Knee aspiration/injection

Direct injection
90度 從patella下面兩個凹陷進針. 有傷害關節面跟 menisci
的風險
不過打玻尿酸OK 因為關節面早壞了...

superolateral approach

1. 學長的方法是找出接到patella的tendon 從旁進針
2. 書上說從patella往外+往上方各1cm(約一指→一指↑)處進去, 以45度角度(水平面)進針，(前後面)則指向關節中心
   略偏下不要碰到patella。較安全 不要碰到patella的韌帶就好
   

從aspiration換成injection的針筒時 可以用止血鉗之類的夾住針頭
因為針頭一動病人會很痛...逆時鐘出 順時鐘進 收針注意針扎

負壓進去關節液就會出來
抽吸的針記得學長是說19號...
抽出的水如果很白(cloudy)或不能排除感染 就不要打steroid

Ref: teaching+ Atlas of Primary Care Procedures

insulin

1. Basic Insulin Regimen
   適合剛用insulin的人, 不想打太多次的人, 中午不想打的人, 飲食規律固定的人, 早餐跟晚餐間隔<10~12hr的人...
   • Daily insulin glargine w/ OAD
   適合 fasting sugar↑, 白天sugar較穩定的人 起始dose: 0.1~0.2 U/kg glargine @ 清晨 or 睡前. 也可直接以10U開始 每4~7天調2~5U，直到 fasting glucose 約為 120mg/dl 左右 OAD: 可續吃 esp. SU + sensitizer 有幫助
   • Daily split-mixed or premixed insulin
   適合 prandial ↑, 白天sugar特高, 願意打兩次, 要打NovoMix的... 起始dose: 0.3~0.5 U/kg (2/3 早餐打, 1/3 晚餐打) 最好混合 rapid-acting 的,考慮 RI: 價錢不行, 常吃甜點, 素食者. 怎麼混看各人囉 .. 高醫去年好像是 NovoMix (70/30) OAD: 不一定要續吃, 但通常留一顆sensitizer
2. Advanced Insulin Regimen適合 Type I. 及 Type II 想更精確控制血糖的人
   Basal用 insulin glargine, bolus 用rapid-acting
   起始dose: 0.3~0.7U/kg (小麻4e: 0.5*BW) Basal/bolus 各半
   
3. Basic → Advanced Regimen
   
   • Daily insulin glargine w/ OAD → Advanced Regimen
     研究不多, 目前(2004)的給法有:
     
     1. 續給 basal, 從prandial 最高的一餐開始給一支bolus
     2. 看HbA1c 總量+10~20%, 再 Basal/bolus 各半, bolus 再分三餐
     當三餐都有打bolus時, DC insulin secretagogue, 續吃 sensitizer
   • Daily split-mixed or premixed → Advanced Regimen
     總量-20% (HbA1c>9% 則-10%) 之後也是 Basal/bolus 各半, bolus 再分三餐
     

Ref: International Textbook of Diabetes Mellitus (2004) 有點舊啦

會查這是因為看過很多版本, 已前上課的(Daily basal, 還有一說是40U開始..忘了),
馬偕的(很像Advanced), 高榮幹來的講義(Basal/bolus似乎是2:1), 小麻也是一個版本
總之一開始的給法很多，都是expert opinion，就入境隨俗啦
因為每個人insulin resistance 都不同, 也不會有最好的方法
sugar不滿意每次調2U or 4U(真的差很多時)
insulin resistance 太誇張，要survey一下為什麼這麼高
藥物的部分 TZD是禁用的. 會加重 edema, CHF 的副作用

suture

From: Wikipedia - Surgical suture

1. 清理傷口 要像小姐一樣大力...
2. 蓋洞巾, irrigation, 三消. 看extend到哪 至少用摸的 照x光可看air, metal
3. 打local
   之前看一本 臨床小秘笈 : 各科臨床技術的小撇步 還有長庚teaching 說打wound中央
   但 Clinical procedures on emergency medicine 跟學姊是說打進針點
   所以我就combine 目前少量樣本顯示 打wound中央+進針點 病人都不會痛XD 都打那麼多了...
   Clinical procedures on emergency medicine 還提到：
   grossly contamination 不要去碰wound, 但是一般L/W 會在"grossly" contamination還縫起來而嗎? 所以應該是都可以
   打進針點也有兩種方法：沒汙染的從wound邊緣的皮下進入；有汙染的(grossly)不要碰到wound 自wound 旁的皮 斜斜插入
   
   • local: 2% xylocaine 一般5cc以內。抽local的針跟打的不同，因為抽完針頭可能會頓掉。三消到一半可先打local，不一定要消完再打，病人不適會稍微少些
   • 小孩可能要先讓她睡著(sedation)
   • digital block: 手指nerve從兩旁走 所以兩邊手指跟部各打一次(1~2cc)；而 youtube 上的影片是，從指背入，碰到骨頭收回1mm 再往左往右打。不管怎樣，注意不要打到血管，打得對皮膚會腫起來
   • 而 Emerg Med J 2010 Jul; 27:533. 提到了種新方法：再指頭最靠近手掌的指節的掌側，打2~3ml的local，但是這篇paper也提到他沒法收到預計的500人 且較遠的部份可能會麻不夠

   a single SC inj. of 2~3 mL of local anesthetic on the palmar surface at the base of the digit just distal to the proximal skin crease, followed by massage of the anesthetic into the area. because this method does not block the dorsal branches of the digital nerve, it might be less effective for injuries proximal to the distal-interphalangeal joint.

