[Sepsis] Early Goal

但若是septic shock或severe sepsis without shock則希望把antibiotic administration的時間縮短為1個小時AFTER recognition

若SCVO₂ <70%或S_VO2 <65% despite adequate intravascular volume repletion, 則考慮：

1.     Dobutamine infusion       (max: 20 mcg/kg/min)

2.     pRBC transfusion             (target Hct > 30%)

Mechanical ventilated or known preexisting decreased ventricular compliance則建議把CVP設定為12~15 mmHg

[Sepsis] Surviving Sepsis Guideline 2012 - Definition

1. Sepsis      = Infection + Systemic manifestations of infection

2. SEVERE sepsis  = Sepsis + Organ Dysfunction or Tissue Hypoperfusion

3. Sepsis induced HYPOTENSION   = SBP < 90 or MAP < 70 or SBP decrease > 40 or less than two SD below normal for age

4. Septic SHOCK   = Sepsis induced hypotension, persisting DESPITE ADEQUATE FLUID RESUSCITATION

5. Sepsis induced TISSUE HYPOPERFUSION = SEPTIC SHOCK, # LACTATE (> 4 mmol/L) or OLIGURIA

Foreign Body Misswallowing

Button Battery Ingestion

Button batteries that have passed the esophagus can be managed expectantly, as long as follow-up in 24 hours can be assured. Repeat films should be obtained at 48 hours to ensure that the cell has passed through the pylorus (which may not occur if the battery is of large diameter and/or the patient is <6 years old).

Sharp Objects
Proximal to pylorus  = PES
Distal to pylorus       = Daily film follow-up
Indication for surgical intervention: >3 days without passage, signs of intestinal injury (pain, emesis, fever, GI bleeding) 

Tetanus prophylaxis

* Other wounds的定義：
(a) Delayed wound care (>6 hr),
(b) Deep (>1 cm),
(c) Grossly contaminated,
(d) Exposed to saliva or feces,
(e) Stellate, ischemic or infected,
(f) Avulsions, punctures, or crush injuries



<整理>
1. 已經進入國小六年級及以上一定要問tetanus status
2. 年限：感淨傷口10年、高風險傷口5年
3. 唯一需要考慮TIG的情形：高風險傷口 合併 小於6個月(<3 doses)

Ascites Analysis

Serum-Ascites Albumin Gradient (SAAG)

I.          SAAG > 1.1 = Portal-hypertension related; 再用AFTP (ascites fluid total protein)來進一步區分：

甲、AFTP > 2.5 : cardiac ascites

乙、AFTP < 2.5 : cirrhosis

II.        SAAG < 1.1 = NON-portal hypertension related: Peritonitis, peritoneal carcinomatosis, pancreatitis, vasculitis, hypoalbuminemia, Meig’s syndrome

Peritonitis :     WBC > 500/ mm³ _or PMN > 250 mm³

Type	PMN/mm3	Ascites culture
Sterile	< 250	(-)	不需治療
NNBA		(+) unimicrobial
SBP	> 250		Cefotaxime 2 gm q8h *5d Ceftriaxone 2 gm/day 70% GNB, 30% GPC
CNNA		(-)
Secondary		(+) polymicrobial	3rd cepha + Metronidazole abscess, perforated gut
PD-associated	> 100	(+)	Vanco + Gentamicin (IV + PD) 70% GPC, 30% GNB

(NNBA: Nonneutrocytic bacterascites, SBP: Spontaneous bacterial peritonitis, CNNA: Culture-negative neutrocytic ascites, PD: Peritoneal dialysis)

õ Secondary peritonitis: 通常AFTP >1 , Glu_ascites <50, LDH_ascites >225

õ Prophylaxis of SBP

-        indication: current GIB(variceal), h/o SBP, AFTP <1

-        Ceftriaxone 1gm (IV) qd *7d _or Baktar DS_{(double strength)} 1# bid _or fluoroquinolone?選

? ABX and dosage

Pleural Effusion

CXR上可以看到的最少量(ml):

(a) PA: 300~500, (b) Lat.: 75, (c) Decubitus: 25 per 1cm

Indications for thoracentesis: Asymmetry, Fever, Pleuritic chest pain, failure to resolve

Light’s criteria                                               (98% Se, 83% Sp; 三項符合一項就夠)

(a) PF/serum protein > 0.5, (b) PF/serum LDH > 0.6 ,(c) PF LDH > 2/3 ULN of serum LDH

但會把25%的transudate誤判成exudate, 故仍強烈懷疑transudate時改用Sp較高的test:

(a) Serum-PF Alb-gradient < 1.2                   (87% Se, 92% Sp)

(b)  PF cholesterol >45 _and PF LDH >200       (90% Se, 98% Sp)

Transudate:     CHF, cirrhosis (hepatic hydrothorax), nephrotic syndrome, CAPD, myxedema, SVC-obstruction, pul.embolism(少)

Exudate:          Infection, malignancy, pul.embolism, collagen-vascular disease _{(RA, SLE, Wegener’s, Churg-Strauss)}, GI _{(pancreatitis, esophageal rupture, abdomominal abscess)}, Others _(見麻2-11)

