Toxic shock syndrome - Wikipedia

TSS resulting from infection with the bacterium Staphylococcus aureus typically manifests in otherwise healthy individuals via signs and symptoms including ... Toxicshocksyndrome FromWikipedia,thefreeencyclopedia Jumptonavigation Jumptosearch MedicalconditionToxicshocksyndromeToxicshocksyndrometoxin-1proteinfromstaphylococcusSpecialtyInfectiousdiseaseSymptomsFever,rash,skinpeeling,lowbloodpressure[1]UsualonsetRapid[1]TypesStaphylococcal(menstrualandnonmenstrual),streptococcal[1]CausesStreptococcuspyogenes,Staphylococcusaureus,others[1][2]RiskfactorsVeryabsorbenttampons,skinlesionsinyoungchildren[1]DiagnosticmethodBasedonsymptoms[1]DifferentialdiagnosisSepticshock,Kawasaki'sdisease,Stevens–Johnsonsyndrome,scarletfever[3]TreatmentAntibiotics,incisionanddrainageofanyabscesses,intravenousimmunoglobulin[1]PrognosisRiskofdeath:~50%(streptococcal),~5%(staphylococcal)[1]Frequency3per100,000peryear(developedworld)[1] Toxicshocksyndrome(TSS)isaconditioncausedbybacterialtoxins.[1]Symptomsmayincludefever,rash,skinpeeling,andlowbloodpressure.[1]Theremayalsobesymptomsrelatedtothespecificunderlyinginfectionsuchasmastitis,osteomyelitis,necrotisingfasciitis,orpneumonia.[1] TSSistypicallycausedbybacteriaoftheStreptococcuspyogenesorStaphylococcusaureustype,thoughothersmayalsobeinvolved.[1][2]Streptococcaltoxicshocksyndromeissometimesreferredtoastoxic-shock-likesyndrome(TSLS).[1]Theunderlyingmechanisminvolvestheproductionofsuperantigensduringaninvasivestreptococcusinfectionoralocalizedstaphylococcusinfection.[1]Riskfactorsforthestaphylococcaltypeincludetheuseofveryabsorbenttampons,andskinlesionsinyoungchildrencharacterizedbyfever,lowbloodpressure,rash,vomitingand/ordiarrhea,andmultiorganfailure.[1][4][5]Diagnosisistypicallybasedonsymptoms.[1] Treatmentincludesintravenousfluids,antibiotics,incisionanddrainageofanyabscesses,andpossiblyintravenousimmunoglobulin.[1][6]Theneedforrapidremovalofinfectedtissueviasurgeryinthosewithastreptococcalcause,whilecommonlyrecommended,ispoorlysupportedbytheevidence.[1]Somerecommenddelayingsurgicaldebridement.[1]Theoverallriskofdeathisabout50%instreptococcaldisease,and5%instaphylococcaldisease.[1]Deathmayoccurwithin2days.[1] IntheUnitedStates,streptococcalTSSoccursinabout3per100,000peryear,andstaphylococcalTSSinabout0.5per100,000peryear.[1]Theconditionismorecommoninthedevelopingworld.[1]Itwasfirstdescribedin1927.[1]Duetotheassociationwithveryabsorbenttampons,theseproductswereremovedfromsale.[1] Contents 1Signsandsymptoms 2Pathophysiology 3Diagnosis 4Treatment 5Prognosis 6Epidemiology 7History 7.1Initialdescription 7.2Relytampons 8Notablecases 9References 10Externallinks Signsandsymptoms[edit] Symptomsoftoxicshocksyndrome(TSS)varydependingontheunderlyingcause.TSSresultingfrominfectionwiththebacteriumStaphylococcusaureustypicallymanifestsinotherwisehealthyindividualsviasignsandsymptomsincludinghighfever,accompaniedbylowbloodpressure,malaiseandconfusion,[2]whichcanrapidlyprogresstostupor,coma,andmultipleorganfailure.Thecharacteristicrash,oftenseenearlyinthecourseofillness,resemblesasunburn[2](conversely,streptococcalTSSwillrarelyinvolveasunburn-likerash),andcaninvolveanyregionofthebodyincludingthelips,mouth,eyes,palmsandsolesofthefeet.[2]Inpatientswhosurvive,therashdesquamates(peelsoff)after10–21days.