[自行整理] Chap. 10: Tube Thoracostomy [Clinical Procedures in Emergency Medicine]

1. Chest tube insertion最常用的位置: Anterior Axillary line with 4th~5th ICS

2. Patient preparation:

(a) 床頭搖高 30~60 degrees & Abduction of ipsilateral arm (i.e. over head)

(b) 置放前先測量預訂深度: Insertion site至到clavicle (?Mid or distal)

3. 一定要把所有的side-holes放進pleural cavity; 只要管子在pleural cavity內, 任何的位置都可以引流blood, fluid以及air (air & fluid that is not loculated will follow the path of least resistance & enter a functioning drainage tube as the lung expands and the pleural space becomes smaller)

4. Anesthesia: GENEROUS local anesthesia (max: 4(7)mg/kg) should be given along the entire anticipated track of the tube's passage; (參考NEJM video)

5. Skin incision要夠長 (at least 4 cm, 用No. 10 blade scaplel)且通常在1~2根肋骨低於預進入的ICS

6. Pleural penetration通常是最痛的 (故居部麻醉時要麻到); Opening in the parietal pleura should be wide enough to comfortably insert a finger AND the tube; however an extensive pleural opening should be avoided to prevent subcutaneous emphysema

7. 永遠要確認pathway的patency! (不管是用手指或器械); 故把Kelly移除之前一定要留一根手指在pleura的洞口, 該根手指也可作為放置tube時的導引 (避免subcutaneous dissection with tube)

8. 用Kelly夾chest tube時要確保Kelly的金屬段不會跑出來(以免傷到lung)

[EKG] Differential Diagnosis

Leftward Axis Deviation
1. Pacemaker
2. WPW
3. Inferior MI
4. LVH
5. LBBB
6. LAFB
7. Hyperkalemia
8. (Normal variant)

Rightward Axis Deviation
1. Lateral MI
2. WPW
3. RVH
4. LPFB
5. Pulmonary embolism
6. COPD
7. Na-channel blocker
8. Septal defect
9. Hyperkalemia

Wide QRS
1. BBB
2. WPW
3. Pacemaker rhythm
4. Na-channel blocker
5. LVH
6. Ventricular ectopic
7. Hyperkalemia or Acidosis

Short QT
1. Hypercalcemia
2. Digoxin Toxicity
3. (Congenital)

QTc-Prolongation
1. Electrolyte imbalance: HYPO-(K, Ca, Mg)
2. IICP
3. Medication: type Ia (quinidine, procainamide), type III (amiodaraone)
4. Hypothermia
5. (Congenital)

T-wave Inversion
1. WPW
2. Hypokalemia
3. CAD
4. Abnormal repolarization: BBB, pacemaker, ventricular hyperthrophy
5. ICH
6. Pulmonary disease: Pul. HTN, Hyperventilation, Pneumonia, Pul. embolism

ST-Elevation
1. STEMI
2. Peri-/myocarditis
3. LVH
4. LBBB
5. Ventricular aneurysm
6. Brugada
7. Hyperkalemia
8. CNS-effect (SAH)
9. Benign early repolarization
(口訣: LAP BAND)
LVH,LBBB / AMI / Pericarditis / Brugada,BER /Aneurysm(LV) / Neurological (SAH) / Drugs(cocaine)

ST-Depression
1. NSTEMI
2. Strain (due to ventricular hypertrophy)
3. Digitalis effect
4. Ischemia
5. Hypokalemia

Low-voltage 

definition:(QRS的amplitude): (a) lead (I + II + III) < 15 mm, or  (b) lead (V1 + V2 + V3) < 30 mm

1. "low power"
(a) Myxedema
(b) Cardiomyopathy
(c) Infiltrative disease (Sarcoidosis)
2. "blocked conduction"
(a) (air) COPD
(b) (fluid) pericardial/ pleural effusion
(c) (fat) obesity

[自行整理] Chap. 35: Methods of Wound Closure [Clinical Procedures in Emergency Medicine]

