Hemostatic strategies for traumatic and surgical bleeding
2025年8月13日 星期三
2025年8月6日 星期三
野外與登山醫學-肺泡內可供擴散氧分壓
2025-08-07 10:06AM
重點
1. 肺泡內的氧分壓公式
- PAO2 = (Patm - PH2O) FiO2 - PACO2 / RQ
2. 聖母峰頂大氣壓力 260 mmHg。肺泡氧分壓(可供擴散的氧氣量)約為54.6 mmHg
3. 海平面大氣壓 760mmHg. 肺泡氧分壓約為99.7 mmHg
海拔上升, 氣壓會降低. 海平面的氣壓定義為一個 atm.
1atm= 760mmHg
海拔2500 公尺的氣壓大約是72.84 kPa，相當於546.3 mmHg。 這個高度的有效含氧量約為15.1%。(氧氣佔比21%不變)
37度C的水蒸氣壓大約 47mmHg. 不會隨海拔上升而改變. 最大水蒸氣壓取決於環境溫度. 肺泡內氣體溫度約等同人的體溫, 肺泡內的水氣來自人體. 呼吸速率不快的狀況, 水蒸氣壓可視為恆定.
** 25°C 時，純水的蒸氣壓約為 23.76 mmHg (或3.17 kPa)
肺部的氣體交換, 氧氣需要先溶於水, 藉由擴散作用穿透肺泡的薄膜,經過組織間隙, 才能與血液接觸, 在血中的氧氣約 98% 與紅血球結合, 僅 2% 溶於血漿內, 藉由連續不斷的血流將富含氧氣的血運輸回左心房, 缺氧血由右心室進
入肺動脈流入兩側肺部, 才能進行正常氣體交換.
氧氣在人體內的供應受到很多因素影響, 例如
血色素不足, 即使血氧飽和度100%還是無法運輸足夠的氧氣
肺泡內積液, 導致氣體無法進入肺泡. 流向這個肺泡的血流無法進行氣體交換(shunt)
組織間隙變大(水腫), 氣體由肺泡表面進入血液的路徑變長, 降低擴散效率
無充足的血液流經肺泡, 很多因素都會造成流向肺泡的血液減少
肺泡內氧分壓下降, 例如在密閉的環境有大量的其他氣體造成氧分壓下降, 或者在高海拔低壓低氧的環境. 外界可供使用的氧氣分壓下降
大氣中二氧化碳的含量約為0.041%，換算成分壓大約是0.00041 大氣壓，或410 ppm 或 0.3mmHg 幾乎可忽略不計
人體換氣吐出的的二氧化碳分壓 38mmHg 相當於人體血中的二氧化碳分壓(約 40mmHg). 可由測量設備直接測得 (例如氣管插管之後使用的潮氣末二氧化碳監測器)
二氧化碳相對於氧氣更容易溶於水, 在肺泡中的擴散比氧氣容易.
溫度25度C時, 外界海平面大氣壓 760mmHg 的組成包括:
氧分壓 160 mmHg
飽和水蒸氣壓 (受到環境溫度影響) 23.76 mmHg
二氧化碳壓 0.3 mmHg
氮氣壓 760* 0.78=592.8
其他氣體壓力約 7-8 mmHg
肺泡內的氣壓約相等於體外大氣壓, 但肺泡內的氣體組成與大氣不同
當氣體進入鼻腔或口腔. 此時水蒸氣壓與外界相同, 經過鼻黏膜, 咽喉黏膜, 氣管, 支氣管, 細支氣管, 肺泡, 這個過程黏膜會將氣體加濕, 水蒸氣壓比例會逐漸上升, 氣體溫度也會朝體內溫度趨近.
呼吸商 RQ=每消耗單位氧氣而製造出的二氧化碳, 會隨著人的飲食改變, 一般約 0.8
The Respiratory Quotient (RQ) is the ratio of carbon dioxide (CO2) produced to oxygen (O2) consumed during respiration. It's a dimensionless number used to understand what kind of fuel the body is primarily using for energy.
Here's a more detailed explanation:
What it measures:
RQ = CO2 produced / O2 consumed .
It indicates the body's substrate utilization (which type of fuel) for energy production.
Indirect calorimetry: is a common method for measuring RQ.
典型的 RQ 值及其意義：
1.0： 表示身體主要燃燒碳水化合物作為能量來源。
0.7： 顯示身體主要利用脂肪來獲取能量。
0.8： 代表混合燃料源，通常是碳水化合物和脂肪的組合。
影響RQ的因素：
飲食： 所消耗的食物類型會影響 RQ，因為不同的常量營養素（碳水化合物、脂肪和蛋白質）有不同的 RQ。
營養支持： 餵食過多或餵食不足都會影響 RQ。
代謝過程： 某些代謝狀態（例如脂肪生成、酮生成）也會影響 RQ。
臨床意義：
監測營養支持：
RQ 可以幫助評估營養攝取是否適當且耐受性良好，尤其是在加護病房等臨床環境中。
移除呼吸器：
RQ 高於 1.0 可能表示碳水化合物攝取過多，可能會妨礙患者脫離呼吸器的能力。
評估代謝狀態：
RQ 可以成為了解患者代謝狀況和整體健康狀況的寶貴工具。
當我們吸氣時, 37度C的人體肺泡內氣壓組成
1. 飽和水蒸汽壓 47mmHg
2. 二氧化碳分壓 PACO2mmHg/呼吸商RQ
37度C的水蒸氣壓大約 47mmHg. 不會隨海拔上升而改變. 最大水蒸氣壓取決於環境溫度. 肺泡內氣體溫度約等同人的體溫, 肺泡內的水氣來自人體. 呼吸速率不快的狀況, 水蒸氣壓可視為恆定.
** 25°C 時，純水的蒸氣壓約為 23.76 mmHg (或3.17 kPa)
肺部的氣體交換, 氧氣需要先溶於水, 藉由擴散作用穿透肺泡的薄膜,經過組織間隙, 才能與血液接觸, 在血中的氧氣約 98% 與紅血球結合, 僅 2% 溶於血漿內, 藉由連續不斷的血流將富含氧氣的血運輸回左心房, 缺氧血由右心室進
入肺動脈流入兩側肺部, 才能進行正常氣體交換.
氧氣在人體內的供應受到很多因素影響, 例如
血色素不足, 即使血氧飽和度100%還是無法運輸足夠的氧氣
肺泡內積液, 導致氣體無法進入肺泡. 流向這個肺泡的血流無法進行氣體交換(shunt)
組織間隙變大(水腫), 氣體由肺泡表面進入血液的路徑變長, 降低擴散效率
無充足的血液流經肺泡, 很多因素都會造成流向肺泡的血液減少
肺泡內氧分壓下降, 例如在密閉的環境有大量的其他氣體造成氧分壓下降, 或者在高海拔低壓低氧的環境. 外界可供使用的氧氣分壓下降
大氣中二氧化碳的含量約為0.041%，換算成分壓大約是0.00041 大氣壓，或410 ppm 或 0.3mmHg 幾乎可忽略不計
人體換氣吐出的的二氧化碳分壓 38mmHg 相當於人體血中的二氧化碳分壓(約 40mmHg). 可由測量設備直接測得 (例如氣管插管之後使用的潮氣末二氧化碳監測器)
二氧化碳相對於氧氣更容易溶於水, 在肺泡中的擴散比氧氣容易.
溫度25度C時, 外界海平面大氣壓 760mmHg 的組成包括:
氧分壓 160 mmHg
飽和水蒸氣壓 (受到環境溫度影響) 23.76 mmHg
二氧化碳壓 0.3 mmHg
氮氣壓 760* 0.78=592.8
其他氣體壓力約 7-8 mmHg
肺泡內的氣壓約相等於體外大氣壓, 但肺泡內的氣體組成與大氣不同
當氣體進入鼻腔或口腔. 此時水蒸氣壓與外界相同, 經過鼻黏膜, 咽喉黏膜, 氣管, 支氣管, 細支氣管, 肺泡, 這個過程黏膜會將氣體加濕, 水蒸氣壓比例會逐漸上升, 氣體溫度也會朝體內溫度趨近.
剛吸入肺泡中氣體的二氧化碳分壓約 0.3mmHg, 經過氣體交換. 呼出的二氧化碳約 38mmHg, 在健康成人, 血中二氧化碳很容易由肺泡氣體交換排出. 主要取決於每分鐘吸入氣體量(MV每分鐘換氣量 minute ventilation), 當MV增加, 血中二氧化碳會隨著呼出的氣體被帶離體外, 血中二氧化碳濃度下降, 血液會偏鹼性. 這個稱為過度換氣. 或呼吸性鹼中毒
呼吸商 RQ=每消耗單位氧氣而製造出的二氧化碳, 會隨著人的飲食改變, 一般約 0.8
The Respiratory Quotient (RQ) is the ratio of carbon dioxide (CO2) produced to oxygen (O2) consumed during respiration. It's a dimensionless number used to understand what kind of fuel the body is primarily using for energy.
