野外與登山醫學-AMS/HACE/HAPE 發生率(急性高山病/高海拔腦水腫/高海拔肺水腫)

2023-08-09 重貼
acute mountain sickness 急性高山病 AMS
high altitude cerebral edema 高海拔腦水腫 HACE

2001年 NEJM High altitude illness
這段寫的是AMS發生時間, 如果在同樣海拔三天後才出現的症狀, 且與典型 HACE 症狀沒有吻合, 例如缺乏頭痛症狀. 補充水分或休息能快速改善. 或治療(下降.氧氣.類固醇)之後症狀沒有緩解等等. 可能要想想是否罹患其他疾病
Many conditions mimic acute mountain sickness and high-altitude cerebral edema. The onset of symptoms more than three days after arrival at a given altitude, the absence of headache, a rapid response to fluids or rest, and the absence of a response to descent, oxygen, or dexamethasone all suggest other diagnoses. Table 1 lists conditions sometimes confused with acute mountain sickness and high-altitude cerebral edema.

2020-05-03 編輯
STATPEARLS 在 2019-12-17 有一篇高海拔肺水腫 HAPE 研究提到HAPE的發生率, 文中數字部分沒有另外標明引用的出處, 不過與我底下以前念過的文章有相同的數值, 應該是引用同一篇研究.
海拔 4500 公尺, 發生率 0.6%~6%
海拔 5500 公尺, 發生率 2%~15%, 上升速率快, 發生率高
HAPE復發率 60%
改善體適能無法降低 HAPE 發生率
HAPE 治療後死亡率 11%, 未治療死亡率 50%
HAPE 患者有 50% 同時罹患急性高山病 AMS
HAPE 患者有 14% 同時罹患高海拔腦水腫 HACE

Epidemiology
The severity of HAPE will depend on multiple factors including altitude, initial recognition and management, and access to medical care. At 4500 meters the incidence is 0.6% to 6%, and at 5500 meters the incidence is 2% to 15%, with faster ascent time correlating to a higher incidence. Those with a prior incidence of HAPE have a recurrence rate as high as a 60%. One’s level of fitness is not proven to be a protective factor. Mortality rate, when treated, can be as high as 11% and as high as 50% when untreated. Up to 50% of cases may have concomitant acute mountain sickness (AMS), and up to 14% will have concomitant high altitude cerebral edema (HACE).

要注意的是, 隨著絕對海拔與上升速率, 高海拔疾病的盛行率會有很大差異.

兒童在台灣玉山的AMS 發生率 incidence 59%
https://www.ncbi.nlm.nih.gov/pubmed/26782126

2013NEJM
AMS 通常在上升到海拔2500公尺以上, 6-12小時之後發生。海拔越高，嚴重度及盛行率越高。沒有做高度適應的人，海拔2500公尺發生率 10-25%, 但症狀通常輕微，在海拔4500-5500公尺發生率50-85%. 且可能病倒。
https://blog.xuite.net/ymmcc/twblog/313336038

尼泊爾地區 4243至5500 公尺的健行者 HACE 發生率約 1%.

在海拔 4555 公尺的西藏, 5355名遊客中, HACE 發生率 0.5%.

已經罹患HAPE的患者. 發生HACE的機率更高.

https://blog.xuite.net/ymmcc/twblog/544392635

2017年HAPE這篇的數據: HAPE嚴重度決定於多項因素, 包括海拔, 初步認知, 處置, 尋求醫療協助, 在海拔 4500 公尺的發生率 0.6%-6%, 在海拔 5500 公尺的發生率高達 60%. 個人體能無法避免HAPE發生. (level of fitness.) 經過治療的死亡率 11%, 未治療死亡率 50%, 大約 50% HAPE患者會同時罹患AMS,. 14% 同時罹患HACE.
https://blog.xuite.net/ymmcc/twblog/580965889

西藏機場海拔 3600 公尺. AMS 57.2% ; HAPE 1.9%; HACE 0% 無

http://blog.xuite.net/ymmcc/twblog/544343502

藥物這篇剛好有提到發生率. 海拔 4500 公尺的HAPE發生率 0.6%-6%,
海拔 5500 公尺的HAPE 發生率高達 60%.
HAPE 高海拔肺水腫發生率 0.01-15% (在同樣海拔上升速率, 比 HACE 高). 通常在到達高海拔之後 2-4 天發作.
HACE 高海拔腦水腫 發生率 1-2%. 通常會合併嚴重AMS 或 HAPE.
https://blog.xuite.net/ymmcc/twblog/114386741

參考資料~

2016年台灣醫師發表在旅遊醫學雜誌的文章 Incidence and risk factors associated with acute mountain sickness in children trekking on Jade Mountain, Taiwan.

