Microsoft PowerPoint - 簡報-Henry

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重點精神在於快速決定病患的嚴重程度級治療優先順序一名機車車禍傷患由EMT至於長背板上推入主訴右膝嚴重疼痛檢傷血壓86/50mmHg 心跳 80BPM 請問檢傷幾級若檢查發現

1 檢傷: 分級急診疾病特定檢傷分類陳輝財醫師新光醫院急診醫學科國際上較通用的方式為四級的分類和一開始針對大量傷患的分級相似有些國家使用五級或三級的分法衛生署檢傷一級病況危急應儘速處理檢傷二級無立即生命危險應在二十分鐘內處理檢傷三級應在六十分鐘內處理檢傷四級可延後處理或門診治療一位中年男子因胸痛冒冷汗求診因其症狀疑似心肌梗塞請問這個病患應該檢傷幾級重點精神在於快速決定病患的嚴重程度級治療優先順序一名機車車禍傷患由EMT至於長背板上推入主訴右膝嚴重疼痛檢傷血壓86/50mmHg 心跳 80BPM 請問檢傷幾級若檢查發現病患有內出血現象懷疑脾臟破裂若檢查發現病患無任何內出血現象病史詢問該病患從小一打針就暈倒兩個診斷為心肌梗塞的病患其中一名病患到院時生命徵象穩定另一名則到院時已呈心因性休克狀態請問兩名病患的嚴重度相同嗎

2 目的強調檢傷是個動態的過程做出疾病診斷及治療後以通行之疾病嚴重指標作re-triage 試圖充分反映疾病的嚴重度針對治療後病患病情的變化改變檢傷級數直接反映病情嚴重度及治療成效特定疾病檢傷 disease-specific triage 指標性疾病慢性阻塞性肺疾病氣喘胰臟炎心衰竭中風慢性阻塞性肺疾病 GOLD (Global Initiative for Chronic Obstructive Lung Disease) stages NHLBI (National Heart, Lung, and Blood Institute) - WHO, 00 GOLD stages Stage Characteristics : At Risk Normal spirometry Chronic symptoms (cough, sputum production) : Mild COPD FEV/FVC < 70%, FEV 80% predicted With or without chronic symptoms (cough, sputum production) : Moderate COPD FEV/FVC < 70%, 0% FEV < 80% predicted (IIA: 50% FEV < 80% predicted) (IIB: 0% FEV < 50% predicted) With or without chronic symptoms (cough, sputum production, dyspnea) : Severe COPD FEV/FVC < 70%, FEV < 0% predicted, or the presence of respiratory failure,* or clinical signs of right heart failure FEV and FVC FEV Forced Expiratory Volume in second, 一秒內用力呼氣量男性 FEV (公升) 正常 = 0.09身高 (公分) 0.00年齡.97 女性 FEV (公升) 正常 = 0.066身高 (公分) 0.090年齡.57 FVC Forced Vital Capacity, 用力肺活量 * Respiratory failure: PaO < 8.0 kpa (60 mm Hg) with or without PaCO > 6.7 kpa (50 mm Hg) while breathing air at sea level.

3 The National Asthma Education and Prevention Program (NAEPP ), 997 一級 Severe Persistent Asthma Symptoms: Continual symptoms after inhalation treatment for times, Severe dyspnea without activity, Impending respiratory failure Lung Function: FEV or PEFR <60% predicted, PEFR variability >0% 二級 Moderate Persistent Asthma Symptoms: Limited physical activity, Dyspnea after mild activity, Frequent exacerbations, Daily symptoms, Daily use of inhaled short-acting beta-agonist, Exacerbations or more times a week; may last days Lung Function: FEV or PEFR >60%-<80% predicted, PEFR variability >0% 三級 Mild Persistent Asthma Symptoms: Dyspnea on exertion, Symptoms > times a week but < time a day, Exacerbations affect activity, Nighttime > times a month Lung Function: FEV or PEFR >80% predicted, PEFR variability 0-0% 四級 Mild Intermittent Asthma Symptoms: Asymptomatic but occasional exacerbations, Symptoms < times a week, Exacerbations brief (from a few hours to a few days); intensity may vary, Nighttime < times a month Lung Function: FEV or PEFR >80% predicted, PEFR variability <0% APACHE scoring systems British Thoracic Society (BTS) rule Only two categories severely ill and not so severely ill American Thoracic Society (ATS) rule CURB-65 score, Thorax 00 Pneumonia Severity Index, NEJM 997 Depends on variables only available in hospital

CURB-65 severity score CURB-65 severity score management groups when urea is available One point given for each feature present Initial C U R B 65 Description Mental Confusion.

