急診筆記

林記賢醫師筆記 https://ppt.cc/fV38wx HINTS test 診斷後循環中風比 MRI 敏感 https://blog.xuite.net/ymmcc/twblog/300021884

HINTS (head impulse- nystagmus-Test of Skew)  診斷早期 posterior circulation stroke.  HINTS test 比 MRI 更準(敏感度99%) Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-10. Screening patients with AVS for one of 3 dangerous oculomotor signs (normal h-HIT, direction-changing nystagmus, skew deviation) appears to be more sensitive than MRI with DWI in detecting acute stroke in the first 24 to 48 hours after symptom onset. These “HINTS” to “INFARCT” could help reduce frontline misdiagnosis of patients with stroke in AVS and should be studied head-to-head for their comparative cost-effectiveness against neuroimaging by MRI DWI.  1 - Patients with peripheral vertigo will have abnormal (positive) head impulse testing, while patients with central vertigo typically have a normal (negative) he...

TG 長期控制的目標在 200 以下.  TG上升造成胰臟發炎. 超過 1000 以上可考慮血漿置換. 治療目標, 將TG降至 500 以下. 如果無法使用血漿置換. 可使用靜脈注射胰島素. 劑量 0.1-0.3u/kg/hr. 以 60 公斤重成人為例, 每小時 6-18u, 胰島素治療需每小時測血糖. 每 12 小時測量 TG. 治療目標也是將TG降到 500 以下.  其他治療方式與別的成因的胰臟炎相同: 空腹, 補充輸液, 止痛 Apheresis 分離術. 將血液某個成分使用機器分離移除. https://www.uptodate.com/contents/hypertriglyceridemia-induced-acute-pancreatitis#H8 Hypertriglyceridemia-induced acute pancreatitis Hypertriglyceridemia (HTG) Severe HTG (1000 to 1999 mg/dL, 11.3 to 22.5 mmol/L) Risk of acute pancreatitis — Mild hypertriglyceridemia is associated with a low risk of acute pancreatitis [2,9-11]. The risk increases progressively with serum triglyceride levels over 500 mg/dL (5.6 mmol/L) with the risk increasing markedly with levels over 1000 mg/dL (11.3 mmol/L) [10,12,13]. The risk of developing acute pancreatitis is approximately 5 percent with serum triglycerides >1000 mg/dL (11.3 mmol/L) and 10 to 20 percent with triglycerides >2000 mg/dL (22.6 mmol/L)  Secondary hypertrig...

潛水相關的疾病可分為四類 1. 下潛過程的疾病 2. 上升過程的疾病 3. 減壓症 4. 其他 1. BAROTRAUMA OF DESCENT 下潛過程氣壓傷 • Barotitis(ear squeeze) 氣壓性耳炎, 中耳受到擠壓 • External ear squeeze 外耳道受到擠壓 • Sinus barotraum 鼻竇氣壓傷 • Inner ear barotrauma 通常下降過程耳壓突然過大產生 • Face, tooth, or dry-suit squeeze 臉部擠壓 牙齒擠壓 乾式防寒衣擠壓 (濕式防寒衣不會形成密閉空間,不會造成擠壓傷) 2. BAROTRAUMA OF ASCENT 上升過程氣壓傷 •Alternobaric vertigo 氣壓變動性眩暈 • Pulmonary barotrauma 肺部氣壓傷 • Arterial gas embolism 動脈氣栓 •Decompression sickness 減壓症 (獨立成第三類) 3. DECOMPRESSION SICKNESS 又可細分成兩或三類. 第一類是骨頭及軟組織疼痛, 第二類是造成腦部.前庭神經.心肺症狀; 第三類是在不該出現減壓症的條件出現的減壓病, 可能是其他個體疾病或異常導致 4. SPECIAL CONSIDERATION . ASTHMA 會增加潛水的氣壓傷害兩倍 (一般人是 1/125000潛水次數) 但符合條件下仍可潛水 . IMMERSION PULMONARY EDEMA 原因不明, 非減壓造成, 因此不需要做 HBO . NITROGEN TOXICITY 通常下潛深度超過 100 英尺(等於30.5公尺)才會出現 . OXYGEN TOXICITY 分兩種，肺部氧損傷與腦部氧損傷 . OTHERS 在一般人會出現的疾病, 壓縮空氣潛水同樣可以發生, 所以不要忘了其他常見的疾病,例如心肌梗塞,肺栓塞,中風,癲癇,腦炎,甚至闌尾炎, 另外,潛水意外或突發性心跳停止可能會被誤認為溺水. 

