发热的急诊科处理—香港大学.ppt

按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,Diagnostic Approach to the Patient with Fever in ER,Present,林立偉醫師,Director,林秋梅醫師,LAEARNING GOALS,To understand the definition and terminology,How to seek the source of fever,How to manage the patient with septic shock,BODY TEMPERATURE,BODY TEMPERATURE,The mean oral temperature 36.8,C,0.4,C,Low level at 6 AM and high level at 4 to 6 PM,with normal daily variation is 0.5,C,Rectal temperature 0.4,C,higher than oral,Unadjusted-mode TM temperature 0.8,C,lower than rectal,Lower esophageal temperature closely reflect core temperature,FEVER,An AM temperature of 37.2,C,or PM temperature 37.7,C,define a fever,Elevation of BT that exceeds the normal variation and occurs,in conjunction with an increase in the hypothalamic set point,Hyperpyrexia,A fever of 41.5,C,Severe infections but mostly common with CNS hemorrhage,HYPERTHERMIA,An unchanged(normothermic)setting of the thermoregulatory center,in conjunction with a uncontrolled increase in body temperature that exceed the bodys ability to lose heat,Cause,D.D.from fever,No response to antipyretics,The event immediately proceed the increase temperature,In heat shock or in those taking drugs that block sweating,skin is hot but dry.,ANTIPYRETIC AGENTS,Acetaminophen,Poor cyclooxygenase inhibitor in peripheral but oxidized(active form)in brain by the p450 system,Aspirin,NSAID,Affect platelets and GI tract,May deteriorate renal function in patients with renal insufficiency(inhibit renal prostaglandin),Glucocorticoid,Inhibit phospholipase A2,Block the transcription of the mRNA for the pyrogenic cytokines,PITFALL,Delirium,New onset of incontinence,Weakness,Weight loss,Loss of appetite or nausea,In newborns,the early,patients with CRF,immunocompromise and patients taking glucocorticoids,fever may not be present despite infection or may be hypothermic.,The atypical(often typical)presentation of infection in elderly,Key point:loss of function,APPROACH TO THE PATIENT,HISTORY,APPROACH TO THE PATIENT,HISTORY,Combined symptoms,Fever pattern,Medication,Surgical or dental procedure,Any prosthetic materials or implanted devices,Occupation(animal;fume;infectious agent or infected individuals),Travel history,Unusual hobbies,Dietary proclivities,Household pets,Sexual exposure,IV drug abuse,alcoholism,Trauma,Animal or insect bite,Blood transfusion,immunization,Family history,APPROACH TO THE PATIENT,PHYSICAL EXAMINATION,APPROACH TO THE PATIENT,PHYSICAL EXAMINATION,Head to toe,Finger to hole,Special attention to skin,lymph nodes,eyes,nail bed,CV system,chest,abdomen,musculoskeletal system,and nerve system.,Rectal examination is imperative,Penis,scrotum,testes,foreskin and pelvic examination in women should be examined,APPROACH TO THE PATIENT,LABORTARY TESTS,Clinical Pathology,CBC+DC+PLT,blood smear,UA,ESR,abnormal fluid accumulation and CSF examination,bone mallow aspiration,stool routine,Chemistry,Electrolyte,BUN,creatinine,LFTs,amylase,CPK and serology,Microbiology,Grams stain and culture,Imaging,Plain film,sonography,CT,MRI and Gallium scan,Case 1,Name,郭,XX,Chart No.111*,Age 65 Y/O,Sex Male,Triage Class II,91/05/07 10:16,AM,自行步入,A,VPU BT 39.5,C,PR 84 RR 17 BP 134/61,Chief Complaint,headache since last W4(5/2),Present Illness,Fever noted at LMD yesterday,Vomiting twice(last W4+today),URI(-),frequency(-),dysuria(-),Past/Drugs History,Drug allergy(-),deny any disease,Physical Examination,Consciousness clear,Head&Neck stiffness,throat：mild injected,Chest clear,Abdomen soft,no tender,no CV angle knocking pain,Extremity