汗皰疹(急性掌蹠濕疹/出汗障礙性濕疹）Acute palmoplantar eczema (dyshidrotic eczema)

2023-08-11 11:19AM

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Acute palmoplantar eczema (dyshidrotic eczema)
介紹
急性掌蹠濕疹（更普遍地稱為出汗障礙性濕疹或汗皰症）是一種嚴重瘙癢的水皰性皮疹，影響手掌、腳底或兩者[ 1,2 ]。臨床上其特徵為深部病變，從小水泡到大而緊張的大皰，組織學上表現為海綿狀水泡。復發很常見，患者通常會經歷數月或數年的頻繁發作。
INTRODUCTION
Acute palmoplantar eczema (more popularly known as dyshidrotic eczema or pompholyx) is an intensely pruritic, vesicular eruption affecting the palms, soles, or both [1,2]. It is characterized by deep-seated lesions ranging from small vesicles to large, tense bullae clinically and by spongiotic vesicles histologically. Recurrence is common, and patients typically experience frequent episodes for months or years.

術語(名稱)

急性掌蹠濕疹的術語(名稱)很混亂。“出汗困難”一詞於 1873 年創造，用於描述手掌和腳底的水皰疾病，人們認為這是汗腺疾病 [ 3 ]。現在人們普遍認為汗腺不參與發病機制[ 4,5 ]。然而，術語(名稱)“出汗障礙性濕疹”仍在使用。

TERMINOLOGY
The terminology for acute palmoplantar eczema is confusing. The term "dyshidrosis" was coined in 1873 to describe a blistering disease of the palms and soles that was believed to be a disorder of the sweat glands [3]. It is now accepted that the sweat glands are not involved in the pathogenesis [4,5]. However, the term "dyshidrotic eczema" continues to be used.

急性掌蹠濕疹的其他術語包括“汗皰症”、“出汗困難”、“水皰性掌蹠濕疹”、“急性和復發性水皰性手部皮炎”、“手汗症”（影響手）或“足汗症”（影響腳）。這些術語並不代表具體的診斷，而是表明手/足濕疹的形態模式，可能因刺激性接觸、過敏性接觸或內源性濕疹而發生。
Other terms for acute palmoplantar eczema include "pompholyx," "dyshidrosis," "vesicular palmoplantar eczema," "acute and recurrent vesicular hand dermatitis," "cheiropompholyx" (affecting the hands), or "podopompholyx" (affecting the feet). These terms do not represent a specific diagnosis but, rather, indicate a morphologic pattern of hand/foot eczema that can occur with irritant contact, allergic contact, or endogenous eczema.

流行病學
出汗不良性濕疹最常見於年輕人和女性[ 6 ]。
一般人群中輕度或重度多汗性濕疹的患病率尚不清楚。對瑞典 107,000 多人的調查和檢查發現患病率為 0.05% [ 7 ]。在手部皮炎患者中，出汗障礙性濕疹佔病例的 5% 至 20% [ 3,8-10 ]。
EPIDEMIOLOGY
Dyshidrotic eczema occurs most commonly in young adults and in females [6].
The prevalence of either mild or severe dyshidrotic eczema in the general population is unknown. A survey and examination of over 107,000 people in Sweden found a prevalence of 0.05 percent [7]. Among patients with hand dermatitis, dyshidrotic eczema accounts for 5 to 20 percent of cases [3,8-10].

風險因素
出汗困難性濕疹的原因尚不清楚，但可能是多因素的。儘管在大多數情況下無法確定病因或誘發因素，但與出汗困難性濕疹的發生相關的因素包括：
●特應性皮炎史[ 11,12 ]
●接觸接觸性過敏原，特別是金屬 [ 11,13,14 ]
●接觸接觸刺激物（例如金屬加工液）[ 15 ]
●全身暴露於接觸性過敏原（例如攝入鎳或鈷）[ 16 ]
●遠處部位的皮膚癬菌感染（id反應）[ 12 ]
●靜脈或皮下免疫球蛋白治療[ 13,17-22 ]
●使用蘇金單抗治療，這是一種白細胞介素 (IL) 17 抑製劑，已被批准用於治療銀屑病和銀屑病關節炎 [ 23 ]
●多汗症 [ 11 ]
●吸煙 [ 24 ]
●暴露於紫外線 (UV) 輻射 [ 25 ]

RISK FACTORS

The cause of dyshidrotic eczema is unknown, but it is probably multifactorial. Although, in most cases, a causative or predisposing factor cannot be identified, factors that have been associated with the development of dyshidrotic eczema include:

●History of atopic dermatitis [11,12]
●Exposure to contact allergens, particularly metals [11,13,14]
●Exposure to contact irritants (eg, metalworking fluids) [15]
●Systemic exposure to contact allergens (eg, ingestion of nickel or cobalt) [16]
●Dermatophyte infection at a distant site (id reaction) [12]
●Treatment with intravenous or subcutaneous immune globulin [13,17-22]
●Treatment with secukinumab, an interleukin (IL) 17 inhibitor approved for the treatment of psoriasis and psoriatic arthritis [23]
●Hyperhidrosis [11]
●Smoking [24]
●Exposure to ultraviolet (UV) radiation [25]

發病(病理學)

多汗性濕疹發生的機制很大程度上尚不清楚。一種假設是，兩種水/甘油通道蛋白（aquaporin-3 和aquaporin-10）在表皮所有層的過度表達可能會改變表皮水滲透屏障的功能，暴露於水和鹼性環境會加劇經表皮失水。皮膚 pH 值 [ 26,27 ]。

PATHOGENESIS
The mechanisms underlying the development of dyshidrotic eczema are largely unknown. One hypothesis is that the overexpression of two water/glycerol channel proteins, aquaporin-3 and aquaporin-10, across all layers of the epidermis may alter the function of the epidermal water permeability barrier, with transepidermal water loss exacerbated by exposure to water and alkaline skin pH [26,27].

臨床表現
出汗不良性濕疹的發作通常以瘙癢開始，隨後在手掌、手指的側面和背面（圖片 1A-D）或腳底上突然、對稱地出現嚴重瘙癢的水皰。70% 至 80% 的患者僅涉及手部 [ 13 ]。輕度病例中，水皰僅出現在手指的側面（圖片 1A、1D）。在一年中最溫暖的月份中，新的發作或惡化往往更為常見。
CLINICAL PRESENTATION
Episodes of dyshidrotic eczema often start with pruritus followed by a sudden, symmetric eruption of intensely pruritic vesicles on the palms, lateral and dorsal aspects of the fingers (picture 1A-D), or on the soles. In 70 to 80 percent of patients, only the hands are involved [13]. In mild cases, vesicles develop only on the lateral aspect of fingers (picture 1A, 1D). New episodes or worsening tend to be more common during the warmest months of the year.

水皰通常是深部的、多房的（“木薯或西米布丁”病變）；它們可能會合併成大皰（圖 2A）。在某些患者中，症狀可能嚴重到足以乾擾職業職責和日常活動（圖 2B）。
The vesicles are typically deep seated and multilocular ("tapioca or sago pudding" lesions); they may coalesce into large bullae (picture 2A). In some patients, symptoms may be severe enough to interfere with occupational duties and daily activities (picture 2B).

臨床病程和並發症

水皰和大皰持續數週，乾燥並脫皮消退（圖片 3）[ 1,3 ]。頻繁複發可能導致慢性手部皮炎，其特徵為紅色、苔蘚樣變、鱗屑斑塊或有裂隙的斑塊（圖片1E）。
CLINICAL COURSE AND COMPLICATIONS

Vesicles and bullae persist for several weeks, desiccate, and resolve with desquamation (picture 3) [1,3]. Frequent relapses may result in chronic hand dermatitis, characterized by red, lichenified, and scaling patches or plaques with fissures (picture 1E).

發作可能每隔三到四個星期就會復發，持續數月或數年。在某些患者中，症狀發作可能與情緒或身體壓力有關，但大多數情況下，症狀發作是在沒有可識別觸發因素的情況下發生的。在發作之間，皮膚恢復正常外觀，這與繼發於刺激性或過敏性接觸性皮炎或特應性皮炎的慢性水皰性手部皮炎的持續體徵和症狀形成鮮明對比。
Episodes may recur at intervals of three to four weeks for months or years. In some patients, flares may be associated with emotional or physical stress, but most often, they occur in the absence of an identifiable trigger. Between episodes, the skin returns to a normal appearance, in contrast to the persistent signs and symptoms of chronic vesicular hand dermatitis secondary to irritant or allergic contact dermatitis or atopic dermatitis.

嚴重的發作會影響指甲基質並產生營養不良的指甲變化，例如水平起皺和顏色變化（圖片1E）。可能會發生繼發感染，通常是金黃色葡萄球菌感染。
Severe episodes can affect the nail matrix and produce dystrophic nail changes such as horizontal ridging and color changes (picture 1E). Secondary infection, usually with Staphylococcus aureus, may occur.

診斷
臨床診斷 — 多汗性皮炎的診斷通常根據臨床表現、症狀和病史進行：
●緊張的深層水皰或大皰位於手掌和腳底，通常位於手指的側面（圖片 1B、1D）
●僅限於手指側面的微小水泡（圖1A）
●劇烈瘙癢
●急性發作
●復發史
DIAGNOSIS
Clinical diagnosis — The diagnosis of dyshidrotic dermatitis is usually made based upon clinical findings, symptoms, and history:
●Tense, deep-seated vesicles or bullae localized on the palms and soles and often on the lateral aspect of the fingers (picture 1B, 1D)
●Tiny vesicles limited to the lateral aspect of fingers (picture 1A)
●Intense pruritus
●Acute onset
●History of recurrence


嚴重程度評估 — 出汗障礙性濕疹的嚴重程度通常是主觀評估的。一種稱為出汗不良性濕疹面積和嚴重程度指數(DASI) 的評分工具，基於水皰的數量、紅斑、脫屑和瘙癢的強度，設計用於臨床試驗，但在臨床實踐中並不常規使用[28 ]：
Assessment of severity — The severity of dyshidrotic eczema is generally assessed subjectively. A scoring tool called the Dyshidrotic Eczema Area and Severity Index (DASI), based upon the number of vesicles, intensity of erythema, desquamation, and itch, was designed for use in clinical trials but is not routinely used in clinical practice [28]:

●輕度至中度- 

如果出汗障礙性濕疹不累及整個手掌或足底表面，我們認為其為輕度至中度；表現為少量水皰或散在的小水皰，無紅斑或輕度紅斑（圖片 1B、1E-G）；患者沒有抱怨難以忍受的瘙癢、燒灼感或疼痛。
●Mild to moderate − We consider dyshidrotic eczema to be mild to moderate if it does not involve the entire palmar or plantar surface; presents as a few crops of vesicles or scattered, small vesicles with absent or modest erythema (picture 1B, 1E-G); and the patient does not complain of intolerable pruritus, burning, or pain.