Chan CW1, Lin YC2, Chiu YH3, Weng YM1, Li WC4, Lin YJ5, Wang SH6, Hsu TY7, Huang KF8, Chiu TF9.
Author information
Abstract
BACKGROUND:
Acute mountain sickness (AMS) is a pathophysiological symptom complex that occurs in high-altitude areas. The incidence of AMS on Jade Mountain, the highest peak in Taiwan (3952 m), has been reported to be ∼36%. There is a lack of data in children trekking at altitude in Taiwan. The purpose of this study was to determine the incidence, risk factors and symptoms of AMS in children trekking on Jade Mountain, Taiwan.

METHODS:
This prospective cohort study included a total of 96 healthy non-acclimatized children aged 11-12 years who trekked from an elevation of 2600-3952 m in 3 days. The Lake Louise AMS score was used to record symptoms associated with AMS.

RESULTS:
AMS were reported in 59% of children trekking on Jade Mountain over a 3 day period. AMS incidence increased significantly with increasing altitude. The most common AMS symptom was headache, followed by fatigue or weakness, difficulty sleeping, dizziness or lightheadedness and gastrointestinal symptoms. Children who had experienced upper respiratory infection (URI) within the 7 days before their trek tended to have a greater risk for development of AMS. AMS incidence did not significantly differ according to gender, recent acute gastroenteritis, menstruation and body mass index.

CONCLUSIONS:
The incidence of AMS in children trekking on Jade Mountain is greater than that observed in adults, and was associated with altitude and recent URI

野外與登山醫學-外傷相關筆記連結整理 (含溺水. 蜂螫.蛇咬.蜈蚣.海洋生物)

2024-11-10 重新整理20:56
體外傷口止血方式(2020-06-30刊登在台灣急診醫學會通訊)

足部摩擦產生的水泡~處置
章魚咬傷處置 Octopus Envenomation Treatment & Management
野外與登山醫學--- 止血帶的使用 2-- from uptodate- Severe upper extremity injury in the adult patient
止血帶的使用 3 ~~ 2014年美國外科醫學會創傷委員會外出血控制指引
止血 Stop the Bleed(Stop The Bleed 是由美國外科學會ACS 的外傷委員會 COT 管理的組織, 隸屬於美國國防部)
傷口處置的無菌技術
外傷處置的氧和原則(這個不適合非醫療人員看)
成人嚴重肢體外傷出血---止血法
手指腳趾甲床及指甲外傷 Fingertip and Nailbed Injuries
傷口到底可不可以碰水？
使用口服抗生素預防傷口感染 (from WMS 2014年.基本傷口處置原則)
貓狗咬傷的緊急處置

2023-08-09 整理一下自己的筆記
傷口癒合與皮膚強度
傷口到底可不可以碰水？
野外與登山醫學-嚴重下肢外傷-止血法
外科-外傷處理組織氧和原則
傷口處置的無菌技術
外出血控制指引-2014年美國外科醫學會創傷委員會
STOP THE BLEED 美國外科學會ACS 的外傷委員會 COT 管理的組織
FAST外傷超音波格式 這是我自己建的版本.內容簡略但是比較省時間.
凍傷/凍瘡 的治療 Treatment of frostbite
止血帶的使用
足底摩擦引起的水泡
燒燙傷水泡處置
傷口處置的無菌技術
傷口沖洗可以用優碘嗎?
預防及避免傷口感染
傷口基本處置指引-僅節錄燒燙傷
傷口清洗 傷口處置 傷口清理 傷口清潔 wound management
傷口感染 抗生素選擇
外傷處置使用無菌手套無法降低傷口感染率(用一般檢診手套即可)
WMS---燒燙傷(截錄自傷口處置指引)
(歐洲)創傷後大出血及凝血障礙處置指引第六版重點摘錄-台中慈濟急診科
溺水到院前處置


