# 低溫療法中要小心低溫期副作用 ACEI D Arrhythmia, Coagulopathy, Electrolyte imbalance(hypokalemia,hypomagnesia, hypocalcemia)( 所以要定期監測 e), infection( 所以要給 prophylax

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PICU 共筆 POST CPCR CARE 口訣 CPC+LKM (LinKou Memorial hospital) IICP sign 1.C: Cerebral A. IICP control ( 口訣 4H+BLS), BLS 比較少用 a. Head elevation b. Hyperosmotic agent Mannitol 2.5ml/kg(Dose,0.

1 PICU 共筆 POST CPCR CARE 口訣 CPC+LKM (LinKou Memorial hospital) IICP sign 1.C: Cerebral A. IICP control ( 口訣 4H+BLS), BLS 比較少用 a. Head elevation b. Hyperosmotic agent Mannitol 2.5ml/kg(Dose,0.5g/kg Max:75ml)/ Q6H 3% NaCl 1ml/kg/hr, keep Na:150~155, Osmo:300~310 c. Hyperventilation( 不是主流 24~48 hrs) d. Hypothermia: 冰枕 keep BT:33~35 C e. BZD/bariturate f. Lasix g. Steroid Brain edema 分為 Cytogenic: 如 Hypoxia Early ( 口訣 ABC: Anisocornid, Babinski, Cheyne-Stokes respiratory) Late: Cushing triad:bradycardia,htn,irregular respiratory Vasogenic: 如 Brain tumor or vasculitis Interstitial( 少 ) B. Seizure( 見 Seizure 一章 ) # 註 : 3%NaCl 算法 BW* 0.6*ΔNa= X ml 3%NaCl* 0.5(3%NaCl 1L=512meq/L) (0.5 and 0.6 大致約分 ) 3% NaCl 1ml/kg 可上升 Na 1meq 可開 BW ml/hr 即為 1ml/kg/hr 的 dose, 一小時上升 1meq # 註 : Mannitol 大致上一兩天即可停掉 Steroid 在 Vasogenic brain edema 才比較有用, 在 hypoxia 造成的水腫效果不大 Osmo Toxicity diruretics caloric Anti-inflammatory cost mannitol Nephron + (dehydration, + + Expensive BP ) 3% NaCL Cheep #IICP 圖示 : 1. 一開始先增加腦壓壓迫腦實質 2. 當壓迫到 hypothalamus (ANS 中樞 ), 開始出現 autonomic dysfunction (neurological shock) (1) Catecholamine 大量釋放 ( 約 2-3 hrs), 臨床上表現為 HR 快 BP 高 (2) 當用完之後,HR & BP 會快速往下掉 3. 當壓迫到 brainstem 後, 呈現 cardiopulmonary failure

