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Red Reflex

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101. CRACKCast E177 – Acute Complications of Pregnancy

of symptoms does not correlate well with the risk of miscarriage, although cramping and passage of clots are thought more likely to occur as the miscarriage becomes inevitable. What are 3 treatment options? (assuming pt is stable) Examination & blood sampling (consider Hgb) and Rh status, followed by Ultrasound and expectant management Good return instructions re: ectopic pregnancy risk and red flags Patient education and support Normal moderate daily activities Avoid tampons, intercourse Cramping from (...) have a demonstrated risk of 4% or higher of one of the pregnancies being ectopic. 6) On US, list 3 diagnostic criteria for IUP, 5 findings suggestive of ectopic, and 4 indeterminate findings. Table 178.3 IUP Abnormal/ indeterminate* Ectopic Red = diagnostic Yellow = suggestive Quant HCG Usually > 1000-2000 mIU/mL Usually < 1500 mIU/mL Any value; < 1000 mIU/mL increases the risk of ectopic pregnancy four fold Location Intrauterine fetal pole Empty uterus Non-specific fluid collections Echogenic

2018 CandiEM

102. CRACKCast E176 – Pediatric Musculoskeletal Disorders

in injury to the brachial plexus. Middle third fractures have been associated with neurovascular bundle injuries, pulmonary injury, and pneumothorax. Reasons to call ortho: (red = obvious; black – you may have to know) Open fracture Skin tenting Neurovascular injury Brachial plexus, artery Suspicion for a posterior clavicle displacement injury Fractures with > 100% displacement of the fracture fragment Pathologic fractures Displaced medial third and lateral third fractures Distal clavicular fractures (...) fracture? See the orthobullets notes here – [29] List seven red flags for pediatric back pain. You need to think broadly From Uptodate: MSK Nonspecific – idiopathic low back pain spondylolysis and spondylolisthesis; scoliosis; Scheuermann’s (juvenile) kyphosis; and intervertebral disc degeneration, herniation, or calcification Infectious discitis, vertebral osteomyelitis (including tuberculous), epidural abscess, and bacterial infection of the sacroiliac joint. Non Spinal infections that can present

2018 CandiEM

103. CRACKCast E175 – Neurologic Disorders

(max 1 g) PR: Diazepam Dose: 5 mg/kg Lorazepam Dose: 1 mg/kg Buccal: Midazolam Dose: 5 mg/kg Lorazepam Dose: 1 mg/kg Pro tip: just memorize lorazepam 0.1 mg/kg for any route except IM or IN; in which case its 0.2 mg/kg for midazolam Note: “ During the administration of medications, pulse rate, respiratory rate, BP, cardiac monitoring and oxygen saturation via pulse oximeter should be followed on a regular basis. Anticonvulsant medications may cause loss of airway reflexes, respiratory depression (...) cortical neuronal depression is accompanied by vascular changes. Derangement of the trigeminovascular reflex results in alterations of regional blood flow, and this neurovascular interaction is thought to contribute to neurogenic inflammation and the development of migraine headaches. The primary goal of the ED evaluation is to differentiate life-threatening causes of headaches from primary headaches, such as migraine or tension headaches. A few different terms are used to characterize headaches: acute

2018 CandiEM

104. CRACKCast E174 – Genitourinary and Renal Tract Disorders

cephalosporin). urologist should be urgently consulted for a scrotal or testicular abscess. [7] Describe the diagnosis and management of testicular torsion. Key points: Can occur at any age – most commonly 12-18 yrs Time sensitive dx! 10% salvage rate at 24 hrs! Diagnosis: Hx: acute constant scrotal pain, swelling, high riding testicle, with nausea and vomiting. acute scrotal pain and swelling, an elevated testicle and, typically, absence of the cremasteric reflex. This reflex can be demonstrated by lightly (...) stroking the skin of the inner thigh downward from the hip toward the knee. The cremaster muscle on the ipsilateral side rapidly contracts and elevates the testicle.Although absent in the vast majority of cases, the presence of the cremasteric reflex does not preclude testicular torsion. Abnormal (high-riding and transverse) epididymal and testicular position may also be noted , with left-sided torsions slightly more common than right. Pain is typically constant, and the patient may have a history

