內科情境教學 黃建華 許瓊元 臺大醫院急診醫學部 主治醫師.

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1 內科情境教學 黃建華 許瓊元 臺大醫院急診醫學部 主治醫師

2 EMT通報為到院前心跳停止(out-of-hospital cardiac arrest)
66歲的男性 EMT通報為到院前心跳停止(out-of-hospital cardiac arrest) 請問你打算作什麼?

3 到院後…… Sudden collapse during sexual intercourse
PH: HTN without control

4 請問你要如何開始急救? 順序組合 A.接心電圖 B.強迫給氧 C.插管 D.使用電擊器 E.打針 ( D B C A E )

5 Initial ECG asystole

6 Asystole時應該做什麼? 選擇題: A. DC shock B. CPR C. 檢查導線 D. Check response

7 During resuscitation VT/VF during resuscitation TX: DC shock

8 認識 Hand-off time 巧妙使用EtCO2 VT 的治療

9 恢復自體循環(ROSC) ROSC after 21 minutes of CPR in the ED
BP: 175/76 mmHg, pulse rate: 67 beats/min PE: unconscious with GCS of 2T symmetrical pupils without light reflex breath sound: clear heart sound: no murmur abdomen: np extremities: areflexia and hypotonia

10 12-lead ECG How to interpretation?
diffuse ST-segment depression in lead I, II and V2-6, and inverted T wave in lead aVL How to interpretation?

11 你的初步診斷為何? & 將安排何種檢查及治療?

12 Cardiac catheterization

13 Cranial CT SAH

14 Final diagnosis: Subarachnoid hemorrhage 你猜對了嗎?

15 OHCA 病患的處置 ACLS guidelines for resuscitation Examinations after ROSC
Vital signs Physical examinations CBC, BCS, cardiac enzyme, ABG Infection workups ECG & CXR Cardiac catheterization Cranial CT

16 處理重點 Identify the causes of OHCA Intensive care after ROSC
Treatments focused on etiology of cardiac arrests

17 外科情境演練墜樓傷害

18 模擬個案 45歲男性從龍眼樹墜下，立即送院處理

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20 抵院時意識清楚 胸口疼痛但呼吸尚可， Cold sweating 兩下肢無法動彈 自兩大腿上部以下知覺喪失，無法自解小便 BP: 105/70, PR 110, SpO2 95%, BT 35.8

21 應該作什麼處置? Advanced Trauma Life Support ABCD
Check the airway Adequate breath Stop bleeding & Restore blood volume Neurology disability How to rescue? O2 IV monitor Intubation or not ? Monitor: EKG monitor、CVP、Pulse oximeter Image: X-ray, echo, CT

22 他可能有什麼傷害? 何者需優先處理? Spine & extremities fractures Pneumohemothorax
Internal bleeding 何者需優先處理?

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27 他還可能有什麼傷害? Right tibia fracture:怎麼看出來的? 還有呢?

28 他還可能有什麼傷害沒看到? 為什麼沒看到?

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31 應該如何處置?為什麼? Pneumohemothorax Hemodynamic stability
Chest tube drainage and monitor Rib fracture

32 Internal bleeding Intra-abdomen bleeding Pelvis fracture
Retroperitonium bleeding Kidney Psoas muscle Aorta Hemopericardium

33 Spine & extremities fractures
Immobilization Neurological/ circulatory complication Open or close fracture

34 小兒科情境演練

35 個案一 3歲的男童在急診室候診時,被人發現手腳抽動 最近有感冒的症狀,今天高燒到39°C 過去並無特殊病史
痙攣自動停止,現在此病童處於睡眠狀態但對聲音會有反應. 理學檢查發現其呼吸和循環狀態均正常. A 3-year-old girl who is in the pediatricians’ waiting room for evaluation of fever has a seizure. It is characterized by shaking of the arms and the legs and lasts for 5 minutes. The child has had a recent cold and has a temperature to 39°C. The seizure stops spontaneously and the child is now sleepy but arousable, with good respiratory effort and good perfusion.

