Answer: Left atrium.
The chest radiograph reveals cardiomegaly, with splaying of the carina and an elevated left main bronchus. These findings are most suggestive of an enlarged left atrium.
Read More: New Engl J Med 358;19:2050
2008年4月30日 星期三
2008年4月29日 星期二
椿象毒液噴眼 眼角膜缺損發炎
〔記者魏怡嘉／台北報導〕打昆蟲時最好保持距離，或是戴上護目鏡。一位六十九歲老婦，在自家瓜園看到一隻椿象，順手拿石頭敲下去，結果「噗」一聲，右眼被椿象毒液噴到，當場淚流不止、眼睛睜不開，直奔台北榮總急診。
椿象毒液為苯?，為一種具有刺激性臭味及毒性的化學物質，眼睛接觸後會產生強烈刺痛及灼熱感。（台北榮總眼科主治醫師陳克華提供）
台北榮總眼科主治醫師陳克華表示，昆蟲造成的眼部傷害，最常見為異物接觸傷害，其次是昆蟲的直接叮咬，遭昆蟲毒液噴傷相當少見，過去台灣並無椿象毒液傷眼的案例發表，國外亦無，台北榮總接到的這個案例，有可能是台灣甚至世界第一例。
陳克華指出，這名婦人到急診時眼睛紅腫，右眼角膜有整片缺損及發炎的情形，醫師立即用一千西西生理食鹽水沖洗，並給予抗生素及類固醇藥膏治療。
由於老婦就診時帶有椿象的屍體，醫院還送往中興大學鑑定，確定是椿象。陳克華表示，由於昆蟲毒液可能造成整個病程惡化得相當快，即使用藥治療進步也很緩慢，這名婦人經三個月追蹤治療後，眼睛才恢復正常。
台北榮總一般眼科主任林佩玉表示，造成眼睛傷害的昆蟲，第一名是不明昆蟲，第二名則是蜜蜂，第三名則是隱翅蟲。臨床上常會碰到被蜜蜂叮到角膜的病患，其中又以土蜂造成的傷害最大，曾有病患因為被土蜂叮到角膜，結果內皮細胞銳減，差一點要做角膜移植。
椿象毒液為苯?，為一種具有刺激性臭味及毒性的化學物質，眼睛接觸後會產生強烈刺痛及灼熱感。（台北榮總眼科主治醫師陳克華提供）
台北榮總眼科主治醫師陳克華表示，昆蟲造成的眼部傷害，最常見為異物接觸傷害，其次是昆蟲的直接叮咬，遭昆蟲毒液噴傷相當少見，過去台灣並無椿象毒液傷眼的案例發表，國外亦無，台北榮總接到的這個案例，有可能是台灣甚至世界第一例。
陳克華指出，這名婦人到急診時眼睛紅腫，右眼角膜有整片缺損及發炎的情形，醫師立即用一千西西生理食鹽水沖洗，並給予抗生素及類固醇藥膏治療。
由於老婦就診時帶有椿象的屍體，醫院還送往中興大學鑑定，確定是椿象。陳克華表示，由於昆蟲毒液可能造成整個病程惡化得相當快，即使用藥治療進步也很緩慢，這名婦人經三個月追蹤治療後，眼睛才恢復正常。
台北榮總一般眼科主任林佩玉表示，造成眼睛傷害的昆蟲，第一名是不明昆蟲，第二名則是蜜蜂，第三名則是隱翅蟲。臨床上常會碰到被蜜蜂叮到角膜的病患，其中又以土蜂造成的傷害最大，曾有病患因為被土蜂叮到角膜，結果內皮細胞銳減，差一點要做角膜移植。
3歲童腹痛 驚見肺炎
台中市一名三歲男童本月中旬咳嗽、肚子痛，家屬以為是感冒，到藥局買成藥給男童服用，不料服藥三天不但病情未改善，還嚴重腹痛、高燒不退，送急診診斷為大葉性肺炎，幸好醫師即時治療才搶回小命。
醫師警告，最近一周就有四名幼童染大葉性肺炎，家長要特別注意。 澄清醫院中港院區小兒急診醫師柯慧明昨指出，本月十四日到二十一日就出現四名二至七歲幼童感染大葉性肺炎，病童出現三十九度以上高燒不退、咳嗽等症狀，「該名三歲男童卻以腹痛表現，被當腸胃型感冒治療，幸好到院時Ｘ光片明顯出現右肺葉感染，即時住院打抗生素，避免膿胸命危」。
【曾雪蒨╱台中報導】
醫師警告，最近一周就有四名幼童染大葉性肺炎，家長要特別注意。 澄清醫院中港院區小兒急診醫師柯慧明昨指出，本月十四日到二十一日就出現四名二至七歲幼童感染大葉性肺炎，病童出現三十九度以上高燒不退、咳嗽等症狀，「該名三歲男童卻以腹痛表現，被當腸胃型感冒治療，幸好到院時Ｘ光片明顯出現右肺葉感染，即時住院打抗生素，避免膿胸命危」。
【曾雪蒨╱台中報導】
2008年4月24日 星期四
2008年4月23日 星期三
Howell-Jolly body
A 34-year-old man came to the emergency room with a 3-day history of fevers (peak temperature, 40°C), accompanied by shaking chills. Laboratory tests revealed a hemolytic anemia, with a hemoglobin level of 8.6 g per deciliter. Nodular sclerosing Hodgkin's lymphoma, stage IIIB, had been diagnosed 12 years earlier, in 1994, and the patient underwent splenectomy at that time. He had traveled recently to Massachusetts, Oregon, Hawaii, Florida, and Illinois and to South Africa and Costa Rica. The peripheral-blood smear shows numerous intracellular organisms