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Yai-Cheng Sun


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敗血症 一小時組套:2018 SSC Update

1-h bundles 取代過去 3-h and 6-h bundles

1. 每 2-4 小時 驗 lactate level 直到正常
2. blood cultures
3. 廣效性抗生素
4. 3小時內給予 crystalloid fluid 30 ml/kg
5. 升壓劑維持 MAP ≥ 65 mmHg.
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2018 Acute Ischemic Stroke Guidelines

Class I
• CT within 20 min ≥50%
• Door-to-needle time within 60 min ≥50%
• EVT, ECG, troponin should not delay IV t-PA
• Only the assessment of blood glucose must precede the initiation of IV t-PA
• Receive IV t-PA: BP <185/110 mmHg
• IV t-PA for AIS < 3 hr

IV t-PA for AIS < 3 – 4.5 hr
Class I
• for pts ≤80 y/o, without both DM and stroke hx, NIHSS ≤25, not taking any OACs, <1/3 MCA territory by CT or MRI
Class IIa
• for pts >80 y/o
Class IIb
• taking OACs and INR ≤1.7 and/or PT <15 s
• with both DM and stroke hx

Endovascular Therapy
Class I
• AIS < 6 hr
• AIS < 6-16 hr: DAWN or DEFUSE 3 criteria
Class IIa
• AIS < 6-24 hr: DAWN criteria
2018 Stroke Guidelines
2018 Stroke Guidelines
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看名畫 學急診
看名畫 學急診
看名畫 學急診
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不打擾家屬休息 不趕病患離院
沒有診療計畫 不須明確診斷
病人自然會改善 自動要求出院
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ATLS 10E 更新要點

Primary Survey
A. Airway Maintenance with Restriction of Cervical Spine Motion
● “cervical spine protection” changed to ”Restriction of Cervical Spine Motion”
● RSI changed to ”Drug Assisted Intubation”
C. Circulation with Hemorrhage Control
● Initial resuscitation: Adult: isotonic solution 1 L; Child < 40 kg: 20 ml/kg
● Hemorrhagic shock classification table amended: Base excess
● Transamic acid: 1 g over 10 min within 3 hr, then 1 g over 8 hr

Thoracic Trauma
● Life threatening chest injury: flail chest out, tracheobrochial injury now in
● Tension pneumothorax:
○ Needle thoracocentesis
- 5th ICS MAL for adult
-UNCHANGED 2nd ICS for child
○ 28-32 Fr chest drain for haemothorax (not 36-40 Fr)
○ eFAST: seashore, bar code, or stratosphere sign in M mode.
● Aortic rupture management with Beta Blocker (esmolol): goal heart rate < 80 bpm and MAP 60-70 mmHg

Abdominal and Pelvic Trauma
● Palpation of prostate gland no longer recommended for urethral injury

Head Trauma
● Classification: “minor” changed to “mild” head trauma
● Detailed guidance on SBP management: Maintain SBP at ≥ 100 mmHg for patients 50-69 years or at ≥ 110 mmHg for patients 15-49 years or older than 70 years.

Spine and Spinal Cord Trauma
● New myotome diagram
● Canadian C-Spine Rule (CCR) and NEXUS Criteria
ATLS® 第10版 更新摘要
ATLS® 第10版 更新摘要
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The European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma: 4E

Major Bleeding
● FAST, CT 找出血
● Damage control surgery if shock or coagulopathy
● Damage control resuscitation 直到找出血並控制
● Restricted volume replacement:
- target SBP: 80-90 mmHg
- severe TBI (GCS ≤8): MAP ≥80 mmHg
● Tranexamic acid (TXA) as early as possible (< 3hr):
- loading dose TXA 1 g over 10 min
- followed by TXA 1 g over 8 h

● Restrictive RBC transfusion: target Hb 7–9 g/dl
● FFP-RBC ratio >1:2
● Fibrinogen maintain at 1.5–2 g/l
● FFP administered to maintain PT and APTT ≤ 1.5 times the normal control
● Platelet count >100K
● PCC administered in patients pre-treated with warfarin or direct-acting oral coagulants
● Off-label use of rFVIIa only if major bleeding and traumatic coagulopathy persist despite standard attempts to control bleeding and best practice use of conventional hemostatic measures.
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Surviving Sepsis Guidelines 2016

Initial Resuscitation
☑ Crystalloid fluid ≥ 30 ml/kg within the first 3 hrs
☐ Target MAP ≥ 65 mmHg
☐ Normalize lactate
☒ EGDT, CVP, ScvO2

Antimicrobial Therapy
☐ Empiric broad-spectrum antibiotics within 1 hr
☐ Procalcitonin to support the discontinuation of antibiotics

Source Control
☐ As soon as possible

Fluid Therapy
☑ Crystalloids ± albumin
☒ HESs

☑ Norepinephrine ± vasopressin or epinephrine
☐ Dopamine only in bradycardia

☐ Hydrocortisone 200 mg per day for refractory shock

Blood Products
☐ pRBC: Hb < 7
☐ platelet: 10K, 20K, 50K

Glucose Control
☐ Target blood glucose ≤ 180 mg/dl

Bicarbonate Therapy
☐ pH < 7 .15
Surviving Sepsis Guidelines 2016
Surviving Sepsis Guidelines 2016
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急診 VBG 可否取代 ABG?

• VBG 的 PvCO2, pH & HCO3 與 ABG 差異不大,可用來評估 ventilation 和 acid-base status
• VBG pCO2< 45 mmHg 可排除臨床有意義的 hypercarbia
• VBG 的 PvO2 無臨床價值,但可用 pulse oximerty 來評估 oxygenation (O2 saturation)
• venous 與 artery 的 Hb-CO 差異不大,可相互取代
• 大部分的臨床情況下,可以根據 VBG 決定病患的診斷與處置。除非病患血壓不穩/休克,或 VBG data 無法解釋臨床症狀,需再抽 ABG 確認
急診 VBG 可否取代 ABG?
急診 VBG 可否取代 ABG?
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UTI 診斷與治療的十個迷思

迷思 ① 尿液混濁惡臭,病人有 UTI

迷思 ② ⑤ 尿液有 bacteria or pyuria, 病人有 UTI
UTI 不是 laboratory-defined diagnosis. 尿液有 bacteria, 病人沒有症狀,不代表 UTI

迷思 ③ ⑥ ⑧ 尿液 leukocyte esterase or nitrates (+), 病人有 UTI
不應僅依據尿液 pyuria, bacteriuria, leukocyte esterase or nitrates (+) 來診斷 UTI 給抗生素
Asymptomatic UTI 需抗生素治療:pregnancy and any urologic procedure with bleeding

迷思 ⑦ 尿管病患尿液有 bacteria, 病人有 UTI
將近100% 兩週內插尿管病患,尿液會長 2-5 株菌
長期插尿管病患,尿液有 bacteria or pyuria, 須配合感染症狀 (fever, leukocytosis, suprapubic pain, and tenderness) 給抗生素

迷思 ⑨ 老人意識變差,病人有 UTI
老人意識變差有很多原因 (dehydration, hypoxia, and poly-pharmacy adverse reaction)
病患沒有尿管,有感染症狀 (fever, leukocytosis, suprapubic pain, and tenderness) 症狀,可下 UTI 診斷
失智或插尿管老人尿液常有 bacteria,診斷 UTI 需排除其他可能原因

迷思 ⑩ 插尿管病患尿液長 Yeast or Candida, 病人有 UTI 需治療
插尿管病患 candiduria 很常見,除非是 systemic candidiasis 高風險病患,一般不需治療
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