36 初步評估 (1 of 2) 兒童三角評估: 生命徵象: 外觀正常,正常呼吸,正常循環
心跳 110, 呼吸 28, 血壓 85/70, 體溫 39.9°C, 體重14 kg, 血氧濃度 95% The PAT is as follows: A: Appearance: Sleepy but easily arousable B: Work of Breathing: Normal. No tachypnea, flaring retractions. Excellent air entry. C: Circulation to the Skin: Normal. Color is normal; there is no evidence of cyanosis. Vital signs include: Heart rate: 110 bpm Respiratory rate: 28 breaths/min Blood pressure: 85/70 mm Hg Temperature: 39.9C Weight: 14 kg Oxygen saturation: 95%

37 初步評估 (2 of 2) A: 通暢 B: 規則,並無呼吸窘迫 C: 紅潤的膚色. 規則且明顯的脈搏 微血管填充時間 = 2 sec.
D: 嗜睡但對聲音會有反應 E: 無明顯外傷 A: Airway: No evidence of obstruction B: Breathing: Regular, without distress C: Circulation: Pink, pulse full, capillary refill 2 seconds D: Disability: Sleepy but will open eyes and move arms on command E: Exposure: No external signs of trauma

38 詳細的理學檢查 頭部:無外傷 頸部: 柔軟 肺部: 乾淨的呼吸音,通氣順暢 腹部: 柔軟, 無壓痛, +腸音
神經學:嗜睡但對聲音會有反應, 無局部神經學缺損 Head: Atraumatic Neck: Supple Lungs: Clear, with good air entry Abdomen: Soft, nontender, positive bowel sounds Neurologic: Sleepy but arousable, no focal deficits

39 問題 你認為這位病童發生了什麼事呢? 你的初步診斷為何? 在初步評估後, 穩定 痙攣但無呼吸窘迫或循環系統的問題
What is your general impression of this patient? Ask the audience to characterize the patient’s condition as one of the following: Stable Respiratory Distress Respiratory Failure Shock Primary CNS Dysfunction Cardiopulmonary Failure/Arrest

40 初步診斷 接下來,你該如何處置這位病童? 你處置的優先順序為何?
Overall the child is stable at this time: The child does not seem to have any cardiovascular instability. The patient is breathing comfortably with no signs of distress. Pulses are strong, perfusion is good, and capillary refill is brisk. The child is somewhat sleepy/postictal but shows no other overt instability. What are your initial management priorities?

41 處置的優先順序 ABCs 有助於確認為單純性痙攣的病史: 大發作發生於發燒病人 年齡介於6個月大至5 歲 發作時間(小於 15 分鐘)
無局部神經學異常 Of course, always assess the ABCs. We know already, however, that they appear normal at this point. Since the seizure has now stopped, try to assess the seizure type. The fact that it was generalized, occurred in a child between 6 months and 5 years of age, was less than 15 minutes, was associated with a fever, and resulted in no focal deficits gives it all five criteria of a simple febrile seizure. This information impacts management as it quickly categorizes this particular seizure type into one which is unlikely to require medication.

42 個案討論 此病童在急診需要更進一步的評估嗎? 他需要更進一步的實驗室檢查或影像學檢查嗎?
Does this child need to be further evaluated in the ED? Does she need any lab tests or radiographic studies?

