Latest Updates

Coma, Cognitive Impairment, and Seizures

    • When treating an unresponsive patient, targeted therapy is advised instead of routine use of the “coma cocktail” (empirical treatment with dextrose, naloxone, thiamine, and sometimes flumazenil).
    • Avoidance of hypotension and maintenance of normoglycemia and normothermia are critical to the management of intracranial hypertension.
    • Differing levels of awareness were noted among patients found to be in a minimally conscious state (MCS); subsequently, this condition was further subdivided into two categories, MCS plus (MCS+) and MCS minus (MCS-), based on the ability to follow commands versus just visual pursuit. Permanent vegetative state is no longer used.

Coma, Cognitive Impairment, and Seizures

    • When treating an unresponsive patient, targeted therapy is advised instead of routine use of the “coma cocktail” (empirical treatment with dextrose, naloxone, thiamine, and sometimes flumazenil).
    • Avoidance of hypotension and maintenance of normoglycemia and normothermia are critical to the management of intracranial hypertension.
    • Differing levels of awareness were noted among patients found to be in a minimally conscious state (MCS); subsequently, this condition was further subdivided into two categories, MCS plus (MCS+) and MCS minus (MCS-), based on the ability to follow commands versus just visual pursuit. Permanent vegetative state is no longer used.

Asthma in Pregnancy

    • Control of asthma symptoms may reduce the risk of obstetric complications
    • Certain known comorbidities may contribute to more severe asthma exacerbation in pregnancy and should be evaluated.
    • For most pregnant patients with asthma, general guidelines for asthma severity evaluation and treatment can be followed, as they would be for non-pregnant patients.
    • Safety data on use of biologic agents such as humanized IgG1 monoclonal anti-immunoglobulin E antibody is increasing.

Appendiceal Neoplasm

Garrett M. Nash, MD, MPH, FACS, FASCRS, Tushar Samdani , MD, FASCRS
    • 2019 ASCRS Practice Guidelines Update. See Table 9 for further details.
    • Recent advances in multimodality treatment of appendiceal neoplasm with peritoneal involvement including surgery and intraperitoneal chemotherapy.
    • Current trends in intraperitoneal chemotherapy: hyperthermic intraperitoneal chemotherapy (HIPEC) versus early postoperative intraperitoneal chemotherapy (EPIC).
    • Recent advances in understanding low-grade appendiceal neoplasm and the focus of current and future clinical trials.

Pediatric Abdominal Emergencies

Jeffrey Bullard-Berent, MD, FAAP, FACEP, Aaron Kornblith, MD
    • Pediatric surgical emergencies occur at characteristic ages, and emergency physicians need to be aware of this on presentation.
    • Diagnosis of incarcerated inguinal hernia is a clinical diagnosis.
    • Ultrasonography is the initial imaging modality of choice for midgut volvulus, pyloric stenosis, intussusception, and appendicitis.
    • Hydrostatic and pneumatic enema is the therapeutic method of choice for reduction of ileocolic intussusception.
    • In children with suspected appendicitis, the application of a staged algorithm, including a scoring system and ultrasonography, can improve test characteristics.

Pediatric Abdominal Emergencies

Jeffrey Bullard-Berent, MD, FAAP, FACEP, Aaron Kornblith, MD
    • Pediatric surgical emergencies occur at characteristic ages, and emergency physicians need to be aware of this on presentation.
    • Diagnosis of incarcerated inguinal hernia is a clinical diagnosis.
    • Ultrasonography is the initial imaging modality of choice for midgut volvulus, pyloric stenosis, intussusception, and appendicitis.
    • Hydrostatic and pneumatic enema is the therapeutic method of choice for reduction of ileocolic intussusception.
    • In children with suspected appendicitis, the application of a staged algorithm, including a scoring system and ultrasonography, can improve test characteristics.

Pediatric Abdominal Emergencies

Jeffrey Bullard-Berent, MD, FAAP, FACEP, Aaron Kornblith, MD
    • Pediatric surgical emergencies occur at characteristic ages, and emergency physicians need to be aware of this on presentation.
    • Diagnosis of incarcerated inguinal hernia is a clinical diagnosis.
    • Ultrasonography is the initial imaging modality of choice for midgut volvulus, pyloric stenosis, intussusception, and appendicitis.
    • Hydrostatic and pneumatic enema is the therapeutic method of choice for reduction of ileocolic intussusception.
    • In children with suspected appendicitis, the application of a staged algorithm, including a scoring system and ultrasonography, can improve test characteristics.

Psychiatric Diseases in Pregnancy

    • In March 2019, the U.S. Food and Drug Administration approved Zulresso (Brexanolone) injection for intravenous (IV) use for the treatment of postpartum depression (PPD) in adult women. This is the first drug approved by the FDA specifically for treatment of PPD and is currently available only under a restricted distribution program due to concerns about serious risks including excessive sedation or sudden loss of consciousness during administration. Specific restrictions and requirements are planned to be detailed on the medication’s associated black box warning label. 
    • All women should be screened multiple times during pregnancy and in the postpartum period for depression, regardless of their risk factors or medical history. Many tools such as the Edinburgh Postnatal Depression Scale form are available to assist in screening.
    • When considering intrapartum pain management in women with opioid use disorder, it is important to avoid drugs with an opioid antagonist component, such as nalbuphine, as this can precipitate withdrawal symptoms. Use of other medications such as NSAIDs can reduce the amount of opioids required.
    • The effect of marijuana use in pregnancy is unclear, as studies are confounded due to co-existing mental health disorders, socioeconomic status, parental education, and cigarette smoking. Despite these limitations, several studies have demonstrated an association with preterm labor, low birth weight, NICU admission, and stillbirth. As with any drug of abuse, abstinence during pregnancy should be encouraged.
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