2018-10-02
今天張主任講 challangine cases
第一個 case . He ate raw sea food 12 hours before. PH: DM. ESRD. --> hemorrhagic bullae --> vibrio vulnificus
治療. 基本款打四合一. 因為雖然 vibrio 的可能性較高. 但治療不能只壓寶在一種. 要考慮其他菌種.
1. 第三代頭孢素
2. penicillin
3. tetracycline or doxicycline
4. clindamycin 需加入 clindamycin 降低內毒素產生.
更強的抗生素 例如 meropenum or imipenum 需會診感染科. 下肢產生出血性水泡的通常較嚴重. 容易進展至死亡.
uptodate 裡面關於治療的建議是這樣
1. minocycline or doxycycline (100 mg orally twice daily) + cefotaxime (2 g intravenously every eight hours) or ceftriaxone (1 g intravenously daily)
2. cefotaxime + ciprofloxacin
3. 僅使用 FQ 做單一治療(但萬一是別的菌種就GG了).
4. third-generation cephalosporin and a tetracycline
5. third-generation cephalosporin plus minocycline 死亡率 14%
6. ciprofloxacin with or without minocycline 死亡率 14%
7. third-generation cephalosporin alone 死亡率 61%
8. 經過 ceftazidime and minocycline 治療無效改用 tigecycline and cefpirome 也有效果
依照台灣的經驗. 十二小時內進行手術清創能改善存活率. 美國報告說 10% 的病患需要截肢.
Severe infections — Case fatality rates for V. vulnificus septicemia and serious wound infections have been shown to increase with greater delays between onset of illness and initiation of antibiotic treatment [9,18]. Thus, patients with a presumptive diagnosis of V. vulnificus septicemia should be started immediately on antibiotic therapy and managed aggressively in an intensive care unit to minimize the possible consequences of hypotension, septic shock, and the risk of multiorgan system failure.
We favor treatment of patients with septicemia or serious wound infections using combination therapy with either minocycline or doxycycline (100 mg orally twice daily), plus either cefotaxime (2 g intravenously every eight hours) or ceftriaxone (1 g intravenously daily); doses should be appropriately adjusted for underlying renal or hepatic disease. The combination of cefotaxime and ciprofloxacin is also likely effective [45]. Fluoroquinolone monotherapy (ie, levofloxacin 750 mg orally or intravenously once daily) is another alternative.
In high-risk patients, more serious wound infections may require aggressive debridement in addition to parenteral antibiotics. In a series of 121 patients in Taiwan who presented with necrotizing fasciitis, surgery within 12 hours of admission resulted in a significant improvement in survival [46]. Among 423 V. vulnificus wound infections reported in the United States, 10 percent of patients required amputation of some type [9].
Clinical data supporting the above antibiotic regimen include a retrospective study involving 93 patients with V. vulnificus septicemia and hemorrhagic bullous cutaneous lesions that suggested combination antibiotic therapy with a third-generation cephalosporin and a tetracycline more effectively reduced mortality than a first- or second-generation cephalosporin plus an aminoglycoside (odds ratio 0.04; 95% CI 0.01-0.19) [43]. Similarly, in a retrospective study of 89 patients with histologically and microbiologically confirmed V. vulnificus necrotizing fasciitis who underwent prompt surgical debridement, those treated with either a third-generation cephalosporin plus minocycline, or ciprofloxacin with or without minocycline had lower mortality rates than those who received a third-generation cephalosporin alone (14, 14, and 61 percent, respectively) . In one case report, the combination of tigecycline and cefpirome was reported to be efficacious as "salvage" therapy in a child with V. vulnificus necrotizing fasciitis who was not responding well clinically to ceftazidime and minocycline [48].
In vitro and in vivo studies in mice have demonstrated an apparent synergism between cefotaxime and minocycline in the treatment of serious V. vulnificus infections [49]. Subsequent mouse studies showed comparable survival with fluoroquinolones [50] and supported the combination of ciprofloxacin and cefotaxime.
https://globalnews.ca/news/4418946/flesh-eating-bacteria-seafood/
necrotizing fasciitis 分四類
DM 病患的 KP (Klebsiella pneumoniae)necrotizing fasciitis 通常是 Fournier gangrene. 比較少在四肢.
第一類是免疫功能不良的患者. 腹部手術或肛門旁膿瘍. 混合菌種. 預後通常較好.
第二類是嗜肉菌 Group A Strep. S. aureus 等等. 侵犯皮膚或喉嚨. 傷口感染. 早期容易誤診. 病情進展迅速.
第三類是海洋相關的菌種. 吃入細菌汙染的食物也會. 通常是肝硬化病患. 淡水的 aeromonas 感染. 這兩種菌種感染死亡率高.
第四類是黴菌感染.
