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FOUR Score Coma Exam

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1. FOUR Score Coma Exam

FOUR Score Coma Exam FOUR Score Coma Exam Toggle navigation Brain Head & Neck Chest Endocrine Abdomen Musculoskeletal Skin Infectious Disease Hematology & Oncology Cohorts Diagnostics Emergency Findings Procedures Prevention & Management Pharmacy Resuscitation Trauma Emergency Procedures Ultrasound Cardiovascular Emergencies Lung Emergencies Infectious Disease Pediatrics Neurologic Emergencies Skin Exposure Miscellaneous Abuse Cancer Administration 4 FOUR Score Coma Exam FOUR Score Coma Exam (...) Aka: FOUR Score Coma Exam , Full Outline of Unresponsiveness , FOUR Score II. Criteria: Calculate total points (4 scores totaling 16 points) Eye Response Score 4: s open or opened, tracks and blinks to command Score 3: s open but are not tracking Score 2: s close but open with loud voice Score 1: s closed but open to pain Score 0: s remain closed despite painful stimuli Motor Response Score 4: Makes thumbs up, fist or peace sign Score 3: Localizes to pain Score 2: Flexion in response to pain Score

2018 FP Notebook

2. FOUR Score Coma Exam

FOUR Score Coma Exam FOUR Score Coma Exam Toggle navigation Brain Head & Neck Chest Endocrine Abdomen Musculoskeletal Skin Infectious Disease Hematology & Oncology Cohorts Diagnostics Emergency Findings Procedures Prevention & Management Pharmacy Resuscitation Trauma Emergency Procedures Ultrasound Cardiovascular Emergencies Lung Emergencies Infectious Disease Pediatrics Neurologic Emergencies Skin Exposure Miscellaneous Abuse Cancer Administration 4 FOUR Score Coma Exam FOUR Score Coma Exam (...) Aka: FOUR Score Coma Exam , Full Outline of Unresponsiveness , FOUR Score II. Criteria: Calculate total points (4 scores totaling 16 points) Eye Response Score 4: s open or opened, tracks and blinks to command Score 3: s open but are not tracking Score 2: s close but open with loud voice Score 1: s closed but open to pain Score 0: s remain closed despite painful stimuli Motor Response Score 4: Makes thumbs up, fist or peace sign Score 3: Localizes to pain Score 2: Flexion in response to pain Score

2017 FP Notebook

3. Coma

causes, or can be . Clinically, a coma can be defined as the inability to consistently follow a one-step command. It can also be defined as a score of ≤ 8 on the (GCS) lasting ≥ 6 hours. For a patient to maintain consciousness, the components of wakefulness and awareness must be maintained. describes the quantitative degree of , whereas relates to the qualitative aspects of the functions mediated by the cortex, including cognitive abilities such as attention, sensory perception, explicit memory (...) of fever (Sydenham, 1685). Signs and Symptoms [ ] Image of a man in a coma. Image of the man still unresponsive to stimuli. General symptoms of a person in a comatose state are: Inability to voluntarily open the eyes A non-existent sleep-wake cycle Lack of response to physical (painful) or verbal stimuli Depressed brainstem reflexes, such as pupils not responding to light Irregular breathing Scores between 3 and 8 on the Causes of Coma [ ] Many types of problems can cause coma. Some examples

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2012 Wikipedia

4. Guidelines for diagnosing and managing pediatric concussion

5.4a(v) Refer the child/adolescent to a pediatric sleep specialist if sleep has not improved. C 5.4b(i) Take a history of any headaches. B 5.4b(ii) Establish the degree and duration of the disability that the headaches cause. B 5.4b(iii) Perform a neurological exam and a head/neck exam. C 5.4b(iv) Consider non-pharmacological, complementary and/or alternative medicine therapies for headache. C 5.4b(v) Consider treating migraine headaches with prescription medication. B Chapter: Tipsheet Guidelines (...) the following tools as appropriate. o Tool 2.1: Management of Acute Symptoms Algorithm. o Tool 2.2: Acute Concussion Evaluation (ACE). o Tool 0.2: ChildSCAT3 Sport Concussion Assessment Tool for Children aged 5-12 (symptom evaluation). o Tool 1.1: SCAT3 Sport Concussion Assessment Tool for Athletes aged 13+ (symptom evaluation). o Tool 2.4: Neurologic and Musculoskeletal Exam. • Consider signs and symptoms in context with the child/adolescent’s normal performance, especially for those with learning

