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Esophageal Rupture

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141. Tide Pod Challenge: Managing caustic laundry pod ingestions

is converted to lactic acid, causing a lactic acidosis. CNS: Ethanol and propylene glycol in the pods are hypothesized to contribute to altered mental status ( ). GI: Pharyngeal and esophageal burns may occur due to caustic burn. These may lead to rupture from liquefaction necrosis in severe cases. GI irritation associated with vomiting, while the long chain polymers are associated with diarrhea. Renal: Dehydration secondary to vomiting and diarrhea, combined with propylene glycol thought to cause renal (...) for surgery include esophageal perforation, peritoneal signs and free intraperitoneal air. Relative indications include large volume (>150 mL) ingestions, signs of shock, respiratory distress, persistent lactic acidosis, ascites and pleural fluid. COMPLICATIONS Overall, short term prognosis is worst with Grade 3 (severe) GI injury, systemic complications, and age >65 years. Long term complications include esophageal strictures, which can form from scar tissue after mucosal remodeling. These strictures can

2018 CandiEM

142. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm

. ---- | ---- Fig 5 Algorithm for management of the patient with a suspected or confirmed ruptured abdominal aortic aneurysm ( AAA ). CT, Computed tomography; IVs, intravenous lines. ---- | ---- Fig 6 Referring hospital checklist for the patient with a suspected or confirmed ruptured aneurysm. ---- | Fig 7 Receiving hospital personnel alert checklist for management of the patient with a suspected or confirmed ruptured aneurysm. Hide Pane Expand all Collapse all Article Outline Abstract Background Decision (...) -making related to the care of patients with an abdominal aortic aneurysm (AAA) is complex. Aneurysms present with varying risks of rupture, and patient-specific factors influence anticipated life expectancy, operative risk, and need to intervene. Careful attention to the choice of operative strategy along with optimal treatment of medical comorbidities is critical to achieving excellent outcomes. Moreover, appropriate postoperative surveillance is necessary to minimize subsequent aneurysm-related

2018 Society for Vascular Surgery

143. CRACKCast E168 – Pediatric Respiratory Emergencies: Upper Airway Obstruction and Infections

with resultant: Clinical distress/toxicity of the patient Degree of airway obstruction Get help from an experienced ENT; These are difficult airways – may be distorted and at risk for rupturing! Features that suggest abscess and require surgical intervention include: imaging findings of scalloping of the abscess wall, rim enhancement, and lesions larger than 2 cm. The decision to admit and provide a trial of antibiotic therapy should be made between the emergency clinician and otolaryngology consultant (...) ] List a differential diagnosis for stridor (8) (review) Epiglottitis RPA Bacterial tracheitis Foreign body Croup Vocal cord paralysis/dysfunction Congenital laryngo-tracheomalacia (Downs, digeorge) Webs/rings/esophageal hemangiomas Extra-tracheal masses (double aortic arch, anomalous arteries, mediastinal masses/cysts) [2] List 5 Xray findings of epiglottitis Shoot that lateral neck xray! Thumbprint sign (big epiG!) Thickened aryepiglottic folds Lack of air in the vallecula Dilated hypopharynx

2018 CandiEM

144. CRACKCast E172 – Pediatric Gastrointestinal Disorders

to suction Labs, cultures, Glucose replacement Vasoactive agents as needed Broad spectrum ABX (See box 171.2) Consult surgery – in consideration of possible GERD GERD occurs as a result of an incompetent lower esophageal sphincter. GER is classified as a disease aka GERD if complications occur. For example, chronic reflux of gastric contents into the esophagus may result in esophagitis, aspiration, and failure to thrive if it is severe. Begins shortly after birth and resolves with time, usually (...) , frequent burpings, formula thickened with cereal, and a semi-upright position after feeding . Pharmacologic regimens are not recommended for infants with uncomplicated reflux (so-called happy spitters). Although lacking supportive evidence, acid suppression can be used, but should be reserved for those with more severe symptoms, such as esophagitis, weight loss, or significant irritability, in whom more conservative lifestyle modifications have failed. [8] What is the preferred diagnostic test

2018 CandiEM

145. CRACKCast E178 – Co-Morbird Medical Emergencies During Pregnancy

. Maternal—variable changes in seizure frequency; alterations in AEM levels; increased seizure frequency secondary to voluntary medication noncompliance; abruption, anemia, hyperemesis gravidarum, preeclampsia, possible need for labor induction and cesarean section, premature rupture of membranes. (AEM = antiepileptic medications) Management of status epilepticus is the same as for the nonpregnant patient. The newer AEM levetiracetam has demonstrated a lower incidence of birth defects and has equal (...) affect labor? Beta agonists are tocolytics and often halt labour. [2] Which types of valvular heart disease cause the most problems during pregnancy? Mitral stenosis > class 1 fcor Advanced aortic stenosis Aortic or mitral lesions associated with pulmonary hypertension or ventricular dysfunction Mechanical prosthetic valves requiring anticoagulation See Table 179.5 in Rosen’s 9 th Edition Ddx of chest pain in pregnancy: Pulmonary embolus, reflux esophagitis, biliary colic, and aortic dissection