●嚴重- 如果出汗不良性濕疹涉及整個手掌或足底表面，並出現大的水皰或大皰，導致殘疾（圖2A-C）（即妨礙行走或使用手），或者如果情況嚴重，則我們認為出汗不良性濕疹為嚴重。疼痛或瘙癢（無論病變大小）。
●Severe − We consider dyshidrotic eczema to be severe if it involves the entire palmar or plantar surface and presents with large vesicles or bullae that are disabling (picture 2A-C) (ie, prevent walking or use of the hands) or if it is intensely painful or pruritic (regardless of the size of the lesions).

活檢的指徵(皮膚切片適應症) —(那些情況需考慮皮膚切片)
很少需要進行皮膚活檢進行組織病理學檢查。皮膚活檢的潛在指徵包括對治療缺乏反應以及在鑑別診斷中排除其他病症（例如牛皮癬或掌蹠膿皰病）。
Indications for biopsy — A skin biopsy for histopathologic examination is rarely needed. Potential indications for skin biopsy include lack of response to treatment and exclusion of other conditions in the differential diagnosis (eg, psoriasis or palmoplantar pustulosis).

如果進行皮膚活檢，對真菌成分進行高碘酸希夫 (PAS) 染色可能有助於排除真菌感染
If a skin biopsy is performed, periodic acid-Schiff (PAS) staining for fungal elements may be useful in excluding a fungal infection. (See 'Differential diagnosis' below.)

組織病理學 — 

出汗障礙性濕疹的組織學特徵取決於疾病的階段（急性或慢性）：
Histopathology — 

The histologic features of dyshidrotic eczema depend upon the stage (acute or chronic) of the disease:

急性階段- 

急性形式的特徵是表皮內海綿狀囊泡或大皰，不涉及小汗腺汗管（頂汗腺）的表皮內部分。通常存在稀疏、淺表、血管周圍的淋巴細胞浸潤。表皮厚度正常，肢端皮膚厚角質層完整。
●Acute stage − The acute form is characterized by intraepidermal spongiotic vesicles or bullae that do not involve the intraepidermal portion of the eccrine sweat duct (acrosyringium). A sparse, superficial, perivascular infiltrate of lymphocytes is usually present. The epidermal thickness is normal, and the thick stratum corneum of acral skin is intact.

慢性階段- 

在慢性病例中，主要是角化不全和棘層肥厚，很少或沒有海綿組織增生以及真皮、淋巴細胞浸潤。
●Chronic stage − 

In chronic cases, there is a predominance of parakeratosis and acanthosis with minimal or no spongiosis and a dermal, lymphocytic infiltrate.

斑貼(貼片)測試 — 

斑貼(貼片)測試通常對診斷出汗困難性濕疹沒有幫助。然而，皮膚科醫生通常會進行此檢查來確定是否存在過敏性接觸性皮炎的成分。對於對初始治療沒有反應的患者也可能需要進行斑貼(貼片)試驗[ 1,3 ]。
Patch testing — 

Patch testing is generally not helpful in making the diagnosis of dyshidrotic eczema. However, it is often performed by dermatologists to determine whether there is a component of allergic contact dermatitis. Patch testing may also be warranted in patients who do not respond to initial therapy [1,3]


鑑別診斷
出汗不良性濕疹的鑑別診斷包括炎症性和傳染性水皰大皰性皮膚病[ 1,3 ]：

DIFFERENTIAL DIAGNOSIS

The differential diagnosis of dyshidrotic eczema includes inflammatory and infectious vesicobullous skin diseases [1,3]:

過敏性接觸性皮炎– 

過敏性接觸性皮炎在臨床上可能與出汗困難性濕疹無法區分(圖片 4A-B )。正確的診斷基於過敏原暴露的評估和斑貼測試的結果。
●Allergic contact dermatitis – 

Allergic contact dermatitis may be clinically indistinguishable from dyshidrotic eczema (picture 4A-B). The correct diagnosis is based upon the assessment of allergen exposure and results of patch testing.

大皰性癬– 

大皰性癬在腳上比在手上更常見，並且通常是單側的（圖片 5A-B）。對病灶刮片進行氫氧化鉀 (KOH) 顯微鏡檢查可發現真菌成分。
●Bullous tinea – 

Bullous tinea occurs more often on the feet than on the hands and is usually unilateral (picture 5A-B). Potassium hydroxide (KOH) microscopic examination of scrapings from the lesions reveals fungal elements.

刺激性接觸性皮炎– 

刺激性接觸性皮炎通常涉及手背和蹼部（圖片 6A-B）。患者經常報告有刺激物接觸史。水皰和大皰很少出現，除非暴露於強烈刺激物並導致化學燒傷。
●Irritant contact dermatitis – 

Irritant contact dermatitis usually involves the dorsal aspect of the hands and web spaces (picture 6A-B). Patients often report a history of irritant exposure. Vesicles and bullae are rarely present, unless there was exposure to a strong irritant with a resultant chemical burn.

特應性手部皮炎– 

特應性手部皮炎通常累及手背（圖 7）。患者報告有特應性皮炎、季節性過敏或哮喘病史，並可能出現濕疹病變或涉及彎曲區域（即肘前窩和膕窩）的苔蘚樣變（圖 7 ）。
●Atopic hand dermatitis – 

Atopic hand dermatitis commonly involves the dorsum of the hands (picture 7). Patients report a history of atopic dermatitis, seasonal allergies, or asthma and may present with eczema lesions or lichenification involving flexural areas (ie, antecubital and popliteal fossae) (picture 7).

 
皮膚癬菌反應——

皮膚癬菌反應，也稱為“自身濕疹”，是一種繼發性、瘙癢性、丘皰疹，可能發生在手掌上，與遠處部位的皮膚癬菌感染有關，更常見於腳部，但也發生在手掌上。頭皮或其他身體部位（圖8）。為了確診，需要進行完整的皮膚檢查和對遠處可疑病變處的刮片進行 KOH 製備。
●Dermatophytid (id) reaction – 

A dermatophytid reaction, also called "autoeczematization," is a secondary, pruritic, papulovesicular eruption that may occur on the palms in association with a dermatophyte infection at a distant site, more often on the foot but also on the scalp or other body area (picture 8). A complete skin examination and a KOH preparation of scrapings from suspicious lesions at a distant site are necessary to confirm the diagnosis.

 
皰疹瘰癧– 

皰疹瘰癧可能模仿出汗障礙性濕疹[ 29 ]。通常，它表現為紅色基底上的成群的水泡，疼痛多於瘙癢，並且通常是單側的（圖 9）。可通過病毒培養、免疫熒光染色、聚合酶鏈反應或 Tzanck 塗片進行診斷。
●Herpetic whitlow – 

Herpetic whitlow may mimic dyshidrotic eczema [29]. Typically, it presents as grouped vesicles on a red base, is more often painful than pruritic, and is usually unilateral (picture 9). The diagnosis can be made by viral culture, immunofluorescence staining, polymerase chain reaction, or Tzanck smear.

掌蹠膿皰病–

掌蹠膿皰病可能有早期的水皰階段，但膿皰通常在幾天內形成（圖片 10A-B）。8～10天后，膿皰顏色變為深褐色，乾燥、脫落（圖11）。
●Palmoplantar pustulosis – 

Palmoplantar pustulosis may have an early, vesicular stage, but pustules usually develop in a few days (picture 10A-B). In 8 to 10 days, the pustules change their color to dark brown, become dry, and desquamate (picture 11).

自身免疫性大皰性疾病– 

大皰性類天皰瘡和尋常型天皰瘡可能很少表現為累及手或腳的局部疾病（圖片 12）。歷史反映了一個更為漫長、不懈的歷程。常規組織學活檢、直接免疫熒光和特定自身抗體的血清學檢測可提供正確的診斷。
●Autoimmune bullous diseases – 

Bullous pemphigoid and pemphigus vulgaris may rarely present as localized disease involving the hands or feet (picture 12). The history reflects a longer and unremitting course. Biopsy for routine histology, direct immunofluorescence, and serologic testing for specific autoantibodies provide the correct diagnosis.

臨床課程(臨床病程)
出汗不良性濕疹發作往往會在幾週內自然消退。然而，出汗不良性濕疹是一種複發性疾病，患者通常會多年經歷水皰性皮炎的頻繁發作。隨著年齡的增長，發作的頻率往往會降低，大多數患者最終會得到完全緩解[ 30 ]。

CLINICAL COURSE
Episodes of dyshidrotic eczema tend to spontaneously resolve over several weeks. However, dyshidrotic eczema is a recurrent disease, and patients typically experience frequent attacks of vesicular dermatitis for many years. Episodes tend to occur less frequently with age, and most patients eventually experience a complete remission [30].