2019 CPG Infobase

5. Guidelines on Diagnosis and Management of Syncope

4.2.3.4 Twenty-four-hour ambulatory and home blood pressure monitoring 1904 4.2.4 Electrocardiographic monitoring (non-invasive and invasive) 1905 4.2.4.1 In-hospital monitoring 1905 4.2.4.2 Holter monitoring 1905 4.2.4.3 Prospective external event recorders 1905 4.2.4.4 Smartphone applications 1906 4.2.4.5 External loop recorders 1906 4.2.4.6 Remote (at home) telemetry 1906 4.2.4.7 Implantable loop recorders 1906 4.2.4.8 Diagnostic criteria 1906 4.2.5 Video recording in suspected syncope 1907 4.2.5.1 (...) is classified into one of four groupings: syncope, epileptic seizures, psychogenic transient loss of consciousness, and a miscellaneous group of rare causes. This order represents their rate of occurrence. Combinations occur; e.g. non-traumatic transient loss of consciousness causes can cause falls with concussion, in which case transient loss of consciousness is both traumatic and non-traumatic. TIA = transient ischaemic attack; TLOC = transient loss of consciousness. Figure 2 Syncope in the context

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2018 European Society of Cardiology

6. Telehealth for Acute and Chronic Care Consultations

Effectiveness Reviews. 14 Risk of bias for economic evaluations were assessed using a modified version of the Consensus Health Economic Criteria. 15,16 Disagreements were resolved by consensus. Strength of evidence was assessed for each outcome and Key Question as described in the Methods Guide for Effectiveness and Comparative Effectiveness Reviews. 14 We assigned a strength of evidence grade of high, moderate, low, or insufficient for the body of evidence for each Key Question, based on evaluation of four (...) in the same hospital or hospitals. The remaining studies include four retrospective and two prospective cohort studies, one cross sectional survey, and one pre-post survey. These studies did not provide details on the nontelehealth care, though it likely included a mix of care by clinicians who are not specialists, less frequent care by specialists, and transfers to other hospitals. We reviewed selected key factors that could help explain the differences in outcomes across studies, including information

2019 Effective Health Care Program (AHRQ)

7. Antipsychotics for the Prevention and Treatment of Delirium

severity scores as measured by the DRS-R-98* in trials comparing haloperidol with second-generation antipsychotics in patients with delirium 87 Figure 17. Meta-analysis of patients with delirium severity scores below identified threshold in trials comparing haloperidol with second-generation antipsychotics in patients with delirium ... 88 Figure 18. Meta-analysis of duration of delirium in trials comparing haloperidol with second- generation antipsychotics in patients with delirium 92 Figure 19. Meta (...) is posted on the AHRQ Effective Health Care Program’s website (www.effectivehealthcare.ahrq.gov) and registered on PROSPERO (CRD42018109552). The searches were conducted in March 2019. Details of the methodology can be found in the full report. Results After screening abstracts and full-text, we included 57 studies (published in 62 articles). Of the eligible studies, 15 studies, including 14 RCTs and 1 observational study, addressed the prevention of delirium. Forty-four studies, including 19 RCTs

