Primary Blast Injury

Primary Blast Injury

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Primary blast injury:
Update on diagnosis and treatment

Crit Care Med 2008; 36:[Suppl.]:S311–S317


Injuries from explosions are traditionally classified into:

1. Primary blast injuries: injuries due solely to the blast wave
2. Secondary blast or explosive injury: primarily ballistic trauma resulting from fragmentation wounds from the explosive device or the environment
3. Tertiary blast or explosive injury: result of displacement of the victim or environmental structures, is largely blunt traumatic injuries
4. Quaternary explosive injuries: burns, toxins, and radiologic contamination

Ocular Injury

• Ophthalmology consultation should be obtained for suspected globe injuries, corneal foreign bodies or abrasions, orbital fractures, retinal detachments, hyphema, intraocular foreign bodies, corneal or eyelid burns, lid lacerations, subconjunctival hemorrhage, or head injuries that involve the orbit or may compromise vision

Aural Injury

• Tympanic membrane rupture is the most common primary blast injury
• Clinicians should make otoscopic examination a routine part of the initial evaluation of explosion injured patients

Pulmonary Injury

• Blast lung injury is the most common fatal injury among initial survivors of explosions
• Clinical diagnosis of blast lung injury is based on the presence of respiratory distress, hypoxia, and “butterfly” or batwing infiltrates.

CVS Injury

• Triad of immediate bradycardia, hypotension, and apnea.

GI Injury

• Mesenteric or mural hematoma in hemodynamically stable patients without peritoneal signs may be managed with NPO, NG tube decompression, and resuscitation.
• Massive hemorrhage or obvious hollow viscus perforation should be treated with laparotomy for hemostasis and control of spillage of enteric contents.

Traumatic Amputations

• Early tourniquet use

Brain Injury

• PE should include a thorough NE to include checking for positive Romberg's sign as well as funduscopy to look for evidence of air emboli.
• CT scan should be used to search for evidence of blunt head injury and ICH.

Patient Risk Stratification

Avoid CT in Kids at Very Low Risk of Brain Injury

Children at very low risk of brain injuries

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Identification of children at very low risk of clinically-important brain injuries after head trauma:
a prospective cohort study

Lancet 2009; 374: 1160–70

Purpose

To identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.

The prediction rule for children < 2 years 

• Normal mental status 
• No scalp haematoma except frontal 
• Loss of consciousness < 5 s 
• Non-severe injury mechanism
• No palpable skull fracture 
• Normal behavior per patient 

Severe mechanism of injury: 

• motor vehicle crash with patient ejection
• death of another passenger, rollover
• pedestrian or bicyclist without helmet struck by a motorised vehicle
• falls of more than 0.9 m
• head struck by a high-impact object

NPV: 100% 
Sensitivity: 100% 

The prediction rule for children > 2 years

• Normal mental status
• No loss of consciousness
• No vomiting
• Non-severe injury mechanism
• No signs of basilar skull fracture
• No severe headache

Severe mechanism of injury:

• motor vehicle crash with patient ejection
• death of another passenger, rollover
• pedestrian or bicyclist without helmet struck by a motorised vehicle
• falls of more than 1.5 m
• head struck by a high-impact object

NPV: 99.95%
Sensitivity: 96.8%

Neither rule missed neurosurgery in validation populations

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4月24日 補充 中文摘要 (by zeno)

兒童頭部外傷，若是六項因素都沒有，可以不用切CT ！
Tintinalli's Emergency Medicine, 7E, p891

一、小於2歲的預測因子

1. 意識改變（昏迷指數14分或有躁動、嗜睡、重複問相同問題、反應變慢）
2. 除了前額之外的區域有頭皮血腫
3. 失去意識5秒以上
4. 嚴重的受傷機制（汽機車相撞且被彈射出去、車子翻覆或其他乘客死亡、走路或騎腳踏車被行進中的車輛撞到、從大於0.9公尺的高度跌落、頭部被高速物體擊中）
5. 觸診可摸到顱骨骨折
6. 主要照顧者注意到有行為異常