壞死性筋膜炎有個診斷的方式. 叫做 finger test. 在局部麻醉之後用刀切開患處皮膚 2-3 公分. 使用手指探查. 壞死性筋膜炎的軟組織不太會流血. 會流出黑色血水(類似水溝水). 組織因壞死. 使用手指能輕易剝離.
第二個case. pneumonia 年輕人. 打抗生素三天後全身性黏膜發炎 mucositis. 診斷~ mycoplasma infection. 包括尿道. 口腔. 眼睛. 耳膜都可能中獎.
第三個case 是 泡疹性指頭炎 herpetic whitlow. 告誡所有醫護人員要戴手套接觸患者. 你無法知道病患有沒有攜帶皰疹病毒.
第四個case 是 62 y M. 4 days after puncture wound. 主任教的記憶方法: 腫脹的香腸. Pyogenic Flexor Tenosynovitis
美國骨科學會建議的手術時機: https://www.amjorthopedics.com/article/5-points-pyogenic-flexor-tenosynovitis-hand
受傷 48 小時內開始治療. 不一定要手術. 治療方式是給予靜脈注射抗生素. 夾板固定. 抬高. 但需要經常檢視患處. 通常治療 48 小時內會改善. 所以如果治療超過 48 小時沒改善. 可能需要手術青創. 多數病例仍需手術治療(因為到院時間通常較晚). 開刀是為了將腱鞘引流及清洗. 依照手術的發現做分級. 第一二級可以做小切開. 第三級需整個切開清創.
第一級. 流出清湯
第二級. 流膿
第三級. septic necrosis of tendon. pulleys. or tendon sheath.
3. WHAT ARE THE TIMING AND INDICATIONS FOR SURGERY?
Nonoperative treatment may be appropriate for PFT patients who present early, typically within 48 hours after penetrating trauma to the hand.21 In a 4-patient series, Neviaser and Gunther19 successfully treated PFT nonoperatively, with IV antibiotics, splinting, and elevation. During nonoperative treatment, the affected hand should be regularly examined. If this treatment is to be successful, clinical symptoms should improve within 48 hours; if they do not, surgical irrigation and débridement should be performed.
Regardless of timing and type of irrigation, surgical treatment remains the treatment of choice for the majority of PFT cases. Michon22 developed a 3-tier PFT classification system that is based on intraoperative findings (Table).
According to Michon22, stage 1 and stage 2 PFT can be treated with limited incision and with drainage and irrigation of the sheath, and stage 3 PFT should be treated with extensile open débridement.
Pyogenic Flexor Tenosynovitis 感染源. S aureus 佔 40-75%. MRSA 佔 29% (通常是靜脈毒癮者).
第五個CASE是加油槍/油漆槍高壓注入的傷害. 一開始傷口可能很小. 過幾天會廣泛壞死.
high pressure injection injury. 如果注射入傷口的是有機溶劑. 有 50% 機會需截肢.
治療: 第三代頭孢素. 破傷風疫苗. 廣泛清創. 減壓. 通常需要在 6-10 小時內清創
第六個case. 5y boy. sudden onset cough wheezing. no fever.
一開始的X光如果沒有特殊異常. 再來可以做 吸氣. 吐氣. x 光.
第七個case. 眼睛被壘球打到. 眼珠無法往上轉. blow out fracture. 眼框內壁和下壁是比較薄弱的部分. 可以先照 Water's view. 找 teardrop sign.
https://aapos.org/terms/conditions/28
第八個 case. 43 Y F. seizure.
PHx: HTN, s/p thyroid surgery 15 years ago
brain CT 發現小腦鈣化.
Brain CT scan in a 14 years old thalassemic girl with hypoparathyroidism shows extensive intracranial calcification
心電圖檢查發現 QTc prolong.
http://www.studypk.com/articles/nursing-ecg-cardiology-study-cards-electrolyte-abnormalities/
第九個case. new born seizure.
CXR
縱膈腔. 在小兒通常是寬的. 因為有胸腺. 但 DiGeorge syndrome 無胸腺.
The 22q11.2 deletion syndrome, also known as the DiGeorge syndrome or velocardiofacial syndrome, is a syndrome where a small portion of the chromosome 22 is lost and results in a variable but a recognisable pattern of physical and behavioural features. 因染色體於22q11區域發生基因缺失(microdeletion)異常，導致 患者有臉型上的異常，患者有心臟方面的多重異常，亦可能有顎裂、聽力異常、副甲狀腺低下、胸腺發育的異常、學習障礙、生長遲緩或智能障礙等異常。多屬自發性突變(de novo mutation)為主，僅有極少數為雙親有染色體變異導致。
第十個. 綠色尿.
urine after surgery for SMA occlusion.
應該是 indocyanine green fluorescence 吧.
第二種是 住 ICU 病患打了很多 propofol 之後
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