ACLS 2025 Part 11: Post–Cardiac Arrest Care:

2026-05-31

心肺復甦之後的照護. TTM

之前的TTM是 target temperature control. 現在 TTM 是 total temperature control. 

目前建議在 ROCS 之後維持體溫 32-37.5 至少 36 小時. 

Part 11: Post–Cardiac Arrest Care: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

.

The optimal overall duration of temperature control, including hypothermic temperature control (32 °C–34 °C) and normothermic or fever-prevention temperature control (36 °C–37.5 °C), is an important area of ongoing investigation. In one randomized trial, there was no difference in outcomes comparing hypothermic temperature control for 24 versus 48 hours, although the trial may have been underpowered and effect estimates favored longer temperature control durations.10 In another recent randomized trial, there was no difference in outcomes comparing a period of device-based fever prevention of 12 versus 48 hours after an initial 24-hour period of temperature control to 36 °C (ie, 36 versus 72 total hours of temperature control, respectively).15 The 2 large TTM randomized trials protocolized patients to 72 hours of total temperature control.6,9 Recognizing evolution of evidence and definitions with respect to temperature control, 36 hours of total temperature control is the shortest recommended duration. Multiple observational studies have found strong associations between post–cardiac arrest fever and poor outcomes, including for fevers occurring after an initial 24-hour period of temperature control.16–19 Results of the ICECAP (Influence of Cooling Duration on Efficacy in Cardiac Arrest Patients) trial, which aimed to identify the optimal duration of hypothermic temperature control for patients with both shockable and nonshockable rhythms, are pending after the study was stopped in June 2025.20

Top 10 Take-Home Messages for Adult Advanced Cardiovascular Life Support

1.

The section on neuroprognostication was updated to include predictors of favorable outcome, and neurofilament light chain (NfL) was added as a serum biomarker: When performed in combination with other prognostic tests, it may be reasonable to consider high serum values of neuron-specific enolase (NSE) or NfL within 72 hours after cardiac arrest to support the prognosis of unfavorable neurological outcome in patients who remain comatose.

2.

It is reasonable that temperature control be maintained for at least 36 hours in adult patients who remain unresponsive to verbal commands after return of spontaneous circulation (ROSC).

3.

It may be reasonable to perform computed tomography (CT) for adult patients after ROSC to investigate the etiology of cardiac arrest and complications from resuscitation, and it may be reasonable to perform echocardiography or point-of-care cardiac ultrasound for adult patients after ROSC to identify clinically significant diagnoses requiring intervention.

4.

Coronary angiography is recommended prior to hospital discharge in adult cardiac arrest survivors with suspected cardiac etiology, particularly in the presence of an initial shockable rhythm, unexplained left ventricular systolic dysfunction, or evidence of severe myocardial ischemia.

5.

Hypotension should be avoided in adults after ROSC by maintaining a minimum mean arterial pressure (MAP) of at least 65 mm Hg, though there is insufficient evidence to recommend a specific vasopressor to treat low blood pressure in adult patients after cardiac arrest.

6.

In adult patients with cardiogenic shock (CS) after cardiac arrest and ROSC, temporary mechanical circulatory support (MCS) should not be routinely used, though in highly selected adult patients with refractory CS after cardiac arrest and ROSC, temporary MCS may be considered.

7.

A new section dedicated to diagnosis and management of myoclonus after cardiac arrest was developed and includes the following: Treatment to suppress myoclonus without an electroencephalography (EEG) correlate is not recommended in adult survivors of cardiac arrest.

8.

A therapeutic trial of a nonsedating antiseizure medication may be reasonable in adult patients who do not follow commands after ROSC with EEG patterns on the ictal-interictal continuum.

9.

It is recommended that cardiac arrest survivors and their caregivers have structured assessment and treatment/referral for emotional distress after medical stabilization and before hospital discharge.

10.

Interventions to address health care professional burnout may be beneficial.

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

2026-05-30

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

 僅節錄標準治療這一段

4.1 氧氣維持90%即可. 過多氧氣並不會減少一年內死亡率. 

