Ddx: anderson syn, Familial hypokalemic periodic paralysis, Thyrotoxic periodic paralysis, Hyper/hypo-kalemic periodic paralysis.
Clinical s/s: 20 y/M, c.c: 2 hours after pushing up, squatting and standing for 1 hour, he felt bilateral lower limb weakness. So he was brought to ER for help, where CK showed around 3000. Pt denied any associated family disease like the same symptom. And this was his first experience. He seldom exercised before. Local tenderness and pain sensation noted a few hours later. There was no tea-colored urine output and nor decreased urine amount.
Background knowledge:
1. Rhabdomyolysis造成的下肢運動weakness，通常K要低於2.0.
2. CK level >10^4, 才多會有tea-color urine. U/A: OB +, indicate myoglobinuria.
3. 在台灣常見還是一些GI drugs or lower lipid （Statin, Fibrate) drugs 所 induced。
4. 臨床上處理：大量hydration, with N/S 2L in 3-3.5L within 24hr. 以前可以回家觀察，只要有小便出來就不需太擔心。
5. 但有些Crushing造成的rhabdomyolysis處理上要小心。在移除外物送病人到救護車時，很容易就cardiac arrest. 多半是因為Crushing後死亡的細胞釋出的K在移除異物後迅速回到心臟所致。因此會有壓脈帶先綁住。或者在原地hydration, 等到有urine output再行移送。
--------------------------------------------------------------------------------------------------------
Q: 那何時需要緊急洗腎？acute hemodialysis?
當然小麻有AEIOU的建議, 於此掠過…
Let’s review Uptodate first:
Accepted indications for renal replacement therapy (RRT) in patients with AKI generally include:
* Refractory fluid overload
* Hyperkalemia (plasma potassium concentration >6.5 meq/L) or rapidly rising potassium levels
* Signs of uremia, such as pericarditis, neuropathy, or an otherwise unexplained decline in mental status
* Metabolic acidosis (pH less than 7.1)
* Certain alcohol and drug intoxications
About the choice of what kind of RRT(renal replacement therapy) and when?
* Among patients with life-threatening complications of acute kidney injury (AKI), we recommend the initiation of renal replacement therapy (RRT) (Grade 1A).
* It is unproven whether initiation of earlier or prophylactic dialysis offers any clinical or survival benefit. We suggest initiating dialysis prior to the development of symptoms and signs of renal failure due to AKI (Grade 2B). It is not possible to specify a specific duration of renal injury or level of azotemia at which RRT should be optimally initiated. General practice is to initiate RRT when the BUN reaches 80 to 100 mg/dL, although there is no consensus and practice patterns vary widely
We suggest the following strategies for dosage of RRT: (uptodate)
* We recommend that intermittent hemodialysis be provided on a three-times per week schedule (alternate days) with monitoring of the delivered dose of dialysis to ensure delivery of a Kt/V of at least 1.2 per treatment (Grade 1B).
* We recommend that CRRT be provided with a delivered effluent flow rate (sum of hemofiltration rate and dialysate flow rate) of at least 20 mL/kg per hour (Grade 1B). In order to ensure delivery of this flow rate, we prescribe an effluent flow rate of at least 25 mL/kg per hour
許V口述：
1. Acute pulmonary edema, when using 200q6h lasix once dose, no satisfied U/O, considering.
2. Hyerkalemia,K>5.5 (EKG: tent T), K>6.5 (p wave decreased and then junctional rhythm, pt may present with weakness), K>7.0-7.5 QRS widening Vf (K>8) ESRD or CRI (renal insufficiency)的pt, K常>5.5
If EKG QRS narrowing: could use conventional way to lower K+
a. Glu +RI transition.
b. Urine, stool passage ( H/D if no use.)
(Lasix, kayexalate enema 80mg in 80-100c.c water for 30min, let alone sorbitol for some case report for ischemic bowel)
If EKG QRS widening: Cal gluconate 1amp push for 30s continuiously. call Nephro for H/D if narrowing…
3. Metabolic Acidosis (MA) if reversible: like sepsis shock, no need) If PH<7.2 or HCO3-<15, considering.
4. Uremic pericarditis, seldom now.
5. Uremic encephalopathy. Dx by exclusion, mostly BUN>100, Cr>10
6. Intoxication: ethylene, lithium, TCA. If 有機磷：打解藥。If Paraquat: HP (吸附)
一相對的indication:
uremic s/s restless leg or induced coagulopathy.
s/s UGIB, but PES no function due to diffuse bleeding. (average BUN>100, Cr>10)
(類似影響VWF所以只有bleeding time prolong) 在H/D前的treatment:
1. 可用DDAVP twice, 4-6amp in N/S 50c.c. run 30min (pending check)
2. cryoprecipitate transplantation.
3. PRBC transfusion, until Hgb >10, or Hct>30~35%.
-------------------------------
so treatment of this pt:
supportive care, followed CK. however, considering pt's age, it's unusual for young men having such rhamdomyolysis caused by exercise only. Maybe some other underlying precipitating factor. Educate pt regularly taking exercise and maybe the same condition will recurrent.
Familial hypokalemic periodic paralysis, unlike pure hypokalemia by GI or Renal loss, may present with general weakness. This pt is unlikely a/c to only bilateral lower limb and no contributory family history.
2010年12月18日 星期六
2010年12月2日 星期四
2010.12.02 Decreased urine output with progressed dyspnea for half month
75 y/M, type 2 DM for 25 years, with DM nephropathy. Poor control: HbA1C: 11.03
HTN for many years, DHP CCB, ACEI, ARB use.
ATN with superimposed acute pulmonary effusion s/p lasix treatment and discharge 1 month ago.
