发热的急诊科处理-香港大学课件

DiagnosticApproachtothePatientwithFeverinERPresent林立偉醫師Director林秋梅醫師LAEARNINGGOALSTounderstandthedefinitionandterminologyHowtoseekthesourceoffeverHowtomanagethepatientwithsepticshockBODYTEMPERATURE

FEVERAnAMtemperatureof>37.2ºCorPMtemperature>37.7ºCdefineafeverElevationofBTthatexceedsthenormalvariationandoccursinconjunctionwithanincreaseinthehypothalamicsetpointHyperpyrexiaAfeverof>41.5ºCSevereinfectionsbutmostlycommonwithCNShemorrhageHYPERTHERMIAAnunchanged(normothermic)settingofthethermoregulatorycenterinconjunctionwithauncontrolledincreaseinbodytemperaturethatexceedthebody’sabilitytoloseheatCauseD.D.fromfeverNoresponsetoantipyreticsTheeventimmediatelyproceedtheincreasetemperatureInheatshockorinthosetakingdrugsthatblocksweating,skinishotbutdry.

CausesofHyperthermiasyndromesHeatstrokeExertion:exerciseinhigher-thannormal-heatand/orhumidityNonexertional:anticholinergics,includingantihistamine;antiparkinsoniandrugs;diuretics;phenothiazinesDrug-inducehyperthermiaAmphetamines;MAOIs;cocaine;phencyclidine;TCA;LSDNeurolepticmalignantsyndromePhenothiazines;butyrophenones,includinghaloperidolandbromperidol;fluoxetine;loxapine;tricyclicdibenzodiazepines;metoclopramide;dompreidone;thiothixene;molindoneMalignanthyperthermiaInhalationalanesthetics;succinylcholineEndocrinopathyThyrotoxicosis;pheochromocytomaANTIPYRETICAGENTSAcetaminophenPoorcyclooxygenaseinhibitorinperipheralbutoxidized(activeform)inbrainbythep450systemAspirinNSAIDAffectplateletsandGItractMaydeterioraterenalfunctioninpatientswithrenalinsufficiency(inhibitrenalprostaglandin)GlucocorticoidInhibitphospholipaseA2BlockthetranscriptionofthemRNAforthepyrogeniccytokinesPITFALLDeliriumNewonsetofincontinenceWeaknessWeightlossLossofappetiteornauseaInnewborns,theearly,patientswithCRF,immunocompromiseandpatientstakingglucocorticoids,fevermaynotbepresentdespiteinfectionormaybehypothermic.Theatypical(oftentypical)presentationofinfectioninelderlyKeypoint:lossoffunctionAPPROACHTOTHEPATIENT

HISTORY

APPROACHTOTHEPATIENT

PHYSICALEXAMINATION

APPROACHTOTHEPATIENT

PHYSICALEXAMINATIONHeadtotoeFingertoholeSpecialattentiontoskin,lymphnodes,eyes,nailbed,CVsystem,chest,abdomen,musculoskeletalsystem,andnervesystem.RectalexaminationisimperativePenis,scrotum,testes,foreskinandpelvicexaminationinwomenshouldbeexamined

APPROACHTOTHEPATIENT

LABORTARYTESTSClinicalPathologyCBC+DC+PLT,bloodsmear,UA,ESR,abnormalfluidaccumulationandCSFexamination,bonemallowaspiration,stoolroutineChemistryElectrolyte,BUN,creatinine,LFTs,amylase,CPKandserology…MicrobiologyGram’sstainandcultureImagingPlainfilm,sonography,CT,MRIandGalliumscanCase1

Name郭XXChartNo.111*****Age65Y/OSexMaleTriageClassII91/05/0710:16AM自行步入AVPUBT39.5ºCPR84RR17BP134/61ChiefComplaintheadachesincelastW4(5/2)PresentIllnessFevernotedatLMDyesterday

Vomitingtwice(lastW4+today)URI(-),frequency(-),dysuria(-)Past/DrugsHistoryDrugallergy(-)denyanydiseaseImpressionR/OmeningitisPlanCBC/DC/PLTPanel1B/C×IICXRBrainCTNSrun60cc/hrScanol2#st11：30AMWBC11500S/L87.2/7.0Hb13.9PLT149K

