誤食硬幣

誤食硬幣

acls TTM

 https://www.ahajournals.org/doi/10.1161/CIR.0000000000001375#sec-6

ACLS 2025 指引-急性冠心症標準治療 Standard Medical Therapies for STEMI and NSTE-ACS

2026-05-30

 
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

 僅節錄標準治療這一段

4.1 氧氣維持90%即可. 過多氧氣並不會減少一年內死亡率. 

4. Standard Medical Therapies for STEMI and NSTE-ACS

4.1. Oxygen Therapy

4.2. Analgesics 止痛

Synopsis 概要 

止痛藥物可改善症狀但並不能改善ACS急性冠心症預後. (改善症狀也是很重要一再被強調的)

通常是使用 Nitrates 硝酸鹽類及鴉片類 opiate 藥物 

若硝酸鹽類無法緩解疼痛症狀. 應盡快將冠狀動脈打通. 而不是只給鴉片類止痛藥物壓住症狀

避免使用NSAIS(除了 aspirin 之外). 因為會增加MACE. 不建議常規使用

Table 6. Analgesic Treatment Options for Cardiac Chest Pain

Medication	Route	Suggested Dosing	Considerations
Nitroglycerin*	SL (tablets, spray)	0.3 or 0.4 mg every 5 min as needed up to a total of 3 doses	Use in hemodynamically stable patients with SBP ≥90 mm Hg.
Nitroglycerin*	IV	Start at 10 μg/min and titrate to pain relief and hemodynamic tolerability.	Consider for persistent anginal pain after oral nitrate therapy, or if ACS is accompanied by hypertension or pulmonary edema.20–22 Avoid use in suspected RV infarction, SBP <90 mm Hg or a change in SBP >30 mm Hg below baseline. Tachyphylaxis may occur after approximately 24 h.
Morphine	IV	2-4 mg; may repeat if needed every 5-15 min. Doses up to 10 mg may be considered.	Use for relief of pain that is resistant to other maximally tolerated anti-ischemic medications. May delay the effects of oral P2Y12 therapy.7,9–12 Monitor closely for adverse effects.
Fentanyl	IV	25-50 μg; may repeat if needed. Doses up to 100 μg may be considered.	Use for relief of pain that is resistant to other maximally tolerated anti-ischemic medications. May delay the effects of oral P2Y12 therapy.8 Monitor closely for adverse effects.

Patients presenting with known or suspected ACS often experience chest pain or other uncomfortable symptoms. Rapid and effective pain relief remains an important treatment goal to prevent sympathetic activation and adverse clinical sequelae (Table 6). Analgesic therapies may provide symptomatic relief, but they have not been shown to improve clinical outcomes in patients with ACS.1,2 Nitrates and opiate medications remain effective treatment options for management of pain in ACS but should be thoughtfully utilized to prevent potential harm.3–6 In particular, rapid coronary revascularization should be pursued for patients with ongoing ischemic symptoms that are not relieved with nitrates, and opiates should not be used solely to mask these symptoms. Concerns have also been raised that the use of opiates may delay gastric and intestinal absorption of orally administered P2Y12 inhibitors, thereby delaying their pharmacodynamic effects in patients undergoing PCI.7–10 However, the clinical relevance of these pharmacodynamic findings remains disputed.11–14 Use of nonaspirin nonsteroidal anti-inflammatory drugs should be avoided for management of suspected or known ischemia pain whenever possible.15–17 Use of nonsteroidal anti-inflammatory drugs is associated with increased risk of MACE in patients with and without prior cardiac disease, with no documented benefit to support routine use in patients with ACS.15–19

4.3. Antiplatelet Therapy
4.3.1. Aspirin

概要 Synopsis

Aspirin 可降低MI後的血管性死亡機率
aspirin 通常建議終身服用. 但在心肌梗塞一至三個月後可慎選個案. 停用aspirin 繼續使用 P2Y12抑制劑, 以減少消化道出血機率

P2Y12抑制劑包括

Clopidogrel (保栓通 / Plavix)

Ticagrelor (百無凝 / Brilinta)