2 # 低溫療法中要小心低溫期副作用 ACEI D Arrhythmia, Coagulopathy, Electrolyte imbalance(hypokalemia,hypomagnesia, hypocalcemia)( 所以要定期監測 e), infection( 所以要給 prophylaxis 的 antibiotics: in PICU 至少 vancomycin + fortum ), Diuretics # 回溫要小心 IICP + seizure # 提供上次跟夏主任討論像在基隆沒有辦法做到真正的低溫療法, 我們還有甚麼其他的做法 : (1) 冰枕 (2) anti-pyretic agent ( 幾乎就是 Q4-6H 塞 Voren/Indomethacin (3) 主任提供另外的建議 : gastric lavage with ice water and give muscle relaxant ( 多半是因為肌肉 tremor 產熱導致, 所以可以使用 ) (4) 不過, 如果能轉回去, 越快越好!! ( 主任希望 8 小時內可轉就轉 ) 2. P: Pulmonary: ARDS 特性 ( 口訣 ABCD) Tx: 1. Treat underlying a. Acute onset 2.Lung protective strategy b. Bilateral -Optimal PEEP c. Non-Cardiac ( 須排除心因性 ) -Hypercapnia (PaCO mmHg) d. Data(PaO2/FiO2< 200) -Low tidal volume (6-18ml/kg 之 tidal volume) Oxygen index > 15 考慮 HFOV; Oxygen index > 35~40 考慮 ECMO 3. C: Cardiac: Ischemia heart Tx: Milrinone 使用, 並規則驗 Troponin-I 和 Myoglobulin 4. L: Liver Tx: 也只能觀察 5. K: Kidney (acute renal failu)e Tx: A. 限水 (60~80%: 為 insensible water loss+ U/O) + Diuretics B.Diuretics Step 1: Lasix 1mg/kg/dose Q6H Step 2: Lasix continuous 0.5~1mg/kg/hr= 12~24mg/kg/day Step 3: Bumetanide 0.1mg/kg/dose q4-6h (Max: 10mg/day=1.5ml/hr ) C. monitor: K, Na, Mg 6. M Muscle : Rhabdomyolysis(LAB: 1-2D Myoglobin 上升 ; 3-4D CPK 上升 ; 7D LDH 上升 ) (v.s AMI: 1-2D TnI 上升 ; 3-4D CK-MB 上升 ; 7D LDH 上升 ) Metabolic: Lactate acidosis Hyperglycemia Post-neural damage care 1. Amantadine (Anti-NMDA): 可以 glutamate, 5mg/kg/day x 1 month q12h ( 自費 ) after feeding 2. Piracetam: 可增加腦部血流, 40mg/kg/day start 1 month later, Contraindication: Upper GI bleeding, Intra-Cranial Hemorrhage

3 3. Vitamin B6, dosage> 40mg/kg/day 4. Brain power basic i. Fish oil, DHA ( 可用 IV Smof 代替, 註 :SMOF 為 Soybean, MCT, Olive, Fish oil 的簡寫 ) ii. Vitamin B complex: Hi-Beston( 自費 ) iii. Brain boost nutrition: Gingo, 請家屬自己買 5. consult 復健 for rehab SHOCK SHOCK 原因的 D/Dx D/DX: S: septic H:Hypovolemic O:obstruction(cardiac temponade) C:Cardiogenic K:Kinetics(Distribution) A: Anaphylaxis N:neurogenic P: pancreatitis 臨床表現也是 : SHOCK S: skin molting H: HR O:O2 C:CNS K:kidney( U/O ) 處理口訣 : 灌水 -> 強心 -> 增壓 Catecholamine resistant shock: 特別是 AIR, Neuro 的病人, consider steroid Shock c/w skin rash 1. septic shock 2. Toxic shock syndrome 3. Kawasaki shock Monitor CVP level: neck > 6 mmhg, Femoral CVP = neck + abdominal pressure ( 6mmHg) > 12 mmhg 但是 ileus, constipation, ascites, ventilator use may abdominal pressure If ventilator use, femoral CVP keep > 16 mmhg Monitor perfusion in shock 1. Lactate 2. SVO2 keep > 70%, (Deep Coma, Hypothermia, Anesthesia, Metabolic disorder 代謝慢, 要上修 )

4 VBG 60% 消耗 20-40% Brain Neck VBG >70% Heart ABG 100% GI Femoral VBG >80% 消耗 10-20% Heart rate βeffect αeffect Dopamin <10 >10 Bosmin (low dose) Nor-epinephrine Milrinone Dobutamine X Nitroprusside X X 速算法 : Dopamin, Dobutamine: BW x 6 mg in D5W dilute to 100cc run 10cc/hr = 10mcg/kg/min Milrinone BW x 0.3 mg in D5W total 20cc run 3cc/hr (0.75mcg loading)x 30 min then 1cc/hr (0.25mcg) Bosmin: Resuscitation: 0.3cc dilute to 3cc (0.1mg/cc) give BWx0.1 (ml) (0.01mg/kg) Continuous: BW x 0.15 mg in D5W total 25 ml, run 0.1cc/hr = 0.1mcg/kg/min Hydrocoritisone: 2mg/kg/day (for SLE 長期使用 steroid, and Cerebral Palsy adrenal insufficiency) Albumin: if abumin <2.5, 1g/kg/day, max: nephrotic syndrome 2PC /day, non-nephrotic syndrome: 1PC/day Amiodarone: Loading: 5mg/kg/dose loading over 25 min( 在玻璃瓶 ), then 300 mg in 150cc D5W give BW x 1/4 (ml/hr)= 0.5mg/kg/hr Jusomin: Resuscitation: BW x 2 (ml), 小小孩可先半量, max: 4PC/day BW x 0.3 x Be x 0.5 (ml), central line 可不用 dilute for metabolic acidosis PH < 7.25 (adult), < 7.2 (child), < 6.9 (DKA)

