Duty Round

Handle , Survive and Off

 Duty Round
Section 1: when you meet fever and consciousness change

R3 徐靖浩 6257C
20200831
What is most important when your are on
duty??
• Vital sign is everything!!!!!
• Always remember to visit the patient!!!!!
• Remember to call for help!!!!!!
 Fever caused by infection??
• Vital sign!!!

• Fever survey!!!

• Antibiotic!!!

• 退燒>>>consider patient’s risk of desaturation, seizure….

desaturation, hypoxia..
 Antibiotic 的即早給予大大的影響病人的存
活!!!!
• 如果確定是sepsis 引發之fever >>> 開血單的同時，覺得不對勁，
趕快換Anti !!!!!!
• 考慮到病人情況差，
抽血抽完請直接開立
Anti更換!!!!!!!

Duration of hypotension before initiation of effective antimicrobial therapy is the critical

determinant of survival in human septic shock
Lab , 要抽什麼?
• CBC, DC, basic SMAC(AST, ALT, T-Bil, BUN, Cre, CRP)
• Blood culture(有 line記得要從 line 留一套), at least two set!!
• Urine routine
• Urine culture
• Tip culture(CVC)
• Sputum stain, culture(TB)
• Chest X-ray
• GAS, lactate(if unstable vital sign; desaturation is not the only
indication for GAS survey!!)
 Survey what??
• Find focus first!!
• Previous culture data
• ICU or hospital or admission
• Post procedure or not(Post TACE? Post ERCP? ?)
• Previous immunocompromised history??(cancer??autoimmune??old??post-
chemo??)
• Immunocompromosed: neutropenic, hema post-transplan, cancer
腸壁變薄,腸道GNB, 身體GPC易跑到血中
• PE!!(dyspnea??dysuria??skin redness??focal neuron sign??swelling??)
• 哪裡的症狀考慮哪裡感染！！
• Line??(Port-A??CVC??Foley??)
• 如果管路紅腫, 管路抽血長出的速度比周邊快, 盡可能及早移除,考慮GPC感染
• Long term TPN, hema, ICU patient---consider fungus
值班常見發燒迷思
Q1. 學長,病人一直燒怎麼辦啦
• 病人如果今天剛換anti, 人沒有toxic sign,發燒的peak也在降,可以再
留一套blood culture後退燒觀察
• 但如果desaturation, hypotension, 建議還是考慮換anti
• 要換什麼anti??要考慮的是,沒有cover到的東西!!
• 我能cover pseudomonas嗎?（院內感染）
• 能cover ESBL嗎（常進出醫院）
• 能cover GPC, MRSA嗎（管路感染）
• 能 cover厭氧菌,腸內菌嗎（肚子破掉, aspiration pneumonia)
• 能 cover CRAB, SM, 伊莉莎白, CRE, CRKP嗎？(ICU)
Consider more uncommon cause!!!!
• If still think is fever caused by infection??
• Fungus>>>fungus culture from blood or sputum
• Virus(Influenza, respiratory virus)>>>Influenza PCR or screen（screen
sensitivy only half）, respiratory virus panel, atypical respiratory panel)
• CNS: lumbar puncture, menigitis panel
• Diarrhea: clostridium difficile infection? Or other infection diarrhea？？
• PCT: a test to distinguish whether fever is came from infection!!(>0.5)
• CMV>>>CMV PCR From blood or bal
• TB>>>Three TB Set
Q2:學長！病人早上已經有抽過血了，還要抽嗎！
• 去看病人！
• 新的fever peak
• 病人狀況變差
• Consciousness change
• 本身underlying disease ，讓人不安....
If antibiotic already exist, should I change or
upgrade antibiotic??
• 要打什麼？？穿透力好嗎？？濃度夠嗎？？是不是有什麼沒cover
到？？
• Fever curve>>Anti的效力發揮了嗎? Peak間距有拉長嗎？
• Cover >>GNB>>GNB cover ESBL + GPC cover MRSA>> drug resistance
• 抗生素，很難!!!有空，寫個note，把你的想法留下來，互相討論
Remember!!!!!!!
• Vital sign is everything!!!!!
• Always remember to visit the patient!!!!!
• Remember to call for help!!!!!!
好朋友
• Cefe, Unasyn, Augmentin (我們可以開出不用審核的最強抗生素)，腹內
感染，procedure愛使用
• Ceftazidime, Cravit: cover pseudomonas
• Tazocin,Cefipime, Cefpirome: probably cover ESBL, anaerobic, cover
pseudomonas
• Carbapenem: definitely cover ESBL, anaerobic, (Erta不咖Pseudo, Dori 沒
evidence for lung)
• GPC: Vancomycin(loading dose, trough level), Teicoplanin(loading dose!),
Linezolid(brain), Daptomycin,
• 最終兵器: Tigecyclin (3P不 cover，blood and urine no evidence)
• CRAB: sulbactam, Brosym, colistin
抗生素沒有一定的配方!!!!
• focus找的對, 打的到, 副作用不影響治療，都可以!!!!
• 請勇敢的找值班區域的感染科老師討論!!!!
• Culture 出來記得降階
Consciousness loss
值班的我

