案例讨论教学-图文.pptx

案例讨论教学_图文.ppt,25 歲男性,12532225,94.2.20 7:47pm,家人陪同,自行步入,TRIAGE 檢傷分級:II,T：39C，P：94/min，R：18/min，BP：128/60 mmHg,Chief complaint 主訴:,Neck swelling 頸部腫脹 for 2 days,Present illness,現病史:,在家不知有無,fever,cough with yellowish sputum for 2 days,sorethroat for 2 days,dyspnea,general soreness,no rhinorrhea,Past history:,Denied allergy,Denied systemic disease,Physical Examination,Cons:,clear,H&N:,conj:not pale,submental swelling 下頷,tender,Chest:,coarse,Abd:,soft,Ext:,freely movable,Impression?,Order,7:50pm,Neck soft tissue view,WBC/DC,Hb,Plt,CRP,N/S run 80 ml/h,Keto 1 amp IM st,Consult ENT,8:20 pm,PCT()If negative,Augmentin 1.2g st+q8h iv,Bun/Cre,Keto,Danzen 1#qid po 2 days,OPD f/u,Result,WBC 25550 Seg 89%Band 4%,Hb:16.4,Platelet:197000,CRP:10.1,Bun/Cre:9/1.1,Neck soft tissue view:,ENT:,Mild injected throat,Patent vocal cord,Imp:neck cellulitis,r/o submandibular sialadenitis,Oral Voren,Augmentin,Simagel,Danzen,OPD f/u.,Order,2/21 am,Genta-C 80mg ivd st+q8h,2:25 am,Neck CT s c contrast,Metronidazole 1 g st iv then 500mg q6h iv,B/C II,VBG,Reconsult ENT,9:40 am,Admission and OP,Result,Neck CT,Ludwig angina:a review of current airway management.,Archives of Otolaryngology-Head&Neck Surgery.Marple BF.125(5):596-9,1999 May.,Ludwigs angina:a clinical review.,European Archives of Oto-Rhino-Laryngology.Srirompotong S.Art-Smart T.260(7):401-3,Aug 2003.,Ludwigs Angina,Background,Hippocrates in 1836,a postmortem findings,Karl Friedrich Wilhelm,von Ludwig,A rapidly progressive gangrenous cellulitis originating in,submandibular gland.,Inflammatory distention of the,fascial planes of the neck,can lead to respiratory tract obstruction and death.,It extends by,continuity,rather than lymphatic spread.,Mortality rate,exceeds 50%during the,preantibiotic era,attributed to overwhelming sepsis.,But in the early 1900s the deadly role of mechanical,respiratory obstruction,was realized.,Etiology,90%odontogenic in origin,Peritonsillar absecess,Parapharyngeal abscesses,Oral lacerations,Mandibular fractures,Submandibular sialadenitis,Presentation,Neck swelling,Tooth pain,Protruding or elevated tongue,Fever,Dysphagia,Trismus,Difficulty breathing,Asphyxia,Pathogens,Bacterial isolates are often,mixed,comprising both aerobes and anaerobes.,Mostly,alpha-hemolytic streptococci,staphylococci and bacteroides.,Treatment,Primary goal:,Preserve the oropharyngeal airway.,Secondary goal:,Antibiotic agent or incision and drainage,Airway maintenance,Question:When,How?,Airway compromise develops,insidiously.,Early s/s of obstruction may be very subtle to neglect.,Whereas actual,obstruction is abrupt.,Limited cases and experience?,Routine endotracheal intubation or tracheotomy?,Recommendations,vary,throughout literature.,The trend is toward,airway observation,as antimicrobial therapy has emerged.,Airway maintenance,The need for immediate artificial airway:,Stridor,Cyanosis,Retractions,difficulty managing secretions.,Rapid progression of edema,Comorbid health problems,DM,Airway maintenance,Airway maintenance may be difficult:,Endotraclear intubation:,Supraglottic edema,Nuchal rigidity,Trismus,Nasal intubation:,Requires careful awake,Flexible endoscope,Patient in an upright position,.,Last resort:,Cricothyroidotomy,Tracheotomy.,Antibiotic agent,Early aggressive antibiotic therapy:,largely replaced surgical decompression,frequently circumvents artificial control of the airway.,Determine the source of infection:,High-dose penicillin G.,Sometime combined with metronidazole.,In penicillin-allergic patients,use clindamycin.,IV dexamethasone,given for 48h,has been beneficial in reducing edema.,Surgical intervention,Decompression,sublingual and submandibular spaces.,Incision and drainage,Debridement,Complication,Deep neck infection,Mediastinitis,Sepsis,Pneumonia,Empyema,Asphyxia,Pneumothorax,Conclusion,The very name,angina,meaning spasmodic suffocative pain when not treated.,Tracheotomy may eliminate the decision-making burden,but,Early aggressive,antimicrobial therapy,has reduced the need for airway intervention.,The treatment plan for each patient should be,individualized.,