2018 CandiEM

105. Neonatal stabilisation for retrieval

work of breathing · Respiratory acidosis (e.g. pH less than 7.25 or partial pressure of carbon dioxide (PaCO2) greater than 60 mmHg) · Increasing apnoeic episodes · Increasing bradycardic episodes · Refer to Table 10. Intermittent positive pressure ventilation Care 33 · Observe nares and nasal septum for redness · If CPAP or bubble not being maintained: o Check circuit—set up, patency o Reposition CPAP delivery device o Reposition the baby o Maintain seal o Reassess prong size o Place chin strap (...) securely o Observe cannula site hourly for patency, redness and infiltration · Use UVC o Consider insertion if: § Peripheral IV cannulation is unsuccessful § Baby is critically unwell or LBW o Use double lumen catheter (if available) o Secure with suture and tape o Observe site for redness, leakage and dislodgement o Confirm position on X-ray prior to infusing fluids except when using for emergency resuscitation · Routine umbilical arterial catheter or peripheral arterial line insertion not required

2018 Clinical Practice Guidelines Portal

106. Neonatal jaundice

for nappy · Protect eyes · Continuous observation of baby · Monitor baby’s temperature · Continue normal oral feeds · Assess hydration status · Discontinue depending on baby’s age, TSB and cause of hyperbilirubinaemia Risk factors Maternal · Blood group O · RhD negative · Red call antibodies · Genetic–family history, East Asian, Mediterranean · Diabetes · Previous jaundiced baby required phototherapy Neonatal · Feeding– BF, reduced intake · Haematoma or bruising · Polycythaemia · Haemolysis causing (...) management plan with parents · Provide parents with information brochure · If conjugated bilirubin elevated: o Urgent LFT/BGL/INR o Refer to paediatric surgeon/ gastroenterologist Baby 14 days Baby >24 hours · Check maternal ABO and RhD type and red cell antibody screening · Blood tests: o ABO and RhD type, DAT o Other tests as indicated Yes No · Usually BF related · History and clinical examination · Blood tests: o TSB including conjugated and unconjugated o FBC and reticulocytes o TFT /LFT · Check

2018 Queensland Health

107. Induction of labour

each vaginal and uterine balloon (from green stopcock marked ‘V’ and from red stopcock marked ‘U’) o Reassess and repeat ensuring a minimum of 50 mL of residual volume remains in each balloon o Document the volume removed · Offer analgesia and sedation if woman not in labour and continues to experience moderate to severe discomfort despite balloon deflation · If persistent pain and discomfort following oral analgesia o Review by an obstetrician, or o Transfer to birth suite for further assessment (...) , flushing, electrocardiograph (ECG) changes (including prolonged QT interval), transient hypotension, reflex tachycardia (common with rapid IV injection) 102 Medication safety · The standard oxytocin preparation and administration regimen is recommended for all Queensland facilities as outlined in Section 4.4.1 Oxytocin regimen administration · If required, the same infusion solution can be continued for PPH management and as PPH prophylaxis following CS Before administration · Verify CTG normal

2018 Queensland Health

109. Low Back Pain, Adult Acute and Subacute

Incapacitating pain and/or advancing neurologic symptoms or other underlying pathology Consider re- evaluation, imaging or referral to specialist no Routine imaging is not recommended See Treatment Algorithm Acute 50) and failure to improve after one month had high false-positive rates. The authors concluded that red flags may be useful when combined or with a history of cancer, but by themselves will result in overtesting (Henschke, 2013). Fracture Single red flags that increase the likelihood of spinal (...) fracture in a patient with low back pain include older age, prolonged corticosteroid use, severe trauma and the presence of contusion or abrasion. These red flags increased the probability of fracture to between 10% and 33% (Downie, 2013). In addition, probability of fracture was higher (increased to between 42% and 90%) with the coexistence of multiple red flags, specifically: (Downie, 2013) • The combination of any four of leg or buttock pain, female, older age, BMI 70, severe trauma, prolonged use

2018 Institute for Clinical Systems Improvement

110. QTc Prolongation and Psychotropic Medications

is not as significant as the risk of psychiatric decompensation with a lower dose. There is evidence to suggest that the FDA warning has not reduced all-cause or cardiac mortality, but has led to increased rates of psychiatric hospitalizations for patients whose dose was reduced reflexively (39). Another study found that patients who had their dose of citalopram reflexively reduced were more likely to be prescribed sedatives or anxiolytics and had higher healthcare utilization (40). These studies highlight