COPD with corpulmonale, with right ventricle systolic dysfunction and moderate TR, LVEF: 60%, no cold limbs. NYHA: I-II
BW gain about 10 kg from 59kg to 67kg within 1 month. Daily water intake: 600c.c
Cr: 1.4-->1.5-->1.7-->2.2-->2.6-->2.8-->2.62(after admission), BUN: from 50 to around 60 in the last two test
acute renal failure, complicated with acute pulmonary effusion, present with major fissure fluid accumulation, cause?
there was no fever, no other medications, no other infection source, no JVE, no murmur. Alb:(2.7), K:3.1 Na: 137
bilateral pitting edema over lower limbs.
How to approach and thinking process?
-------------------------------------------------------
Acute renal failure:
以前就知道臨床上會分Pre-renal, renal, post-renal
pre-renal 又可分為hypovolemia or relative hypoperfusion of kidney
前者補補水，後者就要從病人的underlying：CHF, cirrhosis→hepatorenal, Renal stenosis…依據根本原因做治療
drugs: 除了relative hypoperfusion of kidney造成的ischemia影響以外，drugs of NSAID以及ACEI, ARB往往也有可能impair renal perfusion, 或加劇其惡化情形。（因為PGE1會對入球小動脈有擴張作用、而Angiotensin則對出球小動脈有收縮作用。NSAID限制入球小動脈的擴張而ACEI, ARB讓出球小動脈擴張，影響到glomerular capillary perfusion）
postrenal可以從PE, bladder脹不脹先行判斷。Sono是必備的好診斷工具。
複雜的是renal的部份：
依許V的經驗，區分pre-renal以及renal比較準的parameter是FENa, 不過其實臨床上也有很多檢驗值跟實際病情兜不起來的case，故臨床上其實從history大致上就可先行推斷。
一般可以有四個思考方向: vascular, glomeruli, tubular, and interstitial.
Vascular: obstruction(artery or vain), vasculitis.
Tubular: ATN (necrosis), toxin(分為內生性：rhabdomyolysis, hemolysis及外生性： radiocontrast, calcineurin inhibitors, antibiotics (e.g., aminoglycosides), chemotherapy (e.g., cisplatin), antifungals (e.g., amphotericin B), ethylene glycol), infection, or ischemia (pre-renal的惡化版)
Intersitial: AIN (nephritis), 可區分為allergy(antibiotics [beta-lactams, sulfonamides, quinolones, rifampin], nonsteroidal anti-inflammatory drugs, diuretics, other drugs) or infection. (pyelonephritis)
Glomeruli: 十分複雜，可參考harrison chap.277, clinical s/s: hematuria, proteinuria, BP high or normal, general edema.
臨床分類（依時間進程） 對應病理切片renal bx
Acute 2-3days to 1 week Diffuse Glomerular nephritis
RPGN 2wks to 2months Cresent GN
Slowly progression Months to years Focal (segmental ) proliferation <50%
Micorscopic hematuria Mesangial expansion.
懷疑GN可驗ANCA, Anti-GBM, C3，各有各自的ddx→請翻書。
一般C-ANCA: Wegner’s disease, with pathology: pauci-immune study
Anti-GBM: associated with lung: goodpasture’s disease. with pathlogy: linear immunradio study.
C3 decreased: endocarditis, PSGN…, with pathology granular deposit.
Mimic type: HUS, TTP.
BUN and Creatinine
常見BUN increase的原因（會受蛋白質營養、水份影響）：
protein代謝增加：Tigecycline, NSAID. Absorbtion增加：UGIB. 濃度：dehydration.
Creatinine 增加：(多從glomerular濾出貨從tubular secretion)
Baktar, Cimetidine均會 inhibition tubular secretion。
有哪些情況Creatinine會減少：liver function decreased: cirrhosis, muscle wasting, pregnant.
1. We use Lasix po initially, but change to 100mg Q8h in the afternoon due to no much U/O.
2. Consult CV for help evaluation due to the sign of right heart failure: subtle JVE, Ascites, bilteral lower limb pitting edema.
3. arragned Chest once diagnosed tapping.
1. U/O: 470 cc. BP: 107/60 mmHg. Still dyspnea, change O2 from N/C to Ventri 50% a/c to SpO2 drpped to 89% in night.
2. Cardiologist add dobutamine, run 5ug/kg/min and arragned Thailium scan see if necessary to do Cath. --> treat as right heart failure. And followed Bun/Cr being prone to pre-renal ARF.
3. Consult CM, for immediate pig-tail insertion for s/s relieved and monitor the amount of pleural effusion. (may caused by lymph drainage due to pre-load overload in Right HF) yellowish 1000cc. transudate.
4. keep observation...
HTN for many years, DHP CCB, ACEI, ARB use.
ATN with superimposed acute pulmonary effusion s/p lasix treatment and discharge 1 month ago.
COPD with corpulmonale, with right ventricle systolic dysfunction and moderate TR, LVEF: 60%, no cold limbs. NYHA: I-II
BW gain about 10 kg from 59kg to 67kg within 1 month. Daily water intake: 600c.c
Cr: 1.4-->1.5-->1.7-->2.2-->2.6-->2.8-->2.62(after admission), BUN: from 50 to around 60 in the last two test
acute renal failure, complicated with acute pulmonary effusion, present with major fissure fluid accumulation, cause?
there was no fever, no other medications, no other infection source, no JVE, no murmur. Alb:(2.7), K:3.1 Na: 137
bilateral pitting edema over lower limbs.
How to approach and thinking process?