2019 Effective Health Care Program (AHRQ)

8. Responsible use of high-risk medical devices: the example of 3D printed medical devices

for assessing risk of bias was used. 4 RCTs already included in methodologically valid systematic reviews were not quality appraised again. For example, the methodological quality of the primary studies included in the review of Thienpont et al. was assessed using a modified version of the Detsky Quality Assessment Scale. The individual scores of that particular assessment are reported in the systematic review of Thienpont et al. 16 . Data extraction was performed by one researcher and entered in evidence (...) different RCTs that compared a group using 3D technology versus a group not using 3D technology (Table 1). In addition to the reviews identified through the search, a recent systematic review on patient-specific instruments was provided by experts. 16 Five additional RCTs were cited in this review (Table 1). Finally, our search identified four more RCTs not already included in one of the identified reviews. 17-20 The evidence that was based on (in total 35) RCTs will be discussed below, structured

2018 Belgian Health Care Knowledge Centre

9. Near Infrared Spectroscopy for Detecting Brain Hematoma

involves conducting a physical exam to evaluate the extent of injuries, including impaired consciousness as measured by the Glasgow Coma Scale (GCS), and considering baseline risk factors for intracranial hemorrhage, a potential complication of head injury. Identifying patients with moderate-severe injuries in need of transport and head imaging is usually straightforward. However, determining which patients with mild injuries need further evaluation can be more challenging as many elderly patients have (...) , managers, and policymakers as they work to improve the health and healthcare of Veterans. QUERI provides funding for four ESP Centers, and each Center has an active University affiliation. Center Directors are recognized leaders in the field of evidence synthesis with close ties to the AHRQ Evidence-based Practice Centers. The ESP is governed by a Steering Committee comprised of participants from VHA Policy, Program, and Operations Offices, VISN leadership, field-based investigators, and others

2017 Veterans Affairs Evidence-based Synthesis Program Reports

10. Perinatal Mortality Guideline

Classification The major cause of death determines the group and the four groups are mutually exclusive. Group 1: Lethal Congenital Anomaly (LCA) A. Stillbirth greater than or equal to 500 grams or greater than or equal to 20 wks gestation B. Neonatal Death Note: Termination of pregnancy greater than 20 weeks gestational age are considered Group 1 Group 2: Stillbirth – greater than or equal to 500 grams or greater than or equal to 20 weeks gestation – Indicate degree of maceration A. None – no signs (...) ? Laboratory investigations including serum screening ? Ultrasound(s) ? Past obstetrical history ? Medical history ? ? Laboratory: ? CBC, type/screen* ? Feto-maternal hemorrhage screen* ? Serology for CMV, toxoplasmosis, parvovirus B19, HSV, rubella (if not previously done) ? ? Discuss birth plan. ? ? Vaginal birth is preferable if there is no contraindication. ? ? Consider method of induction in light of clinical circumstances. ? ? Discuss role of autopsy (complete, limited or external exam only

2017 British Columbia Perinatal Health Program

11. Surveillance of healthcare-associated infections and prevention indicators in European intensive care units: HAI-Net ICU protocol, version 2.2

References 28 Annex 1. Microorganisms code list 29 Annex 2. Extended antimicrobial resistance data for ICU-acquired infections 32 Annex 3. Healthcare-associated infections code list 33 Annex 4. Antimicrobial ATC codes 34 Diagnosis (site) code list for antimicrobial use 39 Annex 5. Risk scores definitions: SAPS II, APACHE II, Glasgow 40 SAPS II score 40 SAPS II weights 41 APACHE II score 41 Glasgow Coma Score 43 Other scoring systems 44 Annex 6. List of HAI outcome indicators 45 Annex 7. Structure (...) and process prevention indicators: definition, rationale and references 46 Surveillance of HAI and prevention indicators in European intensive care units TECHNICAL DOCUMENT iv Abbreviations AMR Antimicrobial resistance APACHE score Acute physiology, age, chronic health evaluation score BAL Broncho-alveolar lavage BSI Bloodstream infection CDC Centers for Disease Control and Prevention (USA) CFU Colony-forming units CRI Catheter-related infection CVC Central vascular catheter HAI Healthcare-associated

