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Bioavailability has also been enhanced by formulating tablets with an acid- resistant coating 2.5 mg provera visa, which protects erythromycin while in the stomach and then dissolves in the duodenum generic provera 2.5 mg otc, permitting absorption from the small intestine provera 10 mg discount. As a rule generic 10mg provera fast delivery, food decreases the absorption of erythromycin base and erythromycin stearate, whereas absorption of erythromycin ethylsuccinate is not affected. Only erythromycin base is biologically active; the derivatives must be converted to the base (either in the intestine or after absorption) in order to work. Erythromycin crosses the placenta, but adverse effects on the fetus have not been observed. Adverse Effects Erythromycin is generally free of serious toxicity and is considered one of our safest antibiotics. Gastrointestinal Effects Gastrointestinal disturbances (epigastric pain, nausea, vomiting, diarrhea) are the most common side effects. However, this should be done only when using erythromycin products whose absorption is unaffected by food (erythromycin ethylsuccinate, certain enteric-coated formulations of erythromycin base). Other Adverse Effects By killing off sensitive gut flora, erythromycin can promote superinfection of the bowel. There is evidence that erythromycin may cause hypertrophic pyloric stenosis in infants, especially those younger than 2 weeks. Drug Interactions Erythromycin can increase the plasma levels and half-lives of several drugs, thereby posing a risk for toxicity. Elevated levels are a concern with theophylline (used for asthma), carbamazepine (used for seizures and bipolar disorder), and warfarin (an anticoagulant). Accordingly, when these agents are combined with erythromycin, the patient should be monitored closely for signs of toxicity. Erythromycin prevents binding of chloramphenicol and clindamycin to bacterial ribosomes, thereby antagonizing their antibacterial effects. Accordingly, concurrent use of erythromycin with these two drugs is not recommended. As noted, erythromycin should not be combined with drugs that can inhibit erythromycin metabolism. After absorption, clarithromycin is widely distributed and readily penetrates cells. Adverse Effects and Interactions Clarithromycin is well tolerated and does not produce the intense nausea seen with erythromycin. The most common reactions (3%) have been diarrhea, nausea, and distorted taste—all described as mild to moderate. In clinical trials, only 3% of patients withdrew because of side effects, compared with 20% of those taking erythromycin. High doses of clarithromycin have caused fetal abnormalities in laboratory animals; possible effects on the human fetus are unknown. Like erythromycin, clarithromycin can inhibit hepatic metabolism of other drugs and can thereby elevate their levels. Azithromycin Actions and Therapeutic Uses Like erythromycin, azithromycin [Zithromax, Zmax] binds the 50S subunit of bacterial ribosomes, causing inhibition of protein synthesis. The drug is used for respiratory tract infections, cholera, chancroid, otitis media, uncomplicated infections of the skin and skin structures, disseminated M. It may also be used as a substitute for penicillin G in penicillin-allergic patients. Pharmacokinetics Absorption of azithromycin is decreased by food, and hence dosing should occur on an empty stomach. After absorption, azithromycin is widely distributed to tissues and becomes concentrated in cells. Adverse Effects and Interactions Like clarithromycin, azithromycin is well tolerated and does not produce the intense nausea seen with erythromycin. Aluminum- and magnesium-containing antacids reduce the rate (but not the extent) of absorption. In contrast to erythromycin and clarithromycin, azithromycin does not inhibit the metabolism of other drugs. However, there is concern that azithromycin may enhance the effects of warfarin (an anticoagulant) and may thereby pose a risk for bleeding. In patients taking both drugs, prothrombin time should be closely monitored to ensure that anticoagulation remains at a safe level. Mechanism of Action Clindamycin binds to the 50S subunit of bacterial ribosomes and thereby inhibits protein synthesis. The site at which clindamycin binds overlaps the binding sites for erythromycin and chloramphenicol. Accordingly, there are no indications for concurrent use of clindamycin with these other antibiotics. Antimicrobial Spectrum Clindamycin is active against most anaerobic