-------------------------------------------------------
Acute renal failure:
以前就知道臨床上會分Pre-renal, renal, post-renal
pre-renal 又可分為hypovolemia or relative hypoperfusion of kidney
前者補補水，後者就要從病人的underlying：CHF, cirrhosis→hepatorenal, Renal stenosis…依據根本原因做治療
drugs: 除了relative hypoperfusion of kidney造成的ischemia影響以外，drugs of NSAID以及ACEI, ARB往往也有可能impair renal perfusion, 或加劇其惡化情形。（因為PGE1會對入球小動脈有擴張作用、而Angiotensin則對出球小動脈有收縮作用。NSAID限制入球小動脈的擴張而ACEI, ARB讓出球小動脈擴張，影響到glomerular capillary perfusion）
postrenal可以從PE, bladder脹不脹先行判斷。Sono是必備的好診斷工具。
複雜的是renal的部份：
依許V的經驗，區分pre-renal以及renal比較準的parameter是FENa, 不過其實臨床上也有很多檢驗值跟實際病情兜不起來的case，故臨床上其實從history大致上就可先行推斷。
一般可以有四個思考方向: vascular, glomeruli, tubular, and interstitial.
Vascular: obstruction(artery or vain), vasculitis.
Tubular: ATN (necrosis), toxin(分為內生性：rhabdomyolysis, hemolysis及外生性： radiocontrast, calcineurin inhibitors, antibiotics (e.g., aminoglycosides), chemotherapy (e.g., cisplatin), antifungals (e.g., amphotericin B), ethylene glycol), infection, or ischemia (pre-renal的惡化版)
Intersitial: AIN (nephritis), 可區分為allergy(antibiotics [beta-lactams, sulfonamides, quinolones, rifampin], nonsteroidal anti-inflammatory drugs, diuretics, other drugs) or infection. (pyelonephritis)
Glomeruli: 十分複雜，可參考harrison chap.277, clinical s/s: hematuria, proteinuria, BP high or normal, general edema.
臨床分類（依時間進程） 對應病理切片renal bx
Acute 2-3days to 1 week Diffuse Glomerular nephritis
RPGN 2wks to 2months Cresent GN
Slowly progression Months to years Focal (segmental ) proliferation <50%
Micorscopic hematuria Mesangial expansion.
懷疑GN可驗ANCA, Anti-GBM, C3，各有各自的ddx→請翻書。
一般C-ANCA: Wegner’s disease, with pathology: pauci-immune study
Anti-GBM: associated with lung: goodpasture’s disease. with pathlogy: linear immunradio study.
C3 decreased: endocarditis, PSGN…, with pathology granular deposit.
Mimic type: HUS, TTP.
BUN and Creatinine
常見BUN increase的原因（會受蛋白質營養、水份影響）：
protein代謝增加：Tigecycline, NSAID. Absorbtion增加：UGIB. 濃度：dehydration.
Creatinine 增加：(多從glomerular濾出貨從tubular secretion)
Baktar, Cimetidine均會 inhibition tubular secretion。
有哪些情況Creatinine會減少：liver function decreased: cirrhosis, muscle wasting, pregnant.
----------so the intervention for this patient--------
1. We use Lasix po initially, but change to 100mg Q8h in the afternoon due to no much U/O.
2. Consult CV for help evaluation due to the sign of right heart failure: subtle JVE, Ascites, bilteral lower limb pitting edema.
3. arragned Chest once diagnosed tapping.
----------and the other day-----------------------------
1. U/O: 470 cc. BP: 107/60 mmHg. Still dyspnea, change O2 from N/C to Ventri 50% a/c to SpO2 drpped to 89% in night.
2. Cardiologist add dobutamine, run 5ug/kg/min and arragned Thailium scan see if necessary to do Cath. --> treat as right heart failure. And followed Bun/Cr being prone to pre-renal ARF.
3. Consult CM, for immediate pig-tail insertion for s/s relieved and monitor the amount of pleural effusion. (may caused by lymph drainage due to pre-load overload in Right HF) yellowish 1000cc. transudate.
4. keep observation...
2010年11月25日 星期四
2010.11.23 Thermal Injury, Burn
31y/M, burn after pouring gasoline and lightening the fire for old wood at 1-2:00 this morning.
Height: 168cm, Body Weight: 85.3kg.
Vital sign: relatively stable.
TBSA(total burn surface area): 20%, 2nd degree superficial to deep.
Q: How to approach?
1. Diagnosis (怎麼燒傷？電傷跟化學灼傷、火焰燒傷的處理有所差異)
a. Causes Zones,
b. depth & estimation of burned area(BA) (二度以上會有scar，往往要補皮) ,
BA: rule of nine, or pt’s palm=1%.
c. Burn center referral criteria
2. Resuscitation (body fluid怎麼給？Parkland or Modified Brooke formula)
a. Burn shock
b. Initial fluid resuscitation & maintainance fluids
3. Treatment strategies (Abx, pain control, and?)
a. Surgical Treatment
b. Burn wound treatment
[U.S Burn Depth Categories]
所以這個pt 是從左臉左上軀幹以及左上臂前臂估計達20%的淺、深二度燒傷。一開始建立兩條IV-line, Fluid resuscitation, pain control(Depain, Morphine), covered Abx(Cephazolin). 清洗傷口後用betadine消毒、wetdressing即轉入燒傷加護中心monitor. 另外這個病人因為有面部燒傷，鼻毛呈黑色，有無inhale injury? 有無on endo的必要？
Reference: (Rosen’s Emergency Medicine, 6th/e)
Fires usually emit smoke, which victims may inhale, especially in closed spaces. Smoke inhalation can cause both pulmonary parenchymal damage and CO and other toxic poisoning, which may have lifethreatening consequences. The prehospital care provider should look for signs of inhalation injury (e.g., dyspnea, burns of mouth and nose, singed nasal hairs, sooty sputum, brassy cough). If one or more of these signs are present, humidified oxygen should be administered with a nonrebreathing reservoir mask at a rate of 10 to 12 L/min. The patient who has airway involvement should be intubated early in the course because edema can develop and make intubation increasingly difficult.