Glu110AST39BUN13Cr1.0Na139K3.81：50PMBrainCT：negativeDoLumbarPunctureInitialpressure210mmH2OFinalpressure110mmH2OProcedurewasdonesmoothlybutreddishCSFwasnotedRepeatpunctureatothersitebutreddishCSFwasstillnotedSentsampleforroutine,Glu&protein,culture,TBcultureandGram’sstain

91/05/08Highfever41ºCandSBPdownto80wasnotedINFconsultationBPRUQpain(+)WBC12100S/L/B76/6/18UARBC0-1WBC5-7GOT39CRP22.20IMP：1.Septicshock2.SAHSuggestion：1.B/C*II2.Rocephin2gmst+q12h3.Abdominalecho

91/05/09AbdominalechoHepaticcyst,RtRenalcyst,RtCBDdilationAdenomyomatosisofGB

91/5/10B/C(sampleon5/8)2/2G(-)bacilliFinalreporton5/11K.PsensitivetoCefamazineandGM

Name王XXAge75Y/OSexMaleTriageClassII91/03/1406:10PM自行步入AVPUBT37.4ºCPR86RR36BP102/60O2Sat85%ChiefComplaintLthandpainsincethisnoonPresentIllnessStungbyfishboneyesterdayChronicSOBPast/DrugsHistoryCOPDDMCAD+AAAs/pCABG+graftingbypassofAAAPhysicalExaminationConsciousnessclearHead&NeckChestbilateralwheezingAbdomensoft,notenderPelvisExtremityLthandswellingwitherythemachange

ImpressionCellulitis,LthandR/OvibrioinfectionCOPDwithAEPlanA+BIHst+q6hNS60cc/hrCBC/DC/PltPT/aPTTPanel1B/C*IIABGCXR

Fortum1gmivst+q8hMinocycline100mgivst+q12hWoundaspirationwithculture+Gram’sstainArrangeINFadmissionandconsultINFCM07：27PMWBC8400Hb15.8S/L/B79/10/7PLT99KPT10.65/10.3APTT27.40/30.9INR1.07Glu157AST24BUN46Cr1.7Na141K3.808：00PMGram’sstainG(-)Bacilliheavy08：50PMConsultPS(Imp:necrotizingfasciitisPlan:surgicaldebridement)3/1505：30AMBPdrop(78/30)CVP1mmH2OABGFiO260%PH7.216PaCO230.8PaO2190HCO3-12.6O2Sat99.7%FluidchallengeDopamine35cc/hrJusominuseClinicalcourseOn3/15StilllowBPdespiteoffluidresuscitationwithDopamine+LevopheduseAir-hungerdespiteofventilatoruseProfoundmetabolicacidosisdespiteoffrequentlyJusominadministrationATBincreasedtoCeftazidime2givq8husewithMinocycline100mgivq12h(INFsuggest)Patientexpiredat11:31PMFinalculturereport3/17B/C*II:Vibriovulnificus3/18PUSaerobic:Vibriovulnificus–moderatePathology:skinandsofttissue,Lthand–necrotizinginflammation3/19PUSanaerobic:(-)in5daysCase3

Mycoticaneurysm61y/omale,DMHx,sufferedfromdiarrheafordays,thenfeverandabdominalpainhappened.Hewasadmittedtootherhospital.LLQpainwithmasslesionwasnoted.B/CrevealedSalmonellaGr.D.AbdominalCTshowedabdominalaortaaneurysm.Whatisyourimpression?Case4

HealsogotLBPfordays

X-rayL-5compressionfx

Abdominalandcardiacechonegative63y/omale,withHTN,DM,CVA,complainedofdrycoughfor3daysandfeverfor1day.CXRshowedLLLinfiltrationincreased.WBC19300S/L/B74.5/12.5/5andCRP24.30.LLLpneumoniawasimpressedandAugmentinwasgivenintravenous.3dayslaterfeverpersistedandB/CdiscoveredS.aureus.Whatdoyourthink?GalliumscanshowedT12osteomyelitisFEVEROFUNKNOWNORIGIN

DEFINITIONDefinedbyPetersdorfandBeesonin1961Temperature>38.3ºConseveraloccasionsAdurationoffeverof>3weeksFailuretoreachadiagnosisdespite1weekofinpatientinvestigationDurackandStreetproposedanewsystemin1991FUO