Parapneumonic:     Underlying bacterial lung infection (pneumonia or abscess)

_定義Complicated       = (+) gram stain/ culture _or pH < 7.2 _or glucose < 60

_定義Empyema           = Gross pus

Tintinalli: Gross pus + [(+) gram stain/ culture _or pH < 7.1 _or glucose < 40 _or LDH>1000]

õ Complicated parapneumonic及empyema(exudative stage)需要thoracostomy drainage

# Amylase:             Esophageal rupture, pancreatic, malignancy

Glucose < 60:         Malignancy, infection, RA

Etiology	WBC	RBC	pH	Glc
CHF	< 1,000	< 5,000	Normal	Serum	Bilateral
Cirrhosis					Right, 禁chest tube
Parapneumonic Uncomplicated	5~40,000		$	$
Parapneumonic Complicated			< 7.2	< 60	Drainage
Empyema	25~100,000		< 7.1	< 40
TB	5~10,000 lymp	<10,000	Normal	Serum	AFB, ADA
Malignancy	1~100,000 lymp	<100,000			Cytology
PE	1~50,000				no infarct à transudate
RA/SLE	1~20,000	<1,000	$	RA $$$ SLE nl
Pancreatitis	1~50,000	<10,000	Normal	Serum	Left # Amylase
Esophageal rupture	<5,000 >50,000		$$$	$$

(From Tintinalli)

Empyema        Piperacillin-tazobactam 3.375~4.5 gm         q6h

                        or

                        Imipenem                        0.5~1 gm                 q6h

Hepatic Encephalopathy的Risk Factor

(mnemonic: HEPATICS)

H     _hemorrhage (GI-bleeding)                            Hb, (DRE)

E     _electrolyte (HYPO-kalemia)                         K

P     High protein diet

A     Azotemia                                                  BUN/Cr

T     Deterioration of liver function                  LFTs

I      Infection                                                   WBC, CXR, UA, (PE)

C     Constipation                                             KUB

S     Alcohol withdrawal syndrome                   Hx

Procedural Sedation

Pediatrics: Ketamine (3.5mg/kg) + Atropine (0.01mg/kg)

Pediatric Vaccination

Vaccination Fever

(a)   Killed:                      Within 2 days

(b)  Attenuated/ Live:       Day 5~12

Vaccination	Timing
BCG	Day 1 (BW >2.5 kg)
HBV	Day 2~5 (BW > 2.2 kg)	1M	6M
DPT	2M	4M	6M	18M	7Y
OPV
Varicella	1Y (若不和MMR同時注射則需隔1個月)
MMR	1Y	7Y
JE (和DPT間隔1個月)	15M *2(隔兩週)	27M	7Y	(Mar ~ May施打)
HAV	2Y	2Y6M
Influenza	1st dose是6M以後 (2歲前每年免費)

(a) 新式3合1:        DTaP

(b) 4合1:               DTaP       +      Hib

(c) 5合1:               DTaP       +      Hib     +        IPV

(d) 6合1:               DTaP       +      Hib     +        IPV          +     HBV

õ6合1是1.5M(6W)開始打_{(避開HBV的第二劑)}，第二劑是3M

Attenuated/ Live Vaccine注意事項：

1.     3個月內避免懷孕

2.     有以下處置需延後一段時間：

甲、IVIg (IM)                 : 3M

乙、pRBC                      : 6M

丙、PLT, FFP, IVIg (IV) : 11M

常見自費疫苗：

1.     Rotavirus          : 1.5M(6W) à 3M；和OPV要間隔2週

2.     Pneumococcal  :

甲、13價       : > 2Y

乙、7價         : < 2Y

[EKG] Atrial Enlargement & Ventricular Hypertrophy

Atrial Enlargement  (看lead V1 & II)
1. Right: P wave 高度 > 2.5 mm in lead II, 高度 > 1.5 mm in lead V1
2. Left: P wave duration > 0.12s, P wave 出現notch in lead II, biphasic P (先正再負, 負的時間 > 0.04sec且深度 > 1 mm) in lead V1

整理:
RAE會造成P的高度改變(II:2.5, V1:1.5)；
LAE是時間變長(II: notch, V1:biphasic, deep negative terminal)

Ventricular Hypertrophy
1. RVH:
(a) R > S in V1且S > R in V6,
(b) RAD
2. LVH:
(a) (S in V1 + R in V5 or V6) > 35-mm
(b) R in aVL > 11-mm

LVH久了會看到strain pattern / secondary repolarization abnormalities/ secondary ST-T changes
(a) ST-depression 在lateral leads
(b) TWI
(c) ST-elevation 在right-precordial leads

[EKG] 區分pericarditis VS STEMI

看到STE要如何區別AMI及Pericarditis:

1. (有以下5點任1點就rule in AMI)

(a) ST-Depression (不看V1 & aVR)

(b) STE 是convex-upwards or horizontal

(c) STE in lead III > II
(d) R-T sign or "check mark sign" (R之後沒有明顯的ST就接到T-wave)
(e) new Q-waves