bacteria (gram positive and gram negative) and most gram-positive aerobes. Susceptible anaerobes include Bacteroides fragilis, Fusobacterium species, Clostridium perfringens, and anaerobic streptococci. Therapeutic Use Because of its efficacy against gram-positive cocci, clindamycin has been used widely as an alternative to penicillin. Clindamycin is the drug of choice for severe group A streptococcal infection and for gas gangrene (an infection caused by C. In addition, clindamycin is a preferred drug for abdominal and pelvic infections caused by B. The drug is widely distributed to most body fluids and tissues, including synovial fluid and bone. Elimination Clindamycin undergoes hepatic metabolism to active and inactive products, which are later excreted in the urine and bile. In patients with substantial reductions in liver function or kidney function, the half-life increases slightly, but adjustments in dosage are not needed. However, in patients with combined hepatic and renal disease, the half-life increases significantly, and hence the drug may accumulate to toxic levels if dosage is not reduced. Symptoms usually begin during the first week of treatment but may develop as long as 4 to 6 weeks after clindamycin withdrawal. B l a c k B o x Wa r n i n g : C l i n d a m y c i n Clindamycin can cause potentially fatal Clostridium difficile diarrhea. Hepatotoxicity and blood dyscrasias (agranulocytosis, leukopenia, thrombocytopenia) develop rarely. Clindamycin hydrochloride [Cleocin] is supplied in capsules (75, 150, and 300 mg). Clindamycin palmitate [Cleocin Pediatric] is supplied in flavored granules, which are reconstituted with fluid to make an oral solution containing 15 mg of clindamycin per milliliter. Clindamycin phosphate is supplied in concentrated solution (150 mg/mL) and dilute solution (6, 12, and 18 mg/mL) sold as Cleocin Phosphate for parenteral therapy and in a 2% cream [Cleocin, Clindesse] and 100-mg suppositories [Cleocin] for intravaginal dosing. Oral Dosage and Administration For clindamycin hydrochloride, the adult dosage range is 150 to 450 mg every 6 hours; the pediatric dosage range is 8 to 20 mg/kg daily in three or four divided doses. For clindamycin palmitate, adult and pediatric dosages range from 8 to 25 mg/kg/day administered in three or four divided doses. Intravaginal Administration Intravaginal clindamycin (suppositories or cream) is indicated for bacterial vaginosis. The suppositories are approved only for nonpregnant women; the cream can be used by pregnant women, but only during the second and third trimesters. Women using clindamycin cream should insert 1 applicatorful (5 g containing 100 mg clindamycin) nightly for 7 days (if pregnant) or for 3 to 7 days (if nonpregnant). Women using clindamycin suppositories should insert 1 suppository (100 mg) on three consecutive evenings. Mechanism, Resistance, and Antimicrobial Spectrum Linezolid is a bacteriostatic inhibitor of protein synthesis. The drug binds to the 23S portion of the 50S ribosomal subunit and thereby blocks formation of the initiation complex. In real practice, resistance has been reported in association with extensive linezolid use. Linezolid is active primarily against aerobic and facultative gram-positive bacteria. Susceptible pathogens include Enterococcus faecium (vancomycin- sensitive and vancomycin-resistant strains), Enterococcus fecalis (vancomycin- resistant strains), S. Linezolid is not active against gram-negative bacteria, which readily export the drug.
However discount 10 mg provera with visa, before it can do so 2.5 mg provera for sale, pyridoxine must first be converted to its active form: pyridoxal phosphate generic provera 10 mg on line. Sources In the United States the principal dietary sources of pyridoxine are fortified generic 5 mg provera with visa, ready-to-eat cereals; meat, fish, and poultry; white potatoes and other starchy vegetables; and noncitrus fruits. Deficiency Pyridoxine deficiency may result from poor diet, isoniazid therapy for tuberculosis, and inborn errors of metabolism. Symptoms include seborrheic dermatitis, anemia, peripheral neuritis, convulsions, depression, and confusion. In the United States dietary deficiency of vitamin B is rare, except among6 people who abuse alcohol on a long-term basis. Within this population, vitamin B deficiency is estimated at 20% to 30% and occurs in combination with6 deficiency of other B vitamins. Isoniazid (a drug for tuberculosis) prevents conversion of vitamin B to its6 active form and may thereby induce symptoms of