in red blood cells, with nearly 3% of erythrocytes harboring parasites. Multiple ring forms are seen, as well as rare tetrads (thin arrow). These so-called Maltese cross formations are essentially pathognomonic of babesiosis, since they are not seen in malaria, the primary consideration in the differential diagnosis. The dark, round body in the right lower quadrant of the red blood cell with the tetrad is a Howell-Jolly body (thick arrow), an erythrocyte inclusion representing an incompletely extruded nucleus. Howell–Jolly bodies are seen in patients with functional asplenia, and such patients are particularly susceptible to serious babesial and encapsulated bacterial infections. This single red cell provides both a diagnosis and an understanding of the underlying pathogenesis. Our patient received a 7-day course of treatment with azithromycin and atovaquone. His fever subsided rapidly, and his hematocrit eventually returned to normal.
---
NEJM
Kyle Noskoviak, M.D.
Elizabeth Broome, M.D.
University of California, San Diego, Medical Center San Diego, CA 92115
Malignant Hypertension
Diagnosis at a glance:
The fundus photograph shows
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NEJM Volume 358 Number 17
The fundus photograph shows
- disk edema,
- cottonwool spots,
- a swollen optic nerve, and
- retinal hemorrhages.
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NEJM Volume 358 Number 17
2008年4月22日 星期二
Atypical presentation of an AAA
Ruptured abdominal aortic aneurysm is a great masquerader that can present in a variety of clinical symptoms and signs. This is a case of ruptured abdominal aortic aneurysm that presented as a strangulated left inguinal hernia. The diagnosis of an inguinal hernia, be it complicated or uncomplicated is often simple and straight forward. Rarely this simple presentation may be the external manifestation of a distant pathology, which is in communication with the inguinal canal through its anatomic relationship. . Familiarity with the surgical emergencies that can mimic or present as simple irreducible hernia would enable a rapid diagnosis to be made with timely subsequent intervention. During exploration the presence of haematoma with in the cord warrants further laparotomy. Contrast enhanced CT scan is recommended for all dubious cases at an early stage.
