Acute abdomen with anemia

A previously healthy 22-year-old man presented with a 3-month history of intermittent abdominal pain and hypochromic microcytic anemia, with a hemoglobin level of 5.1 g per deciliter and a mean corpuscular volume of 75 µm3. Initial endoscopy of the upper and lower gastrointestinal tract was unremarkable, despite a positive test for fecal occult blood. Further investigation with video-capsule enteroscopy showed an intraluminal bulge within the proximal jejunum 77 minutes after ingestion of the capsule. Six days later, the patient presented with abdominal pain, nausea, and vomiting. Computed tomography showed the presence of an intussusception (arrow). On emergency laparotomy, a proximal jejunojejunal intussusception was found and resected. Pathological examination revealed that the leading edge of the intussusception was a pedunculated benign lipomatous polyp. At a follow-up visit 2 months later, the patient was free of pain and had no further signs of bleeding.

NEJM Volume 357:e30 December 27, 2007 Number 26

Colin H. Wilson, M.R.C.S.

Steve A. White, M.D., F.R.C.S.

Freeman Hospital

Newcastle upon Tyne NE7 7DN, United Kingdom

ICD storm

Teaching topics from the New England Journal of Medicine - Vol. 357, No. 26, December 27, 2007

ICDs: Not a Cure for VT or VF
Patients with a history of myocardial infarction who survive a spontaneous episode of ventricular arrhythmia are at high risk for subsequent sudden death from recurrent ventricular tachycardia or ventricular fibrillation. Implantable cardioverter-defibrillators (ICDs) decrease mortality and have, therefore, become the mainstay of treatment. However, ICDs are not a cure for ventricular arrhythmias. Defibrillator discharges (shocks) for treatment of recurrent arrhythmias are painful, and syncope may occur before delivery of therapy.

Catheter-Based Mapping and Ablation Techniques
Catheter-based mapping and ablation techniques represent nonpharmacologic methods for the treatment of ventricular tachycardia. The most common indication for radiofrequency ablation is ventricular tachycardia refractory to drug therapy in patients with coronary artery disease that results in frequent shocks from an ICD. However, only 5 to 10% of patients with coronary artery disease show sufficient hemodynamic stability to allow identification of target sites with catheter-based mapping during an episode of ventricular tachycardia. This limitation thus sharply constrains the clinical application of catheter ablation.

Q: What is an 『ICD storm?』
A: An 『ICD storm』 is the term used to describe repeated ICD (implantable cardioverter-defibrillator) shocks delivered within a short time interval. These events occur in 10 to 25% of patients with implantable cardioverter-defibrillators. Clinically significant anxiety and depression as a result of recurrent ICD shocks may occur in more than 50% of patients.

突發性耳聾

耳中風

突發性耳聾為耳鼻喉科的急症，俗稱耳中風，是一種聽力突然降低的疾病，好發於冬春及夏秋的季節轉換之際，多以單側突然或快速進行性的聽力受損呈現，以雙側的聽力喪失型態表現的病例較不常見，其患者可能在一覺醒來後發現一側聽力減弱、耳鳴、耳悶感、甚至合併暈眩等。在疾病的定義上，突發性耳聾是指在聽力圖上連續三個頻率感覺神經性聽力下降超過30 分貝(通常可與對側正常耳比較)，且此情況是在最近三日內發生。其發生率約每年每十萬人口有5到20人。突發性耳聾是一種原因不明之突發性感音性聽力障礙，若未提早發現治療，則可能造成永久性聽障之遺憾，故不可不慎。

一、突發性耳聾的病因
1.血管因素：因支配內耳神經之血管發生痙攣或栓塞造成內耳神經缺氧，甚至壞死。尤其有糖尿病、高血壓、心臟病、高血脂症、甲狀腺功能異常等全身疾病者易得。
2.病毒因素：是最常被提起的。內耳因受到病毒感染發炎，以至此症。如麻疹病毒、腮腺炎病毒、水痘帶狀庖疹病毒及一些感冒病毒等。另外先天性耳聾也有因母親感染了德國麻疹或巨細胞病毒而造成胎兒得此症。
3.免疫學說：自体免疫抗体破壞內耳之部份構造造成，如紅斑性狼瘡、類風溼性關節炎、柯剛氏疾病（Cogans disease）等自体免疫患者亦併有兩耳之突發性耳聾。

