images from NEJM
NG管加上stylet
結果桶破食道
還造成右側氣胸
病人expired……不知道這樣是賠大於還是小於3100萬?
- Limbus Vertebra 通常是trauma造成
- 以X光上的這個位置(白色箭頭)最常見
- 成因：nucleus pulposus herniation之故
白色箭頭是limbus vertebra：錐體邊緣的碎片.具有完整的cortical邊緣
黃色箭頭是Schmorl’s nodes：central defect
左邊圖：fracture：non-sclerotic margins (白箭頭) extends through the vertebral body (藍箭頭).
右邊圖： discitis：adjacent endplates 被破壞
這篇文章的結論：BRACES rule
| B | BNP level ≥ 300 pg/mL and Bradycardia with heart rate ≤ 50 beats/min in emergency department or before hospital visit |
| R | Rectal examination showing fecal occult blood (if gastrointestinal bleeding is suspected) |
| A | Anemia with hemoglobin level ≤ 90 g/L |
| C | Chest pain associated with syncope |
| E | Electrocardiogramshowing Q wave (not in lead III) |
| S | Saturation ≤ 94% while breathing room air |
只要有≥1個一上因素存在可能就必須考慮讓病人住院
- 在這個條件下，病人一個月內的死亡率為7.1%
- ROSE rule: sensitivity 87.2% ; specificity 65.5%; negative predictive value 98.5%.
- BNP 上升是嚴重心血管事件以及死亡的的獨立因子
- ROSE stydy: single-center ; prospective ; observational study
文章來源 consultant Live.com
71歲女性幾天前才剛放了做了心導管檢查也放了心律調節器 (dual chamber)
來急診主訴上腹痛胸口不舒服
ECG如下
- ventricular paced rhythm with native P waves intact
- Marked ST-segment depression was noted in lead V2
- Discordant 5-mm ST elevations in leads II, III, and aVF
第一次的cardiac enzyme 是boderline
但是第二次的cardiac enzyme上升很明顯
確認是STEMI
原文當中敘述了幾篇針對VPR (ventricular paced rhythm)如何診斷AMI的論文
主要是對於Sgarbossa criteria 作描述與解釋
但是1996年NEJM的原始文章設定其實是針對LBBB節律如何診斷AMI的分析
與VPR診斷AMI是不同的setting
wharever，文章認為認識與了解Sgarbossa criteria對於臨床醫師診斷AMI是有幫助的！
| Table — Sgarbossa criteria for acute MI with underlying LBBBa | |
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| ECG findings | Score |
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| ST elevation of ≥ 1 mm concordant with QRS complex | 5 |
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| ST depression of ≥ 1 mm in any lead—V1, V2, V3 | 3 |
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| ST elevation of ≥ 5 mm discordant with QRS complex | 2 |
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| MI, myocardial infarction; LBBB, left bundle-branch block. a An acute MI is highly likely with a total score of 3 or higher. With a score of less than 3, the ECG diagnosis is less certain and additional evaluation is required. From Sgarbossa EB et al. N Engl J Med. 1996.3 |
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17 歲少年被球打到胸部昏了過去
EMT現場做了電擊
電擊前後的ECG如下
可以看得出來電擊前是Vf
電玩之後變sinus rhythm with first degree block and BBB
之後ECG變成更穩定的Sinus taccycardia
標準的Commotio cordis
一位 stage IV lung cancer 病人，月初值病房班的時候把他轉到ICU
轉入的當下就已經跟家屬提過 critical、DNR and enen Hospice
但是病人從一開始到最後一刻都意識清楚
家屬雖然提供意見幫忙做決定
可是Key person 就是病人自己
將近一個月的拖磨
肺炎、敗血症、氣胸、肋膜積水、懷疑肺栓塞
輸液點滴、抗生素、胸管、抗凝血劑、輸血
從鼻管氧氣直到喘拒絕插管、用BiPAP撐著
最後還是決定插氣管內管幫助呼吸
治療來來去去
一開始就知道……是盡頭
只是不知道時間……剩多少
DNR一直沒有簽……病人抱著希望、家屬也跟著一起……
繼續閱讀 ‘ICU story-1′
主訴：牙齦流血與上肢瘀青兩天了
PI：發燒發抖10天
發燒的時候腳會痛
沒有血尿、黑便、咳嗽、咳血
沒有吃任何藥物
結婚生了五個小孩在家煮菜
沒抽菸喝酒也沒出國旅遊史
PE:TPR: 36.8 / 90/ 14 BP: 110 / 70
HEENT: 雙側結膜下出血、軟顎有瘀青、牙齦碰一下就出血
CHEST: unremarkable
HEART:unremarkable
Abdomen:unremarkable
Extremity: 四肢有大片瘀青 (沒有被家暴)
(large bruises and a petechial rash across both forearms and lower extremities)
Lab:
Hb = 8 g/dL
platelet = 1.1 萬/µL
WBC = 1.8 × 103/µL
BUN/Cr, liver function tests, albumin, and electrolytes = normal.
Coagulation (including PT, aPTT, fibrin degradation products, and serum fibrinogen) = normal.
U/A, CXR: negative
診斷是？ 這個診斷對急診科醫師應該是要銘記在心的喔！
發燒、出血、瘀青、骨頭痛……
就是他啦~沒錯 Dengue hemorrhagic fever
Transjugular Intrahepatic Portosystemic Shunt
經頸靜脈肝內門脈與下腔靜脈短路術 (TIPS)
書上每每都提到 TIPS可以大幅降低胃食道的靜脈曲張出血的情況
但是實際的情況跟這篇文章說的一樣
目前肝病TIPS治療在國內並不普遍，只有幾家醫院進行，
而支架費用必須自費，約4萬元左右
ICU現在就躺著一個gastric varices
流血流不止、胃鏡止不了血、家屬/外科都拒絕開刀的病人
sign 了DNR…sign 了拒輸血同意書…等著血流乾的病人……
看了真覺得無奈阿…
來看看TIPS的卡通影片吧~
看起來真難阿！！
關於動脈血/靜脈血的比較
pubmed 有幾篇文章,整理一下
Emerg Med J. 2007 Aug;24(8):569-71.
Comparison of arterial and venous pH, bicarbonate, PCO2 and PO2 in initial emergency department assessment.
結論: VBG的pH, bicarbonate and Pco2的值可以取代ABG的值
Venous blood gas analysis for pH, bicarbonate and Pco(2) may be a reliable substitute for ABG analysis in the initial evaluation of an adult patient population presenting to the ED.
Emerg Med Australas. 2006 Feb;18(1):64-7.
The case for venous rather than arterial blood gases in diabetic ketoacidosis.
結論: 血型動力學穩定.沒有呼吸衰竭的DKA病人,可以用VBG的值取代ABG
There is reasonable evidence that venous and arterial pH have sufficient agreement as to be clinically interchangeable in patients with DKA who are haemodynamically stable and without respiratory failure. There is some evidence that venous and arterial bicarbonate also agree closely in DKA but this requires confirmation.
Emerg Med J. 2006 Aug;23(8):622-4.
Agreement between arterial and central venous values for pH, bicarbonate, base excess, and lactate.
結論:中央靜脈血的pH, bicarbonate, base excess 及 lactate values 與ABG是可以相比擬的.
Central venous pH, bicarbonate, base excess, and lactate values showed a high level of agreement with the respective arterial values, with narrow 95% limits of agreement. These results suggest that venous values may be an acceptable substitute for arterial measurement in this clinical setting.
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