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Emergency Medicine Treatment and Labor Act


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161. 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


162. 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


163. 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


164. 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


165. 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


166. 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


167. 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


168. 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


169. 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


170. 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


171. 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


172. 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


173. 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


174. 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


175. Shoulder Dislocations (Treatment)

Shoulder Dislocations (Treatment) Shoulder Dislocation Surgery Treatment & Management: Approach Considerations, Medical Therapy, Surgical Therapy 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. (...) Medicine Clinic 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. Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine Pekka A Mooar, MD is a member of the following medical societies: Disclosure: Nothing to disclose

2014 eMedicine Surgery

176. Perianal Abscess (Treatment)

if the patient is elderly, febrile, hypotensive, or immunocompromised or has significant comorbidities. Transfer, if warranted, may be safely carried out if the patient is hemodynamically stable. Instability resulting from a concurrent condition or sepsis makes transfer to another institution inappropriate (and possibly illegal under the Emergency Medical Treatment and Active Labor Act [EMTALA]) unless transfer to allow delivery of a higher level of care is in the patient’s best interest. Next: Pharmacologic (...) , Department Of Emergency Medicine, State University of New York Downstate Medical Center Nizar Kifaieh, MD, FACEP is a member of the following medical societies: , , , , , and Disclosure: Nothing to disclose. 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 Patrick B Thomas, MD Fellow, Department of Pediatric Surgery, Texas Children's Hospital Disclosure

2014 eMedicine Surgery

177. Blunt Chest Trauma (Treatment)

. This approach is most frequently used when severe associated injuries are present that require urgent correction. Temporizing medical therapy includes the administration of short-acting beta-blockers (eg, labetalol, esmolol) to control the heart rate and to decrease the mean arterial pressure to approximately 60 mm Hg. Because repair of thoracic aortic injuries using cardiopulmonary bypass is associated with fewer major neurologic complications, some authors advocate stabilization of the victim plus beta (...) , in those with rib fractures. Elderly patients with three or more rib fractures have been shown to have a fivefold increase in mortality and a fourfold increase in the incidence of pneumonia. Effective pain control is the cornerstone of medical therapy for patients with rib fractures. For most patients, this consists of oral or parenteral analgesic agents. Intercostal nerve blocks may be feasible for those with severe pain who do not have numerous rib fractures. A local anesthetic with a relatively long

2014 eMedicine Surgery

178. Abdominal Trauma, Penetrating (Treatment)

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 (...) General Hospital and Harvard Medical School Robert L Sheridan, MD is a member of the following medical societies: , , , and Disclosure: Nothing to disclose. 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 Paul A Testa, MD, JD, MPH Attending Physician, Department of Emergency Medicine, New York University School of Medicine Paul A Testa, MD, JD, MPH

2014 eMedicine Surgery

179. Schizophrenia (Treatment)

, the type of restraint used (eg, locked room vs 4-point leather), the maximum duration of restraint, and reasons for involuntary commitment. [ ] Follow all Consolidated Omnibus Budget Reconciliation Act (COBRA) regulations when transferring patients to another facility for psychiatric care. Be familiar with hospital and ED specific regulations, Health Insurance Portability and Accountability Act (HIPAA) rules, regional statutes, and Emergency Medical Treatment and Labor Act (EMTALA) requirements (...) complications of schizophrenia and its treatment. Blood levels of certain psychiatric drugs, such as lithium and antiseizure medications used as mood-stabilizers (eg, valproic acid, carbamazepine), can be used to confirm compliance or rule out toxicity. Serum alcohol levels and drugs-of-abuse screening (blood and/or urine) can be useful when substance abuse is suspected. Interpreting the results of a fingerstick blood glucose determination is a rapid and inexpensive method of ruling out a diabetic emergency

2014 eMedicine Emergency Medicine

180. 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

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