deficiency (peripheral neuritis). Inborn errors of metabolism can prevent efficient utilization of vitamin B,6 resulting in greatly increased pyridoxine requirements. Unless treatment with vitamin B is initiated early, permanent cognitive deficits may result. Drug Interactions Vitamin B interferes with the utilization of levodopa, a drug for Parkinson6 disease. Accordingly, patients receiving levodopa should be advised against taking the vitamin. Therapeutic Uses Pyridoxine is indicated for prevention and treatment of all vitamin B deficiency6 states (dietary deficiency, isoniazid-induced deficiency, pyridoxine dependency syndrome). Preparations, Dosage, and Administration Pyridoxine is available in solution (200 mg/5 mL), standard tablets (25, 50, 100, 250, and 500 mg), extended-release tablets (200 mg), and capsules (150 mg) for oral use. To correct dietary deficiency, the dosage is 10 to 20 mg/day for 3 weeks followed by 1. To protect against developing isoniazid- induced deficiency, the dosage is 25 to 50 mg/day. Pyridoxine dependency syndrome may require initial doses up to 600 mg/day followed by 25 to 50 mg/day for life. Because deficiency presents as anemia, folic acid and cyanocobalamin are discussed in Chapter 45. Because adults older than 50 years often have difficulty absorbing dietary vitamin B12, they should ingest at least 2. Food Folate Versus Synthetic Folate The form of folate that occurs naturally (food folate) has a different chemical structure than synthetic folate (pteroylglutamic acid). As a result of grain fortification, the incidence of folic acid deficiency in the United States has declined dramatically. Unfortunately, the incidence of birth defects from folate deficiency (see later) has only dropped by 32%. Spina bifida, a condition characterized by defective development of the bony encasement of the spinal cord, can result in nerve damage, paralysis, and other complications. Folic Acid and Cancer Risk There is evidence that folic acid in low doses may reduce cancer risk, whereas folic acid in higher doses may increase cancer risk—suggesting that cancer risk is increased by having either too little folic acid (folic acid deficiency) or by having too much folic acid (folic acid excess). Taking high- dose folic acid to reduce cancer risk is ineffective and should be discouraged. Pantothenic Acid Pantothenic acid is an essential component of two biologically important molecules: coenzyme A and acyl carrier protein. Coenzyme A is an essential factor in multiple biochemical processes, including gluconeogenesis, intermediary metabolism of carbohydrates, and biosynthesis of steroid hormones, porphyrins, and acetylcholine. Pantothenic acid is available in single-ingredient tablets and in multivitamin preparations. However, because deficiency does not occur, there is no reason to take supplements. Biotin Biotin is an essential cofactor for several reactions involved in the metabolism of carbohydrates and fats. The vitamin is found in a wide variety of foods, although the exact amount in most foods has not been determined. In addition to being available in foods, biotin is synthesized by intestinal bacteria. In fact, to determine the effects of deficiency, scientists had to induce it experimentally. When this was done, subjects experienced dermatitis, conjunctivitis, hair loss, muscle pain, peripheral paresthesias, and psychological effects (lethargy, hallucinations, depression). Biotin appears devoid of toxicity: subjects given large doses experienced no adverse effects. Excessive body fat may be associated with increased risk for morbidity from hypertension, coronary heart disease, ischemic stroke, type 2 diabetes, gallbladder disease, liver disease, kidney stones, osteoarthritis, sleep apnea, dementia, and certain cancers. Among women, obesity may increase the risk for menstrual irregularities, amenorrhea, and polycystic ovary syndrome. During pregnancy, obesity may increase the risk for morbidity and mortality for both mother and child. Despite recent declines in obesity prevalence, almost one third of American children and adolescents are overweight or obese. In addition, type 2 diabetes, formerly seen almost exclusively in adults, has increased 10-fold among children and teens, and gallbladder disease has tripled. Contributing factors include genetics, metabolism, and appetite regulation, along with environmental, psychosocial, and cultural factors. Although obese people can lose weight, the tendency to regain weight cannot be eliminated. Assessment of Weight-Related