movable,NE EOM intact,pupil 3/3 LR+/+,MP normal,numbness(-),Babinskis sigh,/,Impression,R/O meningitis,Plan,CBC/DC/PLT,Panel 1,B/C II,CXR,Brain CT,NS run 60 cc/hr,Scanol 2#st,11：30,AM,WBC 11500,S/L 87.2/7.0,Hb 13.9,PLT 149K,Glu 110,AST 39,BUN 13,Cr 1.0,Na 139,K 3.8,1：50,PM,Brain CT：negative,Do Lumbar Puncture,Initial pressure 210 mmH2O,Final pressure 110 mmH2O,Procedure was done smoothly but reddish CSF was,noted,Repeat puncture at other site but reddish CSF was still noted,Sent sample for routine,Glu&protein,culture,TB culture and Grams stain,2：40,PM,CSF,color Bloody,Appearance Cloudy,RBC 11150,WBC 10,L/N 9/1,Grams stain WNL,CSF Biochemistry,Glu 51(F/S 101),Protein 55.5,Favor SAH,Consult NS,Taking Hx again,Patient said he suffered,from abrupt and explosive,headache on 5/2,91/05/08,High fever 41,C and SBP down to 80 was noted,INF consultation,BP,RUQ pain(+),WBC 12100 S/L/B 76/6/18,UA RBC 0-1 WBC 5-7,GOT 39,CRP 22.20,IMP,：1.Septic shock 2.SAH,Suggestion：1.B/C*II 2.Rocephin 2 gm st+q12h,3.Abdominal echo,91/05/09,Abdominal echo,Hepatic cyst,Rt,Renal cyst,Rt,CBD dilation,Adenomyomatosis of GB,91/5/10,B/C(sample on 5/8),2/2 G(-)bacilli,Final report on 5/11,K.P sensitive to Cefamazine and GM,91/05/14,Fever was still noted and do abdominal CT to R/O liver abscess,Abdominal CT,Rt hepatic abscess,Rt hepatic hemangioma,Case 2,Name,王,XX,Age 75 Y/O,Sex Male,Triage Class II,91/03/14 06:10,PM,自行步入,A,VPU BT 37.4,C,PR 86 RR 36 BP 102/60,O2 Sat 85%,Chief Complaint,Lt hand pain since this noon,Present Illness,Stung by fish bone yesterday,Chronic SOB,Past/Drugs History,COPD,DM,CAD+AAA s/p CABG+grafting bypass of AAA,Physical Examination,Consciousness clear,Head&Neck,Chest bilateral wheezing,Abdomen soft,no tender,Pelvis,Extremity Lt hand swelling with,erythema change,Impression,Cellulitis,Lt hand,R/O vibrio infection,COPD with AE,Plan,A+B IH st+q6h,NS 60cc/hr,CBC/DC/Plt,PT/aPTT,Panel 1,B/C*II,ABG,CXR,Fortum 1 gm iv st+q8h,Minocycline 100mg iv st+q12h,Wound aspiration with culture+Grams stain,Arrange INF admission and consult INF CM,07：27,PM,WBC 8400,Hb 15.8,S/L/B 79/10/7,PLT 99K,PT 10.65/10.3,APTT 27.40/30.9,INR 1.07,Glu 157,AST 24,BUN 46,Cr 1.7,Na 141,K 3.8,08：00,PM,Grams stain,G(-)Bacilli heavy,08：50,PM,Consult PS,(Imp:necrotizing fasciitis Plan:surgical debridement),3/15 05：30,AM,BP drop(78/30),CVP 1 mm H2O,ABG FiO2 60%,PH 7.216,PaCO2 30.8,PaO2 190,HCO3-12.6,O2 Sat 99.7%,Fluid challenge,Dopamine 35 cc/hr,Jusomin use,Clinical course On 3/15,Still low BP despite of fluid resuscitation with Dopamine+Levophed use,Air-hunger despite of ventilator use,Profound metabolic acidosis despite of frequently,Jusomin administration,ATB increased to Ceftazidime 2g iv q8h use,with Minocycline 100mg iv q12h(INF suggest),Patient expired at 11:31 PM,Final culture report,3/17,B/C*II:Vibrio vulnificus,3/18 PUS aerobic:Vibrio vulnificus moderate,Pathology:skin and soft tissue,Lt hand,necrotizing inflammation,3/19 PUS anaerobic:(-)in 5 days,Case 3,Mycotic aneurysm,61,y/o male,DM Hx,suffered from diarrhea for days,then fever and abdominal pain happened.He was,admitted to other hospital.LLQ pain with mass lesion,was noted.B/C revealed Salmonella Gr.D.Abdominal,CT showed abdominal aorta aneurysm.What is your,impression?,Case 4,He also got LBP for daysX-ray L-5 compression fxAbdominal and cardiac echo negative,63,y/o male,with HTN,DM,CVA,complained of dry,cough for 3days and fever for 1 day.CXR showed LLL,infiltration increased.WBC19300 S/L/B 74.5/12.5/5,and CRP 24.30.LLL pneumonia was impressed and,Augmentin was given intravenous.3 days later fever,persisted