4 CURB-65 severity score CURB-65 severity score management groups when urea is available One point given for each feature present Initial C U R B 65 Description Mental Confusion. Disorientation in person, place or time. (AMT score of 8 or less.) Blood Urea > 7 mmol/l Respiratory Rate >= 0/min Low Blood Pressure. Diastolic blood pressure (DBP) <= 60 mmhg or systolic blood pressure (SBP) < 90 mmhg. Age >= 65 years CURB-65 score 0 or Description Mortality low (.5%). Likely suitable for home treatment. Mortality intermediate (9.%). Consider hospital supervised treatment. Options may include short stay in patient or hospital supervised outpatient. or or 5 Mortality high (%). Manage in hospital as severe pneumonia. Assess for ICU (intensive care unit) admission especially if CURB-65 score = or 5. PSI - pneumonia severity index Demographic factors Age: Males: Age (in years) Females: Age (in years) -0 Nursing home resident: - pneumonia severity index Comorbid illnesses Neoplastic disease: Liver disease: Congestive heart failure Cerebrovascular disease: Renal disease: +0 - pneumonia severity index Physical examination findings Altered mental status: Respiratory rate 0/minute or more: Systolic blood pressure <90 mmhg: Temperature <5 or 0 or more: +5 Pulse 5/minute or more:

5 - pneumonia severity index Laboratory findings ph <7.5: BUN >0.7 mmol/l: Sodium <0 meq/l: Glucose >.9 mmol/l: Hematocrit <0 percent: PO <60 mmhg (): Pleural effusion: +0 一級 >0 total points 二級 9-0 total points 三級 7-90 total points Mortality Range: 7.0~9. Mortality Range: 8.~9. Mortality Range: 0.9~.8 四級 70 or fewer points Mortality Range: 0.~0.6 胰臟炎 Pancreatitis Ranson s criteria APACHE II scoring systems Balthazar Computed Tomography Severity Index APACHE II CT Severity Index Element Finding grade of acute pancreatitis normal pancreas 0 pancreatic enlargement inflammation involving pancreas and peripancreatic fat single fluid collection or phlegmon two or more fluid collections or phlegmons no necrosis 0 necrosis of / of pancreas necrosis of / of the pancreas necrosis of more than / of the pancreas 6 degree of pancreatic necrosis Points 5

CT Severity Index 胰臟炎 Pancreatitis 利用Ranson s criteria: Classfication severity index mortality complications 0-0% 0% - % 8% -6 6% 5% 7-0 7% 9% 胰臟炎 Pancreatitis 心衰竭 Ranson s criteria 一級 > 6 Predicted

6 CT Severity Index 胰臟炎 Pancreatitis 利用Ranson s criteria: Classfication severity index mortality complications 0-0% 0% - % 8% -6 6% 5% 7-0 7% 9% 胰臟炎 Pancreatitis 心衰竭 Ranson s criteria 一級 > 6 Predicted mortality of 00% 二級 5-6 Predicted mortality of 0% 三級 - Predicted mortality of 5% 四級 < Predicted mortality about % 心衰竭 NYHC Classification Class IV patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest. Class III patients with marked limitation of activity; they are comfortable only at rest. Class II patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion Class I patients with no limitation of activities; they suffer no symptoms from ordinary activities 6

目录 8.3 NOC 医疗服务声明执业注册申请表医疗器械入境申请表药物入境申请表 17

目录 8.3 NOC 医疗服务声明执业注册申请表医疗器械入境申请表药物入境申请表 17 目录 1 概述 1 2. 相关政策 2 2.1 代表团随队医生执业备案 2 2.2 代表团医疗专业人员保险 2 2.3 代表团药物和医疗器械进出境 2 2.4 代表团随队医生药房服务及处方权 3 2.5 运动员治疗用药豁免 (TUE) 3 2.6 医疗费用政策 4 2.7