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
2025年7月23日 星期三
野外與登山醫學－止血帶的使用 5 Hartford-consensus-compendium 哈特福共識會議概要
2025-07-24 10:31AM
Hartford-consensus-compendium:
Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events: A Compendium
民間止血帶
戰場和民間創傷的致傷劑(wounding agents)通常不同，但在出血控制和最佳復甦方面的經驗教訓相同。最近，美國外科醫師學會創傷委員會和美國運輸部工作小組評估了外部出血控制措施的證據。 此工作小組關於止血帶的結論是：
推薦建議無論是專業的急救人員或平民，訓練有素、裝備精良的人員都可以輕鬆控制外部出血。止血帶和止血敷料應該能夠減少平民領域因外部出血造成的可預防死亡，就像它們在軍隊中所扮演的角色一樣。使用商用設備進行早期有效止血的建議非常重要，並且與美國創傷外科醫師學會委員會 (CoTCCC)、美國軍方、美國外科醫師學會創傷委員會、美國急診醫師學會、美國國家緊急醫療技術人員協會和哈特福德共識 III 的建議類似。早期止血的經驗教訓已在殘酷的戰爭中累積並應用。在平民受傷後廣泛應用止血帶和止血敷料進行止血將挽救生命。
Tourniquets in the civilian setting
The wounding agents are usually different in battlefield and civilian trauma, but the lessons learned regarding hemorrhage control and optimal resuscitation are not. Recently, the American College of Surgeons Committee on Trauma and the U.S. Department of Transportation working group evaluated the evidence for external hemorrhage control measures.2 The group’s conclusions on tourniquets were that: (1) commercial windlass-type tourniquets should be used in the prehospital setting for the control of significant extremity hemorrhage when direct pressure is ineffective or impractical, (2) improvised tourniquets should be used only if no commercial device is available, and (3) a tourniquet that has been properly applied in the prehospital setting should not be released until the patient has reached definitive care. The recommendations on hemostatic agents were that: (1) topical hemostatic agents should be used in combination with direct pressure for the control of significant hemorrhage in the prehospital setting when sustained direct pressure is ineffective or impractical, and (2) topical hemostatic agents in a gauze can be used to enhance wound packing.
•There is pulsatile or steady bleeding from the wound.
•Blood is pooling on the ground.
•The overlying clothes are soaked with blood.
•Bandages or makeshift bandages used to cover the wound are ineffective and steadily becoming soaked with blood.
•There is a traumatic amputation of the arm or leg
•There was prior bleeding, and the patient is now in shock (unconscious, confused, pale).
When treating an individual who is in obvious shock from bleeding wounds, hemorrhage control should be the first priority, before fluid resuscitation. Effective hemorrhage control does not stop with the initial tourniquet application. The military experience with tourniquets has provided some key teaching points about their use:
•Waiting too long to place a tourniquet is a mistake.
•Tourniquets should be applied just proximal to the site of the severe bleeding and never placed directly over a joint.
•Tourniquets should be tightened as necessary to stop bleeding from the distal injury.
•If bleeding is not controlled with one tourniquet, a second tourniquet should be applied just proximal to the first.
•The need for a second tourniquet is especially applicable when applying tourniquets to generously sized lower extremities.
•The purpose of tourniquets is to stop arterial bleeding. If a distal pulse is still present, the tourniquet should be tightened or a second tourniquet applied just proximal to the first, and the pulse should be checked again.
•If a tourniquet is used, it should be an effective arterial tourniquet and not an ineffective venous tourniquet, as use of the latter can increase bleeding.
•Casualties with tourniquets in place should be rechecked periodically to ensure that the tourniquet is still working and that hemorrhage is controlled.
•Pulses distal to every tourniquet should be checked.
•Correctly applied tourniquets can cause significant pain, but this pain does not signify that the tourniquet has been applied incorrectly or that it should be removed.
•Pain should be managed with analgesics as appropriate, but not for patients in shock. Mistakes regarding tourniquets include the following: •Not having an effective commercial tourniquet available
•Not using a tourniquet when one should be used
•Using a tourniquet for minimal or minor bleeding when one should not be used
•Putting the tourniquet on too proximally
•Not making the tourniquet tight enough to effectively stop the bleeding •Not using a second tourniquet if needed •Waiting too long to put the tourniquet on
•Not reevaluating the tourniquet’s effectiveness
•Periodically loosening the tourniquet to allow blood flow into the injured extremity
The time when a tourniquet is applied should always be noted on the individual’s body, customarily by writing the letter T on the person’s forehead, along with the time that it was tightened. This notation should be done with an indelible ink marker to ensure that this important information does not wash or wipe off. The information should also be recorded on the individual’s run sheet and total tourniquet ischemia time recorded in the hospital chart. Finally, all manufactured tourniquets are designed for a single use. A separate group of tourniquets should be used for training, and training tourniquets should not subsequently be issued for actual casualty use.
