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High Pressure Injection Wound

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181. Netarsudil plus latanoprost (Roclatan) for glaucoma or ocular hypertension

as these outputs are produced as required for our stakeholders. > > > Netarsudil plus latanoprost (Roclatan) for glaucoma or ocular hypertension Netarsudil plus latanoprost (Roclatan) for glaucoma or ocular hypertension September 2017 Glaucoma describes a group of disorders characterised by sight loss. Glaucoma is generally associated with high pressure in the liquids inside the eye but it can happen when the pressure level is normal. Individuals with consistently high eye pressure are at risk of developing (...) glaucoma. Glaucoma does not normally cause any symptoms but once eye sight is lost it cannot be recovered. Approximately one in every ten blindness registrations is due to glaucoma. There are approximately half a million people living with glaucoma in England. Current treatment options include a number of different eye drop formulations to stop internal eye pressure raising. If the eye drops do not work and glaucoma is diagnosed, laser therapy or eye surgery can also be used to stop sight loss

2017 NIHR Innovation Observatory

182. CRACKCast E096 – Anorectal Disorders

! Managed Medically using the WASH approach. ● Warm water sitz ● Analgesia ● Stool softeners ● High fiber diet See below Usually can be managed supportively as well. (they will ulcerate and ooze dark blood in a few days). But, if within 72 hrs of onset of symptoms, they can have the clot EXCISED. Be sure to warn patients that excision will lead to evacuation of the clot, but also rebleeding, swelling and the formation of a skin tag. People that are bad candidates for this: kids, pregnant women (...) , immunocompromised patients. Rosen’s does mention that an alternative non-surgical therapy: ● Topical nifedipine 0.3% ● Topical lidocaine gel 1.5% + Excision procedure: ● Anesthetic field block ● Elliptic incision (single crescent shaped) made on the hemorrhoid and over top of the clot) ● Clot is removed. Hemorrhoid management: WASH approach Warm water sitz baths (ideally with epsom salts) Water > 40 degrees C helps decrease anal canal pressures (a shower stream can also work). 5-10 mins BID-QID prn Analgesics

2017 CandiEM

183. CrackCAST E129 – Bacteria

diphtheria-tetanus or DTaP. Patients 7 years old or older should receive Tdap. HTIG prophylaxis (250 units IM) is recommended for unimmunized and underimmunized patients with high risk wounds (>6 hours old, >1 cm deep, contaminated, stellate, denervated, ischemic, infected). When tetanus toxoid and HTIG are given concurrently, separate injection sites should be used. The only contraindication to tetanus and diphtheria toxoids is a history oyf a neurologic or severe hypersensitivity reaction to a previous (...) with Td**[see notes below] ***ensure injection is in a SEPARATE SITE FROM THE htig*** Prevention of further toxin production. Metronidazole Doxycycline, macrolides an alternative Toxin production is eliminated by treatment of the C. tetani infection. Wound débridement and antibiotic administration can cause a transient release of tetanospasmin, so these measures should be delayed until after the HTIG is administered. Metronidazole (500 mg orally or IV every 6 hours) is the antibiotic of choice for C

2017 CandiEM

184. CrackCAST E136 – Bone and Joint Infections

assessment of all diabetic patients with infected pedal ulcers. A positive result consists of detection of a hard, gritty surface; also indicated in nondiabetic ulcers due to peripheral neuropathy, vasculopathy, or pressure sores.” (uptodate). Below taken from “ Probing the wound to see if it reaches the bone can help identify osteomyelitis. Other tests such as ESR or x-ray can help make the diagnosis. Aragon-Sanchez, J et al. Diagnosing diabetic foot osteomyelitis: is the combination of probe-to-bone (...) test and plain radiography sufficient for high-risk inpatients? Diabet Me. 2011 Feb;2892):191-4. If you can probe to bone and have a positive x-ray, the likelihood ratio of osteomyelitis is 12. If you can’t probe to bone with a negative x-ray, the negative likelihood ratio is 0.02. How do you probe the wound? Get a sterile probe and gently explore the wound. If you feel something hard or gritty, it is positive. This is a Grade 2C recommendation. A high ESR and CRP obtained in the emergency

2017 CandiEM

185. CRACKCast E137 – Skin Infections

-Clav Erythema migrans Borrelia burgdorferi Doxycycline Puncture wound through foot Pseudomomas aeruginosa Ciprofloxacin [1] List 6 risk factors for cellulitis From Uptodate: Predisposing factors for development of cellulitis and/or skin abscess include: Skin barrier disruption due to trauma (such as abrasion, penetrating wound, pressure ulcer, venous leg ulcer, insect bite, injection drug use) Skin inflammation (such as eczema, radiation therapy) Edema due to impaired lymphatic drainage Edema due (...) common; this aggressively virulent agent is known as flesh-eating bacteria. Risk factors: Type I: Diabetes IV drug use Obesity Immunosuppression recent surgery traumatic wounds peripheral vascular disease Type II: any age group, especially without any medical history history of skin injury (eg laceration or burn) blunt trauma recent surgery Childbirth injection drug use varicella infection (chickenpox) [16] Describe the management of necrotizing fasciitis. Remember: Initial symptoms may be vague (eg