2018 American Psychiatric Association

111. Paediatric Urology

: 44. 45. Kaefer, M., et al. The incidence of intersexuality in children with cryptorchidism and hypospadias: stratification based on gonadal palpability and meatal position. J Urol, 1999. 162: 1003. 46. Kollin, C., et al. Cryptorchidism: a clinical perspective. Pediatr Endocrinol Rev, 2014. 11 Suppl 2: 240. 47. Caesar, R.E., et al. The incidence of the cremasteric reflex in normal boys. J Urol, 1994. 152: 779. 48. Barthold, J.S., et al. The epidemiology of congenital cryptorchidism, testicular (...) epididymitis in boys: evidence of a post-infectious etiology. J Urol, 2004. 171: 391. 151. Yerkes, E.B., et al. Management of perinatal torsion: today, tomorrow or never? J Urol, 2005. 174: 1579. 152. Boettcher, M., et al. Clinical and sonographic features predict testicular torsion in children: a prospective study. BJU Int, 2013. 112: 1201. 153. Nelson, C.P., et al. The cremasteric reflex: a useful but imperfect sign in testicular torsion. J Pediatr Surg, 2003. 38: 1248. 154. Mushtaq, I., et al

2018 European Association of Urology

112. The care of the critically ill woman in childbirth

holders. Whilst the Royal College of Anaesthetists has endeavoured to ensure that this document is as accurate as possible at the time it was published, it can take no responsibility for matters arising from circumstances which may have changed, or information which may become available subsequently. All enquiries in regard to this document should be addressed to the: Royal College of Anaesthetists, Churchill House, 35 Red Lion Square, London WC1R 4SG 020 7092 1677

2018 Intensive Care Society

114. Corneal abrasion

contact in entropion) Predisposing factors Contact lens wear Corneal dystrophy Epithelial Basement Membrane (EBM) dystrophy, in which epithelium is abnormal and easily traumatised Corneal exposure dry eye lagophthalmos facial palsy Diabetes Neurotrophic keratitis Symptoms Pain ranges from mild foreign body sensation to severe pain; may be disproportionate to objective findings absence of pain should alert to possibility of neurotrophic keratitis Blepharospasm Photophobia Lacrimation Redness History (...) by failure of the normal blink reflex, or when its sensitivity to touch is reduced by damage to its nerves, as in diabetes or following shingles of the eye. Corneal abrasion can be very painful as the cornea is one of the most sensitive areas of the body. The clinician will assess the area involved and prescribe treatment accordingly. The damage to the surface can be seen more easily if fluorescein, an orange dye, is instilled into the eye. Anti-inflammatory or antibiotic eye drops are often recommended

2018 College of Optometrists

115. Entropion

of the tarsal plate Predisposing factors Age-related degenerative changes in the lid Severe cicatrising disease affecting the tarsal conjunctiva Ocular irritation or previous surgery Symptoms Foreign body sensation, irritation Red, watery eye Blurring of vision Signs Corneal and/or conjunctival epithelial disturbance from abrasion by the lashes (wide range of severity) Localised conjunctival hyperaemia Lid laxity (involutional entropion) Conjunctival scarring (cicatricial entropion) Absence of lower lid (...) Possible management by ophthalmologist The choice of surgical procedure depends on the underlying cause(s) Surgical intervention is indicated if any of the following are persistent: ocular irritation recurrent bacterial conjunctivitis reflex tear hypersecretion superficial keratopathy risk of ulceration and microbial keratitis There is evidence that the combination of horizontal and vertical eyelid tightening is an effective treatment for entropion Evidence base *GRADE: Grading of Recommendations

2018 College of Optometrists

116. Endophthalmitis (post operative)

, dressings, gloves (in corneal transplants) donor cornea Patient factors: diabetes, immunosuppression, HIV infection Symptoms Acute presentation: visual loss pain redness photophobia Chronic presentation: similar, usually milder, delayed Signs Acute presentation: lid oedema conjunctival chemosis and hyperaemia corneal haze cells and flare in AC; fibrinous exudate and/or hypopyon if severe pupil light reflex may be sluggish or absent IOP can be normal, low or raised vitritis (inflammation of the vitreous (...) ) may eliminate red reflex and preclude view of fundus Chronic presentation: similar, usually milder, delayed Differential diagnosis Post-operative inflammation without infection Other causes of acute red eye, for example acute anterior uveitis Vitreous haemorrhage Management by optometrist Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere GRADE* Level of evidence and strength of recommendation always relates to the statement(s

