急診小醫師ymmcc的醫學筆記

2026年6月16日星期二

Fentanyl fold 毒品造成殭屍般的折疊

2026-06-16

fentanyl 效果是 heroin 海洛英的50倍. 海洛英的效果是嗎啡的 2-5 倍

fentanyl 效果是嗎啡的 50-100 倍

fentanyl 注射液通常是一瓶2cc=0.1mg

嗎啡注射液通常是一瓶 1cc=10mg.

兩種藥物一瓶劑量剛好差100倍

fentanyl 被濫用的原因是. 便宜(化學合成.不需種植). 效果快 10 秒生效

但fentanyl致死劑量低(2mg就可能致死). 容易發生猝死.

YT頻道-芬太尼氾濫

裡面有說明為何 fentanyl 會造成殭屍般的折疊.

YT頻道-吸一口就戒不掉(heroin)

德國拜耳藥廠生產的藥品. 過去仿單標示兒童也可使用. 1920年美國開始禁用

2026年6月15日星期一

ACLS Dose Comparisons of Clopidogrel and Aspirin in Acute Coronary Syndromes 急性冠心症plavix劑量比較

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

2026-06-16
標準劑量初始劑量 clopidogrel 300mg. 之後六天每天 75mg

高劑量初始劑量 clopidogrel 600mg 之後六天每天 150mg

第八天開始兩組均給予每天75mg.

兩組心因性死亡. 心肌梗塞. 中風機率沒有明顯差異.

Dose Comparisons of Clopidogrel and Aspirin in Acute Coronary Syndromes 急性冠心症plavix劑量比較
Immediately after randomization and before coronary angiography, patients randomly assigned to double-dose clopidogrel received a loading dose of 600 mg on day 1, followed by 150 mg once daily on days 2 through 7. Patients assigned to standard-dose clopidogrel received a 300-mg loading dose on day 1 before angiography, followed by 75 mg once daily on days 2 through 7. On days 8 through 30, both the double-dose and standard-dose groups received 75 mg of clopidogrel once daily.

Abstract

Background

Clopidogrel and aspirin are widely used for patients with acute coronary syndromes and those undergoing percutaneous coronary intervention (PCI). However, evidence-based guidelines for dosing have not been established for either agent.

Methods

We randomly assigned, in a 2-by-2 factorial design, 25,086 patients with an acute coronary syndrome who were referred for an invasive strategy to either double-dose clopidogrel (a 600-mg loading dose on day 1, followed by 150 mg daily for 6 days and 75 mg daily thereafter) or standard-dose clopidogrel (a 300-mg loading dose and 75 mg daily thereafter) and either higher-dose aspirin (300 to 325 mg daily) or lower-dose aspirin (75 to 100 mg daily). The primary outcome was cardiovascular death, myocardial infarction, or stroke at 30 days.

Results

The primary outcome occurred in 4.2% of patients assigned to double-dose clopidogrel as compared with 4.4% assigned to standard-dose clopidogrel (hazard ratio, 0.94; 95% confidence interval [CI], 0.83 to 1.06; P=0.30). Major bleeding occurred in 2.5% of patients in the double-dose group and in 2.0% in the standard-dose group (hazard ratio, 1.24; 95% CI, 1.05 to 1.46; P=0.01). Double-dose clopidogrel was associated with a significant reduction in the secondary outcome of stent thrombosis among the 17,263 patients who underwent PCI (1.6% vs. 2.3%; hazard ratio, 0.68; 95% CI, 0.55 to 0.85; P=0.001). There was no significant difference between higher-dose and lower-dose aspirin with respect to the primary outcome (4.2% vs. 4.4%; hazard ratio, 0.97; 95% CI, 0.86 to 1.09; P=0.61) or major bleeding (2.3% vs. 2.3%; hazard ratio, 0.99; 95% CI, 0.84 to 1.17; P=0.90).

Conclusions

In patients with an acute coronary syndrome who were referred for an invasive strategy, there was no significant difference between a 7-day, double-dose clopidogrel regimen and the standard-dose regimen, or between higher-dose aspirin and lower-dose aspirin, with respect to the primary outcome of cardiovascular death, myocardial infarction, or stroke.