Hartford-consensus-compendium:
Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events: A Compendium
這篇共識指引幾乎算一本電子書了. 有92頁. 扣去沒內容的(目錄.專家名單.封面.大標題內頁)還有80頁, 看到頁數就不想念了...
這是美國外科醫學會共識會議的建議. 僅節錄部分內容. 下面中文使用google翻譯. 刪除線的中文字是google翻譯但我覺得不適當而修改的.
這是美國外科醫學會共識會議的建議. 僅節錄部分內容. 下面中文使用google翻譯. 刪除線的中文字是google翻譯但我覺得不適當而修改的.
過去14年的戰爭中我們得到的最重要的教訓之一就是，受傷後儘快使用止血帶和止血敷料絕對是可以挽救生命的。
民間止血帶
戰場和民間創傷的致傷劑(wounding agents)通常不同，但在出血控制和最佳復甦方面的經驗教訓相同。最近，美國外科醫師學會創傷委員會和美國運輸部工作小組評估了外部出血控制措施的證據。 此工作小組關於止血帶的結論是：
(1) 在院前環境中，當直接按壓無效或不切實際時，應使用商用絞盤式止血帶來控制大量肢體出血；
(2) 僅在沒有商用設備可用時才應使用簡易止血帶；
(3) 在院前環境中正確使用的血帶應在患者獲得確定性護理 確切照護(definitive care)之前不要鬆開。
(以前教學說30分鐘鬆開止血帶一下, 目前不建議間隔性鬆開止血帶)
關於止血劑的建議是：
（1）當持續直接加壓無效或不切實際時，應將局部止血劑與直接加壓結合使用，以控制院前環境中的大量出血；
（2）可使用紗布中的局部止血劑來加強傷口填塞。
用止血帶控制出血
自1975年越戰結束至2001年這26年間，院前出血控制幾乎沒有變化。因此，可預防的肢體出血死亡人數在近三十年中也未見變化。在戰術戰鬥傷亡救治委員會（CoTCCC）的止血帶建議廣泛實施後，對4,596名美國戰鬥死亡病例進行的10年回顧顯示，肢體出血導致的戰鬥死亡人數顯著下降。 3 肢體出血死亡人數的急劇下降，得益於現代止血帶和止血敷料在戰場上的廣泛使用，以及對各級急救人員進行有效使用這些敷料的積極訓練。 如前所述，早期使用止血帶可以很大程度上預防肢體出血導致的死亡。由於止血帶可有效控制出血且使用速度快，因此是在戰火紛飛的戰術環境中暫時控制危及生命的肢體出血的最佳選擇。這個概念也適用於平民領域，因為平民傷亡或槍擊事件日益增加。這些概念尤其適用於我國本土發生的恐怖分子爆炸事件。直接加壓和紗布加壓敷料可能有效；然而，缺乏專人進行持續的直接加壓、環境不安全以及可能導致失血的肢體損傷都是快速使用止血帶的指徵適應症(indications)。在常規緊急醫療服務 (EMS,或翻譯為緊急醫療系統) 護理中，對於大量外部出血，所謂的加壓敷料通常是不夠的，只有進行持續的直接手動加壓才有效。由於大多數民間急救醫療服務（EMS）人員受限，止血帶和止血敷料在醫療和後勤方面均有益。 5 儘管大量證據表明其在軍事經驗中獲益良多，但最近的數據表明，只有少數急救醫療系統正在使用推薦的商用止血帶和止血敷料來止血。儘管大量軍事出版物記錄了院前止血帶和止血敷料在戰鬥傷者救治中具有救命的功效且併發症發生率低，但這種情況仍然持續存在。雖然止血帶在患者因失血而休克之前儘早使用效果最佳，但這一點顯而易見。儘管過去急救醫療系統曾因擔心肢體缺血性損傷而不鼓勵使用止血帶，但這種併發症實際上非常罕見。長時間使用止血帶可能會導致截肢，但如果無法移除止血帶，則必須始終優先考慮患者的生命安全。由於其已被證實的救生價值，止血帶如今在現代戰場上隨處可見，然而，許多民用 EMS 系統的採用進展緩慢。儘管數量有限，但有報導稱，軍事上止血帶和止血敷料的使用正在逐漸被民用 EMS 和急救醫學實踐所採用。其中一個關鍵理念是，不僅要讓所有醫護人員，還要讓數量眾多的非醫務第一線反應人員都配備止血設備。在民間領域，許多警察和消防員現在都攜帶這些設備，使其能夠廣泛且快速地普及。對非醫護人員進行有效的止血設備訓練和使用，是減少可預防死亡的關鍵因素。對於肢體嚴重出血的患者，止血是當務之急。大多數肢體損傷不需要止血帶，但危及生命的出血患者則需要止血帶。與大多數創傷情況一樣，過度分診是可以接受的，因為在抵達醫院後，不需要的止血帶可以安全地移除。以下描述是適合使用止血帶的創傷受害者的範例：
•傷口有搏動性或持續性出血。
•血液在地上積聚。
•覆蓋的衣服被血浸透。
•用於包紮傷口的繃帶或暫時繃帶無效，並逐漸被血浸透。
•傷口有搏動性或持續性出血。
•血液在地上積聚。
•覆蓋的衣服被血浸透。
•用於包紮傷口的繃帶或暫時繃帶無效，並逐漸被血浸透。
•手臂或腿部有外傷性截肢
•之前曾有出血，患者現在處於休克狀態（昏迷、神誌恍惚、臉色蒼白）。
在治療因傷口出血而明顯休克的患者時，應先止血，然後進行液體復甦。有效的止血並不會隨著首次止血帶的應用而停止。軍隊使用止血帶的經驗提供了一些關於其使用的關鍵教學要點：
•等待太久才放置止血帶是錯誤的。
•止血帶應放置在嚴重出血部位的近端，切勿直接放置在關節上。
•應視需要收緊止血帶以止住遠端損傷的出血。
•如果一條止血帶無法止血，則應在第一條止血帶的近端使用第二條止血帶。
•當對較大的下肢使用止血帶時，尤其需要使用第二條止血帶。
•止血帶的作用是止住動脈出血。如果遠端脈搏仍然存在，則應收緊止血帶或在第一條止血帶的近端使用第二條止血帶，並再次檢查脈搏。
•如果使用止血帶，則應使用有效的動脈止血帶，而不是無效的靜脈止血帶，因為使用後者會增加出血。
•應定期重新檢查使用止血帶的傷員，以確保止血帶仍然有效且出血得到控制。
•應檢查每個止血帶遠端的脈搏。
•正確使用止血帶可能會引起劇烈疼痛，但這種疼痛並不表示止血帶使用不當或應移除止血帶。
•應酌情使用止痛藥控制疼痛，但休克患者不應使用止血帶。止血帶使用上的錯誤包括：•沒有有效的商用止血帶
•應該使用止血帶時不使用
•在輕微出血或少量出血時使用不應該使用的止血帶
•將止血帶綁得太近
•止血帶綁得不夠緊，無法有效止血•必要時不使用第二條止血帶
•等待太長時間綁上止血帶止血
應始終在患者身上記錄止血帶的使用時間，通常在患者額頭上寫上字母“T”，並註明收緊時間。應使用不褪色的墨水筆進行記錄，以確保這一重要資訊不會被洗掉或擦掉。這些資訊也應記錄在病患的使用記錄表上，並在醫院病歷中記錄止血帶的總缺血時間。最後，所有製造的止血帶均為一次性使用。應使用單獨的一組止血帶進行訓練，訓練用止血帶不應隨後發放用於實際傷員。
•之前曾有出血，患者現在處於休克狀態（昏迷、神誌恍惚、臉色蒼白）。
在治療因傷口出血而明顯休克的患者時，應先止血，然後進行液體復甦。有效的止血並不會隨著首次止血帶的應用而停止。軍隊使用止血帶的經驗提供了一些關於其使用的關鍵教學要點：
•等待太久才放置止血帶是錯誤的。
•止血帶應放置在嚴重出血部位的近端，切勿直接放置在關節上。
•應視需要收緊止血帶以止住遠端損傷的出血。
•如果一條止血帶無法止血，則應在第一條止血帶的近端使用第二條止血帶。
•當對較大的下肢使用止血帶時，尤其需要使用第二條止血帶。
•止血帶的作用是止住動脈出血。如果遠端脈搏仍然存在，則應收緊止血帶或在第一條止血帶的近端使用第二條止血帶，並再次檢查脈搏。
•如果使用止血帶，則應使用有效的動脈止血帶，而不是無效的靜脈止血帶，因為使用後者會增加出血。
•應定期重新檢查使用止血帶的傷員，以確保止血帶仍然有效且出血得到控制。
•應檢查每個止血帶遠端的脈搏。
•正確使用止血帶可能會引起劇烈疼痛，但這種疼痛並不表示止血帶使用不當或應移除止血帶。
•應酌情使用止痛藥控制疼痛，但休克患者不應使用止血帶。止血帶使用上的錯誤包括：•沒有有效的商用止血帶
•應該使用止血帶時不使用
•在輕微出血或少量出血時使用不應該使用的止血帶
•將止血帶綁得太近
•止血帶綁得不夠緊，無法有效止血•必要時不使用第二條止血帶
•等待太長時間綁上止血帶止血
應始終在患者身上記錄止血帶的使用時間，通常在患者額頭上寫上字母“T”，並註明收緊時間。應使用不褪色的墨水筆進行記錄，以確保這一重要資訊不會被洗掉或擦掉。這些資訊也應記錄在病患的使用記錄表上，並在醫院病歷中記錄止血帶的總缺血時間。最後，所有製造的止血帶均為一次性使用。應使用單獨的一組止血帶進行訓練，訓練用止血帶不應隨後發放用於實際傷員。
簡易旋轉柵門
非商用止血帶，或所謂的簡易止血帶，遠不如經過測試和建議的止血帶有效。 2001年阿富汗戰爭爆發時，美軍計畫使用簡易止血帶。然而，簡易止血帶被發現難以組裝和固定。軍事經驗表明，簡易止血帶有時會導致可預防的死亡。在戰爭初期出現不必要的死亡事件後，軍方改變了策略。到2005年，數千條商用止血帶已被送往戰場，由醫護人員和非醫務人員攜帶。 6 將這種經驗和教訓應用到民用領域至關重要。使用止血敷料控制出血
數千年來，人們一直使用各種形式的敷料來止血。 2001年阿富汗戰爭爆發時，美軍使用的紗布敷料自第一次世界大戰以來幾乎沒有改變。在阿富汗戰爭初期，人們開發出了止血敷料，這種敷料重量輕、耐用，止血效果遠勝於標準紗布。在聽取了經驗豐富的軍醫的大量回饋後，美國軍醫協會（CoTCCC）於2003年推薦了一種可以填塞到傷口內，但止血效果優於標準紗布的止血敷料。這些敷料通常與止血帶搭配使用，但對於不適合使用止血帶的傷口尤其有效。 8 研究表明，當出血部位不適合放置止血帶時，止血敷料是控制外部出血的有效輔助。與所有設備一樣，為了確保最大程度的有效性，止血敷料的使用需要經過訓練。關鍵在於確保正確的填塞方法和持續至少三分鐘的手動壓迫。單純施加止血劑而不維持壓力不足以達到最佳止血效果。之後，可以用標準加壓敷料覆蓋傷口和止血敷料。
止血帶和止血劑的選擇
民用急救系統在選擇止血劑時，需要注意的是，研究表明，儘管製造商宣傳和宣傳止血帶和止血劑的效果各不相同，但並非所有止血帶和止血劑都同樣有效。在伊拉克和阿富汗戰爭期間，美國國防部開發了標準化模型和技術，用於評估止血帶、止血敷料、交界性止血帶、胸腔封堵器以及其他用於院前創傷救治的物品。任何機構在購買院前創傷設備時，都應在選擇過程中參考此類文獻。任何選定的採購物品都應符合以下要求：(1) 價格合理；(2) 經過實驗室安全性和有效性測試；(3) 安全性和有效性經驗豐富。 止血帶和止血劑的選擇
個人和預先放置的創傷急救包
軍事經驗表明，至少應有兩類創傷設備：可供多人預先放置的大型急救包和供警官或急救員使用的小型移動急救包。所有專業急救員都應配備止血包。消防員和執法人員在救援時應隨身攜帶止血帶和止血敷料。救護車或直升機上的 EMS 設備應包括止血包。所有創傷中心的急診室都應配備這些設備。培訓至關重要。較大的預先放置的創傷包應放置在最佳位置，以便為當地事件或地點提供醫療服務。這些較大的急救包可在槍擊事件或大規模傷亡情況下滿足緊急需求。預先放置創傷包很有用的場所包括商場、電影院、學校和體育賽事。人們越來越認識到，止血包應放置在自動體外心臟去顫器旁邊。 One of the most important lessons learned in the last 14 years of
war is that using tourniquets and hemostatic dressings as soon as
possible after injury is absolutely lifesaving.
