CT for Acute Aortic Syndrome

CT Imaging for Acute Aortic Syndrome from Sun YaiCheng

CT Imaging for Acute Aortic Syndrome
Cleveland Clinic Journal of Medicine 2008; 75(1):7-24

Diagnostic strategy for acute aortic syndrome

Acute aortic syndrome

1.  Acute aortic dissection

2. Intramural hematoma

Acute intramural hematoma is easily recognized in CT without contrast by the higher Hounsfield-unit value of the blood products in the wall in comparison with the flowing blood in the lumen, eccentric aortic wall-thickening and displacement of intimal calcifications.

3. Penetrating atherosclerotic ulcer

4. Unstable thoracic aneurysm

An aortic aneurysm is defined as a permanent dilation at least 150% of normal size, or > 5 cm in thoracic aorta or > 3 cm in abdominal aorta.

CT signs of imminent rupture include a high-attenuating crescent in the wall of the aorta, discontinuous calcification in a circumferentially calcified aorta, an aorta that conforms to the neighboring vertebral body (“draped” aorta), and an eccentric nipple shape to the aorta.

The Management of Pancreatic Trauma in the Modern Era

The Management of Pancreatic Trauma in the Modern Era from Sun YaiCheng

The Management of Pancreatic Trauma in the Modern Era
Surgical Clinics of North America. Volume 87, Issue 6 (December 2007)

Diagnosis

• Grading system
• Serum amylase levels
• CT
• ERCP
• DSS MRCP
• Exploratory laparotomy

Pancreas Organ Injury Scale of the American Association for the Surgery of Trauma

Grade	Injury	Description
I	Hematoma	Minor contusion without duct injury
	Laceration	Superficial laceration without duct injury
II	Hematoma	Major contusion without duct injury or tissue loss
	Laceration	Major laceration without duct injury or tissue loss
III	Laceration	Distal transection or parenchymal injury with duct injury
IV	Laceration	Proximal transection or parenchymal injury involving ampulla
V	Laceration	Massive disruption of pancreatic head

CT findings suspicious for an injury to the pancreas include the following:

• hematoma surrounding the pancreas
• fluid in the lesser sac
• thickening of the left anterior Gerota's fascia.

CT scans can also demonstrate parenchymal lacerations or transections of the main pancreatic duct.

ERCP is the most reliable method to define continuity of the main pancreatic duct accurately.

Grade	Description
I	Normal main pancreatic duct on ERCP
IIa	Injury to branches of main pancreatic duct on ERCP with contrast extravasation inside the parenchyma
IIb	Injury to branches of main pancreatic duct on ERCP with contrast extravasation into the retroperitoneal space
IIIa	Injury to the main pancreatic duct on ERCP at the body or tail of the pancreas
IIIb	Injury to the main pancreatic duct on ERCP at the head the pancreas

Exploratory Laparotomy

In those patients who are taken emergently to the operating room for abdominal trauma, pancreatic injuries are diagnosed at exploration and it is important to establish the continuity of the main pancreatic duct.

Nonoperative Management

If there is no evidence of a ductal injury on fine-cut CT, non-operative management is acceptable, although it may be wise to perform ERCP to establish normal ductal anatomy definitively.

Operative Treatment
Indications

• Peritonitis on physical examination
• Hypotension and a positive FAST
• Evidence of disruption of the pancreatic duct on fine-cut CT or on ERCP

Isolated injuries to the pancreas without ductal involvement

General principles and exposure

During laparotomy, the initial priorities are control of active hemorrhage and control of gross gastrointestinal contamination.

 Simple external drainage

In the hemodynamically stable patient, pancreatic contusions (AAST grade I), minor capsular injuries, and traumatic pancreatitis can be treated without drainage.
Most other injuries require drainage of some sort.

Treatment options for isolated pancreatic injuries based on the American Association for the Surgery of Trauma pancreas Organ Injury Scale

AAST grade	Treatment options
I	Observation
	Omental pancreatorrhaphy with simple external drainage
II	Simple external drainage
	Omental pancreatorrhaphy and drainage
III	Distal pancreatectomy ± splenectomy
	Roux-en-Y distal pancreatojejunostomy
IV	Pancreatoduodenectomy
	Roux-en-Y distal pancreatojejunostomy
	Anterior Roux-en-Y pancreatojejunostomy
	Endoscopically placed stent
	Simple drainage in damage control situations
V	Pancreatoduodenectomy

Isolated pancreatic injuries with ductal involvement
Distal pancreatectomy
In the hemodynamically stable patient with an isolated pancreatic injury, especially a child 10 years of age or younger, splenic salvage should be considered.