ACLS 氧氣濃度應該維持多少? 何時應改給予氧氣治療

2026-06-16

在2025 成人復甦後照護流程. 建議先給予100% 氧氣. 持續到氧氣飽和度穩定. 之後再將目標設定維持氧氣 90-98%

(動脈氧分壓維持 60-105 mmHg)

2025 ACS 臨床處置指引-ACC/AHA/ACEP/NAEMSP/SCAI
A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

患者血氧飽和度低(<90%) 可給予氧氣治療. 維持 SpO2 ≥90% 即可

例行性給氧可能增加短期或長期死亡率

一般AMI患者(包括疑似AMI的) SpO2 ≥90%時, 常規給氧無法帶來心血管效益.

(排除原本在家就需要使用氧氣. 或伴隨活動性支氣管痙攣, 或OHCA患者)

1. 有一篇觀察性研究發現. 入院時SpO94%至96%的死亡率最低

2. AVOID研究. 針對 STEMI 且 SpO2 ≥94% 的患者給予 8 L/min 氧氣治療. 結果發現常規給氧不但沒有助益, 且可能會增加心肌損傷和梗塞範圍.

3. DETO2X-AMI（疑似心肌梗塞患者補充氧療的療效和結局研究）6629例疑似心肌梗塞且氧飽和度≥90%的患者常規給氧 6 L/min. 補充氧氣治療並未降低1年全因死亡率，也未降低心肌梗塞再住院率。對於基線氧飽和度較低（90%-94%）的患者，補充氧氣治療並未帶來持續的臨床效益。

Sodium Bicarbonate Fails to Improve Kidney Outcomes in ICU

2026-06-15 剛在FB看到這篇發表在NEJM的研究. 撈出來看看

對於ICU重症患者. 使用升壓劑的代謝性酸中毒患者. 給予 bicarbonate 無法改善30天內的腎臟不良事件

Sodium Bicarbonate for Critically Ill Adults with Metabolic Acidosis and Shock
Abstract

Background
Metabolic acidosis is common in critically ill patients and is associated with organ dysfunction and death. Sodium bicarbonate is used to correct acidemia, but its benefit in patients with metabolic acidosis who are receiving vasopressors remains uncertain.
Methods
In this pragmatic, adaptive, double-blind, randomized trial, we assigned adults with metabolic acidosis (pH, <7.30; base excess, no more than −4 mmol per liter; and partial pressure of arterial carbon dioxide, ≤45 mm Hg without intubation or ≤50 mm Hg with intubation) who were receiving vasopressors in the intensive care unit (ICU) to receive either sodium bicarbonate or placebo (5% dextrose). Sodium bicarbonate or placebo was infused for up to 5 hours, with the infusion rate adjusted for a target pH of at least 7.30 and base excess of at least 0 mmol per liter. The primary outcome was a major adverse kidney event, defined as death, use of renal-replacement therapy, or persistent renal dysfunction, within 30 days.
Results
A total of 500 patients were enrolled in 55 ICUs across seven countries; 245 patients were assigned to receive sodium bicarbonate and 255 to receive placebo. A major adverse kidney event within 30 days occurred in 98 of 244 patients (40.2%) in the sodium bicarbonate group and in 100 of 254 patients (39.4%) in the placebo group (adjusted difference, 1.2 percentage points; 95% confidence interval [CI], −7.1 to 9.4; P=0.78). Renal-replacement therapy was used within 30 days in 16.8% of the patients in the sodium bicarbonate group and in 20.9% of those in the placebo group (adjusted difference, −3.9 percentage points; 95% CI, −10.6 to 2.7). In-hospital mortality by day 30 was 25.4% in the sodium bicarbonate group and 24.0% in the placebo group (adjusted difference, 1.8 percentage points; 95% CI, −5.6 to 9.2). Four patients (1.6%) in the sodium bicarbonate group had an adverse effect, as compared with none in the placebo group (P=0.06).

Conclusions
The use of sodium bicarbonate in critically ill patients with metabolic acidosis receiving vasopressors did not lead to a lower risk of major adverse kidney events within 30 days than placebo. (Funded by the National Health and Medical Research Council