Tourniquets in the civilian setting
The wounding agents are usually different in battlefield and civilian trauma, but the lessons learned regarding hemorrhage control and optimal resuscitation are not. Recently, the American College of Surgeons Committee on Trauma and the U.S. Department of Transportation working group evaluated the evidence for external hemorrhage control measures.2 The group’s conclusions on tourniquets were that: (1) commercial windlass-type tourniquets should be used in the prehospital setting for the control of significant extremity hemorrhage when direct pressure is ineffective or impractical, (2) improvised tourniquets should be used only if no commercial device is available, and (3) a tourniquet that has been properly applied in the prehospital setting should not be released until the patient has reached definitive care. The recommendations on hemostatic agents were that: (1) topical hemostatic agents should be used in combination with direct pressure for the control of significant hemorrhage in the prehospital setting when sustained direct pressure is ineffective or impractical, and (2) topical hemostatic agents in a gauze can be used to enhance wound packing.
Hemorrhage control with tourniquets
In the 26 years between the end of the Vietnam War in 1975 and 2001, little changed in prehospital hemorrhage control. As a result, preventable deaths from extremity hemorrhage also did not change in almost three decades. After the widespread implementation of the tourniquet recommendations from the Committee on Tactical Combat Casualty Care (CoTCCC), a 10-year review of 4,596 U.S. combat fatalities noted a significant decrease in combat fatalities from extremity hemorrhage.3 The dramatic decrease in deaths from extremity hemorrhage resulted from the now ubiquitous fieldingof modern tourniquets and hemostatic dressings on the battlefield and aggressive training of all levels of responders in their effective use.4 As noted earlier, deaths from extremity hemorrhage can largely be prevented by early use of tourniquets. Because of their effectiveness at hemorrhage control and the speed with which they can be applied, tourniquets are the best option for temporary control of life-threatening extremity hemorrhage in the tactical environment when under fire. This concept can apply as well in the civilian arena, with its increasing number of mass casualty or active shooter events. These concepts become especially applicable in terrorist-style bombing events on our home soil. Direct pressure and gauze compression dressings can be effective; however, the lack of dedicated personnel to apply continuous direct pressure, a lessthan-secure environment, and extremity injuries that could lead to exsanguination are all indications for rapid tourniquet application. In routine emergency medical services (EMS) care, the so-called pressure dressing for massive external hemorrhage is frequently inadequate and only effective when continuous direct manual compression is applied. Because of the personnel constraints on most civilian EMS runs, tourniquets and hemostatic dressings are both medically and logistically beneficial.5 Despite the overwhelming evidence of benefit from the military experience, recent data indicate that only a few EMS systems are using recommended commercially manufactured tourniquets and hemostatic dressings for exsanguinating hemorrhage. This situation continues despite numerous military publications documenting the lifesaving benefit and low incidence of complications from prehospital tourniquets and hemostatic dressings used in combat casualties.Although it is somewhat obvious, tourniquets are most effective in saving lives when applied early, before the individual has gone into shock from blood loss.Although tourniquet use has been discouraged by EMS systems in the past because of concerns about ischemic damage to the extremity, this complication is actually very rarely seen. Prolonged use of a tourniquet can potentially result in amputation, but saving the life of the individual must always take precedence if the tourniquet cannot be removed. Because of their proven lifesaving value, tourniquets are now ubiquitous on the modern battlefield, yet adoption has been slow in many civilian EMS systems. Although limited, there are reports that the adoption of the military practice of tourniquets and hemostatic dressings into civilian EMS and emergency medicine practice is increasing. One of the key concepts that emerged was placing the hemorrhage control devices in the hands of not only all medical providers, but also the much more numerous nonmedical first-responding personnel. In the civilian sector, many police officers and firefighters now carry these devices, making them widely and rapidly available. Effective training in, and use of, hemorrhage control devices by nonmedical personnel has been a critical element in reducing preventable deaths. In patients with severe extremity bleeding, hemorrhage control is a priority. Most extremity injuries do not require tourniquets, but patients with life-threatening bleeding do require a tourniquet. As in most trauma situations, over-triage is acceptable, as tourniquets found not to be needed can be safely removed on arrival at a hospital. The following descriptions are provided as examples of trauma victims for whom tourniquet use is appropriate:
•There is pulsatile or steady bleeding from the wound.
•Blood is pooling on the ground.
•The overlying clothes are soaked with blood.
•Bandages or makeshift bandages used to cover the wound are ineffective and steadily becoming soaked with blood.
•There is a traumatic amputation of the arm or leg
•There was prior bleeding, and the patient is now in shock (unconscious, confused, pale).
When treating an individual who is in obvious shock from bleeding wounds, hemorrhage control should be the first priority, before fluid resuscitation. Effective hemorrhage control does not stop with the initial tourniquet application. The military experience with tourniquets has provided some key teaching points about their use:
•Waiting too long to place a tourniquet is a mistake.
•Tourniquets should be applied just proximal to the site of the severe bleeding and never placed directly over a joint.
•Tourniquets should be tightened as necessary to stop bleeding from the distal injury.
•If bleeding is not controlled with one tourniquet, a second tourniquet should be applied just proximal to the first.
•The need for a second tourniquet is especially applicable when applying tourniquets to generously sized lower extremities.
•The purpose of tourniquets is to stop arterial bleeding. If a distal pulse is still present, the tourniquet should be tightened or a second tourniquet applied just proximal to the first, and the pulse should be checked again.
•If a tourniquet is used, it should be an effective arterial tourniquet and not an ineffective venous tourniquet, as use of the latter can increase bleeding.
•Casualties with tourniquets in place should be rechecked periodically to ensure that the tourniquet is still working and that hemorrhage is controlled.
•Pulses distal to every tourniquet should be checked.
•Correctly applied tourniquets can cause significant pain, but this pain does not signify that the tourniquet has been applied incorrectly or that it should be removed.
•Pain should be managed with analgesics as appropriate, but not for patients in shock. Mistakes regarding tourniquets include the following: •Not having an effective commercial tourniquet available
•Not using a tourniquet when one should be used
•Using a tourniquet for minimal or minor bleeding when one should not be used
•Putting the tourniquet on too proximally
•Not making the tourniquet tight enough to effectively stop the bleeding •Not using a second tourniquet if needed •Waiting too long to put the tourniquet on
•Not reevaluating the tourniquet’s effectiveness
•Periodically loosening the tourniquet to allow blood flow into the injured extremity
The time when a tourniquet is applied should always be noted on the individual’s body, customarily by writing the letter T on the person’s forehead, along with the time that it was tightened. This notation should be done with an indelible ink marker to ensure that this important information does not wash or wipe off. The information should also be recorded on the individual’s run sheet and total tourniquet ischemia time recorded in the hospital chart. Finally, all manufactured tourniquets are designed for a single use. A separate group of tourniquets should be used for training, and training tourniquets should not subsequently be issued for actual casualty use.
Improvised tourniquets
Noncommercial, or so-called improvised, tourniquets are not nearly as effective as tested and recommended tourniquets. In 2001, at the start of war in Afghanistan, the U.S. military’s plan was to use improvised tourniquets. Improvised tourniquets have been found to be difficult to assemble and secure. Military experience has shown that improvised tourniquets sometimes result in preventable deaths. After unnecessary deaths early in the war, the military’s strategy changed. By 2005, thousands of commercial tourniquets had been sent to the battlefield and were carried by medical and nonmedical personnel.6 Transitioning this experience and lessons learned to the civilian arena is extremely important.7
Hemorrhage control with hemostatic dressings
Dressings in various forms have been used for thousands of years to help stop bleeding. At the start of the war in Afghanistan in 2001, the U.S. military used a gauze dressing that had not changed appreciably since World War I. Early in the war in Afghanistan, hemostatic dressings were developed that were lightweight, durable, and much more effective than standard gauze at stopping bleeding. After significant feedback from experienced military medics, in 2003 the CoTCCC recommended a hemostatic dressing that could be packed into a wound but that had hemostatic performance that was superior to standard gauze. These dressings were often used in conjunction with tourniquets but were especially useful in wounds not amenable to tourniquet use.8 Hemostatic dressings have been clearly shown to be a valuable adjunct in external hemorrhage control when the source of the bleeding is from a site not amenable to tourniquet placement. As with all devices, to ensure maximum effectiveness, the application of hemostatic dressings requires training. Critical elements are to ensure a correct packing technique and sustained manual compression for a minimum of three minutes. Simply applying the agents without maintaining pressure is not adequate to achieve the best possible hemostatic effect. Afterward, a standard pressure dressing can be applied to cover both the wound and the hemostatic dressing.