Prasugrel (抑凝安 / Efient)：

Aspirin has long been considered an integral part of antiplatelet therapy to prevent recurrent atherothrombotic events among patients with ACS.1–3,6 Aspirin reduces the incidence of vascular death after AMI,3 and in secondary prevention trials (that include patients after MI), it reduces the occurrence of vascular and coronary events, including MI and stroke.2 Although aspirin use after ACS was traditionally considered lifelong, a strategy of aspirin discontinuation, rather than P2Y12 inhibitor discontinuation, may now be considered in the maintenance phase after 1 to 3 months in selected patients to reduce risk of bleeding (Section 11.1, “DAPT Strategies in the First 12 Months Postdischarge”). 

做完 PCI 1-4 周之後. 若患者已經在使用完全劑量的抗凝血劑合併 P2Y12抑制劑. 可考慮停用 aspirin

若患者到院後發現無法使用aspirin. 則應儘早使用完整初始劑量的 P2Y12抑制劑.

Aspirin discontinuation after 1 to 4 weeks after PCI is also appropriate for patients on a full-dose anticoagulant in combination with continued use of a P2Y12 inhibitor (Section 11.1.1, “Antiplatelet Therapy in Patients on Anticoagulation Postdischarge”). 

對於aspirin敏感的患者. 建議aspirin去敏治療(在院內有監視的狀況下, 每隔幾小時至幾天. 給予少劑量 aspirin. 以使用雙重抗血小板治療. 

For patients in whom a history of aspirin hypersensitivity is reported, aspirin desensitization is preferred whenever possible to allow for initial use of dual antiplatelet therapy.7–9 The use of a P2Y12 inhibitor is recommended in all patients with ACS regardless of whether they have a history of aspirin hypersensitivity, but should be administered with a loading dose as early as possible for those patients unable to take aspirin at presentation.

Table 7. Dosing Considerations for Oral Antiplatelet Therapy in Patients With ACS

Agent	Setting	Dosing Considerations
Aspirin	NSTE-ACS or STEMI	Loading dose 162-325 mg orally. Aspirin (nonenteric coated) should be chewed, when possible, to achieve faster onset of antiplatelet action. Loading dose should be administered for patients already on aspirin therapy. Maintenance dose 75-100 mg orally daily (nonenteric coated)
Clopidogrel	NSTE-ACS or STEMI without fibrinolytic	Loading dose 300 or 600 mg orally Maintenance 75 mg orally daily
	STEMI with fibrinolytic	Loading dose 300 mg orally if age ≤75 y; Initial dose 75 mg orally if age >75 y Maintenance 75 mg orally daily
Prasugrel	NSTE-ACS or STEMI without fibrinolytic, and undergoing PCI	Loading dose 60 mg orally Maintenance dose 10 mg orally daily if body weight ≥60 kg and age <75 y Maintenance dose 5 mg orally daily if body weight <60 kg or age ≥75 y (use caution)
Ticagrelor	NSTE-ACS or STEMI without fibrinolytic	Loading dose 180 mg orally Maintenance dose 90 mg orally twice daily

4.3.2. Oral P2Y12 Inhibitors During Hospitalization

STEMI患者如果沒做PCI而是使用血栓溶解劑. 仍建議給予 plavix. 

Figure 4. Initial Choice of P2Y12 Inhibitor in Patients Not Requiring an Oral Anticoagulant.

Colors correspond to Class of Recommendation in Table 2.

ACS indicates acute coronary syndromes; ASA, aspirin; CABG, coronary artery bypass grafting; NSTE-ACS, non–ST-segment elevation ACS; PCI, percutaneous coronary intervention; and STEMI, ST-segment elevation myocardial infarction.

跳過 4.4 抗凝血劑. 4.5 降血脂藥物

4.6

24小時內給予乙型阻斷劑可減少再次梗塞及心室心律不整機率

4.6. Beta-Blocker Therapy

跳過標準治療最後一項 4.7 .  下面則進入 STEMI 再灌注策略. 

