FP essentials
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Competence is determined by a court of law, whereas physicians determine medical decision-making capacity (DMC). When patients lack DMC, a surrogate should be identified to make decisions. Ideally, patients will have created a durable power of attorney for health care. ⋯ When no surrogate can be identified and a patient has no written advance directive, hospital ethics committees can assist with decisions, or, for some patients, a court will need to appoint a guardian. When there is a surrogate, difficulties can arise when family members disagree with the surrogate's decisions or when surrogates request treatments that, in the physician's opinion, would be futile or nonbeneficial. Hospital ethics committees may be able to assist in these situations, but appropriately conducted family meetings often resolve such difficulties.
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The major psychoactive compounds in marijuana (cannabis) are cannabinoids, the most significant of which is delta-9-tetrahydrocannabinol. There are also two synthetic pharmaceutical cannabinoids, nabilone and dronabinol, available by prescription in the United States. The use of marijuana has increased in the United States with passage of medical marijuana laws in many states and legalization of recreational marijuana use in several states. ⋯ Marijuana has adverse effects, and has been associated with driving impairment, psychosis, dependence and withdrawal syndromes, hyperemesis, acute cardiac events, some cancers, and impaired lung function. As with studies on the benefits of marijuana, studies of adverse effects have yielded inconsistent results. Except for impaired driving and the occurrence of dependence and withdrawal syndromes, the adverse effects of marijuana use have not been fully studied.
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Rhabdomyolysis is the rapid breakdown of skeletal muscle with release of electrolytes, myoglobin, and other proteins into the circulation. The clinical presentation encompasses a spectrum of patients ranging from those with asymptomatic increases in creatine kinase (CK) levels to those with fulminant disease complicated by acute kidney injury (AKI), severe electrolyte abnormalities, compartment syndrome, and disseminated intravascular coagulation. A CK level at least 10 times the upper limit of normal typically is considered diagnostic, as is myoglobinuria. ⋯ Significant electrolyte abnormalities may be present and must be managed to avoid cardiac arrhythmias and arrest. Compartment syndrome can develop as an early or late finding and requires decompressive fasciotomy for definitive management. Intravenous fluids typically are continued until CK levels are lower than 1,000 U/L.
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When patients present with major or life-threatening bleeding due to warfarin use, rapid reversal with coagulation factors and vitamin K often is warranted. Oral vitamin K should be administered if the international normalized ratio is greater than 10 with no evidence of bleeding, but its use is not recommended if international normalized ratios are between 4.5 and 10. The most important factor in the risk of hemorrhage is the intensity of warfarin therapy. ⋯ Use of anticoagulation management services (eg, intervention using automated hospital information system-generated triggers from laboratory and pharmacy data) in the outpatient and inpatient settings can be considered to decrease the risk of complications for patients taking anticoagulants. Services that incorporate clear communication, evidence-based drug management, and patient education are important to ensure safe use of anticoagulants. Management of heparin-induced thrombocytopenia should include heparin discontinuation and initiation of a nonheparin anticoagulant.