意識不清與昏迷

Altered Mental Status and Coma from Sun YaiCheng

意識不清與昏迷
Altered Mental Status (AMS) and Coma

Mnemonic for Treatable Causes of AMS (AEIOU-TIPS)

• A Alcohol
• E Endocrine, Electrolytes, Encephalopathy
• I  Insulin
• O O2, Opiates
• U Uremia

• T Trauma
• I  Infection, Intra-cranial
• P Poisoning
• S Seizure, Stroke, Sepsis, Shock

Reversible cause of AMS

• Hypoglycemia, narcotic overdose, hypoxia, hypercarbia should be quickly investigation and treatment

• If structural lesion etiology is indicated → non-contrast head CT

Delirium

Diffuse metabolic and multifocal cerebral lesion, generalized impairment of brain functions or at least a bilateral involvement limbic structure

Major brainstem reflexes used in coma examination

• oculocephalic reflex
• pupillary light reflex
• corneal reflex
• oculovestiblar reflex
• gag reflex
• apnea test

Adapted from Rosen's Emergency Medicine, 7E
Chapter 14 Depressed Consciousness and Coma

相關文章：急診神經學檢查

急診神經學檢查

Neurological Examination in the Emergency Room from Sun YaiCheng

急診神經學檢查

Neurological Examination in the Emergency Room

General Considerations 主要原則：

• Always consider left to right symmetry 比較左右對稱

• Consider central vs. peripheral deficits 區分中樞或週邊缺損

Organize your thinking into six categories:

1. Mental Status 意識狀態
2. Cranial Nerves 顱神經檢查
3. Motor Exam 運動功能檢查
4. Reflexes 反射
5. Coordination and Gait 協調性及步態
6. Sensory Exam 感覺功能檢查

Patient with unilateral facial weakness

Adapted from Tintinalli‘s Emergency Medicine: A Comprehensive Study Guide, 7E
Chapter e158.1  The Neurologic Examination in the Emergency Setting

Acute Radiation Syndrome

Acute Radiation Syndrome from Sun YaiCheng

Units of Radiation

Exposure
Conventional unit: Roentgen

Absorbed dose
Conventional unit: rad
International system of unit: Gray
1 Gy = 100 rad

Dose equivalent
Conventional unit: Roentgen equivalents man (rem)
International system of unit: Sievert
1 Sv = 100 rem

Acute Radiation Syndrome

Stage I: Prodromal stage (chiefly gastrointestinal)

• Onset: minutes to hours (ARS is fatal if GI symptoms develop within 2-4 hrs)
• Duration: 48-72 hrs 
• Presentation: nausea, vomiting; also diarrhea, cramps

Stage II: Latent stage (chiefly hematopoietic)

• Onset: hours to days
• Duration: 1.5-2 wks
• Presentation: asymptomatic → bone marrow supression

Stage III: Manifest stage (multisystem involvement)

• Onset: 3-5 wks
• Duration: variable

• Presentation:

CNS/CVS (>15 Sv)
Cardiorespiratory/GI system (>5 Sv)
Reticuloendothelial system (>1 Sv) 

Stage IV: Recovery or Death

• Onset: weeks
• Duration: weeks to months
• Presentation: leading cause of death before recovery is sepsis

Prognosis According to the Lymphocyte Count within the First 48 Hours after Acute Exposure to Penetrating Whole-Body Radiation

MINIMAL LYMPHOCYTE COUNT PER MM2	APPROXIMATE ABSORBED DOSE (GY)	EXTENT OF INJURY	PROGNOSIS
1400–3000 (normal range)	0–0.4	No clinically significant injury	Excellent
1000–1499	0.5–1.9	Clinically significant but probably nonlethal	Good
500–999	2–3.9	Severe	Fair
100–499	4–7.9	Very severe	Poor
<100	≥8	Most severe	High incidence of death even with hematopoietic stimulation

Commonly Treated Forms of Internal Contamination

Radionuclide	Treatment	Mechanism of Action	Usual Administration
Iodine	Potassium iodide	Blocks thyroid uptake	130 milligrams PO for adults
Plutonium	Ca-DTPA or Zn-DTPA	Chelation	1 gram in 250 mL NS or 5% dextrose in water over 60 min
Tritium	Water	Dilution	Oral: 3–4 L a day for 2 wk
Cesium	Prussian blue	Decrease GI uptake	1 gram in 100–200 mL water three times a day for several days
Uranium	Bicarbonate	Alkalinization of urine	2 ampules in 1 L NS at 125 mL/h