Here's a more detailed explanation:
What it measures:
RQ = CO2 produced / O2 consumed .
It indicates the body's substrate utilization (which type of fuel) for energy production.
Indirect calorimetry: is a common method for measuring RQ.
典型的 RQ 值及其意義：
1.0： 表示身體主要燃燒碳水化合物作為能量來源。
0.7： 顯示身體主要利用脂肪來獲取能量。
0.8： 代表混合燃料源，通常是碳水化合物和脂肪的組合。
影響RQ的因素：
飲食： 所消耗的食物類型會影響 RQ，因為不同的常量營養素（碳水化合物、脂肪和蛋白質）有不同的 RQ。
營養支持： 餵食過多或餵食不足都會影響 RQ。
代謝過程： 某些代謝狀態（例如脂肪生成、酮生成）也會影響 RQ。
臨床意義：
監測營養支持：
RQ 可以幫助評估營養攝取是否適當且耐受性良好，尤其是在加護病房等臨床環境中。
移除呼吸器：
RQ 高於 1.0 可能表示碳水化合物攝取過多，可能會妨礙患者脫離呼吸器的能力。
評估代謝狀態：
RQ 可以成為了解患者代謝狀況和整體健康狀況的寶貴工具。
當我們吸氣時, 37度C的人體肺泡內氣壓組成
1. 飽和水蒸汽壓 47mmHg
2. 二氧化碳分壓 PACO2mmHg/呼吸商RQ
3. 再來是吸入的空氣
空氣流動受壓力影響. 當吸入的外界空氣. 加上肺泡內水蒸氣壓, 兩者相加等於外界的氣壓時, 空氣停止進入肺部. 肺泡內的水蒸氣壓理論上會接近飽和蒸汽壓. 外界吸入的空氣分壓為 760-47-38/0.8 約等於 666 mmHg
肺泡內的氧分壓公式
肺泡內的氧分壓公式
- PAO2 = (Patm - PH2O) FiO2 - PACO2 / RQ
- 海平面一大氣壓 760mmHg. PAO2 = (760-47)*0.21 - 40/0.8= 99.7
- 海拔2500公尺=(546-47)*.21 - 40/0.8= 54.79
- 海拔3000公尺.氣壓約0.7atm=532. 肺泡氧分壓=(532-47) - 50=51.85
- 海拔4000公尺.氣壓約 0.61atm=463.6 肺泡氧分壓=(463-47) - 50=37.486
- 海拔5000公尺. 氣壓約 0.53atm= 肺泡氧分壓=(532-47) - 50=34.588
環境空氣
環境空氣的成分約為78%的氮氣、21%的氧氣、1%的氬氣，以及微量的其他氣體，如二氧化碳、氖氣、甲烷、氦氣、氪氣、氫氣、氙氣、臭氧、二氧化氮、碘、一氧化碳和氨氣。因此，在海平面（大氣壓力為760毫米汞柱）下，可以估算出各種氣體的分壓：氮氣分壓約為593毫米汞柱，氧氣分壓約為160毫米汞柱，氬氣分壓約為7.6毫米汞柱。
環境空氣的成分約為78%的氮氣、21%的氧氣、1%的氬氣，以及微量的其他氣體，如二氧化碳、氖氣、甲烷、氦氣、氪氣、氫氣、氙氣、臭氧、二氧化氮、碘、一氧化碳和氨氣。因此，在海平面（大氣壓力為760毫米汞柱）下，可以估算出各種氣體的分壓：氮氣分壓約為593毫米汞柱，氧氣分壓約為160毫米汞柱，氬氣分壓約為7.6毫米汞柱。
氮氣 78%=593 mmHg
氧氣 21%=160mmHg
氬氣 1%=7.6mmHg
二氧化碳 0.041%=0.3mmHg(因為人體肺泡濃度差很多.特別寫上來)
其他微量氣體 (含二氧化碳等等) < 1%
然而，這些分壓並不能準確反映肺泡內可供擴散的分壓。當空氣通過上呼吸道吸入時，它會被肺道加熱和加濕。這個過程會引入水蒸氣，從而調節所有氣體（包括氧氣）的分壓。因此，上呼吸道內的氧氣分壓稱為吸入氧分壓 (PiO)。體溫下，水蒸氣壓為 47 毫米汞柱 (mmHg)，且顯著依賴體溫。[6]
無法直接從肺泡收集氣體。然而，肺泡氣體方程式對於計算和精確估算肺泡內的氧分壓非常有幫助。肺泡氣體方程式用於計算肺泡氧分壓：PAO2 =（P atm - PH2O）FiO2 - PACO2 / RQ
PAO 2是肺泡中的氧分壓，而 P atm 是海平面的大氣壓力，相當於 760 mm Hg。 PH 2 O 是水的分壓，約等於 45 mmHg。 FiO 2是吸入氧氣的分數。 PCO 2是動脈中的二氧化碳分壓，在正常生理條件下約為 40 至 45 mmHg，以及 RQ（呼吸商）。 FiO 2與吸入空氣中的氧氣百分比成分直接相關。在海平面無支撐的情況下，該百分比為 21% 或 0.21。但是，吸入空氣中每增加一公升補充氧氣，數值就會增加約 4% 或 0.04。因此，2 公升補充氧氣會使海平面的 FiO 2增加8% 或 0.08 到 29% 或 0.29。 RQ 的數值會因人的飲食類型和代謝狀態而有所不同。典型人類飲食的標準值為0.82。在海平面，無補充吸入氧氣的情況下，肺泡氧分壓（PAO2 ）為：PAO 2 = (760 - 47) 0.21 - 40 / 0.8 = 99.7 毫米汞柱
肺泡氧分壓是氧氣擴散穿過肺泡膜、肺微血管壁、進入小動脈血流和紅血球，最終輸送至全身外周組織的驅動力。從肺泡腔到微血管的擴散梯度可以透過Aa梯度來量化，其計算公式如下：Aa氧梯度= PAO2 - PaO2
PaO 2是透過動脈血氣測量的，而 PAO 2則透過上述方法計算得出。較大的梯度表示存在阻礙氧氣進入毛細血管的潛在病理，這會影響全身可用的氧分壓。整個組織所需的氧分壓會根據組織的代謝需求而改變。此擴散梯度稱為組織氧分壓 (PtO)，它會隨著毛細血管密度、耗氧量、代謝率和血流量而變化。[7]研究發現，大腦所需的氧分壓在 30 至 48 mmHg 之間。[7] [3]
由於葡萄糖的有氧代謝無法有效產生能量，腦部功能會受到影響。皮膚的氧分壓光譜通常是基於皮膚層距表面的深度。 5 至 10 微米深度的皮膚淺層氧分壓約為 5.0 至 11 毫米汞柱 (mmHg)。 45 至 65 微米深度的真皮乳頭通常氧分壓為 18 至 30 毫米汞柱 (mmHg)。 100 至 120 微米深度的乳頭下叢氧分壓約為 27 至 43 毫米汞柱 (mmHg)。
腸道的氧分壓也不穩定，小腸漿膜部分的氧分壓為 53.0 至 71.0 mmHg。對肝臟的氧分壓進行了研究，結果略有不同，發現兩組的中位數分別為 42.04 mmHg 和 34.53 mmHg。腎臟是另一個需氧量較高的器官系統，因為腎單位重吸收系統的主動運輸過程涉及高能量和隨後的代謝需求。因此，髓質氧分壓為 10 至 20 mmHg，皮質需要 52 至 92 mmHg。肌肉對氧的需求差異很大，取決於肌肉的活動強度和持續時間。在基線，肌肉氧分壓在 27 mmHg 和 31 mmHg 之間。[8]在各組織消耗氧氣的過程中，血液中氧含量下降，動脈血中的 100 毫米汞柱 (mmHg) 下降到靜脈血中的 40 毫米汞柱 (mmHg)。[9]
前往：
臨床意義
評估氧分壓的主要測量方法是動脈血氣分析。此分析可以直接測量動脈血液中的氧分壓、二氧化碳分壓、酸度 (pH)、氧合血紅素飽和度和碳酸氫鹽濃度。所有這些指標都有助於評估和治療各種疾病。
多種疾病過程會導致氧分壓降低。主要過程包括吸入氧減少、通氣不足、擴散受限以及通氣/血流灌注不匹配（V/Q 不匹配）。
環境壓力的改變會影響可供擴散進入體內的氧氣量。在海平面，大氣壓力為760毫米汞柱。然而，隨著海拔升高，大氣壓力會下降。例如，珠穆朗瑪峰頂峰的大氣壓力低至260毫米汞柱。當以此壓力計算環境中的肺泡氧分壓時，可供擴散的氧氣量約為54.6毫米汞柱。這幾乎是海平面可用氧氣量的一半。
然而，這些分壓並不能準確反映肺泡內可供擴散的分壓。當空氣通過上呼吸道吸入時，它會被肺道加熱和加濕。這個過程會引入水蒸氣，從而調節所有氣體（包括氧氣）的分壓。因此，上呼吸道內的氧氣分壓稱為吸入氧分壓 (PiO)。體溫下，水蒸氣壓為 47 毫米汞柱 (mmHg)，且顯著依賴體溫。[6]