2. (有以下2點任1點就rule in pericarditis)
(a) PR-Depression in multiple leads 
(b) T-P segment depression or "Spodick's sign"

[EKG] Sgarbossa Criteria (含modified)

(EKG of normal LBBB)


Sgarbossa Criteria (> 3 points才像STEMI)
[5-points] > 1 mm STE Concordance (any leads除了V1~3)
[3-points] > 1 mm STD Concordance (V1~3) (因為正常的LBBB其V1~3是STE)
[2-points] > 5 mm STE DISCONCORDANCE

Modified Sgarbossa Criteria (Sen. 59 --> 85%, Spec. 99 --> 96%)
把2-point的criteria改成: STE DISCONCORDANCE in lead V1~4且同時符合以下criteria:
(a) ST / S ratio > 0.2
(b) > 2 mm STE

[EKG] Amal Mattu's Weekly 整理

1. 看到 Irregular rhythm (在下A.fib這個診斷之前)，一定要先看是否有 "clumps" (Regularly-irregular); D/dx:

(a) Premature beats (通常會在clumps之後造成pauses)

(b) Mobitz (2nd degree AV block)

2. PR-interval是區分AV-block的主角 (看lead V1)

(a) Fixed: 1st degree AV block, 2-2 AV block

(b) Prolonging: 2-1 AV block

(c) Variating: 3 AV block

3. 若對區分2-1及2-2 AV block有疑慮，就看"沒有傳下去的P"的"前一個"及"下一個"PR-interval長度: (相等: 2-2, (b) 下一個比前一個長: 2-1)

4. 生平第一次發生"seizure"要作EKG來rule-out dysrhythmia

5. AV-dissociation (atrial rhythm & ventricular rhythm各跳各的) 不一定是complete heart block；若atrial rhythm傳的下去就是AV-dissociation without complete heart block (會看到QRS的morphology改變)

6. RBBB有看到STE或V1~3以外的lead有STD皆異常 (正常在V1~3是會有STD及TWI)

7. 在infero-antero-lateral lead (II,III,aVF,V3~6)有看到isolated TWI表示有pulmonary hypertension; 若看到new TWI則要想到pulmonary embolism

8. 看到 (low voltage + tachycardia) 要先rule-out pericardial effusion

[EKG] Pediatric EKG

1. Large R wave in V1~2, Small S wave in V5~6

2. TWI at V1~3, through age 8

3. 若是在V1有看到upright T, 則是RVH

NICE Fever Guidelines for Kids

Points that are most useful to those of us assessing kids in ED.
======================================
Temperature measurement myths dispelled
--------------------------------------------------
The NICE guidance clarifies the numbers: 
(a) 0-3 m.o. with BT > 38 ==> RED 
(b) 3-6 m.o. with BT > 39 ==> AMBER
(C) >6 m.o. BT height does NOT correlate with severity of the illness

Diagnosis
------------
Consider signs of meningitis; UTI; pneumonia; meningococcal disease; herpes simplex encephalitis. But also don’t forget about septic arthritis or osteomyelitis (easily missed). As an additional point always think of Kawasaki disease in a fever lasting more than 5 days.

The importance of tachycardia
------------------------------------
This is one of the most valuable lessons I have learned and it has changed my practice over the last couple of years. I rarely send home a child with tachycardia when they have a fever of no clear focus.
NICE now says that tachycardia puts the child into amber.
Age <12 months HR >160
Age 12-24months HR>150
Age 2-5 years HR >140

Management – 3 months or older
---------------------------------------
Investigate fever with no source if they have any red features – FBC, CRP, B/C and urine. Consider LP, CXR, UEC and gas if indicated.
Investigate fever with no source if there are any amber features unless deemed unnecessary by an experienced paediatrician. This is clearly the greyest area. My rule of thumb is that if they look well (clinical judgement), and are not tachycardic then I would not bother doing bloods – NICE doesn’t offer any further advice on this unfortunately.
Check urine for all children with fever and no source, even if they are green.

Antipyretics
-------------
As well as the meds, children should not be over-wrapped or underdressed. And tepid sponging is not recommended.
Use either paracetamol or ibuprofen but only for a child who appears distressed and not simply to bring down the fever. Don’t give both agents together and only switch agents if the child remains distressed.

When to discharge
---------------------
Do not rely on the temp coming down with antipyretics to distinguish between serious and non-serious illness.
Any child with amber or red features should be reassessed after 1-2 hours.

When to admit
------------------
Use your usual markers of clinical conditions but also other social factors should help with decision: social circumstances; parental anxiety and instinct; serious infectious contacts; travel abroad; repeated presentations; when the child has remained ill for longer than expected for a self-limiting illness.

How to discharge
---------------------
Give the parents advice on recognising red or amber signs by providing written information and/or arranging follow-up.

New in 2013 
========
Assess children using the new traffic light system to predict risk of serious illness (red: high-risk, amber: intermediate-rish, green: low-risk)
Recognise the importance of tachycardia and that this puts children into the amber (intermediate-risk category)
Any child younger than 3 months with fever should be investigated
Alternate antipyretics and don’t use both at the same time
Recognise that lowering the temp does not prevent febrile convulsions