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Emergency Medicine Treatment and Labor Act

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141. 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

142. Eisenmenger Syndrome (Treatment)

. . Hascoet S, Baruteau A, Humbert M. 0425: Prognostic value of invasive hemodynamic parameters in Eisenmenger syndrome [abstract]. Arch Cardiovasc Dis Suppl . Jan 2016. 8(1):101-2. . [Guideline] Badesch DB, Abman SH, Simonneau G, Rubin LJ, McLaughlin VV. Medical therapy for pulmonary arterial hypertension: updated ACCP evidence-based clinical practice guidelines. Chest . 2007 Jun. 131 (6):1917-28. . Maron BA, Galie N. Diagnosis, treatment, and clinical management of pulmonary arterial hypertension (...) syndrome: results of the BREATHE-5 open-label extension study. Int J Cardiol . 2008 Jun 23. 127 (1):27-32. . Elshafay A, Truong DH, AboElnas MM, et al. The effect of endothelin receptor antagonists in patients with Eisenmenger syndrome: a systematic review. Am J Cardiovasc Drugs . 2017 Jun 28. . Ereminiene E, Kinderyte M, Miliauskas S. Impact of advanced medical therapy for the outcome of an adult patient with Eisenmenger syndrome. Respir Med Case Rep . 2017. 21:16-20. . Adriaenssens T, Delcroix M, Van

2014 eMedicine.com

143. 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

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. Cesarean Delivery (Treatment)

in the rate of cesarean delivery. The benefit was driven by the effect of the intervention in low-risk pregnancies. [ , ] Indications Many indications exist for performing a cesarean delivery. In those women who are having a scheduled procedure (ie, an elective or indicated repeat, for malpresentation or placental abnormalities), the decision has already been made that the alternate of medical therapy, ie, a vaginal delivery, is least optimal. For other patients admitted to labor and delivery (...) who are near term should be offered external cephalic version (ECV) to decrease the overall rate of cesarean delivery. [ , ] ACOG/SMFM guidelines for prevention of primary cesarean delivery The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) released joint guidelines for the safe prevention of primary cesarean delivery. These include the following [ , ] : Prolonged latent (early)-phase labor should be permitted The start of active-phase

2014 eMedicine.com

146. Clavicular Injuries (Treatment)

of Wisconsin Craig C Young, MD is a member of the following medical societies: , , , Disclosure: Nothing to disclose. Acknowledgements Lawrence C Brilliant, MD Clinical Assistant Professor, Department of Primary Care and Community Services, MCP Hahnemann University; Attending Physician, Department of Emergency Medicine, Doylestown Hospital Lawrence C Brilliant, MD is a member of the following medical societies: American College of Emergency Physicians Disclosure: Nothing to disclose. Francis Counselman, MD (...) , FACEP Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School Francis Counselman, MD, FACEP is a member of the following medical societies: , , Association of Academic Chairs of Emergency Medicine (AACEM), , and Disclosure: Nothing to disclose. Kevin J Eerkes, MD Clinical Assistant Professor, Department of Medicine, New York University School of Medicine; Medical Team Physician, New York University Athletics Disclosure: Nothing to disclose. Janos P Ertl, MD Assistant

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. Hypercoagulability: Hereditary Thrombophilia and Lupus Anticoagulants Associated With Venous Thrombosis and Emboli (Treatment)

as alternatives to warfarin. They have been approved for use in VTE prophylaxis, VTE treatment, and stroke prevention in non-valvular atrial fibrillation. In patients with heparin-induced thrombocytopenia, fondaparinux, a long-acting anti-Xa agent, is thought to have advantages over the short-acting antithrombin agents argatroban and bivalirudin. [ ] Direct oral anticoagulants have several possible advantages over warfarin, including the following: No or limited interaction with other drugs and diet Metabolic (...) . [ ] Idarucizumab, a humanized monoclonal antibody that binds to and inactivates dabigatran, has received expedited approval from the US Food and Drug Administration (FDA). Andexanet alfa is a genetically engineered factor Xa molecule that has no procoagulant activity but can bind with and neutralize both direct factor Xa inhibitors (eg, rivaroxaban, apixaban, edoxaban) and the factor Xa inhibitors that act through antithrombin (LMWHs and fondaparinux). A of andexanet for treatment of acute major bleeding

2014 eMedicine.com

149. Psychosocial and Environmental Pregnancy Risks (Treatment)

to be measurable in the fetal circulation compared to other chemicals. Recent studies indicate that more than 90% of pregnant women take medication during pregnancy, and many women take more than 4 different drugs during the course of pregnancy. The US Food and Drug Administration (FDA) requires animal testing before the approval of new medications. The FDA also uses a classification system to define fetal risks for all FDA-approved drugs. The pharmaceutical pregnancy risk classification by the FDA (...) of the defined regulations, prescribing through the internet, [ ] medication noncompliance. [ ] Etretinate is an extremely long-lasting oral retinoid used in the treatment of psoriasis. The medication is detectable in serum for more than 2 years after use. Neural tube defects, CNS malformations, skeletal abnormalities, and craniofacial defects have been observed. The duration with which the drug may continue to cause abnormalities is unknown. Etretinate should not be used in women of childbearing age

