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Emergency Medicine Treatment and Labor Act

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141. Preeclampsia and Eclampsia (Treatment)

hypertension in pregnancy Antihypertensive treatment is recommended for severe hypertension (SBP >160 mm Hg; DBP >110 mm Hg). The goal of hypertension treatment is to maintain BP around 140/90 mm Hg. Medications used for BP control include the following: Hydralazine Labetalol Nifedipine Sodium nitroprusside (in severe hypertensive emergency refractory to other medications) Fluid management Diuretics should be avoided Aggressive volume resuscitation may lead to pulmonary edema Patients should be fluid (...) including (nonreassuring nonstress test, biophysical profile score, and/or persistent absent or reversed diastolic flow on umbilical artery Doppler velocimetry) Ruptured membranes Uncontrollable BP (unresponsive to medical therapy) Oligohydramnios, with amniotic fluid index (AFI) of less than 5 cm Severe intrauterine growth restriction in which the estimated fetal weight is less than 5% Oliguria (< 500 mL/24 hr) Serum creatinine level of at least 1.5 mg/dL Pulmonary edema Shortness of breath or chest

2014 eMedicine.com

142. Preeclampsia (Toxemia of Pregnancy) (Treatment)

treatment of severe hypertension in pregnancy Antihypertensive treatment is recommended for severe hypertension (SBP >160 mm Hg; DBP >110 mm Hg). The goal of hypertension treatment is to maintain BP around 140/90 mm Hg. Medications used for BP control include the following: Hydralazine Labetalol Nifedipine Sodium nitroprusside (in severe hypertensive emergency refractory to other medications) Fluid management Diuretics should be avoided Aggressive volume resuscitation may lead to pulmonary edema (...) : Nonreassuring fetal testing including (nonreassuring nonstress test, biophysical profile score, and/or persistent absent or reversed diastolic flow on umbilical artery Doppler velocimetry) Ruptured membranes Uncontrollable BP (unresponsive to medical therapy) Oligohydramnios, with amniotic fluid index (AFI) of less than 5 cm Severe intrauterine growth restriction in which the estimated fetal weight is less than 5% Oliguria (< 500 mL/24 hr) Serum creatinine level of at least 1.5 mg/dL Pulmonary edema

2014 eMedicine.com

143. Hemostatic Disorders, Nonplatelet (Treatment)

for emergent treatment. ADAMTS13 deficiency can be caused by a genetic mutation or the action of autoimmune inhibitors. Several drugs have been implicated in the development of inhibitors and clinical TTP, including cyclosporine A, mitomycin-C, ticlopidine, simvastatin, atorvastatin (Lipitor), and clopidogrel (Plavix). Infection with the human immunodeficiency virus (HIV) has also been associated with TTP. Therapeutic plasma exchange with 40 mL fresh frozen plasma (FFP)/kg of body weight is the treatment (...) these variations, many clinicians consider measurement of fibrinogen activity by thromboelastography to be the most accurate measurement of dysfibrinogenemia or qualitative dysfunctions. [ , ] Treatment Treatment of afibrinogenemia/dysfibrinogenemia depends on the presenting clinical setting. Plasma fibrinogen is best replaced by . Purified, virally inactivated fibrinogen concentrates (eg, ) can be used if available. [ , ] Prophylactic blood product or fibrinogen therapy has no role. Recommendations

2014 eMedicine.com

144. Genital Herpes in Pregnancy (Treatment)

Serdar H Ural, MD Associate Professor of Obstetrics and Gynecology and Radiology, Director, Division of Maternal-Fetal Medicine, Medical Director, Labor and Delivery Suite, Pennsylvania State University College of Medicine Serdar H Ural, MD is a member of the following medical societies: , , , , , Disclosure: Received honoraria from GSK for speaking and teaching; Received honoraria from J&J for speaking and teaching. What would you like to print? What would you like to print? Sections Genital Herpes (...) be associated with an increased risk of neonatal transmission. Unfortunately, PCR does not differentiate actively replicating HSV from latent HSV DNA. Previous Next: Antiviral Therapy Acyclovir , a nucleoside analogue, was the first antiviral therapy approved for the treatment and prevention of HSV infection. Acyclovir selectively inhibits viral DNA replication of HSV, while having little effect on normal cells. Acyclovir is selective for HSV-infected cells because it requires phosphorylation by a viral