4.7. Renin-Angiotensin-Aldosterone System Inhibitors

感染水痘期間若無明顯症狀仍可施打其他疫苗

2026-05-28 中午

剛剛遇到一個小朋友. 2歲4個月. 五天前發燒. 三天前發現下肢有水泡. 但身體其他部位沒有水泡. 目前沒發燒. 活動力食慾都正常. 經詢問兒科醫師. 建議仍可打其他疫苗.

ACLS 缺血性中風打 rtPA 效益與風險 2015

2026-05-22

重點

tPA風險. 2.8% 發生腦出血(未施打tPA腦出血機率 0.2%), 但死亡率沒增加. 

血管內取栓術並不會增加 tPA 風險

建議若符合 tPA 施打條件. 先打 tPA. 之後再根據CT angiography(血管攝影)找出血栓部位. 再取栓(取栓)

由於 CT angiography 需要時間(3D影像重組比檢查更花時間). 打顯影劑可能造成腎功能急性惡化. 但指引建議. 由於中風取栓有明顯效益. 高於顯影劑造成急性腎衰竭的風險 . 不需要等抽血報告可直接打顯影劑(但應先告知病患/家屬存在急性惡化需急洗腎風險) (一般發生在慢性腎病患者. acute on chronic failure)

應先做 BRAIN CT without contrast 評估是否腦出血. 到院45分鐘內CT判讀完成若符合 tPA 施打適應症.先打 IV tPA. 

參考資料 AHA/ASA Current Treatment Approachesfor Acute Ischemic Stroke  
下面第二項. 即使考慮做血栓移除術. 仍建議使用 tPA 治療

1. Emergency non enhanced CT imaging of the brain is recommended before any specific treatment for acute stroke. 

2. Eligible patients should receive Alteplase intravenous r-tPA even if endovascular treatments are being considered. 

3. Noninvasive intracranial vascular imaging should be obtained as quickly as possible after IV r-tPA. 

4. Patients should receive endovascular therapy with a stent retriever if they meet all the criteria. 

5. To ensure benefit, reperfusion to TICI grade 2b/3 should be achieved as early as possible and within 6 hours of stroke onset. 

參考資料 2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke Regarding Endovascular Treatment. Powers WJ, Derdeyn CP, Biller J, et al. Stroke 2015;46):3020-3035.

If eligible, all acute ischemic stroke patients should receive Alteplase (IV r-tPA).

Inclusion Criteria 

Diagnosis of ischemic stroke causing measurable neurological deficit 

Treatment within 4.5 hours (IV r-tPA between 3 & 4.5 hours is not FDA-approved) Exclusion Criteria 

Current intracranial hemorrhage 

Subarachnoid hemorrhage 

Active internal bleeding 

Recent (within 3 months) intracranial or intraspinal surgery or serious head trauma, presence of intracranial conditions that may increase the risk of bleeding (e.g., some neoplasms, arteriovenous malformations, or aneurysms) 

Bleeding diathesis 

Current severe uncontrolled hypertension 

Additional exclusion criteria Between 3 and 4.5 hours: 

Age >80 years 

Severe stroke (NIHSS > 25) 

History of diabetes and prior stroke 

Taking an oral anticoagulant regardless of INR 

Alteplase (IV r-tPA) within 4.5 hours of stroke onset remains the standard of care for most ischemic stroke patients. 

施打tPA之後. 腦血管前循環大動脈阻塞. 考慮血管內取栓術. 最好使用支架取栓器 stent retriever. 

After the patient is administered Alteplase (IV r-tPA), and the cause is deemed to be occlusion of a large cerebral artery in the anterior circulation, considered endovascular therapy, best accomplished with a stent retriever. 

Criteria for Endovascular Therapy: 

Within 6 hours of stroke onset 

Pre-stroke modified Rankin Score (mRs0-1) 

Acute ischemic stroke receiving Alteplase (IV r-tPA) within 4.5 hours of onset according to guidelines from professional medical societies (prior administration of r-tPA is not required) 

內頸動脈或中大腦動脈第一段 M1 阻塞引起的中風

Causative occlusion of the internal carotid artery or proximal Middle Cerebral Artery (M1) 

Age 18 years or older 

National Institutes of Health Stroke Scale (NIHSS) score of ≥6 

Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of ≥6 

Treatment can be initiated (groin puncture) within 6 hours of symptom onset.