管理(處置)

大多數出現瘙癢或其他症狀的患者都需要治療。治療方法以疾病的嚴重程度為指導（參見上文‘嚴重程度的評估’），包括以下內容：
●識別和避免致病因素或加劇因素
●治療皮膚炎症
●採取皮膚護理措施，減少皮膚刺激

MANAGEMENT
Treatment is required for most patients who present with complaints of pruritus or other symptoms. The approach to management is guided by the severity of the disease and involves the following:
●Identification and avoidance of causative or exacerbating factors
●Treatment of skin inflammation
●Adoption of skin care measures to reduce skin irritation

一般措施 — 

根據臨床經驗，避免刺激物或加重因素對大多數出汗困難性濕疹患者是有益的。旨在減少皮膚刺激和恢復皮膚屏障的一般皮膚護理措施包括[ 31 ]：
●使用溫水和溫和的合成洗滌劑（非肥皂）清潔劑洗手。大多數液體沐浴露實際上是具有中性pH值的合成洗滌劑產品。相比之下，“天然”肥皂（例如卡斯提爾肥皂）具有鹼性 pH 值，並且往往是更具腐蝕性的清潔劑。
●洗手後徹底擦乾雙手。
●擦乾手後立即塗抹潤膚劑（例如凡士林）並儘可能頻繁地塗抹。
●進行濕作業時，在乙烯基或其他非乳膠手套下佩戴棉質手套。
●在濕作業前摘下戒指、手錶和手鐲。
●在寒冷的天氣裡戴防護手套。
●佩戴針對摩擦暴露的任務專用手套（例如園藝、木工）。
●避免皮膚接觸刺激物（例如刺激性清潔劑、溶劑、染髮劑、酸性食物[例如柑橘類水果]）。General measures —
In clinical experience, the avoidance of irritants or exacerbating factors is beneficial for most patients with dyshidrotic eczema. General skin care measures aimed at reducing skin irritation and restoring the skin barrier include [31]:
●Using lukewarm water and mild, synthetic detergent (nonsoap) cleansers to wash hands. Most liquid body cleansers are actually synthetic detergent products with a neutral pH. In contrast, "natural" soaps (eg, Castile soap) have an alkaline pH and tend to be more aggressive detergents.
●Drying hands thoroughly after washing.
●Applying emollients (eg, petroleum jelly) immediately after hand drying and as often as possible.
●Wearing cotton gloves under vinyl or other nonlatex gloves when performing wet work.
●Removing rings, watches, and bracelets before wet work.
●Wearing protective gloves in cold weather.
●Wearing task-specific gloves for frictional exposures (eg, gardening, carpentry).
●Avoiding cutaneous exposure to irritants (eg, harsh detergents, solvents, hair dyes, acidic foods [eg, citrus fruit]).

在臨床實踐中, 諸如次乙酸鋁（Burow's 溶液）或金縷梅等收斂劑溶液用於治療潮濕、流淚的皮膚。將手或腳浸泡在該溶液中 15 分鐘，每天 2 至 4 次。或者，可以用薄的濕敷料代替浸泡，空氣可以通過敷料循環，從而增強收斂劑溶液的干燥效果。大的大皰可以使用無菌注射器引流或抽吸，以減輕疼痛并防止自發破裂和局部感染的風險。
In clinical practice, astringent solutions such as aluminum subacetate (Burow's solution) or witch hazel are used for wet, weeping skin. Hands or feet are soaked in the solution for 15 minutes two to four times per day. Alternately, soakings can be replaced by thin, wet dressings through which air will circulate, enhancing the drying effect of astringent solutions. Large bullae may be drained or aspirated using a sterile syringe to reduce pain and prevent spontaneous rupture with risk of local infection.

輕度至中度疾病
Mild to moderate disease
外用皮質類固醇– 

對於一般措施無反應的輕度至中度出汗性濕疹患者（圖 1B、1E-G），我們建議使用超高效或高效外用皮質類固醇（第 1 至第 3 組（表1） ）：一線治療。
●Topical corticosteroids – 

For patients with mild to moderate dyshidrotic eczema (picture 1B, 1E-G) that has not responded to general measures, we suggest super high-potency or high-potency topical corticosteroids (groups 1 to 3 (table 1)) as first-line therapy.

外用皮質類固醇每天使用兩次，持續兩到四個星期。軟膏劑通常優於其他載體（霜劑、溶液或泡沫），因為它們含有較少的潛在刺激物和過敏原，例如添加劑或防腐劑[ 1,3,31 ]。然而，一些患者更喜歡其他工具，因為藥膏使他們的手太油膩，無法執行任務。
Topical corticosteroids are applied twice daily for two to four weeks. Ointments are generally preferred to other vehicles (creams, solutions, or foams) because they contain fewer potential irritants and allergens, such as additives or preservatives [1,3,31]. However, some patients prefer other vehicles because ointments make their hands too greasy for performing tasks.

隨機試驗尚未充分評估外用皮質類固醇與安慰劑或不治療多汗性濕疹的療效。然而，由於它們的抗炎特性和對其他形式的手部濕疹的功效，它們被用於臨床實踐。
The efficacy of topical corticosteroids versus placebo or no treatment for dyshidrotic eczema has not been adequately evaluated in randomized trials. However, they are used in clinical practice because of their anti-inflammatory properties and their efficacy in other forms of hand eczema.

長期使用外用皮質類固醇受到其副作用的限制，包括皮膚萎縮、皮紋和毛細血管擴張。
The long-term use of topical corticosteroids is limited by their side effects, which include skin atrophy, striae, and telangiectasia.

外用鈣調磷酸酶抑製劑——

我們通常不建議將外用鈣調磷酸酶抑製劑作為多汗性濕疹的一線抗炎治療。外用鈣調神經磷酸酶抑製劑的抗炎作用大約相當於中等效力的外用皮質類固醇[ 32 ]。此外，外用鈣調神經磷酸酶抑製劑比許多外用皮質類固醇更昂貴。
●Topical calcineurin inhibitors – We generally do not suggest a topical calcineurin inhibitor as the first-line anti-inflammatory treatment for dyshidrotic eczema. The anti-inflammatory effect of topical calcineurin inhibitors is approximately equivalent to moderate-potency topical corticosteroids [32]. In addition, topical calcineurin inhibitors are more expensive than many topical corticosteroids.

然而，當患者和/或臨床醫生希望避免長期使用外用皮質類固醇來治療輕度至中度出汗性濕疹時（圖 1A -B、1F），外用鈣調神經磷酸酶抑製劑他克莫司是一種替代選擇[ 33,34 ]。他克莫司 0.1% 軟膏每天塗抹兩次，直至症狀消失。
However, when patients and/or clinicians prefer to avoid long-term use of topical corticosteroids for the treatment of mild to moderate dyshidrotic eczema (picture 1A-B, 1F), the topical calcineurin inhibitor tacrolimus is an alternative [33,34]. Tacrolimus 0.1% ointment is applied twice daily until resolution.

在一項納入 16 名中度至重度出汗不良性濕疹患者的隨機試驗中，將外用他克莫司與糠酸莫米松（一種高效外用皮質類固醇）進行了比較（第 3 組）[ 35 ]。使用軟膏治療 4 週後，與基線相比，外用 0.1% 他克莫司和 0.1% 糠酸莫米松均可使出汗不良性濕疹面積和嚴重程度指數 (DASI) 減少 50% 以上。
In a randomized trial including 16 patients with moderate to severe dyshidrotic eczema, topical tacrolimus was compared with mometasone furoate, a high-potency topical corticosteroid (group 3) [35]. After four weeks of treatment ointment, both topical tacrolimus 0.1% and mometasone furoate 0.1% reduced the Dyshidrotic Eczema Area and Severity Index (DASI) by more than 50 percent compared with baseline.

嚴重疾病 — 

除了上述一般措施外，我們建議短期口服皮質類固醇治療嚴重多汗性濕疹(圖片 2A-C )。

Severe disease — 

In addition to the general measures described above, we suggest a short course of oral corticosteroids for the treatment of severe dyshidrotic eczema (picture 2A-C).

我們通常從每天早上服用潑尼松40 至 60 毫克開始，持續一周。如果有足夠的反應，則在接下來的 5 至 7 天內將劑量減少 50%，最後在接下來的兩週內逐漸減少並停藥。
We generally start with prednisone 40 to 60 mg once per day in the morning for one week. If there is an adequate response, the dose is then reduced by 50 percent in the next five to seven days and finally tapered and discontinued over the following two weeks.

口服皮質類固醇治療多汗性濕疹尚未在臨床試驗中進行評估。然而，根據臨床經驗，它們對於出汗困難性濕疹和其他形式的嚴重濕疹性皮炎的短期治療是有益的。
Oral corticosteroids for dyshidrotic eczema have not been evaluated in clinical trials. However, in clinical experience, they have been beneficial for the short-term treatment of dyshidrotic eczema and other forms of severe, eczematous dermatitis.

對於禁忌使用全身性糖皮質激素或希望避免全身性皮質類固醇的患者，在封閉敷料（例如手上使用聚乙烯手套或腳上使用保鮮膜）下使用超強效局部皮質類固醇是治療嚴重出汗性濕疹的一種選擇。閉塞敷料通常在夜間使用三到七天。
Superpotent topical corticosteroids applied under occlusive dressings (eg, polyethylene gloves for the hands or plastic wrap for the feet) are a treatment option for severe dyshidrotic eczema in patients for whom systemic glucocorticoids are contraindicated or in patients who prefer to avoid systemic corticosteroids. Occlusive dressings are usually used at nighttime for three to seven days.

治療反應的評估 — 

用於評估治療反應的臨床標準包括水皰停止；清除先前存在的囊泡；並減少紅斑、瘙癢和疼痛。消退通常與皮膚乾燥和脫屑增加有關。
Evaluation of treatment response — 

Clinical criteria used to evaluate the response to treatment include cessation of vesiculation; clearance of pre-existing vesicles; and reduction of erythema, pruritus, and pain. Resolution is usually associated with increased skin dryness and desquamation.

難治性疾病(頑固性疾病) — 

如果經過兩到四個星期的充分治療後，出汗不良性濕疹沒有改善/消退，則被認為是難治性濕疹。難治性病例可能需要額外評估並重新考慮全面的鑑別診斷。
Refractory disease — Dyshidrotic eczema is considered refractory if there is no improvement/resolution in two to four weeks of adequate treatment. Refractory cases may warrant additional evaluation and reconsideration of the full differential diagnosis.
額外的診斷評估 — 具有出汗不良性濕疹臨床特徵的患者，在使用外用皮質類固醇、外用他克莫司或全身性皮質類固醇2 至4 週後沒有反應或未得到充分控制的患者可能需要進一步評估以確認或排除診斷。
Additional diagnostic evaluation — 

Patients with clinical features of dyshidrotic eczema who do not respond or are not adequately controlled after two to four weeks of topical corticosteroids, topical tacrolimus, or systemic corticosteroids may need further evaluation to confirm or rule out the diagnosis.