( Tintinalli's Emergency Medicine ) Arterial gas embolism 動脈氣栓 當氣體進入左側血管系統會造成動脈氣栓, 潛水的情況通常是由肺部氣壓傷引起, 不慎進入靜脈循環的氣體可經由肺部動靜脈分流或心臟內分流進入左側循環, 不論來源為何, 當氣體在全身發生栓塞, 分布狀態主要是由血流而非重力決定(頭部高低影響不大) Arterial gas embolism occurs when air enters the left side of the vascular  system. In the setting of diving, this most often results from pulmonary  barotrauma. Air inadvertently introduced into the venous circulation  can cross from the right side of the circulation from intracardiac or pulmonary  arteriovenous shunts. Air bubbles may also arterialize through  these same shunts, sometimes making the source of arterial bubbles difficult  to determine.13 Whatever the source, when air embolizes systemically,  distribution depends mainly on blood flow and not gravity.  臨床表徵  Clinical Features  氣栓造成最大的影響在腦部, 導致各種中風症狀, 在罕見狀況, 潛水導致的肺部氣壓傷引起動脈氣栓會造成突然無呼吸, 心跳停止. 造成心血管崩潰的機制是由於氣體在中樞血管床的大靜脈大動脈導致.  The most dramatic effect of arterial gas embolism is  on ...

( Tintinalli's Emergency Medicine ) Pulmonary barotrauma 肺部氣壓傷. 也叫做  pulmonary overinflation  肺部過度充氣症,   burst lung syndrome肺 爆裂症 上升過程因故意閉氣,咳嗽,嘔吐等動作造成聲帶關閉, 造成肺部氣壓大於外界, 通常發生於恐慌的潛水員或氣瓶用盡而快速上升,造成肺部過度膨脹引起氣壓傷, 在淺水也可能發生(例如游泳池), 可導致 縱膈腔 氣腫.  縱膈腔氣腫: 胸部x光可能沒有明顯異常. 通常不需要高壓氧治療, 症狀治療即可(疼痛則給予止痛), 縱膈腔氣體可能會沿著皮下跑到頸部引起頸部皮下氣腫, 肺部過度膨脹 可能造成氣胸 (有些患者可能須用空針抽出氣胸部位的氣體, 有些可能需放置胸管) 如果氣體進入肺部靜脈循環, 可能之後進入動脈循環引起動脈氣栓, 對於氣栓最敏感的器官是腦部, 這種情況稱腦部動脈氣栓   cerebral arterial gas embolism , 但氣栓可能同時散步到其他器官或組織, 上升過程的氣壓傷害如果同時合併中樞神經受損症狀, 要考慮腦部動脈氣栓 有些人因為其他疾病, 可能在沒有閉氣上升, 沒有快速上升的情況出現肺部氣壓傷(例如肺囊腫 lungcyst, 肺部阻塞性疾病, 或其他可能造成肺臟局部氣體滯留的疾病) Air also expands within the lungs with ascent. If a diver breathing compressed  air ascends with a closed glottis (holds breath, coughs, vomits),  most frequently seen in a rapid, panicked, out-of-air ascent, the expanding  air may cause parenchymal lung injury. This can occur even in shallow  water (e.g., a swimming pool). Pulmonary barotrauma, al...

( Tintinalli's Emergency Medicine ) 氣壓變動 性眩暈 ALTERNOBARIC VERTIGO 不常見, 成因是單側外耳道有東西塞住(耳屎,耳塞), 上升過程在密閉的外耳道壓力差上升, 兩側不同的壓力差造成前庭神經不對稱 的電脈衝, 傳到腦部引起不平衡的感覺, 造成眩暈症, 通常是短暫的, 不需要治療 During ascent, the physics of gas in air-containing organs is, of course,  opposite that of descent—that is, air will expand as the pressure  decreases. Air will flow through the ostia of the sinuses, and the expanding  air in the middle ear will open the Eustachian tube (much like during  takeoff in an airplane). Should air be trapped temporarily in one middle ear cavity, the pressure differential may cause unequal vestibular  impulses to the brain, resulting in vertigo (alternobaric vertigo). This is  usually transient and generally requires no specific treatment.