Evaluation of EMD in OHCA in Taipei

Evaluation of EMD in OHCA in Taipei from Sun YaiCheng

Evaluation of Emergency Medical Dispatch in Out-Of-Hospital Cardiac Arrest in Taipei

Resuscitation (2007) 73, 236—245

台北緊急救護派遣員 (EMD) 評估院外心臟停止 (OHCA) 的表現

緊急救護派遣員 (EMD) 的任務：

1. 改善病患的預後，提升存活率
2. 縮短EMSS反應時間，提升EMSS的效率

EMD Telephone-assisted CPR (T-CPR) 電話指導CPR可提升病患50%存活的勝算比

大部分OHCA現場目擊者並無CPR的知識或訓練

EMD開始T-CPR前，必須依照流程，問4個關鍵問題

1. 病患的膚色
2. 有無呼吸道阻塞的症狀
3. 現場是否有人會CPR
4. 病患已經昏迷多久

疑似OHCA個案，EMD應立刻以電話指導CPR(T-CPR)，同時並啟動EMS

• EMD平均通話時間32.5秒；平均取得地址時間7.0秒
• EMD評估OHCA的準確率(sensitivity) 96.9%

「瀕死喟嘆式呼吸 (agonal gasps)」常發生在OHCA早期，沒有發現瀕死呼吸會導致OHCA的誤判

• 民眾在面對「瀕死喟嘆式呼吸（agonal gasps)」的病患時，會誤認為仍有呼吸而未進行CPR，其實這種呼吸型態就是心跳停止的初期表現。

• 緊急救護派遣員 (EMD) 在接獲求救電話時，或在急救教學時，需教導民眾辨識該狀況，並對病患立即進行CPR。
• 對於疑似OHCA個案，最重要的兩個問題是確認『意識狀態』和『呼吸狀態』

• 只有6.5%的病患在接受EMD 指導 T-CPR前，接受過旁人的CPR
• 有將近1/3的病患接受EMD 指導 T-CPR，其餘的人在EMTp到達前未接受任何的CPR
• EMD T-CPR可提升病患50%的存活率

Bowel & Mesenteric Trauma in CT

Evaluation of Bowel and Mesenteric Blunt Trauma with Multidetector CT from Sun YaiCheng

Evaluation of Bowel and Mesenteric Blunt Trauma with Multidetector CT
RadioGraphics 2006; 26:1119–1131

Findings Specific to Bowel Injury

• Bowel Wall Discontinuity
• Extraluminal Contrast Material
• Extraluminal Air

Findings Less Specific to Bowel Injury

• Bowel Wall Thickening
• Abnormal Bowel Wall Enhancement
• Mesenteric Features

Findings Specific to Mesenteric Injury

• Mesenteric Extravasation
• Mesenteric Vascular Beading
• Termination of Mesenteric Vessels

Less Specific Findings

• Mesenteric Infiltration
• Mesenteric Hematoma
• Bowel Features

Common Features in Bowel and Mesenteric Injuries

• Intraperitoneal and Retroperitoneal Fluid
• Abdominal Wall Injury

The Jaw-Thrust Maneuver

Fiberoptic Bronchoscopic View Before and During the Jaw-Thrust Maneuver

在意識不清的病人，舌頭往後倒向咽壁、軟顎和會厭，造成上呼吸道阻塞。由此產生的換氣不足可能會導致高碳酸血症和低氧血症，造成心律不整或心臟停止。

下頜推出法 (The Jaw-Thrust Maneuver)，是BLS教學的一部分，可改善呼吸道的暢通。
由醫生站在病人的頭部或床頭上方，雙手各抓住兩邊的下頜角，把下頜骨向前推出。如果病患雙唇緊閉時，可用拇指將下唇往下推。

下頜推出法可將會厭上提，加大咽喉的入口，打開聲門，進而改善換氣。

在 fiberoptic bronchoscopy影片中，可以看到病人在全身麻醉經口插管前，實施下頜推出法後，對上呼吸道的影響。

translate from N Engl J Med. November 18, 2010; 363:e32

Current Management of Acute Cutaneous Wounds

Current Management of Acute Cutaneous Wounds from Sun YaiCheng

Current Management of Acute Cutaneous Wounds
N Engl J Med. September 4, 2008;359:1037-1046

Primary Goal of Wounds Management

1. No infection
2. Normal function
3. Excellent cosmetic result

General Principles of Care

• All wounds should be thoroughly cleansed with tap water or normal saline.