2018 College of Optometrists

117. Low back pain and radicular pain: development of a clinical pathway

pathways 50 Table 7 – Description of focus group participants in terms of age and sex. 68 Table 8 – List of red flags, grouped by cluster (based on expert opinion) 83 Table 9 – List of predictors for the return to work 100 Table 10 – Patient-reported outcome measures Outcome: the ICHOM list 113 KCE Report 295 Low back pain and radicular pain: development of a clinical pathway 7 LIST OF ABBREVIATIONS ABBREVIATION DEFINITION ASMA Association des Médecins Conseils en Assurance AMSTAR Assessing (...) of a clinical pathway KCE Report 295 • Can be associated with neurological symptoms and signs (numbness and/or tingling, following a dermatome pattern, reflex disturbances or motor weakness in an associated myotome), although this is not always the case. In spite of neurological symptoms and signs, pain is usually the predominant complaint. • In some cases, the radicular pain can present a neuropathic component (sensation of continuous burning, unchanged by movement and can be accompanied by strange

2017 Belgian Health Care Knowledge Centre

118. Low back pain and radicular pain: evaluation and management

a pain in the lower extremity with a dermatomal distribution. In some patients, radicular pain can be dominant over the back pain or can be isolated. Radicular pain can be associated with neurological symptoms and signs (numbness and/or tingling, in a dermatome pattern, reflex disturbances or motor weakness in an associated myotome), although this is not always the case. Not all radicular pain have a neuropathic pain component, i.e. pain caused by a lesion or a disease affecting the somatosensory (...) nervous system. All phases of the affection are covered by the guideline: acute phase from 0 to 6 weeks, sub-acute from 6 to 12 weeks and chronic from 12 weeks. This guideline covers: ? Low back pain without serious underlying cause (red flags) ? Radicular pain (including neurogenic claudication) This guideline does not address: ? Low back pain and radicular pain in children ( 75% in nearly all studies) and a severe spectrum of disease, and cannot be generalised to populations with a lower prevalence

2017 Belgian Health Care Knowledge Centre

119. CRACKCast E119 – Allergy, Hypersensitivity, Angioedema, and Anaphylaxis

Miscellaneous Hypoglycemia Red man syndrome Vocal cord dysfunction syndrome Pheochromocytoma Asthma attack Syncope [8] Outline a treatment algorithm for anaphylaxis The majority of the morbidity and mortality associated with anaphylaxis is caused by acute respiratory failure or cardiovascular collapse. There is no evidence that second line agents improve overall outcome! Remove Any Trigger (stinger, medication) MOVE ABC’s!! Airway!! Call for Epinephrine – all other drugs can wait!! First-line Agent (...) , used for BB overdoses) [10] Compare and contrast the management of angioedema with urticaria and without urticaria Urticaria appears as papules or wheals that consist of central swelling with surrounding reflex erythema, and it is associated with itching or a burning-type sensation. These lesions are a result of mediators (predominantly histamine) released from mast cells. They tend to occur on the extremities and trunk and are usually transient, with skin often returning toits normal appearance

2017 CandiEM

120. One Emergency Medicine Resident. One Month of Palliative Care. Ten lessons.

identify ways that we can help. 4) Ask the question you want answered. Imagine you are five years old and have just been given a new colouring book which you are very excited to colour. You are given the option of two coloured markers, green or red. But, when you choose green you are handed a yellow crayon. How do you feel? Confused? Frustrated? Angry? Sad? This is what so many physicians do every day when asking patients about goals of care. It does not have to be this way. Asking a patient who (...) pain control. 8) Nausea and vomiting have more than one cause… and treatment. Dopaminergic? Cholinergic? Serotonergic? We all learn this in medical school, and subsequently many forget it. But this one deserves the space in your brain: treating nausea appropriately not only improves the patient experience, but will also save us from the reflex treatment with costly, poorly effective and potentially harmful alternatives. There are options beyond dimenhydrinate and ondansetron. Don’t forget your

2017 CandiEM

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