其他測試可能包括
●氫氧化鉀 (KOH) 製劑可排除真菌感染。
●細菌培養以排除細菌重複感染。金黃色葡萄球菌重複感染是手部濕疹患者治療反應不足的常見原因，特別是對於病情嚴重和濕性滲出性病變的患者。細菌二重感染可以用口服抗生素治療。
●皮膚活檢和組織病理學檢查可確診多汗性濕疹並排除其他病症。應包括真菌成分的高碘酸希夫 (PAS) 染色。如果懷疑大皰性類天皰瘡或天皰瘡，可能需要直接免疫熒光檢查。
●斑貼測試和詳細的家庭或工作相關接觸史，以排除過敏性或刺激性接觸性皮炎。

Additional testing may include
●Potassium hydroxide (KOH) preparation to rule out a fungal infection.
●Bacterial culture to rule out bacterial superinfection. Superinfection with S. aureus is a common cause of inadequate response to treatment in patients with hand eczema, especially with severe disease and wet, weeping lesions. Bacterial superinfection is treated with oral antibiotics
●Skin biopsy and histopathologic examination to confirm the diagnosis of dyshidrotic eczema and exclude other conditions. Periodic acid-Schiff (PAS) staining for fungal elements should be included. Direct immunofluorescence may be necessary if bullous pemphigoid or pemphigus are suspected.
●Patch testing and detailed history of household- or work-related exposures to exclude an allergic or irritant contact dermatitis

治療
光療 — 

對於確診為多汗性濕疹且發作頻繁或嚴重且局部或全身皮質類固醇或局部用藥無法充分控制的患者，我們建議口服或局部補骨脂素加紫外線A (PUVA) 療法或窄帶紫外線B ( NBUVB) 光療。他克莫司。
Treatment
Phototherapy — 

We suggest oral or topical psoralen plus ultraviolet A (PUVA) therapy or narrowband ultraviolet B (NBUVB) phototherapy for patients with a confirmed diagnosis of dyshidrotic eczema who have frequent or severe episodes that are not adequately controlled with topical or systemic corticosteroids or topical tacrolimus.

NBUVB 和PUVA 在治療出汗困難性濕疹患者中的使用在很大程度上得到了其在其他炎症性皮膚病治療中的支持，因為只有少數小型臨床試驗證明PUVA 對出汗困難性濕疹患者的臨床改善[36-42 ]。
The use of NBUVB and PUVA for patients with dyshidrotic eczema is largely supported by its use in the treatment of other inflammatory dermatoses, as only a few small clinical trials have demonstrated clinical improvement with PUVA in patients with dyshidrotic eczema [36-42].

並非所有社區都提供光療。光療通常每週進行兩到三次。需要幾週的治療才能引起臨床改善，並且需要幾個月的時間才能緩解。因此，應根據具體情況權衡光療的潛在益處與延長治療的不便。僅限於手掌和腳底的光療幾乎沒有副作用。
Phototherapy may not be available in all communities. Phototherapy treatments are usually delivered two or three times per week. Several weeks of treatment are required to induce clinical improvement, and several months are required for resolution. Thus, the potential benefits of phototherapy should be weighed against the inconvenience of prolonged therapy on a case-by-case basis. Phototherapy that is limited to the palms and soles has few adverse effects.

全身治療
●全身性免疫抑製劑——

全身性免疫抑製劑，如小劑量甲氨蝶呤、嗎替麥考酚酯和環孢菌素，偶爾用於治療嚴重的多汗性濕疹患者[ 43-45 ]。然而，它們的使用尚未在高質量的研究中得到評估，並且沒有足夠的證據表明它們在難治性病例中的使用有益。Systemic therapies
●Systemic immunosuppressive agents – 

Systemic immunosuppressive agents, such as low-dose methotrexate, mycophenolate mofetil, and cyclosporine, have been occasionally used in the management of patients with severe dyshidrotic eczema [43-45]. However, their use has not been evaluated in high-quality studies, and there is insufficient evidence of benefit to suggest their use in refractory cases.

Dupilumab – 

Dupilumab是一種白細胞介素(IL) 4 受體拮抗劑，被批准用於治療特應性皮炎，已被證明對先前局部皮質類固醇治療失敗的多汗性濕疹患者俱有良好的耐受性和有效性[45 ]。一項隨機、安慰劑對照試驗正在進行中，該試驗評估 dupilumab 對超強外用皮質類固醇無法控制的手部濕疹的療效 ( NCT03861455 )。
●Dupilumab – 

Dupilumab, an interleukin (IL) 4 receptor antagonist approved for the treatment of atopic dermatitis, has been shown to be well tolerated and effective in a small series of patients with dyshidrotic eczema who had previously failed topical corticosteroids [45]. A randomized, placebo-controlled trial evaluating the efficacy of dupilumab for hand eczema uncontrolled by superpotent topical corticosteroids is ongoing (NCT03861455).

全身性維A酸——

阿利維A酸在美國不上市，是一種全身性維A酸，在英國、歐洲和加拿大被批准用於治療慢性、難治性手部濕疹。這種口服類維生素A通過類維生素A X受體（RXR）和視黃酸受體（RAR）發揮其抗炎和免疫調節作用。最初預計它對過度角化性手部濕疹效果更好，但後來發現它對水皰性手部皮炎同樣有效[ 46,47 ]。
●Systemic retinoids –

  Alitretinoin, not available in the United States, is a systemic retinoid approved for the treatment of chronic, refractory hand eczema in the United Kingdom, Europe, and Canada. This oral retinoid exerts its anti-inflammatory and immunomodulatory effects through both the retinoid X receptor (RXR) and retinoic acid receptor (RAR). Initially expected to work better with hyperkeratotic hand eczema, it was found equally effective in vesicular hand dermatitis [46,47].

阿利維A酸通常每天服用 30 毫克，持續六個月。停止治療後，一些患者會經歷長時間的緩解，而另一些患者則會更快地複發。當複發時可以恢復治療。有些患者可能需要持續治療。
Alitretinoin is usually given at the dose of 30 mg daily for six months. Upon stopping treatment, some patients experience prolonged remissions, while others will relapse more quickly. Treatment can be resumed when relapse occurs. Some patients may require continuous treatment.

最常見的不良反應是治療最初幾週的頭痛。懷孕注意事項與異維A酸類似。在可用的情況下，這種藥物在超強外用皮質類固醇或光療和全身免疫抑製劑之間找到了一個利基。
The most common adverse effect is headache during the first few weeks of treatment. Pregnancy precautions are similar to isotretinoin. Where available, this medication has found a niche between superpotent topical corticosteroids or phototherapy and systemic immunosuppressive agents.

總結和建議
●流行病學和危險因素——急性掌蹠濕疹（也稱為“出汗障礙性濕疹”或“汗皰疹”）是一種相對罕見的、反復發作的皮疹，影響手掌、腳底或兩者。它最常見於年輕人，更常見於女性。主要危險因素包括特應性皮炎病史、接觸接觸刺激物和過敏原以及靜脈注射免疫球蛋白治療。SUMMARY AND RECOMMENDATIONS
●Epidemiology and risk factors –

 Acute palmoplantar eczema (also known as "dyshidrotic eczema" or "pompholyx") is a relatively uncommon, recurrent eruption affecting the palms, soles, or both. It occurs most commonly in young adults and more frequently in females. Main risk factors include a history of atopic dermatitis, exposure to contact irritants and allergens, and treatment with intravenous immunoglobulins

臨床特徵– 

出汗不良性濕疹的特徵是手掌（圖片 1G）、腳底或手指側面（圖片 1D）突然出現劇烈瘙癢的水皰。水泡持續數週，乾燥並脫落。發作可能每隔三到四個星期就會復發，持續數月或數年。
●Clinical features – Dyshidrotic eczema is characterized by the sudden eruption of intensely pruritic vesicles on the palms (picture 1G), soles, or lateral aspects of the fingers (picture 1D). The vesicles persist for several weeks, desiccate, and resolve with desquamation. Episodes may recur at intervals of three to four weeks for months or years.

診斷——

出汗障礙性濕疹的診斷通常基於臨床表現和病變部位、症狀和病史。對於患有頑固性疾病的選擇性患者，斑貼試驗有助於確定是否存在過敏性接觸性皮炎的成分。
●Diagnosis – 

The diagnosis of dyshidrotic eczema is usually based upon the clinical appearance and location of lesions, symptoms, and history. In selective patients with recalcitrant disease, patch testing is useful to determine whether there is a component of allergic contact dermatitis. (See 'Diagnosis' above.)

鑑別診斷——出汗不良性濕疹的鑑別診斷包括大皰性癬（圖5B）、皮膚癬菌反應（圖8）、大皰性膿皰瘡、單純皰疹感染（圖9）、過敏性接觸性皮炎（圖4A）、掌蹠膿皰病（圖10A-） B）。
Differential diagnosis – The differential diagnosis of dyshidrotic eczema includes bullous tinea (picture 5B), dermatophytid reaction (picture 8), bullous impetigo, herpes simplex infection (picture 9), allergic contact dermatitis (picture 4A), and palmoplantar pustulosis (picture 10A-B). (See 'Differential diagnosis' above.)

管理：
•一般措施– 避免刺激物或加重因素對於大多數出汗困難性濕疹患者很重要。
●Management:
•General measures – Avoidance of irritants or exacerbating factors is important for most patients with dyshidrotic eczema.

輕度至中度疾病– 

對於對一般措施沒有反應的輕度至中度出汗不良性濕疹（圖片 1B、1E-G ）患者（參見上文‘一般措施’），我們建議使用超高效或高效外用皮質類固醇（組1至組3（表1））作為一線治療（2C級）。外用皮質類固醇每天使用兩次，持續兩到四個星期。軟膏優於其他載體。對於希望避免長期使用外用皮質類固醇的患者來說，外用他克莫司是一種替代治療方法。
•Mild to moderate disease – 

For patients with mild to moderate dyshidrotic eczema (picture 1B, 1E-G) that has not responded to general measures (see 'General measures' above), we suggest super high-potency or high-potency topical corticosteroids (groups 1 to 3 (table 1)) as first-line therapy (Grade 2C). Topical corticosteroids are applied twice daily for two to four weeks. Ointments are preferred to other vehicles. Topical tacrolimus is an alternative treatment for patients who wish to avoid long-term use of topical corticosteroids. (See 'Mild to moderate disease' above.)