經判斷後，病人的SpO2 100%, N/C: 2L/min，加上只有臉部灼傷、鼻毛燒焦，沒有明顯stridor，非密閉空間。所以先密切觀察，沒有on endo.
Q：What’s Parkland or Modified Brooke Formula
Parkland: 4c.c./ %TBSA/ kg ,
Modified Brooke: 2c.c/ %TBSA/ kg (Lactate Ringer)
= amount should be infused in 1st 24hr.
Half amount calculated above in 1st 8hr, and then the other half in continuous 16hrs. (And then f/u U/O 0.5-1c.c/kg for decided the amount of L.R)
所以這個病人85.3kg * 二度以上範圍 20% * 4 c.c = 6824 c.c.
Q：為什麼要L.R？而盡量不要N/S？
減少高氯酸血症的發生機率。（不過按Rosen所說，如果沒有L.R也可以用N/S)
Q：為什麼後續要依照U/O 來決定infusion的量？
學長說波灣戰爭之後發現overhydration有可能造成Abdominal Compartment Syndrome. (一來因為Burn injury之後血管的permeability 增加) 一旦發生mortality近100%。 也因此有Modified Brooke for 大範圍燒傷。
Reference:
Q: 學長teaching的其他Fluid Maintain公式。（目前還沒找到出處）
Total daily maintenance fluid requirements=
Basal (1500 cc/m2) + evaporative water loss [(25+%burn) × m2 × 24]
IV route or enteral feeding
IV fluid: 50% N/S + K+ (120 mEq/day) Children needs more fluid than adults
UOP is unreliable after 48 hr of resuscitation:
Adult: 1500-2000 cc/d child: 3-4 cc/Kg/hr
Q: 後續Care…
這個pt隔天跟家屬談到自費的含銀敷料Acticoat後進去op room debride加貼敷料。（目前使用後幾乎沒有wound infection)據學長說是因為滲透壓的關係，在貼的那瞬間病人也會有痛楚感。標準一片可用3天，不過其實可以持續到1 week。外層用pad吸附discharge即可。一個禮拜後再進op debride即更換。兩三個禮拜後tissue生長到一個程度，necrosis的地方就用skin graft去補。（其他以前共筆均有，不贅述）
唯因病人有nightmare，consult psych後加上stilnox CR 6.25 1# HS, setine 20mg 1# QN, mood stable, kept OBS.
Q: 常用的topical agent
Antibacterial ointment (neomycin, bacitracin)
這個病人眼睛我們用erythromycin, 其他部位用neomycin。Erythromycin軟膏對眼睛的結膜刺激較小。
Silver salfadiazide （ex: Acticoat）
Clean 2nd-3rd degree burn wound
S. aureus, E. coli, Klebsiella, P. aeruginosa, Proteus, Candida
Pseudoeschar formation
Transient leukopenia (無其他infection sign不需擔心，2-3wks會恢復)
歡迎討論及補充
Height: 168cm, Body Weight: 85.3kg.
Vital sign: relatively stable.
TBSA(total burn surface area): 20%, 2nd degree superficial to deep.
Q: How to approach?
1. Diagnosis (怎麼燒傷？電傷跟化學灼傷、火焰燒傷的處理有所差異)
a. Causes Zones,
b. depth & estimation of burned area(BA) (二度以上會有scar，往往要補皮) ,
BA: rule of nine, or pt’s palm=1%.
c. Burn center referral criteria
2. Resuscitation (body fluid怎麼給？Parkland or Modified Brooke formula)
a. Burn shock
b. Initial fluid resuscitation & maintainance fluids
3. Treatment strategies (Abx, pain control, and?)
a. Surgical Treatment
b. Burn wound treatment
[U.S Burn Depth Categories]
所以這個pt 是從左臉左上軀幹以及左上臂前臂估計達20%的淺、深二度燒傷。一開始建立兩條IV-line, Fluid resuscitation, pain control(Depain, Morphine), covered Abx(Cephazolin). 清洗傷口後用betadine消毒、wetdressing即轉入燒傷加護中心monitor. 另外這個病人因為有面部燒傷，鼻毛呈黑色，有無inhale injury? 有無on endo的必要？
Reference: (Rosen’s Emergency Medicine, 6th/e)
Fires usually emit smoke, which victims may inhale, especially in closed spaces. Smoke inhalation can cause both pulmonary parenchymal damage and CO and other toxic poisoning, which may have lifethreatening consequences. The prehospital care provider should look for signs of inhalation injury (e.g., dyspnea, burns of mouth and nose, singed nasal hairs, sooty sputum, brassy cough). If one or more of these signs are present, humidified oxygen should be administered with a nonrebreathing reservoir mask at a rate of 10 to 12 L/min. The patient who has airway involvement should be intubated early in the course because edema can develop and make intubation increasingly difficult.
經判斷後，病人的SpO2 100%, N/C: 2L/min，加上只有臉部灼傷、鼻毛燒焦，沒有明顯stridor，非密閉空間。所以先密切觀察，沒有on endo.
Q：What’s Parkland or Modified Brooke Formula
Parkland: 4c.c./ %TBSA/ kg ,
Modified Brooke: 2c.c/ %TBSA/ kg (Lactate Ringer)
= amount should be infused in 1st 24hr.