5 Neuroendocrine 變化前三天會先 SIADH, 之後一兩天演變成 DI(Diabetes insipidus)3 rd day, 之後間歇著 Cerebral salt wasting 7 th day Adrenal insufficiency, 14 th day hypothyroidism( 主任說 :DI 出現時間與 brain injury 的嚴重度成正比 ) DI 特性 : Urine SpGr <1.005, Serum Na> 150 一直尿水 DI control: 1.Line A (for deficiency): D5W # 註 : 算法 : BW* 0.6* Measure Na- Desire Na( 抓 150) meq/l Desire Na(150) meq/l BW*1000(ml)*0.6* Δ Na 150 Bw*4*Δ Na ( 單位 :ml) 的 water deficiency Line B(For maintainence):d 0.225S 2.DDAVP use 1 puff Q4H prn(max:2puff) if U/O> # ml/ Q4H # 註 : 算法 : 150% maintain 除以如果 poor response to DDAVP, 以下三種可能 1. DDAVP deficiency ( 劑量不夠 ) 2. Nephrogenic DI Iatrogenic :Aminoglycoside or K 低 ( 因為 DDAVP 與 renal 鍵結需 K 幫忙 ) Other: Hypothermia(Goal BT: 34.5~35.5 C) 3. Hyperglycemia ( 高血糖會利尿如果 DI 之後慢慢變成 Na 低, 以下三種可能 1. DDAVP overdose 2. Adrenal insufficiency 3. Cerebral salt wasting DDAVP overdose Adrenal insufficiency CSW Urine sodium or 120 >120 U/O decrease increase Cortisone 不足可先補充 ; thyroxine 則需等到 14th Day 後再補充, 避免新代率高造成 Neuro 傷害 Coma Coma scale <8 分為 Coma Unconscious 病人的神經學檢查重點 ( 口訣 : REM-BR) R: respiratory pattern: Midbrain 以上的 lesion: Hyperventilation DIVE dorsal 掌管吸氣 /ventral 掌管呼氣呼吸 pattern: Cheyne-stokes supratentorial lesion Central neurogenic hyperventilation midbrain Apneusis pons Cluster breathing lower pons Ataxic breathing medulla

5mm IICP: sunset eye 因為壓到 CN3 CN6 lesison: cross eye 鬥雞眼 Pinpoint lesion: pons Midbrain 快呼

6 cerebrum Midbrain Pons/medulla E: eye 觀察 pupil 的 size 及位置 size: Newborn 2~2.5mm Children 2.5~3mm Adult 3~3.5mm IICP: sunset eye 因為壓到 CN3 CN6 lesison: cross eye 鬥雞眼 Pinpoint lesion: pons Midbrain 快呼慢呼 Pupil 小 Pupil 大 pinpoint M: posture (motor 的重點是 posture, decorticate /decerebrate) BR: Brainstem reflex 1. Light reflex midbrain Corneal reflex: pons 5 6

3. Gag reflex: medulla: 9 10 4. -Doll eye sign +: brainstem okay -: brainstem depressed - Cold Caloric test: 5.

7 3. Gag reflex: medulla: Doll eye sign +: brainstem okay -: brainstem depressed - Cold Caloric test: 5. Early herniation sign: A: Ansocornia B: Babinski sign C: Cheyne stock respiratory pattern 6. Late IICP signs: Cushing triad = hypertension, tachycardia, RR Encephalitiis Encephalopathy = cortical dysfunction: behavior change, psychiatric, loss of conscious, seizure Encephalitis = encephalopathy + 2/4 (EEG, MRI, CSF, Fever) Mycoplasma 可以是各種表現 Temporal lobe: HSV Basal ganglion: Influenza Thalamus: JVE Brain stem(cerebellum, thalamus) : Enterovirus 71 Lab: Pulse 前 check LDH, Ferritin, Anti-TPN, 後 follow Ferritin, LDH, encephalitis 套餐 CSF 只有 lactate 高, 要注意 mitochondrial disease Treatment: 1. Seizure control 2. Anti-microbials i. Tamiflu