Health Risk Health risk is determined by (1) the degree of obesity (as reflected in the body mass index), (2) the pattern of fat distribution (as reflected in the waist circumference measurement), and (3) the presence of obesity-related diseases or cardiovascular risk factors. Accordingly, all three factors must be assessed when establishing a treatment plan. Nor do they apply to competitive athletes or bodybuilders, who are heavy because of muscle mass rather than excess fat. Accumulation of fat in the upper body, and especially within the abdominal cavity, poses a greater risk to health than does accumulation of fat in the lower body (hips and thighs). People with too much abdominal fat are at increased risk for insulin resistance, diabetes, hypertension, coronary atherosclerosis, ischemic stroke, and dementia. Fat distribution can be estimated simply by looking in the mirror: an apple shape indicates too much abdominal fat, whereas a pear shape indicates fat on the hips and thighs. Certain weight-related diseases—established coronary heart disease, other atherosclerotic diseases, type 2 diabetes, and sleep apnea—confer a risk for complications and mortality. Other weight-related diseases—gynecologic abnormalities, osteoarthritis, gallstones, and stress incontinence—confer less risk. The risk is further increased by weight-related diseases and cardiovascular risk factors. Overview of Obesity Treatment The strategy for losing weight is simple: take in fewer calories per day than are burned. After 6 months, the goal for all patients is to prevent lost weight from returning. This may be accomplished by a combination of diet, physical activity, and behavioral therapy. A more realistic goal is to target a percentage of body weight at which risk is decreased and comorbidities prevented. A weight loss of 10% to 15% is typical for those who diligently adhere to medication and lifestyle regimen, whereas a loss greater than 15% is exceptional. Treatment Modalities Weight loss can be accomplished with five treatment modalities: caloric restriction, physical activity, behavioral therapy, drug therapy, and surgery. For any individual, the treatment mode is determined by the degree of obesity and personal preference. As noted, the only way to lose weight is to take in fewer calories than are burned. Depending on the individual, the caloric deficit should range from 300 to 1000 kcal/day. Because fats contain more calories than either carbohydrates or proteins (on an ounce-for- ounce basis), reducing dietary fat is the easiest way to reduce calorie intake.
Severe respiratory depression can be reversed with naloxone [Narcan] discount provera 2.5mg visa, a pure opioid antagonist provera 5 mg free shipping. However buy provera 2.5mg on line, caution is required: excessive dosing will reverse analgesia provera 2.5 mg without a prescription, thereby putting the patient in great pain. When death is near, should opioids be withheld out of fear that respiratory depression may bring death sooner? Third, when death is imminent, it is more important to provide comfort than prolong life. Accordingly, adequate opioids should be provided, even if doing so means life ends a bit sooner. Opioids promote constipation by decreasing propulsive intestinal contractions, increasing nonpropulsive contractions, increasing the tone of the anal sphincter, and reducing fluid secretion into the intestinal lumen. For prophylaxis of constipation, current guidelines recommend daily therapy with a combination product, such as Senokot-S, which contains both senna and docusate. Methylnaltrexone [Relistor] is indicated only for constipation in patients with end-stage disease. If sedation persists, it can be reduced by giving smaller doses of the opioid more frequently, while keeping the total daily dose the same. Other Side Effects Opioids promote histamine release and can thereby cause itching, which can be relieved with an antihistamine (e. Opioids increase the tone in the urinary bladder sphincter and can thereby cause urinary retention. Benign prostatic hypertrophy and use of anticholinergic drugs will exacerbate the problem. Patients should be monitored for urinary retention and encouraged to void every 4 hours. Patients should be informed about symptoms of hypotension (lightheadedness, dizziness) and instructed to sit or lie down if they occur. Orthostatic hypotension can be minimized by moving slowly when changing from a supine or seated position to an upright posture. Primary risk factors are renal impairment, preexisting cognitive