病人
Consciousness change, 先看….
Vital sign!!!!
神經學檢查（pupil size,muscle power, GCS, Babinski ）
血壓，氧合，體溫，心跳，呼吸次數!!!
可以馬上做什麼?
• Review drug!!!! Beware of overdose morphine, BZD, psych drug, toxin…
• Check glucose!!!! Hypoglycemia>>D50W
• Focal neuron sign :Babinski positive? DTR hyperactive? Face?Pupil?
• GAS!!!>>>sent to recent ICU if needed>>>immediate PH, basic electrolyte?
（中正樓14樓RCUA,2樓MICU,思源樓5樓RCUB,4樓CCU,抽完血帶病人貼
紙請護理師幫忙弄）
• Vital sign, hypotension or not!?>>try fluid challenge if indicated
• EKG: arrhythmia ? AMI??
• PE: arrhythmia?? abnormal breathing sound or breathing pattern?? ,
muscle twiching?
Lab, 要抽甚麼?
• 要先尋找consciousness change 的原因!!!
• 基礎的survey可以找:
• CBC, DC, electrolyte imbalance(Na, K ,Ca, CL), survey GAS, Lactate,
CRP, BUN, Cre, T-bil, AST, ALT, Ammonia(if previous liver related
history), cardiac enzyme, PT, APTT
什麼時候，要急做 image?
• 你覺得有需要，就做！病人有high risk 就做！
• 有需要: fall down, new onset focal neuron sign, TIA, seizure…
• High risk: fall down, NOAC or antiplatelet use, previous stroke, cancer
that may involve CNS
• 懷疑stroke的同時，電聯值班神經科CR評估NIHSS!!
五分鐘工商服務！！怎麼找會診CR！？
Endo indication
• Protect airway!! (Tonic-clonic Seizures , massive GI bleeding)
• Vital sign undtable may be needed!!
• GAS is your guidewire
Consciousness change，隨時做好最壞打算
• Prepare for ACLS
• Prepare for acute HD!!!!
• Acidosis：嚴重酸血症(pH<7.1)，且不適合給sodium bicarbonate者
• Electrolyte：對於藥物反應不佳的高血鉀
• Intoxication：部分藥物和毒素可以經由透析除去
• Overload：給予利尿劑後，仍無法控制的體液過多
• Uremia：出現尿毒症狀
 VGHTPE PGY Duty Round
Section 2: Shock, GI bleeding & I/O management

Date: Aug. 31, 2020 (v2.0)

Presenter: Guo, Jiun-Yu
R3, Department of Medicine, Taipei Veterans General Hospital.
 My Suggestion
Check & Stabilize Vital Sign • 看病人! 露臉少糾紛!
• O2, IV, Monitor • 沒Vital sign就啥都沒有

Survey etiology!!!! • 求求你至少先Survey吧!

• Hx, PE, Blood, Image
• 小夜結束前有Data

Management (+/- Call help) • OBS前先想想!

• 大廟和尚多，不要怕!
• Fluid, Meds, Procedure, ICU, Assistance?
• Call help 打群架!
若病況允許
建議有Data決定是否上報 • 睡前巡視好入睡
Zzzzz & Shift handover • 留下Duty Note & 請主護交班
• 後續追蹤! 知道自己的判斷&能力
• 認清同儕! 知道以後可以倚靠誰
 Shock

GI Bleeding

I/O
1. Check & Stabilize Vital Sign
先抓出Shock之前的徵兆，防範未然！
HR/RR↑(早期) & BP↓(晚期)
U/O↓  i.e. 沒有尿!!
Cold/cyanotic skin
𝛥Con’s (= cerebral circulation)
Renal function↓, metabolic acidosis (esp. lactate!)
買時間，初步處置！
ABC?
On大號IV (不是CVC!)
抽血：三管 + ABG + 備血
* CBC/DC + 肝腎 + lactate +e- + PT/aPTT/d-dimer + 心(enz/NT pro-BNP)
EKG?
Image? (CXR, CT/CTA)
2. Survey Etiology