Top 10 Key Points For Medical Management of Radiation Casualties

1. Patients should be medically stabilized from their traumatic injuries before radiation injuries are considered, then evaluated for either external radiation exposure or radioactive contamination.
2. An external radiation exposure outside the person does not make the person radioactive. Even such lethally exposed patients are no hazard to medical staff.
3. Nausea, vomiting, diarrhea, and skin erythema within 4 hours may indicate very high external radiation exposures. Such patients will show obvious lymphopenia in 8 to 24 hours. Evaluate with serial CBCs. 
4. Radioactive material may have been deposited on or in the person (contamination). More than 90% of surface radioactive contamination may be removed by removal of the clothing. Most remaining contamination on exposed skin is effectively removed with soap, warm water, and a washcloth. 
5. Protect yourself from radioactive contamination by observing standard precautions, including protective clothing, gloves, and a mask.
6. Radioactive contamination in wound or burns should be handled as if it were simple dirt.
7. In a terrorist incident, there may be continuing exposure of the public that is essential to evaluate. Initially suggest sheltering and a change of clothing or showering. Administration of potassium iodide is indicated only when there has been a confirmed release of radioiodine.
8. When there is any type of radiation incident, many persons will want to know whether they have been exposed or are contaminated. Provision needs to be made to potentially screen thousands of such persons.
9. Clinically significant acute radiation syndrome seldom if ever occurs in people receiving less than 1 Gy of whole-body radiation.
10. The principles of time/distance/shielding are key. Radiation dose is diminished by reducing time spent in the radiation area (moderately effective), increasing distance from a radiation source (very effective), or using metal or concrete shielding (less practical).

Reference

Radiation Injuries. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 2011, pp 56-61

Disaster Management and Emergency Preparedness. Advanced Trauma Life Support, 2008, pp 333-334

Medical Treatment of Radiological Casualties: Current Concepts. Ann Emerg Med. 2005;45:643-652

Ectopic Pregnancy

Ectopic Pregnancy from Sun YaiCheng

Ectopic  Pregnancy
N Engl J Med 2009;361:379-87

Ultrasonographic Examination

In gestations longer than 5.5 weeks, a transvaginal ultrasonographic examination should identify an intrauterine pregnancy with almost 100% accuracy.

Ultrasonographic Findings in  Ectopic Pregnancy

Change in the hCG Level in Intrauterine Pregnancy, Ectopic Pregnancy, and Spontaneous Abortion

Correlation of Ultrasonographic Findings with hCG Values  

“Discriminatory hCG value”   1500—3000 mIU/ml

the sensitivity of ultrasonography for the detection of intrauterine pregnancy approaches 100% and at which the absence of an intrauterine pregnancy suggests abnormal or ectopic gestation.

Management

Surgical Management

• Salpingectomy or Salpingostomy

Medical Management

• Intramuscular administration of the Methotrexate
• single-dose or multidose regimen

九十八年  急專考題

有關子宮外孕的臨床特性及診斷，下列敘述何者錯誤？

(A) 危險因子包括曾經發生子宮外孕、輸卵管結紮、人工受孕、和骨盆腔發炎的病史。
(B) 典型的症狀是腹痛、陰道出血、及無月經。
(C) 若尿液懷孕測試陰性就能排除子宮外孕。  X
(D) 病人可能發生危及生命的休克症狀。
(E) 腹痛或腹部不適是最常見的症狀，一般而言是突然的單側劇烈疼痛