2017 CandiEM

186. CRACKCast E120 – Dermatologic presentations

, systemic symptoms, or vesicle formation raise concern for Stevens-Johnson syndrome. The treatment of Stevens – Johnson syndrome and toxic epider – mal necrolysis includes discontinuation of the offending agent and supportive care , including hydration , prevention of secondary infection , and expert wound management ( at a burn centre ). Morbidity and mortality are often related to infection and dehydration. High-dose IVIG may be administered to patients with severe toxic epidermal necrolysis (...) soft tissue infections, drug eruptions, or immune disorders. Patients with Stevens-Johnson syndrome (<10% TBSA) and toxic epidermal necrolysis require inpatient treatment, preferably in a burn unit. Cutaneous signs of systemic disease may include pruritus, urticaria, erythema multiforme, erythema nodosum, pyoderma gangrenosum, and others. Physicians should be familiar with one or two topical steroid preparations of low, medium, and high potency and their appropriate therapeutic use. Hydrocortisone

2017 CandiEM

187. Guidelines for the management of acute joint bleeds and chronic synovitis in haemophilia

carefully as radioactive burns may occur along the needle track. Injecting an anti-in?ammatory agent such as hydrocortisone acetate into the joint before removal also effectively ?ushes isotope out, reducing both the risk of leakage as well as a subsequent in?am- matory reaction and radiation skin burn. High dose radiation has been shown to damage articular cartilage in experimental studies, but at the therapeutic doses used in radioactive synovectomy this is unlikely [64]. A recent longitudinal study (...) , ‘recommended’) are made when there is con?dence that the bene?ts either do or do not out- weigh the harm and costs of treatment. Where the magnitude of bene?t or not is less certain, a weaker grade 2 recommendation (‘suggested’) is made. Grade 1 recommendations can be applied uniformly to most patients, whereas grade 2 recommendations require a more individualized application. The qual- ity of evidence is graded as high (A), based on high quality randomized clinical trials, moderate (B), low (C) or very

2017 United Kingdom Haemophilia Centre Doctors' Organisation

188. Management of Suspected Opioid Overdose with Naloxone by Emergency Medical Services Personnel

framework * Patients with confirmed or suspected opioid overdose who exhibit altered mental status, miosis, or respiratory distress and who are treated in the out-of-hospital setting by emergency medical services personnel †Administration of naloxone hydrochloride via the nasal, intravenous, intramuscular, or subcutaneous injection (including the naloxone auto-injector) ‡ Key Question 1 addresses comparisons involving route of administration and dose; Key Question 2 addresses comparisons involving dose (...) • Nasal spray, intranasal (IN) o Single dose intranasal device: 4 mg/0.1 mL, 2 mg/0.1 mL o Improvised intranasal device: 2mg/2mL † • Injection, intravenous, intramuscular or subcutaneous o 0.4 mg/mL, 1 mg/mL, 2 mg/mL * Manufacturer has stopped production of 0.4mg/0.4mL IM † Formulation not currently approved by the FDA for intranasal administration • Potential modifiers of interventions: Based on training and background of the person administering naloxone • For Key Question 4: Transport to health

2017 Effective Health Care Program (AHRQ)

189. Management of Uterine Fibroids

p=NR Yang Z et al. (2014) 58 HIFU plus USg intramural ethanol injection 20 1 157.7 ± 198.5 112.8 ± 145.2 ? 44. 9 p=NR CEUS = contrast enhanced ultrasound; cm3 = cubic centimeters; HIFU = high intensity focused ultrasound; NR = not reported; USg = ultrasound-guided a Single study may contribute more than one entry if more than one arm received the intervention. Effects of HIFU for Fibroid Ablation on Bleeding and Fibroid-Related Pain There was no change in hemoglobin levels after twelve weeks (...) embolism (UAE) reduce fibroid size, and improve symptoms and quality of life. High intensity focused ultrasound reduces fibroid size, but impact on quality of life was not measured. Myomectomy and hysterectomy also improve quality of life. Direct comparisons of interventions provide little evidence. • For women in their 30s, the chance of needing retreatment for fibroids within the next 2 years was 6–7 percent after medical treatment or myomectomy and 44 percent after UAE. For older women, the chance

