夏日殺手：腸病毒....

天氣變熱了，請各位醫師多注意！

腸病毒感染症簡介 (Enterovirus)
腸病毒腸病毒係濾過性病毒之一種，可分為克沙奇病毒A群、B群 、小兒麻痺病毒、依科病毒及其他腸病毒。此種病毒世界各地均有，常於夏季、初秋流行，可經由接觸病人的口鼻分泌物、糞便、飛沫等途徑傳染，多發生於十歲以下之小孩，雖有成人個案，但很少見，人群密集處，易發生流行。

臨床症狀
潛伏期約為三至五天，大多數感染者，並無臨床症狀或臨床症狀極為輕微，而大部分病例過了幾天之後即會自然痊癒。典型症狀為口腔、手掌．腳掌出現水泡、潰瘍，可能合併發燒。病程為七至十天。極少數個案，有可能發生無菌性腦膜炎、腦炎、心肌炎、心包膜炎、肺炎、麻痺等併發症。尤其新生兒及小嬰兒感染者偶而會發生電擊性病毒性休克症候群，侵犯多種器官，死亡率很高。

診斷及治療
(1)只有經由實驗室檢驗，才能確定診斷是由何種腸病毒引起，但是，病毒之分型對於治療並無助益。(2)絕大多數症狀輕微者，予以症狀治療即可。對於極少數有併發症之個案，則採對症療法。請洽可信賴之，小兒科醫師診治。(3)病患於身體免疫力克服感染後即逐漸康復，但病毒仍可經由糞便排出，持續數周之久，而致感染他人。(4)如出現持續或反覆高燒、嘔吐、嗜睡、不安．意識不清．活力不佳．咳嗽、呼吸急促等非典型症狀，或有任何疑義，請儘速就醫。(5)有關免疫球蛋白之使用，因其效果尚在試驗階段，同時必須考慮其可能之潛在危險，故應由醫師審慎評估。(6)腸病毒感染後，免疫力可持續一段時間 ; 對於不同型之腸病毒，亦可有短期之交叉免疫。(7)有關例行預防接種之問題，特別是兩個月大嬰幼兒，請於接種前洽請醫師審慎評估。

預防方法
(1)目前腸病毒中除小兒麻痺病毒外，沒有疫苗可供預防。(2)請儘量避免出入公共場所，不要與疑似病患接觸。(3)家中如有病患，症狀輕微者，請在家隔離，以免傳染他人。並請多休息，適當補充水份。(4)加強個人衛生，請常洗手。(5)加強居家環境衛生及通風。(6)如有學童罹病，應建請家長予以請假暫勿上課，以免傳染其他學童。(7)目前並無證據顯示腸病毒導致胎兒先天性畸形之可能，但孕婦須避免感染，以預防生產時感染給新生兒。

行政院衛生署 印製
More at...http://kids.yam.com/act/events/enterovirus/index.htm

請 junior 醫師上班時多請教學長腸病毒的多樣化表現及一些臨床上遇到過的嚴重個案，要如何早期診斷收住院？還有..... 要如何做好衛教等等。

尿黑水...

Hemoglobinuria with Malaria

An otherwise healthy 30-year-old man had been ill for 2 days when he presented with a temperature of 39°C and reported passing dark urine (his case was noted in Bhatt et al., East African Medical Journal 1994;71:755-7). He reported taking no medication before coming to the hospital. Laboratory evaluation on admission was notable for a hemoglobin level of 7.6 g per deciliter, a serum urea nitrogen level of 4.8 mmol per liter (0.13 mg per deciliter), and a creatinine level of 89 µmol per liter (1.0 mg per deciliter). The total bilirubin level was 15 µmol per liter (0.88 mg per deciliter), and the conjugated bilirubin level 1 µmol per liter (0.06 mg per deciliter). A urinary dipstick test was positive for blood but microscopical examination showed no red blood cells (the dipstick test used could not differentiate red blood cells from hemoglobin). The blood smear showed 5% parasitemia of red blood cells with Plasmodium falciparum. Progressive clearance of his urine is shown, from dark brown on admission (T0, or zero hour) to yellow 42 hours after admission (T42). His condition improved on treatment with quinine, initially administered intravenously and then orally for a total of 7 days. He stayed in the hospital for 48 hours. The qualitative glucose-6-phosphate dehydrogenase (G6PD) level 28 days later was very low. Black-water fever is most often associated with the use of antimalarial medication, especially quinine, but in this patient, dark urine developed before quinine therapy, making this diagnosis less likely. As many Africans are heterozygotes for G6PD deficiency, which is thought to provide protection against malaria, this may be the cause of his hemolysis.