蛇咬傷考慮停用 ASPIRIN 和 抗凝血劑
治療蛇咬傷應避免的行為
蛇咬傷到院前處置
疾管署-毒蛇咬傷-五要五不
蛇咬傷到底要不要使用彈性繃帶或止血帶
台灣毒蛇咬傷預防及處置-家庭醫學科鄭可醫師-蛇咬傷-毒蛇
2021-05-11 台中榮總毒物科- 台灣常見毒蛇咬傷診斷與治療手冊(毛彥喬主任同意可公開分享)
毒蛇咬傷時的血清注射方法
2017-09-18 毒蛇咬傷新觀念
抗毒蛇血清開放自費使用於動物遭毒蛇咬傷
2021-05-15 蛇咬傷無症狀患者需觀察多久
2017-11-13 蛇咬傷到底要不要使用彈性繃帶或止血帶
2017-09-18 疾管署-毒蛇咬傷-五要五不(這篇剛剛加入2023-03-28 疾管署新聞稿)
2017-09-18 冰敷對於蛇咬傷的影響
2015-12-24 蛇咬傷沒有出現毒性症狀處置
2015-12-24 蛇咬傷使用加壓固定的條件
2012-07-18 毒蛇咬傷時的血清注射方法
衛生福利部疾病管制署供應抗蛇毒血清予
獸醫師可申請之 抗蛇毒血清產品為「抗雨傘節及飯匙倩蛇毒血清凍晶注射劑」、「抗龜 殼花及赤尾鮐蛇毒血清凍晶注射劑」、「抗百步蛇毒血清凍晶注射劑」 及「抗鎖鏈蛇毒血清凍晶注射劑」。


戶外作業虎頭蜂攻擊預防手冊 104年勞動部出版
虎頭蜂蜂螫 賴育民醫師

恙蟲病 SCRUB TYPHUS 診斷

蜈蚣咬傷 Centipedes bite




海洋生物螫咬
章魚咬傷處置
海洋生物毒性反應處置
水母 珊瑚蟲 螫傷cnidaria coelenterates jellyfish sea anemons stings


下面是貼在xuite隨意窩的文章連結. 之後可能失效.
2021-05-15 蛇咬傷無症狀患者需觀察多久
2017-11-13 蛇咬傷到底要不要使用彈性繃帶或止血帶
2017-09-18 疾管署-毒蛇咬傷-五要五不(這篇剛剛加入2023-03-28 疾管署新聞稿)
2017-09-18 冰敷對於蛇咬傷的影響
2016-06-25 蛇咬傷 到院前處置
2015-12-24 蛇咬傷沒有出現毒性症狀處置
2015-12-24 治療蛇咬傷應避免的行為
2015-12-24 蛇咬傷使用加壓固定的條件
2015-12-24 蛇咬傷考慮停用 ASPIRIN 和 抗凝血劑
2012-07-18 毒蛇咬傷時的血清注射方法


高級外傷救命術第九版 氣管內管壓力 兒童氣管內管的壓力 維持 30mmHg 以下.

傷口到底可不可以碰水？

以前看教科書. 記得是手術傷口是 24小時之後可以洗澡. 但UPTODATE上面說. 目前並無明確建議

手術後的切口
手術後的傷口通常會放上乾敷料(乾紗), 以膠帶固定, 維持傷口乾燥. 敷料可在48小時內移除
手術後何時可洗澡, 並無明確界定
Postoperative surgical incision – Postoperative surgical incisions (clean, clean-contaminated) are typically covered with a dry dressing that is held in place with an adhesive (eg, tape, Tegaderm). The initial postoperative dressing can be removed within 48 hours, provided the wound has remained dry. The timing with which the patient can resume bathing/showering is not well defined [175,176].

175 Early versus delayed post-operative bathing or showering to prevent wound complications.
176 Postoperative Showering for Clean and Clean-contaminated Wounds: A Prospective, Randomized Controlled Trial.