Half amount calculated above in 1st 8hr, and then the other half in continuous 16hrs. (And then f/u U/O 0.5-1c.c/kg for decided the amount of L.R)
所以這個病人85.3kg * 二度以上範圍 20% * 4 c.c = 6824 c.c.
Q：為什麼要L.R？而盡量不要N/S？
減少高氯酸血症的發生機率。（不過按Rosen所說，如果沒有L.R也可以用N/S)
Q：為什麼後續要依照U/O 來決定infusion的量？
學長說波灣戰爭之後發現overhydration有可能造成Abdominal Compartment Syndrome. (一來因為Burn injury之後血管的permeability 增加) 一旦發生mortality近100%。 也因此有Modified Brooke for 大範圍燒傷。
Reference:
Q: 學長teaching的其他Fluid Maintain公式。（目前還沒找到出處）
Total daily maintenance fluid requirements=
Basal (1500 cc/m2) + evaporative water loss [(25+%burn) × m2 × 24]
IV route or enteral feeding
IV fluid: 50% N/S + K+ (120 mEq/day) Children needs more fluid than adults
UOP is unreliable after 48 hr of resuscitation:
Adult: 1500-2000 cc/d child: 3-4 cc/Kg/hr
Q: 後續Care…
這個pt隔天跟家屬談到自費的含銀敷料Acticoat後進去op room debride加貼敷料。（目前使用後幾乎沒有wound infection)據學長說是因為滲透壓的關係，在貼的那瞬間病人也會有痛楚感。標準一片可用3天，不過其實可以持續到1 week。外層用pad吸附discharge即可。一個禮拜後再進op debride即更換。兩三個禮拜後tissue生長到一個程度，necrosis的地方就用skin graft去補。（其他以前共筆均有，不贅述）
唯因病人有nightmare，consult psych後加上stilnox CR 6.25 1# HS, setine 20mg 1# QN, mood stable, kept OBS.
Q: 常用的topical agent
Antibacterial ointment (neomycin, bacitracin)
這個病人眼睛我們用erythromycin, 其他部位用neomycin。Erythromycin軟膏對眼睛的結膜刺激較小。
Silver salfadiazide （ex: Acticoat）
Clean 2nd-3rd degree burn wound
S. aureus, E. coli, Klebsiella, P. aeruginosa, Proteus, Candida
Pseudoeschar formation
Transient leukopenia (無其他infection sign不需擔心，2-3wks會恢復)
歡迎討論及補充
2010年11月18日 星期四
2010.11.11 Acute Abdomen, analysis by sonography
1. Acute Abdomen常見的原因：
a. Vessel dissection, tumor rupture
b. Ischemic bowel
c. Obstruction
d. Perforation
因此適合分析肚痛的工具從 KUB, sono, CT均需視History以及其他臨床症狀而定。
2. Q：Acute cholecystitis中，影像學發現哪個不是診斷的criteria?
a. Wall tickening
b. Fluid accumulation next to GB.
c. Gall bladder stone inside.
d. Length>8cm
e. Wideth>4cm
A: d. 因有個人差異。Acute cholecystitis中95%有發現GB stone.
3. What’s Courvoisier's law?
References: http://www.springerlink.com/content/g78076558l257j41/
Courvoisier described 187 cases of common bile duct obstruction, observing that gallbladder dilatation seldom occurred with stone obstruction of the bile duct. The classic explanation for Courvoisier’s finding is based on the process that presence of gallstones come repeated episodes of infection and subsequent fibrosis of the gallbladder.
a. In the event that a gallstone causes the obstruction, the gallbladder is shrunken owing to fibrosis and is unlikely to be distensible and, hence, palpable.
b. With other causes of obstruction, the gallbladder distends as a result of the back-pressure from obstructed bile flow. However, recent experiments show that gallbladders are equally distensible in vitro, irrespective of the pathology, suggesting that chronicity of the obstruction is the key. Chronically elevated intraductal pressures are more likely to develop with malignant obstruction owing to the progressive nature of the disease. Gallstones cause obstruction in an intermittent fashion, which is generally not consistent enough to produce such a chronic rise in pressure.
目前臨床的應用是如果在一黃疸的病人有painless GB or CBD, 則懷疑可能有ampulla maliganancy. （of pancreas)
4. Acute, chronic cholecystitis 的sonography.
a. Clinical s/s: Harrison, Sabiston 有相關reference可參考。舉凡疼痛的時間pattern, acute通常都會持續一天以上。Chronic則多半發作多於1hr但少超過24hr。
i. sono上因為chronic造成的纖維化，所以不會有dilate GB, 而可見wall thickening and fibrosis.
ii. Acute 則可能見到BTI obstruction的too many tubes sign. (與 hereditary hepatic telangiectasia 可用doppler 區分)
b. Rx: 治療方式也不相同。而在chronic cholecystits, Abx以及 PTGBD多半是不需要的。（後者因為fibrosis, 難以approach)
From uptodate: A meta-analysis of 12 controlled trials concluded that early cholecystectomy (ranging from immediate cholecystectomy to cholecystectomy within seven days of symptoms) was the preferred approach.
Although there is consensus that incidentally discovered asymptomatic gallstones should not be treated, once a patient develops symptoms or complications related to gallstones (such as acute cholecystitis), treatment to eliminate the gallstones should be recommended, because the likelihood of subsequent symptoms or complications is high. The National Cooperative Gallstone Study demonstrated that the risk of recurrent symptoms was approximately 70 percent during the two years following initial presentation
5. Pneumobilia 以及portal venous gas的區分。（這大家應該已經很熟了，簡單複習一下）
因為分布的不同，Biliary tract多半從周圍往中央集中，而portal vein則是侷限在中央，可作為一判斷線索。另外如果sonography中有高反差的gas存在時，可參考移動速度，在portal vein的air移動較快。à聯想：r/o ischemic bowel
6. Chilaiditi syndrome
多半是因為T-colon的一些variant造成看起來類似pneumoperitoneum的sign.
