內科值班04

Sepsis 敗血症

定義：感染 + Organ Dysfunction (SOFA≥2), not SIRS now

重點：內科急症，如果懷疑，盡早使用廣效抗生素

前言：當一個病人(1)發燒或(2)有既存感染+臨床(vital signs, UOP, GCS)有變化，都要評估有無sepsis的可能性

懷疑sepsis先算qSOFA (≥兩項):

意識 GCS<15
血壓 SBP≤100
呼吸 RR≥22

如果qSOFA≥兩項，進入Hour-1 Bundle流程

1. 抽血:

CBC/DC, BCS, ABG(?), Lactate, 兩套B/C, U/A, U/C, S/C, CXR

2. 廣效抗生素(一小時內給，依腎功能調整劑量):

本院首選tazocin，已經在用的話升階meropenem
懷疑MRSA感染再加Vancomycin or teicoplanin (腎功能差選teico，前三天都不用腎調)
感染科會診單可暫存，先把醫囑開出去，病歷後面再慢慢打

3. 點滴(血壓掉或 lactate>4):

先給N/S 500ml (病房有可以直接給)，再給L/R (優於N/S)
總量30ml/kg in 3hr，但如果給到要喘起來還是問一下二線比較好 (eg. 年紀大或有HF)
Vital signs不穩的話要放Foley，記I/O，Hold 血壓藥

4. 醫囑(抽血、抗生素、點滴)先開完，接下來好好survey，找infection focus

Hx (Underlying dz, Associated s/s) + PE (from head to toe) + Lab (eg. 之前的Culture, CXR)
Sourse control (跟二線或原主治討論), eg. 切CT排除IAI, APN+水腎放 PCN, calculous cholecystitis 做 ERCP, abscess 做 aspiration 或 drainage…

5. 升壓劑 (1st line: levophed): 通知二線，狀況不穩定且需要下ICU

使用時機: 輸液無法維持MAP≥65 (CRT>2s, UOP<0.5ml/kg/hr, AMS 也要懷疑shock)
確認DNR status，有沒有拒升壓藥

[Duty note]

I was called for ___. 
___-year-old ___ with underlying ___, admitted for ___.
The patient developed ___ at ___, accompanied by ___, ___

Vital Signs:
GCS:
PE: 
UOP:
Lab:
Previous culture and abx:
CXR:

# Fever/Hypotension/Dyspnea with qSOFA(___/3), 
favor sepsis with response to fluid resuscitation/
impending septic shock refractory to fluid resuscitation, 
septic workup showed ___,  
infection focus: peumonia, UTI, IAI, catheter-related infection, soft tissue infection...
- empirical ___ was administered, pending for culture and ID consultation
- fluid resuscitation to keep MAP≥65, transfer to ICU if unstable hemodynamic status / 
  for refracotry to keep MAP≥65 after fluid resuscitation, transfer to ICU for unstable hemodynamic status
- consider sourse control with___
- DNR status:___

施老大: 值班懷疑sepsis，抽完血抗生素早點上，水給夠，剩下的交給大人處理

SOFA (影響重要器官) 用計算機算，但在ICU比病房實用

心 BP (MAP or 升壓劑使用)
肺 PaO2/FiO2
腦 GCS
肝 T-bili
腎 Cr and UOP
血 PLT

Septic shock

定義: sepsis + 需vessopressor維持MAP≥65 + Serum lactate >2 mmol/L

Pneumonia

定義:

Pneumonia: s/s (fever, cough, purulent sputum, dyspnea) + new infiltrate on CXR/CT
CAP (醫院外感染)/ HAP (住院後≥48hr)/ VAP (插管後≥48hr)
Lung empyema: pus 積在 pleural space
Lung abscess: 肺實質壞死 + cavitation
Aspiration pneumonitis: 吸入胃內容物後的急性肺損傷，細菌感染可在24-72hr後發生

Hx: Fever, cough, purulent sputum, dyspnea, aspiration, TOCC(住院/安養機構), COVID (確診/疫苗)
PE: Vital signs, SpO2, chest exam, extra-pulmonary signs?