二、2歲以上的預測因子

1. 意識改變（昏迷指數14分或有躁動、嗜睡、重複問相同問題、反應變慢）
2. 嘔吐
3. 有失去意識
4. 嚴重的受傷機制（汽機車相撞且被彈射出去、車子翻覆或其他乘客死亡、走路或騎腳踏車被行進中的車輛撞到；從大於1.5公尺的高度跌落、頭部被高速物體擊中）
5. 熊貓眼、耳後區域瘀血等顱底骨折的表徵
6. 嚴重頭痛 

 (99.95-100% 陰性預測值； 96-8100% 敏感度)

Definition and Evaluation of Transient Ischemic Attack

Definition and Evaluation of Transient Ischemic Attack

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AHA/ASA Scientific Statement
Definition and Evaluation of Transient Ischemic Attack

Stroke. 2009;40:2276-2293


Traditional Definition

Transient Ischemic Attack (TIA) was a sudden, focal neurological deficit of presumed vascular origin lasting <24 hours

2002 AHA-Endorsed Revised Definition of TIA

a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction

Risk Stratification

Patients with TIAs are at high risk of early stroke, and their risk may be stratified by clinical scale, vessel imaging, and diffusion MRI

The California score and the ABCD2 scores

• Age ≥60 years (1)
• Blood pressure ≥140/90 mmHg on first evaluation (1)
• Clinical symptoms of focal weakness with the spell (2) or speech impairment without weakness (1)
• Duration ≥60 minutes (2) or 10 to 59 minutes (1)
• Diabetes (1)

Hospitalization

It is reasonable to hospitalize patients with TIA if they present within 72 hours of the event and any of the following criteria are present:    

• ABCD2 scores of 3 (Class IIa, Level of Evidence C)
• ABCD2 scores of 0 to 2 and uncertainty that diagnostic workup can be completed within 2 days as an outpatient (Class IIa, Level of Evidence C)
• ABCD2 scores of 0 to 2 and other evidence that indicates the patient’s event was caused by focal ischemia (Class IIa, Level of Evidence C)

Patients with TIA or minor stroke who have DWI lesions, especially when multiple, are at higher risk of recurrent ischemic events

Diagnostic Evaluation

• Patients with TIA should preferably undergo neuroimaging evaluation within 24 hours of symptom onset 

• MRI, including DWI, is the preferred brain diagnostic imaging modality. If MRI is not available, CT should be performed (Class I, Level of Evidence B) 

• Noninvasive imaging of the cervicocephalic vessels should be performed routinely as part of the evaluation of patients with suspected TIAs (Class I, Level of Evidence A) 

• Initial assessment of the extracranial vasculature may involve any of the following: carotid ultrasound/ transcranial Doppler (CUS/TCD), MRA, or CTA, depending on local availability and expertise, and characteristics of the patient (Class IIa, Level of Evidence B)

• ECG and prolonged cardiac monitoring 

• Echocardiography (TTE or TEE) 

• Routine blood tests (CBC, chemistry panel, PT and aPPT, and fasting lipid panel) 

• Optional Coagulation Screening Tests 

Consider in Younger Patients With TIAs, Particularly When No Vascular Risk Factors Exist and No Underlying Cause Is Identified

• Protein C, protein S, antithrombin III activities
• Activated protein C resistance/factor V Leiden
• Fibrinogen
• D-Dimer
• Anticardiolipin antibody
• Lupus anticoagulant
• Homocysteine
• Prothrombin gene G20210A mutation
• Factor VIII
• Von Willebrand factor
• Plasminogen activator inhibitor-1
• Endogenous tissue plasminogen activator activity

老人急診守則

Principles of Geriatric Emergency Medicine

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老人急診守則 

Principles of Geriatric Emergency Medicine


1.   疾病臨床表現通常很複雜

The patient’s presentation is frequently complex. 