Lacerations

1. Skin Tears
2. Plantar Puncture Wounds
3. Mammalian Bites
4. Subungual Hematomas

1. Skin Tears

• Long-term corticosteroid therapy, the elderly.
• Category I tears (without tissue loss), the wound edges can be approximated with surgical tapes, and the area covered with a non-adherent dressing.
• Category II skin tears (partial tissue loss) and category III skin tears (complete tissue loss) can be managed with absorbent dressings such as petroleum-based gauzes, hydrogels, foams, hydrocolloids, nylon-impregnated gauzes, and silicone-coated dressings.

Treatment of a Category I Skin Tear of the Dorsal Forearm

2. Plantar Puncture Wounds

• Superficial infection rate (i.e., cellulitis): 2-10%.
• Most of the infections are caused by Staphylococcus aureus or Streptococcus pyogenes.
• Cleansing alone may be adequate therapy and antibiotics should be administered immediately in patients who have signs and symptoms of infection.
• If  foreign body is suspected, CT or sonography should be used to detect non-adiopaque objects.
• The incidence of osteomyelitis (in most cases caused by pseudomonas), chondritis, and septic arthritis is considerably lower, antibacterial agents (e.g., dicloxacillin and ciprofloxacin) should be used.

3. Mammalian Bites

• After high-pressure irrigation of the wound, it is safe to close most bite wounds up to 12 hours after injury (healing by primary intention).
• Puncture wounds and scratches should be allowed to heal by secondary intention.
• For large, heavily contaminated lacerations, delayed primary closure, after an observation period of 3-5 days (healing by tertiary intention.
• Human bites that are sustained over the MCP joints ("clenched-fist bites") are especially prone to infection.
• These bites require aggressive irrigation and treatment with antibiotics (e.g., amoxicillin–clavulanate) and should not be closed.

4. Subungual Hematomas

• In the past, for hematomas involving more than 50% of the nail bed, many physicians recommended removal of the nail and repair of any underlying laceration of the nail bed, since the incidence of underlying lacerations was found to be quite high.
• Simple nail trephination with the use of a handheld portable cautery is recommended for most subungual hematomas.
• Do not routinely replace the nail plate or put other materials, such as aluminum foil or gauze impregnated with petrolatum, to separate the nail fold from the nail bed unless there has been a serious injury that requires surgical repair.

Burns
Determination of Burn Depth

• Cooling of burns with the use of cold (15-25°C) tap water within 30 minutes should continue until the pain is substantially reduced or resolves.

Management of Blisters

• Intact blisters healed faster and were less likely to become infected than blisters that were ruptured.
• Removal of the necrotic epidermis slowed reepithelialization and increased the rate of infection and scarring.
• Blisters larger than 3 cm in diameter and those over mobile areas usually rupture spontaneously and may be aspirated under sterile conditions.
• When blisters rupture, the wound should be washed with soap and water, and the nonadherent necrotic epidermis carefully removed.

HF Burns

• Exposure to HF leads to intense pain and tissue damage.
• Treatment includes copious irrigation followed by the application of calcium gluconate gel or subcutaneous injection of calcium gluconate, with the goal of relieving the pain.
• A burn from HF that involves >5% of TBSA, or >1% of TBSA if the concentration of hydrofluoric acid >50%, requires admission for ECG monitoring and serial measurements of calcium levels, since life-threatening arrhythmias and hypocalcemia can occur. 

相關文章：Wound Management

Acute Heart Failure Syndromes

Acute Heart Failure Syndromes from Sun YaiCheng

Acute Heart Failure Syndromes: 
Emergency Department Presentation, Treatment, and Disposition:
Current Approaches and Future Aims
Circulation. Nov 9, 2010;122:1975-1996


Current Diagnostics

• The evaluation of possible AHFS in the ED includes history, physical examination, CXR, 12-lead ECG,cardiac troponin I or T, electrolytes, and CBC.
• The BNP and NT-proBNP have demonstrated diagnostic utility when clinical uncertainty remains after initial history, physical examination, and CXR.
• Either BNP or NT-proBNP should be measured in patients in whom there is clinical uncertainty concerning the diagnosis of AHFS.