If the patient is hemodynamically unstable, an expeditious distal pancreatectomy with splenectomyshould be performed.






Roux-en-Y distal pancreatojejunostomy is indicated in hemodynamically stable patient who has a transection of the pancreas at the neck or just to the right of the mesenteric vessels and few associated injuries.


Combined pancreatoduodenal injuries

Pancreatoduodenectomy is indicated when there is extensive trauma to the head of the pancreas, a severe combined pancreatoduodenal injury, or destruction of the ampulla of Vater.

• In the hemodynamically stable patient, this procedure can be performed at the time of the original trauma laparotomy.
• In most of the patients who are hypothermic, acidotic, or coagulopathic, a damage control procedure is indicated. In this instance, the pancreatoduodenectomy or the reconstruction after a prior pancreatoduodenectomy should be performed at the reoperation.
• Control of hemorrhage and gastrointestinal contamination must occur first.

Sudden Infant Death Syndrome

Sudden Infant Death Syndrome from Sun YaiCheng

Sudden Infant Death Syndrome (SIDS)
N Engl J Med 2009; 361:795-805


Definition

Sudden death of an infant or young child, which is unexpected by history, and in which a thorough post mortem examination fails to demonstrate an adequate cause of death.

Triple-Risk Model of SIDS

1. Intrinsic risk factors

• Genetic

• Male sex
• Polymorphism in the gene encoding the promoter region of the serotonin transporter
• Black or Native American race or ethnic group

• Developmental

• Prematurity

• Environmental

• Perinatal exposure to smoking
• Parental smoking, ethanol intake, or drug use
• Socio-economic disadvantage

2. Extrinsic risk factors

• Sleeping on the side or in prone position
• Soft bedding
• Bed sharing
• Mild infections, including colds

5 Steps in the Putative Terminal Respiratory Pathway Associated with SIDS

Recommendations for Risk Reduction and Counseling

• Putting infants to bed in the supine position on a firm mattress, preferably with a pacifier and in a shared room (but in a separate bed).
• Prone and side sleeping, overheating, bed sharing, soft bedding, and smoking by mothers during pregnancy or around infants should be avoided.
• Home cardio-respiratory monitoring of apnea and bradycardia is not recommended because it has not been shown to prevent SIDS.

Safe sleeping positions

Safe clothes and bedding

Safe sleeping dos and don'ts

嬰兒猝死 (sudden infant death syndrome) 的危險因子，下列敘述何者錯誤？【96急專】

（Ａ）早產
（Ｂ）母親抽菸
（Ｃ）父母親低社經地位，教育水準低
（Ｄ）冬天易發生
（Ｅ）高齡母親    X

 急診醫學科專科醫師甄審筆試試

精彩簡報的五大原則

創造精彩簡報的五大原則  
Duarte Design's Five Rules for Presentations by Nancy Duarte 

The Five Theses of the Power of a Presentation 

創造精彩簡報的五大原則

1. Treat Your Audience as King

   以客為尊，觀眾才是老大

   觀眾不是來看你表演

   簡報內容必須符合觀眾的需求

2. Spread Ideas and Move People

   分享理念，感動觀眾

   用視覺化的效果來傳達你的觀點

3. Help Them See What You're Saying

   圖片勝過千言萬語

   利用圖片和觀眾溝通

4. Practice Design, Not Decoration

   讓設計更簡化

   把複雜的訊息清楚呈現

5. Cultivate Healthy Relationships

   建立健康的關係

   藉由簡報內容，讓你、觀眾和投影片建立連結與互動

片頭影片 Five Rules For Creating Great Presentations 是 Duarte Design 專業簡報設計公司為 Microsoft Office PowerPoint 2010 發表所設計的形象宣傳影片。

文字說明摘錄自 slide:ology 第12章

2011年10月21日更新：
slide:ology 中文版-《視覺溝通：讓簡報與聽眾形成一種對話》即將於2011年10月26日出版，這本可說是"簡報學"的教科書，內容著重在簡報的"設計"層面，教你如何讓簡報看起來既專業又有美感。



相關文章：Nancy Duarte TED 演講：視覺溝通的九大法則

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Cardiac Tamponade

Pericardial Tamponade from Sun YaiCheng

Beck Triads

1. Increased venous pressure
2. Decreased arterial pressure
3. Muffled heart sounds

Grade	Pericardial Volume (mL)	Cardiac Index	MAP	CVP	HR	Beck's Triad
I	<200	Normal or ↑	Normal	↑	↑	usually not present
II	≥200	↓	Normal or ↓	↑ (≥12 cm H2O)	↑	May or may not be present
III	>200	↓↓	↓↓	↑↑  (≤30–40 cm H2O)	↓	usually present