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2008年4月15日 星期二
2008年4月14日 星期一
Emergency treatment of anaphylactic reactions
Guidelines for healthcare providers
STATEMENT PAPER from Resuscitation
Working Group of the Resuscitation Council (UK)
2008年4月12日 星期六
兒童呼吸急症 及早發現以免病情加重
文／范修平
兩歲多的婷婷一向是家中可愛又活潑的小公主，最近因為天氣變化，時有輕微的感冒症狀，沒想到兩天後，婷婷的咳嗽聲變成像是狗在吠，晚上更是睡不安穩、呼吸急促，而且連嘴唇都變成紫色的。送來急診，經過醫師細心診治，才知道婷婷得了「哮吼病」。還好婷婷的爸媽及早送來，若不趕緊醫治，嚴重時，甚至可能會要了她的小命。
最近正值季節交替，早晚氣溫變化大，正是各種呼吸急症肆虐的時候，類似婷婷這樣的案例，幾乎每天都在急診室上演。大部分的病人可以穩定下來，在門診追蹤治療，但是少數較為嚴重的病人，必須入院觀察，甚至需要緊急插管，才能救回一條寶貴的小生命。然而，呼吸道疾病種類繁多，在此提供疾病徵兆，家長可從觀察孩子的外觀、呼吸及皮膚狀況做辨識，以便能夠及早發現，及早治療，避免悲劇發生。
◎外觀：小朋友天生就好動、愛玩，生病的小朋友若是照樣玩耍、照樣吃喝，在這種情況下，就算是發燒，疾病程度大概也不會太嚴重。
若是小朋友整天躺在床上不起來，就算沒有發燒，父母也應該警覺。
可以從下面5個方法來評估小朋友活力：
●肌張力：就算是新生嬰兒，腳也是彎曲著動來動去，四肢不動的小朋友絕對是生病了。
●互動：生病的小朋友總是特別黏人。
●安撫：年齡較小的孩童和外界溝通的唯一方式就是哭，當父母無論怎麼安撫，孩子仍一直哭，就有可能是生病了。
●眼神：所有的小朋友天生就是好奇寶寶，在安全的環境中（如父母的懷裡），眼睛總是咕嚕嚕地轉來轉去，若是雙眼無神，呆呆地望向同一個地方，是不正常的現象。
●哭聲：一直哭的小朋友有問題，但是連打針、打點滴都不哭的小朋友更有問題。
◎呼吸：小朋友的呼吸次數原本就比成人快，以下的方法可以客觀而簡單的評估一個小朋友的呼吸狀況：
●異常呼吸音：無論是吸氣時的喘鳴聲（STRIDOR）或是吐氣時的哮喘聲（WHEEZING）都代表著呼吸道阻塞。
●異常姿勢：若小朋友得一直維持嗅吸姿勢（打噴嚏時的姿勢）才能呼吸，或是呼吸時，會一直點頭，代表呼吸道有大問題。
●胸凹：觀察部位為胸骨上方（脖子中線下半部），及肋骨下方（胸部與腹部交接處），正常呼吸時，這兩處外觀是平坦的，若會費力到兩處的軟組織凹陷下去，就是一個危險的訊號。
●鼻翼搧動：也是費力呼吸的表現之一。
◎皮膚：當呼吸出現問題時，會造成缺氧，皮膚的顏色也會出現變化，若呼吸問題無法獲得改善，可能會造成病人休克而致命。皮膚的變化主要有3種：
●蒼白。
●發紺。
●大理石斑：皮膚出現紅褐色樹枝狀條紋，這是休克的臨床表現之一。
---
作者為秀傳紀念醫院小兒急診主治醫師
兩歲多的婷婷一向是家中可愛又活潑的小公主，最近因為天氣變化，時有輕微的感冒症狀，沒想到兩天後，婷婷的咳嗽聲變成像是狗在吠，晚上更是睡不安穩、呼吸急促，而且連嘴唇都變成紫色的。送來急診，經過醫師細心診治，才知道婷婷得了「哮吼病」。還好婷婷的爸媽及早送來，若不趕緊醫治，嚴重時，甚至可能會要了她的小命。
最近正值季節交替，早晚氣溫變化大，正是各種呼吸急症肆虐的時候，類似婷婷這樣的案例，幾乎每天都在急診室上演。大部分的病人可以穩定下來，在門診追蹤治療，但是少數較為嚴重的病人，必須入院觀察，甚至需要緊急插管，才能救回一條寶貴的小生命。然而，呼吸道疾病種類繁多，在此提供疾病徵兆，家長可從觀察孩子的外觀、呼吸及皮膚狀況做辨識，以便能夠及早發現，及早治療，避免悲劇發生。
◎外觀：小朋友天生就好動、愛玩，生病的小朋友若是照樣玩耍、照樣吃喝，在這種情況下，就算是發燒，疾病程度大概也不會太嚴重。
若是小朋友整天躺在床上不起來，就算沒有發燒，父母也應該警覺。
可以從下面5個方法來評估小朋友活力：