嚴重疾病– 

除了上述一般措施外，我們建議短期口服皮質類固醇治療嚴重出汗性濕疹（2C 級）。治療開始時每天使用潑尼松40 至 60 毫克，持續一周。在接下來的五到七天內，劑量可能會減少 50%，然後在接下來的兩週內逐漸減少並停藥。
•Severe disease – 

In addition to the general measures described above, we suggest a short course of oral corticosteroids for the treatment of severe dyshidrotic eczema (Grade 2C). Treatment is started with prednisone 40 to 60 mg per day for one week. The dose may be reduced by 50 percent in the next five to seven days and then tapered and discontinued over the following two weeks.

難治性(頑固性)疾病– 

對於具有出汗困難性濕疹臨床特徵的患者，在使用超強外用皮質類固醇或全身皮質類固醇2 至4 週後疾病沒有反應或未得到充分控制，可能需要進一步的診斷評估以確認或排除診斷。
•Refractory disease – 

For patients with clinical features of dyshidrotic eczema whose disease does not respond or is not adequately controlled after two to four weeks of superpotent topical corticosteroids or systemic corticosteroids, further diagnostic evaluation may be needed to confirm or rule out the diagnosis. 

對於確診的難治性出汗困難性濕疹患者，我們建議採用口服或局部補骨脂素加紫外線 A (PUVA) 或窄帶紫外線 B (NBUVB) 療法進行光療，而不是全身免疫抑製劑（2C 級）。
For patients with confirmed, refractory dyshidrotic eczema, we suggest phototherapy with oral or topical psoralen plus ultraviolet A (PUVA) or narrowband ultraviolet B (NBUVB) therapy rather than systemic immunosuppressants (Grade 2C).

口服阿利維A酸是一種全身性維A酸，在英國、歐洲和加拿大被批准用於治療慢性、難治性手部濕疹（但在美國尚未上市），對於難治性汗濕性濕疹患者來說，它可能是光療的替代方案。
Oral alitretinoin, a systemic retinoid approved for the treatment of chronic, refractory hand eczema in the United Kingdom, Europe, and Canada (but not available in the United States), may be an alternative to phototherapy for patients with refractory dyshidrotic eczema

美國心臟學會CCD(慢性冠心症 chronic coronary disease)新的指引---轉貼自洪惠風醫師臉書

2023-08-10 18:30
修改一下原文的時間, 不然過幾年之後就忘了是何時的更新

洪惠風醫師臉書
2023/07/20 美國心臟學會CCD(慢性冠心症 chronic coronary disease)新的指引，最重要的3點
1. 慢性冠心症心血管介入治療（支架....這些）跟外科繞道重新定位
2. 乙型阻斷劑 重要性降階
3. 慢性冠心症患者症狀及功能穩定時，不建議規則追蹤運動心電圖、核醫、心血管電腦斷層，也不建議定期追蹤心臟射出率，還說定期追蹤心導管，是有害的
支架或繞道最該做的兩大時機(Class I)
1) 用了所有藥物，症狀仍然影響生活品質，可用支架或繞道來減少症狀（無法減少死亡率）
2) 左主幹或多條血管阻塞 合併 左心室射出率小於35%時，繞道手術（非支架）可減少死亡率
強調醫病共享決策

DKA sodium bicarbonate NaHCO3 201601190909

2023-08-10 18:17
基本上. 我的建議是能不給就不給. 如果你堅持要給. 請說明你的理由. 
醫療決策不該只治療數據. 給予碳酸氫鈉將目前 pH 值暫時校正回來. 
可能會誤判 DKA 已經控制
事實上. 血液氣體分析的 pH 值, 是決定是否繼續施打靜脈胰島素的重要指標
DKA 缺的是胰島素. 當然也會合併一些脫水( NKHS 非酮酸中毒之高滲透壓血症. 脫水問題會比DKA 更嚴重)

急診醫師教科書 ROSEN (忘了當初是看第幾版了) 關於 DKA部分. page 1634

裡面說. sodium bicarbonate 不建議泡在 normal saline 內使用. 因為滲透壓太高
pH < 7.1 每公斤給 1mEq. 一支NaHCO3 約 17 mEq. 成人一次可以補 3-4 支
不建議例行補充. 很多醫師甚至 pH 6.7 以上都建議不要給.
治療目標. 將 pH 校正到 7.1 即可. 讓 HCO3 上升 10 mEq/L
使用方式. 將 NaHCO3 泡在 D5W 裡面. 九支泡一公升.

考慮到這些潛在危害且缺乏已證實的益處，許多作者質疑即使在嚴重酸血症的情況下碳酸氫鹽治療的效用。 13 然而，儘管缺乏證據，但通常建議根據經驗使用碳酸氫鈉治療血清pH值低於7.1。 1 mEq/kg，除非潛在的酸中毒被認為對治療有快速反應。14 然而，許多專家不會治療pH 值高於6.7 的情況，尤其是糖尿病酮症酸中毒，在糾正潛在病變的同時，通常可以很好地耐受嚴重酸血症。治療終點包括 pH 值高於 7.1 和血清碳酸氫鹽濃度高於 10 mEq/L。通過添加 150 mEq 碳酸氫鈉（三個“急救車安瓿”，通常為 50 mL，每瓶 8 個）來製備碳酸氫鹽滴注。4% 溶液）加入 1 升 5% 葡萄糖水溶液中，並在臨床情況允許的情況下緩慢輸注。出於高滲的考慮，碳酸氫鈉通常不應添加到生理鹽水中。
Many authors question the utility of bicarbonate therapy even in cases of severe acidemia, given these potential harms and the absence of demonstrated benefit.13 However, although evidence is lacking, it is commonly recommended to treat serum pH less than 7.1 empirically with sodium bicarbonate, 1 mEq/kg, unless the underlying acidosis is thought to be quickly responsive to therapy.14 Many experts will not treat pH above 6.7, however, especially in diabetic ketoacidosis, in which profound acidemia is usually well tolerated while the underlying lesion is corrected. Endpoints of therapy include pH above 7.1 and serum bicarbonate concentration above 10 mEq/L. A bicarbonate drip is prepared by adding 150 mEq sodium bicarbonate (three “crash cart ampules,” which are usually 50 mL of 8.4% solution) to 1 liter of 5% dextrose in water and infusing as slowly as the clinical situation permits. Sodium bicarbonate should generally not be added to normal saline for concern of hypertonicity.

下面資料來自 uptodate
Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment

碳酸氫鹽和代謝性酸中毒 — 如果動脈 pH 值低於 6.90，我們建議使用碳酸氫鹽。如果血清鉀低於 5.3 mEq/L，我們會在 400 mL 無菌水中加入 100 mEq 碳酸氫鈉和 20 mEq氯化鉀，給藥時間超過 2 小時。
Bicarbonate and metabolic acidosis — We suggest administering bicarbonate if the arterial pH is less than 6.90. We give 100 mEq of sodium bicarbonate in 400 mL sterile water with 20 mEq of potassium chloride, if the serum potassium is less than 5.3 mEq/L, administered over two hours.

應每兩小時監測一次靜脈 pH 值和碳酸氫鹽濃度，並且可以重複碳酸氫鹽劑量，直到 pH 值升至 7.00 以上（參見下面的“監測”）。當碳酸氫鹽 (HCO3) 濃度增加時，血清 K 值可能會下降，可能需要更積極的 KCl 補充。
The venous pH and bicarbonate concentration should be monitored every two hours, and bicarbonate doses can be repeated until the pH rises above 7.00 (see 'Monitoring' below). When the bicarbonate (HCO3) concentration increases, the serum K may fall and more aggressive KCl replacement may be required.

DKA 中碳酸氫鹽治療的適應症存在爭議[ 34 ]，並且缺乏益處的證據[ 35-37 ]。在一項對 21 名入院動脈 pH 值在 6.90 至 7.14（平均 7.01）之間的 DKA 患者進行的隨機試驗中，碳酸氫鹽治療並未改變發病率或死亡率[ 35 ]。然而，該研究規模較小，僅限於動脈pH值6.90及以上的患者，碳酸氫鹽組和安慰劑組之間動脈pH值和血清碳酸氫鹽的上升率沒有差異。尚未進行有關在 pH 值低於 6.90 的 DKA 中使用碳酸氫鹽的前瞻性隨機試驗。
The indications for bicarbonate therapy in DKA are controversial [34], and evidence of benefit is lacking [35-37]. In a randomized trial of 21 DKA patients with an admission arterial pH between 6.90 and 7.14 (mean 7.01), bicarbonate therapy did not change morbidity or mortality [35]. However, the study was small, limited to patients with an arterial pH 6.90 and above, and there was no difference in the rate of rise in the arterial pH and serum bicarbonate between the bicarbonate and placebo groups. No prospective randomized trials have been performed concerning the use of bicarbonate in DKA with pH values less than 6.90.

碳酸氫鹽的給藥也存在爭議，因為除了缺乏證據證明其益處外，還存在一些潛在的有害影響： ●如果碳酸氫鹽輸注成功地增加了血液碳酸氫鹽濃度，則可以
Bicarbonate administration is also controversial because in addition to lack of evidence for benefit, there are several potential harmful effects:

減少過度換氣驅動，從而升高血液pCO2。血液 CO2 張力的增加比動脈 HCO3 的增加更快地反映在血腦屏障上。這可能會導致大腦 pH 值的反常下降。儘管神經系統惡化已歸因於這種機制，但它仍然是一個非常有爭議的效應，而且即使發生，也很少見[ 38 ]。
●If bicarbonate infusion successfully increases the blood bicarbonate concentration, this can reduce the hyperventilatory drive, which will raise the blood pCO2. Increased blood CO2 tension is more quickly reflected across the blood brain barrier than the increased arterial HCO3. This may cause a paradoxical fall in cerebral pH. Although neurologic deterioration has been attributed to this mechanism, it remains a very controversial effect and, if it occurs, is rare [38].

