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.

        2017年2月4日 星期六

        Surviving Sepsis Guidelines 2016



        Surviving Sepsis Campaign:
        International Guidelines for Management of Sepsis and Septic Shock: 2016


        Intensive Care Medicine 2016
        doi: 10.1007/s00134-017-4683-6



        Initial Resuscitation
        ☑ Crystalloid fluid ≥ 30 ml/kg within the first 3 hrs
        ☐ Target MAP ≥ 65 mmHg
        ☐ Normalize lactate
        ☒ EGDT, CVP, ScvO2

        Antimicrobial Therapy
        ☐ Empiric broad-spectrum antibiotics within 1 hr
        ☐ Procalcitonin to support the discontinuation of antibiotics

        Source Control
        ☐ As soon as possible

        Fluid Therapy
        ☑ Crystalloids ± albumin
        ☒ HESs

        Vasopressors
        ☑ Norepinephrine ± vasopressin or epinephrine
        ☐ Dopamine only in bradycardia

        Corticosteroids
        ☐ Hydrocortisone 200 mg per day for refractory shock

        Blood Products
        ☐ pRBC: Hb < 7
        ☐ platelet: 10K, 20K, 50K

        Glucose Control
        ☐ Target blood glucose ≤ 180 mg/dl

        Bicarbonate Therapy
        ☐ pH < 7 .15


        《Surviving Sepsis Guidelines 2016 改版摘要》


        初步復甦
        • 3小時內給予 Crystalloid fluid ≥ 30 ml/kg
        • 復甦目標 MAP > 65 mmHg, lactate 降至正常
        • EGDT, CVP, ScvO2 不再被建議用來評估復甦成效!改以非侵入性動態指標監測
        • 不建議使用 hydroxyethyl starches 作為急救輸液
        一小時內給予廣效性經驗性抗生素治療
        利用 procalcitonin 輔助決定是否停用抗生素

        第一線強心劑首選:Levophed

        輸血時機:Hb小於 7
        輸血小板時機:
            血小板 < 1萬
            血小板 < 2萬,有出血風險
            血小板 < 5萬,有出血或執行侵入性處置

        血糖控制目標 ≤ 180 mg/dl

        Bicarbonate 時機: pH 小於 7.15

        2016年11月12日 星期六

        急診 VBG 可否取代 ABG?



        Can VBG analysis replace ABG analysis in emergency care?

        Blood Gas Analysis 臨床主要用來評估病患的 Respiratory or Metabolic conditions:
        病患是否缺氧、呼吸衰竭、需呼吸器,有無/何種酸鹼異常,對治療有無反應… 
        VBG 的 PvO2 無臨床價值。除此之外,PvCO2, venous pH & HCO3 可用來評估 ventilation and/or acid-base status;SvO2 可用在 severe sepsis or septic shock (EGDT) 治療指引。

        VBG 轉換 ABG 校正:



        Central
        Peripheral
          pH
        0.03 to 0.05
        0.02 to 0.04
          pCO2
        4 to 5 mmHg
        3 to 8 mmHg
          HCO3
        1 to 2 meq/L
         

        CASE 1:

        26歲女性,DM病史。上吐下瀉兩天,急診就醫
        Pulse 120, BP 100, RR 30. PE 無明顯異常
        Bedside glucose show ‘Hi’
        VBG: pH 7.26, pCO2 16, HCO3 7.1, K 3.8, BE −14, lactate 7.2
        pH↓, pCO2↓, HCO3 ↓ →metabolic acidosis
        加上 glucose ‘Hi’ 可診斷 DKA

        CASE 2:

        74歲男性,COPD病史。「感冒」後 呼吸急促,急診就醫。
        休息時會喘,僅能講簡短字句。
        Pulse 125, BP 140, RR 35, SpO2 86% on air
        Chest examination: generally reduced breath sounds with scattered rhonchi
        VBG: pH 7.16, pCO2 82.6, HCO3 28.8

        pH↓, pCO2↑, HCO3 near normal
        診斷:COPD with acute hypercarbia and respiratory failure
        治療:ventilatory support with non-invasive ventilation.

        CASE 2: A VARIATION

        Symptoms/Signs are the same
        Pulse 110, BP 140, RR 30 with SpO2 86% on air
        VBG: pH 7.45, pCO2 42 and HCO3 28.7 

        VBG pCO2< 45 mmHg 可排除臨床有意義的 hypercarbia
        Sensitivity 100% (95% CI 97% to 100%) & NPV 100% (97% to 100%)

        此病患沒有acute respiratory failure 也沒有 significantly hypercarbia

        VBG 的臨床侷限

        血壓不穩或休克病患,仍以 ABG優先
        若 VBG data 無法解釋臨床症狀,抽 ABG 確認

        【摘要】

        • VBG 的 PvCO2, pH & HCO3 與 ABG 差異不大,可用來評估 ventilation 和 acid-base status
        • VBG pCO2< 45 mmHg 可排除臨床有意義的 hypercarbia
        • VBG的 PvO2 無臨床價值,但可用 pulse oximerty 來評估 oxygenation (O2 saturation)
        • venous 與 artery 的 CO-Hb 差異 < ±2%,可相互取代
        • 大部分的臨床情況下,可以根據 VBG 決定病患的診斷與處置。除非病患血壓不穩/休克,或 VBG data 無法解釋臨床症狀,需再抽 ABG 確認

        Reference:

        • Emerg Med J 2014;0:1–3. Can VBG analysis replace ABG analysis in emergency care?
        • UpToDate. VBG and other alternatives to ABG. Literature review current through: Sep 2016. This topic last updated: Feb 29, 2016.
        • Ann Emerg Med 1995;33:105-109. Relationship between venous and arterial carboxyhemoglobin levels in patients with suspected carbon monoxide poisoning.
        • AliEM PV card. ABG vs VBG