4. Standard Medical Therapies for STEMI and NSTE-ACS

4.1. Oxygen Therapy
4.2. Analgesics 止痛

Synopsis 概要 

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

通常是使用 Nitrates 硝酸鹽類及鴉片類 opiate 藥物 

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

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

Table 6. Analgesic Treatment Options for Cardiac Chest Pain

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

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

4.3. Antiplatelet Therapy
4.3.1. Aspirin

概要 Synopsis

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

P2Y12抑制劑包括

Clopidogrel (保栓通 / Plavix)

Ticagrelor (百無凝 / Brilinta)

Prasugrel (抑凝安 / Efient)：

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

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

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

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

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

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

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

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

4.3.2. Oral P2Y12 Inhibitors During Hospitalization

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

跳過 4.4 抗凝血劑. 4.5 降血脂藥物

4.6

24小時內給予乙型阻斷劑可減少再次梗塞及心室心律不整機率

4.6. Beta-Blocker Therapy

跳過標準治療最後一項 4.7

4.7. Renin-Angiotensin-Aldosterone System Inhibitors

感染水痘期間若無明顯症狀仍可施打其他疫苗

2026-05-28 中午

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

ACLS 缺血性中風打 rtPA 效益與風險 2015

2026-05-22

重點

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

血管內取栓術並不會增加 tPA 風險

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

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

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

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

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

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

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

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

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

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

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

Inclusion Criteria 

Diagnosis of ischemic stroke causing measurable neurological deficit 

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

Current intracranial hemorrhage 

Subarachnoid hemorrhage 

Active internal bleeding 

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

Bleeding diathesis 

Current severe uncontrolled hypertension 

Additional exclusion criteria Between 3 and 4.5 hours: 

Age >80 years 

Severe stroke (NIHSS > 25) 

History of diabetes and prior stroke 

Taking an oral anticoagulant regardless of INR 

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

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

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

Criteria for Endovascular Therapy: 

Within 6 hours of stroke onset 

Pre-stroke modified Rankin Score (mRs0-1) 

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

內頸動脈或中大腦動脈第一段 M1 阻塞引起的中風

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

Age 18 years or older 

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

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

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

施打tPA效益

預後較佳(43% vs 未施打tPA 32%)

能回復到日常生活 53% (未施打32%)

一年後無中風後遺症或很輕微後遺症 39% (未施打tPA第三個月26%)

3-4.5小時施打 tPA

90天無殘障(或輕微殘障) 52.4% (未施打 45.2%)

tPA及血管內取栓術風險

tPA風險

2.8%腦出血(未打tPA 0.2%)

死亡率未增加

Risks Of Alteplase (IV r-tPA) 

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

Mortality: No increase from placebo groups 

取栓術風險

主要是取栓過程可能發生血管破裂

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

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

Systemic bleeding 

Bleeding at the site of catheter introduction 

Catheter infection 

Death

90天無殘障或輕微殘障比例; 血管內取栓術 47%. 未取栓 28%

取栓術能增加20%良好預後

modified Rankin score 

0分代表無殘障

2分代表輕微殘障

Massive Hemorrhage 止血 節錄自 2026 TCCC 指引

2026-05-21

2026 TCCC指引--01 May 2026

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

Basic Management Plan for Care Under Fire/Threat

Basic Management Plan for Tactical Field Care-

Principles of Tactical Evacuation Care (TACEVAC)

Basic Management Plan for Tactical Evacuation Care

下面節錄各大標題關於出血部分

Basic Management Plan for Care Under Fire/Threat

-共有七點建議. 僅節錄第六點(第六點下又有三項建議)

-第六點. 在戰術情況許可時. 停止危及生命的外出血

a. 由傷員自行止血

b. 使用 CoTCCC建議的肢體止血帶. 商用止血帶較能符合人體解剖構造

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

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

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

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

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

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

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

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

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

TCCC.

3. Massive Hemorrhage 大出血

4. Airway Management

5. Respiration/Breathing

6. Circulation 循環

7. Hypothermia Prevention

8. Traumatic Brain Injury:

9. Penetrating Eye Trauma

10. Monitoring

11. Analgesia

12. Antibiotics

13. Inspect and dress known wounds

14. Check for additional wounds.

15. Burns.

16. Splint fractures and re-check pulses.

17. Cardiopulmonary resuscitation (CPR).

18. Communication

19. Documentation of Care.

20. Prepare for Evacuation

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

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

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

Massive hemorrhage b.

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

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

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

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

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

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

Massive hemorrhage c.

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

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

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

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

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

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

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

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

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

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

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

Massive hemorrhage d. 