台灣整形外科醫學會 2019/10/02 醫療新知 有一篇文章. 下面有連結.
傷口到底可不可以碰水？徐矢達（欣藝整形外科診所院長）

高雄醫學大學附設中和醫院外傷科李維哲主任
外傷後傷口清潔與照護
因此，除非手術或是處理傷口的醫師有特別交代，否則縫合後的傷口，只要外觀看起來乾爽，就可以放心清洗或碰水，只要立即除去多於水分，避免長時間潮濕就好了。保持傷處的清潔，也是防止發炎很重要的一步喔！。




Medline ® Abstracts for References 175,176 of 'Basic principles of wound management'


下面是第一篇參考資料.
175 | PubMed TI Early versus delayed post-operative bathing or showering to prevent wound complications. AU Toon CD, Sinha S, Davidson BR, Gurusamy KS SO Cochrane Database Syst Rev. 2015;
BACKGROUND
Many people undergo surgical operations during their life-time, which result in surgical wounds. After an operation the incision is closed using stiches, staples, steri-strips or an adhesive glue. Usually, towards the end of the surgical procedure and before the patient leaves the operating theatre, the surgeon covers the closed surgical wound using gauze and adhesive tape or an adhesive tape containing a pad (a wound dressing) that covers the surgical wound. There is currently no guidance about when the wound can be made wet by post-operative bathing or showering. Early bathing may encourage early mobilisation of the patient, which is good after most types of operation. Avoiding post-operative bathing or showering for two to three days may result in accumulation of sweat and dirt on the body. Conversely, early washing of the surgical wound may have an adverse effect on healing, for example by irritating or macerating the wound, and disturbing the healing environment.


OBJECTIVES
To compare the benefits (such as potential improvements to quality of life) and harms (potentially increased wound-related morbidity) of early post-operative bathing or showering (i.e. within 48 hours after surgery, the period during which epithelialisation of the wound occurs) compared with delayed post-operative bathing or showering (i.e. no bathing or showering for over 48 hours after surgery) in patients with closed surgical wounds.


SEARCH METHODS
We searched The Cochrane Wounds Group Specialised Register (30th June 2015); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); The Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process&Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; the metaRegister of Controlled Trials (mRCT) and the International Clinical Trials Registry Platform (ICTRP).


SELECTION CRITERIA
We considered all randomised trials conducted in patients who had undergone any surgical procedure and had surgical closure of their wounds, irrespective of the location of the wound and whether or not the wound was dressed. We excluded trials if they included patients with contaminated, dirty or infected wounds and those that included open wounds. We also excluded quasi-randomised trials, cohort studies and case-control studies.

DATA COLLECTION AND ANALYSIS
We extracted data on the characteristics of the patients included in the trials, risk of bias in the trials and outcomes from each trial. For binary outcomes, we calculated the risk ratio (RR) with 95% confidence interval (CI). For continuous variables we planned to calculate the mean difference (MD), or standardised mean difference (SMD) with 95% CI. For count data outcomes, we planned to calculate the rate ratio (RaR) with 95% CI. We used RevMan 5 software for performing these calculations.

MAIN RESULTS
Only one trial was identified for inclusion in this review. This trial was at a high risk of bias. This trial included 857 patients undergoing minor skin excision surgery in the primary care setting. The wounds were sutured after the excision. Patients were randomised to early post-operative bathing (dressing to be removed after 12 hours and normal bathing resumed) (n = 415) or delayed post-operative bathing (dressing to be retained for at least 48 hours before removal and resumption of normal bathing) (n = 442). The only outcome of interest reported in this trial was surgical site infection (SSI). There was no statistically significant difference in the proportion of patients who developed SSIs between the two groups (857 patients; RR 0.96; 95% CI 0.62 to 1.48). The proportions of patients who developed SSIs were 8.5% in the early bathing group and 8.8% in the delayed bathing group.


AUTHORS' CONCLUSIONS
There is currently no conclusive evidence available from randomised trials regarding the benefits or harms of early versus delayed post-operative showering or bathing for the prevention of wound complications, as the confidence intervals around the point estimate are wide, and, therefore, a clinically significant increase or decrease in SSI by early post-operative bathing cannot be ruled out. We recommend running further randomised controlled trials to compare early versus delayed post-operative showering or bathing.