CAUSEBigthreeInfection(25-30%)Malignancy(10-30%)Collagenvasculardisorder(10-15%)Unknown(5-10%)FUO

MALIGNANCYASSOCIATEDHodgkin’slymphomaNon-HodgkinlymphomaLeukemiaRenalcellcarcinomaHematomaColoncarcinomaFUO

AUTOIMMUNEASSOCIATEDSLERAAdultStill’sdiseaseTemporalarteritisMixedconnectivetissuediseaseFUO

INFECTIONASSOCIATEDIntra-abdominalorpelvicabscessAbscess1/3infectionoriginofFUO,mostintra-abdominalorpelvicVaguelocalizedabdominalpainSurgicalcomplicationorleakageofvisceralcontentsLiverabscess:elevatedALK-pK.pneumoniaebacteremiainDM,alcoholism,LivercirrhosisLiverechomaybenegative,soabdominalCTisimportantfordiagnosis

FUO

INFECTIONASSOCIATEDOsteomyelitisandseptichipTendernessoverinfectedsite,butsomepatientsonlywithfeverAssociatedsign:L-spineOMwithrootcompressionsign,vertebralOMwithpsoasmuscleabscessorCVsurgerywithsternalOMSeptichip:16%ofsepticarthritis,mostwithOAordestructivejoint,sothatwithprolongedandinsidiousonsetDiagnostictool:BonescanorGalliumscanCTorMRIFUO

INFECTIONASSOCIATEDInfectiousendocarditisClueofDX:continuousbacteremia,newmurmurs,vascularphenomenon,vegetationoncardiacecho,andunexplainedfeverCulturenegativeendocarditisRecentlyreceivedantibioticsHACEKgrouporganisms.Haemophilusparainfluenaze/aphrophilus,Actinobacillusactinomycetemcomitans,Cardiobacteriumhominis,Eikenellacorrodens,and

KingellakingaeFungus,RickettsiaandChlamydiaTTE(60%)andTEE(95%)

FUO

INFECTIONASSOCIATEDGranulomatousinfectionTB(extrapulmonaryTBormiliaryTB)isthemostcommoncauseinTaiwanTBmayinvolveliver,spleen,bone,kidneys,pericardiumormeningesandinmiliaryTBoflungCXRmaybenegativeinitialBonemarrowstudymaydiagnoseNontuberculousmycobacterialinfectionsanddeep-seatedfungalinfection

FUO

INFECTIONASSOCIATEDDenguefeverInfectiousmononucleosisScrubtyphusTyphoidfeverHIVMalariaAmebiasisNGrelatedsinusitisANTIBIOTISCHOICEINED(1)Community-acquiredpneumoniaPCN3MUivq6hAugmentin1.2gmivq8hAugmentin1#q8hCOPDwith2ndinfectionAugmentinAspirationpneumoniaPCNorclindamycin600mgivq8hAtypicalpneumoniaKlaricid1#bid

ANTIBIOTISCHOICEINED(2)Acutecholecystitis,acutecholangitis,liverabscessandSBPCefamazine1gmivq6h+GM60mgq8hInfectiousdiarrheaCiprofloxacin2#q12hBaccidal1#qidANTIBIOTISCHOICEINED(3)CystitisBaktar2#bidUTIorAPNCefamazine+GMBaccidal1#qid

PIDClindamycin+GMCleocin1#qidANTIBIOTISCHOICEINED(4)ErysipelasPCNCellulitisOxacillin2gmivq6hProstaphine-A1#qidNecrotizingfasciitisPCN4MUq4h+clindamycinANTIBIOTISCHOICEINED(5)BactericmeningitisPCNq4h+Ceftriaxone(Rocephin)1gmivq12hEndocarditisAcute:oxacillinq4h+GMSubacute:PCNq4h+GMNeutropenicfeverPiperacillin(Pipril)2gmq6h+GMSEPSISANDSEPTICSHOCKDefinitionBacteremiaSepticemiaSIRSSepsisSeveresepsis(sepsissyndrome)SepsisshockRefractorysepticshockMODSSEPTICSHOCK60-70%GNBThechiefmediatorsofsepsisislipopolysaccharideInrecentyears,garm-positivesepsisincreasedMorepatientsarebeingtreatedathomeforchronicimmunocompromisingdiseasewithindwellingcatheters(S.aureusandcoagulase-negativestaphylococci)Thefrequencyofcommunity-acquiredinfectionscausedATB-resistantgarm-positiveorganismincreased(S.aureus,S.pneumoniaeandS.pyogenes)SEPTICSHOCK