二、突發性耳聾的檢查
聽力檢查，平衡功能檢查是需要先做的，另外抽血及眼振圖也可能是需要的，若高度懷疑腦中風或聽神經瘤則需進一步行電腦斷層檢查或核磁共振掃描。

三、突發性耳聾的治療
1.類固醇：初期大量使用類固醇再慢慢減量，尤其針對可能是病毒或自体免疫病造成的耳聾較有效。
2.血漿擴張劑：用一種分子量四萬之葡萄糖聚合物（Dextran）來擴張血漿容積、改善血流可針對血管原因造成之突發性耳聾有助益。
3.其它 : 像是高壓氧治療、星狀神經節阻斷術等。高壓氧是一個具有潛在效益的另類輔助治療。
4.最重要的就是臥床休息及避免壓力。有研究曾指出那些完全臥床休息者之預後與用藥物治療比起來並無差別。

四、突發性耳聾之預後
治療痊癒率為55%至85%，越早發現越早治療效果越佳，當聽力喪失的程度愈多，患者恢復愈差。類固醇的使用則攸關治療成敗，若是發病後開始治療的時間，超過2週以上才開始治療者，聽力改善的可能性很小。

五、預防與調養
1.突發性耳聾的病人應在家安心靜養，尤應避免接觸雜訊或過大的聲音。保持家庭環境整潔，病人心情舒暢，才有利於疾病恢復。
2.預防感冒，有一部分突發性耳聾的病人可能與感冒有間接關係。
3.注意勿過度勞累，做到起居正常，飲食定量。故中年人更應注意這一點。
4.情緒穩定，勿暴怒狂喜，因可使人體內神經體液調節失去平衡，造成耳部血循環障礙，發生耳聾。

By 台中榮總急診室護士 - 張惠風

主動脈剝離

急診醫師的夢靨 - 主動脈剝離

主動脈剝離，在臨床上的表徵變化多端，病程的進展也往往變化快速，屢屢是急診室醫師產生醫療糾紛，而且是病患家屬相當陌生無法接受的疾病之一。

顧名思義，主動脈剝離之定義為任何主動脈段落有其結構上之問題，使其主動脈內之血流被導引從真腔經過內膜撕裂處，進入主動脈壁中產生所謂的假腔。在此情況除主動脈壁之保護結構受到嚴重之破壞外，另外，由主動脈灌經各個器官之血流都有可能受到影響，並產生各類器官缺血性症狀。有時會嚴重到動脈破裂造成病人的突發性死亡。

因此，病人的臨床徵狀之表現千變萬化－除了最常見撕裂感劇烈胸痛外；也可能因剝離侵犯至冠狀動脈而造成缺血性心臟病之變化；侵犯腎動脈而造成急性腎衰竭；侵犯主動脈瓣而造成急性心衰竭；侵犯二側頸動脈而造成腦中風；侵犯脊髓血管而造成下半身麻痺；侵犯腸繫膜動脈阻塞造成腸壞死；或是侵犯下肢單側、雙側缺血而造成肢體缺血之情形。所以即使是經驗豐富的急診醫師也往往被局部症狀誘導而第一時間無法正確的診斷出來。

危險因子主要包括高血壓、外因性血管傷害、使用cocaine、孕婦及先天性疾病( 如Marfan syndrome )等。如果病患高血壓沒有控制得宜，往往是造成主動脈剝離的最大原因。

在臨床上Stanford （史丹福）分類以有無侵犯升主動脈作為分類之依據，如侵犯到升主動脈為Stanford （史丹福） A 型，其餘皆稱作 B 型。手術對A 型的主動脈剝離可以降低一半之死亡率，也被推薦為標準的治療方法。以長期預後而言，手術仍比藥物治療有較長的存活率。Stanford （史丹福）B 型的急性主動脈剝離是以藥物為主要治療方法，主要原則是控制血壓。

急性主動脈剝離之病患不管是接受手術或藥物治療，在出院後長期追蹤是極為重要的。必須預防另一次破裂之可能性，所以影像學原則之追蹤是絕對必要的。如有升主動脈直徑五公分或降主動脈大於六公分都是被建議再做一次治療之機。

主動脈剝離為緊急突發性疾病，若未迅速診斷出而適當治療，其死亡率相當高，所以當急診醫師高度懷疑有主動脈剝離時，應立即謹慎給予內科療法，如Nitroprusside併用乙型阻斷劑或Labetalol等，並立刻安排影像學檢查，以確定是否有緊急手術之必要，並即刻送至加護病房嚴密觀察；待病情穩定之後，病患除了須要長期接受降壓劑治療外，還應定期追蹤及避免過度劇烈運動，以降低主動脈剝離復發之可能性。