施打tPA效益

預後較佳(43% vs 未施打tPA 32%)

能回復到日常生活 53% (未施打32%)

一年後無中風後遺症或很輕微後遺症 39% (未施打tPA第三個月26%)

3-4.5小時施打 tPA

90天無殘障(或輕微殘障) 52.4% (未施打 45.2%)

tPA及血管內取栓術風險

tPA風險

2.8%腦出血(未打tPA 0.2%)

死亡率未增加

Risks Of Alteplase (IV r-tPA) 

Bleeding: 2.8% (vs. 0.2% without r-tPA) intracerebral bleeding in patients treated in the 3-4.5 hour window (ECASS III Study) 

Mortality: No increase from placebo groups 

取栓術風險

主要是取栓過程可能發生血管破裂

Risks of Endovascular Treatment with Stent Retriever at 0-6 Hours: 

The major risk is intracranial hemorrhage due to: vessel perforation (ripping the blood vessel) or stent retriever device perforating a vessel while attempting to remove the blood clot from the artery. 

Systemic bleeding 

Bleeding at the site of catheter introduction 

Catheter infection 

Death

90天無殘障或輕微殘障比例; 血管內取栓術 47%. 未取栓 28%

取栓術能增加20%良好預後

modified Rankin score 

0分代表無殘障

2分代表輕微殘障

Massive Hemorrhage 止血 節錄自 2026 TCCC 指引

2026-05-21

2026 TCCC指引--01 May 2026

TCCC guideline 有幾個大標題. 下面僅節錄各大標題中出血相關建議

Basic Management Plan for Care Under Fire/Threat

Basic Management Plan for Tactical Field Care-

Principles of Tactical Evacuation Care (TACEVAC)

Basic Management Plan for Tactical Evacuation Care

下面節錄各大標題關於出血部分

Basic Management Plan for Care Under Fire/Threat

-共有七點建議. 僅節錄第六點(第六點下又有三項建議)

-第六點. 在戰術情況許可時. 停止危及生命的外出血

a. 由傷員自行止血

b. 使用 CoTCCC建議的肢體止血帶. 商用止血帶較能符合人體解剖構造

c. 由制服外. 將受傷部位近心端打上止血帶. 若無法確認出血部位. 盡量靠軀幹方向打止血帶. 越接近越好(越高越高).並將傷員轉移到遮蔽處

6. Stop life-threatening external hemorrhage if tactically feasible: 

a. Direct casualty to control hemorrhage by self-aid if able. 

b. Use a CoTCCC-recommended limb tourniquet for hemorrhage that is anatomically amenable to tourniquet use. 

c. Apply the limb tourniquet over the uniform clearly proximal to the bleeding site(s). If the site of the life-threatening bleeding is not readily apparent, place the tourniquet “high and tight” (as proximal as possible) on the injured limb and move the casualty to cover.

Basic Management Plan for Tactical Field Care
-之下有20點. 節錄第3點. 第6點. 

1. Establish a security perimeter in accordance with unit tactical standard operating

procedures and/or battle drills. Maintain tactical situational awareness.

2. Triage casualties as required. See Triage Recommendations in Supplement A – Triage in

TCCC.

3. Massive Hemorrhage 大出血

4. Airway Management

5. Respiration/Breathing

6. Circulation 循環

7. Hypothermia Prevention

8. Traumatic Brain Injury:

9. Penetrating Eye Trauma

10. Monitoring

11. Analgesia

12. Antibiotics

13. Inspect and dress known wounds

14. Check for additional wounds.

15. Burns.

16. Splint fractures and re-check pulses.

17. Cardiopulmonary resuscitation (CPR).

18. Communication

19. Documentation of Care.

20. Prepare for Evacuation

3. 大出血 Massive hemorrhage (包含a.b.c.d.四點)
Massive hemorrhage a. 

