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Emergency Medicine Treatment and Labor Act

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161. 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

162. 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

163. Impairment Rating of Neuromusculoskeletal Conditions (Treatment)

to evaluate, report on, and communicate information about impairments to any human organ system. [ ] According to the AMA Guides, impairment is an alteration of an individual's health status that has been assessed by medical means. Impairment is used to describe a static or stable condition that has had sufficient time to allow optimal tissue repair and that is unlikely to change, despite further medical or surgical therapy. The Florida Impairment Schedule defines impairment as anatomic or functional (...) and eliminate bias. For purposes of evaluation, the patient's medical condition should be stable and unlikely to change in the future despite further treatment. Treatment at this point is palliative rather than restorative. Obtain clinical information from the patient's medical records and from physical examination. Compare clinical information from several sources to check for consistency. Resolve disparities when possible, if the clinical information is inconsistent. Use medically accepted

2014 eMedicine.com

164. 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

165. 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

166. Normal and Abnormal Puerperium (Treatment)

ice applied to the perineum to reduce the swelling and to help with pain relief. Conventional treatment is to use ice for the first 24 hours after delivery and then switch to warm sitz baths. However, little evidence supports this method over other methods of postpartum perineum treatment. Pain medications are helpful both systemically as nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotics and as local anesthetic spray to the perineum. Hemorrhoids are another postpartum issue likely (...) blood count and coagulation studies (fibrinogen, prothrombin time/activated partial thromboplastin time) to exclude resulting anemia or coagulopathy, which may require further treatment with blood products. It is also important that any patient admitted to the labor and delivery unit have an active blood sample (type and screen) available if the need for urgent transfusion arises. A “clot observation test” has been used to detect coagulation problems prior to the return of laboratory studies

2014 eMedicine.com

167. Neurologic Disease and Pregnancy (Treatment)

posterior leukoencephalopathy (RPLE) (see below) is occasionally seen on imaging studies. [ ] Brain images are usually normal. Treatment of seizures usually includes , but benzodiazepines or rapidly acting antiepileptic drugs (AEDs), such as , may be required. Generally, long-term AED treatment is not needed once the patient’s blood pressure has returned to normal and stabilized. However, no data are available to determine precisely how long short-term treatment should last; for the most part, local (...) with low serum folate levels were most likely to have restless legs. Dopamine receptor agonists have been highly effective in relieving RLS, but their safety during pregnancy has not been demonstrated; other proven treatments include narcotics, benzodiazepines, certain antiepileptic drugs (AEDs), and . These agents are associated with varying levels of risk to the fetus (see Table 3 below). Table 3. Risks of Drug Therapies for Restless Leg Syndrome in Pregnancy Drug Class Generic Name level of Risk

2014 eMedicine.com

168. Neurosyphilis (Treatment)

with antibiotic therapy. Treatment of Neurosyphilis The earliest effort at treatment is key. Prevention, overall, from a public health standpoint, would be most appropriate. Identification of high-risk groups (eg, men who have sex with men [ ] ) with educational programs would limit disease and consequent suffering. Vigilant screening of high-risk patients, including in the area of congenital syphilis, by the medical community remains essential. Adequate treatment of neurosyphilis is based largely (...) ashamed to seek medical treatment from their regular clinicians. Some were so stigmatized and marginalized that they simply committed suicide. The recipes, of note, included a variety of everyday herbs and substances, such as incense, chamomile, earthworms, and chicken fat. Occasionally, more expensive and exotic ingredients, such as Artemisia dracunculus (tarragon), badger fat, bear fat, goose fat, or blood from a male pig, were used, especially if the case seemed particularly stubborn. The Italian

2014 eMedicine.com

169. 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

170. 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

171. Thrombocytopenia in Pregnancy (Treatment)

from the mother), with IVIG emerging as the first-line therapy. PUBS is used to assess the response to medical therapy; however, a significantly higher risk of fetal exsanguination exists with PUBS and fetal thrombocytopenia. Randomized clinical trials are ongoing to determine the optimal antenatal therapy for this potentially devastating condition. Prevention The key to prevention is the recognition of a previously affected infant with alloimmune thrombocytopenia, because recurrence is close (...) purpura, ecchymoses, and melena. Major bleeding complications include intracranial hemorrhage leading to neurologic impairment or death. Diagnosis ITP is a diagnosis of exclusion as there are no diagnostic tests or signs and symptoms. The following may be noted: Persistent thrombocytopenia (< 100,000/μL), increased number of megakaryocytes in the bone marrow, exclusion of systemic disorders or medications/drugs, absence of splenomegaly Approximately 80% of cases are associated with antiplatelet