Septic • Fever, chillness, DOE, ongoing infection, neutropenic condition

Hypovolemic • Bleeding, diarrhea, trauma, poor oral intake

Cardiogenic • DOE, desaturation, chest pain, arrhythmia, extreme tachy/brady

Obstructive • DOE + known coagulopathy, malignancy, thrombosis (E.G. DVT)

Anaphylactic • Sudden onset, rash, stridor/wheezing, drug exposure

3. Management
Septic shock
Surviving Sepsis Campaign 2018: “Hour-1 Bundle”
 Lactate level! (recheck if >2mmol/L = 18mg/dL)
 Blood Cx (before ABX)
 Broad-spectrum ABX
 Fluid: 30mL/kg crystalloid rapidly (hypotension or lactate ≥4 mmol/L)
 +/- Vasopressors: MAP ≥ 65 mmHg!
 Steroid (?)
我的經驗
 不要只會掐水! (快速掐30mL/kg???)
 決定掐的強度: DNR status, age, BW, heart, Alb…
 莫忘Albumin 4 amp ST (專案用藥申請)
 頭低腳高
 Levophed是你的好朋友
3. Management
• Cardiogenic Shock:
三大種類：
 Arrhythmic (tachycardia, bradycardia)
 Mechanical (VHD, AMI)
 Cardiomyopathic (esp. AMI)
First: Confirm ACS or not!!!  Immediate intervention?
Vasopressor, Inotropies, mechanical support
3. Management
• Anaphylactic Shock:
• Epinephrine (0.3-0.5 amp, IM, Q5-15M)!!
[NOT 1amp, NOT IV (more adverse rx), NOT Anti-Histamine!!]
• Fluid + IV line
• Airway!
 Shock

GI Bleeding

I/O
1. Check & Stabilize Vital Sign
永遠先問 Vital Sign!!
 血壓? 心跳?
 Hemorrhagic shock: Stage I, II, III, IV ? (但…準嗎?)
可以跟妳要個Line嗎?
不要遲疑! Before profound shock!
順便抽血+備血
流速: 大支Cath >>> CVC
加值項目
NPO?
On NG Lavage?
• UGIB: 無法協助確診，(-)也無法排除
• EVB: 也可以On (c.f. GI交班: 剛綁完EV不要on)
• 可加速執行胃鏡、但是沒有額外benefit
On endo?: 保護呼吸道、喘
2. Survey Etiology
一定要問Underlying
先看顏色猜猜看: Terry? Bloody? BUN/Cr (>20~30:1: UGI), try DRE?
GU/DU?
Cirrhosis?  EV bleeding!! (25-35%) [No PHTN, no EV]
Uremia?  Uremic bleeding
GI tumor?
Hemorrhoid?
Medication? (Anti-PLT, Anti-coagulant, NSAID, steroid…)
3. Management
掐水!
NS or LR，小心fluid status
Vasopressor
輸血!
PRBC
 教科書:
 Hb<7開始輸
 目標: >7 or >9 (if active bleeding, stable CAD…)
 EVB: 不要 >10
 2U PRBC: [Hb] +1mg/dL
 PRBC: FFP=4:1
PLT: keep >50K (“理論上”>20K就可以做胃鏡)
FFP: keep INR<2.0
“急救領血”: 可跳過備血流程 (Call 血庫!!)
3. Management
止血!
藥物 (你!):
 High dose PPI: 80mg ST  40mg Q12H (間斷給效果同pump) (cf. H2B無益處…)
 Somatostatin pump: GU/DU, EV (Octreotide)
 Telipressin: EV (GU/DU證據較少)
 Transamine: 無證據
 Uremic bleeding (ddAVP, Cryo, estrogen)
 藥物治療在UGIB比較有證據，cf. LGIB fluid, BT, scope, angio…
Packing: epinephrine紗
3. Management
止血!
EGD/Colonoscopy (call GI/CRS)
 Time to scope: after adequate resuscitation!!
 Nonvariceal UGIB: <24hr
 Cf. emergent <12hr: 沒有先stable反而增加complication (想走GI嗎？)
 Variceal UGIB: <12hr
 LGIB: <24hr (if high risk, ongoing bleeding)
 Erythromycin IV 250 mg (30m before EGD)
Angio (call RAD)
 Emergent CT angiography  Then angio…
 (X) Barium study
Operation (call GS/CRS…)
ABX prophylaxis: if cirrhosis (+) (e.g. ceftriaxone)
4. Shift handover
Recheck Hb! Recheck Hb! Recheck Hb!
Keep Monitor?
Record I/O, Foley?
交班給本team! (後續胃/腸鏡?)
 Shock