[2] STSScausedbythebacteriumStreptococcuspyogenes,orTSLS,typicallypresentsinpeoplewithpre-existingskininfectionswiththebacteria.Theseindividualsoftenexperienceseverepainatthesiteoftheskininfection,followedbyrapidprogressionofsymptomsasdescribedaboveforTSS.[citationneeded] Pathophysiology[edit] InbothTSS(causedbyS.aureus)andTSLS(causedbyS.pyogenes),diseaseprogressionstemsfromasuperantigentoxin.ThetoxininS.aureusinfectionsisTSSToxin-1,orTSST-1.TheTSST-1issecretedasasinglepolypeptidechain.ThegeneencodingtoxicshocksyndrometoxiniscarriedbyamobilegeneticelementofS.aureusintheSaPIfamilyofpathogenicityislands.[7]Thetoxincausesthenon-specificbindingofMHCII,onprofessionalantigenpresentingcells,withT-cellreceptors,onTcells. IntypicalT-cellrecognition,anantigenistakenupbyanantigen-presentingcell,processed,expressedonthecellsurfaceincomplexwithclassIImajorhistocompatibilitycomplex(MHC)inagrooveformedbythealphaandbetachainsofclassIIMHC,andrecognizedbyanantigen-specificT-cellreceptor.ThisresultsinpolyclonalT-cellactivation.Superantigensdonotrequireprocessingbyantigen-presentingcellsbutinstead,interactdirectlywiththeinvariantregion[citationneeded]oftheclassIIMHCmolecule.InpatientswithTSS,upto20%ofthebody'sT-cellscanbeactivatedatonetime.ThispolyclonalT-cellpopulationcausesacytokinestorm,[6]followedbyamultisystemdisease. Diagnosis[edit] Forstaphylococcaltoxicshocksyndrome,thediagnosisisbaseduponCDCcriteriadefinedin2011,asfollows:[4] Bodytemperature>38.9 °C(102.02 °F) Systolicbloodpressure<90mmHg Diffusemacularerythroderma Desquamation(especiallyofthepalmsandsoles)1–2weeksafteronset Involvementofthreeormoreorgansystems: Gastrointestinal(vomiting,diarrhea) Muscular:severemyalgiaorcreatinephosphokinaselevelatleasttwicetheupperlimitofnormalforlaboratory Mucousmembranehyperemia(vaginal,oral,conjunctival) Kidneyfailure(serumcreatinine>2timesnormal) Liverinflammation(bilirubin,AST,orALT>2timesnormal) Lowplateletcount(plateletcount<100,000/mm3) Centralnervoussysteminvolvement(confusionwithoutanyfocalneurologicalfindings) Negativeresultsof: Blood,throat,andCSFculturesforotherbacteria(besidesS.aureus) NegativeserologyforRickettsiainfection,leptospirosis,andmeasles Casesareclassifiedasconfirmedorprobableasfollows: Confirmed:Allsixofthecriteriaabovearemet(unlessthepatientdiesbeforedesquamationcanoccur) Probable:Fiveofthesixcriteriaabovearemet Treatment[edit] Theseverityofthisdiseasefrequentlywarrantshospitalization.Admissiontotheintensivecareunitisoftennecessaryforsupportivecare(foraggressivefluidmanagement,ventilation,renalreplacementtherapyandinotropicsupport),particularlyinthecaseofmultipleorganfailure.[8]Treatmentincludesremovalordrainingofthesourceofinfection—oftenatampon—anddrainingofabscesses.Outcomesarepoorerinpatientswhodonothavethesourceofinfectionremoved.[8] AntibiotictreatmentshouldcoverbothS. pyogenesandS. aureus.Thismayincludeacombinationofcephalosporins,penicillinsorvancomycin.Theadditionofclindamycin[9]orgentamicin[10]reducestoxinproductionandmortality. Prognosis[edit] Withpropertreatment,peopleusuallyrecoverintwotothreeweeks.[citationneeded]Theconditioncan,however,befatalwithinhours. Epidemiology[edit] Staphylococcaltoxicshocksyndromeisrareandthenumberofreportedcaseshasdeclinedsignificantlysincethe1980s.PatrickSchlievert,whopublishedastudyonitin2004,determinedincidenceatthreetofouroutof100,000tamponusersperyear;theinformationsuppliedbymanufacturersofsanitaryproductssuchasTampaxandStayfreeputsitatoneto17ofevery100,000menstruatingfemalesperyear.