Selection of tourniquets and hemostatic agents
Selection of tourniquets and hemostatic agents
As civilian EMS systems make decisions about hemostatic agents, they need to be aware that research has shown that not all tourniquets and hemostatic agents are equally effective despite the manufacturers’ claims and advertising. During the wars in Iraq and Afghanistan, the Department of Defense developed standardized models and techniques for evaluating tourniquets, hemostatic dressings, junctional tourniquets, chest seals, and other items designed to be used in prehospital trauma care. A review of this literature should be part of the selection process for any agency making procurement decisions about prehospital trauma equipment. Any item selected for procurement should ideally be (1) reasonable in price; (2) laboratory tested for safety and effectiveness; and (3) experience proven for safety and effectiveness.
Individual and pre-positioned trauma kits
Military experience suggests that there should be at least two lists of trauma equipment: large kits that are pre-positioned for multiple people and smaller mobile kits for officers or first responders. All professional first responders should be equipped with bleeding control kits. Firefighters and law enforcement officers should carry tourniquets and hemostatic dressings in a kit on their person when responding. EMS equipment in the ambulance or helicopter should include hemorrhage control kits. All trauma centers should have these devices in their emergency departments. Training is paramount. Larger pre-positioned trauma kits should be placed at optimal locations for medical coverage of local events or locations. These larger kits would supply immediate needs in an active shooter event or mass casualty situation. Examples of locations where pre-positioned trauma kits would be of value are malls, movie theaters, schools, and sporting events. There is a growing recognition that the hemorrhage control kits should be positioned next to automated external defibrillators.
Recommendation
External hemorrhage control can be accomplished easily by welltrained and well-equipped people, whether they are professional first responders or civilians. Tourniquets and hemostatic dressings should reduce preventable deaths from external hemorrhage in the civilian sector, just as they have done in the military. The recommendations for early effective hemorrhage control with commercial devices are important and similar to those of the CoTCCC, the U.S. military, the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Technicians, and the Hartford Consensus III. The lessons learned in early hemorrhage control have been gained and applied in the crucible of battle. Widespread application of tourniquets and hemostatic dressings for hemorrhage control after civilian injury will save lives.
野外與登山醫學-到院前止血-傷口填塞 Wound Packing Essentials (這篇是寫給EMT救護員的)
2025-07-24 08:00AM
Wound Packing Essentials for EMTs and Paramedics
April 1, 2017 Scotty Bolleter, BS, EMT-P. A.J. Heightman, MPA, EMT-P . Peter P. Taillac, MD, FACEP
這篇論文發表於2017年JEMS (Journal of Emergency Medical Services).
何時打包填塞
簡而言之，如果傷口沒有出血（或僅少量出血），則無需填塞。四肢和交界處的傷口可以填塞。如果最初在四肢傷口上放置了止血帶，之後可以換成加壓敷料或填塞物，這樣可能對患者更舒適，並能提供適量的遠端血液循環。
直接按壓通常足以治療頸部出血的傷口。頸部傷口通常不進行包紮傷口填塞，因為有損害呼吸道的風險。
雖然背部傷口的出血通常不會很多，並且可以透過簡單的加壓敷料來控制，但根據以色列的經驗，背部傷口的包紮傷口填塞是成功的。
胸部、腹部或骨盆的傷口不應進行包紮傷口填塞，因為這些傷口的出血通常來自非常深的部位，無法從外部觸及。這些患者必須迅速轉運至外科醫師處進行手術止血。因此，這些部位傷口的包紮傷口填塞應由當地急救醫療服務（EMS）的醫療主任或相關州政府機構酌情決定。
傷口包紮材料
用於止血的填塞材料有很多種選擇。市售的止血紗布產品中浸漬了各種旨在促進血塊形成的物質，包括高嶺土、殼聚醣等。
在 2017 年 1 月的更新中，軍事戰術戰鬥傷亡護理委員會 (CoTCCC) 推薦使用 QuikClot 戰鬥紗布作為「首選止血敷料」。
CoTCCC 批准的替代方案包括 Celox Gauze、ChitoGauze 和 XStat。軍醫對 Combat Gauze 的使用經驗最豐富，因為它已被廣泛使用多年。
所有止血產品只要使用得當，都非常有效。有趣的是，即使是普通紗布（未浸漬止血劑）也被發現非常有效。 6 如果您沒有止血劑，可以使用普通紗布，這真是太好了。
傷口填塞技術
對於現場提供者施救者來說，使用哪種產品並不重要；更重要的是如何使用產品。
步驟1：止血。立即！立即用紗布、乾淨的布、手肘、膝蓋等任何能減緩或止血的物體直接按壓傷口，直到有時間取出傷口包紮用品。
將戴手套的手指（無論是否包紮敷料）伸入傷口，對目標區域（目標可以是靜脈、動脈或兩者）施加初始壓力，並壓迫出血源。請記住，人體解剖學中，主要血管靠近骨骼。因此，盡可能利用骨骼來輔助控制血管（即出血）。這也能讓你了解傷口的走向，並據此插入紗布。
第二步：用紗布填塞傷口。一定要填塞緊實！目標是將傷口完全填塞嚴實，以止血。用手指將紗布填塞進傷口，同時保持對傷口的壓力。
至關重要的是，紗布必須盡可能深入傷口，確保其直接接觸出血血管。這樣，既能直接壓迫出血血管，又能讓止血劑發揮其神奇功效。
第三步：繼續包紮！成功包紮傷口的關鍵在於將傷口包紮得非常緊密，並盡可能對出血血管施加壓力。這種對血管的壓力是控制出血最重要的因素。這解釋了為什麼普通紗布（未浸漬止血劑）在緊密包紮的情況下也非常有效。
步驟4：用力按壓包紮好的傷口3分鐘。此步驟可將包紮物牢固地壓在出血血管上，並有助於凝血。
步驟5：固定貼合的壓力敷料並轉運。加壓3分鐘後，將貼合的壓力敷料覆蓋在傷口上。如果可能的話，可以考慮用夾板固定或固定傷口，因為轉運過程中的移動可能會使敷料移位，導致再次出血。
When to Pack
Simply stated, if there’s no (or only minimal) bleeding, the wound doesn’t need packing. Wounds of the extremities and junctional areas are amenable to packing. If a tourniquet is initially placed on an extremity wound, it may later be replaced with a pressure dressing or with packing, which may be more comfortable for the patient and provide for a moderate amount of distal circulation.
Direct pressure will usually suffice for bleeding neck wounds. Wounds of the neck aren’t generally packed because of the risk for airway compromise.
Although the bleeding from a back wound will typically not be profuse and may be controlled with a simple pressure dressing, in the Israeli experience, wounds of the back were packed successfully.
Wounds of the chest, abdomen or pelvis shouldn’t be packed because bleeding from these wounds is generally from a very deep source that can’t be reached from the outside. These patients must be rapidly transported to a surgeon for operative bleeding control. Packing of wounds in these areas should therefore be performed at the discretion of local EMS Medical Directors or the appropriate state agencies where applicable.
Wound Packing Material
There are many choices for packing material designed to control hemorrhage. The commercial hemostatic gauze products are impregnated with a variety of substances designed to enhance clot formation, including kaolin, chitosan and others.
In its January 2017 update, the military’s Committee on Tactical Combat Casualty Care (CoTCCC) recommended QuikClot Combat Gauze as the “hemostatic dressing of choice.”5
Alternatives approved by the CoTCCC include Celox Gauze, ChitoGauze and XStat. Military medics have the most experience with Combat Gauze, as it has been widely deployed for years.
All the hemostatic products are highly effective when used properly. Interestingly, even plain gauze (without an impregnated hemostatic agent) has been found to be highly effective.6 It’s nice to know you can use plain gauze if hemostatic agents are not available to you.
Wound Packing Technique
It’s less important to the field provider which product is used; what’s more important is how the product is used.
Step 1: Stop the bleeding. Now! Immediately apply direct pressure to the wound, using gauze, clean cloth, elbow, knee-whatever it takes to slow or stop the hemorrhage-until you have time to get out your wound packing supplies.
Place your gloved fingers-with or without a dressing-into the wound to apply initial pressure to the target area (with your target being the vein, artery or both) and compress the source of bleeding. Keep in mind that the body’s anatomy presents with major vessels running close to bones. So, whenever possible, utilize a bone to assist with vessel (i.e., bleeding) control. This will also give you an idea of which direction the wound travels and you can insert the gauze accordingly.