GI Bleeding

I/O
1. Check & Stabilize Vital Sign
永遠先問 Vital Sign!!
喘? 血壓?
怪怪的? 記的去看病人! (病人突然沒尿，你敢just OBS?)
盡信數據? 不如先質疑數據!
比較前幾天數據! (檢查本team是不是太廢)
I/O準嗎?: [NG + Foley + Bed-ridden] vs. [兩光照顧者 + 閃尿杯]
 Loss 幾次?
 Insensible loss: > 800 ml/d (皮膚、呼吸道各400 ml/d) [Fluid Physiology]
BW準嗎?: 換病房? 換磅秤?
2. Survey Etiology
Red flags: Something wrong?
 AUR: bladder scan, Foley…
 Sepsis: BT, BP, Lab, U/O…
 Heart failure: edema, CXR, sono, U/O…
3. Management
考量點:
Fluid status: CXR, PE, Na/K, BUN/Cr
ALB: intravascular oncotic pressure
掐水空間: Age & BW
腎功能決定灌/脫水效果
給水?
Na/K, oral intake: 決定N/S, 1/2S? +/- D5?, +/- K?, Taita3/5?
夜班我建議你慢慢掐! (e.g. 1bot keep overnight)
脫水?
Loop > Thiazide & MRA
留意K! K! K! (你知道多少人因為低血鉀CPR嗎?)
 不掉K (GI黃金比例): spironolactone : furosemide =100:40
強化脫水(?): $Alb, FP (窮人版Alb) 其實證據不強…
Foley: 關係病人(&你)的睡眠品質
4. Shift handover
Record I/O, BW?
On Foley? Monitor?
f/u exam? (e.g. Na/K, CXR…)
交班給本team!
先生緣，主人福。
 PGY Round
Section 3: Chest pain, abdominal pain, hyperglycemia

R3 曾致學
大夫，病人說他胸痛
Herpes Zoster
How to Survey
• History and PE
• 悶還是痛？綁綁、雜雜、悶悶？ 痛多久？痛有沒有
radiate到哪裡？會不會越走越痛？ 跟呼吸有沒有關係？

• What else?
• MI: CK + hs-cTnT Q3H (Troponin I? CK-MB?)
EKG Q15-30min or Q6H
• Aortic dissection: CXR, EKG, if highly suspect -> Chest CTA
• Pulmonary embolism: D-dimer, fibrinogen -> Chest CTA
STEMI
Anterior STEMI
Inferior STEMI

做Right side EKG!

Right side EKG – Check RV infarction

V4R
Lateral STEMI
Left Main syndrome – STEMI Equivalent
De Winter T wave – STEMI Equivalent
Posterior MI – STEMI Equivalent

不尋常高的R + STD in V1-V3

做Posterior ECG
Posterior ECG
不尋常高的R + STD in V1-V3 = Q wave + STE
STEMI equivalent
• Hyperacute T
• De Winter T wave
• Left main syndrome
• Posterior MI
• Wellen syndrome
• LBBB fulfilling Sagarbossa criteria/Barcelona criteria
Cardiac enzyme
• “Troponin I” baseline 30% 上升, 可以一直抽 Q4-Q6H
• Hs-cTnT 0-3hr protocol
• CK-MB現在少用
• CK: 通常真正MI要數百或甚至上千
CK正常、TnI高 -> heart failure?....
Cardiac enzyme – hs-cTnT
STEMI Management
• 穩定Vital sign! 穩定Vital sign! 穩定Vital sign!
• Call CV for primary PCI
• Loading Dual anti-platelet
• 3# Aspirin(Ropal) 嚼碎吞服+ 4# Plavix STAT
• Lipitor 1# STAT
• Clexane(LMWH) 6000U Q12H, (考慮）
• NTG? (RV infarction不可用 NTG)
• O2: Keep > 90%
• Pray…..
NSTEMI Management
• 穩定Vital sign! 穩定Vital sign! 穩定Vital sign!
• Call CV for early PCI
• Loading Dual anti-platelet
• 3# Aspirin(Ropal) 嚼碎吞服+ 4# Plavix STAT
• Lipitor 1# STAT
• Clexane(LMWH) 6000U Q12H, (考慮）
• NTG? (RV infarction不可用 NTG)
• O2: Keep > 90%
• Pray…..
NSTEMI Management
• Primary PCI when 血壓不穩、用藥後持續胸痛、VT/VF、EKG有變化
Aortic Dissection
• History: 前胸痛後背，坐立難安
• Four limb BP
• 左右手差20mmHg
• 上肢比下肢高

