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