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

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

Basic Management Plan for Tactical Field Care

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

    a. bleeding

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

    c. IV/IO Access

    d. Tranexamic Acid (TXA)

    e. Fluid Resuscitation

    f. Refractory Shock

a. Bleeding (bleeding 之下又分成四點)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

緩釋型藥物-結構

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

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

 
使用雷射在藥錠表面打孔(youtube模擬動畫及實際製作過程)

前五個連結是在已經成形的藥錠打動

第六個連結是使用細針將藥物注射入空膠囊. 注射孔就是藥物釋放孔

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

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

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

ACLS 考前重點整理

縮寫及名詞解釋

AHA美國心臟學會
ASA美國腦中風學會

VF 心室顫動

VT 心室頻脈

AF 心房顫動(建議不要以英文大小些區分顫動或撲動)

AFL 心房撲動

MACE 主要不良心血管事件

MACE包含心因性死亡, 非致死的心肌梗塞, 非致死的中風(CV death, non-fatal MI, and non-fatal stroke

ACS急性冠心症 acute coronary syndrome
****** ACS包含 unstable angina不穩定心絞痛. 急性心肌梗塞STEMI或NSTEMI
CAG (Coronary Angiography)冠狀動脈攝影
PTCA (Percutaneous Transluminal Coronary Angioplasty)冠狀動脈氣球擴張術
PCI (Percutaneous Coronary Intervention) 是比較廣義的, 包含 CAG,PTCA及其他新發展的斑塊切除術等等所有技術

tPA= tPA=tissue plasminogen activator 

  ******最初的tPA是由人體組織(子宮組織或黑色素瘤組織)分離

rtPA=使用基因重組技術製造的tPA (將重組基因置入大腸桿菌或酵母菌)

5H5T記憶口訣: 兩心兩肺低氧高鉀,孫耀威(酸藥溫), 低血容

**兩心. 心肌梗塞,心包膜填塞

**兩肺:張力性氣胸,肺栓塞

**高鉀是指低血鉀或高血鉀. 口訣只寫高鉀是方便記憶

**CPR 過程通常會快速輸液(生理食鹽水或其他晶體溶液). 因此低血容通常最先被處置

**酸藥溫= 酸中毒. 藥物. 低體溫

推薦 臨床筆記 2026 ACLS 急救流程圖(中文版) 作者 林世崇醫師 Alex Lin, MD, 心臟科

CPR心肺復甦流程

1. 初次評估先檢查意識反應, 再評估有無正常呼吸. 一般民眾不建議檢查脈搏

2. 人工呼吸每次吹氣一秒鐘. 當胸部下降可吹第二次

    壓胸速率100-120次/每分鐘. 按壓深度至少 5 公分, 不可超過6公分

2. 一般民眾可持續壓胸不用間斷(不做人工呼吸)

3. 醫護人員CPR每兩分鐘或五次循環再次評估時先檢查脈搏

5. 有脈搏但呼吸不正常. 每分鐘給予10-12次人工呼吸     

6. 有脈搏. 有正常呼吸. 可擺復甦姿勢 (復甦姿勢無法作人工呼吸或胸部按壓)

7. 氣管插管並非CPR過程必要處置. 

    (流程圖一般是將插管與epinephrine放在一起, 屬於ALS)

院內心肺復甦術過程及ROSC之後照護

1. ROSC定義. 恢復自發性循環, 有脈搏持續超過30秒

2. 若患者尚未清醒. 尚未作氣管插管的可考慮先插管. 呼吸器設定, 初始速率每分鐘12次, 潮氣容積每次500cc(之後根據狀況調整速率或容積)

3. CPR過程, 氣管插管應同時使用潮氣末二氧化碳監視器(end-tidal CO2 monitor), 維持 CO2 約 35-45 mmHg, 避免過度換氣.

4. CPR過程過度換氣會減少回心血量. 進一步減少心臟輸出血量

中風
AHA 2026 缺血性中風早期處置指引(英文版)
美國辛辛那提到院前中風計分法包含三項檢查
請患者露出牙齒或微笑時單側臉部下垂
患者閉眼睛，兩手臂抬起伸直超過 10秒，單側手臂下移
請患者念一句較難唸的話，有口吃或無法說話

缺血性中風患者施打 tPA
症狀發生時間明確, 且在3小時內能開始注射tPA, 目前在特定對象可放寬時間至4.5小時, 但給藥時間延遲至4.5小時的風險是腦出血機率會增加. 需慎選個案
  心肌梗塞(MI)打tPA不需等待抽血報告出來

  中風主要問題是殘障/ 心肌梗塞主要問題是猝死. 當然AMI後也會有殘障問題. 
缺血性中風患者施打tPA條件
(不符合施打 tPA的中風患者，仍可考慮顱內血栓移除術)
需在三小時內開始注射藥物. 缺血性中風施打tPA前需看抽血報告. 需要影像檢查並判讀完成, 經過專家醫師向家屬解釋病情. 家屬可能也需要一點時間思考做決定. 這些過程如果醫院內各單位配合良好. 一小時內能做完就算品質優良了. 所以在中風症狀發生後兩小時內到達急診. 比較有機會能打tPA.