PATHOPHYSIOLOGYHypovolemiaRelative:increasevenouscapacitanceAbsolute:GIloss,tachypnea,sweating,decreaseddrinkandcapillaryleakCardiovasculardepressionMyocardialdepressionimpairedearlywithvasodepressionandcapillaryleakInducedbyTNF-andIL-1,overproductionNOandimpairmentinmitochondrialoxidativephosphorylation

SystemicinflammationCausecapillaryleakintothelungandcauseARDSearlyinupto40%ofsepticshockpatients.SEPTICSHOCK

CLINICALFEATURESIllappearing,pale,oftensweating,usuallytachypneicandoftenwithaweakandrapidpulse.HRcanbenormalorlow,esp.incasescomplicatedbymedicationthatdepressedHRorprofoundhypoxemiaBPcanbenormalduetoadrenergicreflexesormeasurementerrors(HR/SBP<0.8isnormalratio)Urineoutputisaexcellentindicatorbutrequireatleast30mintodetermineMeasurementsofarteriallactateoranarterialbasedeficit

SEPTICSHOCK

MANAGEMENTMonitoringPerfusionStatusEKGmonitor,pulseoximetryandcuffBPmonitor(q2-5min)Urineoutput(1ml/kg/hr)NormalizationofthebasedeficitorlactatewithimprovingvitalsignsandU/OCVPmeasurementmayberequiredwithcardiacorrenalfailureSEPTICSHOCK

MANAGEMENTVentilationEstablishingadequateventilationtocorrecthypoxemiaandpHandtoreducesystemicoxygenconsumptionandLVwork.Ventilatortherapyisindicatedforprogressivehypoxemia,hypercapnia,neurologicdeteriorationorrespiratorymusclefailure.RSIispreferredwithanestheticagent,suchasketamineoretomidate.SEPTICSHOCK

MANAGEMENTVolumeReplacementIntravenousaccess:Peripheral(218-or116-gauge)vsCVPInitiallyadminister20ml/kgofcrystalloidor5ml/kgcolloidInsepsisandtraumapatientshydroxyethylstarchsolutionsresultedinlesstissueedemaandbetterpreservedmicrocapillaryintegrityBecausebothventriclestendtostiffenduringshock,ahighCVP(10-15mmH2O)isoftenneededSEPTICSHOCK

MANAGEMENTVasopressorSupportDopamineasthemostoftenappropriatefirstchoiceCombinationofdobutamineandnorepinephrineincreasebothCOandSVRandtoimprovedindicesoftissueoxygenationinpatientswithseveresepsisSEPTICSHOCK

MANAGEMENTAntimicrobialTherapyIfanfocusisfound,theantibioticscanbedirectedbyclinicalexperienceRemovalordrainageofafocalsourceisessentialWhennofocuscanbefound,asemisyntheticpenicillinwith-lactamaseinhibitorwithanaminoglycosideormonotherapywithimipenem-cilastatinisarationalempiricchoice

SEPTICSHOCK

MANAGEMENTNoevidencesupportsempirictreatmentofmetabolicacidosiswithbicarbonateandonlyconsiderwhenseveremetabolicacidosis(pH<7.2)BloodtransfusionisindicatediflowHb(<8-10g/dL)Adrenalinsufficiencyshouldbesuspectedinsepticpatientswithrefractoryhypotension(hydrocortisone50mgIVq6h)

KeyPointsEarlyrecognitionA-B-CO2-IV-MonitorEradicateinfectionsourceCase5

Name陳XXAge35Y/OSexMaleTriageClassII90/08/1410:26AM由診所護士陪同步入AVPUBT38.5ºCPR153RR18BP83/43

O2sat94%ChiefComplaintSOBandgeneralmyalgiatodayPresentIllnessHeroinabuserAdmittedto省立新竹醫院1monthagoforcessationdruguseHevisited重生醫院forcessationon8/11butstilluseillicitdrugLowerlegedema(+)Past/DrugsHistoryDrugallergy(?),DM(?)HeroinaddictionPhysicalExaminationConsciousnessagitationHead&NecksuppleChesttachycardia,nomurmurs