impairment, and prolonged, high- dose opioid use. Adjuvant Analgesics Adjuvant analgesics are used to complement the effects of opioids. Accordingly, these drugs are employed in combination with opioids—not as substitutes. Adjuvant analgesics can (1) enhance analgesia from opioids, (2) help manage concurrent symptoms that exacerbate pain, and (3) treat side effects caused by opioids. The adjuvant analgesics differ from opioids in that pain relief is limited and less predictable and often develops slowly. The adjuvants are interesting in that, although they can relieve pain, all of them were developed to treat other conditions (e. Accordingly, it is important to reassure patients that the adjuvant is being used to alleviate pain, and not for its original purpose. Important adverse effects are orthostatic hypotension, sedation, anticholinergic effects (dry mouth, urinary retention, constipation), and weight gain (secondary to improved appetite). Dosing at bedtime takes advantage of sedative effects and minimizes hypotension during the day. Other Antidepressants In addition to the tricyclic agents, certain other antidepressants (e. Acute pain (sharp, darting pain) is especially responsive, although other forms of neuropathic pain (cramping pain, aching pain, burning pain) also respond. Of the available antiseizure drugs, carbamazepine [Tegretol] has been used most widely. Because carbamazepine is myelosuppressive, it must be used with caution in patients receiving anticancer drugs that suppress bone marrow function. As discussed in Chapter 19, caution is also needed in patients of Asian descent, owing to an increased risk for severe dermatologic reactions. Another drug—gabapentin [Neurontin]—is also very effective and causes fewer side effects than carbamazepine. Dosage should be low initially (100 mg once a day) and then gradually increased; dosages as high as 1200 mg 3 times a day have been employed. Local Anesthetics/Antidysrhythmics Lidocaine (a local anesthetic and antidysrhythmic) and mexiletine (an antidysrhythmic related to lidocaine) are considered second-line agents for neuropathic pain. Antihistamines Hydroxyzine [Vistaril], an antihistamine, promotes drowsiness and reduces anxiety. Drawbacks include worsening of constipation, urinary retention, and cognitive impairment. Glucocorticoids Although glucocorticoids lack direct analgesic actions, they can help manage painful cancer-related conditions. Because glucocorticoids can reduce cerebral and spinal edema, they are essential for the emergency management of elevated intracranial pressure and epidural spinal cord compression. Similarly, glucocorticoids are part of the standard therapy for tumor-induced spinal cord compression. In addition to these benefits, glucocorticoids can improve appetite and impart a general sense of well-being; both actions help in managing anorexia and cachexia-associated with terminal illness. Glucocorticoids are very safe when used short term (even in high doses) and very dangerous when used long term (even in low doses). In particular, long- term therapy can cause adrenal insufficiency, osteoporosis, glucose intolerance (hyperglycemia), increased vulnerability to infection, thinning of the skin, and, possibly, peptic ulcer disease. The risk for osteoporosis can be reduced by giving calcium supplements and vitamin D along with calcitonin or a bisphosphonate (e. Bisphosphonates Bisphosphonates, such as etidronate [Didronel] and pamidronate, can reduce cancer-related bone pain in some patients. The cause of pain may be tumor-induced bone resorption, which can also cause hypercalcemia, osteoporosis, and related fractures. Bisphosphonates inhibit bone resorption and are approved for treating hypercalcemia of malignancy and bone metastases in breast cancer—but not bone pain itself. However, when these drugs are given to treat hypercalcemia, many patients report a reduction in bone pain, although others do not. Hence, although these drugs appear promising, their use for management of bone pain is still considered investigational. Nondrug Therapy Neurolytic Nerve Block The goal of this procedure is to destroy neurons that transmit pain from a limited area, thereby providing permanent pain relief. Nerve destruction is accomplished through local injection of a neurolytic (neurotoxic) substance, typically alcohol or phenol. To ensure that the correct nerves are destroyed, reversible nerve block is done first, using a local anesthetic. If the local anesthetic relieves the pain, a neurolytic agent is then applied to