常考的 Salter-Harris Classification

• Type I - fracture through the physis (widened physis)
• Type II - fracture partway through the physis extending up into metaphysis
• Type III - fracture partway through the physis extending down into the epiphysis
• Type IV - fracture through the metaphysis, physis, and epiphysis -- can lead to angulation deformities when healing
• Type V - crush injury to the physis

請問：哪種 type 是 child abuse 中最常見的呢？

Hypercalcemia 的定義

---------- Forwarded message ----------
From: bryan;

Dear all,

M&M報完回去重新查了一次hypercalcemia的定義
在正常的情況下 ionized Ca佔大約50%
但是到Ca濃度越高 因為能夠結合的albumin根本就全部被佔滿了
所以ionized Ca的level就會越來越接近total calcium的level

In plasma, calcium exists in 3 different forms,

• (1) 50% as ionized or the biologically active form,
• (2) 45% bound to plasma proteins (mainly albumin), and
• (3) 5% complexed to phosphate and citrate

Hypercalcemia:

• Mild: Total Ca 10.5-11.9 mg/dL (2.5-3 mmol/L) or Ionized Ca 5.6-8 mg/dL (1.4-2 mmol/L)
• Moderate: Total Ca 12-13.9 mg/dL (3-3.5 mmol/L) or Ionized Ca 8-10 mg/dL (2-2.5 mmol/L)
• Hypercalcemic crisis: Total Ca 14-16 mg/dL (3.5-4 mmol/L) or Ionized Ca 10-12 mg/dL (2.5-3 mmol/L)

子堯

很棒的 sepsis 網站

---------- Forwarded message ----------
From: Vei Ken Seow;
Date: 2007/8/30 上午 7:34

Dear All,

一個很棒的surviving sepsis campaign網頁
大家可以上去看看...(會不會是我最後一個知道有這個網頁 ?)

http://www.survivingsepsis.org

http://www.survivingsepsis.org/files/Implementing%20the%20Surviving%20Sepsis%20Campaign.pdf

蔚全..敬

Inherited Bleeding Disorders

何謂敗血症？

Sepsis:
Sepsis is systemic infection accompanied by a reaction that has been termed the systemic inflammatory response syndrome (SIRS). SIRS represents an acute inflammatory reaction with systemic manifestations caused by release into the bloodstream of numerous endogenous mediators of inflammation. SIRS can also be caused by acute pancreatitis and major trauma, including burns. It has previously been defined by 2 or more of the following:

1. Temperature > 38° C or less than 35° C
2. Heart rate > 90 beats/min
3. Respiratory rate > 20 breaths/min or Paco2 less than 32 mmHg
4. WBC count > 12,000 or less than 4,000 cells/μL or > 10% immature forms

However, these criteria are now viewed as suggestive but not sufficiently precise to be diagnostic.

Severe sepsis:
Severe sepsis is sepsis accompanied by signs of failure of at least one organ. Cardiovascular failure is typically manifested by hypotension, respiratory failure by hypoxemia, renal failure by oliguria, and hematologic failure by coagulopathy.

Septic shock:
Septic shock is severe sepsis with organ hypoperfusion and hypotension that are poorly responsive to initial fluid resuscitation.

什麼雞雞？

A 19-year-old man was referred for treatment of multiple papular lesions that had appeared 8 years earlier on the glans of his circumcised penis and had been diagnosed as condyloma accuminatum. The lesions did not respond to treatment with various topical wart preparations. The patient reported no history of sexually transmitted infections and was anxious and embarrassed by the lesions.

http://content.nejm.org/cgi/content/full/357/7/691

答案是：Pearly Penile Papules (是珍珠雞，不是性病！)

Dome-shaped or hairlike projections appear on the corona of the penis and sometimes on the shaft just proximal to the corona. These are small angiofibromas, and represent normal variants that do not require any treatment. Pearly penile papules are sometimes mistaken for warts.

貓在泥巴堆裡打滾...

Increases in the anion gap are seen with excessive acid production or with addition of exogenous acids. The differential for an increased anion gap acidosis can be readily recalled using the mnemonic "CAT MUD PILES" ：

• Carbon monoxide, Cyanide,
• Alcoholic ketoacidosis,
• Toluene,
• Methanol,
• Uremia,
• Diabetic ketoacidosis,
• Paraldehyde, Phenformin,
• Iron, Isoniazid,
• Lactic acidosis,
• Ethylene glycol,
• Salicylates.

Appendicitis Score

NEJM: Stroke 新知

TPA: Within 180 Minutes

The National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator (NINDS rt-PA) Stroke Study, a multicenter, randomized trial, has demonstrated the efficacy of treatment with intravenous rt-PA (alteplase) started within 3 hours after the onset of symptoms. Pooled analysis of six randomized trials has suggested a potential benefit within up to 6 hours after the onset of stroke. Trials assessing treatment in this extended time frame among broad populations of patients with ischemic stroke are underway.

Ischemic Stroke and Acute Management of Blood Pressure

Given concerns about adverse effects of the short-term lowering of blood pressure on cerebral perfusion just after an ischemic stroke, current guidelines based on consensus opinion recommend withholding antihypertensive therapy during the active phase of ischemic stroke unless the diastolic blood pressure exceeds 120 mm Hg or the systolic blood pressure exceeds 220 mm Hg in patients who are not candidates for rt-PA. In contrast, blood pressure monitoring is recommended before, during, and after rt-PA therapy, and intravenous antihypertensive therapy is recommended to maintain the systolic blood pressure below 180 mm Hg and the diastolic below 105 mm Hg.

CT versus MRI for Stroke

CT has high sensitivity for acute intracranial hemorrhage, but MRI has a much higher sensitivity than CT for acute ischemic changes, especially those in the posterior fossa and in the first hours after an ischemic stroke. Edema due to cytotoxicity is detectable within minutes after the onset of ischemia, with a reduced apparent diffusion coefficient on diffusion-weighted imaging. However, it remains unclear whether early visualization of ischemia has important implications for management.

Questions
Q: What are the contraindications to intravenous thrombolysis in patients with acute ischemic stroke?
A: Among the major contraindications to thrombolysis in patients with an acute ischemic stroke are onset of symptoms more than 3 hours before the start of treatment, intracranial hemorrhage on CT or MRI, head trauma or stroke in previous 3 months, myocardial infarction in the previous 3 months, major surgery in the previous 14 days, history of intracranial hemorrhage, systolic blood pressure equal to or greater than 185 mm Hg or diastolic blood pressure equal to or greater than 110 mm Hg, and other contraindications listed in the table below.

C-spine fractures, stable or not?

下載 lecture slides:

http://er119.org/xoops_er119/er119uploads/c_spine_radiology.pdf