2014 eMedicine.com

172. Suicide (Treatment)

event (SE) suicides by diagnosis and method. Courtesy of the New York State Office of Mental Health. The choice of treatment is dictated by the specific mental illness affecting the patient. Talking therapies can help, and in many instances, medication can alleviate symptoms of mental illness. However, despite intervention, if the patient does die by suicide, a number of steps can and should be undertaken for the patient's family, other patients, the staff, and the therapist. Terminology Suicide (...) means killing oneself. The act constitutes a person willingly, perhaps ambivalently, taking his or her own life. Several forms of suicidal behavior fall within the self-destructive spectrum. Death by suicide means the person has died. It is important not to use the term successful suicide; the goal is to prevent suicide and provide treatment. A suicide attempt involves a serious act, such as taking a fatal amount of medication and someone intervening accidentally. Without the accidental discovery

2014 eMedicine.com

173. 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

174. 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

175. Toxicity, Cocaine (Treatment)

MI) and subarachnoid hemorrhage or concomitant use of other drugs (eg, heroin). Most patients with cocaine-associated pulmonary edema respond to standard medical treatment. For resistant hypoxemia, positive-pressure ventilation with continuous positive airway pressure (CPAP) or intubation supplemented with positive end-expiratory pressure (PEEP) is usually effective. For patients with respiratory depression intubation may be indicated, as it is for those with apnea. Administration of naloxone (...) and treatment. JAMA . 1983 Sep 16. 250(11):1417-20. . Prosser JM, Perrone J. Cocaine and Amphetamines. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide . 8th ed. NY: McGraw-Hill Education; 2016. 1256-59. Renzi FP. Cocaine poisoning. Harwood-Nuss AL, ed. The Clinical Practice of Emergency Medicine . 2nd ed. Philadelphia, Pa: Lippincott Raven Publishers; 1996. [Guideline] American Heart Association. Part 10: Special

2014 eMedicine.com

176. Toxicity, MDMA (Treatment)

. . Amoroso T. The Psychopharmacology of ±3,4 Methylenedioxymethamphetamine and its Role in the Treatment of Posttraumatic Stress Disorder. J Psychoactive Drugs . 2015 Nov-Dec. 47 (5):337-44. . Media Gallery of 0 Tables Contributor Information and Disclosures Author In-Hei Hahn, MD, FACEP, FACMT Attending Physician, Department of Emergency Medicine, NYU Langone-Cobble Hill In-Hei Hahn, MD, FACEP, FACMT 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. 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: , , , , , , Disclosure

2014 eMedicine Emergency Medicine

177. Toxicity, Chlorine Gas (Treatment)

Medicine, Albert Einstein Medical Center Gerald F O'Malley, DO is a member of the following medical societies: , , , , , Disclosure: Received consulting fee from McNeil Pharmaceuticals for speaking and teaching. Coauthor(s) Robert Bassett, DO, FAAEM Fellow in Medical Toxicology, Department of Emergency Medicine, Einstein Medical Center; Clinical Assistant Professor of Emergency Medicine, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine Robert Bassett, DO, FAAEM is a member (...) . Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital Disclosure: Nothing to disclose. John T VanDeVoort, PharmD Regional Director of Pharmacy

2014 eMedicine Emergency Medicine

178. Toxicity, Cocaine (Treatment)

MI) and subarachnoid hemorrhage or concomitant use of other drugs (eg, heroin). Most patients with cocaine-associated pulmonary edema respond to standard medical treatment. For resistant hypoxemia, positive-pressure ventilation with continuous positive airway pressure (CPAP) or intubation supplemented with positive end-expiratory pressure (PEEP) is usually effective. For patients with respiratory depression intubation may be indicated, as it is for those with apnea. Administration of naloxone (...) and treatment. JAMA . 1983 Sep 16. 250(11):1417-20. . Prosser JM, Perrone J. Cocaine and Amphetamines. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide . 8th ed. NY: McGraw-Hill Education; 2016. 1256-59. Renzi FP. Cocaine poisoning. Harwood-Nuss AL, ed. The Clinical Practice of Emergency Medicine . 2nd ed. Philadelphia, Pa: Lippincott Raven Publishers; 1996. [Guideline] American Heart Association. Part 10: Special

2014 eMedicine Emergency Medicine

179. Pregnancy, Delivery (Treatment)

was passed as a part of a much larger bill, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Consequently, the acronym COBRA was used frequently in medical literature when referring to the statute. This statute is also titled the Emergency Medical Treatment and Active Labor Act (EMTALA). Since the latter name is more specific and descriptive, it has become the preferred acronym for referring to the statute. The full text of the statute can be found in any public library's reference (...) of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. Mark Zwanger, MD, MBA Mark Zwanger, MD, MBA is a member of the following medical societies: Disclosure: Nothing to disclose. Chief Editor Mark A Clark, MD Medical Director, Block Island Medical Center; Assistant Clinical Professor, Department of Emergency Medicine, St Luke's-Roosevelt Hospital Center Mark A Clark, MD is a member of the following medical societies: , , , Disclosure

2014 eMedicine Emergency Medicine

180. Pregnancy, Preeclampsia (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 Emergency Medicine

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