AD Public Health Research Unit, West Sussex County Council, The Grange, County Hall Campus, Tower Street, Chichester, West Sussex, UK, PO19 1QT. PMID 26204454




下面是第二篇參考資料.
176| PubMed TI Postoperative Showering for Clean and Clean-contaminated Wounds: A Prospective, Randomized Controlled Trial. AU Hsieh PY, Chen KY, Chen HY, Sheng WH, Chang CH, Wang CL, Chiag PY, Chen HP, Shiao CW, Lee PC, Tai HC, Chien HF, Yu PJ, Lin BR, Lai YH, Chen JS, Lai HS
SO Ann Surg. 2016 May;263(5):931-6.

OBJECTIVETo evaluate wound infection rates, pain scores, satisfaction with wound care, and wound care costs starting 48 hours after surgery.

BACKGROUNDShowering after surgery is a controversial issue for wound care providers and patients. We investigated the benefits and detriments of showering for postoperative wound care.

METHODSPatients undergoing thyroid, lung, inguinal hernia, and face and extremity surgeries with clean or clean-contaminated wounds were included. The patients were randomized to allow showering (shower group) or to keep the wound dry (nonshower group) for postoperative wound care starting 48 hours after surgery. The primary endpoint was the rate of surgical wound infection. The secondary endpoints included the wound pain score, satisfaction with wound care, and cost of wound care.

RESULTS
Between May 2013 and March 2014, there were 222 patients randomized to the shower group and 222 to the nonshower group. Two patients in each group were lost to follow-up. There were 4 superficial surgical site infections in the shower group and 6 in the nonshower group (4/220, 1.8% vs 6/220, 2.7%, P = 0.751). Postoperative pain scores were comparable between the 2 groups. Patients in the shower group were more satisfied with their method of wound care, and their wound care costs were lower when compared with the nonshower group.

CONCLUSIONS
Clean and clean-contaminated wounds can be safely showered 48 hours after surgery. Postoperative showering does not increase the risk of surgical site complications. It may increase patients' satisfaction and lower the cost of wound care.


AD *Department of Nursing, National Taiwan University College of Medicine, Taipei, Taiwan†Department of Surgery, National Taiwan University College of Medicine, Taipei, Taiwan‡Institute of Statistical Science, Academia Sinica, National Taiwan University College of Medicine, Taipei, Taiwan§Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan¶Department of Medical Research, National Taiwan University College of Medicine, Taipei, Taiwan ||Department of Traumatology, National Taiwan University College of Medicine, Taipei, Taiwan **School of Nursing, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
PMID
26655923

2023-08-09 Dexamethasone dose 不同疾病/狀態劑量選擇 高海拔疾病/氣喘/腦水腫/休克/過敏

2018-06-08 20:10
Dexamethasone dose

高海拔疾病 Altitude Sickness (Off-label) 標示外使用.
預防性使用 Prophylaxis
2 mg PO q6hr or 4 mg PO q12hr beginning on day of ascent; may be discontinued after 2- to 3-day stay at same elevation or initiation of descent
治療性使用 Treatment
急性高山病 Acute mountain sickness (AMS): 4 mg PO/IV/IM q6hr
高海拔腦水腫 High-altitude cerebral edema (HACE): 8 mg once followed by 4 mg PO/IV/IM q6hr until symptoms resolve


氣喘發作的類固醇

嚴重病患，給予 methylprednisolone 125 mg iv stat. 或者給予 dexamethasone 10mg iv stat. 給完可能要 6-12 小時才會出現作用。


Cerebral Edema 腦水腫劑量.
10 mg IV, then 4 mg IM q6hr until clinical improvement is observed; may be reduced after 2-4 days and gradually discontinued over 5-7 days

Shock 休克劑量
1-6 mg/kg IV once or 40 mg IV q2-6hr PRN
Alternative: 20 mg IV, then 3 mg/kg/day by continuous IV infusion
High-dose treatment not to be continued beyond 48-72 hours

Allergic Conditions 過敏
For control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment in asthma, atopic dermatitis, contact dermatitis, drug hypersensitivity reactions, perennial or seasonal allergic rhinitis, and serum sickness

Day 1: 4-8 mg IM 第一天可以給 4-8 mg IM.
Days 2-3: 3 mg/day PO divided q12hr
Day 4: 1.5 mg/day PO divided q12hr
Days 5-6: 0.75 mg/day PO in single daily dose 

7: No treatmen

201810021103 晨會筆記 challangine clinical cases

2023-08-09 重貼.

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