●服用鹼可能會減慢酮症的恢復速度[ 39,40]。在一項針對七名患者的研究中，三名接受碳酸氫鹽治療的患者血清酮酸陰離子水平升高，酮症消退延遲六小時[39 ]。動物研究表明，碳酸氫鹽輸注可以加速生酮。這被認為與酸血症對有機性酸中毒有“制動作用”有關。任何增加全身 pH 值的操作都會減弱這種制動作用 [ 35 ]。
●The administration of alkali may slow the rate of recovery of the ketosis [39,40]. In a study of seven patients, the three patients treated with bicarbonate had a rise in serum ketoacid anion levels and a six-hour delay in resolution of ketosis [39]. Animal studies indicate that bicarbonate infusion can accelerate ketogenesis. This is thought to be related to the fact that acidemia has a “braking effect” on organic acidosis. This brake is lessened by any maneuver that increases systemic pH [35].


●給予鹼可導致治療後代謝性鹼中毒，因為酮酸陰離子與胰島素的代謝會導致碳酸氫根的產生，並自發糾正大部分代謝性酸中毒。(參見“成人糖尿病酮症酸中毒和高滲性高血糖狀態：流行病學和發病機制”，關於‘陰離子間隙代謝性酸中毒’一節)
●Alkali administration can lead to a posttreatment metabolic alkalosis, since metabolism of ketoacid anions with insulin results in the generation of bicarbonate and spontaneous correction of most of the metabolic acidosis. (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Epidemiology and pathogenesis", section on 'Anion gap metabolic acidosis'.)



























There are, however, selected patients who may benefit from cautious alkali therapy [38]. They include:

●Patients with an arterial pH ≤6.9 in whom decreased cardiac contractility and vasodilatation can further impair tissue perfusion [41,42]. At an arterial pH above 7.00, most experts agree that bicarbonate therapy is not necessary, since therapy with insulin and volume expansion largely reverse the metabolic acidosis [43].

●Patients with potentially life-threatening hyperkalemia, since bicarbonate administration in acidemic patients may drive potassium into cells, thereby lowering the serum potassium concentration [44]. (See"Treatment and prevention of hyperkalemia in adults".)









一篇 2011 年回顧文章說. 沒有證據顯示在 DKA 給予 bicarbonate 有好處. 尤其是兒科病人. 在 pH 6.9 以下也缺乏足夠證據給予建議.


處理目標, 減少高氯酸中毒, 減少 CSF 酸化, 減少腦水腫.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3224469/


Conclusions



The evidence to date does not support the use of bicarbonate administration for the emergent treatment of DKA, especially in the pediatric population, in view of possible clinical and physiological harm and the lack of clinical or sustained physiological benefits. There also is insufficient evidence to justify the recommendation of bicarbonate administration in more extreme acidemia of pH < 6.90. Future research should focus on the use of more balanced and physiological resuscitation fluids with buffering capacity, in the modern context of DKA management, with the goal of reducing the component of hyperchloremic acidosis in DKA while minimizing the risk of CSF acidosis and associated CE

酮酸中毒補充體液 2016.01.19.15.52 DKA fluid therapy

參考資料 uptodate Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment

第一個小時, 補充大約 1000CC 等張生理食鹽水. 不要超過 50cc/kg.
Glucose 每上升 100. Na 濃度往上加 2. 例如血糖 300. Na 135. 校正後的Na= 135+4= 139
如果校正後的 Na < 135. 每小時給 250-500cc 等張食鹽水.
如果校正後的 Na 正常或略高. 給予 half saline 250-500 cc/小時.
鈉鉀都會增加血中滲透壓. 所以如果補充 K 的時候, 也可以考慮給予 half saline.

Fluid replacement — In patients with DKA or HHS, we recommend vigorous IV electrolyte and fluid replacement to correct both hypovolemia and hyperosmolality.

Fluid repletion is usually initiated with isotonic saline (0.9 percent sodium chloride). The optimal rate of isotonic saline infusion is dependent upon the clinical state of the patient. Isotonic saline should be infused as quickly as possible in patients with hypovolemic shock. (See "Treatment of severe hypovolemia or hypovolemic shock in adults".)

In hypovolemic patients without shock (and without heart failure), isotonic saline is infused at a rate of 15 to 20 mL/kg lean body weight per hour (about 1000 mL/hour in an average-sized person), for the first couple hours, with a maximum of <50 mL/kg in the first four hours (algorithm 1 and algorithm 2) [1].

After the second or third hour, the choice for fluid replacement depends upon the state of hydration, serum electrolyte levels, and the urine output. The most appropriate IV fluid composition is determined by the “corrected” sodium concentration. The “corrected” sodium concentration can be approximated by adding 2.0mEq/L to the plasma sodium concentration for each 100 mg/100 mL (5.5 mmol/L) increase above normal in glucose concentration (calculator 1). If the “corrected” serum sodium concentration is less than 135 mEq/L,then isotonic saline should be continued at a rate of about 250 to 500 mL/hour [1]. However, if the “corrected” sodium concentration is normal or elevated, then the IV fluid is generally switched to one-half isotonic saline at a rate of 250 to 500 mL/hour in order to provide electrolyte-free water. The timing of one-half isotonic saline therapy may also be influenced by potassium balance. Potassium repletion affects the saline solution that is given, since potassium is as osmotically active as sodium. Thus, concurrent potassium replacement may be another indication for the use of one-half isotonic saline. (See 'Potassium replacement' below.)

當血糖降低至 200(DKA) 或 250-300(HHS) 補充糖水和生理食鹽水.

We add dextrose to the saline solution when the serum glucose reaches 200 mg/dL (11.1 mmol/L) in DKA or 250 to 300 mg/dL (13.9 to 16.7 mmol/L) in HHS. (See 'Intravenous regular insulin' below.)

適當補充水分可以改善高滲透壓狀態, 加強 insulin 療效.
心臟腎臟功能不良的患者要更加強監測, 避免補充過多水分.
治療目標是 24 小時內將預估的缺乏體液電解質補充完畢
不要將滲透壓降太快. 以免引起腦水腫.

Adequate rehydration with correction of the hyperosmolar state may result in a more robust response to low-dose insulin therapy [11,12]. Adequacy of fluid replacement is judged by frequent hemodynamic and laboratory monitoring (see 'Monitoring' below). In patients with abnormal renal or cardiac function, more frequent monitoring must be performed to avoid iatrogenic fluid overload [9,10,12,15-18]. The goal is to correct estimated deficits (table 2) within the first 24 hours. Osmolality should not be reduced too rapidly because of concern that this may cause development of cerebral edema. (See 'Cerebral edema' below and"Treatment and complications of diabetic ketoacidosis in children", section on 'Cerebral edema'.

軟組織感染/壞死性筋膜炎之抗生素選擇ANTIBIOTICS FOR SOFT TISSUE INFECTION/ NECROTIZING FASCIITIS

2023-08-10 18:01 重貼

2016-02-02 02:35
ANTIBIOTICS FOR SOFT TISSUE INFECTION/ NECROTIZING FASCIITIS


2017-03-02 海洋弧菌 Vibrio vulnioficus infection in patient with viral hepatitis, alcoholism, hemochromatosis, diabetes mellitus, thalassemia major, chronic renal disease, use of TNF inhibitors, and lymphoma
http://www.emnote.org/emnotes/vibrio-sepsis-in-cirrhotic-patients

張志華主任說

肝病併發海洋弧菌敗血症的重點
1. Necrotizing fasciitis
2. Antibiotic: doxycycline + ceftazidime
註：在未排除Gr. A beta-hemolytic strep之前，要加penicillin(+/- clindamycin)

如果是 GAS: Clindamycin may be more effective in invasive infections. Unlike with penicillin, the efficacy of clindamycin is unaffected by the size of the inoculum and the stage of bacterial growth. In addition, clindamycin inhibits the production of toxin by streptococci.

Antibiotic: doxycycline + ceftazidime + penicillin
... to cover vibrio and GAS.

黃醫師發問
1.台灣沒penicillin iv了
2.doxycycline只有口服 即使此抗生素bioavailability很高 但重症病患消化不好 無法預估吸收多少 君不見surviving sepsis campaign告訴各位 sepsis時 抗生素應iv 通常這種complicated skin and soft tissue infection 都是sepsis了
3.好 那IV minocycline可行吧? 台灣也沒有iv minocycline了 QQ


ANTIBIOTICS CHOICE FOR SOFT TISSUE INFECTION/ NECROTIZING FASCIITIS
Treatment recommendations based on Gram stain result
Gram-positive cocci in chains:
· Penicillin 1-4 million U IV q4h or ampicillin-sulbactam 1.5-3 g IV q6-8h plus
· Clindamycin 600-900 mg/kg IV q8h
Gram-positive rods:
· Clindamycin 600 mg/kg IV q8h or
· Ampicillin-sulbactam 1.5-3 g IV q6h
Gram-negative rods or gram-positive cocci in clusters or mixed:[10]
· Ampicillin-sulbactam 1.5-3 g IV q6-8h plus clindamycin 600-900 mg/kg IV q8h plus ciprofloxacin 400 mg IV q12h or
· Piperacillin-tazobactam 3.375 g IV q6-8h plus clindamycin 600-900 mg/kg IV q8h plus ciprofloxacin 400 mg IV q12h or
· Imipenem-cilastatin 1 g IV q6-8h or
· Meropenem 1 g IV q8h or
· Ertapenem 1 g IV q24h or
· Cefotaxime 2 g IV q6h plus ( metronidazole 500 mg IV q6h or clindamycin 600-900 mg/kg IV q8h)
· Since none of the above covers MRSA, in appropriate clinical situations consider vancomycin 1 g IV q12h, daptomycin 6-10 mg/kg IV q24h, [11] or linezolid 600 mg IV q12h

Treatment recommendations for penicillin-allergic patients
See the list below:
· Clindamycin 600 mg/kg IV q8h plus ( vancomycin 15 mg/kg IV q12h orlinezolid 600 mg PO or IV q12h) plus ( aztreonam 1-2 g IV q6-8h orgentamicin 3-5 mg/kg/day IV in 3 divided doses or ciprofloxacin 400 mg IV q12h)

  
Guidelines
The Infectious Diseases Society of America recently updated their guidelines for the diagnosis and management of skin and soft tissue infections. For the full guidelines, see Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America.[12, 13]

嚴重低血鈣處置 Severe symptomatic and/or acute hypocalcemia

2023-08-10 17:42


下面資料來自uptodate(僅節錄部分), 中文是先用google翻譯之後再修改.