Step 2: Pack the wound with gauze. Tightly! Your goal is to completely and tightly pack the wound cavity to stop hemorrhage. Begin packing the gauze into the wound with your finger, while simultaneously maintaining pressure on the wound.
It’s critical that the gauze be packed as deeply into the wound as possible to put the gauze into direct contact with the bleeding vessel. By doing so, you’re simultaneously putting direct pressure onto the bleeding vessel and allowing the hemostatic agent to do work its magic.
Step 3: Keep packing! The key to successful wound packing is that the wound be very tightly packed, applying as much pressure as possible to the bleeding vessel. This pressure against the vessel is the most important component of hemorrhage control. This explains why plain gauze (without an impregnated hemostatic agent), when tightly packed, is also quite effective.
Step 4: Apply very firm pressure to the packed wound for 3 minutes. This step pushes the packing firmly against the bleeding vessel and aids in clotting.
Step 5: Secure a snug pressure dressing and transport. After applying pressure for 3 minutes, place a snug pressure dressing over the wound. You may consider splinting or immobilizing the area, if possible because movement during transport can dislodge the packing and allow hemorrhage to restart.
重點, 傷口填塞注意事項
1. 腹股溝或腋窩傷口不容易直接加壓止血. 也無法使用一般止血帶. 使用紗布填塞入傷口. 可加強直接加壓止血效果
2. 少量出血不需要填塞紗布
3. 可用於腹股溝, 腋窩, 背部, 四肢的大傷口
4. 禁止使用於頸部、胸部、腹部或骨盆的傷口
5. 填充的紗布可加上止血劑進行填塞
6. 危及生命的狀況. 填充物是否無菌不是很重要. 但仍建議盡量使用乾淨材料
7. 雙手是最好用的加壓工具. 無法長時間用手加壓傷處, 可使用輔助裝備. 例如止血帶.
Wound Packing Essentials for EMTs and Paramedics
April 1, 2017 Scotty Bolleter, BS, EMT-P. A.J. Heightman, MPA, EMT-P . Peter P. Taillac, MD, FACEP
這篇論文發表於2017年JEMS (Journal of Emergency Medical Services).
作者 Scotty Bolleter 是美國德州高級救護技術員
Emergency Medical Services, EMS, 緊急醫療服務(也有論文翻譯成緊急醫療系統)
Emergency Medical Services, EMS, 緊急醫療服務(也有論文翻譯成緊急醫療系統)
是指確保患者在到院前能得到必要的急救醫療服務以及決策管理運送患者至適當的醫療單位的系統機制，其內容包含傷病現場急救處理、救護車送醫途中的到院前緊急救護以及到院後的急診醫療服務。
剛搜尋了一下 JEMS 的 impact factor 2.3 不算太高但也不低.
剛搜尋了一下 JEMS 的 impact factor 2.3 不算太高但也不低.
原文太長. 僅節錄幾段. 下面中文是大部分使用 google 中文翻譯. 刪除線的文字是google翻譯的詞.我覺得不恰當而修改的.
前言
無法控制的出血是創傷中可預防死亡的最大原因。當肢體出血無法控制時，許多（即使不是大多數）急救機構已經認識到使用止血帶的益處。
如今，由於全國各地進行的「止血」教育活動強調旁觀者對槍擊事件的反應，許多一般民眾現在開始熟悉簡單但有效的止血技術。 1
對於急救人員來說，使用直接壓迫和止血帶治療肢體出血相對簡單。然而，最棘手的傷口是交界處——腹股溝和腋窩——這些部位無法使用止血帶。這些部位的出血通常較深，維持足夠的外部壓力可能很困難，甚至不可能。 2
多年來，美國軍方一直在向醫護人員傳授使用標準紗布和止血敷料進行傷口填塞的技巧。 3就像止血帶從軍用急救醫療服務到民間急救醫療服務的過渡一樣，這些技能如今也正被戰術急救醫療團隊以及戰地急救醫療隊和護理人員所採用。傷口填塞可以與止血帶搭配使用，也可以單獨作為出血管理處置技術。
何時
簡而言之，如果傷口沒有出血（或僅少量出血），則無需填塞。四肢和交界處的傷口可以填塞。如果最初在四肢傷口上放置了止血帶，之後可以換成加壓敷料或填塞物，這樣可能對患者更舒適，並能提供適量的遠端血液循環。
直接按壓通常足以治療頸部出血的傷口。頸部傷口通常不進行
雖然背部傷口的出血通常不會很多，並且可以透過簡單的加壓敷料來控制，但根據以色列的經驗，背部傷口的
胸部、腹部或骨盆的傷口不應進行
傷口包紮材料
用於止血的填塞材料有很多種選擇。市售的止血紗布產品中浸漬了各種旨在促進血塊形成的物質，包括高嶺土、殼聚醣等。
在 2017 年 1 月的更新中，軍事戰術戰鬥傷亡護理委員會 (CoTCCC) 推薦使用 QuikClot 戰鬥紗布作為「首選止血敷料」。
CoTCCC 批准的替代方案包括 Celox Gauze、ChitoGauze 和 XStat。軍醫對 Combat Gauze 的使用經驗最豐富，因為它已被廣泛使用多年。
所有止血產品只要使用得當，都非常有效。有趣的是，即使是普通紗布（未浸漬止血劑）也被發現非常有效。 6 如果您沒有止血劑，可以使用普通紗布，這真是太好了。
傷口填塞技術
對於現場
步驟1：止血。立即！立即用紗布、乾淨的布、手肘、膝蓋等任何能減緩或止血的物體直接按壓傷口，直到有時間取出傷口包紮用品。
將戴手套的手指（無論是否包紮敷料）伸入傷口，對目標區域（目標可以是靜脈、動脈或兩者）施加初始壓力，並壓迫出血源。請記住，人體解剖學中，主要血管靠近骨骼。因此，盡可能利用骨骼來輔助控制血管（即出血）。這也能讓你了解傷口的走向，並據此插入紗布。
第二步：用紗布填塞傷口。一定要填塞緊實！目標是將傷口完全填塞嚴實，以止血。用手指將紗布填塞進傷口，同時保持對傷口的壓力。
至關重要的是，紗布必須盡可能深入傷口，確保其直接接觸出血血管。這樣，既能直接壓迫出血血管，又能讓止血劑發揮其神奇功效。
第三步：繼續包紮！成功包紮傷口的關鍵在於將傷口包紮得非常緊密，並盡可能對出血血管施加壓力。這種對血管的壓力是控制出血最重要的因素。這解釋了為什麼普通紗布（未浸漬止血劑）在緊密包紮的情況下也非常有效。
步驟4：用力按壓包紮好的傷口3分鐘。此步驟可將包紮物牢固地壓在出血血管上，並有助於凝血。
步驟5：固定貼合的壓力敷料並轉運。加壓3分鐘後，將貼合的壓力敷料覆蓋在傷口上。如果可能的話，可以考慮用夾板固定或固定傷口，因為轉運過程中的移動可能會使敷料移位，導致再次出血。
When to Pack
Simply stated, if there’s no (or only minimal) bleeding, the wound doesn’t need packing. Wounds of the extremities and junctional areas are amenable to packing. If a tourniquet is initially placed on an extremity wound, it may later be replaced with a pressure dressing or with packing, which may be more comfortable for the patient and provide for a moderate amount of distal circulation.
Direct pressure will usually suffice for bleeding neck wounds. Wounds of the neck aren’t generally packed because of the risk for airway compromise.
Although the bleeding from a back wound will typically not be profuse and may be controlled with a simple pressure dressing, in the Israeli experience, wounds of the back were packed successfully.
Wounds of the chest, abdomen or pelvis shouldn’t be packed because bleeding from these wounds is generally from a very deep source that can’t be reached from the outside. These patients must be rapidly transported to a surgeon for operative bleeding control. Packing of wounds in these areas should therefore be performed at the discretion of local EMS Medical Directors or the appropriate state agencies where applicable.
Wound Packing Material
There are many choices for packing material designed to control hemorrhage. The commercial hemostatic gauze products are impregnated with a variety of substances designed to enhance clot formation, including kaolin, chitosan and others.
In its January 2017 update, the military’s Committee on Tactical Combat Casualty Care (CoTCCC) recommended QuikClot Combat Gauze as the “hemostatic dressing of choice.”5
Alternatives approved by the CoTCCC include Celox Gauze, ChitoGauze and XStat. Military medics have the most experience with Combat Gauze, as it has been widely deployed for years.
All the hemostatic products are highly effective when used properly. Interestingly, even plain gauze (without an impregnated hemostatic agent) has been found to be highly effective.6 It’s nice to know you can use plain gauze if hemostatic agents are not available to you.
Wound Packing Technique
It’s less important to the field provider which product is used; what’s more important is how the product is used.