無法直接從肺泡收集氣體。然而，肺泡氣體方程式對於計算和精確估算肺泡內的氧分壓非常有幫助。肺泡氣體方程式用於計算肺泡氧分壓：PAO2 =（P atm - PH2O）FiO2 - PACO2 / RQ
PAO 2是肺泡中的氧分壓，而 P atm 是海平面的大氣壓力，相當於 760 mm Hg。 PH 2 O 是水的分壓，約等於 45 mmHg。 FiO 2是吸入氧氣的分數。 PCO 2是動脈中的二氧化碳分壓，在正常生理條件下約為 40 至 45 mmHg，以及 RQ（呼吸商）。 FiO 2與吸入空氣中的氧氣百分比成分直接相關。在海平面無支撐的情況下，該百分比為 21% 或 0.21。但是，吸入空氣中每增加一公升補充氧氣，數值就會增加約 4% 或 0.04。因此，2 公升補充氧氣會使海平面的 FiO 2增加8% 或 0.08 到 29% 或 0.29。 RQ 的數值會因人的飲食類型和代謝狀態而有所不同。典型人類飲食的標準值為0.82。在海平面，無補充吸入氧氣的情況下，肺泡氧分壓（PAO2 ）為：PAO 2 = (760 - 47) 0.21 - 40 / 0.8 = 99.7 毫米汞柱
肺泡氧分壓是氧氣擴散穿過肺泡膜、肺微血管壁、進入小動脈血流和紅血球，最終輸送至全身外周組織的驅動力。從肺泡腔到微血管的擴散梯度可以透過Aa梯度來量化，其計算公式如下：Aa氧梯度= PAO2 - PaO2
PaO 2是透過動脈血氣測量的，而 PAO 2則透過上述方法計算得出。較大的梯度表示存在阻礙氧氣進入毛細血管的潛在病理，這會影響全身可用的氧分壓。整個組織所需的氧分壓會根據組織的代謝需求而改變。此擴散梯度稱為組織氧分壓 (PtO)，它會隨著毛細血管密度、耗氧量、代謝率和血流量而變化。[7]研究發現，大腦所需的氧分壓在 30 至 48 mmHg 之間。[7] [3]
由於葡萄糖的有氧代謝無法有效產生能量，腦部功能會受到影響。皮膚的氧分壓光譜通常是基於皮膚層距表面的深度。 5 至 10 微米深度的皮膚淺層氧分壓約為 5.0 至 11 毫米汞柱 (mmHg)。 45 至 65 微米深度的真皮乳頭通常氧分壓為 18 至 30 毫米汞柱 (mmHg)。 100 至 120 微米深度的乳頭下叢氧分壓約為 27 至 43 毫米汞柱 (mmHg)。
腸道的氧分壓也不穩定，小腸漿膜部分的氧分壓為 53.0 至 71.0 mmHg。對肝臟的氧分壓進行了研究，結果略有不同，發現兩組的中位數分別為 42.04 mmHg 和 34.53 mmHg。腎臟是另一個需氧量較高的器官系統，因為腎單位重吸收系統的主動運輸過程涉及高能量和隨後的代謝需求。因此，髓質氧分壓為 10 至 20 mmHg，皮質需要 52 至 92 mmHg。肌肉對氧的需求差異很大，取決於肌肉的活動強度和持續時間。在基線，肌肉氧分壓在 27 mmHg 和 31 mmHg 之間。[8]在各組織消耗氧氣的過程中，血液中氧含量下降，動脈血中的 100 毫米汞柱 (mmHg) 下降到靜脈血中的 40 毫米汞柱 (mmHg)。[9]
前往：
臨床意義
評估氧分壓的主要測量方法是動脈血氣分析。此分析可以直接測量動脈血液中的氧分壓、二氧化碳分壓、酸度 (pH)、氧合血紅素飽和度和碳酸氫鹽濃度。所有這些指標都有助於評估和治療各種疾病。
多種疾病過程會導致氧分壓降低。主要過程包括吸入氧減少、通氣不足、擴散受限以及通氣/血流灌注不匹配（V/Q 不匹配）。
環境壓力的改變會影響可供擴散進入體內的氧氣量。在海平面，大氣壓力為760毫米汞柱。然而，隨著海拔升高，大氣壓力會下降。例如，珠穆朗瑪峰頂峰的大氣壓力低至260毫米汞柱。當以此壓力計算環境中的肺泡氧分壓時，可供擴散的氧氣量約為54.6毫米汞柱。這幾乎是海平面可用氧氣量的一半。
2025年8月5日 星期二
野外與登山醫學-動物咬傷的傷口縫合考量 from uptodate
2025-08-06 10:20AM
初級縫合: 傷口經初步清理後直接縫合
延遲初級縫合: 汙染較嚴重或感染率較高的傷口, 經過清洗清創之後, 觀察數天(一般是72小時)視傷口狀況評估是否縫合
一般傷口建議12小時內縫合(臉部24小時內)
受傷超過12小時以上的傷口不建議初級縫合, 可選擇延遲初級縫合
內容來自 uptodate:Animal bites (dogs, cats, and other mammals): Evaluation and management
以下中文使用google翻譯
傷口縫合 — 對於大多數咬傷傷口未感染的患者，我們建議讓傷口保持開放，透過次級縫合而非初級縫合自行癒合(流程圖 1和圖 2 )。
對於臉部撕裂傷（包括貓咬傷）較大，影響美觀，或軀幹、手臂或腿部（不是手或腳）被狗咬傷，且傷口較大，且符合以下所有標準的患者，初級縫合是合理的選擇：
●未感染的傷口
●免疫功能正常的患者
●近期咬傷（四肢咬傷時間少於 12 小時，臉部咬傷時間少於 24 小時）
●無擠壓傷或刺傷
●患肢無蜂窩性組織炎或靜脈/淋巴系統損害病史
對於可能受益於初級縫合但存在上述禁忌症之一的傷口，患者可開始預防性抗生素治療，並計劃在3-4日後進行延遲初級縫合。除非臨床醫生在延遲初級縫合方面經驗豐富，否則建議轉診至外科醫生或其他傷口專家，因為縫合時可能需要額外清創（例如，清除過多積聚的肉芽組織）。
咬傷傷口縫合方法的選擇（即初級縫合, 次級縫合或延遲初級縫合）應根據傷口性質、沖洗和清創是否能合理清潔傷口以及宿主的免疫狀態進行個體化選擇。
以下中文使用google翻譯
傷口縫合 — 對於大多數咬傷傷口未感染的患者，我們建議讓傷口保持開放，透過次級縫合而非初級縫合自行癒合(流程圖 1和圖 2 )。
對於臉部撕裂傷（包括貓咬傷）較大，影響美觀，或軀幹、手臂或腿部（不是手或腳）被狗咬傷，且傷口較大，且符合以下所有標準的患者，初級縫合是合理的選擇：
●未感染的傷口
●免疫功能正常的患者
●近期咬傷（四肢咬傷時間少於 12 小時，臉部咬傷時間少於 24 小時）
●無擠壓傷或刺傷
●患肢無蜂窩性組織炎或靜脈/淋巴系統損害病史
對於可能受益於初級縫合但存在上述禁忌症之一的傷口，患者可開始預防性抗生素治療，並計劃在3-4日後進行延遲初級縫合。除非臨床醫生在延遲初級縫合方面經驗豐富，否則建議轉診至外科醫生或其他傷口專家，因為縫合時可能需要額外清創（例如，清除過多積聚的肉芽組織）。
咬傷傷口縫合方法的選擇（即初級縫合, 次級縫合或延遲初級縫合）應根據傷口性質、沖洗和清創是否能合理清潔傷口以及宿主的免疫狀態進行個體化選擇。
初級縫合可加速癒合並減少不良美容後果 [ 1,22,44,52-55 ]。然而，對於小傷口和刺傷，初級縫合可能增加的感染風險通常超過其最小的美容益處 [ 24 ]。臉部傷口是例外，因為與其他解剖部位相比，臉部傷口更有利於美容，且感染率較低 [ 1,44,49-51 ]。延遲初級縫合期間的等待期可使宿主的防禦系統減少細菌負荷，並確保不會發生感染，而感染是縫合的禁忌症。
我們同意美國傳染病學會 (IDSA) 對大多數病例的指南（例如，反對對非臉部貓咬傷進行初級縫合）[ 1 ]。然而，儘管 IDSA 不建議對非面部犬咬傷進行初級縫合，但我們同意其他專家的觀點，他們支持對軀幹、手臂或腿部（但不包括手和腳）的犬咬傷造成的撕裂傷進行初級縫合[ 46,47 ]。研究發現，初級縫合傷口不會增加此類咬傷的感染風險，反而與改善美容效果有關[ 44,46,47 ]。然而，手部傷口、刺傷或延遲出現的傷口（例如，受傷後 > 8 小時）的初級縫合與感染率增加相關[ 24,44,46 ]。
Wound closure — For most patients with uninfected bite wounds, we suggest that the wounds be left open to heal by secondary intention rather than by primary closure (algorithm 1 and figure 2). (See "Minor wound evaluation and preparation for closure", section on 'Type of closure'.)