嚴重症狀和/或急性低鈣血症 — 我們建議靜脈注射 (IV) 鈣劑治療以下患者的低鈣血症（流程圖 1）：
●症狀（例如手足痙攣、喉痙攣、支氣管痙攣、癲癇發作）
●QT間期延長

Severe symptomatic and/or acute hypocalcemia — We recommend intravenous (IV) calcium for the treatment of hypocalcemia in patients with (algorithm 1):

●Symptoms (eg, carpopedal spasm, laryngospasm, bronchospasm, seizures)
●A prolonged QT interval

or

●血清校正鈣急劇下降至≤7.5 mg/dL（≤1.9 mmol/L）的無症狀患者，如果不治療可能會出現嚴重並發症。在離子鈣測定中，正常範圍為 4.8 至 5.6 mg/dL（1.2 至 1.4 mmol/L），閾值約為 ≤3 mg/dL（≤0.8 mmol/L）。當血清鈣快速、進行性降低時，可能會發生急性低鈣血症（例如，頭頸癌根治性頸清掃術後出現急性甲狀旁腺功能減退症）。
●In asymptomatic patients with an acute decrease in serum corrected calcium to ≤7.5 mg/dL (≤1.9 mmol/L), who may develop serious complications if untreated. In an ionized calcium assay with a normal range of 4.8 to 5.6 mg/dL (1.2 to 1.4 mmol/L), the threshold is approximately ≤3 mg/dL (≤0.8 mmol/L). Acute hypocalcemia can occur when there is a rapid and progressive reduction in serum calcium (eg, acute hypoparathyroidism following radical neck dissection for head and neck cancer).

應密切監測接受地高辛治療的患者，最好通過遙測技術監測急性洋地黃毒性，這種毒性可因靜脈輸注鈣劑而發生。然而，一項對 23 名患者的回顧性圖表審查發現，靜脈注射鈣不會導致地高辛中毒患者出現惡性心律失常或死亡率增加 [ 4 ]。
Patients receiving digoxin should be monitored closely, preferably with telemetry, for acute digitalis toxicity, which can develop with IV calcium infusion. However, one retrospective chart review of 23 patients found that IV calcium did not cause malignant dysrhythmias or increased mortality in digoxin-intoxicated patients [4].


對於無症狀或患有慢性穩定低鈣血症且僅有輕微症狀（例如感覺異常）的慢性腎病患者，不建議將靜脈鈣作為初始治療。對於慢性腎病患者，糾正高磷血症和低循環 1,25-二羥基維生素 D 通常是首要目標。(參見 “成人慢性腎髒病患者高磷血症的治療”和 “成人透析患者繼發性甲狀旁腺功能亢進症的治療”和 “成人非透析慢性腎髒病患者繼發性甲狀旁腺功能亢進症的治療” )
IV calcium is not warranted as initial therapy in patients with chronic kidney disease who are asymptomatic or who have chronic stable hypocalcemia with only mild symptoms (eg, paresthesias). In patients with chronic kidney disease, correction of hyperphosphatemia and of low circulating 1,25-dihydroxyvitamin D are usually the primary goals. (See "Management of hyperphosphatemia in adults with chronic kidney disease" and "Management of secondary hyperparathyroidism in adult dialysis patients" and "Management of secondary hyperparathyroidism in adult nondialysis patients with chronic kidney disease".)

靜脈鈣給藥 — 最初，可以在 10 至 20 分鐘內輸注靜脈鈣（1 或 2 g葡萄糖酸鈣，相當於 90 或 180 mg 元素鈣，溶於 50 mL 5% 葡萄糖或生理鹽水） 。如果需要緩解症狀，可在 10 至 60 分鐘後重複推注。不應更快地給予鈣，因為存在嚴重心功能障礙的風險，包括收縮期驟停[ 5 ]。推注葡萄糖酸鈣只會使血清鈣濃度升高兩到三個小時；因此，對於持續性低鈣血症患者，應緩慢輸注鈣。
Intravenous calcium dosing — Initially, IV calcium (1 or 2 g of calcium gluconate, equivalent to 90 or 180 mg elemental calcium, in 50 mL of 5% dextrose or normal saline) can be infused over 10 to 20 minutes. The bolus may be repeated after 10 to 60 minutes, if needed to resolve symptoms. The calcium should not be given more rapidly, because of the risk of serious cardiac dysfunction, including systolic arrest [5]. The bolus dose of calcium gluconate will raise the serum calcium concentration for only two or three hours; as a result, it should be followed by a slow infusion of calcium in patients with persistent hypocalcemia.

可以使用10%葡萄糖酸鈣溶液（每 10 mL 含有 90 mg 元素鈣）來製備連續輸注。葡萄糖酸鈣優於氯化鈣，因為如果外滲，它不太可能導致組織壞死。如果沒有葡萄糖酸鈣，可以使用 10% 氯化鈣溶液（每 10 毫升含 270 毫克元素鈣）作為替代方案。
A solution of 10% calcium gluconate (90 mg of elemental calcium per 10 mL) can be used to prepare the continuous infusion. Calcium gluconate is preferred to calcium chloride because it is less likely to cause tissue necrosis if extravasated. A solution of 10% calcium chloride (270 mg of elemental calcium per 10 mL) is an alternative if calcium gluconate is unavailable.

將 11 g 葡萄糖酸鈣（相當於 1000 mg 元素鈣）添加到生理鹽水或5% 葡萄糖水中以提供 1000 mL 的最終體積，製備含有 1 mg/mL 元素鈣的 IV 溶液。該溶液的初始輸注速度為 50 mL/小時（相當於 50 mg 元素鈣/小時）。可以調整劑量以將血清鈣濃度維持在正常範圍的下限（如上所述根據血清白蛋白的任何異常校正血清鈣）。患者通常每小時需要 0.5 至 1.5 毫克/公斤的元素鈣。
An IV solution containing 1 mg/mL of elemental calcium is prepared by adding 11 g of calcium gluconate (equivalent to 1000 mg elemental calcium) to normal saline or 5% dextrose water to provide a final volume of 1000 mL. This solution is administered at an initial infusion rate of 50 mL/hour (equivalent to 50 mg elemental calcium/hour). The dose can be adjusted to maintain the serum calcium concentration at the lower end of the normal range (with the serum calcium corrected for any abnormalities in serum albumin as noted above). Patients typically require 0.5 to 1.5 mg/kg of elemental calcium per hour.

準備輸液時應考慮以下因素：
●鈣應在葡萄糖和水或鹽水中稀釋，因為濃鈣溶液會刺激靜脈。
The infusion should be prepared with the following considerations:
●The calcium should be diluted in dextrose and water or saline because concentrated calcium solutions are irritating to veins.

●靜脈注射溶液不應含有碳酸氫鹽或磷酸鹽，它們會形成不溶性鈣鹽。如果需要這些陰離子，應使用另一條靜脈輸液管（在另一肢）。
●The IV solution should not contain bicarbonate or phosphate, which can form insoluble calcium salts. If these anions are needed, another IV line (in another limb) should be used.

應繼續靜脈補鈣，直至患者接受口服鈣和維生素 D 的有效治療方案。對於急性甲狀旁腺功能減退症患者，可使用骨化三醇（劑量為0.25至0.5 微克，每日兩次）和口服鈣（1 至4 克元素鈣）應盡快開始服用（每天分次服用）。骨化三醇是嚴重急性低鈣血症患者的首選維生素 D 製劑，因為其起效快（數小時）。急性和慢性甲狀旁腺功能減退症的治療詳見其他專題。
IV calcium should be continued until the patient is receiving an effective regimen of oral calcium and vitamin D. For patients with acute hypoparathyroidism, calcitriol (in a dose of 0.25 to 0.5 mcg twice daily) and oral calcium (1 to 4 g of elemental calcium carbonate daily in divided doses) should be initiated as soon as possible. Calcitriol is the preferred preparation of vitamin D for patients with severe acute hypocalcemia because of its rapid onset of action (hours). The management of acute and chronic hypoparathyroidism are reviewed in more detail separately.

氫氟酸中毒 HF EXPOSURE TREATMENT GUIDE FOR PHYSICIANS

2023-08-10 重貼
以前學到的是可以將 gel 放在醫用手套裡面. 請病人戴手套. 讓皮膚可以持續接觸gel
還有就是病患不一定在暴露當下就來掛急診.
氫氟酸的工業用途是酸洗金屬表面. 所以電鍍工廠會用到.
有些病患是在工廠少量持續暴露一整天. 下班才來掛急診

如果是大面積 160 平方公分 (大約13公分正方形)暴露可能導致急性低血鈣. 鈣離子過低除了會造成肌肉痙攣, 感覺異常, 還會引起 QT prolong. 進一步導致心律不整. 
(嚴重低血鈣處置另外寫一篇: )

國科會-科技大觀園-蝕骨水解密：氫氟酸

氫氟酸的用途非常廣泛，不僅是清潔業裡常用的清洗劑，製作不鏽鋼、非鐵金屬的過程中，也用氫氟酸清洗表面含氧化物與鏽蝕物（即酸洗），更是石化製程中重要的催化劑。 值得關注的是，氫氟酸亦是半導體、面板、太陽能電池等產業製程中，用於清洗與蝕刻製程最常用的化學溶液之一。

參考資料-- 下面中文是google翻譯
201602022306HF EXPOSURE TREATMENT GUIDE FOR PHYSICIANS

HF EXPOSURE TREATMENT GUIDE FOR PHYSICIANS 

University of Southern California Environmental Health and Safety

醫師版-暴露治療指南
簡介
氟化氫是一種高腐蝕性化學品，接觸後會導致嚴重深度燒傷。必須為任何接觸 HF 的人提供醫療援助並立即開始治療。氟化氫與其他腐蝕性化學物質的不同之處在於，氟離子很容易滲透皮膚，導致包括骨骼在內的深層組織層遭到破壞。然而，其嚴重的有害作用來自氟化物（F-）的作用，而不是酸燒傷。HF 中的氟化鐵與骨骼中的 Ca2+ 形成如此牢固的結合。它到達骨骼並從骨骼中濾出鈣，並可能將鈣束縛在神經細胞中。當破壞心臟功能時，這種神經狀況的破壞可能會危及生命。
HF Exposure Treatment Guide for Physicians
Introduction
Hydrogen fluoride is a highly corrosive chemical that can cause severe and deep burns on exposure. It is imperative that medical assistance be provided for any exposure to HF and the treatment be initiated promptly. Hydrogen fluoride differs from other corrosive chemicals in that the fluoride ion readily penetrates the skin causing destruction of deep tissue layers including bone. However, its critical harmful effect comes from the action of the fluoride (F-), not acid burn. Fluoride iron from HF forms such a strong bond to Ca2+ in bones. It reaches to bones and leaches calcium from bones and may tie up calcium in nerve cell. This disruption of nerve condition can be life threatening when disrupting a heart function.