急診心訣

急診心訣 from Sun YaiCheng

1. 『專業』才是你的生存之道，注意細節就是專業。
2. 有了情緒就會失去理智，先處理心情，再處理事情。盡量不要讓病人或家屬帶著不滿的情緒離開急診（包括住院或離院）。
3. 面對病患或醫護夥伴不合理的要求，你可以塘塞、敷衍、忽視、閃避、拖延、冷靜傾聽、充耳不聞，但絶不可在線上與對方爭吵。最重要的原則是『態度溫和，立場堅定，委婉說明而不表現出專業醫師的傲慢』。
4. 說服對方，首先應安撫其情緒，否則對方難以接受你的說服。若對方在情緒上與您是對立的，則說服的難度會大很多。
5. 『第一印象決定醫病關係』。良好的醫病關係大多在第一次接觸的前幾分鐘就決定。首先讓人接受你的個人，接下來才能讓人接受你的專業能力。
6. 在急診室，遠離災難和錯誤最好的方法就是避免急診壅塞，盡快讓病患去到他們該去的地方（決定住院或出院）。你無需事事站在第一線，但應讓住院醫師找得到你。如果你的住院醫師夠聰明，他會讓你了解全局。
7. 『兵貴拙速』。在急診，並不需要把所有的疑難雜症都診斷出來，若一時找不出診斷，排除可能致命的診斷就夠了。重要的是能處置明快，兼顧品質與速度，拙劣一點沒有關係。
8. 做急診不可死守規則，然而你必需清楚知道界線在那裡，才能站穩立場，隨機應變。

2009 ACCF/AHA Heart Failure Guidelines

2009 ACCF/AHA Heart Failure Guidelines from Sun YaiCheng

2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults

J. Am. Coll. Cardiol. April 14, 2009; 53;1343-1382

Circulation. April 14, 2009;119;1977-2016

Initial Clinical Assessment

• Coronary arteriography should be performed in HF who have angina or significant ischemia unless the pt is not eligible for revascularization.

• BNP or NT-proNBP can be useful in the urgent care setting in whom the clinical diagnosis of HF is uncertain. 
• Measurement of BNP can be helpful in risk stratification.

Patients with Reduced Left Ventricular Ejection Fraction

• Diuretics and salt restriction

• ACE inhibitors or angiotensin II receptor blockers

• beta blockers 

• Implantable Cardioverter-Defibrillatoras (ICD)

• ICD is recommended in pts with of HF and reduced LVEF who have a history of cardiac arrest, VF, or hemodynamically destabilizing VT.
• ICD is recommended for primary prevention of SCD to reduce total mortality in pts with non-ischemic DCM or IHD > 40 days post-MI, LVEF ≤ 35%, NYHA Fc II or III while receiving chronic optimal medical therapy, and who have expectation of survival with good functional status > 1 year.

• Resynchronization Therapy

• Digitalis

• Hydralazine and Nitrate Combination

• Positive Inotropic Drugs 

Recommendations for the Hospitalized Patient (New Recommendations)

Diagnosis of HF

Clinicians should determine the following:

• adequacy of systemic perfusion
• volume status
• contribution of precipitating factors and/or co-morbidities
• if the heart failure is new onset or an exacerbation of chronic disease
• whether it is associated with preserved normal or reduced ejection fraction

CXR, ECG, and echocardiography are key tests in this assessment

Patients Being Evaluated for Dyspnea

• BNP or NT-proBNP should be measured in pts being evaluated for dyspnea in which the contribution of HF is not known.

• Precipitating Factors for Acute HF

• ACS/coronary ischemia
• severe hypertension
• atrial and ventricular arrhythmias
• infections
• pulmonary emboli
• renal failure
• medical or dietary non-compliance

• Oxygen Therapy and Rapid Intervention 

• Intravenous Loop Diuretics

• Monitoring Fluid Intake and Output

• Intensifying the Diuretic Regimen

• Preserving End-Organ Performance

In pts with clinical evidence of hypotension associated with hypoperfusion and obvious evidence of elevated cardiac filling pressures (e.g., elevated jugular venous pressure; elevated PAWP), IV inotropic or vasopressor drugs should be administered to maintain systemic perfusion and preserve end-organ performance while more definitive therapy is considered.

• ACE inhibitors or ARBs and beta-blocker therapy

• Urgent Cardiac Catheterization and Revascularization

When pts present with acute HF and known or suspected acute myocardial ischemia due to occlusive coronary disease, especially when there are signs and symptoms of inadequate systemic perfusion.

• Severe Symptomatic Fluid Overload

in the absence of systemic hypotension, vasodilators such as IV NTG, nitroprusside or neseritide can be beneficial.

• Invasive Hemodynamic Monitoring

for carefully selected pts with acute HF who have persistent symptoms despite empiric adjustment of standard therapies, and

• whose fluid status, perfusion, or systemic or pulmonary vascular resistances are uncertain
• whose SBP remains low, associated with symptoms, despite initial therapy
• whose renal function is worsening with therapy
• who require parenteral vasoactive agents
• who may need consideration for advanced device therapy or transplantation

相關文章：Acute Heart Failure Syndromes