2011年1月28日 星期五

高壓氧治療CO中毒,效果沒想像中好?!

Is Hyperbaric Oxygen Therapy Beneficial in Carbon Monoxide Poisoning?
HBO therapy did not add benefit to normobaric oxygen therapy in these studies.

In two parallel prospective randomized studies, researchers evaluated the effectiveness of hyperbaric oxygen therapy (HBOT) in patients (age, ≥15 years) with acute isolated carbon monoxide (CO) poisoning who presented to an academic hospital in France between 1989 and 2000. In trial A (mild poisoning), 179 patients with transient loss of consciousness received normobaric oxygen therapy (NBOT) for 6 hours or NBOT for 4 hours plus one session of HBOT. In trial B (severe poisoning), 206 comatose patients (Glasgow Coma Scale score below 8) received NBOT for 4 hours plus either one or two HBOT sessions. Each HBOT session lasted 2 hours in a multiplace chamber at 2.0 atmospheres absolute; interval between sessions was 6 to 12 hours. At baseline, 82% of patients in trial A and 65% in trial B had headaches, and 4% and 10%, respectively, had seizures.

At 1 month, patients completed a symptom questionnaire and were evaluated by an intensivist with neurology training who was blinded to treatment group. Complete recovery was defined as absence of patient-reported symptoms and normal physical and neuropsychological exam, "moderate sequelae" was defined as one or more self-reported symptoms, and "severe sequelae" was defined as any objective physical exam finding. In trial A, complete recovery rates were similar in the two groups (approximately 60%), and no patient in either group had severe sequelae. In trial B, complete recovery rates were significantly lower in the group that received two HBOT sessions than in the group that received one session (47% vs. 68%; unadjusted odds ratio, 0.42).

Comment:
The trial A findings support the teaching that most patients with mild CO poisoning will improve after removal from the exposure and treatment with high-flow oxygen. The trial B finding is surprising and suggests that HBOT might not benefit even those patients with severe toxicity. Pending a larger trial with clearer toxicity definitions, physicians should contact a regional poison center or HBOT referral center to discuss with consultants the best approach for an individual patient with known CO poisoning, particularly when the treatment might involve transfer of an unstable patient.


Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine January 28, 2011

Citation(s):
Annane D et al. Hyperbaric oxygen therapy for acute domestic carbon monoxide poisoning: Two randomized controlled trials. Intensive Care Med 2010 Dec 2; [e-pub ahead of print]. (http://dx.doi.org/10.1007/s00134-010-2093-0)

2011年1月25日 星期二

小兒急救 - 新版的指引

Updated Recommendations for Pediatric Resuscitation

The 2010 International Liaison Committee on Resuscitation Pediatric Task Force has updated the 2005 treatment recommendations for pediatric resuscitation. Highlights include the following:
  • Initiate cardiopulmonary resuscitation (CPR) if there are no signs of life and a pulse is not palpated within 10 seconds.
  • Provide conventional CPR (chest compressions with rescue breathing).
  • Compress at least one third of the anterior-posterior dimension of the chest.
  • Consider using cuffed tracheal tubes in infants and young children; cuff pressure should not exceed 25 cm H2O. Appropriate sized tubes by age are as follows:
    # 3 mm for age ≤1 year
    # 3.5 mm for age 1–2 years
    # Age in years/4 + 3.5 mm for age >2 years
  • Modify or discontinue cricoid pressure if it impedes preintubation ventilation or intubation.
  • Monitor capnography to confirm endotracheal tube position, recognizing that end-tidal CO2 in infants and children might be below detectable limits for colorimetric devices (85% sensitivity and 100% specificity).
  • Consider use of an esophageal detector device in children weighing >20 kg.
  • Use capnography monitoring to assess effectiveness of chest compressions.
  • Avoid excessive ventilation, which can decrease cerebral perfusion pressure, rates of return of spontaneous circulation (ROSC), and survival rates.
  • After ROSC, titrate oxygen concentration to limit the risk for toxic oxygen byproducts.
  • For pediatric septic shock, include therapy directed at normalizing central venous oxygen saturation to ≥70%.
  • Do not routinely use bicarbonate or calcium for pediatric cardiac arrest: Both agents are associated with decreased survival.
Comment:
These consensus recommendations are based on a thorough evaluation of the literature, and emergency physicians should know them.


Katherine Bakes, MD
Published in Journal Watch Emergency Medicine January 21, 2011

Citation(s): Kleinman ME et al. Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010 Nov; 126:e1261.

2011年1月23日 星期日

國內再度出現百日咳死亡個案

國內再度出現百日咳死亡個案,家有嬰幼兒的民眾請小心防範

行政院衛生署疾病管制局公布一例新生兒百日咳死亡個案該個案為去(99)年底出生之女嬰,出生後於接生之婦產科接受照護10天後返家,當日出現輕微咳嗽,赴某兒科診所診斷疑似感冒,本年15日因發燒、咳嗽有痰、發紺、嘔吐等症狀轉診至某醫學中心隔離治療,110日通報,2日後因敗血性休克死亡,經該局檢驗確認並研判死因與百日咳相關。經調查個案之母於生產前數天即有咳嗽症狀並就醫治療,防疫人員已對個案雙親及婦產科診所之醫護人員等密切接觸者進行採檢及預防性投藥,並實施健康監視中,目前尚無新增疑似個案。近期同時另有一起新生兒病例,個案目前仍住院治療,病情穩定恢復中,該局提醒家有嬰幼兒的民眾應注意防範。

