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)

Trauma Rules (V6 網誌分享)

Rule 1: 如有頻脈或皮膚血管收縮現象，則先當休克直到証明不是為止。
Rule 2: 外傷 + 休克，則先當出血性休克直到証明不是為止。
Rule 3: 先找外出血再找內出血;沒有出血就找非出血。

Internal bleeding (CRAMP)
Chest                              ->CXR
Retroperitoneum          ->UA/CT
Abdomen                       ->FAST
Missed long bone fx    ->PE
Pelvic-                            ->pelvic XR

Non-bleeding     (NPC)
Neurogenic shock
Pneumothorax,tension
Cardiac tamponade/cardiac contusion

<自行整理>
1. Ultrasound (E-FAST)可以cover Chest, Abdomen, PTX & Cardiac tamponade/contusion
2. CT可以cover Retropenium, Neurogenic shock
3. PE rule out long bone fracture

[自行整理]Distal Clavicular Fracture

Neer classification of distal clavicle fractures. 
Type I fracture occurs distal to the coracoclavicular (CC) ligaments (ie, trapezoid, conoid) and involves minimal fracture displacement. The acromioclavicular (AC) joint remains intact. 
Type IIA fracture occurs medial to the conoid ligament. Type IIB fracture occurs between the CC ligaments and includes disruption of the conoid ligament. The trapezoid ligament remains intact. 
Type III fracture occurs distal to the CC ligaments and extends into the AC joint. 
Type IV fracture occurs in pediatric patients. The physis and epiphysis remain adjacent to the AC joint, but there is displacement at the junction of the metaphysis and physis. 
In type V fracture, a small inferior clavicular fragment remains attached to the CC ligaments.
只有Type II & V需要early orthopedic consultation due to unstable (Minor Emergencies 2e, P434)

[自行整理] Immobilization Devices and Uses

Table 264-3 Immobilization Devices and Uses

Immobilization Technique Clinical Application Shoulder immobilizer Clavicle fracture. Acromioclavicular separation. Shoulder dislocation (postreduction). Humeral neck fracture. Sling A variety of upper extremity injuries, in conjunction with other immobilization techniques; may be used alone for nondisplaced or clinically suspected fracture of the radial head. Long-arm gutter Elbow fracture other than nondisplaced radial head fracture. Reduced elbow dislocation  Sugar-tong (可prevent pronation/supination) Wrist or forearm fracture. Distal radial and ulna (Robert & Hedges) Short-arm gutter Metacarpal or proximal phalanx fracture. [Ulnar gutter for fourth or fifth ray] [Radial gutter for second (index) or third (middle) ray.] 若是metacarpal neck fracture, 則把MCP固定在90度 (Robert & Hedges) Thumb spica 固定時維持opposition (OK sign) Scaphoid fracture (proven or suspected). Thumb metacarpal or proximal thumb phalanx fracture Knee immobilizer Fracture or reduced subluxation of patella. Knee dislocation, postreduction (temporary). Tibial plateau fracture. Knee ligament injury. Suspected meniscal tear (provided the knee can be fully extended). Posterior ankle mold (consider above-the-knee extension and/or adjunctive use of ankle sugar-tong for unstable ankle injuries) Ankle dislocation or fracture-dislocation. Unstable ankle fracture (high distal fibular fracture or medial and/or posterior malleolar fracture). Widened medial mortise (indicates disruption of stabilizing medial structures). Metatarsal fracture (alternative immobilization dressings may be used). Ankle stirrup Simple ankle sprain Stable lateral malleolus fracture (below the superior border of the talus) without other ankle involvement (no medial swelling or tenderness, posterior malleolus intact). Hard-soled shoe Toe fracture. Some metatarsal fractures Short-leg walking boot Some toe or foot contusions or fractures where weightbearing is allowed

[自行整理] C-Spine CT Rules (NEXUS, CCR)

NEXUS Criteria (National Emergency X-radiography Utilization Study Low-Risk Criteria)       NEJM2000;343:94 –99

A patient’s neck can be clinically cleared safely without radiographic imaging if ALL 5 low-risk conditions are NEGATIVE:                            (mnemonic: NSAID)

1. Focal Neurological deficit

2. Spinal (posterior midline) tenderness

3. Altered mental status

4. Intoxication 

5. Clinically apparent, painful Distracting injury

Canadian C-spine Rules (CCR)                                                                       NEJM2003;349:2510 –2518

The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.                                                                                         N Engl J Med. 2003 Dec 25;349(26):2510-8.

CCR was more sensitive than the NLC (99.4 % vs. 90.7 %, P<0.001) and more specific (45.1 % vs. 36.8 %, P<0.001) for injury, and its use would have resulted in lower radiography rates (55.9 % vs. 66.6 %, P<0.001).

In secondary analyses that included all patients, the sensitivity and specificity of CCR, assuming that the indeterminate cases were all positive, were 99.4 % and 40.4 %, respectively (P<0.001 for both comparisons with the NLC). Assuming that the CCR was negative for all indeterminate cases, these rates were 95.3 % (P=0.09 for the comparison with the NLC) and 50.7 % (P=0.001). The CCR would have missed 1 patient and the NLC would have missed 16 patients with important injuries.

Conclusion: For alert patients with trauma who are in stable condition, the CCR is superior to the NLC with respect to sensitivity and specificity for cervical-spine injury