Calcium sign
Aortic Dissection - Management
• 穩定Vital sign
• Control Blood pressure <120/80 mmHg
• Perdipine pump: 5 amp in 200ml NS -> 5ml/hr
• NTG pump: 5amp in 200ml D5W -> start from 3ml/hr
• Call CVS
Chest pain
• 時時記著最嚴重的D/D
• 大膽假設，小心求證，不要神經過敏什麼都是MI
• Repeat EKG, enzyme, CXR都能提升抓到嚴重問題的機會
大夫，病人說他肚子痛
 大夫，病人說他肚子痛
• Warning sign
• Cold Sweating
• Muscle guarding
• Rebounding pain (整個肚子)
• Massive bleeding: upper or
lower GI
• Vital sign不穩
• 結合History、PE，再排檢查
Survey
• Take history: 痛哪裡？ 有沒有拉或吐？有沒有冒冷汗？ 有沒有解
便？有沒有黑便？ 之前有沒有這樣過？以前肚子有沒有開過刀?
• Physical examination
• Lab data
• General: CBC/DC, CRP
• GU/DU: stool routine, Hb, Hct
• Liver: AST/ALT, AKP, GGT, T-Bil/D-Bil (但肝通常不會痛，除非liver abscess)
• Pancreas: Lipase, Amylase
• Biliary tract: T-Bil/D-Bil, AKP
• Appen: CBC/DC, CRP
• Stool routine, if diarrhea or tarry stool
• Image: KUB, sono, CT 想看什麼再開什麼
 D/D you should keep in mind

• Hollow organ perforation -> 切CT

• Ischemic bowel -> 切CTA
• Tumor rupture -> 切CT or diagnostic tapping or Sono
• Aortic dissection -> 切CTA

• Call 792977急診CT請幫忙急做
• 片子切完看不懂，call 792977急診CT找放射科R問片子
• 問過上級再決定要不要切，CT屬重點核刪項目，但如果真的判斷
非常必要且情況危急，可考慮直接切
望聞問
切
Special Condition Management
• Hollow organ perforation -> NPO, Call GS
• Ischemic bowel -> call GS, start LMWH and wafarin
• Tumor rupture -> 輸血、angio/surgery
• Aortic dissection -> control BP, Call CVS
 1.
• 阿公肚子突然好痛
• 今天沒吃什麼東西
• 突然就痛起來

Double wall sign: perforation

Left Decubitus
2.
• 阿公這幾天都拉肚子
解水便
• 可不可以給阿公止瀉
藥～拜託～
Constipation
• 可選擇以下幾種方式
• EVAC灌腸
• Senokot 7mg 2# HS
• Through 20mg 2# HS
• Lactulose 10-15ml BID-TID
• 請家屬買黑棗汁
• Bisacodyl 2# HS
• Klean powder
• 用手挖
3.
• 阿公肚子脹，在絞痛
• 平常都有在吃通便藥，
三天前有點拉肚子，
值班醫生把軟便藥停
掉，給他開始吃粉就
變這樣了
＊Smecta 1WP TID 14天
Stack of coin sign: ileus
Ileus
• Functional
• 試試看Primperan or Mosapride可以通看看
• Mechanical
• 盡量不要通腸，會破！！

• 不易區分
4.
• 阿公說上腹悶悶的，
以前有胃潰瘍過，能
不能給阿公一點胃藥
就好？
不過阿公有點冒冷汗，血壓有點低（80/50mmHg）
R: 他最近血壓baseline就這樣，沒關係啦～
Epigastric pain v.s. AMI
• 時時刻刻心中放著你的好朋友 AMI

• NTG含了症狀有好一點，一定是angina ???
大夫跟你報個血糖，血糖300要不要加打
How to approach
• 病人在家怎麼控制? OHA or Insulin
• 現在為什麼高? 6I
• Insulin
• Iatrogenic
• Infection/Inflammation
• Ischemia/Infarction
• Intoxication
• 或是嘴饞亂吃
血糖藥
• OHA
• 注意副作用，尤其跟腎功能相關的: SGLT-2, Metformin(lactate
acidosis)
• 注意給付規定: e.g. SGLT-2要Metformin使用後無法控制才能加
• 注意低血糖: Sulfonylurea(e.g. Amaryl), Glinide
• 注意Heart failure & TZD
 快又有效
Novorapid 三段分開調
Apidra 一筆order搞定

Toujeo 作用慢，但持久
易堆積
Levemir 今天開，明天就有效
何時打?
• 一時加打，一時爽，一直加打…. 在幹嘛?
• 加打、低血糖 會讓前面調的亂掉，全盤重調
• 血糖沒超過400，調整前一段(e.g. 晚上300，隔天中午加4U)
• 加量盡量一次2-4U
• RI 1U 降 25-30，要矯正算打到150-200，勿太低