Lab:

必做:
CBC/DC, BCS (±lactate), 兩套B/C (before abx!), ±ABG
CXR (PA+LAT)
Sputum culture (Gram stain & Aerobic, Legionella/S. Pneumo urine Ag, ±AFB ± Mycobact.)
考慮:
COVID PCR, Influenza Ag
Pneumonia panel? (high risk of aspiration, refractory to tx?)
Chest CT (懷疑細菌性肺炎以外的診斷, eg. fungal/viral/chemical/PE/CHF/ARDS/DAH/ILD, 懷疑ILD要做HRCT)
BAL (懷疑VAP或Atypical pneumonia)
PCT (<0.25可停abx, 免疫不全跟CKD不適用, 偽陽: CPR, shock, burns, surgery)

Severity (qSOFA, CURB65, PSI)

CURB-65: confusion, BUN>20, RR>30, BP<90/60, Age>65 (>2: admit, >3: ICU)
PSI(按計算機): age, sex, 住機構, 共病, vital signs, AMS, lab (pH, BUN, Na, Glu, Hct, PaO2, pleural effusion)

Management

Sepsis → Early Abx ; Cover pathogen accordingly
CAP (5-7d) → IV Augmentin + 3d of Oral Azithromycin ± Vanco if MRSA carrier
(Tazocin + azithromycin if recent Hx of PsA肺炎, 住院, iv abx)
HAP (7d) → Tazocin + 3d of Azithromycin ± Vanco if MRSA carrier
If severe → Tazocin + Ciproxin/Levofloxicin/Amikacin + Vanco
Consider PJP/Flu/Fungus/Autoimmune/Tumor/Treat-relate?

Urinary tract infection

Voiding U/C >10^5
Upper or lower; complicated or uncomplicated?
排除其他疾病 (pyuria ≠ UTI): eg. Appen? Psoas abscess?

Hx: LUTs?, fever, rigors, malaise, back pain, GI s/s (if APN)
PE: Vitals, CV angle knocking, DRE if man
Labs: CBC,B/C,UA,U/C, ± Echo: hydronephrosis? Stone? BPH?
WBC太低的病人不會有pyuria，U/C 記得直接留
CT A/P: severely illness, obstruction, persisted sx after 48-72hr of appropriate abx

Management

Hydration
如果有Foley，拔掉或重放
沒症狀的話只有孕婦、腎移植跟做泌尿科procedure前要治療 (狀況差或意識不清除外)
經驗性抗生素 (記得留U/C, B/C，記得看之前culture結果，記得腎調)
- 下泌尿道症狀 (simple or uncomplicated): Cefazolin or cefuroxime
- 發燒冷顫、後腰痛或男生DRE有壓痛 (upper or complicated): Ceftriaxone
- 懷疑院內感染: Ceftazidime (+pseudo)
- Critical illness: Tazocin (+enterococcus)
If sepsis + hydronephrosis → consider PCN (跟二線討論)

Skin and soft tissue infection

Carbuncle (毛囊), erysipelas (真皮), cellulitis (皮下組織)
急症要開刀: Necrotizing fasciitis, Fournier gangrene, Ludwig angina

DX:

Hx: TOCC, Pain+progress?, sea/river/cat/dog
PE: skin erythema (with sharp margin in erysipelas, edema, warmth, petechiae, hemorrhage, superficial bullae, crepitant and gangrenous)
懷疑Necrotizing fasciitis
- crepitant 捏氣泡紙的聲音/ bullae/ necrosis or ecchymosis
- 不成比例的劇烈疼痛/ 對疼痛的感覺減弱/ 快速進展/ 低血壓/ systemic illness
懷疑深部感染：
- erythema without sharp margins 邊緣不清楚
- edema extends beyond the visible erythema 水腫範圍大於紅斑
- 眼肌麻痺 ophthalomoplagia/ 眼球突出protosis/ 眼球運動疼痛
- 牙關緊閉trismus/ 斜頸/ 聲音低沉不清楚 muffled voice
- 流口水/ 唾液積聚/ 喘鳴/ 吞嚥困難/ 吞嚥痛
Labs: CBC/CRP, pus culture, B/C; lactate, AST, CK (for deep tissue necrosis); PT/aPTT if surgical indicated; CT if fasciitis