2018 CandiEM

146. Neonatal stabilisation for retrieval

is not possible contact the Retrieval Service Queensland (RSQ) for advice regarding management prior to the baby’s birth. Early activation of the retrieval team prior to the baby’s birth can be made when indicated. Table 1. Indications for transfer Aspect Comment Antenatal 7,8 · Known congenital anomaly · Multiple birth · Suspected cardiac anomaly · Fetal growth restriction · Preterm labour (as relevant to CSCF) · Placenta praevia · Pre-eclampsia · Prolonged rupture of membranes Neonatal 8,9 · Birth weight: o (...) of respiratory distress. Group B Streptococcus is recognised as the most frequent cause of early onset neonatal sepsis. 50 Refer to Queensland Clinical Guideline Early onset Group B Streptococcal disease (EOGBSD). 51 Table 13. Sepsis Aspect Consideration Risk factors 49,50 · Maternal: o Intrapartum fever o Chorioamnionitis o Prolonged rupture of membranes o Group B Streptococcal colonisation or bacteriuria o Other infections—herpes, hepatitis B, syphilis · Neonatal: o Prematurity—less than 37 weeks gestation

2018 Clinical Practice Guidelines Portal

147. Imaging Guidelines

scan is positive or inconclusive for the purpose of: 4 z Evaluating collecting system rupture in the setting of renal trauma, or z Evaluating for active bleeding and formation of hematomas. Delayed scans are focused on the area of interest and are performed with a lower dose than the initial scan. MDCT must be readily available 24/7/365 in trauma centers. Technology advances have reduced acquisition times and improved image quality. Consequently, MDCT has replaced conventional diagnostic

2018 American College of Surgeons

148. Unique case of esophageal rupture after a fall from height. (PubMed)

Unique case of esophageal rupture after a fall from height. Traumatic ruptures of the esophagus are relatively rare. This condition is associated with high morbidity and mortality. Most traumatic ruptures occur after motor vehicle accidents.We describe a unique case of a 23 year old woman that presented at our trauma resuscitation room after a fall from 8 meters. During physical examination there were no clinical signs of life-threatening injuries. She did however have a massive amount (...) presents a high cervical esophageal rupture without associated local injuries after a fall from height.

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2009 BMC Emergency Medicine

150. CRACKCast E130 – Viruses

impairment, and ocular disturbances. Most severe infections occur in immunocompromised people: Post solid organ transplant HIV with CD4 < 100/mcL CMV manifests initially as fever, malaise, and myalgias. The infection can then progress to cause leukopenia, pneumonia, esophagitis/gastritis, hepatitis, colitis, encephalitis, polyradiculopathy, and retinitis. Diagnosis PCR, viral culture, or antibody testing. Treatment: Immunocompetent patients: supportive care (as for EBV) unless life-threatening infection (...) , streptococcal pharyngitis, toxoplasmosis, and other causes of viral pharyngitis should all be considered in potential mononucleosis patients. Splenomegaly (50% of patients) – with subsequent risk of rupture (<0.5%) advise patients to avoid contact sports for at least 3 weeks to avoid the feared complication of splenic rupture. Abdominal ultrasound for assessment of spleen size may have a role in determining when it is safe to return to sports. Airway obstruction in children – <5% Iatrogenic rash – post

2017 CandiEM

151. CRACKCast E089 – Esophagus, Stomach & Duodenum

dilation 4) List 5 diagnostics tests that may be utilized for dysphagia. Video esophagography Barium swallow Manometry Impedance monitoring CT – imaging with/without contrast for vascular / malignancy / external compression ***These are RARELY indicated in the ED workup of a patient, and should be coordinated with the PCP or consultant*** Admit those patients who: 1) Cannot swallow safely (risk for aspiration or risk for esophageal rupture) 2) Are unable to maintain adequate hydration 5) What are 4 (...) to section: throat-esophagus and then stomach. 1) List the the types of dysphagia. What is an ED approach to this condition? Swallowing is divided into oral, pharyngeal, and esophageal phases. Failure at any one of these levels results in dysphagia, which literally means “difficulty Swallowing.” When it comes to causes, just think M&M. The problem is either a mechanical block or a motility problem. The upper swallowing action is very complex neuro-muscular action that involves the lips, tongue, pharynx

2017 CandiEM

152. CRACKCast E077 – Pleural Disease

difference on supine apical capping obliteration of the hemidiaphragm widened minor fissure 12) Describe Light’s Criteria for pleural effusion and list 5 other tests to perform on pleural fluid. Spaced repetition from last chapter… Cell count (High counts = empyema) Glucose (Pleurisy, malignancy or esophageal rupture) Amylase (pancreatitis, esophageal rupture or malignancy) Gram stain and culture Cytology A pH <7.0 is strongly suggestive of empyema or esophageal rupture: these patients need a tube (...) : due to underlying pulmonary disease 1) List 5 risk factors for 1° spontaneous pneumothorax Tall Male Smoker Changes in Ambient atmospheric pressures Hx Mitral valve prolapse Marfan Syndrome Family History of primary pneumothorax 2) What is the most common pathophysiologic cause of pneumothorax? Primary: Even though this is technically in a person without lung disease, the most common cause is unrecognized pleural disease and rupture of a bleb Secondary: Easy, COPD – accounts for 70% of cases