百日咳為百日咳桿菌所引起之急性呼吸道傳染病,主要是經由飛沫,臨床症狀為咳嗽持續至少兩週,且伴隨陣發性咳嗽、吸入性哮聲或咳嗽後嘔吐等。常發生於5歲以下兒童其他年齡層亦可能發生,但症狀較輕微或不明顯。依據該局監視資料顯示,近年國內百日咳個案每年約在4090間,以未完成接種疫苗的嬰幼兒為主要感染族群最近一起死亡個案發生於92年,為出生一個月的男嬰,近年來青少年個案的比率有上升趨勢,澳洲及美國等先進國家之疫情亦十分嚴重

接種疫苗可有效預防百日咳,現行預防接種政策為出生滿2,4,6,18個月國小一年級各接種一劑百日咳相關疫苗,家中有嬰幼兒的民眾,請務必按時攜帶嬰幼兒前往接種,以獲得足夠的保護力。此外,在普遍施打疫苗的環境下,百日咳常經由成人或較年長孩童傳播民眾務必注意自身及其他較年長孩童的衛生,尤其自外返家,在接觸嬰幼兒前,應先更衣洗手,以免將細菌傳染給幼兒,並儘量避免帶嬰幼兒出入人潮擁擠、空氣不流通之公共場所,或到醫院探病,以降低感染機會。如發現自身或家人出現疑似症狀,應立即就醫、配戴口罩,並按醫囑確實完成治療,勿任意停藥,且務必配合衛生機關進行防治措施,以防杜疾病傳播。

由於小於6個月的寶寶是感染百日咳的高危險族群,主要的感染源為親密照顧的媽媽及其他照顧者各國亦陸續建議未曾接種百日咳疫苗的育齡婦女,應接種一劑適用於成人的減量破傷風白喉非細胞性百日咳混合疫苗(Tdap以預防感染百日咳傳染幼兒。而之前未曾接種 Tdap之產婦,則應於產後離開醫院前完成接種。而因醫療照護人員及產後護理機構之醫療照護者為除母親及親密照顧的親人外,與新生寶寶最親密接觸者,為預防該等人員感染百日咳傳染新生幼兒,針對該等機構之各相關單位照護人員,建議接種一劑Tdap以避免百日咳之發生,危及新生兒健康,同時提升國內照護品質。

疫情資訊請查詢:
http://www.cdc.gov.tw/mp.asp?mp=1

2011年1月13日 星期四

中耳炎還是用抗生素比較好〔?〕

What is the most effective treatment for acute otitis media?
Amoxicillin–clavulanate has been shown to be the most effective treatment for acute otitis media.

As compared to placebo treatment, what were the benefits of antibiotic treatment for children 6 to 23 months of age with acute otitis media in this clinical trial?
Children who were treated with amoxicillin–clavulanate, as compared with those who received placebo, had consistently more favorable short-term outcomes, including a sustained symptomatic response, an absence of otoscopic evidence of persistent middle-ear infection, and a reduced rate of residual middle-ear effusion.

As compared to placebo treatment, was speed of resolution different for children who received antibiotic treatment in this study?
Yes, among the children who received amoxicillin–clavulanate, 35% had initial resolution of symptoms by day 2, 61% by day 4, and 80% by day 7; among children who received placebo, 28% had initial resolution of symptoms by day 2, 54% by day 4, and 74% by day 7.

As compared to placebo-treated children, what adverse effects were significantly more common among children with acute otitis media who received antibiotic treatment?
Dermatitis in the diaper area and protocol-defined diarrhea occurred commonly, and often together, among children receiving antimicrobial agents. Both protocol-defined diarrhea and diaper area dermatitis occurred significantly more frequently among children who received amoxicillin–clavulanate than those that received placebo.

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NEJM

2011年1月7日 星期五

急診的CVP不會比ICU容易感染

Are Central Lines Placed in the ED Associated with Higher Risk for Bloodstream Infections?
The rate of bloodstream infections for central lines placed in a single emergency department was comparable to the rate for lines placed in the intensive care unit.

On January 1, 2010, The Joint Commission added to its quality measures a National Patient Safety Goal for use of maximum barrier precautions and a checklist and standardized protocol for placement of central venous catheters throughout the hospital, including in the emergency department (ED). In a retrospective chart review, researchers determined the rate of central line–associated bloodstream infections (CLABSIs) in a single urban academic ED in Boston before implementation of the checklist.

During 2007 and 2008, 656 patients underwent placement of central lines in the ED and 7 CLABSIs were reported. The CLABSI rate for lines placed in the ED was 1.93 per 1000 catheter-days. The CLABSI rate for lines placed in the hospital's ICU during 2008 was 1.51 per 1000 catheter-days, and the nationally reported rate for ICU-placed central lines was 2.05 per 1000 catheter-days.

Comment:
Central lines placed in the ED are perceived as being more prone to infection than those placed in the ICU for myriad reasons, particularly the urgency with which such lines often are placed. However, in this single-hospital study, CLABSI rates were similar for lines placed in the ED and the ICU.


Richard D. Zane, MD, FAAEM
Published in Journal Watch Emergency Medicine January 7, 2011

Citation(s): LeMaster CH et al. Infection and natural history of emergency department–placed central venous catheters. Ann Emerg Med 2010 Nov; 56:492.