and B/C discovered,S.aureus.,What do your,think?,Gallium scan showed,T 12 osteomyelitis,FEVER OF UNKNOWN ORIGIN,DEFINITION,Defined by Petersdorf and Beeson in 1961,Temperature 38.3,C on several occasions,A duration of fever of 3 weeks,Failure to reach a diagnosis despite 1 week of inpatient investigation,Durack and Street proposed a new system in 1991,FUO,CAUSE,Big three,Infection25-30%),Malignancy(10-30%),Collagen vascular disorder(10-15%),Unknown(5-10%),FUO,MALIGNANCY ASSOCIATED,Hodgkins lymphoma,Non-Hodgkin lymphoma,Leukemia,Renal cell carcinoma,Hematoma,Colon carcinoma,FUO,AUTOIMMUNE ASSOCIATED,SLE,RA,Adult Stills disease,Temporal arteritis,Mixed connective tissue disease,FUO,INFECTION ASSOCIATED,Intra-abdominal or pelvic abscess,Abscess 1/3 infection origin of FUO,most intra-abdominal or pelvic,Vague localized abdominal pain,Surgical complication or leakage of visceral contents,Liver abscess:,elevated ALK-p,K.pneumoniae bacteremia in DM,alcoholism,Liver cirrhosisLiver echo may be negative,so abdominal CT is important for diagnosis,FUO,INFECTION ASSOCIATED,Osteomyelitis and septic hip,Tenderness over infected site,but some patients only with fever,Associated sign:L-spine OM with root compression sign,vertebral OM with psoas muscle abscess or CV surgery with sternal OM,Septic hip:16%of septic arthritis,most with OA or destructive joint,so that with prolonged and insidious onset,Diagnostic tool:Bone scan or Gallium scan,CT or MRI,FUO,INFECTION ASSOCIATED,Infectious endocarditis,Clue of DX:continuous bacteremia,new murmurs,vascular phenomenon,vegetation on cardiac echo,and unexplained fever,Culture negative endocarditis,Recently received antibiotics,HACEK group organisms,.,H,aemophilus parainfluenaze/aphrophilus,A,ctinobacillus actinomycetemcomitans,C,ardiobacterium hominis,E,ikenella corrodens,and,K,ingella kingae,Fungus,Rickettsia and Chlamydia,TTE(60%)and TEE(95%),FUO,INFECTION ASSOCIATED,Granulomatous infection,TB(extrapulmonary TB or miliary TB)is the most common cause in Taiwan,TB may involve liver,spleen,bone,kidneys,pericardium or meninges and in miliary TB of lung CXR may be negative initial,Bone marrow study may diagnose,Nontuberculous mycobacterial infections and deep-seated fungal infection,FUO,INFECTION ASSOCIATED,Dengue fever,Infectious mononucleosis,Scrub typhus,Typhoid fever,HIV,Malaria,Amebiasis,NG related sinusitis,ANTIBIOTIS CHOICE IN ED(1),Community-acquired pneumonia,PCN 3 MU iv q6h,Augmentin 1.2 gm iv q8h,Augmentin 1#q8h,COPD with 2nd infection,Augmentin,Aspiration pneumonia,PCN or clindamycin 600mg iv q8h,Atypical pneumonia,Klaricid 1#bid,ANTIBIOTIS CHOICE IN ED(2),Acute cholecystitis,acute cholangitis,liver abscess and SBP,Cefamazine 1 gm iv q6h+GM 60 mg q8h,Infectious diarrhea,Ciprofloxacin 2#q12h,Baccidal 1#qid,ANTIBIOTIS CHOICE IN ED(3),Cystitis,Baktar 2#bid,UTI or APN,Cefamazine+GM,Baccidal 1#qid,PID,Clindamycin+GM,Cleocin 1#qid,ANTIBIOTIS CHOICE IN ED(4),Erysipelas,PCN,Cellulitis,Oxacillin 2 gm iv q6h,Prostaphine-A 1#qid,Necrotizing fasciitis,PCN 4 MU q4h+clindamycin,ANTIBIOTIS CHOICE IN ED(5),Bacteric meningitis,PCN q4h+Ceftriaxone(Rocephin)1 gm iv q12h,Endocarditis,Acute:oxacillin q4h+GM,Subacute:PCN q4h+GM,Neutropenic fever,Piperacillin(Pipril)2 gm q6h+GM,SEPSIS AND SEPTIC SHOCK,Definition,Bacteremia,Septicemia,SIRS,Sepsis,Severe sepsis(sepsis syndrome),Sepsis shock,Refractory septic shock,MODS,SEPTIC SHOCK,60-70%,GNB,The chief mediators of sepsis is lipopolysaccharide,In recent years,garm-positive sepsis increased,More patients are being treated at home for chronic