2014 eMedicine.com

145. Filariasis (Treatment)

reactions. Assays to detect specific antibodies to Onchocerca and polymerase chain reaction to detect onchocercal DNA in skin snips are now in use in specialized laboratories and are highly sensitive and specific. Although current serologic assays have limited ability to discriminate past exposures from current infections, the detection of O volvulus DNA in microscopically negative skin snips is useful in individuals with subtle infections. Treatment of onchocerciasis Medical therapy is the drug (...) of choice for the treatment of onchocerciasis. It functions as a single dose and is a rapidly effective microfilaricide for O volvulus . Unlike , ivermectin does not produce a significant Mazzotti reaction in onchocerciasis, most likely because it acts by paralyzing the microfilariae in the skin tissue spaces and lymphatics. [ ] They are then swept away into the local lymph nodes, which may swell up, and only cause some local limb edema. On the other hand, DEC unmasks the microfilariae in the tissue

2014 eMedicine.com

146. Breech Presentation (Treatment)

subjects in the planned vaginal delivery group, 591 (56.7%) had vaginal deliveries. Indications for cesarean delivery included: fetopelvic disproportion or failure to progress in labor (226), nonreassuring fetal heart rate tracing (129), footling breech (69), request for cesarean delivery (61), obstetrical or medical indications (45), or cord prolapse (12). The composite measurement of either perinatal mortality or serious neonatal morbidity by 6 weeks of life was significantly lower in the planned (...) are attempted prior to 39 weeks, as long as there are no obstetrical or medical indications for induction, discharging the patient to await spontaneous labor would seem most prudent. In those with an unsuccessful ECV, the practitioner has the option of sending the patient home or proceeding with a cesarean delivery. Expectant management allows for the possibility of spontaneous version. Alternatively, cesarean delivery may be performed at the time of the failed ECV, especially if regional anesthesia is used

2014 eMedicine.com

147. Autonomic Dysreflexia in Spinal Cord Injury (Treatment)

with individuals with spinal cord injuries must be aware of this syndrome, recognize the symptoms, and understand the causes and treatment algorithm. [ , ] Briefly, autonomic dysreflexia develops in individuals with a neurologic level of spinal cord injury at or above the sixth thoracic vertebral level (T6). Autonomic dysreflexia causes an imbalanced reflex sympathetic discharge, leading to potentially life-threatening hypertension. It is considered a medical emergency and must be recognized immediately (...) symptoms and treatment for autonomic dysreflexia. Such cards can be found from multiple sources, including the following: Previous Next: Consultations If the cause of the episode of autonomic dysreflexia is not found and blood pressure remains elevated, emergency department care is recommended for medication management, close monitoring, and further investigation of the possible cause. Consult an ICU specialist for ICU monitoring and treatment of the hypertension. Physicians specializing in physical

2014 eMedicine.com

148. Neonatal Resuscitation (Treatment)

of regulated suction, instruments and supplies for establishing intravenous (IV) access, trays equipped for emergency procedures, and drugs that may be useful in resuscitation. Respiration equipment includes the following: Stethoscope Cardiorespiratory leads for neonates and cardiorespiratory monitor Pulse oximeter leads (neonatal size) and pulse oximeter monitor Oxygen supply with blender, set to 10 L/minute Assorted masks (term and preterm mask sizes) Positive Pressure Ventilation (PPV) device and tubing (...) compressions. Additional personnel should be immediately available to assist in tasks that may be required as part of resuscitation, including intubation, medication administration, and emergency procedures, if needed. If the delivery is identified as high-risk, at least 2 or more skilled individuals should be assigned to the infant at delivery. Remember that staff trained in neonatal resuscitation must apprentice with experienced personnel for some time before they can be independently responsible

2014 eMedicine Pediatrics

149. Maternal Chorioamnionitis (Treatment)

sepsis in neonates are prompt recognition of bacterial infection, antimicrobial therapy, and supportive care. (In this review, supportive care is only briefly discussed below. See the Medscape Drugs and Disease article for a more in-depth care of these critically-ill neonates.) Treatment of the neonate Communication between obstetric and pediatric caregivers is essential to recognize neonatal infection. Recognition or suspicion of maternal chorioamnionitis is essential to reducing neonatal morbidity (...) Maternal Chorioamnionitis (Treatment) Chorioamnionitis Treatment & Management: Approach Considerations, Medical Care, Consultations Edition: No Results No Results Please confirm that you would like to log out of Medscape. If you log out, you will be required to enter your username and password the next time you visit. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvOTczMjM3LXRyZWF0bWVudA

2014 eMedicine Pediatrics

150. Pathophysiology of Chronic Back Pain (Treatment)

Nonphysiological or implausible descriptions of pain may provide clues that operant or other psychosocial influences coexist. Prognostic red flags See the list below: Nonorganic signs and symptoms Dissociation between verbal and nonverbal pain behaviors Compensable cause of injury Out of work, disabled, or seeking disability Psychological features, including depression and anxiety Narcotic or psychoactive drug requests Repeated failed surgical or medical treatment for LBP or other chronic illnesses Physical (...) and interfere with the organism’s capacity to function and cope. Spinal pain is multifaceted, involving structural, biomechanical, biochemical, medical, and psychosocial influences that result in dilemmas of such complexity that treatment is often difficult or ineffective. [ ] Low back pain (LBP) is defined as chronic after 3 months because most normal connective tissues heal within 6-12 weeks, unless pathoanatomic instability persists. A slower rate of tissue repair in the relatively avascular