  一個小時完成上面所有事項真的要很趕, 需要放射科.檢驗科.急診科,神經內外科密切配合才有辦法達成. 

參考資料 1台灣腦中風學會靜脈血栓溶解劑治療急性缺血性腦中風之一般準則

參考資料 2GUIDELINES FOR THE EARLYMANAGEMENT OF PATIENTSWITH ACUTE ISCHEMIC STROKE:2019 Update to the 2018 Guidelines for the EarlyManagement of Acute Ischemic Stroke

參考資料3 Guidelines for the Early Management of Patients With Ischemic Stroke: 2005 Guidelines Update A Scientific Statement From the Stroke Council of the American Heart Association/American Stroke Association

施打tPA檢查清單

症狀太輕或太嚴重接排除 (NIHSS > 25 or NIHSS < 4)

給藥前血壓必須控制在 185/110 mmHg以下, 開始治療後各減5. 打tPA 24 小時內維持血壓 < 180/105 mmHg.(剛到急診血壓高於185/110, 可給予降壓藥物之後, 通常是給 Labetalol (商品名trandate) 10–20 mg IV for 1–2 min, 每10分鐘可重複給藥, 最大劑量 300mg, 若能以降壓藥物控制血壓, 仍可施打tPA)
關於Labetarol可參考2005 AHA/ASA 缺血性中風早期處置指引table 6)
下列抽血項目若異常則不建議打tPA
血小板 < 10萬
INR >1.7 (口服抗凝血劑 warfarin會造成INR上升)
aPTT > 40秒(heparin會造成aPTT延長)
PT > 15秒

血糖<50 或血糖 > 400

之前在醫院. 神內醫師會將腎功能不良的直接從清單排除. 但洗腎患者若打了heparin之後, 若APTT < 40 秒仍可考慮打 tPA
台灣版將 NIHSS < 6 列為 tPA 排除條件. 但 ACLS 建議 NIHSS 即使低到2-4分. 若有明顯肢體殘障/功能喪失, 例如下肢肌力2分. 仍可考慮打 tPA
其他主要考量是易出血體質, 或身體局部可能出現危及生命的出血

但月經到來並不影響施打 tPA

參考資料:台灣腦中風學會, 各項指引

急性腦中風一般照護
1. 若血糖 > 180mg/dL以上，可給予胰島素治療
(目前ACLS及台灣腦中風學會指引都建議控制在140-180)

(2008台灣腦中風治療指引建議200以上打胰島素)

(2022台灣腦中風學會-腦血管疾病血糖控制指引)建議控制在140-180)

(很久之前歐洲版建議140以下. 台灣建議200, ACLS建議185)

(2010年AHA版本的急性中風治療指引建議控制在185以下)
2. 若體溫>38度建議給退燒藥物(能改善預後)
3. 不建議給予葡萄糖輸液(台灣指引建議70以下要立即治療), 建議給予生理食鹽水，給予的流速約為 60-100cc/hr

4. 不建議常規使用預防癲癇藥物
5. 評估病患吞嚥功能，若有嗆到可能性，應考慮鼻胃管餵食
(若個案符合施打tPA條件, 不要做在急診作吞嚥功能評估, 也不建議在急診插鼻胃管. 但已經放置且短期長期使用鼻胃管的無妨, 打 tPA 之後需保持空腹24小時)
血糖值 < 50 建議給予 50%葡萄糖溶液, 

如果是單純低血糖造成類似中風症狀. 補充葡萄糖溶液之後通常症狀很快會改善(有很小的機率不會馬上改善)
如果不符合施打 tPA條件, 缺血性中風急性期住院過程, 血壓超過220/110才考慮給予降壓藥物. 缺血性中風急性期血壓降到正常反而有可能擴大腦部缺血範圍

急性冠心症ACS

ACS患者於到院10分鐘之內應完成下列評估

      評估生命徵象、血氧飽和濃度、病史詢問與身體檢查

      抽血檢驗心肌酵素、全血球數與凝血測試
      做12導程心電圖與判讀

STEMI通常代表一條主要血管突然阻塞. 如果因種種原因無法在120分鐘內做PCI, 可考慮先給予 tPA(PCI優於 tPA)