Optimal NT-proBNP cut-points for the diagnosis or exclusion of AHFS

• BNP and NT-proBNP single cut point of 300 pg/mL to rule out AHFS
• 2 cut points to rule in AHFS depending on age:

<50 years old ( >450 pg/mL)
>50 years old ( >900pg/mL)

Am J Cardiol. 2005;95:948–954.

• Age-independent cutoff of 900 pg/mL
• Age-stratified approach of 450/900/1800 for patients aged <50/50 to 75/>75 years

Category	Optimal cut-point	Sensitivity  (%)	Specificity (%)	PPV (%)	NPV (%)	Accuracy (%)
Confirmatory (‘rule in’) cut-points
<50 years (n=184)	450 pg/mL	97	93	76	99	94
50–75 years (n=537)	900 pg/mL	90	82	83	88	85
>75 years (n=535)	1800 pg/mL	85	73	92	55	83
Rule in, overall		90	84	88	66	85
Exclusionary (‘rule out’) cut-point
All patients (n=1256)	300 pg/mL	99	60	77	98	83

Eur Heart J. 2006;27:330–337
Am J Cardiol. 2008;101:29–38

Current Therapy: Heterogeneous Presentations Met With Homogeneous Therapy

• Regardless of the baseline cardiac pathophysiology, critical presenting features such as hemodynamic status, presence of myocardial ischemia, and renal dysfunction, the current goals of ED therapy are to relieve congestion, balance hemodynamics, achieve euvolemia.
• Initial stabilization focuses on determining whether the patient requires ventilatory support.
• Diuretics and vasodilators are frequently used in the treatment of AHFS with congestion and normal or elevated blood pressure.
• Hypertension may appear to be the most acutely ill, but aggressive blood pressure management often results in rapid resolution of symptoms. 

ED Disposition

• 80% of patients who present to the ED with AHFS are hospitalized.

Predictors of Adverse Events

• Elevated BUN or creatinine 
• Hyponatremia 
• Ischemic ECG changes 
• Elevated BNP levels 
• Elevated troponins 
• Low systolic blood pressure 

Morbidity and Mortality in Hospitalized Patients with AHFS

• The average risk of death during hospital admission for AHFS is apprximately 4%. 
• Patients requiring the use of inotropic agents had a mortality rate of 12% to 13%. 
• Traditional HF medical therapy including ACE inhibitors, ARB, β-blockers, and selective aldosterone receptor antagonists. Early initiation of this therapy, before hospital discharge, with appropriate titration, improves symptoms, reduces hospitalizations, and saves lives. 

Patient Characterization
The European Society of Cardiology classification:

1. Worsening or decompensated chronic HF 
2. Cardiogenic pulmonary edema 
3. Hypertensive AHFS 
4. Cardiogenic shock 
5. Isolated right HF 
6. AHFS with ACS

• Nitrates might be used in higher relative doses to diuretics in the hypertensive profile Ultrafiltration could be usedin the diuretic-resistant patient 
• Inotropic agents should be considered in the rarer cases of advanced/low-output HF 
• Hypotension and tachycardia should be avoided, especially in patients with coronary artery disease 

ACC/AHA Stages of Heart Failure

• A: At high risk for HF but without structural heart disease or symptoms of HF 
• B: Structural heart disease but without signs or symptoms of HF 
• C: Structural heart disease with prior or current symptoms of HF 
• D: Refractory HF requiring specialized interventions

Risk Stratification: Low-Risk, Not High-Risk Markers Are Necessary

• Hypotension, hyponatremia, renal dysfunction, increased troponin levels, and elevated BNP all portend a poor prognosis. 
• The absence of high-risk markers does not define a low-risk patient.
• Data suggest that EP would be comfortable discharging a patient if there was a combined overall risk of in-hospital events or 30-day mortality of <2%. 

第4張 slide 更正：

• BNP and NT-proBNP can be elevated in sepsis, pulmonary hypertension, older age, renal insufficiency, atrial fibrillation, pulmonary embolism and obesity. 

• Obesity is associated with disproportionately low BNP levels.