2.   常見的疾病，常有不典型的表現

Common diseases present atypically in this age group.

3.   合併多種疾病，使臨床表現產生混淆效果

The confounding effects of comorbid diseases must be considered.

4.   常使用多種藥物，對臨床表現、診斷及處置會有影響

Polypharmacy is common and may be a factor in presentation, diagnosis, and management.

5.   要識別出認知功能障礙的可能

Recognition of the possibility for cognitive impairment is important.

6.   有些檢驗數值可能會有不同的正常值

Some diagnostic tests may have different normal values.

7.   要有生理儲備功能可能下降的預期

The likelihood of decreased functional reserve must be anticipated.

8.   社會支持系統可能不足，病患可能需仰賴照護者

Social support systems may not be adequate, and patients may need to rely on caregivers.

9.   評估新的主訴時，必須要了解年老病患平時的功能狀態

A knowledge of baseline functional status is essential for evaluating new complaints.

10.  老年人的健康問題會受其相關的心理社會狀況影響

Health problems must be evaluated for associated psychosocial adjustment.

11.  年老病患急診就醫，是評估病患個人主要生活條件的機會

The emergency department encounter is an opportunity to assess important conditions in the patient’s personal life.

資料來源：美國學術急診學會老年病患緊急照護教師手冊

Reference: SAEM Emergency Care of the Elder Person: Instructor's Manual

Tintinalli's Emergency Medicine, 6E, Chapter 307 The Elder Patient

註: 本章節於第七版已被刪除

Hand Hygiene

Unified visuals for “My five moments for hand hygiene”

The patient zone, health-care area, and critical sites with inserted time-space representation of “My five moments for hand hygiene”

Indication for hand hygiene defined by CDC and WHO

1. before touching a patient 
2. after touching a patient
3. after touching objects located in the vicinity of the patient
4. before touching nonintact skin
   manipulating invasive devices
5. after contact with body fluids, mucous membrances, nonintact skin or wound dressings

Situations requiring and not requiring glove use

1.  STERILE GLOVES INDICATED

• Any surgical procedure; vaginal delivery; invasive radiological procedures; performing vascular access and procedures (central lines); 
• preparing total parental nutrition and chemotherapeutic agents

2.   EXAMINATION GLOVES INDICATED IN

CLINICAL SITUATIONS

• Potential for touching blood, body fluids, secretions, excretions and items visibly soiled by body fluids

DIRECT PATIENT EXPOSURE:

• contact with blood, muscous membrane and with non-intact skin
• potential presence of highly infectious and dangerous organism; epidemic or emergency situations
• IV insertion and removal; drawing blood; discontinuation of venous line
• pelvic and vaginal examination
• suctioning non-closed systems of endotracheal tubes

INDIRECT PATIENT EXPOSURE:

• emptying emesis basins
• handling/cleaning instruments
• handling waste
• cleaning up spills of body fluids

3.  GLOVES NOT INDICATED (except for CONTACT precautions)

No potential for exposure to blood or body fluids, or contaminated environment

DIRECT PATIENT EXPOSURE:

• taking blood pressure; temperatureand pulse
• performing SC and IM injections
• bathing and dressing the patient
• transporting patient
• caring for eyes and ears (without secretions)
• any vascular line manipulation in absence of blood leakage

INDIRECT PATIENT EXPOSURE:

• using the telephone
• writing in the patient chart
• giving oral medications
• distributing or collecting patient dietary trays
• removing and replacing linen for patient bed
• placing non-invasive ventilation equipment and oxygen cannula
• moving patient furniture

How to Handrub

How to Handwash

Reference:

Hand Hygiene. 
N Engl J Med 2011;364:e24.

WHO guidelines on hand hygiene in health care. 
Geneva: World Health Organization, 2009.