Step 1: Stop the bleeding. Now! Immediately apply direct pressure to the wound, using gauze, clean cloth, elbow, knee-whatever it takes to slow or stop the hemorrhage-until you have time to get out your wound packing supplies.
Place your gloved fingers-with or without a dressing-into the wound to apply initial pressure to the target area (with your target being the vein, artery or both) and compress the source of bleeding. Keep in mind that the body’s anatomy presents with major vessels running close to bones. So, whenever possible, utilize a bone to assist with vessel (i.e., bleeding) control. This will also give you an idea of which direction the wound travels and you can insert the gauze accordingly.
Step 2: Pack the wound with gauze. Tightly! Your goal is to completely and tightly pack the wound cavity to stop hemorrhage. Begin packing the gauze into the wound with your finger, while simultaneously maintaining pressure on the wound.
It’s critical that the gauze be packed as deeply into the wound as possible to put the gauze into direct contact with the bleeding vessel. By doing so, you’re simultaneously putting direct pressure onto the bleeding vessel and allowing the hemostatic agent to do work its magic.
Step 3: Keep packing! The key to successful wound packing is that the wound be very tightly packed, applying as much pressure as possible to the bleeding vessel. This pressure against the vessel is the most important component of hemorrhage control. This explains why plain gauze (without an impregnated hemostatic agent), when tightly packed, is also quite effective.
Step 4: Apply very firm pressure to the packed wound for 3 minutes. This step pushes the packing firmly against the bleeding vessel and aids in clotting.
Step 5: Secure a snug pressure dressing and transport. After applying pressure for 3 minutes, place a snug pressure dressing over the wound. You may consider splinting or immobilizing the area, if possible because movement during transport can dislodge the packing and allow hemorrhage to restart.
2025年7月22日 星期二
野外與登山醫學-[目錄]高海拔疾病相關藥物筆記
2025-07-22 18:55
如何使用藥物預防高海拔疾病 (2025-08-15更新)
2024 WMS 高海拔疾病藥物
2025年7月11日 星期五
野外與登山醫學-止血法-傷口填塞 wound packing
另一篇相關筆記.
到院前止血-傷口填塞 Wound Packing Essentials (針對EMT救護員)
2025-07-11 15:45
傷口填塞一般使用於比較深且不容易止血的傷口. 不建議使用於頸部, 胸部, 腹部.
還有一種止血法, 稱為 Preperitoneal pelvic packing, 用於外傷導致骨盆骨折合併嚴重出血, 無法以其他方式有效止血時. 醫師在手術中將紗布填塞於病患骨盆腔(腹膜之外)
Preperitoneal Packing for Pelvic Fracture Bleeding Control:
上圖來自 Thr trauma pro
下面資料來自 uptodate-Control of external hemorrhage in trauma patients
僅節錄傷口填塞這段.
以下中文使用google翻譯
傷口填塞可填充任何死腔區域，並增加對傷口深層血管的直接壓力[ 18 ]。
填塞創傷性傷口時，應將乾淨的布、紗布或含止血劑的敷料深深地、牢固地壓入傷口。在保持直接壓力的同時，應繼續填塞直至傷口填滿。填塞完成後，塗抹敷料覆蓋傷口，並用雙手施加壓力。然後，應保持該壓力直至止血[ 18 ]。
市售的含止血劑敷料包括因子濃縮劑、黏膜黏附劑和促凝血劑。這些敷料可用於施加直接壓力並填塞傷口。放置這些敷料後，應施加至少3分鐘的直接壓力[ 19,20 ]。需要注意的是，某些敷料可能含有不透射線的標記，這可能會導致CT成像出現散射。 (請參閱“局部止血劑和組織黏合劑的概述”，關於‘外用藥物’一節)
Wound packing — Wound packing fills any area of dead space and increases direct pressure on the vessels deep within the wound [18].
To pack a traumatic wound, a clean cloth, gauze, or hemostatic-impregnated dressing is pressed deeply and firmly into the wound. While maintaining direct pressure, packing should be added until the wound is filled. Once packed, the wound should be covered with a dressing, and pressure should be applied using two hands. Then, it should be maintained until hemostasis is achieved [18].
Factor concentrators, mucoadhesives, and procoagulants are options for commercially available hemostatic-impregnated dressings. These dressings can be used to apply direct pressure and pack a wound. At least three minutes of direct pressure should be applied after placing these dressings [19,20]. Note that some dressings may have a radiopaque marker that can cause scatter on computed tomographic (CT) imaging. (See "Overview of topical hemostatic agents and tissue adhesives", section on 'External agents'.)
傷口填塞一般使用於比較深且不容易止血的傷口. 不建議使用於頸部, 胸部, 腹部.
還有一種止血法, 稱為 Preperitoneal pelvic packing, 用於外傷導致骨盆骨折合併嚴重出血, 無法以其他方式有效止血時. 醫師在手術中將紗布填塞於病患骨盆腔(腹膜之外)
Preperitoneal Packing for Pelvic Fracture Bleeding Control:
上圖來自 Thr trauma pro
下面資料來自 uptodate-Control of external hemorrhage in trauma patients
僅節錄傷口填塞這段.
以下中文使用google翻譯
傷口填塞可填充任何死腔區域，並增加對傷口深層血管的直接壓力[ 18 ]。
填塞創傷性傷口時，應將乾淨的布、紗布或含止血劑的敷料深深地、牢固地壓入傷口。在保持直接壓力的同時，應繼續填塞直至傷口填滿。填塞完成後，塗抹敷料覆蓋傷口，並用雙手施加壓力。然後，應保持該壓力直至止血[ 18 ]。
市售的含止血劑敷料包括因子濃縮劑、黏膜黏附劑和促凝血劑。這些敷料可用於施加直接壓力並填塞傷口。放置這些敷料後，應施加至少3分鐘的直接壓力[ 19,20 ]。需要注意的是，某些敷料可能含有不透射線的標記，這可能會導致CT成像出現散射。 (請參閱“局部止血劑和組織黏合劑的概述”，關於‘外用藥物’一節)
Wound packing — Wound packing fills any area of dead space and increases direct pressure on the vessels deep within the wound [18].
To pack a traumatic wound, a clean cloth, gauze, or hemostatic-impregnated dressing is pressed deeply and firmly into the wound. While maintaining direct pressure, packing should be added until the wound is filled. Once packed, the wound should be covered with a dressing, and pressure should be applied using two hands. Then, it should be maintained until hemostasis is achieved [18].
Factor concentrators, mucoadhesives, and procoagulants are options for commercially available hemostatic-impregnated dressings. These dressings can be used to apply direct pressure and pack a wound. At least three minutes of direct pressure should be applied after placing these dressings [19,20]. Note that some dressings may have a radiopaque marker that can cause scatter on computed tomographic (CT) imaging. (See "Overview of topical hemostatic agents and tissue adhesives", section on 'External agents'.)
2025年7月10日 星期四
兒科-兒童-小兒-Pediatric 年齡定義
2025-07-11
Pediatric 中文可翻譯為小兒. 兒童. 但這個詞是指幾歲以下的人. 在不同地方有不同標準.
台灣兒科醫學會的公告 2007-09-12
行政院衛生署「兒童健康推展委員會」96年第2次會議討論我國兒科之就診年齡，建議醫療機構得參酌兒童及少年福利法之定義，將兒科就診年齡認定為未滿18歲之人乙案。
美國FDA Pediatric Medical Devices(更新至2024-04-18) 出生至21歲(滿22足歲之前)
Pediatric medical devices treat or diagnose diseases and conditions from birth through age 21. The Federal Food, Drug, and Cosmetic Act (FD&C Act) defines pediatric patients as persons aged 21 or younger at the time of their diagnosis or treatment. Pediatric subpopulations are further categorized as follows:
Neonates - from birth through the first 28 days of life
Infants - 29 days to less than 2 years
Children - 2 years to less than 12 years
Adolescents - aged 12 through 21 (up to but not including the 22nd birthday)
同樣是美國FDA~這裡是指出生至16歲(滿17歲之前)
Pediatric Drug Development: RegulatoryConsiderations — Complying With thePediatric Research Equity Act andQualifying for Pediatric Exclusivity Underthe Best Pharmaceuticals for Children ActGuidance for IndustryDRAFT GUIDANCE
For purposes of pediatric drug development, FDA generally considers the pediatric population to include those patients from birth to younger than 17 years (i.e., birth through 16 years of age), and to include the subpopulation age groups of neonates, infants, children, and adolescents. 11 Consistent with International Council for Harmonisation (ICH) guidelines, 12 FDA considers 67 these subpopulation age groups to be divided as follows:
• Neonates: birth through 27 days (corrected gestational age)
• Infants: 28 days to 23 months
• Children: 2 years to 11 years
• Adolescents: 12 years to younger than 17 years
11 See 21 CFR 201.57(c)(9)(iv)(A) (“the terms pediatric population(s) and pediatric patient(s) are defined as the pediatric age group, from birth to 16 years, including age groups often called neonates, infants, children, and adolescents”). FDA interprets “birth to 16 years” in 21 CFR 201.57(c)(9)(iv)(A) to mean from birth to younger than 17 years old. See, for example, the guidance for industry Pediatric Information Incorporated Into Human Prescription Drug and Biological Product Labeling (March 2019).