評估是否有未識別的出血，並控制所有出血點。如果尚未進行，請使用 CoTCCC 建議的肢體止血帶控制解剖結構上適合使用止血帶的危及生命的外部出血，或用於任何創傷性截肢。直接將止血帶綁在出血部位上方 2-3 英吋的皮膚上。如果第一個止血帶未能控制出血，則在第一個止血帶旁邊並排綁上第二個止血帶。

a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not
already done, use a CoTCCC-recommended limb tourniquet to control lifethreatening external hemorrhage that is anatomically amenable to tourniquet use or for any traumatic amputation. Apply directly to the skin 2-3 inches above the bleeing site. If bleeding is not controlled with the first tourniquet, apply a second tourniquet side-by-side with the first.

Massive hemorrhage b.

對於無法使用肢體止血帶或作為止血帶移除輔助手段的可壓迫性（外部）出血，首選的戰術戰鬥傷亡救護（CoTCCC）止血敷料是戰鬥紗布。 

For compressible (external) hemorrhage not amenable to limb tourniquet use or as an adjunct to tourniquet removal, use Combat Gauze as the CoTCCC hemostatic dressing of choice.

1. 其他止血輔助用品：
 Celox 紗布或
 Chito 紗布或
 XStat（最適用於深部、狹窄的交界處傷口）
 iTClamp（可單獨使用，也可與止血敷料或 XStat 聯合使用）
• 止血敷料應至少直接按壓 3 分鐘（XStat 可選擇按壓）。每種敷料的作用機制不同，因此如果一種敷料無法止血，可以將其移除，並更換相同類型或不同類型的敷料。 （注意：XStat 不得在現場移除，但可以在其上覆蓋額外的 XStat、其他止血輔助用品或創傷敷料。）

Hemostatic dressings should be applied with at least 3 minutes of direct pressure (optional for XStat). Each dressing works differently, so if one fails to control bleeding, it may be removed and a fresh dressing of the same type or a different type applied. (Note: XStat is not to be removed in the field, but additional XStat, other hemostatic adjuncts, or trauma dressings may be applied over it.)

• 如果出血部位適合使用交界處止血帶，請立即使用。一旦適合使用，請勿延遲使用交界處止血帶。如果沒有連接止血帶，或在準備使用連接止血帶時，應使用止血敷料進行直接加壓止血。

 If the bleeding site is amenable to use of a junctional tourniquet, immediately apply a junctional tourniquet. Do not delay in the application of the junctional tourniquet once it is ready for use. Apply hemostatic dressings with direct pressure if a junctional tourniquet is not available or while the junctional tourniquet is being readied for use.

Massive hemorrhage c.

對於頭部和頸部外部出血，如果傷口邊緣容易重新對合，則可使用iTClamp作為控制出血的首選方法。如有必要，在應用iTClamp之前，應使用止血敷料或XStat填塞傷口。 

** 但頸部及胸腔不建議使用填塞止血, 這裡的填塞應該不是直接用紗布將傷口塞到止血. 而是在傷口內稍微填充止血敷料. 再用 iTClamp夾住外皮. 與腹股溝大出血的填塞止血不同

1. iTClamp 單獨使用或與其他止血輔助手段合併使用時，均無須額外施加直接壓力。 

** 可將 iTClamp 想像成手術縫合線. 我縫合傷口時. 會先用紗布加壓順便吸走血水. 紗布放開瞬間趕緊看清楚傷口狀況. 傷口常常不是直線. 有時候需先用手指將兩側表皮拉靠近. 將兩側皮膚左右上下挪移. 傷口兩側皮膚先推到正常解剖位置才下針. 避免下針後出現傷口兩側不對齊的狀況. 在縫合針刺入皮膚的時候. 不會在傷口加壓. 這句話應該是這個意思. 