NSTEMI不可施打 tPA

STEMI可由EMT在到院前依照當地醫療規定給予口服aspirin(台灣 不行)

STEMI若無法做PCI需轉院. 建議在到院30分鐘內轉出

STEMI若無法在120分鐘內做PCI, 考慮給予 tPA時, 建議在到院30分鐘內給予

STEMI作PCI建議在到院60分鐘內執行. 到院90分鐘內打通血管

STEMI作PCI之前通常建議先給予兩種抗血小板藥物(Dual Antiplatelet Therapy, DAPT), 常用處方如下擇一, 第三個藥物處方顆數最少. 比較方便

1. aspirin 3顆 300mg + Clopidogrel (plavix)8顆600mg(一顆75mg)

2. aspirin 100mg+ Prasugrel 20mg(5mg四顆)

   台灣的prasugrel商品是Efient®, 有兩種劑量 3.75mg 和 5mg, 歐美國家初始劑量60mg. 亞洲人建議20mg

3. asoirin 100mg + Ticagrelor 2顆 (初始劑量兩顆共180mg)

PPCI (primary PCI): 發生ACS之後立即執行的PCI, 90-120分鐘內完成

Immediate PCI 症狀發作兩小時內執行PCI 

early PCI: 6-24小時內做PCI. 不同研究在設定的時間有差異, 一般是指 24 小時內

  ****也有些研究是指打入tPA之後 3-24 小時做PCI, 稱為 early PCI

rescue PCI 心肌梗塞患者給予靜脈注射 tPA 之後. 若症狀未改善或更嚴重(代表 tPA 失敗, tPA打通血管機率大約70%), 要考慮盡快做 PCI

delayed PCI 一般指24小時之後再做PCI, NSTEMI患者立即做PCI可能反而會增加死亡率. 建議先收入ICU或CCU. 先使用藥物治療. 但藥物治療過程若症狀更嚴重, 此時不做PCI病患可能很快死亡, 這時候可考慮盡快做PCI, 

STEMI 通常是由一條主要血管突然阻塞引起. NSTEMI 通常不是單一血管突然塞住, 而是有很多共病連帶心臟發生缺血. 

NSTEMI病人不建議使用 tPA 血栓溶解劑
NSTEMI病人胸痛惡化，對藥物治療無效時，建議 early PCI 

口服B-blocker 可減少致命性的心律不整發生,  通常建議症狀發生之後24小時內給予, 但給予B-blocker需排除禁忌症(active asthma 氣喘輕微發作. bradycardia 心跳<50, CHF 充血性心衰竭. 血壓<100, 心臟傳導阻滯)

不建議例行給予靜脈注射 beta-blocker
在院內觀察(急診或病房或ICU)過程需要持續追蹤心肌酵素、心電圖與臨床症狀

STEMI或NSTEMI患者, 若有肺水腫或心衰竭(EF < 40%). 在血液循環穩定狀態. 建議24小時內給予 ACEI (若無法使用ACEI可給 ARB取代), 但不建議同時使用ACEI與ARB

ACEI可降低AMI全因死亡率, 減少MACE

ACEI禁忌症. 腎衰竭 Cr>2.5, 高血鉀 K > 5.0 

有一篇薈萃分析研究, AMI 30天死亡率,使用ACEI組 7.1%, 使用安慰劑組 7.6%  (參考資料2025 AHA ACS治療指引)

Standard of Care: Angiotensin-Converting Enzyme (ACE) inhibitors are considered the first-line and preferred choice for patients who develop pulmonary edema or reduced left ventricular ejection fraction (LVEF) following an infarction.

STEMI(ST Elevation Myocardial Infarct), 若是 II、 III、 aVF ST段升高, 可能是心臟下壁缺血, 有一部分會合併右心室梗塞, 建議加做右側心電圖

ACS/AMI 治療
   (ACS是比較廣義的, ACS包含心絞痛及AMI
立即給予口服 ASPIRIN 160-325mg, 可考慮在24小時內給予口服Beta-blocker 乙型阻斷劑及PCI(經皮冠狀動脈介入性治療), 肺水腫或有心衰竭徵象患者可考慮在24小時內給予ACEI, 以上治療可降低AMI死亡率
氧氣濃度維持94%以上
NTG舌下含片，雖可改善胸悶胸痛症狀. 但不會降低死亡率

不建議給NTG的情況包括= 血壓< 90, 或血壓比患者平常血壓低了30%以上, 心跳<50, 右心梗塞(下壁梗塞患者容易合併右心室梗塞)