• 盡量不要開PRN加打, 你真的會去看打了多少?
含糖點滴
• DM病人若要使用含糖點滴，要記得加RI
• D10W, Tai. No 5: 8-10U/瓶
• D5W, Tai. No 3: 4-6U/瓶
低血糖
• 血糖<70
• 症狀: cons change, 手抖, 冒冷汗
• 處置: 1-2支D50W IV STAT

• 為什麼低?
• 前一天打太多?
• 病人吃太少?
• 額外的insulin來源?
• 肝腎功能變化? (e.g. Amaryl, Glinide)
• Stress解除忘了下調RI: 感染改善、發炎改善….
• What else you can do
• 確認diet跟最近RI, OHA使用變化
• 點滴中RI考慮停止
• 停掉可能低血糖的藥物
DKA & HHS
• 血糖 show high -> Glu>600
• Survey: Glu, CK, TnI, BUN/Crea, Na/K, VBG, Ketone body
• 謹記6個I

• Show high 一定是HHS? Osm>320, Glu>600mg/dL

• 算!! Serum effective Osm: 2 x [Na] + [Glu]/18
 Hyperosmolar hyperglycemic status

• 灌水!!!! 1000ml NS -> 500ml ½ Saline

• 補鉀 if K <4.5
• IVII
• 10U RI IVA STAT
• Sliding scale correction: 100U in 100ml NS
• Q1-2H 血糖, Q4H Na/K
• 血糖正常後，算一天insulin總量，分
到四段
Thank you
PGY Duty Round
Section 4
Hypertension and dyspnea

臺北榮總胸腔部 R3 廖映庭
Hypertension
 Hypertension
• Etiology
– Medication 加藥(CNS stimulants, steroid, NSAIDs…)/減藥
– Fluid
– Discomfort
• Resistant hypertension: survey for 2nd cause
– Oral contraceptives, pheochromocytoma, Cushing syndrome,
Coarctation of the aorta…
 Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline

Hypertension
• Hypertensive crisis: > 180/120mmHg
• Hypertensive emergency: End organ damage
– Neurologic (IICP, ischemia): headache, blurred vision, altered mental status, seizure,
bradycardia, irregular breathing pattern…
– Cardiac (ACS, heart failure): chest pain, palpitation, dyspnea, fluid overload signs…
– Vascular (dissection): chest pain, BP difference…
– Renal (acute hypertensive nephrosclerosis): oliguria, gross hematuria…
– Eclampsia/ Preeclampsia
• Hypertensive urgency
 Hypertension
• Treatment goal:
– 1hr Reduce maximal MAP <25% (beware of hypoperfusion)
– 2-6hr 160/100-110 mmHg
例外
– 24-48hr Normalize
Aortic dissection
140 in 1h and 120 after 1h
Acute ischemic stroke
180/110 if tPA or
220/110 if no tPA
ICH 140/90
 pump可Google:常用藥物之安定
性與泡製法, 注意劑量(每支多
Medication 少mg)是否與本院相同?

• Review current medication, 尚未給到maximal dose可考慮加量

• 注意contraindications, dosage, side effects

• Parenteral: set a goal SBP or MAP

– Nicardipine (Perdipine)
1mg QxHPRN, or 5Amp in NS 200ml, start with 3-5ml/h
– Labetalol (Trandate)
0.5-1Amp QxHPRN
– Nitroglycerin (NTG)
5Amp in D5W 200ml, start with 3ml/h
10amp in D5W 150ml, start with 1.5ml/h
maximal 3 days
 Common medication AE/ contraindications

ACEi Captopril, Ramipril, Lisinopril, Perindopril Cough, hyperK, AKI, pregnancy

Valsartan, Irbesartan, Candesartan, Losartan,

ARB Telmisartan, Olmesartan, Azilsartan
HyperK, AKI, pregnancy

Atenolol, Bisoprolol, Carvedilol, Propranolol,

β-blocker Nebivolol, Labetalol
Bradycardia, ADHF, asthma, AV block

Amlodipine, Benidipine, Lacidipine, Nimodipine, HFrEF (except Amlo, Felo), peripheral

CCB (DHP) Nifedipine, Felodipine, Lercanidipine, Nicardipine edema

Diuretic hypoNa, K, Mg, P, hyperUA, hyperCa,

Hydrochlorothiazide
(Thiazide) dehydration
 Common medication AE/ contraindications

Hydralazine, Isosorbide dinitrate/ 5-mononitrate, RV failure, IICP, concomitant use of

Vasodilator Nitroglycerin PDE5i

Doxazosin, Terazosin, Tamsulosin, Alfuzosin,

α-blocker Silodosin
Postural hypotension
 Hypertension: Conclusion
• Red flag signs (end organ damage)
• Etiology: medication, fluid, discomfort
• Medication:
– Oral or parenteral
– Contraindications, dosage, adverse events
– 用藥後追蹤療效
– Different BP goal in different diseases
Dyspnea
 ATS guideline for dyspnea Am J Respir Crit Care Med. 2012 Feb 15; 185(4): 435–452.