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Martin Tombe, M.D.

Mpilo Central Hospital

Bulawayo, Zimbabwe

NEJM Volume 358:1837 April 24, 2008 Number 17

Sudden Cardiac Arrest

The estimated U.S. incidence of sudden cardiac arrest is 166,200 per year, with a median survival to hospital discharge of only 6.4%. In this study by the American Heart Association (2008), the survival of patients with a witnessed arrest and a shockable rhythm who underwent defibrillation within 3 minutes after the event was 74%; in patients without a shockable rhythm, survival was only 5%. Only 20 to 38% of patients have a shockable first rhythm during sudden cardiac arrest.

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http://content.nejm.org/cgi/content/short/358/17/1793

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Ketamine Without Atropine

Is Ketamine Sedation Without Atropine Prophylaxis Safe in Children?
Findings of an observational study suggest that it is.

Because ketamine can cause hypersalivation, adjunctive atropine prophylaxis traditionally has been recommended for sedation in children. However, many emergency physicians no longer administer atropine prophylaxis. In a prospective observational study, researchers evaluated the incidence of hypersalivation and associated airway compromise in children who were undergoing ketamine sedation in an emergency department where atropine was administered at the treating physician's discretion.

Of 1090 children who received ketamine for sedation during a 3-year period, 87% did not receive atropine. Among patients who did not receive atropine, 4% developed excessive salivation that required intervention (mostly suctioning) and 3% experienced airway compromise. Only one case of airway compromise was thought to be related to hypersalivation. No child required intubation. The authors conclude that routine atropine prophylaxis is not necessary when ketamine is used for sedation in children.

Comment: Of the nearly 1000 children who were sedated with ketamine without atropine in this observational study, none required assisted ventilation or intubation, even though 4% developed hypersalivation. Many practitioners have stopped using adjunctive atropine, and the practice seems to be safe.

— Diane M. Birnbaumer, MD, FACEP
Published in Journal Watch Emergency Medicine May 2, 2008
Citation(s): Brown L et al. Adjunctive atropine is unnecessary during ketamine sedation in children. Acad Emerg Med 2008 Apr; 15:314.

最新胸痛流程

http://dx.doi.org/10.1016/j.annemergmed.2007.09.004

http://er119.org/xoops_er119/er119uploads/journals/chestpain2007x.pdf

Malignant Hypertension

A 53-year-old man presented with a 4-week history of bilateral retrobulbar headache and blurred vision. His blood pressure was 220/135 mm Hg; his neurologic examination was unremarkable. He had no history of hypertension and was not taking any medication for its treatment. Fundus examination showed bilateral disk edema, lipid exudate (Panel A, short arrow), cotton-wool spots (Panel A, long arrow), a swollen optic nerve (Panel B, long arrow), and retinal hemorrhages (Panel B, short arrow). Magnetic resonance imaging of the brain showed an isolated hyperintense abnormality on fluid-attenuated inversion recovery (FLAIR) images in the pons and midbrain (Panel C, arrow) that did not enhance with gadolinium (Panel D, arrow). Good control of blood pressure was established, and the appearance of the fundus and brain stem returned to normal (Panel E, arrow) 4 months later.

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NEJM, Lee and Tienor 358 (18): 1951, Figure 1, May 1, 2008.
http://content.nejm.org/cgi/reprint/358/18/1951.pdf