2017 European Centre for Disease Prevention and Control - Technical Guidance

12. Appropriate Use Criteria: Imaging of the Head & Neck

and at least one of the following features is present: ? Age 65 or greater ? Retrograde amnesia ? At least two (2) episodes of emesis ? Evidence of open, depressed or basilar skull fracture ? Focal neurologic findings ? Glasgow coma score less than 15 or altered mental status ? High risk mechanism of injury ? Seizure Tumor (benign or malignant) Diagnosis of suspected tumor when supported by the clinical presentation Management (including perioperative evaluation) of established tumor when imaging (...) of its Guidelines at least annually. AIM makes its Guidelines publicly available on its website twenty-four hours a day, seven days a week. Copies of AIM’s Clinical Appropriateness Guidelines are also available upon oral or written request. Although the Guidelines are publicly-available, AIM considers the Guidelines to be important, proprietary information of AIM, which cannot be sold, assigned, leased, licensed, reproduced or distributed without the written consent of AIM. AIM applies objective

2018 AIM Specialty Health

13. Practice Guideline Update Systematic Review Summary: Disorders of Consciousness

, University of Rochester Medical Center, Rochester, NY 8. Indiana University Department of Physical Medicine & Rehabilitation, University of Indiana School of Medicine, Indianapolis, IN 9. Coma Science Group - GIGA Research and Department of Neurology, Sart Tillman Liège University & University Hospital, Liège, Belgium 10. Department Neurology, Uniformed Services University of Health Sciences, Bethesda, MD; Department of Neurology, Johns Hopkins University, Baltimore, MD 11. James A. Haley Veterans (...) Medical Inc. and Enspire DBS, Inc. (Cleveland, Ohio); is listed as inventor for multiple patents held by Cornell University; receives royalties for Plum and Posner’s Stupor and Coma, Oxford University Press; and holds 0.25% stock option in Enspire DBS, Inc (no current value). J. Whyte served on a scientific advisory board for INTRuST; received funding for travel and honoraria from several noncommercial institutions for academic lectures; performs diagnostic behavioral assessments of patients with DoC

2018 American Academy of Neurology

14. Continuous glucose monitoring (CGM real-time) and flash glucose monitoring (FGM) as personal, standalone systems in patients with diabetes mellitus treated with insulin

of morbidity and mortality in patients with diabetes [101]. Macrovascular complications in patients with diabetes cause an estimated two- to four-fold increased risk of cor- onary artery disease (CAD), peripheral arterial disease, and cerebrovascular disease. An estimat- ed 37% to 42% of all ischemic strokes in Americans are attributable to the effects of diabetes, alone or in combination with hypertension. The prevalence of CAD or stroke in patients with dia- betes is approximately 34% in both men (...) of the heart and arteries in the limbs). All cases of acute cardiovascular disease, diabetic coma, kidney failure, and infected foot ulcers should be managed in a hospital. Patient education is an important component of diabetes management since the effectiveness of diabetes management ultimately depends on patient compliance with recommendations and treat- ment [16]. National guidelines and management protocols developed for (or adapted to) individual settings are useful tools in achieving a standardized

2018 EUnetHTA

15. Soft tissue and visceral sarcomas: ESMO-EURACAN Clinical Practice Guidelines for diagnosis, treatment and follow-up

?cans, and in retroperitoneal tumours, where the performance is identical to MRI. Ultrasound may be the ?rst exam, but it should be followed by CT or MRI. Following appropriate imaging assessment, the standard approach to diagnosis consists of multiple core needle biopsies, possibly by using 14–16 G needles. However, an excisional biopsy may be the most practical option for 5cm lesions [II, B] [11–13]. RT is not given in the case of a currently unusual, truly compartmental resection of a tumour (...) phase III trial (whose accrual is already completed) are awaited so that the drug can be administered more widely in Europe [II, C b ][seenote b in Table 2); ESMO Magnitude of Clinical Bene?t Scale (ESMO-MCBS) v1.1 score: 4]. The mechanisms for the added value of the com- bination of doxorubicin with a PDGFRA inhibitor are not fully understood. The standard arm in the phase II and III studies was doxorubicin alone, so it must be clari?ed whether the com- bination is superior to doxorubicin