2. 如果將 iTClamp 用在頸部，應頻繁監測氣道，並評估血腫擴大程度是否會壓迫呼吸道。如果發現血腫擴大，應考慮建立確定性氣道。 

** 在ACLS說的 definitive airway 是指將管子插入氣管內. 並將管子末端氣囊打飽. 一般都是指氣管內管. 不過氣管內管本來就有不同種類(例如雙腔氣管內管). 所以 laryngeal mask airway 或者 iGel 這些不算是 definitive airway. 若傷患需要空運. 應以蒸餾水取代空氣打入氣管內管氣囊. 避免空中低壓造成氣囊過度膨脹損傷氣管黏膜. 

3. 請勿將 iTClamp 用於在眼部或眼瞼附近（距眼眶 1 公分以內）。

For external hemorrhage of the head and neck where the wound edges can be easily re-approximated, the iTClamp may be used as a primary option for hemorrhage control. Wounds should be packed with a hemostatic dressing or XStat, if appropriate, prior to iTClamp application. 

1. The iTClamp does not require additional direct pressure, either when used alone or in combination with other hemostatic adjuncts. 

2. If the iTClamp is applied to the neck, perform frequent airway monitoring and evaluate for an expanding hematoma that may compromise the airway Consider placing a definitive airway if there is evidence of an expanding hematoma. 

3. DO NOT APPLY on or near the eye or eyelid (within 1cm of the orbit)

Massive hemorrhage d. 

進行出血性休克的初步評估（頭部無外傷的情況下出現意識狀態改變和/或橈動脈搏動微弱或消失），並考慮立即啟動休克復甦措施。

Perform initial assessment for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse) and consider immediate initiation of shock resuscitation efforts.

Basic Management Plan for Tactical Field Care

6. Circulation 第六點之下又有 6 個次標題. 僅節錄 a. bleeding 這段. 

    a. bleeding

    b. Assess for hemorrhagic shock (altered mental status in the absence of brain             injury and/or weak or absent radial pulse). 

    c. IV/IO Access

    d. Tranexamic Acid (TXA)

    e. Fluid Resuscitation

    f. Refractory Shock

a. Bleeding (bleeding 之下又分成四點)

若懷疑骨盆骨折. 需使用骨盆固定帶
6. Circulation a. Bleeding 1.下列狀況應懷疑骨盆骨折. 需使用骨盆固定帶

1. 嚴重鈍力或爆炸傷，並伴隨以下一項或多項指徵： 骨盆疼痛  任何嚴重的下肢截肢或接近截肢  身體檢查結果提示骨盆骨折  意識喪失  休克 

A pelvic binder should be applied for cases of suspected pelvic fracture: 

1. Severe blunt force or blast injury with one or more of the following indications:  Pelvic pain  Any major lower limb amputation or near amputation  Physical exam findings suggestive of a pelvic fracture  Unconsciousness  Shock 

6. Circulation a. Bleeding 2. 重新評估先前的止血帶使用情況。

暴露傷口，確定是否需要止血帶。如有需要，將先前綁在制服外的肢體止血帶重新定位，方法是在出血點上方 2-3 英吋處直接綁上第二個止血帶，然後鬆開第一個止血帶。確保出血已止住。如果沒有創傷性截肢，應檢查遠端脈搏。如果出血持續或遠端脈搏仍然存在，則考慮進一步收緊止血帶，或與第一個止血帶並排使用第二個止血帶，以同時止血並消除遠端脈搏。如果重新評估確定先前的止血帶不需要，則移除止血帶，並在 TCCC 傷亡卡上記錄移除時間。

2. Reassess prior tourniquet application. Expose the wound and determine if a tourniquet is needed. If it is needed, reposition any limb tourniquet placed over the uniform by applying a second one directly to the skin 2-3 inches above the bleeding site, then loosening the first tourniquet. Ensure that bleeding is stopped. If there is no traumatic amputation, a distal pulse should be checked. If bleeding persists or a distal pulse is still present, consider additional tightening of the tourniquet or the use of a second tourniquet sideby-side with the first to eliminate both bleeding and the distal pulse. If the reassessment determines that the prior tourniquet was not needed, then remove the tourniquet and note time of removal on the TCCC Casualty Card.