Primary closure is a reasonable alternative in a patient with a facial laceration (including a cat bite) that is sufficiently large to affect cosmesis or a gaping dog bite on the trunk, arm, or leg (not on a hand or foot) who meets all of the following criteria:
●Uninfected wound
●Immunocompetent patient
●Recent bite (<12 hours old for bites on an extremity, <24 hours old for facial bites)
●No crush injury or puncture wound
●No prior episode of cellulitis or venous/lymphatic compromise on the affected extremity
For a wound that may benefit from primary closure but has one of these contraindications, the patient may be started on prophylactic antibiotics with a plan for delayed primary closure after three to four days. Unless the clinician has extensive experience with delayed primary closure, referral to a surgeon or other wound expert is advised since additional debridement (eg, of excessive accumulated granulation tissue) may be necessary at the time of closure. (See "Minor wound evaluation and preparation for closure", section on 'Delayed primary closure'.)
The choice of bite wound closure (ie, primary closure, healing by secondary intention, or delayed primary closure) should be individualized to the nature of the wound, whether irrigation and debridement can reasonably clean the wound, and the immune status of the host. Primary closure hastens healing and reduces adverse cosmetic outcomes [1,22,44,52-55]. However, for small wounds and puncture wounds, the potentially increased risk of infection from primary closure typically outweighs the minimal cosmetic benefit [24]. Facial wounds are an exception given increased cosmetic consequences and a lower rate of infection compared with other anatomic sites [1,44,49-51]. The waiting period during delayed primary closure permits the host defense system to decrease bacterial load and to ensure that no infection develops, which is a contraindication to closure.
We agree with the Infectious Diseases Society of American (IDSA) guidelines for most cases (eg, against primary closure of nonfacial cat bites) [1]. However, even though the IDSA recommends against primary closure of nonfacial dog bites, we agree with other experts who favor primary closure of lacerations due to dog bites on the trunk, arms, or legs (though not on the hands or feet) [46,47]. Studies have found that primary wound closure does not increase the risk of infection in such bites but is associated with improved cosmetic outcomes [44,46,47]. However, primary closure of hand wounds, puncture wounds, or wounds with delayed presentations (eg, >8 hours since injury) is associated with an increased rate of infection [24,44,46].
我們同意美國傳染病學會 (IDSA) 對大多數病例的指南（例如，反對對非臉部貓咬傷進行初級縫合）[ 1 ]。然而，儘管 IDSA 不建議對非面部犬咬傷進行初級縫合，但我們同意其他專家的觀點，他們支持對軀幹、手臂或腿部（但不包括手和腳）的犬咬傷造成的撕裂傷進行初級縫合[ 46,47 ]。研究發現，初級縫合傷口不會增加此類咬傷的感染風險，反而與改善美容效果有關[ 44,46,47 ]。然而，手部傷口、刺傷或延遲出現的傷口（例如，受傷後 > 8 小時）的初級縫合與感染率增加相關[ 24,44,46 ]。
Wound closure — For most patients with uninfected bite wounds, we suggest that the wounds be left open to heal by secondary intention rather than by primary closure (algorithm 1 and figure 2). (See "Minor wound evaluation and preparation for closure", section on 'Type of closure'.)
Primary closure is a reasonable alternative in a patient with a facial laceration (including a cat bite) that is sufficiently large to affect cosmesis or a gaping dog bite on the trunk, arm, or leg (not on a hand or foot) who meets all of the following criteria:
●Uninfected wound
●Immunocompetent patient
●Recent bite (<12 hours old for bites on an extremity, <24 hours old for facial bites)
●No crush injury or puncture wound
●No prior episode of cellulitis or venous/lymphatic compromise on the affected extremity
For a wound that may benefit from primary closure but has one of these contraindications, the patient may be started on prophylactic antibiotics with a plan for delayed primary closure after three to four days. Unless the clinician has extensive experience with delayed primary closure, referral to a surgeon or other wound expert is advised since additional debridement (eg, of excessive accumulated granulation tissue) may be necessary at the time of closure. (See "Minor wound evaluation and preparation for closure", section on 'Delayed primary closure'.)
The choice of bite wound closure (ie, primary closure, healing by secondary intention, or delayed primary closure) should be individualized to the nature of the wound, whether irrigation and debridement can reasonably clean the wound, and the immune status of the host. Primary closure hastens healing and reduces adverse cosmetic outcomes [1,22,44,52-55]. However, for small wounds and puncture wounds, the potentially increased risk of infection from primary closure typically outweighs the minimal cosmetic benefit [24]. Facial wounds are an exception given increased cosmetic consequences and a lower rate of infection compared with other anatomic sites [1,44,49-51]. The waiting period during delayed primary closure permits the host defense system to decrease bacterial load and to ensure that no infection develops, which is a contraindication to closure.
We agree with the Infectious Diseases Society of American (IDSA) guidelines for most cases (eg, against primary closure of nonfacial cat bites) [1]. However, even though the IDSA recommends against primary closure of nonfacial dog bites, we agree with other experts who favor primary closure of lacerations due to dog bites on the trunk, arms, or legs (though not on the hands or feet) [46,47]. Studies have found that primary wound closure does not increase the risk of infection in such bites but is associated with improved cosmetic outcomes [44,46,47]. However, primary closure of hand wounds, puncture wounds, or wounds with delayed presentations (eg, >8 hours since injury) is associated with an increased rate of infection [24,44,46].
野外與登山醫學- 高海拔肺水腫診斷 from uptodate
2025-08-05 15:01
不確定是否貼過這段. 先貼上來
不確定是否貼過這段. 先貼上來
筆記
1. HAPE 通常發生在抵達高海拔之後 2-4 天
2. 乾咳, 咳痰, 咳血痰, 極度疲憊, 運動時呼吸困難, 上坡困難
靜止時呼吸困難, 端坐呼吸
3. 有些個案會發燒(通常低於38度C)
4. 血氧濃度低於預期值 10%
5. 聽診可聽到肺部有泡泡聲(濕囉音)
下面中文使用google 翻譯
高海拔肺水腫通常根據病史和檢查結果進行臨床診斷。
高海拔肺水腫通常根據病史和檢查結果進行臨床診斷。
初始症狀通常在到達高海拔地區後兩到四天出現，包括輕微乾咳、運動時氣短和上坡行走困難。兒童的症狀可能更為突然。
一到兩天後，咳嗽常常轉為咳痰。
早期從運動時呼吸困難進展為靜止時呼吸困難是一個主要特徵。
突出的檢查結果包括心跳過速、呼吸急促、低燒（最高 38°C）和肺部濕囉音。
血氧飽和度通常比特定海拔的預期值低至少 10 個點。吸氧和休息治療可使病情迅速好轉。如有條件，影像學檢查的特徵性發現有助於確診。
DIAGNOSIS
HAPE is typically diagnosed clinically based on the history and examination findings. The initial symptoms typically begin two to four days after arrival at high altitude, including a subtle nonproductive cough, shortness of breath on exertion, and difficulty walking uphill. Symptoms can develop more precipitously in children. Over one to two days, the cough often becomes productive. Early progression from dyspnea with exertion to dyspnea at rest is a cardinal feature. Prominent examination findings include tachycardia, tachypnea, low-grade fever (up to 38°C), and pulmonary crackles. Oxygen saturation is usually at least 10 points lower than expected for a given altitude. Treatment with supplemental oxygen and rest can lead to rapid improvement. When available, characteristic findings on imaging studies help confirm the diagnosis.