the same site. However, even if pain relief is only partial, the procedure can still permit some reduction in opioid dosage and can thereby decrease side effects, such as sedation and constipation. When nerve block is successful and opioids are discontinued, opioid dosage should be tapered gradually to avoid withdrawal. Potential complications include hypotension, paresis (slight paralysis), paralysis, and disruption of bowel and bladder function (e. Palliative treatment can be directed at primary tumors and at metastases anywhere in the body. With brachytherapy, cell kill is limited to the immediate area of the implanted pellets; hence the technique is suited only for localized tumors. With teletherapy, cell kill can be localized or widespread, depending on the size of the beam employed; hence the technique can be used for both localized tumors and metastases. Radiofrequency ablation uses a thin, needle-like probe inserted into a tumor through an incision in the skin. The probe extends electrodes that emit high-frequency electrical current, producing heat to destroy cancer cells; hence the technique is best suited for localized tumors.
He has bloody stools discount provera 5mg, but he also has bilious emesis cheap provera 10 mg online, colicky abdominal pain discount 10 mg provera mastercard, and a right upper quadrant mass 10mg provera free shipping. In experienced hands, an air contrast enema procedure may be diagnostic and therapeutic. Ensure that a surgeon and a prepared operating room are avail- able should the reduction through contrast enema fail or result in intestinal perforation. Hemolytic-uremic syndrome may be seen after bloody diarrhea, present- ing with anemia, thrombocytopenia, and nephropathy. The child in question is hypertensive and has edema, so large amounts of fluids may be counter- productive. The thrombocytopenia is con- sumptive; unless the patient is actively bleeding, platelet transfusion is not helpful. Most of the care for such patients is supportive, concentrating on fluids and electrolytes. Antibiotics are not indicated for this healthy family, and antimotility agents may prolong the ill- ness. Clostridium difficile colonizes approximately half of normal healthy infants in the first 12 months. In this infant without a history of antibiotic treatment or current symptoms, treatment is unnecessary. Clostridium difficile colitis rarely occurs without a history of recent antibiotic use. European Society for Paediatric Gastroenterology, Hepatology, and Nutrition/European Society for Paediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe. The father was holding him in his lap in the front passenger seat of their vehicle when the driver lost control and crashed into a tree. He had a self-limited, 2-minute generalized tonic-clonic seizure en route to the hospital. His endotracheal tube is in the correct position, and his arterial blood gas reflects effective oxy- genation and ventilation. His anterior fontanelle is bulging, his sutures are slightly separated, and his funduscopic examination reveals bilateral retinal hemorrhages. Compare the typical findings of subdural hematoma with those of epidural hematoma. Considerations This child is younger than 1 year, and subdural hematomas are more common in this age group; epidural hematomas are more common in older children. Seizures are more common with subdural hematomas, occurring in 75% of affected patients; seizures occur in less than 25% of epidural hematoma patients. The infant’s ejection at the crash provides an appropriate mechanism of injury, making other considerations (such as abusive head trauma, formerly known as shaken baby syndrome) less likely. Comparison of the anatomic locations of an epidural and subdural hematoma relative to the dura. For infants and toddlers, several “modified” scales exist that attempt to adapt the verbal portion to reflect language development and modify the motor component to reflect the lack of purposeful movement in early infancy (Table 29–1). Subdural hemorrhage is more common in children younger than 1 year and is far more common than a supratentorial epidural hemorrhage. Seizures occur in 60% to 90% of afflicted patients, and retinal hemorrhages are frequently associated. Patients with subacute subdural hematoma display symptoms between 3 and 21 days after injury, whereas chronic hematomas cause symptoms after 21 days. Chronic subdural hematomas are more common in older children than in infants; symptoms may include chronic emesis, seizures, hypertonicity, irritability, personality