8 ii. Azithromycin 10mg/kg/dose QD iii. Acyclovir 10mg/kg/dose q8h 3. Anti-inflammatory i. Methylprednisolone 1mg/kg/dose q6h, (if status or GCS < 8 pulse therapy pulse therapy 1mg/kg/dose q6h x 4 day, q8h x 2 day, q12h x 2 day, qd x 2 use steroid > two week, tapper 要慢, 注意 adrenal crisis ii. IVIG 2g/kg 分成五天打 or plasmaphoresis if s/s deteriorate 4. IICP control i. Mannitol 2.5cc/kg/dose (Max:75cc/dose) to prevent IIcp +- Half > 30 min, q6h x 3 days 再 tapper, seizure < 30min, 可打 stat one dose mannitol q8h x 1 day, q12h x 1 day, qd x 1 day Conscious change 口訣 :AEIOU TIPS 1. Abuse/alcohol/anemia 2. Electrolyte/encephalopathy/endocrine/epilepsy 3. Infection/intussusception 4. Oxygen, opioid 5. Uremia 6. Trauma/Toxin/Temperature 7. Insulin /Hypoglycemia/inborn error of metabolism 8. Psychogenic/porphyria/pharmacology 9. Space occupy lesion, Stroke, SAH, seizure, sepsis Young stroke/tia 1. 血管本身 A. Vasculitis: check ANA, C3,C4, B. Vasculopathy i. Metabolic: check TG, cholesterol, homocysteine, or Mitochondrial disease ii. Congenital: Moyamoya disease MRA iii. Acquired: Trauma, carotid artery disease 2. 血管內的 disorder(thrombus) A.Hemologic: check PT/APTT, D-dimer, Protein C and S, anti-thrombin III B.Cardiologic: check cardiac echo for thrombus (CHD, valvular disease, operation) C.Septic embolism 3.Intravascular calcification A.If newborn: toxoplasma or CMV B.If neurologic patient: suspect neuro-cutaneous disease: tuberosclerosis, choroid plexus tumor(ex: papilloma, 發生率 2 nd ventricle > 3 rd > 4 th ) ii.

9 Seizure Ativan 0.1mg/kg Max: 4mg Step 1 BZD Diazepam 0.25mg/kg Max: 10mg X 2 次 Midazolam 0.1mg/kg Max:5mg Step2 Loading: Luminal / Dilantin / VPA(depakine) / Keppra Max: 用 40kg 算 ( 一支 100mg) (250mg) (400mg) (500mg) Max:7~8 支 3 支 2 支 2 支 All loading 20mg/kg/dose run 20mins Maintain: Luminal/Dilantin 2mg/kg/dose(6mg/kg/day) Q8H VPA/ Keppra 30~60mg/kg/day Q8H 如果仍無效, 可考慮加用 4 種廣效藥物 Depakine/Lamital/Keppra/ Tobramax 如果之前即有 AED 1.check level 2.Re-loading Luminal 1mg/kg/dose 可上升 0.9 Dilantin 1mg/kg/dose 可上升 0.6 VPA 1mg/kg/dose 上升 4 Step3 無效的話, on line and on ETT Midazolam loading 0.1~0.2mg/kg/dose Infusion 2mcg/kg/min ( 約 BW/40) Max:20mcg/kg/min Citosol/ propofol Midazolam 會 distribution 到 fat,tapper 要小心!! 另 > 10 mcg/kg/min BP 會 drop Step4 Lidocaine 20=>100mcg/kg/min Step5 Ketogenic diet IV(Fat: sugar+ protein= 3~4:1), TG keep <500, avoid pancreatitis Status epilepsy 一定會 IICP!! 所以要 4H BLS 控制 Hypoxemic ischemia encephalopathy 的 Seizure 藥物首選 Luminal/ BZD (side effect: 口鼻分泌物 ) Post HIE Acute stage AED Luminal Midazolam Keppra/ Depakine/TPM/Lamicta Post traumatic seizure Chronic stage AED Luminal+ rivotril( 現可用 clobazam)+ Keppra+ TPM Early: < 7 days, 預後好