德國的慕尼黑兒科年齡分類標準定義為滿18歲以前
19歲第一天開始定義為成人 adult
Systemic review of age brackets in pediatric emergency medicine literature and the development of a universal age classification for pediatric emergency patients - the Munich Age Classification System (MACS)
The following classification is one of the most common used in Germany [7].
Newborn: up to the completed 28th day of life.
Infant: 29 days – 12 months.
Toddler: 2–3 years.
Child: 4–12 years.
Adolescent: 13–18 years.
Adult: from the beginning of the 19th year
Pediatric 中文可翻譯為小兒. 兒童. 但這個詞是指幾歲以下的人. 在不同地方有不同標準.
台灣兒科醫學會的公告 2007-09-12
行政院衛生署「兒童健康推展委員會」96年第2次會議討論我國兒科之就診年齡，建議醫療機構得參酌兒童及少年福利法之定義，將兒科就診年齡認定為未滿18歲之人乙案。
衛生署藥政處 中華民國九十一年七月公告的~~小兒族群的藥動學試驗基準 Guidance for Pediatric Pharmacokinetic Studies 年齡是指 16歲以下. 但後來衛生福利部於中華民國110年3月23日以衛授食字第1101401255號公告修訂「小兒族群的藥動學試驗基準」，已經將年齡修正為18歲
美國FDA Pediatric Medical Devices(更新至2024-04-18) 出生至21歲(滿22足歲之前)
Pediatric medical devices treat or diagnose diseases and conditions from birth through age 21. The Federal Food, Drug, and Cosmetic Act (FD&C Act) defines pediatric patients as persons aged 21 or younger at the time of their diagnosis or treatment. Pediatric subpopulations are further categorized as follows:
Neonates - from birth through the first 28 days of life
Infants - 29 days to less than 2 years
Children - 2 years to less than 12 years
Adolescents - aged 12 through 21 (up to but not including the 22nd birthday)
同樣是美國FDA~這裡是指出生至16歲(滿17歲之前)
Pediatric Drug Development: RegulatoryConsiderations — Complying With thePediatric Research Equity Act andQualifying for Pediatric Exclusivity Underthe Best Pharmaceuticals for Children ActGuidance for IndustryDRAFT GUIDANCE
For purposes of pediatric drug development, FDA generally considers the pediatric population to include those patients from birth to younger than 17 years (i.e., birth through 16 years of age), and to include the subpopulation age groups of neonates, infants, children, and adolescents. 11 Consistent with International Council for Harmonisation (ICH) guidelines, 12 FDA considers 67 these subpopulation age groups to be divided as follows:
• Neonates: birth through 27 days (corrected gestational age)
• Infants: 28 days to 23 months
• Children: 2 years to 11 years
• Adolescents: 12 years to younger than 17 years
11 See 21 CFR 201.57(c)(9)(iv)(A) (“the terms pediatric population(s) and pediatric patient(s) are defined as the pediatric age group, from birth to 16 years, including age groups often called neonates, infants, children, and adolescents”). FDA interprets “birth to 16 years” in 21 CFR 201.57(c)(9)(iv)(A) to mean from birth to younger than 17 years old. See, for example, the guidance for industry Pediatric Information Incorporated Into Human Prescription Drug and Biological Product Labeling (March 2019).
德國的慕尼黑兒科年齡分類標準定義為滿18歲以前
19歲第一天開始定義為成人 adult
Systemic review of age brackets in pediatric emergency medicine literature and the development of a universal age classification for pediatric emergency patients - the Munich Age Classification System (MACS)
The following classification is one of the most common used in Germany [7].
Newborn: up to the completed 28th day of life.
Infant: 29 days – 12 months.
Toddler: 2–3 years.
Child: 4–12 years.
Adolescent: 13–18 years.
Adult: from the beginning of the 19th year
2025年7月9日 星期三
野外與登山醫學-Frostbite: Acute care and prevention 凍瘡-名詞定義(frostbite; frostnip; warm ischemia time; immersion foot)
2025-07-10 08:58AM
另一篇相關筆記 浸足症-壕溝足
資料來源 uptodate Frostbite: Acute care and prevention
Frostnip 組織內無冰晶, 嚴重度較輕, 可能完全恢復
壕溝足發生的環境主要是潮濕與低溫, 但溫度還不到達會結冰的低溫.
下面中文使用google中文翻譯, 原文的內容很多. 這裡僅節錄名詞定義與到院前處置的部分.
名詞定義
●Frostbite 凍瘡－組織凍結造成的局部冷損傷。(這段我自己加上的: 凍傷的組織內會出現冰晶, 可能發生永久性損傷, 例如截肢)
到院前處置
●盡快將患者轉移到溫暖的環境。盡可能覆蓋、墊上或夾住患處，以防止進一步暴露，最大程度地減少途中受傷。
●脫掉濕的或緊身的衣服和首飾。
●避免凍傷的腳部行走；這會加劇組織損傷。若撤離需要步行，請勿在行走前回溫。(最好有旁人協助移動,萬不得已需要自己走路,不要回溫患處)
●如果在接受最終治療之前凍傷組織有可能再次凍傷，請勿回溫。這會導致更嚴重的組織損傷。
●若嘗試院前保暖，可選擇的方法包括將患處放入溫水（不是熱水）或使用體溫保暖（例如，將凍傷的手指放在自己腋窩中）。
●不要摩擦凍傷部位以試圖使其回溫；這可能會導致進一步的組織損傷。
●避免使用爐灶或火來回溫凍傷組織。凍傷組織沒有知覺，有可能發生燒燙傷(應使用溫水回溫.避免乾式回溫)
DEFINITIONS
●Frostbite – A localized cold-induced injury caused by freezing of tissue.
●Frostnip – Cold-induced, severe vasoconstriction of the skin with frost (ice crystals) on the surface of the skin. There is no ice in the tissue. Frostnip resolves after rewarming without permanent tissue damage.
●Warm ischemia time – The time from the start of thawing frostbitten tissue to reperfusion (ie, treatment with thrombolysis or vasodilator).
●Immersion foot ("trench foot") – A nonfreezing cold injury (NFCI) that results from prolonged exposure of the feet to a combination of dampness and cold and may also cause tissue loss and long-term sequelae. Immersion foot involves injury to the sympathetic nerves and vasculature of the feet. Feet and occasionally hands can be numb or extremely painful (picture 1). It was first described in 1914 during World War I trench warfare. Tight-fitting boots exacerbate the condition. Improved foot hygiene, including better boot design and frequent sock changes, resulted in a much lower prevalence among soldiers by 1917. Not just of historical significance, immersion foot was a major medical issue during the Falklands War of 1982 and still occurs, especially among individuals experiencing homelessness [6,7].
●Pernio ("chilblains") – A form of NFCI characterized by localized inflammatory lesions that can result from acute or repetitive exposure to cold. Lesions are red or purple, often nodular, and are often very painful or pruritic (picture 2). Pernio is most common in young females, but males and females of all ages may be affected [8]. Permanent damage from a single episode of pernio is uncommon, with symptoms and signs generally resolving within two to three weeks.
Prehospital care
●Get the patient to a warm environment as soon as possible. Whenever possible, cover, pad or splint the affected area to prevent further exposure, minimizing injury en route.
●Remove wet or restrictive clothing and jewelry.
●Avoid walking on frostbitten feet; this can increase tissue damage. If walking is necessary for evacuation, do not rewarm the feet before walking.
●Do not rewarm frostbitten tissue if there is a possibility of refreezing before reaching definitive care. This will result in worse tissue damage.
●If prehospital warming is attempted, options include placing the affected area in warm (not hot) water or warming it using body heat (eg, placing frostbitten fingers in the axillae).
●Do not rub frostbitten areas in an attempt to rewarm them; this can cause further tissue damage.
●Avoid the use of stoves or fires to rewarm frostbitten tissue. Frostbitten tissue is insensate, allowing the possibility of burns [9,41,55].
另一篇相關筆記 浸足症-壕溝足
資料來源 uptodate Frostbite: Acute care and prevention
Frostnip 組織內無冰晶, 嚴重度較輕, 可能完全恢復
Ftostbite 組織內有冰晶. 嚴重度較高, 可能須清創或截肢
因寒冷造成血管收縮, 甚至皮膚表面結霜, 但組織內尚未出現冰晶, 這個階段有可能完全恢復不留下後遺症. 稱為 frostnip.