changes, inattention, poor weight gain, fever, and anemia. Epidural hemorrhages occur more commonly in older children and adults and are seen more typically in the supratentorial space. Although most adult epidural hemorrhages are arterial in origin, in children approximately half originate from venous injuries. Fewer than 25% of epidural hematoma patients have seizures, and retinal hemorrhages are uncommon. Mortality is greater with epidural hemorrhage than with subdural hemorrhage, but in survivors, long-term morbidity is low. In infants with open sutures, symptoms may be nonspecific and include lethargy, vomiting, separated sutures, and a bulging fontanelle. Epidural hematomas are frequently rapidly progressive and may require urgent surgical evac- uation with identification of the bleeding source. Subdural hemorrhage usually does not require urgent evacuation but may require evacuation at a later date. Similarly, Case 21 (Sudden Infant Death Syndrome) requires a thor- ough investigation of the events surrounding the child’s death; unfortunately some cases of apparent sudden infant death syndrome are in reality inflicted trauma with a resultant subdural hematoma. During the first quarter of a district playoff game, you watch as your star quarterback is sacked with a helmet-to-helmet tackle. He remembers his name but cannot remember the day, his position in the team, or how he got to the game. He has no sensory or motor deficit suggestive of a cervical spine injury, and you assist him off the field. Tell the player that he will need sequential evaluations before he can come back to practice. He has returned to class and complains of dif- ficulty concentrating, especially in his mathematics class. Despite these symptoms, he is eager to start football practice again so that he can play in next Friday’s game. Allow the player to return to practice this week and then return to play the following week. Follow-up in 1 week to monitor for resolution of symptoms prior to returning to play. Follow-up in 1 week to monitor for resolution of symptoms prior to returning to play. Follow-up in 2 months to monitor for resolution of symptoms prior to returning to play. She and her boyfriend had been drinking beer and were on their way home when she lost control of the car and hit the side wall of the local police station. She reportedly had a brief loss of consciousness but currently is ori- ented to name, place, and time. While waiting for her cervical spine series, she vomits and lapses into unconsciousness. She will need extensive neuropsychiatric evaluation before she can return to school. She will likely develop seizures and needs 2 years of prophylactic seizure medicine. She can no longer be legally permitted to drive because she has had brain surgery. Your examination reveals a few old bruises but no evidence of acute trauma or fracture. The pediatric radiologist reports bilateral frontal subdural hematomas and notes two healing skull fractures that she estimates to be approximately 2 weeks old. Although controversial, the correct answer is for a player who sustains a con- cussion resulting in loss of consciousness to refrain from play for the remain- der of the day. The most recent clinical report from the American Academy of Pediatrics concerning conditions affecting sports participation references the 3rd International Conference on Concussion in Sports from 2008. This report suggests that individualized and frequent reassessment over time, and a step- wise return to play, is more useful than a predetermined length of time to refrain from additional sports. This approach was affirmed in the American Academy of Neurology’s concussion guideline update in 2013. There are no standardized guidelines for postconcussive players to return to play. A graduated return-to-play schedule should be used that pro- gresses from no activity, to light aerobic exercise, sport-specific exercise, non- contact training drills, full-contact practice, and finally return to play. If the patient develops symptoms with an increase in activity level, activity should be stopped and then returned to the previous level once symptom free. This patient should be followed closely and needs documented medical clearance from a health care provider prior to returning to play. The acute epidural hemorrhage mortality rate is higher than that of acute subdural hemorrhage, but long-term morbidity in survivors is less. If the hematoma blood age correlates with the estimated skull fracture age, child abuse should be considered.