By 台中榮總急診部總醫師 - 黃植謙

ARDSNET Study

Society of Critical Care Medicine 2007

Surviving Sepsis Campaign 2008

Society of Critical Care Medicine 2007

LR 和 NS 之差異

Lactated Ringer's Solution 在 125 年前由英國的 Sydney Ringer 發明，現在仍很普遍。

Normal Saline = 0.9% NaCl. 1 L 之 Normal Saline 含154 mEq/L of Na+ and154 mEq/L of Cl-

1 L 之 Lactated Ringer's Solution 含:130 mEq/L of Na+109 mEq/L of Cl-28 mEq/L of lactate4 mEq/L of potassium3 mEq/L of calcium


重點：
Lactate converts to bicarbonate in liver. Patients with lactic acidosis usually have inadequate liver metabolism of lactate so conversion to HCO3- from the infused lactate of LR is impaired and may give false readings of serial lactate measurements but may be a better choice in regular situations where hyperchloremia restricts use of normal saline.

Central Venous Catheterization

Teaching topics from the New England Journal of Medicine - Vol. 357, No. 24, December 13, 2007

Procedure: Central Venous Catheterization
The placement of a central venous catheter is indicated for the continuous monitoring of central venous pressure and for the delivery of critical or caustic medications.

Complications of Central Line Placement
Specific complications associated temporarily with placement of a subclavian line include hemothorax and pneumothorax, air embolism, inadvertent arterial puncture, and aortic perforation. Obtain a chest radiograph after placement to assess for complications and to confirm correct placement of the catheter. Common malplacement locations include placement transverse to the contralateral subclavian vein, retrograde into the ipsilateral internal jugular vein, or potentially the contralateral internal jugular vein.

Guidelines to Decrease Risk of Infection
The Institute for Healthcare Improvement has developed specific guidelines to help decrease the risk of infection in patients with central venous catheters. The guidelines include the use of proper hand hygiene, the use of maximal barrier precautions during placement, the use of chlorhexidine skin antisepsis, and daily review of the need for the catheter.

Morning Report Questions

Q: In what position should a patient be placed in for insertion of a central line in the subclavian vein? Does the use of a rolled towel under the spine increase or decrease the size of the subclavian vein?
A: A patient who is undergoing placement of a central line in the subclavian vein should be placed in a 15-degree Trendelenburg position. If you place a rolled towel or similar object under the spine to help identify the patient's external landmarks, be aware that propping the shoulder or turning the head has been shown to decrease the size of the vein on ultrasonography.

Q: What are general contraindications for placement of a central venous catheter?
A: General contraindications for placement of a central venous catheter include infection of the area overlying the target vein and thrombosis of the target vein. Specific contraindications to the subclavian approach include fracture of the ipsilateral clavicle or anterior proximal ribs, which can distort the anatomy and make placement difficult. Greater caution should be used when placing a central venous catheter in coagulopathic patients. The location of the artery (beneath the clavicle) makes application of direct pressure nearly impossible in attempts to control bleeding.

這裡有 teaching video 可以下載：
http://content.nejm.org/cgi/video_dl/357/24/e26/

Peutz-Jeghers Syndrome

Teaching topics from the New England Journal of Medicine - Vol. 357, No. 23, December 6, 2007
Peutz–Jeghers Syndrome

Peutz–Jeghers syndrome is an autosomal dominant disorder caused by a germ-line mutation of the serine/threonine kinase 11 (STK11) gene. Hamartomatous polyps, the hallmark of the disorder, are seen in 88% of all patients. Pigmented mucocutaneous lesions are present in nearly all patients by 2 years of age and most commonly occur on the lips and perioral region, followed by the hands, buccal mucosa, and the feet. The most frequent complication of polyps is intussusception. Patients with Peutz–Jeghers syndrome are also at high risk for intestinal and extraintestinal cancer. The most common cancers are gastrointestinal and breast.

Morning Report Question

Q: What are some causes of intussusception in adults?

A: Causes of small-intestinal intussusception in the adult population include tumors, foreign bodies, unusual endoluminal infections such as ascariasis — and endometrial implants (in females). Of note, only 5% of intussusceptions occur in adults. An underlying cause of intussusception is identified in 90% of adults. Benign and malignant neoplasms account for the majority of cases.

Depression 病史該問什麼？

要問的是：傷心人的逃離 - 『SAD PERSON'S ESCAPE』。
如圖。