10 Late: > 7 days, 預後差 7 days 後做 EEG, 如果沒 finding 可慢慢 tapper 藥物有 finding,aed 要吃兩年 AED 的選擇 1. Neurotransmitter: - 興奮 : Glutamate - 抑制 : GABA 2. Voltage-gate ion channel: - 興奮 : Na, Ca - 抑制 : K ** Vitamin B6/GAD: 增進 Glutamate GABA 機轉不明但屬廣效 BZD PHT Luminal VPA Keppra Topamax Lamital Tegretal Na blocker ++ +/- +/-? 沒有 K agnosit Ca blocker GABA agonist ++ +/ ? + + Glutamate blocker +? ++ + 框起來的四種為廣效 local and general 機轉都有 VPA( 有 IV form)/keppra( 有 IV form)/ TPM/ Lamicta 四種 renal 代謝 : LG-TV(L: keppra, G:gabapentin, T:topramax, V:Vigabatrim) 四種易過敏 ( 含苯環 ): Tegretal/Luminal/PHT/Lamital

11 Seizure 型態 Frontal lobe Temperal lobe 特性來的快去得快有 aura Aura X OO Ictal period OOO( 因動作劇烈 ) O( 因小抽,focal) Seizure 一定要問 AIDD Aura, Ictal 表現, duration, post ictal 變化 Duration 短長 Post ictal X OO GI s/s seldom often Seizure 原因 ( 口訣 :CDEFGHI) AST/ALT BUN/Cr C: CNS structure 可排 CT, MRI D: drug level E: electrolyte(na, Ca)/Encephalopathy(Hepatics, Uremic, Inborn error metabolism) F:Febrile convulsion G:glucose 臨床 step 1 有無 fever H: HIE 有 fever: CNS infection/febrile I: infection 可驗 CBC/DC CRP, PCT convulsion / Inflammation SLE/vasculitis survey 無 fever, 如右 CDEFGHI ABG.Lactate,ammonia, sugar Nystagmus 分 Horizontal ear 的問題做 BAEP! 小腦的問題做 Finger-nose-finger Vertical brainstam 的問題 : light reflex/corneal reflex/gag reflex/doll s eye Brain CT Mass effect 1. 同側 venticle 消失 2. Midline shift 3. Suprasella cistern(basal cistern) 消失 < 1y/o 有 0.4~0.5cm subdural space, 因為 frontal lobe 晚發育

12 Basal cistern 五角形消失怕 uncal herniation brainstem compression by uncal herniation 1. 會 Neurogenic shock (24~48hrs) 2. Autonomic dysfunction,( 類似腸病毒, sugar/bp/hr ) 因為內源性 catecholamine 大量釋放最後 catecholamine 用完後 Neurogenic myocarditis Cardiopulmonary failure ARDS (neurogenic pulmonary edema) TX: Bosmin inhalation High PEEP ECMO MRI: 參考北榮 Dr. 莊銘榮 ppt 1. 先看 T1: 看 structure( 類似 CT), 有無 Infarction (hypo-dense), hydrocephalus, parenchymal mass leision, tumor hemorrhage (hyper-dense) 2. T2 flaring: 看水腫, infection, inflammation, infarction 都會亮, 再和 T1 比較 3. T1 +C i. 腫瘤或感染會亮 4. DWI: 看 iskemia i. ventricle 白 - infarction 黑, ventricle 黑 infarction 白 ii. Stroke, Tumor, Infection 皆會造成 DWI signal 升高 iii. DWI 對在 6 個小時內發生的 early ischemia 和 infarct 的偵測是高度 sensitive 和 specific iv. 相對的, 水分子的 diffusion 愈好,ADC 的值越高 v. 在 Ring Enhencement lesion 的鑑別診斷中 High signal on DWI and low signal on ADC 傾向是 Abscess 5. 常見聯想 i. T2 很亮 => 水或腫 ii. T1 很亮 => 7-14 天的血或脂肪 iii. T1T2 都很暗 => 鈣化 iv. T2 很暗 => 很舊的血或脂肪 v. T1C+ 有顯影 => 腫瘤或感染 6. Hemorrhage i. 看到 T1 Hyper-signal, 想到 Hemorrhage (MetHgb), 這時候出血時間是 3-14 天 (Subacute) ii. T1 hyper => 再看 T2 i. T2 hypo 表示 MetHgb in RBC, 這時候出血時間是 3-7 天 (Early stage subacute) ii. 若 T2 已經變 hyper 表示 MetHgb 已經跑出 RBC 變成 Free type 這時候出血時間為 7-14 天 (Late stage subacute) iii. T1T2 都變 Hypo, 表示已經變成 Hemosiderin, 這時候出血時間大於 14 天 (Chronic)