[11][12] PhilipM.TiernoJr.helpeddeterminethattamponswerebehindTSScasesintheearly1980s.Tiernoblamestheintroductionofhigher-absorbencytamponsin1978.AstudybyTiernoalsodeterminedthatall-cottontamponswerelesslikelytoproducetheconditionsinwhichTSScangrow;thiswasdoneusingadirectcomparisonof20brandsoftamponsincludingconventionalcotton/rayontamponsand100%organiccottontamponsfromNatracare.Infact,DrTiernogoesasfartostate,"ThebottomlineisthatyoucangetTSSwithsynthetictampons,butnotwithanall-cottontampon."[13] Ariseinreportedcasesoccurredintheearly2000s:eightdeathsfromthesyndromeinCaliforniain2002afterthreesuccessiveyearsoffourdeathsperyear,andSchlievert'sstudyfoundcasesinpartofMinnesotamorethantripledfrom2000to2003.[11]Schlievertconsidersearlieronsetofmenstruationtobeacauseoftherise;others,suchasPhilipM.TiernoandBruceA.Hanna,blamenewhigh-absorbencytamponsintroducedin1999andmanufacturersdiscontinuingwarningsnottoleavetamponsinovernight.[11] TSSismorecommonduringthewinterandspringandoccursmostoftenintheyoungandold.[2] History[edit] Awarenessposterfrom1985 Initialdescription[edit] Theterm"toxicshocksyndrome"wasfirstusedin1978byaDenverpediatrician,JamesK.Todd,todescribethestaphylococcalillnessinthreeboysandfourgirlsaged8–17years.[14]EventhoughS.aureuswasisolatedfrommucosalsitesinthepatients,bacteriacouldnotbeisolatedfromtheblood,cerebrospinalfluid,orurine,raisingsuspicionthatatoxinwasinvolved.Theauthorsofthestudynotedreportsofsimilarstaphylococcalillnesseshadappearedoccasionallyasfarbackas1927,buttheauthorsatthetimefailedtoconsiderthepossibilityofaconnectionbetweentoxicshocksyndromeandtamponuse,asthreeofthegirlswhoweremenstruatingwhentheillnessdevelopedwereusingtampons.ManycasesofTSSoccurredaftertamponswereleftinaftertheyshouldhavebeenremoved.[15] Relytampons[edit] FollowingcontroversialtestmarketinginRochester,NewYork,andFortWayne,Indiana,[16]inAugust1978,ProcterandGambleintroducedsuperabsorbentRelytamponstotheUnitedStatesmarket[17]inresponsetowomen'sdemandsfortamponsthatcouldcontainanentiremenstrualflowwithoutleakingorreplacement.[18]Relyusedcarboxymethylcellulose(CMC)andcompressedbeadsofpolyesterforabsorption.Thistampondesigncouldabsorbnearly20timesitsownweightinfluid.[19]Further,thetamponwould"blossom"intoacupshapeinthevaginatoholdmenstrualfluidswithoutleakage.[citationneeded] InJanuary1980,epidemiologistsinWisconsinandMinnesotareportedtheappearanceofTSS,mostlyinthosemenstruating,totheCDC.[20]S.aureuswassuccessfullyculturedfrommostofthesubjects.TheToxicShockSyndromeTaskForcewascreatedandinvestigatedtheepidemicasthenumberofreportedcasesrosethroughoutthesummerof1980.[21]InSeptember1980,CDCreportedusersofRelywereatincreasedriskfordevelopingTSS.[22] On22September1980,ProcterandGamblerecalledRely[23]followingreleaseoftheCDCreport.Aspartofthevoluntaryrecall,ProcterandGambleenteredintoaconsentagreementwiththeFDA"providingforaprogramfornotificationtoconsumersandretrievaloftheproductfromthemarket".[24]However,itwascleartootherinvestigatorsthatRelywasnottheonlyculprit.OtherregionsoftheUnitedStatessawincreasesinmenstrualTSSbeforeRelywasintroduced.[25] ItwasshownlaterthathigherabsorbencyoftamponswasassociatedwithanincreasedriskforTSS,regardlessofthechemicalcompositionorthebrandofthetampon.ThesoleexceptionwasRely,forwhichtheriskforTSSwasstillhigherwhencorrectedforitsabsorbency.