4. suture (多出自長庚teaching)
   線:
   
   • 常用 3-0, 4-0.
   • 臉多用5-0, 6-0, 舌3-0,
   • oral mucosa用軟線.
   • scalp 年輕人3-0, 老人小孩4-0 (但馬偕都2-0) 線留長些.
   • 皮下之下用 dexon, vicryl (multifilament, absorbable 約30天)
   
   
   • scalp可用頭髮綁，之後再用tissue adhesive. indication: 符合下列條件：1)頭髮要夠長 2) 邊緣不可有挫傷 3) 無 grossly contamination 4) 已止血 5) 未傷到 galea (occipitofrontalis aponeurosis) 6) skull 沒有 fx
     但如果要打local確認wound下方組織，那還是suture起來的好(Clinical procedures on emergency medicine 及 Ann Emerg Med 2002; 40:19)
     
   
   持針: 在 Clinical procedures on emergency medicine 及 NEJM 2006;355;17 都建議用 open 拿法，食指去壓持針器的"關節" 用食指控制方向
   
   入針: 拿在距離線端1/2~1/3處. 針頭與皮膚成90度. 用forcep 去evert時，只能用一邊撐著 兩邊夾下去會傷害組織. 針到中央，再從中央拿針，用forcep evert另一側面 再繼續
   深度要大於寬度 底部要比表皮寬 間距=寬度
   
   傷口小其實不一定要用forcep, 這樣反而很卡
   一針到底~ 可用大拇指去壓對側皮膚 也可evert 但要小心被刺到
   出針後 用力拉起線的兩端 也可有 evert的效果 但也不要太緊@.@
   
   打結至少4個
   nylon, prolene易鬆脫 要多打幾個結
   
   剪刀: 一樣用食指壓 姆指向前 其他向後
   
   
5. 拆線: 臉5~7天 身體10~14天 手掌>2wks, hip&knee 要很久
   
   

Shock

EMPIRICAL CRITERIA FOR DIAGNOSIS OF CIRCULATORY SHOCK** Regardless of cause. Four criteria should be met.
Ill appearance or altered mental status
Heart rate >100 beats/min
Respiratory rate >20 breaths/min or Paco2 <32>4 mM/L
Urine output <0.5>20 minutes duration

DEFINITIONS AND CRITERIA FOR SEPTIC, HEMORRHAGIC, AND CARDIOGENIC SHOCK

• Septic Shock
  
  • Systemic Inflammatory Response Syndrome (SIRS)
  有兩個以上：
  1) Temperature >38℃ or <36℃>90 beats/min
  3) RR >20 breaths/min or Paco2 <32>12,000/mm3, <4000/mm3,>10% band neutrophilia
  
  • Severe Sepsis
  SIRS + suspected or confirmed infection + associated with organ dysfunction or hypotension; organ dysfunction may include presence of lactic acidosis, oliguria, or altered mental status
  
  • Septic Shock
    SIRS + suspected or confirmed infection + hypotension despite adequate fluid resuscitation; septic shock should still be diagnosed if vasopressor therapy has normalized blood pressure
• Hemorrhagic Shock
  
  • Simple Hemorrhage
    Suspected bleeding + pulse < 100
  • Hemorrhage with Hypoperfusion
    Suspected bleeding + base deficit <−4 mEq/L or persistent pulse >100 beats/min
  • Hemorrhagic Shock
    Suspected bleeding + Circulation Shock
  
  
• Cardiogenic Shock
  
  • Cardiac Failure
    Clinical evidence of impaired forward flow of the heart, including presence of dyspnea, tachycardia, pulmonary edema, peripheral edema, or cyanosis
    
  • Cardiogenic Shock
    Cardiac failure + Circulation Shock
    

CLINICAL MANAGEMENT GUIDELINES FOR FOUR COMMON CAUSES OF SHOCK

• Hemorrhagic Shock
  1) Ensure adequate ventilation/oxygenation
  2) Provide immediate control of hemorrhage, when possible (e.g., traction for long bone fractures, direct pressure)
  3) Initiate judicious infusion of isotonic crystalloid solution (10–20 mL/kg)
  4) With evidence of poor organ perfusion and 30-minute anticipated delay to hemorrhage control, begin packed red blood cell (PRBC) infusion (5–10 mL/kg)
  5) With suspected central nervous system trauma or Glasgow Coma Scale score <9, immediate PRBC transfusion may be preferable as initial resuscitation fluid
  6) Treat coincident dysrhythmias (e.g., atrial fibrillation with synchronized cardioversion)


• Cardiogenic Shock
  1) Ameliorate increased work of breathing; provide oxygen and positive end-expiratory pressure (PEEP) for pulmonary edema
  2) Begin vasopressor or inotropic support; norepinephine (0.5 μg/min) and dobutamine (5 μg/kg/min) are common empirical agents
  3) Seek to reverse the insult (e.g., initiate thrombolysis, arrange percutaneous transluminal angioplasty)
  4) Consider intra-aortic balloon pump counterpulsation for refractory shock


• Septic Shock
  1) Ensure adequate oxygenation; remove work of breathing
  2) Administer 20 mL/kg of crystalloid or 5 mL/kg of colloid, and titrate infusion to adequate central venous pressure and urine output
  3) Begin antimicrobial therapy; attempt surgical drainage or d?bridement
  4) Begin PRBC infusion for hemoglobin < 8 g/dL
  5) If volume restoration fails to improve organ perfusion, begin vasopressor support; initial choice includes dopamine, infused at 5–15 μg/kg/min, or norepinephrine, infused at 0.5 μg/min

Ref: Marx: Rosen's Emergency Medicine, 7th ed. Chp. 4 Shock