7. 在sonography下，if hydronephrosis noted, 懷疑stone obstruction，在U/3 or L/3較易trace到。（看到pelvic dilate不一定是hydronephosis，有可能是renal vessel or cyst, 可從有無跟pelvis相連以及doppler協助ddx)
8. Renal pelvis 內髒髒的，ddx: pyelonephritis, tumor。
9. 如果在renal hilum處看到slight increased echoic lesion, ddx: UCC, blood clot, RCC with pelvis invasion, sinus lipomatosis(rare cause hydronephrosis). If stone, it will be hyperechoic.
10. Pseudokidney: ddx:
a. bowel tumor, colon CA or GIST.
b. Duplicated kidney
c. Intussusception.
a. Vessel dissection, tumor rupture
b. Ischemic bowel
c. Obstruction
d. Perforation
因此適合分析肚痛的工具從 KUB, sono, CT均需視History以及其他臨床症狀而定。
2. Q：Acute cholecystitis中，影像學發現哪個不是診斷的criteria?
a. Wall tickening
b. Fluid accumulation next to GB.
c. Gall bladder stone inside.
d. Length>8cm
e. Wideth>4cm
A: d. 因有個人差異。Acute cholecystitis中95%有發現GB stone.
3. What’s Courvoisier's law?
References: http://www.springerlink.com/content/g78076558l257j41/
Courvoisier described 187 cases of common bile duct obstruction, observing that gallbladder dilatation seldom occurred with stone obstruction of the bile duct. The classic explanation for Courvoisier’s finding is based on the process that presence of gallstones come repeated episodes of infection and subsequent fibrosis of the gallbladder.
a. In the event that a gallstone causes the obstruction, the gallbladder is shrunken owing to fibrosis and is unlikely to be distensible and, hence, palpable.
b. With other causes of obstruction, the gallbladder distends as a result of the back-pressure from obstructed bile flow. However, recent experiments show that gallbladders are equally distensible in vitro, irrespective of the pathology, suggesting that chronicity of the obstruction is the key. Chronically elevated intraductal pressures are more likely to develop with malignant obstruction owing to the progressive nature of the disease. Gallstones cause obstruction in an intermittent fashion, which is generally not consistent enough to produce such a chronic rise in pressure.
目前臨床的應用是如果在一黃疸的病人有painless GB or CBD, 則懷疑可能有ampulla maliganancy. （of pancreas)
4. Acute, chronic cholecystitis 的sonography.
a. Clinical s/s: Harrison, Sabiston 有相關reference可參考。舉凡疼痛的時間pattern, acute通常都會持續一天以上。Chronic則多半發作多於1hr但少超過24hr。
i. sono上因為chronic造成的纖維化，所以不會有dilate GB, 而可見wall thickening and fibrosis.
ii. Acute 則可能見到BTI obstruction的too many tubes sign. (與 hereditary hepatic telangiectasia 可用doppler 區分)
b. Rx: 治療方式也不相同。而在chronic cholecystits, Abx以及 PTGBD多半是不需要的。（後者因為fibrosis, 難以approach)
From uptodate: A meta-analysis of 12 controlled trials concluded that early cholecystectomy (ranging from immediate cholecystectomy to cholecystectomy within seven days of symptoms) was the preferred approach.
Although there is consensus that incidentally discovered asymptomatic gallstones should not be treated, once a patient develops symptoms or complications related to gallstones (such as acute cholecystitis), treatment to eliminate the gallstones should be recommended, because the likelihood of subsequent symptoms or complications is high. The National Cooperative Gallstone Study demonstrated that the risk of recurrent symptoms was approximately 70 percent during the two years following initial presentation
5. Pneumobilia 以及portal venous gas的區分。（這大家應該已經很熟了，簡單複習一下）
因為分布的不同，Biliary tract多半從周圍往中央集中，而portal vein則是侷限在中央，可作為一判斷線索。另外如果sonography中有高反差的gas存在時，可參考移動速度，在portal vein的air移動較快。à聯想：r/o ischemic bowel
6. Chilaiditi syndrome
多半是因為T-colon的一些variant造成看起來類似pneumoperitoneum的sign.
上圖from radiographics, 下圖from wikipedia.
7. 在sonography下，if hydronephrosis noted, 懷疑stone obstruction，在U/3 or L/3較易trace到。（看到pelvic dilate不一定是hydronephosis，有可能是renal vessel or cyst, 可從有無跟pelvis相連以及doppler協助ddx)
8. Renal pelvis 內髒髒的，ddx: pyelonephritis, tumor。
9. 如果在renal hilum處看到slight increased echoic lesion, ddx: UCC, blood clot, RCC with pelvis invasion, sinus lipomatosis(rare cause hydronephrosis). If stone, it will be hyperechoic.
10. Pseudokidney: ddx:
a. bowel tumor, colon CA or GIST.
b. Duplicated kidney
c. Intussusception.