參考資料: contraindication to the use of NTG in ACS

參考資料: uptodate-ST-elevation myocardial infarction (STEMI) or non-ST-elevation acute coronary syndrome (NSTEACS): Rapid overview of emergency management

嗎啡的角色是止痛, 舒緩病患症狀. 在台灣或在國外, 醫師給予嗎啡比較保守, 但指引中註明: 沒有適當的幫患者減輕疼痛症狀是不能接受的.
雖NTG與嗎啡的角色都是減輕症狀而不是降低死亡率, 仍需視情況該給就給

NTG劑量. 舌下含錠或噴劑. 每次0.3-0.4mg, 每5分鐘一次

嗎啡劑量. 每次2-4 mg 靜脈注射
AMI發生後的四-小時內最容易出現致命性的心律不整, 例如心室顫動VF
發生V時, 心臟無法輸出血液, 需立即給予電擊去顫, 當反覆出現嚴重心律不整時, 可考慮使用 amiodarone 連續滴注. 前 6小時 1mg/min，後 18小時 0.5mg/min
(若QT延長 > 440-500 ms 不建議使用 amiodarone, 可能會讓心律不整更惡化)

心律不整/去顫術/同步整流(整律)

1. VF發生時心臟無法有效輸出血流. 因此摸不到脈搏. 發生VF不需檢查脈搏直接電擊去顫

(VF發生於使用左心室輔助器或體外循環的病患時, 也沒有脈搏. 但因機器能提供持續血流. 病患可以是清醒的)

2. 去顫是指按壓電擊器開關馬上放電. 去顫劑量通常是指雙向120-200J. 去顫劑量如果太小有可能遇到 R on T 現象(電擊放電打到病患心電圖上T波出現時間). R on T 會引發 VF, 因此去顫電擊劑量要夠大. 去顫術用於VF或無脈搏VT(pVT)(p-pulseless)

3. 同步整流, 是指按下電擊開關後. 機器會抓到心電圖上R波出現位置才放電. 因此放電時間會稍延遲, 同步整流劑量雙相 100J 開始(單相=單相位., 雙相=雙相位)

4. 危險徵象unstable signs包括: 喘-痛-悶-休克-低血壓-神智改變 

5. VT心室頻脈, 是可以有脈搏的. VT若無脈搏(pVT)則馬上給予去顫電擊, 若有脈搏且相對穩定可考慮藥物治療, 但若臨床狀況突然惡化(仍有脈搏). 不需等藥物給完, 直接同步整流(整律)

 同步整流前. 行有餘力應先注射鎮靜劑/止痛藥(通常選opioid)

 臨床上會遇到反覆出現的短暫 VT(short run VT). 這時可以一邊用藥物治療. 並隨時準備同步整流

6. 電量選擇. 規則的比較容易同步整流電擊成功. 2025年更新建議使用較高的初始電量. 原因是成功率較高. 以前認為使用低的同步整流電量比較不會造成心肌損傷(抽血驗心臟酵素). 但現有的研究認為較高電擊電量能提高成功率. 使用低電量失敗又反覆累加電擊劑量反而會造成更大損傷. 

PSVT 規則, 容易電成功, 同步整流雙相 100J開始

 單型性 VT,  規則容易電成功. 同步整流雙相100J開始. 

AF及AFL 視為同一種狀況. 不規則, 不容易電成功, 同步整流雙相200開始
2025年修改

Higher first-shock energy settings (≥200 J) are preferable to lower settings for cardioversion of atrial fibrillation and atrial flutter.

7. PSVT患者若相對穩定, 可先做頸動脈竇按壓(考試標準答案), 同時準備打上點滴, 準備給予藥物. 

8. 寬而規則QRS的 tachycardia 不建議使用 CCB(diltiazem or verapamil)治療

9. 2025年更新. 多形性VT應盡早電擊

Polymorphic ventricular tachycardia is always unstable and should be treated immediately with defibrillation, because delays in shock delivery worsen outcomes.

情境題目作答技巧

1. 若題目有心電圖, 先考慮病患是否有脈搏(是否為PEA)
2. PEA 定義. 無脈搏. 但心電圖監視器出現任何有組織的波形(扣除 VF/VT)

    辨識出PEA之後要盡快給予腎上腺素, 盡快CPR.