Management

Consider Necrotizing fasciitis!! → Surgical Debridement (叩二線/外科/放射科)
→ Cefepime/Tazo ± Vancomycin ± clindamycin ± Doxy
特殊情況: 懷疑深部感染/臉部危險三角 (叩二線)
Erysipelas: cefazolin or ceftriaxone (出院: Amoxicillin or Cephalexin)
Cellulitis: oxacillin or cefazolin (出院: Dicloxacillin or Cephalexin)
Consider MRSA if poor response
懷疑abscess -> sono抽吸或引流

感染症抗生素使用可參考:
uCentral>> 醫療專區(contents) >> 3. Infectious Diseases Guidelines (感染症診治及用藥指引)
UpToDate

Acute heart failure

鑑別診斷: 肺栓塞、氣喘發作、肺炎、ARDS、pericardial tamponade

多因呼吸困難或氧合能力不佳而就醫

找原因:

飲食不當或服藥依從性不佳 (40%)
心肌缺血/梗塞 (10-15%); myocarditis
腎衰竭 (↑ preload)
高血壓、AS (↑ left-sided afterload)
藥物: βB, CCB, NSAIDs, TZDs, anthracyclines, trastuzumab, EtOH
心律不整、瓣膜疾病、Aortic dissection
COPD、PE、Anemia、壓力、感染、甲狀腺亢進/低下

臨床表現:

Acute dyspnea, orthopnea, tachypnea, tachycardia, and hypertension
低血壓反映疾病較嚴重，需要評估周邊組織及重要器官的灌流 (GCS, UOP, CRT)
PE: JVE, diffuse rales, wheezing (cardiac asthma), S3/S4, pitting edema
ECG: ACS, Arrythmia, LVH
CXR: pulmonary edema, cardiomegaly, pneumonia; CXR正常不能排除ADHF
Lab: CBC/DC, 肝腎, Na/K/Mg/Cl/HCO3-, Cardiac enzymes, NT-proBNP, thyroid function, lactate if suspect shock, D-dimer if unlikely PE (likely PE 要做CTA)
心臟超音波

Management:

監測血氧、VS、心律
給氧 if SpO2 <90%, 坐直
Furosemide 40 mg IV，血壓高沒有shock可用NTG
找上述原因並治療
Af with RVR: 藥物降HR, new onset 考慮 Cardioversion (ACLS)
已知HF
- HFrEF (LVEF<40%) 合併 cardiogenic shock: 停用長期使用的βB，上強心劑
- HFpEF (LVEF≧50%) 合併 cardiogenic shock: βB + IV fluid + 升壓劑 + 心超 (排除 acute AR/MR)
- LVEF未知但合併cardiogenic shock: 強心劑 +/- 升壓劑 + 心超

HFrEF四支柱: ACEi/ARB/ARNi + βB + MRA + SGLT2i

COPD AE

特徵: Diffuse wheezing, 桶狀胸, tachypnea, tachycardia, 吸菸 >20 pack years
嚴重: 用呼吸輔助肌、講話零碎/片段、無法躺平、冒汗/躁動、蹺蹺板呼吸、初始治療未能改善。
合併/加重: ACS, ADHF, PE, pneumonia, pneumothorax, sepsis

Hx, PE and Labs

Infection(sputum↑)? Chest pain? Vital signs, wheezes;
CBC,BCS,CRP,ABG(CO2); CXR, ± CTPA if PE suspected, influenza?