Kussmaul signs

 

RV early diastolic collapse

Management
ATLS 7^th Edition

• Pericardiocentesis is the initial management of traumatic tamponade

ATLS 8^th Edition

• Acute cardiac tamponade due to trauma is best managed by pericardiotomy via thoracotomy
• Pericardiocentesis may be used as a temporizing maneuver when thoracotomy is not an available option

九十九年  急專考題 急診醫學科專科醫師甄審考題

30 歲男性病人由救護車送達急診，主訴剛剛發生車禍有撞擊到胸口，現覺胸口悶痛且呼吸不順暢。血壓 98/62 mmHg、心率 120 次/分鐘、呼吸 26次/分鐘、體溫 37.2 ℃。有關此病患可能出現的症狀及徵候，下列敘述何者錯誤？

1. 心包膜填塞表現出來的 Beck triad 包括頸靜脈怒張、低血壓及低沉的心音。
2. 心包膜填塞可能會有的 Kussmaul signs，病人深吐氣時頸靜脈會更加擴張。
3. 若病人出現 Hamman sign，要考慮病人有 pneumo-mediastinum 的可能性。
4. 若理學檢查發現病人的右鎖骨中線有穿刺傷，需將心臟損傷列入鑑別診斷。
5. 創傷性主動脈破裂在胸部 X 光上可能出現食道偏離胸椎第 4 節棘突（spinous process）的右側大於 1－2 公分。

關於心包膜積液的敘述，下列何者錯誤？

1. 可能的病因包括心包膜炎、甲狀腺功能低下、癌症、尿毒症、心臟腔室破裂、創傷等。
2. 典型的臨床表徵為低血壓、靜脈怒張，及遙遠、低沉的心音（muffled heart sound），若沒有出現這些表徵，即可排除急性心包膜積液。
3. 若急性胸痛病患突然昏厥且血壓突然測量不到，床邊超音波發現中量之心包膜積液，應考慮心肌梗塞併心肌破裂或主動脈剝離。
4. 若血壓偏低，治療上首先應給予靜脈輸液以增進右心的壓力，克服心包膜積液的壓迫。
5. 若已出現心包膜填塞，而以針抽吸又無法引流出積液，則應考慮以手術方式將心包膜打開（pericardiotomy）。

Blunt Aortic Injury

Blunt Aortic Injury from Sun YaiCheng

Blunt Aortic Injury
N Engl J Med  2008;359:1708-16.

Pathophysiology

• Sudden increase in intra-abdominal pressure may explain the association between blunt aortic injury and diaphragmatic rupture.
• "Water-hammer" effect: simultaneous occlusion of the aorta and a sudden elevation in blood pressure
• "Osseous pinch" effect: entrapment of the aorta between the anterior chest wall and the vertebral column.

Diagnosis

• The absence of the following signs on CXR were valuable to exclude the diagnosis of aortic injury:

• loss of the aortico-pulmonary window
• abnormality of the aortic arch
• rightward tracheal shift
• widening of the left para-spinal line without associated fracture

• Between 7.3% and 44% of patients with blunt aortic injury may have a normal mediastinum on CXR.

• Helical CT of the thorax is now the diagnostic test of choice (sensitivity 100%).

• Minimal Aortic Injury was defined as an intimalflap of less than 1 cm with no or minimal peri-aortic hematoma, 50% of minimal aortic injuries that were followed up had developed pseudo-aneurysms by 8 weeks after injury.

• If the injury is associated with significant thrombus, peri-aortic hematoma, lumen encroachment, or pseudo-aneurysm, it is our practice to proceed with endograft coverage.

Surgical Repair

• Advantages of the veno-arterial bypass include the ability to cool the patient, which potentially enhances spinal-cord protection.

Endovascular Repair

Advantages

• No physiological burden
• In brain injury, the device can be deployed with the head of the bed elevated
• Not require single-lung ventilation
• Minimal or no heparin
• No need for a bypass of any kind
• No cause of paraplegia

Technical Limitations to Endografting

• Injuries that occur adjacent to a sharp bend in the aorta may result in poor apposition of the covered stent to the aortic wall.
• Lesions adjacent to the left subclavian artery.
• Coverage of the left subclavian artery can result in ischemia of the upper extremity or territory perfused by the left vertebral artery.