3. 再評估病患是否穩定: 喘-痛-悶-休克-低血壓-神智改變

4. 穩定的PSVT可先做頸動脈竇按摩, 如果無效再給藥物
 (考題的情境是簡化的, 臨床狀況卻千變萬化,  考試以先做頸動脈竇按壓為標準答案, 不代表臨床操作不會發生意外)

情境題目演練

情境1

六十歲男性，過去有心肌梗塞病史。今因心悸、頭暈、持續胸痛至急診室就診。血壓為 70/40 mmHg，心電圖如下

解析

1. 先要能辨識波形為單型性VT, 有脈搏但血壓低. 代表不穩定

2. 頭暈. 持續胸痛, 代表不穩定

3. 不穩定先電擊,不要等藥物作用, 太慢

4. 單型性VT, 有脈搏需同步. 雙相同步電量100J

5. 所有題目. 電擊前先給予鎮靜止痛藥物是標準答案 (雖實際工作中常被省略)

情境題2. 

老年女性，數周前作心瓣膜手術. 到急診後先CPR及插氣管內管, 插管後確認氣管內管位置正常, 心電圖有波形. 無脈搏

解析

1. PEA定義, 扣除 VF, VT 以外所有其他有組織的心律, 摸不到脈搏都叫做PEA

2. 辨識出PEA之後應盡快 CPR, 盡快打 Epinephrine

3. PEA不可電擊或使用體外心律調節器TCP, 會增加死亡率

2. PEA 不打 Atropine

3. PEA 如果沒有先恢復自發性循環. 會診手術醫師沒有意義

4. 如果在Megacode 遇到PEA. 除了CPE和打 epinephrine. 下一步是找原因 5H5T 

情境題3

病人胸痛超過 30分鐘, 血壓心跳正常, EKG 沒有明顯異常, 給予氧氣, aspirin. NTG 之後症狀仍未改善, 此時可考慮給嗎啡止痛

解析

1. 舒緩症狀在ACLS課程中一再被強調, 嗎啡和 NTG常用於緩解ACS症狀

2. 緩解症狀首選是NTG, 若無效才考慮給嗎啡, 不建議例行使用嗎啡. 也不建議使用嗎啡預防疼痛(疼痛之後才考慮給)

3. 嗎啡的血管擴張作用可能會減少心輸出, 增加梗塞區域及死亡率

4. 嗎啡可能會減少胃腸蠕動. 降低抗血小板藥物吸收速率

5. 有些狀況不建議給嗎啡: 低血壓, 低血容, 右心梗塞, 

Morphine should be strictly avoided in patients with hypotension, volume depletion, or right ventricular infarction, as its vasodilatory effects can trigger profound drops in cardiac output.

情境題4

當辨識出心電圖為單型性VT. 血壓正常. 接下來應該如何處置

解析

1. 有血壓. 沒有危險徵象, 藥物優先於電擊

    PSVT, AF, AFL 的考量也是如此

2. 藥物可給 amiodarone 1支 150mg in D5W 100cc, iv drip >10 min

3. 給藥過程若病患情況突然變嚴重, 不需等藥物給完. 先電擊

4. 有脈搏VT選擇電量 雙相100J 同步整流  . 無脈搏VT (pVT) 則選擇雙相 120-200 去顫

5. 若觀察過程常出現VT, 可給予 amiodarone 持續滴注

藥物適應症/劑量/使用方式/禁忌症

1. epinephrine. CPR過程每次1mg靜脈推注(不可用drip的). 每3-5分鐘一次

    PEA應盡快給予epinephrine

2. adenosine 腺苷, 一支6mg. 用於PSVT治療. 第一次給6mg. 若沒有成功, 第二次給12mg. 若兩次都沒成功. 第三次可給予 adenosine 或 Betablocker 或 CCB.

 adenosine 作用時間不超過一分鐘. 因此需快速注射入靜脈中. 臨床使用時. 可以準備一大一小兩支針筒, 第一支3-5cc針筒抽藥物, 第二支10-20cc針筒抽滿生理食鹽水. 兩支同時插入同一條靜脈管路. 第一支藥物快速推注之後. 馬上將第二支食鹽水快速推入靜脈. 讓藥物可以快速進入血中. 之後將病患打點滴的那隻手舉高. 加速血液回流至心臟. 如果藥物推注一分鐘仍沒有效果. 或心電圖監視器看到心跳變慢之後又變快. 可判定為無效.

如果adenosine 有作用. 可以見到心電圖監視器上面的心跳逐漸減緩. 甚至出現心跳短暫完全停止, 心跳停止一般不超過一分鐘. 不需 CPR. 
因為adenosine可能造成心跳短暫停止. 這個過程病患會非常不舒服. 甚至暈厥. 給藥前先對病患做心理建設. 給予事前說明. 告知醫師會在一旁隨時準備急救. 不要慌. 當下醫師可能比病人還慌....