DIAGNOSIS
HAPE is typically diagnosed clinically based on the history and examination findings. The initial symptoms typically begin two to four days after arrival at high altitude, including a subtle nonproductive cough, shortness of breath on exertion, and difficulty walking uphill. Symptoms can develop more precipitously in children. Over one to two days, the cough often becomes productive. Early progression from dyspnea with exertion to dyspnea at rest is a cardinal feature. Prominent examination findings include tachycardia, tachypnea, low-grade fever (up to 38°C), and pulmonary crackles. Oxygen saturation is usually at least 10 points lower than expected for a given altitude. Treatment with supplemental oxygen and rest can lead to rapid improvement. When available, characteristic findings on imaging studies help confirm the diagnosis.
2025年8月4日 星期一
FORXIGA使用於慢性腎病健保給付規定
2025-08-05 12:07中午
今天遠距醫療會診腎臟科. 提到了 FORXIGA 可用於 UACR 200-5000 的患者.
目前個案 UACR 140. Cr 1.94 eGFR 34.75 A1C 6.4
使用的DM藥物是 trajenta + Toujeo injection. 血糖一直控制不錯
患者有蛋白尿. 已經有使用 pentoxiphylline + ARB
慢性腎臟病：(114/3/1） (1)限用於參加「初期慢性腎臟病照 護整合方案」或「全民健康保險末 期腎臟病前期(Pre-ESRD)之病人照 護與衛教計畫」之慢性腎臟病病 人，應完全符合下列條件： Ⅰ.接受 dapagliflozin 或 empagliflozin 治療前應穩定接 受最大耐受劑量的 ACEI 或 ARB 至 少4週。 Ⅱ.起始治療 eGFR≧25且 ≦60mL/min/1.73m2。 Ⅲ.uACR≧200且≦5000/mg/g。
2025年8月3日 星期日
野外與登山醫學-恙蟲病治療 from uptodate
2025-08-04 from uptodate
筆記摘要
1. 輕度至中度: 二擇一. 通常選 doxycycline, 因為使用經驗及研究報告最多. 但azithromycin 的臨床研究也逐漸增加, 治療效果或副作用或住院天數與 doxycycline 相似
doxycycline 100mg po or IV BID
azithromycin 500mg po or IV qd
2. 重度: 建議選擇 doxycycline, 總共療程是 7 天
第一天劑量加倍 200 mg po bid
第二天起劑量改為 100mg po bid
不建議 doxycycline 與 azithromycin 常規合併使用(死亡率可能上升). 在選擇性個案可考慮合併藥物治療.
研究共收入794位患者, 平均年齡 48歲. 出現呼吸道併發症佔62%, 肝臟併發症佔 54%., 心血管併發症佔 42%, 腎臟併發症佔 30%, 神經併發症佔20%
合併兩種抗生素治療與單一藥物治療, 相較之下有較低的 primary efficacy outcome.
Outcomes
The primary efficacy outcome was a composite of death from any cause at day 28, persistent complications at day 7, and persistent fever (oral temperature, ≥37.5°C [99.5°F]) on day 5. Persistent complications at day 7 were defined as the presence of dysfunction in any organ system, including cardiovascular, respiratory, central nervous system, hepatic, or renal, as outlined in the criteria described in Section S1D. Secondary outcomes were death from any cause at 28 days; measures of recovery, including time to fever defervescence (oral temperature, <99.5°F) sustained for 24 hours, duration of ventilation, duration of ICU stay, duration of hospitalization, and the time until recovery to normal sensorium (a score of 15 on the Glasgow Coma Scale, which ranges from 3 to 15, with higher scores indicating greater awareness); and safety.
下面內容來自 uptodate, 中文部分使用google翻譯
首選處方 — 取決於疾病的嚴重程度以及患者是否懷孕。
輕度至中度疾病患者 —
對於推定為輕度至中度恙蟲病的患者，我們建議使用多西環素或阿奇黴素單藥治療。
對於大多數患者，我們傾向於使用多西環素(每次100 mg，口服或靜脈內，每日2次)，因為我們對該藥物有豐富的經驗，包括在已發表的研究中使用[ 59,60 ]。此外，它對可能引起類似臨床綜合徵的其他病原體(例如，其他立克次體病)具有廣泛的活性；這一點很重要，因為在初始治療時通常無法確診恙蟲病。 (參見上文『鑑別診斷』 )
然而，當強烈懷疑恙蟲病診斷或有血清學證據支持恙蟲病診斷時，阿奇黴素(每次500 mg，口服或靜脈內，每日1次)也是一個合理的選擇。越來越多的臨床試驗表明，阿奇黴素在一系列相關結局指標(例如，退燒時間、併發症風險、住院時長)上的療效與多西環素相似[ 42,57,61,62 ]。
重症患者 —
對於大多數重症患者，我們建議使用多西環素單一藥物治療。在這種情況下，我們在第1天給予多西環素，每次200mg，每日2次；之後給予多西環素，每次100mg，每日2次，共治療7天。多西環素一直是重症恙蟲病患者的標準治療方案。此外，近期一項隨機試驗納入了794例恙蟲病患者，這些患者出現併發症，需要靜脈注射治療。結果顯示，接受多西環素單一藥物治療的患者，其絕對死亡率低於接受多西環素和阿奇黴素合併治療的患者（分別為11% vs 13%），但差異不顯著[ 62 ]。在該試驗中，兩組患者的機械通氣需求、通氣時長、ICU住院時長、總住院時長也相似。然而，多西環素和阿奇黴素 聯合治療可依具體情況考慮。在上述隨機試驗中，合併治療組的複合主要結局（第28日全因死亡、第7日持續性併發症和第5日持續性發燒）發生率低於多西環素單藥治療組（33% vs 47%；風險差異為-13.3%，95% CI -21.6至5.1）或阿奇黴素 13.3%，95% CI -21.6至5.1）或阿奇黴素第8%， -23.1至-6.5）[ 62 ]。這種差異主要是因為第7日某些併發症的持續性減少（例如，需要輔助供氧、高膽紅素血症[膽紅素血症>2]消退以及肌酸酐升高消退）。因此，聯合治療可更快地緩解某些次要結局和實驗室檢查異常，如果患者認為這是當務之急，聯合治療可能是合理的。
療程 — 最佳治療療程仍不確定。使用多西環素時，我們通常傾向於7日療程，儘管已發表的試驗採用了多種方案。對於阿奇黴素，我們對大多數患者實施5-7日的療程，對較輕微病例則採用較短療程。在上述隨機研究中，7日的多西環素、阿奇黴素或合併療法與重症患者的治癒率較高相關[ 62 ]。開始靜脈治療的患者一旦臨床狀況穩定，就可以改用口服療法。
雖然有人提倡使用短至1日的多西環素(400mg，分2次服用)的方案來治療恙蟲病[ 63 ]，但短期多西環素療程與復發風險增加有關。在一項評估3日療程的研究中，7名接受氯黴素治療的患者中有3名復發，6名接受多西環素治療的患者中有3名復發；相比之下，接受任一方案治療 5 天或更長時間的 37 名患者均未出現復發[ 59 ]。鑑於治療通常是在診斷未確診時進行的，標準 7 天多西環素療程的另一個好處是它與用於類似感染綜合徵的治療方案有重疊。
對於阿奇黴素單一治療，已研究了各種療程（從 1 到 7 天不等），儘管沒有進行比較。鑑於已發表研究中治療時長差異較大，且部分研究認為較短的療程可能與發燒持續時間延長有關，我們傾向於 5 至 7 天的療程[ 42,57,61,62 ]。
替代抗菌方案—
鑑於多西環素和在阿奇黴素之後，雖然現有數據顯示其他替代藥物可能有效，但一般不建議使用它們治療恙蟲病。但是，有時患者可能有強力黴素和阿奇黴素的禁忌症，在這種情況下，可以考慮使用以下藥物之一：
●利福平– 當患者對強力黴素和阿奇黴素（首選藥物）有禁忌症時，利福平是治療恙蟲病的一種選擇。雖然利福平通常是一種有效的選擇，但它存在許多藥物交互作用，因此存在挑戰。再加上目前已發表的支持強力黴素和阿奇黴素的證據較多，在大多數情況下，利福平只能作為三線治療藥物。 (參見上文『首選抗菌方案』 )與多西環素
相比，利福平(600 mg，每日1次，連用5日)療法治癒了所有接受該療法的患者(n = 119)，且發燒、肌痛、頭痛或皮疹的消退時間無差異[ 64 ]。多西環素合併利福平療法也已被研究，但鑑於其他方案的有效性和安全性，很少適用這種聯合療法。在泰國北部地區進行的一項隨機試驗，在86例輕度恙蟲病感染患者中，比較了多西環素單藥治療與多西環素聯合利福平治療的療效[ 65 ]。 24位每日服用900毫克和600毫克利福平的患者（平均退燒時間分別為22.5毫克和27.5小時），其發燒時間中位數顯著短於52例僅接受多西環素治療的患者（平均退燒時間52小時）。 ●氟喹諾酮類藥物– 氟喹諾酮類藥物(FQ)已被證明可有效治療恙蟲病，尤其對於輕度/中度患者。然而，與多西環素或米諾環素相比，使用FQ治療恙蟲病也已被證明與緩解時間延遲和死亡率更高相關[ 66 ]。●氯黴素－氯黴素（每6小時口服或靜脈注射250至500毫克）是第一種被證實對治療恙蟲病有效的藥物，一項包含3項治療試驗的分析發現，在接受多西環素或氯黴素治療的患者中，退燒時間和復發率沒有顯著差異[ 67]
然而，鑑於該藥物的毒性且在大多數國家難以獲得，應僅在沒有其他選擇的情況下才使用氯黴素。
妊娠注意事項 —
恙蟲病可能導致懷孕婦女自然流產或死產[ 4,68-70 ]。例如，一篇文獻回顧納入了 55 例恙蟲病孕婦（其中 3 例同時患有恙蟲病和瘧疾）的信息，發現 55 例患者中有 24 例（44%）新生兒結局不良，定義為死產、早產或低出生體重[ 69 ]。
對於此類患者，我們通常給予阿奇黴素（每日 500 mg），連續 7 天，因為這種方案有最多已發表的數據支持其在妊娠期使用[ 68,71 ]。
文獻中表明，較短療程(1-5天)的阿奇黴素治療方案在妊娠期也可能有效，但支持該人群採用任何特定方案的數據仍然很少，並且有報導稱，較短療程的阿奇黴素治療會導致發熱和其他臨床體徵緩解較慢，這也提示在選擇較短療程的方案時應謹慎[ 62,72 ]。
Preferred antimicrobial regimens — The choice of regimen depends on the severity of disease and if the patient is pregnant.