皮膚接觸
局部使用的葡萄糖酸鈣凝膠（2.5%）必須持續塗抹，直至疼痛完全消退。用水徹底（至少 15 分鐘）清洗皮膚後才能使用葡萄糖酸鈣凝膠。疼痛消退後，每隔 3 或 4 小時擦一次葡萄糖酸鈣凝膠，每次 30 分鐘。如果皮膚深度或廣泛燒傷，應將 2.5% 葡萄糖酸鈣凝膠按摩到皮膚上，持續 3 至 4 天，每天 4 至 6 次。應注意塗抹凝膠的人員，尤其是初次塗抹時，應佩戴橡膠手套，以防止皮膚被氫氟酸污染以及可能發生的手部灼傷。
Skin contact
Topically applied calcium gluconate gel (2.5 percent) must be rubbed-in continuously until pain has completely subsided. Calcium gluconate gel should not be used until after complete (at least 15 minutes) washing of the skin with water. After the pain has subsided, the calcium gluconate gel should be rubbed-in for 30 minutes at 3 or 4 hour intervals. If the skin burns are deep or extensive, calcium gluconage gel, 2.5%, should be massaged into the skin for 3 to 4 days, 4 to 6 times daily. Care should be taken to see that personnel who apply the gel, especially on the initial application, wear rubber gloves to prevent skin contamination with HF and possible development of hand burns.

如果皮膚燒傷面積大於 25 平方英寸（160 平方厘米），可能會出現低鈣血症。因此，系統性施用葡萄糖酸鈣可能是必要的。經常監測血清鈣、腎和肝功能是必要的。
In cases where skin burns are greater than 25 square inches (160 cm2) in area, hypocalcemia may be present. Therefore, systematic administration of calcium gluconate may be necessary. Frequent monitoring of serum calcium, renal and hepatic functions is necessary.

當二度或三度燒傷有皮膚穿透跡象時，可採用與註射葡萄糖酸鈣溶液相同的方式，將5%葡萄糖酸鈣溶液（靜脈使用的標準安瓿為10%）注入皮膚和皮下組織。局部麻醉劑。應注意避免過量服用鈣。所有暴露的皮膚都應被滲透，包括該區域周圍 6 毫米（1/4 英寸）的範圍。這可以防止嚴重燒傷的發生。
When there is evidence of skin penetration as in second or third degree burns, a 5 percent calcium gluconate solution (the standard ampule is 10 percent for intravenous use) may be injected by infiltrating the skin and subcutaneous tissues in the same manner as the injection of a local anesthetic. Care should be taken to avoid overdosing with calcium. All skin which has been exposed should be infiltrated including up to ¼ inch (6 mm) around the area. This may prevent the development of severe burns.

指甲周圍的燒傷可能需要將指甲從遠端劈開，以減輕疼痛并促進排水，然後再用上述溶液之一浸泡。
Burns around the fingernail may require splitting the nail from the distal end in order to relieve pain and facilitate draining prior to soaking with one of the above-mentioned solutions.

立即切除用濃縮氫氟酸溶液燒傷的小面積區域可以防止疼痛且癒合緩慢的燒傷。如果有需要的話，切除植皮後進行一期閉合可以提供更快的癒合和更少的疤痕。
Immediate excision of small areas burned with concentrated solutions of HF may prevent a painful, slow-healing burn. Primary closure after excision of skin grafting, if indicated, may provide more rapid healing and less scarring.

眼睛接觸(google翻譯成眼神)
立即用大量水清洗眼睛，同時將眼瞼分開至少 15 分鐘，然後用冰袋敷上。應使用冰袋直至到達醫療機構。此時，應使用1%葡萄糖酸鈣生理鹽水徹底沖洗眼睛5至10分鐘，此後每兩或三個小時滴注葡萄糖酸鈣生理鹽水一次，持續48至72小時。不得使用油或藥膏。使用眼用皮質類固醇溶液可以減少炎症。應立即諮詢眼科專家。
Eye Contact
Immediate washing of the eyes with large quantities of water while holding eyelids apart for at least 15 minutes should be followed by ice packs. The ice packs should be used until a medical facility is reached. Here the eyes should be washed thoroughly with 1 percent calcium gluconate in normal, sterile saline for 5 to 10 minutes, thereafter, calcium gluconate in normal saline should be instilled every two or three hours for 48 to 72 hours. No oils or ointments should be used. Inflammation may be decreased by the use of corticosteroid solutions for ophthalmic use. An eye specialist should be consulted immediately.

蒸氣吸入
應通過面罩或導管向吸入 HF 的人員提供 100% 的氧氣。應盡快通過吸入方式給予他們 2.5% 至 3% 的葡萄糖酸鈣溶液，最好使用霧化器進行間歇性正壓呼吸 (IPPB)，或單獨使用霧化器。應仔細觀察患者有無上氣道水腫伴呼吸阻塞，必要時通過氣管切開或氣管插管維持氣道。
Vapor Inhalation
Persons exposed to HF by inhalation should be given 100 percent oxygen by mask or catheter. As soon as possible, they should be given 2.5 to 3 percent calcium gluconate solution by inhalation, preferably by intermittent Positive Pressure Breathing (IPPB) utilizing a nebulizer, or by nebulizer alone. The patient should be carefully watched for edema of the upper airway with respiratory obstruction and the airway maintained by tracheostomy or endotracheal intubation if necessary.

如果出現肺水腫，應將患者置於呼氣正壓 (PEEP) 的 IPPB 上。應密切監督呼吸系統護理，包括吸入葡萄糖酸鈣。肺部吸收氟離子引起的毒性可能會在肝臟和腎臟中迅速發展，如果血液尿素氮和鉀升高，可能需要採取更有力的控制措施，直至並包括血液透析。支持治療對於所有器官系統都是必要的。
If pulmonary edema develops, the patient should be placed on IPPB with Positive Expiratory Pressure (PEEP). The administration of respiratory care should be very closely supervised, including the administration of calcium gluconate by inhalation. Toxicity from pulmonary absorption of fluoride ion may rapidly develop in the liver and kidneys and may require more energetic measure of control, up to and including hemodialysis, if the blood urea nitrogen and potassium rise. Supportive care is necessary for all organ systems.

食入
根據需要採取急救措施，包括讓患者飲用大量牛奶或添加氧化鎂乳的水。不要催吐。喉嚨燒傷可能會導致嚴重腫脹，需要進行氣管切開術。應將患者送往醫院並仔細觀察。

Ingestion
Apply first aid measures as needed, including having the patient drink a large quantity of milk or water with added milk of magnesia. Do not induce vomiting. Throat burns may cause severe swelling and require a tracheostomy. The patient should be administered to the hospital and carefully watched.


醫療用品
葡萄糖酸鈣凝膠，2.5 %
（強烈建議在工作現場保留商業級葡萄糖酸鈣凝膠以備緊急情況）
葡萄糖酸鈣，1 % 正常無菌鹽水溶液
葡萄糖酸鈣，10 % 用於注射（標準安瓿）。使用等量葡萄糖酸鈣和無菌生理鹽水混合的 5% 溶液。
Medical Supplies
Calcium gluoconate gel, 2.5 %
(Keeping a commercial grade calcium gluconate gel at the work site is highly recommended for an emergency)
Calcium gluconate, 1 % normal, sterile saline solution
Calcium gluconate, 10 % for injecting (standard ampule). Use 5 percent solution mixing equal quantities of calcium gluconate and sterile normal saline.


要製備用於高頻燒傷皮下注射的 5% 葡萄糖酸鈣溶液，請將等量的無菌 10% 葡萄糖酸鈣溶液和無菌生理鹽水混合。
要製備供霧化器吸入的 2.5% 葡萄糖酸鈣溶液，請將一份 10% 葡萄糖酸鈣與三份無菌生理鹽水混合。
25cc 10% 葡萄糖酸鈣加 225cc 生理鹽水 = 1% 滴眼液
To make a 5 % solution of calcium gluconate for subcutaneous injection in HF burns, mix equal amounts of sterile 10% calcium gluconate solution and sterile normal saline.
To make a 2.5% solution of calcium gluconate for inhalation exposure to be given by nebulizer, mix one part of 10% calcium gluconate with three parts of sterile normal saline.
25cc 10% calcium gluconate with 225cc normal saline = 1% eye solution



製備葡萄糖酸鈣凝膠
將定量的 KY Jelly (Johnson & Johnson) 加熱至 50-60oC，通常為 395 克
添加按重量計2.5% 的葡萄糖酸鈣，試劑級，緩慢地充分攪拌直至全部溶解。
Preparation of Calcium Gluconate Gel
Heat a measured amount of K-Y Jelly (Johnson & Johnson) to 50-60oC, typically 395 gram
Add 2.5% by weight of calcium gluconate, reagent grade, slowly with good stirring until all dissolved.




An alternate method of adding the calcium gluconate is to add 2 grams and stir in until mostly dissolved, then add the remaining calcium gluconate (added to 35 cc of H2O)) with good stirring until dissolved into the jelly


透明含有許多氣泡，靜置後可以通過讓氣泡上升到表面來去除
Finished gel will be water-clear with many air bubbles which can be removed by allowing the bubbles to rise to the surface after standing


上述數量將填滿十一個四盎司罐子，大約四分之三滿
The above quantities will fill eleven four ounce jars approximately three quarters full












Additional Information
Article: M.A. Trevino et al, J. Occ. Med., 25, p. 861
Product Information, EI. DuPont De Nemours & Company, 1-800-441-7515 (product) or 3637 (medical assistance)