因寒冷造成血管收縮, 甚至皮膚表面結霜, 但組織內尚未出現冰晶, 這個階段有可能完全恢復不留下後遺症. 稱為 frostnip.
更嚴重的情況. 凍傷部位組織內出現冰晶, 組織局部壞死, 需清創或截肢手術. 稱為 frostbite.
Pernio (chilblains) 這個詞很難翻譯., google 直接翻譯成凍瘡. 但這個並不是 frosbite或 frostnip. 是由暴露在潮濕寒冷但不到結冰溫度的環境, 而引起手腳紅腫發紫甚至起水泡. 通常2-3周內能完全恢復
壕溝足發生的環境主要是潮濕與低溫, 但溫度還不到達會結冰的低溫.
下面中文使用google中文翻譯, 原文的內容很多. 這裡僅節錄名詞定義與到院前處置的部分.
名詞定義
●Frostbite 凍瘡－組織凍結造成的局部冷損傷。(這段我自己加上的: 凍傷的組織內會出現冰晶, 可能發生永久性損傷, 例如截肢)
●Frostnip 凍傷 －皮膚因寒冷引起的嚴重血管收縮，皮膚表面結霜（冰晶）。組織中沒有冰。復溫後，凍傷消退，不會造成永久性組織損傷。
●熱缺血時間－從凍傷組織開始解凍到再灌注（即以血栓溶解或血管擴張劑治療）的時間。
●浸水足（「戰壕足」）－一種非凍傷性冷損傷 (NFCI)，由足部長期暴露於潮濕和寒冷的環境中引起，也可能導致組織損失和長期後遺症。浸水足涉及足部交感神經和血管的損傷。足部，有時手部，可能會出現麻木或劇烈疼痛(圖 1 )。它最早在1914年第一次世界大戰的塹壕戰中被描述。過緊的靴子會加重病情。到1917年，足部衛生的改善，包括更好的靴子設計和頻繁更換襪子，使士兵的足部患病率大大降低。浸泡足不僅具有歷史意義，而且在1982年的福克蘭群島戰爭期間也是一個主要的醫療問題，至今仍然存在，尤其是在無家可歸的人群中[ 6,7 ]。
●Pernio ("chilblains") –一種非凍傷性冷損傷 (NFCI)，其特徵是局部發炎性病變，可由急性或反覆暴露於寒冷(未達結冰溫度)潮濕的空氣中引起。症狀通常發生在受冷的數小時後 (可參考 MAYO CLINIC CHILBLAINS的說明)
●熱缺血時間－從凍傷組織開始解凍到再灌注（即以血栓溶解或血管擴張劑治療）的時間。
●浸水足（「戰壕足」）－一種非凍傷性冷損傷 (NFCI)，由足部長期暴露於潮濕和寒冷的環境中引起，也可能導致組織損失和長期後遺症。浸水足涉及足部交感神經和血管的損傷。足部，有時手部，可能會出現麻木或劇烈疼痛(圖 1 )。它最早在1914年第一次世界大戰的塹壕戰中被描述。過緊的靴子會加重病情。到1917年，足部衛生的改善，包括更好的靴子設計和頻繁更換襪子，使士兵的足部患病率大大降低。浸泡足不僅具有歷史意義，而且在1982年的福克蘭群島戰爭期間也是一個主要的醫療問題，至今仍然存在，尤其是在無家可歸的人群中[ 6,7 ]。
●Pernio ("chilblains") –一種非凍傷性冷損傷 (NFCI)，其特徵是局部發炎性病變，可由急性或反覆暴露於寒冷(未達結冰溫度)潮濕的空氣中引起。症狀通常發生在受冷的數小時後 (可參考 MAYO CLINIC CHILBLAINS的說明)
病灶呈紅色或紫色，通常呈結節性，有時候會起水泡，通常非常疼痛或搔癢(圖片2 )。pernio 最常見於年輕女性，但所有年齡層的男性和女性都可能受累[ 8 ]。單次pernio 發作造成永久性損傷並不常見，症狀和徵兆通常會在2-3週內消退。
到院前處置
●盡快將患者轉移到溫暖的環境。盡可能覆蓋、墊上或夾住患處，以防止進一步暴露，最大程度地減少途中受傷。
●脫掉濕的或緊身的衣服和首飾。
●避免凍傷的腳部行走；這會加劇組織損傷。若撤離需要步行，請勿在行走前回溫。(最好有旁人協助移動,萬不得已需要自己走路,不要回溫患處)
●如果在接受最終治療之前凍傷組織有可能再次凍傷，請勿回溫。這會導致更嚴重的組織損傷。
●若嘗試院前保暖，可選擇的方法包括將患處放入溫水（不是熱水）或使用體溫保暖（例如，將凍傷的手指放在自己腋窩中）。
●不要摩擦凍傷部位以試圖使其回溫；這可能會導致進一步的組織損傷。
●避免使用爐灶或火來回溫凍傷組織。凍傷組織沒有知覺，有可能發生燒燙傷(應使用溫水回溫.避免乾式回溫)
DEFINITIONS
●Frostbite – A localized cold-induced injury caused by freezing of tissue.
●Frostnip – Cold-induced, severe vasoconstriction of the skin with frost (ice crystals) on the surface of the skin. There is no ice in the tissue. Frostnip resolves after rewarming without permanent tissue damage.
●Warm ischemia time – The time from the start of thawing frostbitten tissue to reperfusion (ie, treatment with thrombolysis or vasodilator).
●Immersion foot ("trench foot") – A nonfreezing cold injury (NFCI) that results from prolonged exposure of the feet to a combination of dampness and cold and may also cause tissue loss and long-term sequelae. Immersion foot involves injury to the sympathetic nerves and vasculature of the feet. Feet and occasionally hands can be numb or extremely painful (picture 1). It was first described in 1914 during World War I trench warfare. Tight-fitting boots exacerbate the condition. Improved foot hygiene, including better boot design and frequent sock changes, resulted in a much lower prevalence among soldiers by 1917. Not just of historical significance, immersion foot was a major medical issue during the Falklands War of 1982 and still occurs, especially among individuals experiencing homelessness [6,7].
●Pernio ("chilblains") – A form of NFCI characterized by localized inflammatory lesions that can result from acute or repetitive exposure to cold. Lesions are red or purple, often nodular, and are often very painful or pruritic (picture 2). Pernio is most common in young females, but males and females of all ages may be affected [8]. Permanent damage from a single episode of pernio is uncommon, with symptoms and signs generally resolving within two to three weeks.
Prehospital care
●Get the patient to a warm environment as soon as possible. Whenever possible, cover, pad or splint the affected area to prevent further exposure, minimizing injury en route.
●Remove wet or restrictive clothing and jewelry.
●Avoid walking on frostbitten feet; this can increase tissue damage. If walking is necessary for evacuation, do not rewarm the feet before walking.
●Do not rewarm frostbitten tissue if there is a possibility of refreezing before reaching definitive care. This will result in worse tissue damage.
●If prehospital warming is attempted, options include placing the affected area in warm (not hot) water or warming it using body heat (eg, placing frostbitten fingers in the axillae).
●Do not rub frostbitten areas in an attempt to rewarm them; this can cause further tissue damage.
●Avoid the use of stoves or fires to rewarm frostbitten tissue. Frostbitten tissue is insensate, allowing the possibility of burns [9,41,55].
腎臟超音波參考格式
開單日期：2025-05-09
腎臟科超音波 檢查報告單
Examination For : HTN,CKD,Cr:1.31
1.Size R’t : 5.5 cm L’t : 9.51 cm
2.Cortical echogenecity R’t : Severely elevated L’t : Normal
3.Central Echo R’t : Not dilated L’t : Not dilated
4.Solid lesion R’t : Several hyperechoic lesions with/without pAS L’t : Nil
5.Cystic lesion R’t : Nil L’t : Nil 6.Urinary bladder Smooth bladder wall
7.Impression Right atrophied kidney and severe parenchymal renal disease
8.Suggestion
9.Others
腎臟科超音波 檢查報告單
Examination For : HTN,CKD,Cr:1.31
1.Size R’t : 5.5 cm L’t : 9.51 cm
2.Cortical echogenecity R’t : Severely elevated L’t : Normal
3.Central Echo R’t : Not dilated L’t : Not dilated
4.Solid lesion R’t : Several hyperechoic lesions with/without pAS L’t : Nil
5.Cystic lesion R’t : Nil L’t : Nil 6.Urinary bladder Smooth bladder wall
7.Impression Right atrophied kidney and severe parenchymal renal disease
8.Suggestion
9.Others
2025年7月1日 星期二
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