●肌張力：就算是新生嬰兒，腳也是彎曲著動來動去，四肢不動的小朋友絕對是生病了。
●互動：生病的小朋友總是特別黏人。
●安撫：年齡較小的孩童和外界溝通的唯一方式就是哭，當父母無論怎麼安撫，孩子仍一直哭，就有可能是生病了。
●眼神：所有的小朋友天生就是好奇寶寶，在安全的環境中（如父母的懷裡），眼睛總是咕嚕嚕地轉來轉去，若是雙眼無神，呆呆地望向同一個地方，是不正常的現象。
●哭聲：一直哭的小朋友有問題，但是連打針、打點滴都不哭的小朋友更有問題。
◎呼吸：小朋友的呼吸次數原本就比成人快，以下的方法可以客觀而簡單的評估一個小朋友的呼吸狀況：
●異常呼吸音：無論是吸氣時的喘鳴聲（STRIDOR）或是吐氣時的哮喘聲（WHEEZING）都代表著呼吸道阻塞。
●異常姿勢：若小朋友得一直維持嗅吸姿勢（打噴嚏時的姿勢）才能呼吸，或是呼吸時，會一直點頭，代表呼吸道有大問題。
●胸凹：觀察部位為胸骨上方（脖子中線下半部），及肋骨下方（胸部與腹部交接處），正常呼吸時，這兩處外觀是平坦的，若會費力到兩處的軟組織凹陷下去，就是一個危險的訊號。
●鼻翼搧動：也是費力呼吸的表現之一。
◎皮膚：當呼吸出現問題時，會造成缺氧，皮膚的顏色也會出現變化，若呼吸問題無法獲得改善，可能會造成病人休克而致命。皮膚的變化主要有3種：
●蒼白。
●發紺。
●大理石斑：皮膚出現紅褐色樹枝狀條紋，這是休克的臨床表現之一。
---
作者為秀傳紀念醫院小兒急診主治醫師
2008年4月11日 星期五
AHA Call to Action: Compression-Only CPR
For adults with witnessed cardiac arrest, compression-only bystander CPR might improve survival.
The American Heart Association (AHA) has issued a call to action for bystanders who witness adult cardiac arrest to provide cardiopulmonary resuscitation using chest compressions only. This advisory amends the 2005 AHA guidelines for CPR and emergency cardiovascular care.
The AHA based the change on recent evidence, which suggests that the best strategy for resuscitating adults with non–asphyxia-related cardiac arrest is to start CPR quickly and to minimize interruptions of chest compressions. In addition, the AHA recognized that multiple reasons might cause bystanders to be unwilling or unable to provide rescue breathing (e.g., fear of contagion, lack of training). Current research demonstrates that survival outcomes are not worsened, and might be improved, by de-emphasizing bystander rescue breathing. The recommendation for compression-only CPR does not apply to arrest in children, unwitnessed cardiac arrest, or suspected asphyxia-related cardiac arrest (e.g., drug overdose, drowning).