2010年11月12日 星期五
progressive paralysis
簡單地報一個case，data很多忘記懶得查，敬請見諒6359406
86歲的龔先生是個老菸槍，有高血壓，慢性咳嗽的問題，這兩年來常服用Brown mixture與國安感冒糖漿。他這兩年逐漸有下肢無力的現象，跌倒過數次，最近發現上肢有時也會無力，另外他也提到最近容易口渴，喝比較多水。入院兩天前甚至脖子發軟，無法抬頭，且有頭暈現象，因此被送入急診。
EKG: sinus rhythm, QT prolong, CK:40000, K:2, normal range of CBC/DC, liver, renal function,
ABG: metabolic alkalosis, TTKG>10
normal cortisol, thyroid function, normal renin, aldosterone level
鉀離子補回正常值後，一切症狀消失，出院
Dx: Hypokalemia c/w rhabdomyolysis, favor licorice related
Discussion:
B.M.和感冒糖漿中的止咳成分：Licorice含有甘草酸Glycyrrhizin，會作用在11-beta hydroxysteroid dehydrogenase ，此酵素能把active cortisol 轉換為inactive cortisone，然而過量服用licorice 的患者，會有pseudohyper-minerocorticoid 的狀況，cortisol相對較多，繼續合成為Glucocorticoid, minerocorticoid，而有留鈉排鉀的效果。
病人常見progressive paralysis，從下肢慢慢延伸，又，低血鉀可能造成橫紋肌溶解症。
In addition, rhabdomyolysis can develop as a result of potassium depletion. Potassium release from muscle cells during exertion normally mediates blood flow to muscles during exercise. Decreased potassium release causes less blood flow to the muscles. This decreased blood flow can lead to rhabdomyolysis and the associated cascade of metabolic problems.
要小心的有
1. Potassium levels below 3.0 mEq/L (3.0 mmol/L) are associated with a 2-fold increase in ventricular dysrhythmia.
2. Patients with hypokalemia almost always have coincident hypomagnesemia and should be treated empirically with magnesium repletion. Until the magnesium deficit is corrected, potassium will not return to normal levels despite the administration of appropriate potassium.
86歲的龔先生是個老菸槍，有高血壓，慢性咳嗽的問題，這兩年來常服用Brown mixture與國安感冒糖漿。他這兩年逐漸有下肢無力的現象，跌倒過數次，最近發現上肢有時也會無力，另外他也提到最近容易口渴，喝比較多水。入院兩天前甚至脖子發軟，無法抬頭，且有頭暈現象，因此被送入急診。
EKG: sinus rhythm, QT prolong, CK:40000, K:2, normal range of CBC/DC, liver, renal function,
ABG: metabolic alkalosis, TTKG>10
normal cortisol, thyroid function, normal renin, aldosterone level
鉀離子補回正常值後，一切症狀消失，出院
Dx: Hypokalemia c/w rhabdomyolysis, favor licorice related
Discussion:
B.M.和感冒糖漿中的止咳成分：Licorice含有甘草酸Glycyrrhizin，會作用在11-beta hydroxysteroid dehydrogenase ，此酵素能把active cortisol 轉換為inactive cortisone，然而過量服用licorice 的患者，會有pseudohyper-minerocorticoid 的狀況，cortisol相對較多，繼續合成為Glucocorticoid, minerocorticoid，而有留鈉排鉀的效果。
病人常見progressive paralysis，從下肢慢慢延伸，又，低血鉀可能造成橫紋肌溶解症。
In addition, rhabdomyolysis can develop as a result of potassium depletion. Potassium release from muscle cells during exertion normally mediates blood flow to muscles during exercise. Decreased potassium release causes less blood flow to the muscles. This decreased blood flow can lead to rhabdomyolysis and the associated cascade of metabolic problems.
要小心的有
1. Potassium levels below 3.0 mEq/L (3.0 mmol/L) are associated with a 2-fold increase in ventricular dysrhythmia.
2. Patients with hypokalemia almost always have coincident hypomagnesemia and should be treated empirically with magnesium repletion. Until the magnesium deficit is corrected, potassium will not return to normal levels despite the administration of appropriate potassium.
2010年11月4日 星期四
2010.11.04 Critical Care/ ER Chest X Ray Discussion
1. How to ddx AP view or PA view?
Ans:
• Scapular Spine
• C spine morphology: if PA, due to mild neck extension, 看起來可能像一個倒v尖端向上的飛鏢狀。If AP, vertebral body 則多成長方形。
2. Status post Endo, followed CxR, if one lung white out, do check the position of endotracheal tube first.
3. How to ddx the white out lung caused by extrapleural lesion, like hemimediastinum, or intrapulmonary lesion, like collapse, pneumonia? ( not too difficult, basic question)
4. On ETT, then fever, bollowed CxR, which initially present one lung white out then bilateral. → aspiration pneumonia.
(There is no guarantee of exclusion of aspiration pneumonia after ETT, esp when pt also on NG tube. )
5. Double (bronchial) wall sign, one sign for penumomediastinum （下圖左側支氣管）. The most important thing to ddx pneumothorax: notice whether there is lung marking at the least dependent part of lung field. (ex: when standing or sitting, apex. When supine, sulcus.)
http://radiographics.rsna.org/content/20/4/1043.full?sid=a4123d96-94e1-4577-98a2-4ff395739a47 (cited from)
6. One Case. K.P liver abscess with septic emboli, on ETT.
Sudden onset desaturation: thick of barotrauma, lower PEEP.
7. Naclerio's V Sign. Pneumomediastinum.
Reference: doi: 10.1148/radiol.2451042197 October 2007 Radiology, 245, 296-297
8. Vascular Pedicle Width. 有興趣的朋友可以自行google。主要協助判斷intravascular fluid status.
Other reference: http://ccforum.com/content/11/S2/P291
9. Pneumothorax, s/p Chest tube insertion. Recurrent SOB. Ddx: re-expansion pulmonary edema should be ruled out.
Reference:
N Engl J Med 2006; 354:2046 May 11, 2006
Ann Thorac Surg 2005;80:1933-1934
10. Neurogenic pulmonary edema. Pt with Brain Trauma history, but no rib fracture.
Reference:
Emedicine.