Dyspnea
• Dyspnea and Desaturation
• 是否須立即插管? Timing for intubation:
– To maintain airway patency or protective reflexes:
obstruction (foreign body, hemoptysis, deep neck
infection, anaphylaxis), conscious disturbance (GCS < 8,
seizure), neuromuscular failure
– Refractory hypoxemia (PaO2 < 60 when FiO2 >50%) or
hypercapnia
“病人現在戴什麼氧氣，血氧如何?”
Nasal cannula (N/C)
1-5L/min
FiO2 24-45 %

Venturi mask (V/M) Non-rebreathing mask (NRM)

4-6L/min 10-15L/min
FiO2 24-50% FiO2 60-100 %
藍24 白28 橘31 黃35 紅40 粉50

All-purpose nebulizer
Simple mask
加濕器
5-10L/min
2-12L/min
FiO2 35-50 %
FiO2 24-100%
Positive pressure ventilation (PPV)
“讓機器幫忙呼吸”
BiPAP
1-15L/min
使用時機:
FiO2 24-80%
Poor oxygenation
Poor ventilation (CO2 retention)
Poor respiratory drive or pattern
Ventilator (MV)
BiPAP: COPDAE, ADHF with APE
FiO2 21-100%
使用後請注意病人與機器的配
合度，並追蹤ABG!
 Non-invasive ventilation indications and assessment | ICNSW

When to consider BiPAP?

• Respiratory failure hypoxemic/ hypercapnic
• Impending failure accessory muscle use, paradoxical pattern,
tachycardia, irritability, drowsiness…
• Etiology that could benefit from BiPAP
– COPD, cardiogenic pulmonary edema, atelectasis

• Remember contraindications:
– Inability to maintain patent airway (出血, 意識不清, 阻塞,
facial trauma), unmanageable airway secretions, profound
hypoxemia, untreated pneumothorax
Common etiology of dyspnea

Metabolic
Airway
Miscellaneous

Cardiac Pulmonary
 Sepsis Angioedema
Anemia Anaphylaxis
Metabolic acidosis Deep neck infection
Ascites Foreign body
Neuromuscular disease Poor airway clearance
Hyperventilation
COPD/ Asthma
Acute coronary syndrome Pulmonary embolism
Decompensated heart failure Pleural effusion/Pneumothorax
Arrhythmia Pneumonia
Tamponade ARDS
Valvular disease Pulmonary hemorrhage
Cardiomyopathy Pneumonitis
 Approach
• Vital signs: fever, shock, tachycardia…
• PE: Consciousness, Breathing pattern, Airway patency,
Breathing sounds, heart sounds, signs of fluid overload…
• Lab
– ABG, CBC/DC, renal function, e-, CRP(pct), Lactate, CK/TnI, D-
dimer, NT-pro-BNP…
• CXR
• EKG
• Chest CT/CTA
 Arterial blood gas
• 抽了gas要會判讀!
1. Acid-base status: pH (7.35-7.45), HCO3 (22-26)
2. Oxygenation: PaO2, A-a gradient, P/F ratio
3. Ventilation: PaCO2 (35-45)
PaO2 / FiO2
ARDS < 200-300

• ABG v.s. VBG ECMO < 70

– pH, HCO3
– 不能推估PaO2, PaCO2 !!!
 Poor oxygenation
Poor ventilation
Hypercapnic
respiratory failure
→ BiPAP

Poor oxygenation
Met. acidosis
Pneumonia and
sepsis
→ ABx, Bicarbonate,
ETT+MV
 大夫，病人原本戴N/C，現在V/M 50%，
血氧有92%，但病人還是覺得有點喘
那戴NRM好了，氧氣就夠了
PaO2~70
P/F ratio: 140
高濃度純氧，抑制呼吸，
並未解決氧合問題
→ CO2 retention
→ acidosis, progressive
hypoxemia
 CPCR!
請找出原因治療病人!
 Treat the etiology of Dyspnea
• Oxygen, sputum suction…
• Pneumonia, sepsis: change antibiotics, obtain 台灣肺炎診治
指引(有App)
culture, review previous microbiology data (and IDSA guideline
quality), review current antibiotics
• Heart failure: diuretics, NTG… 5Amp in D5W 200ml or 10Amp in
D5W 150ml