6. Circulation a. Bleeding 3. 若符合以下三個條件，肢體止血帶和連接處止血帶應盡快更換為止血敷料或加壓敷料：

傷患未處於休克狀態；可以密切監測傷口出血情況；止血帶並非用於控制截肢肢體的出血。如果可以透過其他方法控制出血，應盡一切努力在2小時內更換止血帶。除非有密切監測和實驗室檢測能力，否則不要移除已使用超過6小時的止血帶。

** 若止血帶已經使用超過6小時. 受傷肢體可能已經發生細胞壞死. 貿然移除止血帶. 有可能讓肢體缺氧的血液回流到心臟. 這些缺氧血可能會將壞死組織產生的物質帶到心臟. 例如鉀離子. 可能誘發心律不整造成猝死. 還有一些毒素可能造成其他器官衰竭(例如橫紋肌溶解造成急性腎衰竭)

3. Limb tourniquets and junctional tourniquets should be converted to hemostatic or pressure dressings as soon as possible if three criteria are met: the casualty is not in shock; it is possible to monitor the wound closely for bleeding; and the tourniquet is not being used to control bleeding from an amputated extremity. Every effort should be made to convert tourniquets in less than 2 hours if bleeding can be controlled with other means. Do not remove a tourniquet that has been in place more than 6 hours unless close monitoring and lab capability are available. 

注意：接受過TCCC ASM/CLS訓練的人員，除非得到TCCC CMC/CPP人員或其他高級醫務人員的指示，否則不應在止血帶使用2小時後嘗試更換止血帶。在缺乏醫療監督的情況下，應保持止血帶原位並繼續監測，直到傷者轉入更高等級的醫療機構。

NOTE: TCCC ASM/CLS trained personnel, should not attempt tourniquet conversion beyond 2 hours post-application unless directed by TCCC CMC/CPP personnel or other advanced medical personnel. In the absence of medical oversight, maintain the tourniquet in place and continue monitoring until the casualty reaches a higher level of care. 4. Expose and clearly mark all tourniquets with the time of tourniquet application. Note tourniquets applied and time of application; time of reapplication; time of conversion; and time of removal on the TCCC Casualty Card. Use a permanent marker to mark on the tourniquet and the casualty card.

6. Circulation a. Bleeding 4. 暴露所有止血帶，並清楚標示止血帶的使用時間。在TCCC傷亡卡上記錄止血帶的使用情況和使用時間、再次使用時間、轉換止血方式的時間以及移除止血帶的時間。使用記號筆在止血帶和傷亡卡上進行標記。

Expose and clearly mark all tourniquets with the time of tourniquet application. Note tourniquets applied and time of application; time of reapplication; time of conversion; and time of removal on the TCCC Casualty Card. Use a permanent marker to mark on the tourniquet and the casualty card.

** 搜尋pelvic binder剛好看到這篇由急診醫師Mike Shertz寫的文章 Improvised Pant-leg Pelvic Binder .以長褲製造臨時的骨盆固定帶. 順便貼上 

緩釋型藥物-結構

2026-05-19 09:31am
緩釋型藥物有很多種結構. 有些使用特殊結構.

這些藥錠或膠囊不可切開. 不可打碎. 緩釋結構必須保持藥錠/膠囊完整性. 才有緩釋效果. 

 
使用雷射在藥錠表面打孔(youtube模擬動畫及實際製作過程)

前五個連結是在已經成形的藥錠打動

第六個連結是使用細針將藥物注射入空膠囊. 注射孔就是藥物釋放孔

1. Tablet Laser Drilling, Pharmaceutical 3D Animation
2. Laser Drilling System for Pharmaceutical Tablets | TD-70
3. Laser Drilling Cylindrical Tablets - OROS - Sustain Release - SR
4. High-Speed Laser Drilling Machines for Pharmaceutical Tablets

    這個影片後面的 R&D Pharmaceutical Tabler driller 使用托盤承載藥錠. 使用9個雷射頭. 一次打9個藥錠

5. R&D Pharmaceutical Tabler driller 這個影片是上面第四個連結最後面一段
6. Osmotic Pump Mechanism 動畫 這種製造方法與上面不同. 使用細針將藥物注入膠囊內