immunocompromising disease with indwelling catheters(,S.aureus,and coagulase-negative staphylococci),The frequency of community-acquired infections caused ATB-resistant garm-positive organism increased(,S.aureus,S.pneumoniae,and,S.pyogenes,),SEPTIC SHOCK,PATHOPHYSIOLOGY,Hypovolemia,Relative:increase venous capacitance,Absolute:GI loss,tachypnea,sweating,decreased drink and capillary leak,Cardiovascular depression,Myocardial depression impaired early with vasodepression and capillary leak,Induced by TNF-,and IL-1,overproduction NO and impairment in mitochondrial oxidative phosphorylation,Systemic inflammation,Cause capillary leak into the lung and cause ARDS early in up to 40%of septic shock patients.,SEPTIC SHOCK,CLINICAL FEATURES,Ill appearing,pale,often sweating,usually tachypneic and often with a weak and rapid pulse.,HR can be normal or low,esp.in cases complicated by medication that depressed HR or profound hypoxemia,BP can be normal due to adrenergic reflexes or measurement errors(HR/SBP 0.8 is normal ratio),Urine output is a excellent indicator but require at least 30 min to determine,Measurements of arterial lactate or an arterial base deficit,SEPTIC SHOCK,MANAGEMENT,Monitoring Perfusion Status,EKG monitor,pulse oximetry and cuff BP monitor(q 2-5 min),Urine output(1ml/kg/hr),Normalization of the base deficit or lactate with improving vital signs and U/O,CVP measurement may be required with cardiac or renal failure,SEPTIC SHOCK,MANAGEMENT,Ventilation,Establishing adequate ventilation to correct hypoxemia and pH and to reduce systemic oxygen consumption and LV work.,Ventilator therapy is indicated for progressive hypoxemia,hypercapnia,neurologic deterioration or respiratory muscle failure.,RSI is preferred with anesthetic agent,such as ketamine or etomidate.,SEPTIC SHOCK,MANAGEMENT,Volume Replacement,Intravenous access:Peripheral(2,18-or 1,16-gauge)vs CVP,Initially administer 20 ml/kg of crystalloid or 5ml/kg colloid,In sepsis and trauma patients hydroxyethyl starch solutions resulted in less tissue edema and better preserved microcapillary integrity,Because both ventricles tend to stiffen during shock,a high CVP(10-15 mmH,2,O)is often needed,SEPTIC SHOCK,MANAGEMENT,Vasopressor Support,Dopamine as the most often appropriate first choice,Combination of dobutamine and norepinephrine increase both CO and SVR and to improved indices of tissue oxygenation in patients with severe sepsis,SEPTIC SHOCK,MANAGEMENT,Antimicrobial Therapy,If an focus is found,the antibiotics can be directed by clinical experience,Removal or drainage of a focal source is essential,When no focus can be found,a semisynthetic penicillin with,-,lactamase inhibitor with an aminoglycoside or monotherapy with imipenem-cilastatin is a rational empiric choice,SEPTIC SHOCK,MANAGEMENT,No evidence supports empiric treatment of metabolic acidosis with bicarbonate and only consider when severe metabolic acidosis(pH 7.2),Blood transfusion is indicated if low Hb(100,WBC 16-30,Bacteria,ABG,PH 7.532,PaCO2 22.8,PaO2 58,HCO3-19.3,O2 Sat 93.4%,NS 100 cc hr,Cefuroxime 1.5 gm iv st,+q8h,ABG NRM 10 L/min,PH 7447,PaCO2 28.5,PaO2 259.1,HCO3-19.8,O2 Sat 99.9,1:56 PM,Glu 314,AST 43,BUN 34,Cr 0.7,Na 136,K 3.0,Ketone 2+,Osm 290,3 pm in AICU,DIC was noted(PLT 39k,D-dimer+,FDP40,Fibrinogen 548.5),Severe dyspnea,RR36,Plain,On endo,BT c FFP+PLT,5:40 PM,BP drop 70/40 mm Hg,PEA,start CPCRVTshock 200J PEA sinus tachycardia(HR 180 and BP 177/93),7:12 PM,EKG showed standstill,family sigh DNR,and expired,Final culture report,8/16,U/C:K.P.,8/17 B/C:K.P.,All sensitive to Cefuroxim,