[26]TheabilityofcarboxymethylcellulosetofiltertheS.aureustoxinthatcausesTSSmayaccountfortheincreasedriskassociatedwithRely.[19] Notablecases[edit] CliveBarker,fullyrecovered,contractedthesyndromeaftervisitingthedentist.[27] LanaCoc-Kroft,fullyrecovered,contractedthesyndromeduetogroupAstreptococcalinfection.[28] JimHenson,d.1990,contractedthesyndromeduetogroupAstreptococcalinfectionandsubsequentlydiedfromit.[29][30] NanC.Robertson,d.2009,the1983winnerofthePulitzerPrizeforFeatureWritingforhermedicallydetailedaccountofherstrugglewithtoxicshocksyndrome,acoverstoryforTheNewYorkTimesMagazinewhichatthattimebecamethemostwidelysyndicatedarticleinTimeshistory.[31] MikeVonErich,d.1987,developedthesyndromeaftershouldersurgery:hemadeanapparentrecoverybutsufferedbraindamageandweightlossasaresultofthecondition;hediedbysuicidelater.[32] References[edit] ^abcdefghijklmnopqrstuvwxyzLow,DE(July2013)."Toxicshocksyndrome:majoradvancesinpathogenesis,butnottreatment".CriticalCareClinics.29(3):651–75.doi:10.1016/j.ccc.2013.03.012.PMID 23830657. ^abcdefgGottlieb,Michael;Long,Brit;Koyfman,Alex(June2018)."TheEvaluationandManagementofToxicShockSyndromeintheEmergencyDepartment:AReviewoftheLiterature".TheJournalofEmergencyMedicine.54(6):807–814.doi:10.1016/j.jemermed.2017.12.048.PMID 29366615. ^Ferri,FredF.(2010).Ferri'sdifferentialdiagnosis :apracticalguidetothedifferentialdiagnosisofsymptoms,signs,andclinicaldisorders(2nd ed.).Philadelphia:Elsevier/Mosby.p. ChapterT.ISBN 978-0323076999. ^ab"Toxicshocksyndrome(otherthanStreptococcal)(TSS):2011CaseDefinition".CentersforDiseaseControlandPrevention.8May2014.Archivedfromtheoriginalon2November2020.Retrieved9February2021. ^Khajuria,A;Nadam,HH;Gallagher,M;Jones,I;Atkins,J(2020)."PediatricToxicShockSyndromeAftera7%Burn:ACaseStudyandSystematicLiteratureReview".Ann.Plast.Surg.84(1):35–42.doi:10.1097/SAP.0000000000001990.PMID 31192868.S2CID 189815024. ^abWilkins,AmandaL.;Steer,AndrewC.;Smeesters,PierreR.;Curtis,Nigel(2017)."Toxicshocksyndrome–thesevenRsofmanagementandtreatment".JournalofInfection.74:S147–S152.doi:10.1016/S0163-4453(17)30206-2.PMID 28646955. ^Lindsay,JA;Ruzin,A;Ross,HF;Kurepina,N;Novick,RP(July1998)."ThegenefortoxicshocktoxiniscarriedbyafamilyofmobilepathogenicityislandsinStaphylococcusaureus".MolecularMicrobiology.29(2):527–43.doi:10.1046/j.1365-2958.1998.00947.x.PMID 9720870.S2CID 30680160. ^abZimbelmanJ,PalmerA,ToddJ(1999)."Improvedoutcomeofclindamycincomparedwithbeta-lactamantibiotictreatmentforinvasiveStreptococcuspyogenesinfection".ThePediatricInfectiousDiseaseJournal.18(12):1096–1100.doi:10.1097/00006454-199912000-00014.PMID 10608632. ^SchlievertPM,KellyJA(1984)."Clindamycin-inducedsuppressionoftoxic-shocksyndrome-associatedexotoxinproduction".TheJournalofInfectiousDiseases.149(3):471.doi:10.1093/infdis/149.3.471.PMID 6715902. ^vanLangeveldeP,vanDisselJT,MeursCJ,RenzJ,GroeneveldPH(1August1997)."Combinationofflucloxacillinandgentamicininhibitstoxicshocksyndrometoxin1productionbyStaphylococcusaureusinbothlogarithmicandstationaryphasesofgrowth".AntimicrobialAgentsandChemotherapy.41(8):1682–5.doi:10.1128/AAC.41.8.1682.PMC 163985.PMID 9257741. ^abcLyons,JulieSevrens(25January2005)."ANewGenerationFacesToxicShockSyndrome".TheSeattleTimes.KnightRidderNewspapers.firstpublishedas"LingeringRisk",SanJoseMercuryNews,13December2004 ^"Stayfree—FAQAboutToxicShockSyndrome(TSS)".2006.Archivedfromtheoriginalon23March2007.Retrieved13October2006. ^Lindsey,Emma(6November2003)."Welcometothecottonclub".TheGuardian.Archivedfromtheoriginalon9November2016. ^ToddJ,FishautM,KapralF,WelchT(1978)."Toxic-shocksyndromeassociatedwithphage-group-Istaphylococci".TheLancet.2(8100):1116–8.doi:10.1016/S0140-6736(78)92274-2.PMID 82681.S2CID 54231145. ^ToddJ(1981)."Toxicshocksyndrome—scientificuncertaintyandthepublicmedia".Pediatrics.67(6):921–3.PMID 7232057. ^Finley,Harry."RelyTampon:ItEvenAbsorbedtheWorry!".MuseumofMenstruation.Archivedfromtheoriginalon14April2006.Retrieved20March2006. ^HanrahanS;Submission,HaworthContinuingFeatures(1994)."Historicalreviewofmenstrualtoxicshocksyndrome".Women&Health.21(2–3):141–65.doi:10.1300/J013v21n02_09.PMID 8073784. ^Citrinbaum,Joanna(14October2003)."Thequestion'sabsorbing:'Aretamponslittlewhitelies?'".TheDailyCollegian.Archivedfromtheoriginalon20June2017.Retrieved27December2015. ^abVitale,Sidra(1997)."ToxicShockSyndrome".WebbyWomen,forWomen.Archivedfromtheoriginalon16March2006.Retrieved20March2006. ^CDC(23May1980)."Toxic-shocksyndrome—UnitedStates".MorbidityandMortalityWeeklyReport.29(20):229–230.Archivedfromtheoriginalon20October2014. ^DennisHevesi(10September2011)."BruceDan,WhoHelpedLinkToxicShockandTampons,IsDeadat64".TheNewYorkTimes.Archivedfromtheoriginalon11September2011.Retrieved12September2011.Dr.BruceDan,whoasaleadingfederalresearcherhelpedestablishalinkbetweenthelife-threateningdiseasetoxicshocksyndromeandtheuseoftampons,promptingamajorshiftinthewaytamponsareproduced,diedTuesdayinBaltimore.Hewas64. ^CDC(19September1980)."Follow-upontoxic-shocksyndrome".MorbidityandMortalityWeeklyReport.29(37):441–5.Archivedfromtheoriginalon4March2016. ^HanrahanS;Submission,HaworthContinuingFeatures(1994)."Historicalreviewofmenstrualtoxicshocksyndrome".Women&Health.21(2–3):141–165.doi:10.1300/J013v21n02_09.PMID 8073784. ^Kohen,Jamie(2001)."TheHistoryoftheRegulationofMenstrualTampons".LEDAatHarvardLawSchool.Archivedfromtheoriginalon20October2016.Retrieved5March2017. ^PetittiD,ReingoldA,ChinJ(1986)."TheincidenceoftoxicshocksyndromeinNorthernCalifornia.1972through1983".JAMA.255(3):368–72.doi:10.1001/jama.255.3.368.PMID 3941516. ^BerkleyS,HightowerA,BroomeC,ReingoldA(1987)."Therelationshipoftamponcharacteristicstomenstrualtoxicshocksyndrome".JAMA.258(7):917–20.doi:10.1001/jama.258.7.917.PMID 3613021. ^"CliveBarkerrecoveringfrom'nearfatal'caseoftoxicshocksyndrome".EntertainmentWeekly.7February2012.Archivedfromtheoriginalon11November2014.Retrieved11November2014. ^Lang,Sarah(15February2009)."Lana'sleapoutsidehercomfortzone".TheNewZealandHerald.Archivedfromtheoriginalon23February2013.Retrieved26January2010. ^Altman,Lawrence(29May1990)."TheDoctor'sWorld;HensonDeathShowsDangerofPneumonia".TheNewYorkTimes.Archivedfromtheoriginalon16October2007.Retrieved10June2017. ^RyanKJ;RayCG(editors)(2004).SherrisMedicalMicrobiology(4th ed.).McGrawHill.pp. 276–286.ISBN 0-8385-8529-9.CS1maint:multiplenames:authorslist(link)CS1maint:extratext:authorslist(link) ^Rupp,CarlaMarie."TheTimesGoesComputer".InDitlea,Steve(ed.).DigitalDeli.AtariArchives.Archivedfromtheoriginalon27August2013.Retrieved12October2013. ^Mercer,Bill(2007).Play-by-Play:TalesfromaSportscastingInsider.TaylorTradePublishing.pp. 277–.ISBN 978-1-4617-3474-1.Archivedfromtheoriginalon15October2013.Retrieved12October2013. Externallinks[edit] StevensDL(1995)."Streptococcaltoxic-shocksyndrome:spectrumofdisease,pathogenesis,andnewconceptsintreatment".EmergingInfectiousDiseases.1(3):69–78.doi:10.3201/eid0103.950301.PMC 