Persons with mild to moderate disease — For patients with presumed mild to moderate scrub typhus, we suggest monotherapy with doxycycline or azithromycin.
For most patients, we favor doxycycline (100 mg orally or intravenously twice daily) due to extensive experience with this agent, including its use in published studies [59,60]. In addition, it has broad activity against other organisms that may cause similar clinical syndromes (eg, other rickettsial diseases); this is important since the diagnosis is often not confirmed at the time of initial treatment. (See 'Differential diagnosis' above.)
However, azithromycin (500 mg orally or intravenously daily) is also a reasonable choice when the diagnosis of scrub typhus is strongly suspected or supported by serologic evidence. An increasing number of clinical trials have shown that azithromycin offers similar efficacy to doxycycline across a wide array of relevant outcomes (eg, time to defervescence, risk of complications, length of hospitalization) [42,57,61,62].
Specific considerations for regimen selection in persons who are pregnant are discussed below. (See 'Considerations during pregnancy' below.)
Persons with severe disease — For most patients with severe disease, we suggest monotherapy with doxycycline. In this setting, we administer 200 mg of doxycycline twice daily on day one, followed by 100 mg twice daily for a total duration of seven days. Doxycycline has been the historical standard of care for patients with severe scrub typhus. In addition, in a recent randomized trial of 794 patients with scrub typhus who had complications requiring intravenous therapy, those who received monotherapy with doxycycline had a nonsignificant but lower absolute mortality than those who received combination therapy with doxycycline and azithromycin (11 versus 13 percent, respectively) [62]. In this trial, the need for mechanical ventilation, the duration of ventilation, the length of stay in the ICU, and the overall hospital length of stay were also similar between the groups.
However, combination therapy with doxycycline and azithromycin may be considered on a case-by-case basis. In the randomized trial above, those who received combination therapy had a lower incidence of a composite primary outcome (death from any cause at day 28, persistent complications at day 7, and persistent fever at day 5) than those who received monotherapy with doxycycline (33 versus 47 percent; risk difference of -13.3 percent, 95% CI -21.6 to -5.1) or azithromycin (33 versus 48 percent; risk difference -14.8 percent, 95% CI -23.1 to -6.5) [62]. This difference was due primarily to a reduction in persistence of certain complications at day 7 (eg, the need for supplemental oxygen, resolution of hyperbilirubinemia [T. bili >2], and resolution of elevated creatinine). Thus, combination therapy may offer more rapid resolution of some secondary outcomes and laboratory abnormalities and may be reasonable in patients if this is deemed to be a priority.
Duration — The optimal duration of treatment remains uncertain. When doxycycline is used, we typically favor seven days of therapy, although published trials have utilized a variety of regimens. For azithromycin we administer therapy for five to seven days for most patients, reserving shorter durations for milder cases. In the randomized study discussed above, seven days of doxycycline, azithromycin, or combination therapy was associated with high rates of cure in those with severe disease [62]. Patients who initiate intravenous therapy can switch to oral therapy as soon as they are clinically stable.
Although regimens as short as one day of doxycycline (400 mg given in two divided doses) have been advocated for the therapy of scrub typhus [63], short courses of doxycycline have been associated with an increased risk of relapse. In one study evaluating a three-day course of therapy, relapse occurred in three of seven patients treated with chloramphenicol and three of six treated with doxycycline; in comparison, no relapses were noted in 37 patients treated with either regimen for five days or longer [59]. Given that treatment is often given while the diagnosis remains unconfirmed, another benefit of a standard seven-day course of doxycycline is its overlap with regimens used for similar infectious syndromes.
For azithromycin monotherapy, a variety of durations (ranging from one to seven days) have been studied, although not comparatively. We favor the five to seven day duration given the heterogeneity of lengths of therapy in published studies and the suggestion from some that shorter courses may be associated with prolonged duration of fever [42,57,61,62].
Alternate antimicrobial regimens — Given the efficacy and safety of doxycycline and azithromycin, the use of alternative agents for treatment of scrub typhus is generally not warranted, even though available data suggest they may be effective. However, on occasion, a patient may have contraindications to doxycycline and azithromycin, and in this setting, one of the following agents can be considered:
●Rifampin – Rifampin is an option for treatment of scrub typhus when there are contraindications to doxycycline and azithromycin (the preferred agents). While a generally effective option, rifampin creates challenges with its many drug-drug interactions. This, combined with the overall greater body of published evidence supporting doxycycline and azithromycin, relegates rifampin to third-line therapy in most situations. (See 'Preferred antimicrobial regimens' above.)
When compared with doxycycline, rifampin (600 mg once daily for five days) therapy cured all patients who received it (n = 119) and showed no difference in time to resolution of fever, myalgias, headache, or rash [64].
Combination therapy with doxycycline plus rifampin has also been studied, but given the efficacy and safety of other regimens, this combination is rarely indicated. A randomized trial performed in an area of northern Thailand compared the efficacy of doxycycline alone with the combination of doxycycline and rifampin in 86 patients with mild scrub typhus infection [65]. The median duration of fever was significantly shorter in the 24 patients treated with daily doses of 900 and 600 mg of rifampin (mean fever clearance times 22.5 and 27.5 hours, respectively) than in 52 patients treated with doxycycline therapy alone (mean fever clearance time 52 hours).
●Fluoroquinolones – Fluoroquinolones (FQ) have shown efficacy for the treatment of scrub typhus, particularly in mild/moderate disease. However, use of FQ for scrub typhus has also been shown to be associated with delayed time to resolution and higher mortality compared with doxycycline or minocycline [66].
●Chloramphenicol – Chloramphenicol (250 to 500 mg orally or intravenously every six hours) was the first drug shown to be effective for the treatment of scrub typhus, and an analysis that included three treatment trials found no significant differences in time to resolution of fever and incidence of relapse in patients treated with doxycycline or chloramphenicol [67]. However, given the toxicity of this drug and difficulty obtaining it in most countries, chloramphenicol should be reserved for situations when other options are not available.
Considerations during pregnancy — Scrub typhus may cause spontaneous abortions or stillbirths in pregnant persons [4,68-70]. As an example, a literature review that included information on 55 pregnant persons with scrub typhus (including three who had both scrub typhus and malaria) found that 24 out of 55 patients (44 percent) had a poor neonatal outcome, defined as stillbirths, preterm birth, or low birth weight [69].
For such patients we typically administer azithromycin (500 mg daily) for seven days, as this regimen has the greatest amount of published data supporting its use in pregnancy [68,71].
There is suggestion in the literature that shorter regimens (ranging one to five days) of azithromycin may also be effective in pregnancy, but the data supporting any specific regimen in this population remain sparse, and reports of slower resolution of fever and other clinical signs with shorter courses of azithromycin also suggest caution when selecting regimens of shorter duration [62,72]. (See 'Duration' above.)
筆記摘要
1. 輕度至中度: 二擇一. 通常選 doxycycline, 因為使用經驗及研究報告最多. 但azithromycin 的臨床研究也逐漸增加, 治療效果或副作用或住院天數與 doxycycline 相似
doxycycline 100mg po or IV BID
azithromycin 500mg po or IV qd
2. 重度: 建議選擇 doxycycline, 總共療程是 7 天
第一天劑量加倍 200 mg po bid
第二天起劑量改為 100mg po bid
不建議 doxycycline 與 azithromycin 常規合併使用(死亡率可能上升). 在選擇性個案可考慮合併藥物治療.