13 Brain tumor in pediatrics Brain tumor 以大腦天幕分上下上 : 1/3 下 : 2/3 ( 兒童常見 ) 下 : 四種常見 tumor 以位置記上 : Midline 非 midline 非 midline Midline: 由前到後

14 Midbrain Pons Medulla Spinal Cord VEP report N75 P100 left 68 ms 101ms right 63.0ms 109ms ( 約 75ms) ( 約 100ms) Right: Left: Threshold(db): _ Stimululus(DB):1= 40 2= 80 I= 1.95 II = III=4.20 IV= V=6.25 VI= VII= I-III= 2.25 III-V=2.05 I-V=4.30 Threshold(db): _ Stimululus(DB):1= 80 2= 40 I= 1.90 II= III=4.50 IV= V=6.25 VI= VII= I-III= 2.60 III-V=1.75 I-V= I~III: auditory n. to pons, < 3 正常 2. III~V: 看 brain stem 3. I~V: < 正常 4. V~VII: ~ cortex, 長庚沒有做

15 # 如何從 brain sonogram 評估 IICP ( 我盡量按照建志學長教我的寫上去, 但確切的數值可能需要再確定 ) STEP 1 PI N N N RI N N N N=normal range STEP 2 MAP < 10 y/o > 10 y/o Adult MCA 90 +/ / /- 15 ACA 80 +/ / /- 15 PCA 70 +/ / /- 15 Q: 如何區分正常的 PI/RI 代表正常腦壓還是準備 progressed to auto-regulation dysfunction 之前的一小段 normal range? A: 若正常的 PI/RI 但 MAP 已經開始下降, 代表已經是嚴重進展到 dysfunction 的程度了 Cholinergic storm( 副交感 )( 口訣 SLUDGE ) S: salivation L: Lacrimation U: Urination 解藥 : Atropine 0.02mg/kg/dose D: defecation Max: 0.1mg/dose GE: gastric emisis Miosis(pupil 小 )

16 Limb weakness Limb weakness Step 1 Barbinski or DTR 區分 upper motor neuron or lower UMN LMN Step 2 是否有 facial palsy(cn7) ( 在 pons and medulla 交界 ) 有無 Medulla 以上 Medulla 以下 Central facial palsy 中腦以上 lesion Peripheral facial palsy 中腦以 C1~C5 無法抬手呼吸會喘 C5 以下可抬手下 lesion