2626872.PMID 8903167. "ToxicShockSyndrome(TSS):TheFacts".ToxicShockSyndromeinformationservice.tssis.com. ClassificationDICD-10:A48.3ICD-9-CM:040.82MeSH:D012772DiseasesDB:13187ExternalresourcesMedlinePlus:000653eMedicine:med/2292emerg/600derm/425ped/2269PatientUK:Toxicshocksyndrome vte Firmicutes(low-G+C)Infectiousdiseases Bacterialdiseases:G+ BacilliLactobacillales(Cat-)Streptococcusαoptochinsusceptible S.pneumoniae Pneumococcalinfection optochinresistant Viridansstreptococci:S.mitis S.mutans S.oralis S.sanguinis S.sobrinus S.anginosusgroup βA bacitracinsusceptible:S.pyogenes GroupAstreptococcalinfection Streptococcalpharyngitis Scarletfever Erysipelas Rheumaticfever B bacitracinresistant,CAMPtest+:S.agalactiae GroupBstreptococcalinfection ungrouped Streptococcusiniae CutaneousStreptococcusiniaeinfection γ D BEA+:Streptococcusbovis Enterococcus BEA+:Enterococcusfaecalis Urinarytractinfection Enterococcusfaecium Bacillales(Cat+)StaphylococcusCg+ S.aureus Staphylococcalscaldedskinsyndrome Toxicshocksyndrome MRSA Cg- novobiocinsusceptible S.epidermidis novobiocinresistant S.saprophyticus Bacillus Bacillusanthracis Anthrax Bacilluscereus Foodpoisoning Listeria Listeriamonocytogenes Listeriosis ClostridiaClostridium(spore-forming)motile: Clostridiumdifficile Pseudomembranouscolitis Clostridiumbotulinum Botulism Clostridiumtetani Tetanus nonmotile: Clostridiumperfringens Gasgangrene Clostridialnecrotizingenteritis Finegoldia(non-sporeforming) Finegoldiamagna MollicutesMycoplasmataceae Ureaplasmaurealyticum Ureaplasmainfection Mycoplasmagenitalium Mycoplasmapneumoniae Mycoplasmapneumonia Anaeroplasmatales Erysipelothrixrhusiopathiae Erysipeloid vteShockDistributive Septicshock Neurogenicshock Anaphylacticshock Toxicshocksyndrome Obstructive Abdominalcompartmentsyndrome Lowvolume Hemorrhage Hypovolemia Osmoticshock Other Cardiogenic Spinalshock Crypticshock Vasodilatoryshock Retrievedfrom"https://en.wikipedia.org/w/index.php?title=Toxic_shock_syndrome&oldid=1057011876" Categories:BacterialdiseasesBacterialtoxinsBacterium-relatedcutaneousconditionsSyndromesHiddencategories:CS1maint:multiplenames:authorslistCS1maint:extratext:authorslistUsedmydatesfromJune2017ArticleswithshortdescriptionShortdescriptionisdifferentfromWikidataAllarticleswithunsourcedstatementsArticleswithunsourcedstatementsfromJune2021ArticleswithunsourcedstatementsfromMay2013ArticleswithunsourcedstatementsfromJanuary2013WikipediaemergencymedicinearticlesreadytotranslateWikipediamedicinearticlesreadytotranslate Navigationmenu Personaltools NotloggedinTalkContributionsCreateaccountLogin Namespaces ArticleTalk Variants expanded collapsed Views ReadEditViewhistory More expanded collapsed Search Navigation MainpageContentsCurrenteventsRandomarticleAboutWikipediaContactusDonate Contribute HelpLearntoeditCommunityportalRecentchangesUploadfile Tools WhatlinkshereRelatedchangesUploadfileSpecialpagesPermanentlinkPageinformationCitethispageWikidataitem Print/export DownloadasPDFPrintableversion Inotherprojects WikimediaCommons Languages العربيةCatalàČeštinaDanskDeutschEspañolEuskaraفارسیFrançaisGaeilgeՀայերենHrvatskiBahasaIndonesiaItalianoעבריתLatviešuNederlands日本語Norskbokmålଓଡ଼ିଆPolskiPortuguêsРусскийSimpleEnglishSrpskohrvatski/српскохрватскиSvenskaTürkçeTiếngViệt中文 Editlinks