重度患者使用單方 doxycycline 治療這項建議來自於下面這篇研究(於2023年發表於NEJM) Intravenous Doxycycline, Azithromycin, or Both for Severe Scrub Typhus.
研究共收入794位患者, 平均年齡 48歲. 出現呼吸道併發症佔62%, 肝臟併發症佔 54%., 心血管併發症佔 42%, 腎臟併發症佔 30%, 神經併發症佔20%
合併兩種抗生素治療與單一藥物治療, 相較之下有較低的 primary efficacy outcome.
primary efficacy outcome 包括: 28天全因死亡率. 第七天持續出現併發症, 第五天持續發燒
第七天持續出現併發症定義: 任何器官系統異常, 包括心血管, 呼吸, 中樞神經, 肝臟, 腎臟
secondary outcomes: 28天全因死亡率, 恢復期, 包括持續24小時不發燒時間, 使用呼吸器時間, ICU住院天數. 恢復正常神智時間, 安全性.
Outcomes
The primary efficacy outcome was a composite of death from any cause at day 28, persistent complications at day 7, and persistent fever (oral temperature, ≥37.5°C [99.5°F]) on day 5. Persistent complications at day 7 were defined as the presence of dysfunction in any organ system, including cardiovascular, respiratory, central nervous system, hepatic, or renal, as outlined in the criteria described in Section S1D. Secondary outcomes were death from any cause at 28 days; measures of recovery, including time to fever defervescence (oral temperature, <99.5°F) sustained for 24 hours, duration of ventilation, duration of ICU stay, duration of hospitalization, and the time until recovery to normal sensorium (a score of 15 on the Glasgow Coma Scale, which ranges from 3 to 15, with higher scores indicating greater awareness); and safety.
The Common Terminology Criteria for Adverse Events, version 5, was used to grade adverse events.
Results: Among 794 patients (median age, 48 years) who were included in the modified intention-to-treat analysis, complications included those that were respiratory (in 62%), hepatic (in 54%), cardiovascular (in 42%), renal (in 30%), and neurologic (in 20%).
The use of combination therapy resulted in a lower incidence of the composite primary outcome than the use of doxycycline (33% and 47%, respectively), for a risk difference of -13.3 percentage points (95% confidence interval [CI], -21.6 to -5.1; P = 0.002).
The incidence with combination therapy was also lower than that with azithromycin (48%), for a risk difference of -14.8 percentage points (95% CI, -23.1 to -6.5; P<0.001).
No significant difference was seen between the azithromycin and doxycycline groups (risk difference, 1.5 percentage points; 95% CI, -7.0 to 10.0; P = 0.73).
The results in the per-protocol analysis were similar to those in the primary analysis.
Adverse events and 28-day mortality were similar in the three groups.
下面內容來自 uptodate, 中文部分使用google翻譯
首選處方 — 取決於疾病的嚴重程度以及患者是否懷孕。
輕度至中度疾病患者 —
對於推定為輕度至中度恙蟲病的患者，我們建議使用多西環素或阿奇黴素單藥治療。
對於大多數患者，我們傾向於使用多西環素(每次100 mg，口服或靜脈內，每日2次)，因為我們對該藥物有豐富的經驗，包括在已發表的研究中使用[ 59,60 ]。此外，它對可能引起類似臨床綜合徵的其他病原體(例如，其他立克次體病)具有廣泛的活性；這一點很重要，因為在初始治療時通常無法確診恙蟲病。 (參見上文『鑑別診斷』 )
然而，當強烈懷疑恙蟲病診斷或有血清學證據支持恙蟲病診斷時，阿奇黴素(每次500 mg，口服或靜脈內，每日1次)也是一個合理的選擇。越來越多的臨床試驗表明，阿奇黴素在一系列相關結局指標(例如，退燒時間、併發症風險、住院時長)上的療效與多西環素相似[ 42,57,61,62 ]。
重症患者 —
對於大多數重症患者，我們建議使用多西環素單一藥物治療。在這種情況下，我們在第1天給予多西環素，每次200mg，每日2次；之後給予多西環素，每次100mg，每日2次，共治療7天。多西環素一直是重症恙蟲病患者的標準治療方案。此外，近期一項隨機試驗納入了794例恙蟲病患者，這些患者出現併發症，需要靜脈注射治療。結果顯示，接受多西環素單一藥物治療的患者，其絕對死亡率低於接受多西環素和阿奇黴素合併治療的患者（分別為11% vs 13%），但差異不顯著[ 62 ]。在該試驗中，兩組患者的機械通氣需求、通氣時長、ICU住院時長、總住院時長也相似。然而，多西環素和阿奇黴素 聯合治療可依具體情況考慮。在上述隨機試驗中，合併治療組的複合主要結局（第28日全因死亡、第7日持續性併發症和第5日持續性發燒）發生率低於多西環素單藥治療組（33% vs 47%；風險差異為-13.3%，95% CI -21.6至5.1）或阿奇黴素 13.3%，95% CI -21.6至5.1）或阿奇黴素第8%， -23.1至-6.5）[ 62 ]。這種差異主要是因為第7日某些併發症的持續性減少（例如，需要輔助供氧、高膽紅素血症[膽紅素血症>2]消退以及肌酸酐升高消退）。因此，聯合治療可更快地緩解某些次要結局和實驗室檢查異常，如果患者認為這是當務之急，聯合治療可能是合理的。
療程 — 最佳治療療程仍不確定。使用多西環素時，我們通常傾向於7日療程，儘管已發表的試驗採用了多種方案。對於阿奇黴素，我們對大多數患者實施5-7日的療程，對較輕微病例則採用較短療程。在上述隨機研究中，7日的多西環素、阿奇黴素或合併療法與重症患者的治癒率較高相關[ 62 ]。開始靜脈治療的患者一旦臨床狀況穩定，就可以改用口服療法。
雖然有人提倡使用短至1日的多西環素(400mg，分2次服用)的方案來治療恙蟲病[ 63 ]，但短期多西環素療程與復發風險增加有關。在一項評估3日療程的研究中，7名接受氯黴素治療的患者中有3名復發，6名接受多西環素治療的患者中有3名復發；相比之下，接受任一方案治療 5 天或更長時間的 37 名患者均未出現復發[ 59 ]。鑑於治療通常是在診斷未確診時進行的，標準 7 天多西環素療程的另一個好處是它與用於類似感染綜合徵的治療方案有重疊。
對於阿奇黴素單一治療，已研究了各種療程（從 1 到 7 天不等），儘管沒有進行比較。鑑於已發表研究中治療時長差異較大，且部分研究認為較短的療程可能與發燒持續時間延長有關，我們傾向於 5 至 7 天的療程[ 42,57,61,62 ]。
替代抗菌方案—
鑑於多西環素和在阿奇黴素之後，雖然現有數據顯示其他替代藥物可能有效，但一般不建議使用它們治療恙蟲病。但是，有時患者可能有強力黴素和阿奇黴素的禁忌症，在這種情況下，可以考慮使用以下藥物之一：
●利福平– 當患者對強力黴素和阿奇黴素（首選藥物）有禁忌症時，利福平是治療恙蟲病的一種選擇。雖然利福平通常是一種有效的選擇，但它存在許多藥物交互作用，因此存在挑戰。再加上目前已發表的支持強力黴素和阿奇黴素的證據較多，在大多數情況下，利福平只能作為三線治療藥物。 (參見上文『首選抗菌方案』 )與多西環素
相比，利福平(600 mg，每日1次，連用5日)療法治癒了所有接受該療法的患者(n = 119)，且發燒、肌痛、頭痛或皮疹的消退時間無差異[ 64 ]。多西環素合併利福平療法也已被研究，但鑑於其他方案的有效性和安全性，很少適用這種聯合療法。在泰國北部地區進行的一項隨機試驗，在86例輕度恙蟲病感染患者中，比較了多西環素單藥治療與多西環素聯合利福平治療的療效[ 65 ]。 24位每日服用900毫克和600毫克利福平的患者（平均退燒時間分別為22.5毫克和27.5小時），其發燒時間中位數顯著短於52例僅接受多西環素治療的患者（平均退燒時間52小時）。 ●氟喹諾酮類藥物– 氟喹諾酮類藥物(FQ)已被證明可有效治療恙蟲病，尤其對於輕度/中度患者。然而，與多西環素或米諾環素相比，使用FQ治療恙蟲病也已被證明與緩解時間延遲和死亡率更高相關[ 66 ]。●氯黴素－氯黴素（每6小時口服或靜脈注射250至500毫克）是第一種被證實對治療恙蟲病有效的藥物，一項包含3項治療試驗的分析發現，在接受多西環素或氯黴素治療的患者中，退燒時間和復發率沒有顯著差異[ 67]
然而，鑑於該藥物的毒性且在大多數國家難以獲得，應僅在沒有其他選擇的情況下才使用氯黴素。
妊娠注意事項 —
恙蟲病可能導致懷孕婦女自然流產或死產[ 4,68-70 ]。例如，一篇文獻回顧納入了 55 例恙蟲病孕婦（其中 3 例同時患有恙蟲病和瘧疾）的信息，發現 55 例患者中有 24 例（44%）新生兒結局不良，定義為死產、早產或低出生體重[ 69 ]。
對於此類患者，我們通常給予阿奇黴素（每日 500 mg），連續 7 天，因為這種方案有最多已發表的數據支持其在妊娠期使用[ 68,71 ]。
文獻中表明，較短療程(1-5天)的阿奇黴素治療方案在妊娠期也可能有效，但支持該人群採用任何特定方案的數據仍然很少，並且有報導稱，較短療程的阿奇黴素治療會導致發熱和其他臨床體徵緩解較慢，這也提示在選擇較短療程的方案時應謹慎[ 62,72 ]。
Preferred antimicrobial regimens — The choice of regimen depends on the severity of disease and if the patient is pregnant.