2014 eMedicine.com

150. Pulmonary Disease and Pregnancy (Treatment)

concentration. Because the glomerular filtration rate increases during gestation, drugs primarily eliminated by renal excretion are cleared more rapidly during pregnancy. Evaluation of medication use during pregnancy When considering use of a drug during pregnancy, ask the following questions: Is the drug necessary? What animal or human data are available to assess the effect of the drug on the fetus? What is the effect of the drug on the pregnancy, including labor and delivery? Does the dose or dosing (...) woman have symptomatic reflux. Initial therapy might consist of small meals and raising the head of the bed by 6 inches. Some patients might require antacids or H2-receptor–blocking medications. Medications during pregnancy While a natural reluctance exists to prescribe drug therapy in pregnancy, poorly controlled asthma is potentially more dangerous for the fetus than medication. The classic teratogenic period in humans occurs from 4-10 weeks after the last menstrual period. Medications are added

2014 eMedicine.com

151. Pyelonephritis, Acute (Treatment)

be treated initially in the emergency department (ED) with vigorous oral or IV fluids, antipyretic pain medication, and a dose of parenteral antibiotics. Studies have shown that outpatient therapy for selected patients is as safe as inpatient therapy for a comparable group of patients and is much less expensive. Use analgesics as needed. Early in the course of the illness, parenteral analgesics are often necessary to reduce morbidity from symptoms. Nonsteroidal anti-inflammatory drugs and narcotics (...) University School of Medicine; Chief, Renal Section, Southeast Louisiana Veterans Health Care System Vecihi Batuman, MD, FASN is a member of the following medical societies: , , , , Disclosure: Nothing to disclose. Acknowledgements Amy J Behrman, MD Associate Professor, Department of Emergency Medicine, Director, Division of Occupational Medicine, University of Pennsylvania School of Medicine Amy J Behrman, MD is a member of the following medical societies: Disclosure: Nothing to disclose. Christopher

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. Vaginal Birth After Cesarean Delivery (Treatment)

, PhD Department Chair, Department of Obstetrics and Gynecology, Julie Newpert Stott Director of Center for Women's Health, Oregon Health and Science University School of Medicine Aaron B Caughey, MD, MPH, PhD 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 (...) related to managing patients undergoing trials of labor after cesarean delivery, they are less likely to allow new patients to undergo a trial of labor. In addition, 1999 guidelines from the American College of Obstetricians and Gynecologists (ACOG) stated explicitly that patients undergoing TOLAC require the presence of an obstetrician, an anesthesiologist, and/or a staff capable of performing an emergency cesarean delivery throughout the patient’s active phase of labor. [ ] Whereas academic centers

2014 eMedicine.com

154. Urological Management in Neurological Disease (Treatment)

sensory deficit and erectile dysfunction. [ ] A flaccid, unresponsive bladder can be seen in patients who are overmedicated with tricyclic antidepressants or antiparkinson medications or who have electrolyte imbalances. Tricyclic antidepressants have anticholinergic properties and tend to decrease detrusor contractility. This property of drugs such as imipramine and amitriptyline has led to their being frequently used for the treatment of detrusor instability. When used in higher dose ranges (...) neck. Medical management is focused on increasing pelvic floor function. Estrogen replacement helps restore mucosal function, which in the female plays a large role in maintaining intraurethral pressure. Drugs that increase outflow resistance include alpha-agonists. and phenylpropanolamine have been used, but their adverse effects, such as palpitations, headache, and tremor, can be troublesome. Imipramine (and other tricyclic antidepressants) decrease bladder activity but also increase outflow

2014 eMedicine.com

155. 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

156. Women's Health and Epilepsy (Treatment)

vaginal blood flow in women with epilepsy compared with controls. [ ] Treatment of sexual dysfunction must begin with identification of potential psychologic factors and appropriate counseling or therapy. Physiologic factors should be identified by an overall review of health and medications. Simplifying polytherapy to monotherapy or changing an antiepileptic drug to another better-tolerated agent may be considered. Previous Next: Contraception Issues in Epilepsy Women taking cytochrome P450 enzyme (...) patients on anticonvulsant treatment. Contraception . 1986 Jun. 33(6):559-65. . Thorneycroft I, Klein P, Simon J. The impact of antiepileptic drug therapy on steroidal contraceptive efficacy. Epilepsy Behav . 2006 Aug. 9(1):31-9. . Harden CL. Do the results of pregnancy registries contradict one another?. Epilepsy Curr . 2006 May-Jun. 6(3):73-5. . . Dansky LV, Rosenblatt DS, Andermann E. Mechanisms of teratogenesis: folic acid and antiepileptic therapy. Neurology . 1992 Apr. 42(4 Suppl 5):32-42

2014 eMedicine.com

157. Hypothyroidism (Treatment)

to treatment Some patients with subacute or postpartum thyroiditis can develop thyrotoxicosis (or symptoms consistent with hyperthyroidism) before developing hypothyroidism. These patients also may benefit from consultation with an endocrinologist. Suspected myxedema coma is a medical emergency with a high risk of mortality, and it necessitates requires initiation of IV LT4 and glucocorticoid therapy before laboratory confirmation. An urgent endocrinology consultation should be obtained. Rarely (...) increments in the dose titrated upward using serum TSH as the goal. Dose adjustments should be made upon significant changes in body weight, with aging, and with pregnancy; TSH assessment should be performed 4-6 weeks after any dosage change. Reference ranges of serum TSH levels are higher in older populations (eg, >65 years), so higher serum TSH targets may be appropriate. A meta-analysis of randomized, controlled trials of T4-triiodothyronine (T3) combination therapy versus T4 monotherapy for treatment

2014 eMedicine.com

158. 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

159. 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

160. 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

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