2018年5月11日 星期五

看名畫 學急診

急診假日班

 連值四天夜班....

急診 HIS 系統當機!

 119 通報,患者酒醉路倒


我認識你們家院長, 
自費沒關係,全都給我用最好的!

外傭比較清楚,病歷裡面都有寫

為什麼簽病危通知單?剛剛人不都還好好的!

會診醫師:這不是我們科的問題

寫急診健保申覆

收到法院傳票

2017年12月18日 星期一

ATLS® 第10版 更新摘要



ATLS 10th Edition Compendium of Change

Primary Survey
Airway Maintenance with Restriction of Cervical Spine Motion
  • “cervical spine protection” changed to ”Restriction of Cervical Spine Motion
  • RSI changed to ”Drug Assisted Intubation
Breathing and Ventilation 
Circulation with Hemorrhage Control
  • Initial resuscitation: Adult: 1 L isotonic solution; Child < 40 kg: 20 ml/kg
  • Tranexamic acid: 1 g over 10 min within 3 hr, then 1 g over 8 hr
  • Hemorrhagic shock classification table amended: Base excess 

Thoracic Trauma
  • Life threatening chest injury: flail chest out, tracheobrochial injury now in
  • Tension pneumothorax:
    • Needle thoracocentesis
      • 5th  ICS mid-axillary line for adult
      • UNCHANGED 2nd ICS mid-clavicular line for child
    • 28-32 Fr chest drain for hemothorax (not 36-40 Fr)
      • eFAST (extended FAST): seashore, bar code, or stratosphere sign in M mode
    • Aortic rupture management with Beta Blocker (esmolol): goal heart rate < 80 bpm and MAP 60-70 mmHg
    • Algorithm for circulation arrest approach

    Abdominal and Pelvic Trauma
    • Palpation of prostate gland no longer recommended for urethral injury

    Head Trauma
    • Classification: “minor” changed to “mild” head trauma
    • Detailed guidance on SBP management
      • Maintain SBP at ≥ 100 mmHg for patients 50-69 years or at ≥ 110 mmHg for patients 15-49 years or older than 70 years.
    • Anticoagulation reversal guidance

    Spine and Spinal Cord Trauma
    • New myotome diagram
    • Canadian C-Spine Rule (CCR) and NEXUS Criteria




      Musculoskeletal Trauma
      • Highlighting risk factor of bilateral femur fractures

      Thermal Injury

      Paediatric Trauma
      • Pediatric Emergency Care Applied Research Network (PECARN) Criteria for Head CT

        Transfer to Definitive Care
        • Specific mention of avoiding CT in primary hospital
        • SBAR template for communication

        Mobile ATLS: New to this edition

        Royal College Surgeons ATLS course 時程公告:
        2018年 2月   以前,ATLS 第 9 版
        2018年 3月到 5月,ATLS 第 9 版 + 第 10版 重點導讀
        2018年 6月   以後,ATLS 第 10版

        2017年9月7日 星期四

        The European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma: 4E



        The European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma: Fourth Edition

        Rossaint et al. Critical Care (2016) 20:100
        DOI 10.1186/s13054-016-1265-x


        Major Bleeding
        • FAST, CT 找出血
        • Damage control surgery if shock or coagulopathy
        • Damage control resuscitation 直到找到出血來源並控制
        • Restricted volume replacement: target SBP: 80-90 mmHg; severe TBI (GCS ≤8): MAP ≥80 mmHg
        • Tranexamic acid (TXA) as early as possible (< 3hr): loading dose TXA 1 g over 10 min, followed by TXA 1 g over 8 h
        Transfusion
        • Restrictive RBC transfusion: target Hb 7–9 g/dl
        • FFP-RBC ratio >1:2
        • Fibrinogen maintain at 1.5–2 g/l
        • FFP administered to maintain PT and APTT ≤ 1.5 times the normal control
        • Platelet count >100K
        • PCC administered in patients pre-treated with warfarin or direct-acting oral coagulants
        • Off-label use of rFVIIa only if major bleeding and traumatic coagulopathy persist despite standard attempts to control bleeding and best practice use of conventional hemostatic measures.