)

as soon as possible to salvage as much of the jeopardized myocardium as possible. This may be accomplished through medical or mechanical means, such as percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG) surgery. Although the initial treatment of the different types of acute coronary syndrome (ACS) may appear to be similar, it is very important to distinguish whether the patient is having an ST-elevation MI (STEMI) or a non–STEMI (NSTEMI), because definitive therapies (...) death. [ ] Morbidity and mortality from MI are significantly reduced if patients and bystanders recognize symptoms early, activate the emergency medical service (EMS) system, and thereby shorten the time to definitive treatment. Trained prehospital personnel can provide life-saving interventions if the patient develops cardiac arrest. The key to improved survival is the availability of early defibrillation. Approximately 1 in every 300 patients with chest pain transported to the emergency department

2014 eMedicine Emergency Medicine

8976. Metabolic Acidosis (Treatment)

metabolic acidosis in the setting of renal failure. Previous References Hopkins E, Sharma S. Physiology, Acid Base Balance. 2018 Jan. . . Brubaker RH, Meseeha M. High Anion Gap Metabolic Acidosis. 2017 Jun. . . Reddy P, Mooradian AD. Clinical utility of anion gap in deciphering acid-base disorders. Int J Clin Pract . 2009 Oct. 63(10):1516-25. . Stewart PA. Modern quantitative acid-base chemistry. Can J Physiol Pharmacol . 1983 Dec. 61(12):1444-61. . Masevicius FD, Dubin A. Has Stewart approach improved (...) our ability to diagnose acid-base disorders in critically ill patients?. World J Crit Care Med . 2015 Feb 4. 4 (1):62-70. . . Raikou VD Md PhD. Metabolic acidosis status and mortality in patients on the end stage of renal disease. J Transl Int Med . 2016 Dec 1. 4 (4):170-7. . . Park S, Kang E, Park S, et al. Metabolic Acidosis and Long-Term Clinical Outcomes in Kidney Transplant Recipients. J Am Soc Nephrol . 2017 Jun. 28 (6):1886-97. . Safari S, Hashemi B, Forouzanfar MM, Shahhoseini M, Heidari M

2014 eMedicine Emergency Medicine

8977. Multiple Sclerosis (Treatment)

. Currently, most disease-modifying agents have been approved for use only in relapsing forms of MS. Mitoxantrone (see below) is also approved for the treatment of secondary (long-term) progressive and progressive relapsing MS. Although therapy for clinically isolated syndrome (CIS) (a single episode of neurologic symptoms) with immunomodulatory medications has not yet become standard practice throughout the world, trials such as the TOPIC trial suggest that early intervention may be appropriate (...) . Decisions regarding early treatment of relapsing MS can be guided by using the McDonald diagnostic criteria. Results from the multicenter TOPIC trial provide evidence that treatment of clinically CIS with the drug teriflunomide delays conversion to MS. [ ] Patients with CIS have a high likelihood of developing MS. In the study, 618 patients were treated either with teriflunomide in doses of 14 mg or 7 mg per day or placebo. [ ] Patients were included if they experienced a first acute or subacute well

2014 eMedicine Emergency Medicine

8978. Neoplasms, Lung (Treatment)

Group (RTOG). SBRT was associated with shorter overall survival but similar recurrence rates and cause-specific mortality in a nonrandomized study by Grills et al. The study compared outcomes in patients with stage T1-2N0M0 NSCLC who were ineligible for lobectomy and thus underwent either wedge resection or, if deemed medically inoperable, SBRT. [ ] Radiofrequency ablation (RFA) has also been used for inoperable patients who have peripheral tumors that are less than 3 cm in size, and occasionally (...) that large-scale screening of patients with lung cancer for EGFR mutations is feasible and can have a role in decisions about treatment. [ ] The NCCN guidelines add that EGFR mutations are present in adenocarcinomas in approximately 10% of Western patients and up to 50% of Asian patients, and that the EGFR mutation frequency is higher in nonsmokers, women, and patients with non-mucinous cancers. In squamous cell carcinomas, however, the observed incidence of EGFR mutations is 2.7% and the true incidence

2014 eMedicine Emergency Medicine

8979. Asthma (Treatment)

-agonists and anticholinergics), theophylline, leukotriene modifiers, and more recent strategies such as the use of anti-immunoglobulin E (IgE) antibodies (omalizumab) and anti-IL-5 antibodies in selected patients. Relief medications include short-acting bronchodilators, systemic corticosteroids, and ipratropium. For all but the most severely affected patients, the ultimate goal is to prevent symptoms, minimize morbidity from acute episodes, and prevent functional and psychological morbidity to provide (...) should be reassessed in 2-4 weeks to make sure that control is maintained with the new treatment. A study by Bruzzese et al assessed the Asthma Self-Management for Adolescents (ASMA) approach, which is a school-based intervention for adolescents and medical providers. [ ] The study found that ASMA helped improve self-management and reduced morbidity and urgent health care use in low-income, urban, minority adolescents. Next: Environmental Control Environmental exposures and irritants can play

2014 eMedicine Emergency Medicine

8980. Anxiety (Treatment)

of fluoxetine and placebo. The Fluoxetine Panic Disorder Study Group. Am J Psychiatry . 1998 Nov. 155(11):1570-7. . Uhlenhuth EH, Balter MB, Ban TA, Yang K. International study of expert judgment on therapeutic use of benzodiazepines and other psychotherapeutic medications: VI. Trends in recommendations for the pharmacotherapy of anxiety disorders, 1992-1997. Depress Anxiety . 1999. 9(3):107-16. . Herrera-Arellano A, Jiménez-Ferrer E, Zamilpa A, Morales-Valdéz M, García-Valencia CE, Tortoriello J. Efficacy (...) . Acknowledgements Edward Bessman, MD Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine Edward Bessman, MD 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

2014 eMedicine Emergency Medicine

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