2017 CandiEM

153. Suspected Thoracic Aortic Aneurysm

aortic aneurysms (AAA) that may present with pain or a pulsatile abdominal mass [1]. Although individuals with TAA are generally asymptomatic, some patients may describe chest or back pain. When patients with known or suspected TAA present with sudden onset of pain, complications such as dissection, hemorrhage, or impending rupture should be considered [2,3]. Although uncommon, cases involving a large TAA may present with anatomical mass effect, which can manifest due to compression of adjacent (...) , such as chest wall alterations from recent surgery, pneumothorax, or emphysema. [17,18]. Likewise, esophageal varices are a relative contraindication for TEE due to bleeding risk. TTE allows for evaluation of the aortic root, important anatomy to visualize due to the frequency of associated findings such as valvular abnormalities, incompetence, and regurgitation. However, the transthoracic approach is often limited by superimposed soft-tissue structures for evaluating the ascending and descending aortic

2017 American College of Radiology

154. Stereotactic body radiation therapy for early-stage non-small cell lung cancer: executive summary of an ASTRO evidence-based guideline.

, infectious pneumonia, and pericardial effusion. Other retrospective studies have also reported severe toxicities and fatal complications following stereotactic or hypofractionated radiation therapy directed at central tumors. These include potentially devastating toxicities, such as tracheal or great vessel rupture, esophageal ulceration, and spinal cord myelopathy. Interpretation of surveillance imaging following SBRT is challenging and may lead to unnecessary biopsies, salvage surgery, or false (...) to meet the constraints that have been utilized in prospective studies or otherwise reported in the literature given the severe esophageal toxicities that have been reported. Recommendation strength: Strong Quality of evidence: Low Statement KQ3C : For tumors in close proximity to the heart and pericardium, SBRT should be delivered in 4 to 5 fractions with low incidence of serious toxicities to the heart, pericardium and large vessels observed. Adherence to volumetric and maximum dose constraints

2017 National Guideline Clearinghouse (partial archive)

157. Diagnosis and Management of Noncardiac Complications in Adults With Congenital Heart Disease: A Scientific Statement From the American Heart Association

- TERL and CHARGE syndromes. These syndromes consist of vertebral defects, anal atresia, cardiac defects, tra- cheo-esophageal fistula, renal anomalies, and limb ab- normalities in VACTERL and coloboma of the eye, heart defects, atresia of the choanae, retardation of growth and development, and ear abnormalities in CHARGE. A small retrospective series reported that 30% of pa- tients with CHD also had renal anomalies. 42 Although the true prevalence is likely lower, many pediatric car- diac centers

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2017 American Heart Association

159. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

of the cytokine cascade, chemokine response, and inducible NO synthase expression associated with coronary plaque rupture. , As previously described, putative mechanisms also are associated with a “wet and warm” CS presentation wherein a systemic inflammatory response syndrome and vasodilation can occur after an MI. , This phenotype is characterized by systemic inflammatory response syndrome features, lower systemic vascular resistance, and a higher risk of sepsis and mortality. , Overlaid on this framework (...) syndrome (ACS). Thus, among patients with CS within the appropriate demographic or with risk factors for coronary artery disease, ACS should be the focus of initial diagnostic testing, and this testing should include an ECG within 10 minutes of presentation. Although 5% to 12% of ACS cases are complicated by CS, this presentation is often associated with a large degree of at-risk myocardium. , In patients with a recent ACS, mechanical complications (including papillary muscle rupture, ventricular

2017 American Heart Association

160. Proton Beam Therapy

, treatment protocol, location, or other such concerns. Conditions included in the evidence review are as follows: ? Cancers ? Bone tumors ? Brain, spinal, and paraspinal tumors ? Breast cancer ? Esophageal cancer ? Gastrointestinal cancers ? Gynecologic cancers ? Head and neck cancers (including skull base tumors) ? Liver cancer ? Lung cancer ? Lymphomas ? Ocular tumors ? Pediatric cancers (e.g., medulloblastoma, retinoblastoma, Ewing’s sarcoma) ? Prostate cancer ? Soft tissue sarcomas ? Seminoma (...) for the subgroup of patients with hereditary disease. Other harms are presented in detail for each condition type in the sections that follow. No comparative studies were identified for curative therapy of: breast, esophageal, gastrointestinal, gynecologic, and pediatric cancers; lymphomas, sarcomas, seminomas, and thymomas; arteriovenous malformations. 5 Proton Beam Therapy Approved January 14, 2016 No comparative studies were identified for salvage treatment of: brain/spinal/paraspinal, breast, esophageal

2016 Oregon Health Evidence Review Commission

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