Ans:
• Scapular Spine
• C spine morphology: if PA, due to mild neck extension, 看起來可能像一個倒v尖端向上的飛鏢狀。If AP, vertebral body 則多成長方形。
2. Status post Endo, followed CxR, if one lung white out, do check the position of endotracheal tube first.
3. How to ddx the white out lung caused by extrapleural lesion, like hemimediastinum, or intrapulmonary lesion, like collapse, pneumonia? ( not too difficult, basic question)
4. On ETT, then fever, bollowed CxR, which initially present one lung white out then bilateral. → aspiration pneumonia.
(There is no guarantee of exclusion of aspiration pneumonia after ETT, esp when pt also on NG tube. )
5. Double (bronchial) wall sign, one sign for penumomediastinum （下圖左側支氣管）. The most important thing to ddx pneumothorax: notice whether there is lung marking at the least dependent part of lung field. (ex: when standing or sitting, apex. When supine, sulcus.)
6. One Case. K.P liver abscess with septic emboli, on ETT.
Sudden onset desaturation: thick of barotrauma, lower PEEP.
7. Naclerio's V Sign. Pneumomediastinum.
Reference: doi: 10.1148/radiol.2451042197 October 2007 Radiology, 245, 296-297
8. Vascular Pedicle Width. 有興趣的朋友可以自行google。主要協助判斷intravascular fluid status.
Other reference: http://ccforum.com/content/11/S2/P291
9. Pneumothorax, s/p Chest tube insertion. Recurrent SOB. Ddx: re-expansion pulmonary edema should be ruled out.
Reference:
N Engl J Med 2006; 354:2046 May 11, 2006
Ann Thorac Surg 2005;80:1933-1934
10. Neurogenic pulmonary edema. Pt with Brain Trauma history, but no rib fracture.
Reference:
Emedicine.
2010年10月20日 星期三
ER Case Discussion
2010.10.20 ER note
Case1.
S:
48 y/M, slim and tall, 保全人員, complain of acute onset chest tightness and pain, with cold sweating 30 mins ago when he was making a phone call. He could not discribed the characteristic of pain specifically, only with some ‘tightness’ instead of ‘compressed’ adjuctives. There was no ratiation pain, and no other nausea/vomiting sensation.
O:
Heart: no murmur, RHB, Chest: clear breathing sound.
Vital sign: relative normal stable. (no BP down, no increased HR 80bpm)
EKG: revealed bigeminal VPC.
Past History: arrhythmia, unknown
Impressive of ACS first, MONA was prescribe, however, after 15 mins, symptom persist…then the next?
WE TRANSFER PT TO 急救間. On monitor…
郭V接著問我們應該做什麼？
Recheck: vital sign 仍然stable…
個人認為重新PE, recheck chest, heart sound. Four limbs BP. 重follow EKG
接著當然建議cardiac sono. （if heart sound with murmur finding…）
主要是想跟aorta dissection 做區別。
後來sono就發現其實已經有aortic root dilatation, with moderate AR. Confirmed classic type A aortic dissection, 後續治療…（當然就是aortic dissection才要進一步討論的）
Take Home Message
Case1.
S:
48 y/M, slim and tall, 保全人員, complain of acute onset chest tightness and pain, with cold sweating 30 mins ago when he was making a phone call. He could not discribed the characteristic of pain specifically, only with some ‘tightness’ instead of ‘compressed’ adjuctives. There was no ratiation pain, and no other nausea/vomiting sensation.
O:
Heart: no murmur, RHB, Chest: clear breathing sound.
Vital sign: relative normal stable. (no BP down, no increased HR 80bpm)
EKG: revealed bigeminal VPC.
Past History: arrhythmia, unknown
Impressive of ACS first, MONA was prescribe, however, after 15 mins, symptom persist…then the next?
WE TRANSFER PT TO 急救間. On monitor…
郭V接著問我們應該做什麼？
Recheck: vital sign 仍然stable…
個人認為重新PE, recheck chest, heart sound. Four limbs BP. 重follow EKG
接著當然建議cardiac sono. （if heart sound with murmur finding…）
主要是想跟aorta dissection 做區別。
後來sono就發現其實已經有aortic root dilatation, with moderate AR. Confirmed classic type A aortic dissection, 後續治療…（當然就是aortic dissection才要進一步討論的）
Take Home Message
- 當用MONA治療後，病人症狀沒有緩解，EKG也沒有進一步ischemia finding, 仍然要考慮其他的ddx…
- Aortic Dissection確診後，要趕忙停止nitroglycerin以及ASA, Plavix…
- 有些Aortic Dissection在Aortic Arch以上時，也可能以stroke來表現。這個ddx就更困難了…
- 歡迎討論
2010年10月13日 星期三
How to Treat MRSA?
[Current Medications]
IV. Vancomycin, Teicoplanin, Tigecycline, linezolid, Daptomycin.
(if endocarditis, 1st seldom use linezoid, Daptomycin documented only 2 indication: Bacteremia, Endocarditis.)
Po. Rifampin, Doxycycline/ Clindamycin, Baktar, chloramphenicol, Fusidic Acid.
IV. Vancomycin, Teicoplanin, Tigecycline, linezolid, Daptomycin.
(if endocarditis, 1st seldom use linezoid, Daptomycin documented only 2 indication: Bacteremia, Endocarditis.)
Po. Rifampin, Doxycycline/ Clindamycin, Baktar, chloramphenicol, Fusidic Acid.
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