Management

Primary ABC，血氧目標: SpO2: 88-92% or PaO2: 60-70 mmHg
評估需不需要插管 (嚴重度及病家意願)，要插或看起來快插->叩二線
A (Atrovent) + B (Ventolin) INHL Q4HPRN
Methylprednisolone 60-125 mg IV, Q6H-Q12H，記得驗血糖
BIPAP if CO2 retention (禁忌: AMS、無法保護airway、high aspiration risk)
Intubate if AMS, with RSI (eg, etomidate, ketamine, or propofol)
Abx: Ceftriaxone 2g QD or Tazocin 4.5gm Q6H if cover Peudo

DVT & PE

Risk factors

Virchow’s triad
- Stasis: 臥床少活動, CHF, 三個月內中風過, 坐飛機超過六小時
- 血管內皮受損: trauma, surgery, prior DVT/PE, central line
- Thrombophilia: genetic disorders, 避孕藥, HRT
Malignancy
肥胖、抽菸、急性感染、產後

DVT

小腿或患肢有紅/腫/熱/痛
Homan’s sign (dorsiﬂexion 更痛)

PE

喘 (50%), 肋膜性胸痛 (40%), 咳嗽 (20%), 咳血 (10%)
↑ RR (>70%), crackles (50%), ↑ HR (30%)
fever, cyanosis, pleural friction rub, loud P2
Massive: syncope, HoTN, ↑JVP
ECG: sinus tachycardia, S1Q3T3 (<10%)
CXR: 正常 (12%), 肺塌陷, 肋膜積液, Hampton hump (wedge-shaped, pleural-based opacification), Westermark sign (栓塞處distal端的肺紋變少/radiolucency)
Lab: ABG (hypoxemia, ↑ A-a gradient), D-dimer, ±TnI ±NT-proBNP
心超: RV strain, D-shape LV

Approach to suspected DVT (Simpliﬁed Wells Pretest Probability Scoring of DVT)

Approach to suspected PE (Modiﬁed Wells Pretest Probability Scoring for PE)

Management

穩定 vital signs (O2, IV, vessopressor)
不穩定: 轉ICU 打tPA
穩定: heparin/LMWH/DOAC/warfarin
IVC filter if contraindicated to anticoagulants
Refractory → Catheter(EKOS為導管超音波震波溶栓) or surgical thrombectomy

Clostridium difficile infection

Risk factors: 之前抗生素使用, 高強度化療, PPI, GI surgery, HSCT, etc.
特徵: ≥3 unformed stools in 24 hours, 連續兩天 (排除ileus)
診斷:
- Stool CDI toxin PCR
  - 大便未成形才要驗, 太水流不到檢體可用rectal swab
  - PCR (+) toxin (-) 不一定要治療
- CBC/DC and BCS if no data, B/C if fever
- CT if megacolon/unstable
治療 (依嚴重程度):
- Non-severe (WBC <15K and SCr <1.5 or Cr 上升 <50%)
  - Metronidazole 500mg PO/IV TID
- Severe (WBC ≥15K or SCr ≥1.5 or Cr 上升 ≥50%)
  - Vancomycin 125mg PO QID
- Fulminant colitis (HoTN, ileus, toxic megacolon, perforation, need colectomuy or ICU)
  - Vancomycin 500mg PO/NG/Rectal/colostomy QID + Metronidazole 500mg IV Q8H + surgical consultation

Acute pancreatitis

Enzymes → autodigestion; Lipase↑ ± Imaging, 排除其他
3rd space fluid; ARDS, hemorrhage, infected pseudocyst

Hx, PE and Labs

Abd pain(worse when lying), gallstone/alcohol/Drugs?
SIRS, abd PE; CBC+ B/C(if fever) + Lipase/BUN, CXR ± CT

Management

BISAP score for prognosis
NPO + fluid resuscitation +early feeds ; follow up BUN
ERCP for gallstone pancreatitis (in 24 hours)
ABx if signs of infection/shock

內科值班04

Sepsis 敗血症

定義：感染 + Organ Dysfunction (SOFA≥2), not SIRS now

懷疑sepsis先算qSOFA (≥兩項):

如果qSOFA≥兩項，進入Hour-1 Bundle流程

Septic shock

Pneumonia

Urinary tract infection

Skin and soft tissue infection

Acute heart failure

COPD AE

DVT & PE

Risk factors

DVT

PE

Approach to suspected DVT (Simpliﬁed Wells Pretest Probability Scoring of DVT)

Approach to suspected PE (Modiﬁed Wells Pretest Probability Scoring for PE)

Management

Clostridium difficile infection

Acute pancreatitis

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