• Acidosis: bicarbonate BE/2Amp

 Treat the etiology of Dyspnea
“solu-cortef” “MeDason 125mg”
hydrocortisone 100-200mg / methylprednisolone 31.25mg ST
• COPD/ Asthma then methylprednisolone 31.25mg Q6-12H depends on severity
Check blood sugar while steroid in use, monitor GI bleeding
– Steroids (0.5-2mg/kg/day in 2-4 doses)
– Bronchodilators SABA (Ventolin)/ SAMA (Atrovent)/ SABA+SAMA (Combivent) Q6-8H
– NIPPV
– Consider also to treat secondary infection Heparin
• Embolism: Embolectomy/ anticoagulants LMWH (Clexane):
100iu/kg Q12H, CCr<30 減半
• Pneumothorax, pleural effusion, AMI, tamponade…:
complete survey and call expert if needed
Oxygen demand有變化就有問題!
• Find and treat the cause of dyspnea
• Goal: avoid further hypoxia/ hypercapnia and CPCR
• 給氧氣、用呼吸器、插管，都只是治標，
不是keep SpO2 >90%到下一班就好，請找到
喘/血氧改變的原因，對症下藥!
 Dyspnea: Conclusion
• Vital signs, oxygen device, oxygenation status
• Survey for etiology: cardiogenic, pulmonary,
airway, metabolic…
• PE, Lab, CXR, EKG…
• ABG: pH (HCO3), Oxygenation (PaO2, P/F ratio),
Ventilation (PaCO2)
• Treat the etiology of dyspnea
PGY Duty Round: Final Words
臺北榮總胸腔部 R3 廖映庭
 First, to stabilize vital sign
• 讓病人活過你的班之外，希望能讓他活過下一班
• 交班你的病人: 現在問題、治療方向、可能發生的
狀況、可以如何處理
• DNR只生效於疾病不可逆時的侵入性急救措施，簽
了DNR不代表放棄醫療、放棄檢查! 發生狀況時，
也需重新確認DNR意願!
 Second, to survey for etiology
• 建立正確的診斷，才會有正確的治療
• 不一味相信病歷!
• 過去病史，門急診史，住院療程，用藥，lab,
culture(一般報告-微生物科), image…
• 自己去床邊看病人，做PE/NE/bedside sono
• 看不懂，就做檢查!
• 有impression後，記得做相應的處置!
Take responsibility for your treatment
• 你有執照了，要對每筆醫囑/每筆藥負責
• 開藥時確認: 藥物名稱、病人、indication、
contraindication、副作用、劑量、過敏史
• 北榮藥典、micromedex、熱病、google、uptodate、
Lexicomp都是你的好幫手

北榮藥典
Uptodate Lexicomp Micromedex
(有手機app)
 Record what you have done
• Duty note: SOAP
• 確實交班給下一班，包括你有做的survey與
處置，包括你不確定的部分
• 行有餘力，追蹤一下病人後續動態，看看
你的處置是否正確?
 Call for help if needed
• 護理師/ 隔壁區的R/ CR/ VS
• 轉ICU前，整理好已知的History和病況改變的可能
原因，交班給ICU的住院醫師，記得transfer note
• 沒有survey完全，沒有初步的處置，你只是讓病房
少一台呼吸器，並沒有幫到病人，甚至delay治療!
 Categorize your priorities
• 值班開始時/前先看過critical/特殊病人，不一定與被交班
狀況相符! 若轉ICU時也能知道如何交班
– Note(診斷、治療方向、DNR status), 用藥(抗生素、升壓劑、
特殊用藥), 本人(T/P/R/BP/O2、照顧者), data (抽血、影像、
culture、I/O/BW)
• Vital sign不穩定、聽起來緊急、不確定性高的優先處理；
可以請護理師將小order一起寫下來給你
• 寫下待辦事項checklist，逐項確定完成
• 新病人：檢查、治療處置、藥物 開完再打 Note
• 善用公務機錄音軟體
 Learn from your mistakes
• 人非聖賢，孰能無過
• 病人是我們最好的老師
• 虛心學習，但也要建立自信
• 多與人討論，不會就查
Feel free to contact us

郭鈞育 8#6251
[email protected]
曾致學 8#6265
[email protected]
徐靖浩 8#6257
[email protected]
廖映庭 8#3174
[email protected]