血循穩定的個案. 心搏過快且QRS是規則且寬. 在無法確認是否為SVT心室上心搏過速或VT時, 可考慮使用 adenosine (可用以鑑別是否為VT或SVT)
In hemodynamically stable adult patients with regular monomorphic wide-complex tachycardia, IV adenosine may be considered for treatment or aiding rhythm diagnosis when the cause of the rhythm cannot be determined. 

雖然有些醫師認用 adenosine 鑑別是否 VT 有風險. 但通常是安全的. 另外. 有少數 VT 可能會被 adenosine 終止. 所以不能說打 adenosine 有效就是 PSVT. 而血循不穩定的PSVT個案. 也不建議等藥物作用. 應先考慮電擊同步整流. 

Safety & Warnings: For hemodynamically unstable or structurally compromised hearts, adenosine should generally be avoided. Rapid administration in VT patients can occasionally cause temporary paradoxical worsening or hypotension.

參考資料 AHA-2025 CPR and ECC GuidelinesPart 9 Adult ALS

參考資料 SVT With Aberrancy Versus VT 以波形變化鑑別是 VT 或 PSVT with aberrancy. 這篇寫了很多特徵. 但我覺得最重要的是這句. Differentiating between SVT with aberrancy versus VT can be very difficult. 

adenosine 禁忌症: 氣喘. 

3. amiodarone 一支150mg. 

== 用於VF. pVT 時, 一次300mg(兩支). 快速推注至靜脈, 給藥之後大約30-60秒藥物到達心臟開始發揮作用. 可提高去顫電擊成功率.

== 用於反覆發作但相對穩定的心律不整 (例如 short run VT). 可給予靜脈滴注, 初始劑量一支150mg 加入 100cc D5W, iv drip > 10 minutes. 

之後可維持持續滴注24小時. 前6小時劑量每分鐘每公斤 1mg. 之後18小時劑量每分鐘每公斤 0.5mg (如果要泡成24小時使用, 建議以D5W. 不要用生理食鹽水)
amiodarone 不建議用於 QT prolong 患者. 因為可能導致更嚴重的心律不整. normal QTc < 440mg (之前曾會診心臟科. 專家說 QTc<500mg可以使用)

 
4. CCB Diltiazem. 可用於 PSVT. AF心房顫動, AFL心房撲動
AF患者使用 diltiazem 主要是控制心跳速率不要太快. 臨床上很少能將AF轉換成正常心律(NSR=normal sinus rhythm) (既然說很少就是有例外)
AF在沒有用藥的情況. 有時候會自發性轉換為NSR.稱為 paroxysmal AF
與另一種CCB verapanil 作比較. diltiazem 相對比較不會降低心臟收縮力
口服 diltiazem 一顆30mg.
靜脈注射的 diltiazem 一支通常是50mg劑型, 

diltiazem 治療PSVT初始劑量可給20mg(或每公斤0.25mg), 兩分鐘靜脈注射完畢(緩慢推注), 如果有效果. 在五分鐘內會終止PSVT, 如果第一次給藥無效. 第二次可以給 25-35mg. 成功率約 90%

參考資料 AHA 2003 PSVT處置指引

The AV node action potential is calcium channel-dependent, and the non-dihydropyridine calcium channel blockers verapamil and diltiazem are very effective for terminating AV node-dependent PSVT.8,9 The recommended dosage of verapamil is 5 mg IV over 2 minutes, followed in 5 to 10 minutes by a second 5 to 7.5 mg dose. The recommended dosage of diltiazem is 20 mg followed, if necessary, by a second dose of 25 to 35 mg. PSVT termination should occur within 5 minutes of the end of the infusion, and over 90% of patients with AV node-dependent PSVT respond.
diltiazem 禁忌症 wide- complex tachycardia. hypotension, severe heart failure, or specific arrhythmias like Wolff-Parkinson-White (WPW) syndrome.
參考資料 AHA-2025 CPR and ECC Guidelines-Part 9 Adult ALS
Verapamil and diltiazem should not be administered for adult patients with wide- complex tachycardia.

其他藥物可參考臨床筆記 2026 ACLS 急救流程圖(中文版) 作者 林世崇醫師 Alex Lin, MD, 心臟科

網頁裡面有列出藥物用途及劑量. 舉例 verapamil