2017 Effective Health Care Program (AHRQ)

190. British Association of Dermatologists guidelines for the management of pemphigus vulgaris

is presented as a detailed review with high- lighted recommendations for practical use in the clinic (see Tables 1 and 4), in addition to an updated patient information lea?et (available on the BAD website, http://www.bad.org. uk/for-the-public/patient-information-leaflets). 1.1 Exclusions This guideline does not cover other forms of pemphigus. 2.0 Stakeholder involvement and peer review The Guideline Development Group (GDG) consisted of consul- tant dermatologists and a clinical nurse specialist (...) Guidelines for the management of pemphigus vulgaris 2017, K.E. Harman et al. 1171there are no skin lesions and a sample for DIF is to be taken from the oral mucosa, the buccal mucosa can be exposed by everting the cheek, placing the thumb at the commissure and re?ecting the corner of the mouth, applying external pressure on the cheek with the index ?nger to present the buccal mucosa. The transport medium into which samples for DIF are placed varies, including saline, Michel’s medium and snap freezing

2017 British Association of Dermatologists

191. WHO recommendations on maternal health

includes the synthesis and assessment of the quality of evidence, and is based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. GRADE categorizes the quality (or certainty) of the evidence underpinning a recommendation as high, moderate, low or very low. ¦ High: further research is very unlikely to change our confidence in the estimate of effect; ¦ Moderate: further research is likely to have an impact on our confidence in the effect; ¦ Low: further research (...) ¦ ¦ In undernourished populations, balanced energy and protein dietary supplementation is recommended for pregnant women to reduce the risk of stillbirths and small-for-gestational- age neonates. (Context-specific recommendation). Source ¦ ¦ In undernourished populations, high-protein supplementation is not recommended for pregnant women to improve maternal and perinatal outcomes. (Not recommended). Source Iron and folic acid supplements ¦ ¦ Daily oral iron and folic acid supplementation with 30 mg to 60 mg

2017 World Health Organisation Guidelines

192. Treatment of Osteoarthritis of the Knee: An Update Review

as the direction of the reported effect across studies (or within studies if a single RCT used multiple tools to measure the same outcome), precision was assessed in terms of the similarity in effect sizes, the average variance, and the numbers of studies. Directness was assessed as it would be for pooled outcomes. Lack of pooling automatically decreased the SoE grade by one unit. Based on these domains, we rated the SoE for each comparison of interest as high, moderate, low, or insufficient (if no or too few

2017 Effective Health Care Program (AHRQ)

193. Diagnosis and Management of Noncardiac Complications in Adults With Congenital Heart Disease: A Scientific Statement From the American Heart Association Full Text available with Trip Pro

of wound infection or invasive procedures occurring at sites distant from the initial graft procedures, presumably by hematogenous spread. Extracardiac graft infection can be difficult to diagnose and requires a high degree of suspicion in patients who may have had vascular graft procedures months or years before clinical presentation. A full suite of imaging is usually required (echocardiography, MR, CT, positron emission tomography) to diagnose Downloaded from http://ahajournals.org by on March 27 (...) pulmonary angiograms with a standard protocol have significant swirling artifact, heterogeneous contrast en- hancement, and a high rate of false-positive results. 233 Nuclear lung perfusion scans are similarly unreliable be- cause of asymmetric pulmonary blood flow patterns. Multidetector CT angiography with simultaneous up- per and lower extremity contrast power injection with early- and late-phase image acquisition can improve diagnostic accuracy. 234 Thrombus in the pulmonary ve- nous atrium

2017 American Heart Association

194. Ankle and Foot Surgical Guideline

-related ankle injury Catching AND/OR Locking AND/OR Effusion Documented loose body on computed tomography (CT) or magnetic resonance imaging (MRI) Not required Ankle Cheilectomy Bony impingement A discrete documented work-related ankle injury AND Pain Decrease in range of motion (ROM) Plain radiographs demonstrating osteophyte formation on the distal tibia or talus At least 6 weeks of any of the following: Activity modification, Non- opioid analgesics, Steroid injection, Bracing Ankle Arthroplasty (...) analgesics, Bracing, Immobilization, Orthotics, Injections 5 Washington State Department of Labor and Industries Surgical Guideline for Work-related Ankle and Foot Injuries – October 2017 A request may be appropriate for If the patient has AND the diagnosis is supported by these clinical findings: AND this has been done Surgical Procedure Condition or Diagnosis Subjective Objective Imaging Non-operative care Debridement or Stabilization of a Medial Lesion of the Talus Osteochondral defect of the talus