4種常見的wound closure方法：Tape, Tissue Adhesive(Glue), Metal Staples, Sutures

TAPE
1. Indication
(a) Superficial straight lacerations under little tension (forehead, chin, malar eminence, thorax, non-joint extremities)
(b) Delayed suture removal (e.g. under plaster casts)
(c) Flaps and grafts in place, particularly over fingers, flat areas of extremities, and trunk
(d) Pretibial area
(e) After early suture removal (i.e. on the face)
(f) Areas due to vascular insufficiency or altered by prolonged steroid use
2. Contraindication
(a) Naturally moist areas (axilla, palm, sole & perineum)
(b) Secretions, copious exudates, or persistent bleeding
(c) High concentration of hair follicles (scalp)
3. Pearls & Pitfalls
(a) 傷口周圍一定要乾，止血要做好
(b) 先從傷口的中間開始貼， 要覆蓋傷口以外的2.5公分
(c) 不要整條傷口都被覆蓋 (?原因)
(d) 結束時要在貼紙的末端再貼上和傷口平行的貼紙 (避免tape ends blistering of skin)

Staples 最大的優點 -- Speed of closure
1. Indication: Linear lacerations with straight, sharp edges (superficial scalp lacerations)
2. Contraindication: Face, neck, hands or feet
3. Pearls & Pitfalls
(a) 傷口在approximation時要維持eversion (因為stapling會造成inversion)
(b) 不要用力往傷口壓 (以免造成ischemia within staple loop; 理想是離皮膚約2~3mm)

[保險]

http://mcintyre.pixnet.net/blog/post/44684989-%E5%A6%82%E4%BD%95%E6%8C%91%E9%81%B8%E9%81%A9%E5%90%88%E7%9A%84%E9%86%AB%E7%99%82%E5%AF%A6%E6%94%AF%E5%AF%A6%E4%BB%98%E9%9A%AA

Altered Mental Status

Altered Mental Status
A.      Alcohol
E.       Endocrine(thyroid), Electrolyte(Na,Ca), Epilepsy, Encephalopathy
I.        Insulin ( hyper-/hypoGlycemia)
O.       Oxygen, Opioid
U.       Uremia
T.       Trauma, Temperature
I.        Infection (CNS, Systemic)
P.       Poison, Psychosis
S.       Shock(HypoVolemic, AMI), Stroke/SAH/Structural lesion


Hx: 什麼候開始, 怎麼不一樣(baseline如何), Seizure/Epilepsy, Headache/ head injury, Drug (new drugs)
PE: TPR, BP, SpO2, Auscultation, Tongue-biting, Head trauma, Odor(EtOH, Ketone)
NE: Pupil(pinpoint/dilate, deviation), GCS, Babinski
Lab: FingerSugar, BUN/Cr, Na/Ca, LFTs/NH3, CBC-DC/PLT, PT/aPTT, BloodCulture, UA/U.culture, Toxic Screen, Alcohol, BZD, TFTs, Troponin
Exam: EKG, CXR, (Brain + C-spine) CT, Lumbar puncture

[AITFL] Manage of Syncope

The most common causes of syncope are: Unknown (34-36%), Vasovagal (18-21%), and Cardiac (9.5-18%). Soteriades et al noted that if patients have a history of CV disease, the incidence of cardiac etiology also increases.

Causes of Syncope & The Presence or Absence of CV Disease
CV Disease	CV Disease Absent		CV Disease Present
Sex	Male	Female	Male	Female
Cardiac Etiology	6.5%	3.8%	26.7%	16.8%

San Francisco Syncope Rule

The mnemonic for features of the rule is CHESS:

• C - History of congestive heart failure

• H - Hematocrit < 30%

• E - Abnormal ECG

• S - Shortness of breath

• S - Triage systolic blood pressure < 90

What is the ACEP Level-B Recommendation for Admission?

• Older age and associated comorbidities (No set definition) 
• Abnormal EKG findings (acute ischemia, dysrhythmias, or significant conduction abnormalities) 
• Hematocrit <30 
• History or presence of CHF, CAD, or structural heart disease 

Does Everyone with Syncope Need a Head CT?

Bottom Line: Clinicians might consider obtaining a Head CT as part of the syncope evaluation for the following findings:

• Trauma above the clavicle 
• Persistent neurologic deficit or complaint 
• Age >65 
• Sudden onset headache 
• Patients on warfarin (coumadin)

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