43 個案討論 痙攣自動停止 呼吸道,呼吸和循環都很穩定. 此病童仍嗜睡但脖子並無僵硬. 此病童符合單純熱痙攣的診斷標準
完整的理學檢查顯示並無明顯的感染病兆 As this case progresses, the patient is no longer seizing, is stable from a cardiovascular standpoint, meets all the criteria for a simple febrile seizure, and is postictal yet showing no signs of nuchal rigidity or toxicity. Once the ABCs have been addressed, there are three critical management points of this case: First, rule out meningitis. As this child had a seizure and has a fever, you have focused in on the pathology on the neurologic system. Certainly, one of the worst diagnoses the child could have at this point would be meningitis. Therefore, make sure that you have an awake child with a normal neurologic exam and no nuchal rigidity before you discharge this patient. If not, lumbar puncture is indicated. Next, assure yourself that the seizure did in fact meet the criteria of a simple febrile seizure, as that will greatly affect your management and your counsel to the parent. Finally, assess this patient as you would any patient with a fever and look for signs of infection.

44 背景知識 熱性痙攣是最常見的兒童痙攣疾病 可分類為單純性熱痙攣和複雜性熱痙攣兩類
No, this child does not require transfer or further studies. (Emphasize the distinguishing factors of a complex febrile seizure as well as the difference in their rates of recurrence and epilepsy.) Febrile seizures are the most common convulsive disorder of childhood. Febrile seizures are classified as simple and complex. Complex seizures last more than 15 minutes, are focal, or occur more than once in 24 hours. They show higher rates of CNS infection and of epilepsy than simple febrile seizures. Some studies show higher recurrence rates; others do not.

45 單純性 vs. 複雜性熱痙攣 單純性 複雜性 發作時間 < 15 分鐘 神經學檢查並無局部異常 24小時內不會復發
發作時間> 15 分鐘 小發作或神經學檢查局部異常 通常在24小時內會復發 Simple versus complex features are outlined in the table. This distinction is important because complex (more than 15 minutes, focal, or occurring more than once in 24 hours) seizures show higher rates of CNS infection and of epilepsy than simple febrile seizures.

46 更進一步的診斷檢查 單純性熱痙攣並不需要安排更進一步的檢查 若臨床上已排除腦膜炎, 就不需要再安排腦脊液的檢查
處置此類病童的原則,與其他發燒未合併痙攣兒童是相同的.重點在於積極尋找發燒的原因. If a child has a simple febrile seizure, no specific studies are indicated. Again, be sure that the patient does not have meningitis. Once you’ve made that decision, approach the child just like you would any other child of this particular age group with a high fever.

47 除了單純性熱痙攣外,還有其他的鑑別診斷嗎? 複雜性熱痙攣 發燒前的寒顫 癲癇
The main differential diagnoses in the differential of a simple febrile seizure include: Complex febrile seizures: Distinguished from simple febrile seizures if they possess any of the following three criteria: Last longer than 15 minutes Recur within 24 hours Focality to the seizure Rigors: The shaking chills that children often get as their body tries to raise temperature at the onset of a fever. Epilepsy: A standard seizure disorder triggered by this fever. You will not be able to determine this diagnosis at this time and time will only tell if this child is one of the 2% to 4% of children with febrile seizures who go on to have epilepsy.

48 處置 對於痙攣的復發,給予支持性療法 將病人搬到一安全的地點 病人的口中請勿放置任何物品 目前並無證據支持下列藥物對於治療熱痙攣是有效的:
抗痙攣藥物 抗生素 The management of a simple febrile seizure is relatively straightforward. Make sure that the child does not hurt him/herself during the seizure. Move the child to a low-lying place, making sure that there are soft objects around the side of the head in particular. While you would like to make sure that the child does not bite his tongue during the episode, it is not recommended to put anything in the child’s mouth. There is no evidence for the use of anticonvulsants or antibiotics in this instance.

49 個案病情進展 病童留院觀察12 hr 病童於次日出院,並安排電話追蹤病情 病童也逐漸退燒 並無痙攣的復發
As with most febrile seizures, this child was observed in the pediatrician’s office, woke up, and returned to her normal self. Complete physical examination showed no sign of a focal infection and the child was clearly not meningitic. She was discharged to home and the pediatrician asked mom to call him the next day to report how she been during the night. Another happy ending in the pediatric world.