Comment: We should advise our patients about this important change in recommendations. By simplifying CPR, the change might increase bystanders’ willingness to initiate CPR, especially on an unknown victim. The change, however, does not affect current recommendations for skilled providers who can provide chest compressions and ventilations efficiently with minimal interruption. The keys to the best outcome are getting CPR performed and minimizing the frequency and duration of any interruption in chest compressions.
— Aaron E. Bair, MD, MSc, FAAEM, FACEPPublished in Journal Watch Emergency Medicine April 11, 2008
Citation(s): Sayre MR et al. Hands-only (compression-only) cardiopulmonary resuscitation: A call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest. A science advisory for the public from the American Heart Association Emergency Cardiovascular Care Committee. Circulation 2008 Mar 31; [e-pub ahead of print].
http://dx.doi.org/10.1161/CIRCULATIONAHA.107.189380
The American Heart Association (AHA) has issued a call to action for bystanders who witness adult cardiac arrest to provide cardiopulmonary resuscitation using chest compressions only. This advisory amends the 2005 AHA guidelines for CPR and emergency cardiovascular care.
The AHA based the change on recent evidence, which suggests that the best strategy for resuscitating adults with non–asphyxia-related cardiac arrest is to start CPR quickly and to minimize interruptions of chest compressions. In addition, the AHA recognized that multiple reasons might cause bystanders to be unwilling or unable to provide rescue breathing (e.g., fear of contagion, lack of training). Current research demonstrates that survival outcomes are not worsened, and might be improved, by de-emphasizing bystander rescue breathing. The recommendation for compression-only CPR does not apply to arrest in children, unwitnessed cardiac arrest, or suspected asphyxia-related cardiac arrest (e.g., drug overdose, drowning).
Comment: We should advise our patients about this important change in recommendations. By simplifying CPR, the change might increase bystanders’ willingness to initiate CPR, especially on an unknown victim. The change, however, does not affect current recommendations for skilled providers who can provide chest compressions and ventilations efficiently with minimal interruption. The keys to the best outcome are getting CPR performed and minimizing the frequency and duration of any interruption in chest compressions.
— Aaron E. Bair, MD, MSc, FAAEM, FACEPPublished in Journal Watch Emergency Medicine April 11, 2008
Citation(s): Sayre MR et al. Hands-only (compression-only) cardiopulmonary resuscitation: A call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest. A science advisory for the public from the American Heart Association Emergency Cardiovascular Care Committee. Circulation 2008 Mar 31; [e-pub ahead of print].
http://dx.doi.org/10.1161/CIRCULATIONAHA.107.189380
2008年4月9日 星期三
2008年4月3日 星期四
Fever of unknown origin (FUO)
Q:
What is the clinical definition of fever of unknown origin (FUO)?
When should you start antibiotics in a case of FUO?
Ans:
Fever of unknown origin is, by definition, a fever persisting for more than 3 weeks with no obvious clinical cause after adequate evaluation. It can be caused by infections, malignant conditions, and rheumatic or connective-tissue diseases such as temporal arteritis and polymyalgia rheumatica. Renal cancer, leukemia, and lymphomas are the most likely malignancies to cause fever. Other conditions associated with fever of unknown origin include pheochromocytoma, drug fever, and thyrotoxicosis.
Empirical antimicrobial therapy is generally discouraged, unless clinically warranted, during the diagnostic evaluation of a patient with fever of unknown origin, since antibiotics may reduce the yield of diagnostic testing and rarely result in a lasting resolution of symptoms.
Teaching topics from the New England Journal of Medicine - Vol. 358, No. 14, April 3, 2008
What is the clinical definition of fever of unknown origin (FUO)?
When should you start antibiotics in a case of FUO?