2018 European Society for Medical Oncology

16. Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient

the ability of neuromuscular blockade to attenuate the rise in ICP and the fall in cerebral perfusion pressure (CPP) that can accompany tracheal suctioning in brain-injured patients with elevated ICP ( , ). In a prospective crossover study of 18 sedated neurosurgical patients (Glasgow Coma Scale score of < 7), vecuronium and atracurium were equally effective in mitigating cough and changes in ICP and CPP during tracheal suctioning ( ). A smaller study found that the combination of opioids and NMBA therapy (...) for the management of intracranial hypertension, with a focus on clinically important outcomes. One study of 514 patients with traumatic brain injury and a Glasgow Coma Scale score of less than 8 found that patients treated with early neuromuscular blockade for more than 12 hours had a higher risk of pneumonia and having a prolonged ICU stay than patients treated with NMBAs for less than 6 hours, even after controlling for age, preresuscitation Glasgow Coma Scale and hypotension, CT findings, and single- versus

2016 Society of Critical Care Medicine

18. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients

of echocardiography expertise of the intensivist. These results are summarized in . shows a detailed statistical analysis of two recommendations as an example of applying the agreement/disagreement rules and degree of consensus based on the median score and the dispersion of voting around the median. is an example of the summary of findings (SoF) tables. The remainder of the SoF tables can be found in the digital supplement (Supplemental Digital Content 1, ). The detailed explanation of the domains and subdomains (...) . It can be used by a bedside operator with basic training. Alternatively, the American Society of Echocardiography recommends the volumetric-modified Simpson’s method ( ). This method calculates end-systolic volume, end-diastolic volume, stroke volume, and EF in two planes (apical four- and two-chamber views) and averages them. This method is well suited for experienced (advanced level) operators and nonemergent situations ( , ). | Assessment of LV Diastolic Function (Suggested for an Expert Level

2016 Society of Critical Care Medicine

19. Perinatal substance use: maternal

Finnegan score 34 to assist with identifying signs of NAS o Education to parents about signs of withdrawal and need to present for care if discharged from hospital o Outpatient review within four weeks of age • Treatment includes: o Supportive care o Phenobarbitone may be required if treatment threshold is reached (Finnegan score of eight or more) ? Loading dose likely to be more beneficial 20 • Research on the longer-term effects on the child exposed to benzodiazepines is largely lacking 33 Lactation (...) for resuscitation) if maternal opioids used in pregnancy Setting for care • Initial care may be with mother on postnatal ward • Closer care and observation may be required in a special care nursery for symptomatic babies Breastfeeding • Generally breastfeeding is encouraged and supported—consider individual drugs • Encourage to stop substance use Monitoring • Finnegan Neonatal Abstinence Severity Score used to monitor and record signs of withdrawal NAS treatment • Non-pharmacological supportive therapy

2016 Queensland Health

20. Management of Concussion-mild Traumatic Brain Injury (mTBI)

category of severity, the higher severity level is assigned) Criteria Mild Moderate Severe Structural imaging Normal Normal or abnormal Normal or abnormal Loss of Consciousness (LOC) 0-30 min >30 min and 24 hours Alteration of consciousness/ mental state (AOC)* up to 24 hours >24 hours; severity based on other criteria Posttraumatic amnesia (PTA) 0-1 day >1 and 7 days Glasgow Coma Scale (GCS) (best available score in first 24 hours)** 13-15 9-12 12 weeks post-injury B. Additional Educational Materials (...) criteria obtained during a history and physical exam (see Algorithms for definition). Symptoms associated with mTBI are identified while conducting the history of present illness. The signs and symptoms associated with mTBI are evaluated through physical examination and history and are treated in accordance with this guideline. This recommendation was not reviewed in the recent literature review; however, the strength of this recommendation is strong. The content of the 2009 mTBI CPG was reviewed

2016 VA/DoD Clinical Practice Guidelines

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