2014 eMedicine.com

151. Uterine Rupture in Pregnancy (Treatment)

% (1 in 8,434). This rate of spontaneous uterine rupture has not changed appreciably over the last 50 years, and most of these events occur at term and during labor. An 8-fold increased incidence of uterine rupture of 0.11% (1 in 920) has been noted in developing countries, with this increased incidence of uterine rupture having been attributed to a higher-than-average incidence of neglected and obstructed labor due to inadequate access to medical care. When the risk of uterine rupture for women (...) versus those with documented previous low-transverse hysterotomies. [ , ] The Maternal-Fetal Medicine Units (MFMU) Network cesarean delivery registry reports a 0.5% risk (15 of 3,206) of uterine rupture for patients who underwent a TOLAC with an unknown uterine scar. [ ] For cases in which there are 1 or 2 unknown prior uterine incisions, there is a single small, randomized, controlled trial by Grubb et al that compared labor augmentation with oxytocin (n=95) with no intervention (n=93) in women

2014 eMedicine.com

152. Viral Infections of the Mouth (Treatment)

varicella or zoster may benefit from oral antiviral drugs. Medical care for HHV-4 (EBV) Topical tretinoin gel may be used to manage oral hairy leukoplakia, but it often is not necessary. Topical podophyllin applications (a keratotic agent) may help to control HHV-4-associated hairy leukoplakia. Repeated treatment may be necessary to obtain satisfactory results. Management of the underlying immunosuppressed status may be a more useful strategy. Occasionally, the use of systemic antiviral medication may (...) be warranted. Potential toxicity, adverse effects, and complications of systemic therapy combined with a high risk of lesion reappearance and the benign nature of hairy leukoplakia support a conservative approach in the management of hairy leukoplakia. Medical care for HHV-5 (CMV) Similar to HHV-1/HHV-2, HHV-5-related ulceration of the oral cavity requires immediate referral to an ophthalmologist if ocular involvement is of concern. Systemic antiviral treatment (ie, with ganciclovir or valganciclovir

2014 eMedicine.com

153. Subdural Hematoma (Treatment)

no significant mass effect on imaging studies and no neurologic symptoms or signs except mild headache, chronic subdural hematomas have been observed with serial scans and have been seen to remain stable or to resolve. Although hematoma resolution has been reported, it cannot be reliably predicted, and no medical therapy has been shown to be effective in expediting the resolution of acute or chronic subdural hematomas. For more information, see the Medscape Reference article . Next: Surgical Decompression (...) requires surgical treatment, temporizing medical maneuvers can be used preoperatively to decrease intracranial pressure. These measures are germane for any acute mass lesion and have been standardized by the neurosurgical community. They are discussed only briefly. Adequate respiration should be initially addressed and maintained to avoid hypoxia. The patient's blood pressure should be maintained at normal or high levels using isotonic saline, pressors, or both. Hypoxia and hypotension, which

2014 eMedicine.com

154. Shock and Pregnancy (Treatment)

embolism mortality, United States, 1970-85. Am J Public Health . 1990 Jun. 80(6):720-2. . Media Gallery Determinants of cardiac function and oxygen delivery to tissues. Adapted from Strange GR. APLS: The Pediatric Emergency Medicine Course. 3rd ed. Elk Grove Village, Ill: American Academy of Pediatrics; 1998:34. of 1 Tables Contributor Information and Disclosures Author Marie Rosanne Baldisseri, MD, FCCM Associate Professor, Department of Critical Care Medicine, University of Pittsburgh Medical Center (...) , perfusion is insufficient to meet the metabolic demands of the tissues; consequently, cellular hypoxia and end-organ damage ensue. [ , ] Determinants of cardiac function and oxygen delivery to tissues. Adapted from Strange GR. APLS: The Pediatric Emergency Medicine Course. 3rd ed. Elk Grove Village, Ill: American Academy of Pediatrics; 1998:34. Next: Cardiovascular Physiology During Normal Pregnancy During pregnancy, significant cardiovascular changes occur, including changes in the blood volume, heart