2017 Washington State Department of Labor and Industries

195. Palliative Care

and symptom management, and patient and family outcomes across a wide range of conditions. In addition, the delivery of high-quality palliative care increases hospice utilization and reduces the utilization of long-term care beds and/or facilities for patients with poor functional outcomes. Best practice palliative care in the trauma center can be accomplished through “primary” or “generalist” palliative care delivered by the interdisciplinary team of trauma care providers, including, but not limited (...) to be successful. z Ongoing education for all staff in palliative care communication skills is important to enabling them to provide high-quality palliative care. z Shared decision-making between patients and providers and within provider teams is essential. z Organizational support structures such as debriefing and peer review are essential in this highly stressful arena of end-of- life care among the injured. Leadership of the team providing palliative care services is critical and is typically within

2017 American College of Surgeons

196. Management of Brain Arteriovenous Malformations: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Full Text available with Trip Pro

in both feeding arteries and draining veins and higher-than-normal pressure on the venous side. Other factors that contribute to complex vascular physiology include high flow rates and shear stress, venous outflow obstruction that can result from long-standing arterial flow rates, arterial steal, and compartmentalization. Anatomic features associated with hemorrhagic presentation include the presence of intranidal aneurysms ( ) or deep venous drainage (drainage into the galenic system), venous outflow (...) , magnified views, and multiple injections, which, together with CT studies and potential additional exposure from endovascular procedures, may lead to high doses to the head and lens of the eye. For these reasons and the highly specific angioarchitectural information (discussed below) obtained in these studies, DSA may be best performed by the members of the cerebrovascular team contemplating treatment. Angiographic features that have been associated with hemorrhage in retrospective studies comparing

2017 American Heart Association

197. Management of Opioid Therapy (OT) for Chronic Pain

, substance use disorders, and/or mental health problems for patients presenting with high risk and/or aberrant behavior. Strong for Reviewed, New- replaced 17. We recommend offering medication assisted treatment for opioid use disorder to patients with chronic pain and opioid use disorder. Note: See the VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. Strong for Reviewed, New- replaced Opioid Therapy for Acute Pain 18. a) We recommend alternatives to opioids for mild (...) for “fun” or to “get high,” while 22% used the medication to relieve day-to-day stress.[18] Concurrent with the increase in prescription opioid use, the rate of heroin overdose deaths increased nearly four-fold between 2000 and 2013.[19] According to a survey of patients entering SUD treatment for heroin use, the prescription opioid epidemic has resulted in a marked shift in how and which opioids are abused. In the 1960s, 80% of people entering treatment for heroin use started using heroin

2017 VA/DoD Clinical Practice Guidelines

198. Rehabilitation of Lower Limb Amputation

particular socket design, prosthetic foot categories, and suspensions and interfaces. Weak for Reviewed, New-added D. Prosthetic Training Phase 16. We recommend the use of valid, reliable, and responsive functional outcome measures, including, but not limited to, the Comprehensive High-level Activity Mobility Predictor, Amputee Mobility Predictor, 10-meter walk test, and 6-minute walk test. Strong for Reviewed, New-replaced 17. We suggest the use of a combination of measures with acceptable psychometric (...) of arteriosclerosis and diabetes, patients with these conditions are at high risk for further complications to their amputated residual limb and/or amputation of the contralateral limb. In addition, they are at higher risk for other health problems such as cardiovascular disease, cerebrovascular accident, renal disease, peripheral neuropathy, etc. While this guideline focuses on rehabilitation of patients with LLA, preservation of the residual and contralateral limb, as well as the patients’ general health

2017 VA/DoD Clinical Practice Guidelines

199. Management of Diabetes Mellitus in Primary Care

with appropriate providers to ensure continuity of high-quality care and timely referral to an endocrinologist. E. Create a support system for patients with DM such as online groups, chats, other support groups, and diabetes education classes to enhance involvement and support among patients with DM. C. Conflict of Interest At the start of this guideline development process and at other key points throughout, the project team was required to submit disclosure statements to reveal any areas of potential COI (...) have examined the effect of intensive glycemic control compared to standard/conventional glycemic control in managing adults with T2DM and the recommendations in this guideline are consistent with the individual RCTs and follow-up studies.[59-61] Three medications—metformin, empagliflozin, and liraglutide—have demonstrated a medication- specific benefit on cardiovascular outcomes in patients with T2DM at high risk for cardiovascular events.[62-64] However, while each of these medications lower

2017 VA/DoD Clinical Practice Guidelines

200. Improving Nasal Form and Function after Rhinoplasty Full Text available with Trip Pro

of life, medical consequences, motor vehicle accidents (estimated to cost $15.9 billion in 2000), and occupational losses. The estimated annual cost of treating the medical sequelae of OSA is $3.4 billion in the United States. Post-rhinoplasty, the burden of managing OSA can be challenging. For patients using nasal continuous positive airway pressure (CPAP) devices preoperatively, clinicians must consider the utility of nasal packing, wound care, and the timing to reinstatement of CPAP use (...) to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work. The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline

2017 American Academy of Otolaryngology - Head and Neck Surgery

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