Persons with mild to moderate disease — For patients with presumed mild to moderate scrub typhus, we suggest monotherapy with doxycycline or azithromycin.
For most patients, we favor doxycycline (100 mg orally or intravenously twice daily) due to extensive experience with this agent, including its use in published studies [59,60]. In addition, it has broad activity against other organisms that may cause similar clinical syndromes (eg, other rickettsial diseases); this is important since the diagnosis is often not confirmed at the time of initial treatment. (See 'Differential diagnosis' above.)
However, azithromycin (500 mg orally or intravenously daily) is also a reasonable choice when the diagnosis of scrub typhus is strongly suspected or supported by serologic evidence. An increasing number of clinical trials have shown that azithromycin offers similar efficacy to doxycycline across a wide array of relevant outcomes (eg, time to defervescence, risk of complications, length of hospitalization) [42,57,61,62].
Specific considerations for regimen selection in persons who are pregnant are discussed below. (See 'Considerations during pregnancy' below.)
Persons with severe disease — For most patients with severe disease, we suggest monotherapy with doxycycline. In this setting, we administer 200 mg of doxycycline twice daily on day one, followed by 100 mg twice daily for a total duration of seven days. Doxycycline has been the historical standard of care for patients with severe scrub typhus. In addition, in a recent randomized trial of 794 patients with scrub typhus who had complications requiring intravenous therapy, those who received monotherapy with doxycycline had a nonsignificant but lower absolute mortality than those who received combination therapy with doxycycline and azithromycin (11 versus 13 percent, respectively) [62]. In this trial, the need for mechanical ventilation, the duration of ventilation, the length of stay in the ICU, and the overall hospital length of stay were also similar between the groups.
However, combination therapy with doxycycline and azithromycin may be considered on a case-by-case basis. In the randomized trial above, those who received combination therapy had a lower incidence of a composite primary outcome (death from any cause at day 28, persistent complications at day 7, and persistent fever at day 5) than those who received monotherapy with doxycycline (33 versus 47 percent; risk difference of -13.3 percent, 95% CI -21.6 to -5.1) or azithromycin (33 versus 48 percent; risk difference -14.8 percent, 95% CI -23.1 to -6.5) [62]. This difference was due primarily to a reduction in persistence of certain complications at day 7 (eg, the need for supplemental oxygen, resolution of hyperbilirubinemia [T. bili >2], and resolution of elevated creatinine). Thus, combination therapy may offer more rapid resolution of some secondary outcomes and laboratory abnormalities and may be reasonable in patients if this is deemed to be a priority.
Duration — The optimal duration of treatment remains uncertain. When doxycycline is used, we typically favor seven days of therapy, although published trials have utilized a variety of regimens. For azithromycin we administer therapy for five to seven days for most patients, reserving shorter durations for milder cases. In the randomized study discussed above, seven days of doxycycline, azithromycin, or combination therapy was associated with high rates of cure in those with severe disease [62]. Patients who initiate intravenous therapy can switch to oral therapy as soon as they are clinically stable.
Although regimens as short as one day of doxycycline (400 mg given in two divided doses) have been advocated for the therapy of scrub typhus [63], short courses of doxycycline have been associated with an increased risk of relapse. In one study evaluating a three-day course of therapy, relapse occurred in three of seven patients treated with chloramphenicol and three of six treated with doxycycline; in comparison, no relapses were noted in 37 patients treated with either regimen for five days or longer [59]. Given that treatment is often given while the diagnosis remains unconfirmed, another benefit of a standard seven-day course of doxycycline is its overlap with regimens used for similar infectious syndromes.
For azithromycin monotherapy, a variety of durations (ranging from one to seven days) have been studied, although not comparatively. We favor the five to seven day duration given the heterogeneity of lengths of therapy in published studies and the suggestion from some that shorter courses may be associated with prolonged duration of fever [42,57,61,62].
Alternate antimicrobial regimens — Given the efficacy and safety of doxycycline and azithromycin, the use of alternative agents for treatment of scrub typhus is generally not warranted, even though available data suggest they may be effective. However, on occasion, a patient may have contraindications to doxycycline and azithromycin, and in this setting, one of the following agents can be considered:
●Rifampin – Rifampin is an option for treatment of scrub typhus when there are contraindications to doxycycline and azithromycin (the preferred agents). While a generally effective option, rifampin creates challenges with its many drug-drug interactions. This, combined with the overall greater body of published evidence supporting doxycycline and azithromycin, relegates rifampin to third-line therapy in most situations. (See 'Preferred antimicrobial regimens' above.)
When compared with doxycycline, rifampin (600 mg once daily for five days) therapy cured all patients who received it (n = 119) and showed no difference in time to resolution of fever, myalgias, headache, or rash [64].
Combination therapy with doxycycline plus rifampin has also been studied, but given the efficacy and safety of other regimens, this combination is rarely indicated. A randomized trial performed in an area of northern Thailand compared the efficacy of doxycycline alone with the combination of doxycycline and rifampin in 86 patients with mild scrub typhus infection [65]. The median duration of fever was significantly shorter in the 24 patients treated with daily doses of 900 and 600 mg of rifampin (mean fever clearance times 22.5 and 27.5 hours, respectively) than in 52 patients treated with doxycycline therapy alone (mean fever clearance time 52 hours).
●Fluoroquinolones – Fluoroquinolones (FQ) have shown efficacy for the treatment of scrub typhus, particularly in mild/moderate disease. However, use of FQ for scrub typhus has also been shown to be associated with delayed time to resolution and higher mortality compared with doxycycline or minocycline [66].
●Chloramphenicol – Chloramphenicol (250 to 500 mg orally or intravenously every six hours) was the first drug shown to be effective for the treatment of scrub typhus, and an analysis that included three treatment trials found no significant differences in time to resolution of fever and incidence of relapse in patients treated with doxycycline or chloramphenicol [67]. However, given the toxicity of this drug and difficulty obtaining it in most countries, chloramphenicol should be reserved for situations when other options are not available.
Considerations during pregnancy — Scrub typhus may cause spontaneous abortions or stillbirths in pregnant persons [4,68-70]. As an example, a literature review that included information on 55 pregnant persons with scrub typhus (including three who had both scrub typhus and malaria) found that 24 out of 55 patients (44 percent) had a poor neonatal outcome, defined as stillbirths, preterm birth, or low birth weight [69].
For such patients we typically administer azithromycin (500 mg daily) for seven days, as this regimen has the greatest amount of published data supporting its use in pregnancy [68,71].
There is suggestion in the literature that shorter regimens (ranging one to five days) of azithromycin may also be effective in pregnancy, but the data supporting any specific regimen in this population remain sparse, and reports of slower resolution of fever and other clinical signs with shorter courses of azithromycin also suggest caution when selecting regimens of shorter duration [62,72]. (See 'Duration' above.)
2025年8月1日 星期五
轉貼 心因性猝死機轉 BY DR Ming Hung Tsai
2025-08-01 15:30
資料來源: 臨床筆記社團
病因
資料來源: 臨床筆記社團
病因
1. 缺血性心臟病: 冠狀動脈心臟病佔致命性心律不整80%
2. 結構性心臟異常
3. 分子或基因異常
心肌梗塞發生心律不整機轉
1. 缺血狀態引起 VT 或 VF
2. 心肌疤痕易成為致命性心律不整起始病灶
2. 心肌疤痕易成為致命性心律不整起始病灶
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