2014 eMedicine.com

155. Seizure Disorders in Pregnancy (Treatment)

, treatment of seizures should be discussed a priori with the group of practitioners who are caring for the patient. AED levels should be checked upon admission. If the serum drug level is low, patients may be administered extra doses or may be switched over to intravenous benzodiazepines or phenytoin, although benzodiazepines can cause respiratory depression in the mother and the newborn. Status epilepticus Rarely, a patient has intractable seizures upon labor and delivery. When these last longer than 30 (...) 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 Ronald M Ramus, MD Professor of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Virginia Commonwealth University School of Medicine Ronald M Ramus, MD is a member of the following medical societies: , , , Disclosure

2014 eMedicine.com

156. Spatial Neglect (Treatment)

to this treatment are its simplicity and feasibility. The disadvantage is that, like prism adaptation treatment, few occupational therapists are trained to use this approach. Therapists report that this treatment is labor-intensive, as they need to remember to implement the movement cuing, which interrupts the chain of activities in training dressing, bathing, or other therapy goals during treatment sessions. Alternate approaches. Optikinetic stimulation, virtual reality, mental imagery, and neck vibration (...) neglect on impairment tests have persistent deficits.at 8–9 days. [ ] At 3 months, the NIH Stroke Scale detects neglect symptoms in 9.1% of patients. [ ] Because the NIH Stroke Scale does not sample functional performance, this is likely to underestimate chronic neglect prevalence. Patients who demonstrate symptoms of spatial neglect would be expected to benefit from referral for outpatient treatment with speech therapy, occupational and physical therapy, [ ] neuropsychological therapy

2014 eMedicine.com

157. Malposition of the Uterus (Treatment)

uterine suspension or a similar procedure. Therefore, clinicians must act conservatively and critically review claims about the relief or lessening of abdominal-pelvic distress after any procedure or therapy to correct retroversion. [ ] Diagnosis A common clue is a history of progressive difficulty with normal voiding that develops in the early midtrimester. Complaints of pelvic pain and/or pressure or uterine cramping usually accompanies the urinary symptoms. Vaginal spotting may also be present (...) in symptoms of pressure or urinary dysfunction similar to those of simple incarceration. Treatment Possible therapies for retroversion with incarceration include the following: Bladder decompression by means of intermittent or indwelling catheter drainage Patient positioning (eg, intermittent knee-chest or all-fours positioning, sleeping prone) Manual uterine replacement: manipulation of the uterus into its usual anatomic position, with or without tocolysis and/or anesthesia Colonoscopic manipulation

2014 eMedicine.com

158. Liver Disease and Pregnancy (Treatment)

vomiting; consider administering thiamine before dextrose infusion to prevent Wernicke encephalopathy. Begin enteral tube feeding (nasogastric or nasoduodenal) as first-line treatment to support nutrition for women with hyperemesis gravidarum who do not respond to medical therapy and who are unable to maintain their weight. Use peripherally inserted central catheters only as a last resort in women with hyperemesis gravidarum, as significant complications are associated with this intervention (...) history of injection drug use, having had multiple sexual partners in the previous 6 months, having a sexual partner who is positive for HBsAg, or previous treatment for an STI in pregnancy should be tested upon admission to labor and delivery. Women who test positive should be reported to the state or local health department as per the local law requirements. The patient should be counseled about the modes of transmission and the prevention of hepatitis B, neonatal concerns, and understand that all

2014 eMedicine.com

159. Nephrolithiasis: Acute Renal Colic (Treatment)

=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvNDM3MDk2LXRyZWF0bWVudA== processing > Nephrolithiasis Treatment & Management Updated: Jun 21, 2018 Author: Chirag N Dave, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS Share Email Print Feedback Close Sections Sections Nephrolithiasis Treatment Approach Considerations Treatment of nephrolithiasis involves emergency management of renal (ureteral) colic, including surgical interventions where indicated, and medical therapy for stone disease. In emergency settings where concern exists about possible renal failure (...) individual. For example, the presence of a ureteropelvic junction (UPJ) obstruction or a ureteral stricture could make passing even very small stones difficult or impossible. Most experienced emergency department (ED) physicians and urologists have observed very large stones passing and some very small stones that do not move. Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage. Aggressive treatment of any

2014 eMedicine.com

160. Nephrolithiasis (Treatment)

== processing > Nephrolithiasis Treatment & Management Updated: Jun 21, 2018 Author: Chirag N Dave, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS Share Email Print Feedback Close Sections Sections Nephrolithiasis Treatment Approach Considerations Treatment of nephrolithiasis involves emergency management of renal (ureteral) colic, including surgical interventions where indicated, and medical therapy for stone disease. In emergency settings where concern exists about possible renal failure, the focus (...) , the presence of a ureteropelvic junction (UPJ) obstruction or a ureteral stricture could make passing even very small stones difficult or impossible. Most experienced emergency department (ED) physicians and urologists have observed very large stones passing and some very small stones that do not move. Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage. Aggressive treatment of any proximal urinary infection

2014 eMedicine.com

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