Traumatic Retroperitoneal Hematoma

Traumatic Retroperitoneal Hematoma from Sun YaiCheng

Traumatic Retroperitoneal Hematoma Spreads Through the Interfascial Planes
J Trauma. 2005;59:595– 608.

In the early 1980s, Sheldon introduced a treatment principle founded on a location-based classification of traumatic RH as

1. Central-medial (zone I) RH
2. Flank or perirenal (zone II) RH
3. Pelvic (zone III) RH

Traditionally, the retroperitoneal space was believed to comprise only 3 compartments:

1. Anterior pararenal space (APS)
2. Perirenal space (PRS)
3. Posterior pararenal space (PPS)

which are demarcated by 3 well-defined fascias:

1. Anterior renal fascia
2. Posterior renal fascia
3. Lateroconal fascia

Assessment of RH on CT Images
10 component parts of the retroperitoneal space were identified:
 3 compartments

1. Anterior pararenal space (APS)
2. Perirenal space (PRS)
3. Posterior pararenal space (PPS)

4 interfascial planes comprise

1. Retromesenteric plane (RMP)
2. Retrorenal plane (RRP)
3. Lateroconal plane (LCP)
4. Combined interfascial plane (CIP), providing a route for the spread of disease from the abdominal retroperitoneum into the pelvis.

3 other extraperitoneal spaces are

1. Retrohepatic space (rhe)
2. Prevesical space (PV)
3. Presacral space (PS)

New Classification of RH
Each RH was first classified by the component where bleeding originated:

1. Type I derived from the APS or RMP
2. Type II from the PRS, LCP, Rhe, or PPS above the pelvis
3. Type III from the pelvis
4. Type IV from the RRP or CIP

Each type was subdivided according to the degree of extension into subtype

“a” if the RH never exceeded the promontory
“b” if the RH spread beyond the promontory

This Classification Also Indicated The Appropriate Treatment Policy

1. Type I RH requires emergent retroperitoneal exploration, which also affords a good prognosis.
2. Type II RH is treatable with conservative therapy unless renal vein injury is complicated.
3. Type III RH requires TAE, C-clamp, or external fixation but no laparotomy for RH hemostasis.
4. Treatment of Type IV RH is still challenging and requires further investigation.

ACC/AHA 2009 Guidelines for STEMI & PCI

ACC/AHA 2009 Guidelines for STEMI & PCI from Sun YaiCheng

ACC/AHA 2009 STEMI/PCI Guidelines 
ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction (STEMI) and the ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (PCI)

J. Am. Coll. Cardiol.  2009;54;2205-2241
Circulation. 2009;120;2271-2306

Glycoprotein IIb/IIIa Antagonists in STEMI

• It is reasonable to start treatment with GP IIb/IIIa antagonists (abciximab, tirofiban and eptifibatide) at the time of primary PCI in selected patients with STEMI

Thienopyridine in STEMI
A loading dose of thienopyridine is recommended for STEMI patients for whom PCI is planned.
Regimens should be one of the following:

• Clopidogrel at least 300 to 600 mg should be given as early as possible before or at the time of primary or non-primary PCI.
• Prasugrel 60 mg should be given as soon as possible for primary PCI.

Parenteral Anticoagulants in STEMI

• For prior treatment with UFH, additional boluses of UFH should be administered as needed to maintain therapeutic activated clotting time levels, taking into account whether GP IIb/IIIa antagonists have been administered; or
• Bivalirudin is useful as support for primary PCI with or without prior treatment with heparin.

Triage and Transfer for PCI in STEMI
High Risk Definition: 

• Defined in CARESS-in-AMI as STEMI patients with one or more high-risk features:

– extensive ST-segment elevation
– new-onset left BBB
– previous MI
– Killip class >2
– LVEF <35% for inferior MI

Anterior MI alone with 2 mm or more ST-elevation in 2 or more leads qualifies

• Defined in TRANSFER-AMI as >2 mm ST-segment elevation in 2 anterior leads or ST elevation at least 1 mm in inferior leads with at least one of the following:

– SBP <100 mmHg
– heart rate >100 bpm
– Killip Class II-III
– >2 mm of ST-segment depression in the anterior leads
– >1mm of ST elevation in right-sided lead V4

相關文章：
ACC/AHA 2007 Guidelines for UA/NSTEMI

Acute Calculous Cholecystitis

Peptic Ulcer Bleeding from Sun YaiCheng

Acute Calculous Cholecystitis
NEJM June 26, 2008;358;26:2804-11

Pathogenesis

• With inflammation, the gallbladder becomes enlarged, tense, and reddened, and wall thickening and an exudate of peri-cholecystic fluid may develop.
• Enterobacteriaceae family or with enterococci or anerobes occurs in the majority of patients.
• The wall of the gallbladder may undergo necrosis and gangrene (gangrenous cholecystitis).
• Bacterial super-infection with gas-forming organisms may lead to gas in the wall or lumen of the gallbladder (emphysematous cholecystitis).