17 Insensible water loss: 400(ml)/ 但由呼吸器吐出的沒那麼多, 約計算出來的 1/2~2/3 Hydration in PICU(especially 24~48 hrs) 1. DKA 10% of dehydration (max: 4000 ml 算 ) 150~200% maintain 2. Acute abdomen(ischemia bowel) 150~200% maintain 3. Rhabdomyolysis/ Tumor lysis 150~200% maintain 4. Pancreatitis 120~150% maintain 特殊情況 CPC: Cerebral edema / Pulmonary ARDS / CHF 需要限水但又 Rhabdomyolysis 80~100% maintain + early HD/CVVH 若 CPC: Cerebral edema / Pulmonary ARDS / CHF 但又 Acute abdomen or pancreatitis 100~120% maintain Half saline 用於 1. Neuro 2.DKA 3.Acute abdomen Hyperglycemia in PICU 1. DKA (* blood sugar> 180 就會 glucouria 開始利尿 ). DKA 定義 : a. sugar >250 b. Ketone + c. PH<7.2 or HCO3<15 2. Acute CNS insult, EX: seizure, trauma, EV71 3. Sepsis 4. Pancreatitis 5. Drugs, Ex: steroid,tpn Management: BW x 1 (ml) dilute to 2 倍 run 30 min RI run 法 In DKA: i. 1 st hr: Hydration, N/S challenge 20cc/kg x 1, don t give jusomin ii. 2 nd hr~48hr: two bag system i. 50u in N/S 500ml: 0.1u/ml run BW ml/hr 0.1u/kg/hr, initial K <5, 加 KCL ii. If sugar < 100, change to 0.05u/kg/hr iii. If sugar < 70, line B add glucose: D0.225S(420) + 4PC 50% G/W (12.2%), 更高濃度需要 central line (central line max D25W) iv. Monitor Sugar < 70~100/hr, 降太快會 cerebral edema ( 依照 IICP 處理 ) iii. >48hr: SC RI+ DM diet (Start feeding indication HCO3> 15, PH > 7.2 and Sugar < 250 mg/dl) iv. DKA with persist acisosis: i. < 8 hr(12 hr): dehydration related ii. >8 hr(12 hr): RI 不夠 v. DKA 補 jusomin indication: PH < 6.9, CPCR, Arrythemia, 0.1 x BW x Be dilute 兩倍 run 30 min If sugar>220, consider RI: 50u in N/S 500ml run BW/2 ml/hr 0.05u/kg/hr

18 Blood transfusion 1, 洗腎, or acute blood loss(δhb>2) Keep Hb>10 2. PT>15.5S, aptt> 75.5S 輸 FFP * If PT prolonged and APTT 正常可打 vitamin K1 0.1mg/kg stat, Hepatic failure 需打 QD x 3days 3. HUS 禁輸 FFP, 只可輸 wash RBC, LPP 4. 大量輸血 ( 成人 >1000ml, 小孩 > 25ml/kg), 要小心 Electrolyte 大亂 (K, Ca )and TRALI(transfusion related acute lung injury) Diamox (Acetazolamide) 功能 ( 口訣 2A2D) 1. AED~ catamenial epilepsy 的第一線用藥 2. Alkalization urine~ 當 blood HCO3> 40, Dose: 10mg/kg/dose Q12H*2 days 3. Diuretics 4. Decreased IICP( 高山症 ) 其餘 dose: 5mg/kg/dose Q12H MIlrinone BW*0.3 in D5W/ NS, total 20ml, Loading 3ml/hr* 30mins= 0.75mcg/kg/min Maintain 1ml/hr=0.25mcg/kg/min Fentanyl 1ml dilute 到 total 5ml, run BW/10 ml/hr= 1mcg/kg/hr Intoxication 口訣 CLEAN+HD Charcoal( 四小時內 ) Lavage( 一小時內 ) Emesis( 不建議 ) Anti-dote Hydration+ Alkalosis Diuretics/ HD 那些 Charcol 沒用?( 記法 : 小藥罐 PHIALS, Vials 字頭改成 PH ) Pesticide 農藥 Hydrocarbon Iron Acid and alkalosis Lithium Solven 溶劑 Traffic accident 1. Liver: hematoma ( 有 capsule 包住, 可稍微抑制出血量 ) 2. Pancreas: 斷裂 ( 因為橫跨在 spine 前 ) 3. Spleen hematoma, rupture: 無 capsule, 容易大量出血造成 shock

《附件二》

《附件二》徴 71 71 0 5 71 80% 3 7 71, 7 3 7 71 tremor ataxia 疱疱 tremor 24 疱 myoclonic jerks brief history present illness 1.general symptoms and signs 2. neurological symptoms and signs myoclonic 3. cardiopulmonary