Ans:
Fever of unknown origin is, by definition, a fever persisting for more than 3 weeks with no obvious clinical cause after adequate evaluation. It can be caused by infections, malignant conditions, and rheumatic or connective-tissue diseases such as temporal arteritis and polymyalgia rheumatica. Renal cancer, leukemia, and lymphomas are the most likely malignancies to cause fever. Other conditions associated with fever of unknown origin include pheochromocytoma, drug fever, and thyrotoxicosis.
Empirical antimicrobial therapy is generally discouraged, unless clinically warranted, during the diagnostic evaluation of a patient with fever of unknown origin, since antibiotics may reduce the yield of diagnostic testing and rarely result in a lasting resolution of symptoms.
Teaching topics from the New England Journal of Medicine - Vol. 358, No. 14, April 3, 2008
2008年4月1日 星期二
Can Home AEDs Improve Survival?
Home Use of Automated External Defibrillators for Sudden Cardiac Arrest
ABSTRACT
ABSTRACT
AHA 建議路人做 CPR 只壓胸不吹氣
Bystanders Should Use Hands-Only CPR, American Heart Association Says
People who witness an adult collapse with apparent cardiac arrest should be urged to provide chest compressions without ventilations, according to a new American Heart Association advisory.
The guidelines, published online in Circulation, suggest that eliminating the expectation of mouth-to-mouth contact could improve the chances that bystanders will offer help. The AHA recommends that bystanders call 911 and then push hard and fast in the center of the victim's chest, minimizing interruptions. The effort should continue until the arrival of an automated external defibrillator or emergency medical personnel.
The AHA cited several studies suggesting that the results of compression-only response are equivalent to those of conventional CPR. The advisory's lead author told the New York Times that the ideal compression rate would be about 100 a minute, causing the chest to depress about 2 inches.
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壓200-電擊-壓200-脈搏-壓200-插管
Minimally Interrupted Cardiac Resuscitation for Out-of-Hospital Cardiac Arrest
This new approach to cardiac resuscitation significantly improved survival rates in an observational study.
Patients with out-of-hospital cardiac arrest have a dismal chance of survival. In this study, investigators sought to determine whether survival of such patients would improve with minimally interrupted cardiac resuscitation (MICR). This novel approach, aimed at maximizing cerebral perfusion, involves
- an initial series of 200 uninterrupted chest compressions;
- rhythm analysis, with a single defibrillator shock if indicated;
- 200 immediate post-shock chest compressions before pulse check or rhythm reanalysis;
- administration of epinephrine as soon as possible, repeated with each cycle of compressions and rhythm analysis;
- delay of intubation until after three cycles of chest compression and rhythm analysis.
The researchers trained emergency medical services staff in two Arizona metropolitan areas to perform MICR. They then assessed records for patients with out-of-hospital cardiac arrest before and after the training. In a separate analysis that included data from 60 additional Arizona fire departments, they also compared outcomes in patients who received MICR according to the protocol with those in patients who did not. The main outcome of interest in both analyses was survival to hospital discharge.
A total of 886 patients with cardiac arrest from January 2005 through June 2007 were included in the two-city analysis. Survival to hospital discharge increased significantly, from 1.8% before MICR training to 5.4% after training (odds ratio, 3.0). In 174 patients with witnessed arrest and ventricular fibrillation, survival rates increased from 4.7% to 17.6% (OR, 8.6). The rate of compliance with the MICR protocol was 61%. In the larger analysis, involving 2460 patients with cardiac arrest between January 1, 2005, and November 22, 2007, survival to discharge was significantly better in patients who received MICR than in those who did not (9.1% vs. 3.8%; OR, 2.7).
Comment: Minimally interrupted cardiac resuscitation was associated with improved survival to hospital discharge in patients with out-of-hospital cardiac arrest. Encouraging as these results are, the study is limited by its observational design and by the possibility of the Hawthorne effect, whereby a short-term improvement is caused by observing worker performance. These findings are quite promising but need validation before being adopted into practice.
Published in Journal Watch Cardiology March 11, 2008
Citation(s):
Bobrow BJ et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA 2008 Mar 12; 299:1158.
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