經鼻氣管插管不再流行的原因

以下跟大家說明經鼻氣管插管不再流行的原因。

Nasotracheal intubation 的適應症：

1. 病人接受maxillofacial surgery或dental procedures.
2. 當無法經口插管時：如嘴巴張不開(eg, trismus).
3. 可能有頸椎受傷者(questionable cervical spine stability).
4. 嚴重degenerative C-spine disease.
5. 口腔內有腫塊或病灶。

但，即使是有以上適應症，也建議要採 awake fiberoptic intubation technique，不建議 blind nasal intubation.

Nasotracheal intubation 的缺點：

1. 鼻腔受損。
2. 鼻竇炎、VAP (呼吸器肺炎)。
3. 局部膿瘍形成。
4. 管徑較細使得pulmonary toilet困難。
5. 管徑較細使得airway resistance增高。

Nasotracheal intubation 的絕對禁忌症：

1. 疑似epiglottitis.
2. Midface instability.
3. Coagulopathy.
4. 疑似顱底骨折。
5. 情況危急：Apnea or impending respiratory arrest.

Nasotracheal intubation 的相對禁忌症：

1. Large nasal polyps.
2. 鼻腔內可能有foreign bodies.
3. Recent nasal surgery.
4. Upper neck hematoma or infection.
5. History of frequent episodes of epistaxis.
6. 人工心瓣膜 (increased risk of bacteremia).

結論：綜合以上論述，第一線的插管已不再推崇經鼻氣管插管，取而代之的 technique of choice是「orotracheal intubation under direct vision following rapid sequence induction.」

課程設計研討會

日期：99-12-14
地點：國泰人壽大樓
題目：課程設計研討會
檔案下載：http://jack119.org/mylectures/curriculardesign2010.pdf

手術麻醉前到底要空腹多久？

There is NO recommendation for ROUTINE use of:

• Gastrointestinal stimulants (metoclopramide)
• Gastric acid secretion blockers (H2 blockers)
• Antacids (bicarb, Na citrate)
• Antiemetics (droperidol, ondansetron)
• Anticholinergics (atropine, glycopyrrolate)
• Combinations of the above
  

Hint:

• These recommendations apply to healthy patients who are undergoing elective procedures. They are not intended for women in labor. Following the guidelines does not guarantee a complete gastric emptying has occurred.
• The fasting periods noted above apply to all ages.
• Examples of clear liquids include water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee.
• Since non-human milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period.
• A light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or meat may prolong gastric emptying time. Both the amount and type of foods ingested must be considered when determining an appropriate fasting period.
  

困難氣管內管插管

PE findings of the difficult airway

• Significant obesity (especially neck and face)
• Short neck, limited neck extension, decreased hyoid mental distance (below 3 cm), neck mass, cervical trauma, tracheal deviation and dysmorphic features
• Small mouth (below 3 cm), edentulous, loose teeth, high arched palate, macroglossia, tonsillar hypertrophy, non-visible uvula
• Micrognathia, retrognathia, trismus, significant malocclusion
  

Predicting The Difficult Airway with LEMON

頭皮撕裂傷可以不用縫合，可用頭髮打結後黏起來

Hair apposition technique




RECOMMENDATIONS FOR CLINICAL PRACTICE
Using hair apposition with tissue adhesive appears to be an effective technique for closing simple scalp lacerations. It is faster and better tolerated than suturing, and appears to result in less scarring. The superficial apposition provided by this technique will not be adequate in those cases were deep sutures are required. Using the hair apposition technique appears to be a practical method of treating scalp lacerations.

Ann Emerg Med 2002; 40:19–26.
http://www.aafp.org/afp/20000301/1383.html

Contraindications to Use of Skin Adhesives

Jagged or stellate lacerations Bites, punctures or crush wounds Contaminated wounds Mucosal surfaces Axillae and perineum (high-moisture areas) Hands, feet and joints (unless kept dry and immobilized)

Steps in Use of Dermabond

1. Apply topical anesthetic as needed. 2. Prepare wound with antiseptic. 3. Appose wound edges. 4. Crush Dermabond vial and invert. 5. Gently brush adhesive over laceration. 6. Avoid pushing adhesive into wound. 7. Apply three layers of adhesive.

Lumbar puncture 如何做？

分享網路上找到的三段有關如何做脊椎穿刺的影片。

Nail trephination

Subungual hematoma drainage using nail trephination.

The tool for nail penetration could be anyone of the following:
1. Needle, 18 gauge.
2. Electrocautery tool.
3. Paper clip and sterilizing flame.

槍擊傷害之急診處置

日期：99-12-06
地點：新光醫院
對象：全體急診醫師及PGY、UGY、MS
題目：槍擊傷害之急診處置
檔案下載：http://jack119.org/mylectures/Gunshots_protected.pdf

如何預防老人跌倒

日期：99-12-05
地點：台北馬偕
對象：台灣老人急重症醫學會會員
題目：如何預防老人跌倒
檔案下載：http://jack119.org/mylectures/sgecm_fall2010.pdf