Diagnosis

• Murphy's sign — the arrest of inspiration while palpating the gallbladder during a deep breath.
• Systemic sepsis and organ failure → gangrenous or emphysematous cholecystitis.
• Fever, elevation in the WBC and CRP.
• Elevated serum amylase level →concomitant gallstone pancreatitis or gangrenous cholecystitis.
• In elderly patients, delays in diagnosis are common, the only symptoms may be a change in mental status or decreased food intake, and physical examination and laboratory indexes may be normal.

Imaging

• Ultrasonography detects cholelithiasis in about 98% of patients.
• Acute calculous cholecystitis is diagnosed radiologically by the concomitant presence of thickening of the gallbladder wall ( >5 mm), peri-cholecystic fluid, or direct tenderness when the probe is pushed against the gallbladder (ultrasonographic Murphy's sign).

• Hepatobiliary scintigraphy involves intravenous injection of technetium-labeled analogues of iminodiacetic acid, which are excreted into bile. The absence of gallbladder filling within 60 minutes after the administration of tracer indicates obstruction of the cystic duct and has a sensitivity of 80 to 90% for acute cholecystitis.
• The " rim sign " is a blush of increased pericholecystic radioactivity, which is present in about 30% of patients with acute cholecystitis and in about 60% with acute gangrenous cholecystitis.

Treatment

1. Timing of Cholecystectomy
2. Antibiotic Therapy
3. Percutaneous Cholecystostomy

1. Timing of Cholecystectomy

• Cholecystectomy can be performed by laparotomy or by laparoscopy, either at the time of the initial attack (early treatment) or 2 to 3 months after the initial attack has subsided (delayed treatment).
• “ Early" has been variably defined as anywhere from 24 hours to 7 days after either the onset of symptoms or the time of diagnosis.
• If delayed, or "conservative," treatment is selected, patients are treated during the acute phase with antibiotics and intravenous fluids and NPO.
• Early laparoscopic cholecystectomy is considered the treatment of choice for most patients.
• Predictors of the need for conversion include

• WBC > 18000
• duration of symptoms of more than a range of 72 to 96 hrs
• age over 60 years

2. Antibiotic Therapy

• The guidelines of the Infectious Diseases Society of America recommend that antimicrobial therapy be instituted if infection is suspected on the basis of laboratory and clinical findings (WBC > 12500/mm3 or temperature > 38.5°C) and radiographic findings (e.g., air in the gallbladder or gallbladder wall).
• Antibiotics coverage against micro-organisms in the Enterobacteriaceae family (e.g., 2° cephalosporin or a combination of a quinolone and metronidazole); activity against enterococci is not required.
• Antibiotics are also recommended for routine use in patients who are elderly or have diabetes or immunodeficiency and for prophylaxis in patients undergoing cholecystectomy to reduce septic complications even when infection is not suspected.

3. Percutaneous Cholecystostomy

• Percutaneous cholecystostomy is often used when the patient presents with sepsis (severe acute cholecystitis, according to the Tokyo guidelines) and in cases in which conservative treatment alone fails, especially in patients who are poor candidates for surgery.

Guidelines

• Mild acute cholecystitis : early laparoscopic cholecystectomy is recommended. 

• Moderate acute cholecystitis : either early or delayed cholecystectomy may be selected but that early laparoscopic cholecystectomy should be performed only by a highly experienced surgeon and promptly terminated by conversion to open cholecystostomy if operative conditions make anatomical identification difficult. 

• Severe acute cholecystitis : initial conservative management with antibiotics is recommended, preferably in a high-acuity setting, with the use of percutaneous cholecystostomy as needed; surgery is reserved for patients in whom this treatment fails.