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83 Cards in this Set
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22. 一般常用來作燒燙傷病患輸液急救(fluid resustation)的乳酸林格氏液(Ringer’s lactate solution),每公升中Na+的含量是多少mEq
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130
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23. 有關高壓電傷的敘述
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(A)發生於四肢者較易有嚴重程度之傷害而發生於軀幹者較不會有嚴重程度之傷害
(C)因為肌肉壞死,釋出大量肌蛋白(myoglobin)而較容易發生急性腎衰竭 (D)傷及肢體者在進行擴創術時經常可發現即使淺層肌肉無恙在骨頭旁較深層之肌肉卻可能已產生壞死 |
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24. 林先生於工作時誤觸高壓電而致電灼傷,電流自右肩入,從右手出,傷後三個月右上肢漸漸無力。此結果最可能肇因於下列何者組織之損傷
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神經
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25. 下列有關大面積燒傷引起的微血管反應,何者正確
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微血管壁滲透性(capillary permeability)上升
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26. 一位60公斤37歲女性,引火自焚導致軀幹、四肢、臉部二至三度46%大面積燒傷,經手術植皮後燒傷面積在傷後14天仍有15%未癒合,理學檢查發現四隻有浮腫現象,請問四肢浮腫的原因是
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血中白蛋白偏低
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27. 有呼吸道燒傷之病人,如同時有一氧化碳中毒時,測carboxy hemoglobin在何濃度以上時,需做高壓氧治療(Hyperbaric oxygen therapy)
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25%
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28. 有關tunor necrosis factor-α之敘述,何者正確
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燒傷後血清中之濃度會增加
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29. 發生化學藥品灼傷眼球時,急救的第一步驟是
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大量清水沖洗眼球
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30. 王先生於家中洗澡時不幸發生瓦斯氣爆,經救護車送至急診室,急診醫師身體檢查發現,燒傷範圍在兩側上肢、前胸及腹部深二度燒傷,於急診室測量體重為60公斤;請問依據“rule of nines” 及“Parkland formula” 其燒傷面積為何?前24小時應如何給予輸液?
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36%;8640 mL 乳酸鹽林格氏液(lactated Ringer’s solution)
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31. 有關40%大面積燒傷的治療,早期切除早期植皮的好處?
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(B)減少清創手術的次數
(C)減緩高代謝率(hypermetabolism) (D)降低死亡率 |
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32. 陳先生是一位28歲的電力公司新進員工,1個小時前受到11000 伏特電擊傷,尿液常規檢查(urinalysis)顯示,外觀呈暗褐色,pH 值7.28,潛血反應4+,蛋白質2+,酮體-,紅血球2~6/高倍視野(high power field, HPF ),細菌(-)。下列診斷何者最適當?
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肌球蛋白尿症(myoglobulinuria)
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33. 下列有關燒傷的緊急處理之敘述,何者正確?
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所有小面積燙傷皆可以自來水降溫
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34. 謝先生是一位42 歲貿易公司基層員工,因被公司遣散,在隱蔽的山區隧道內自焚。全身煙燻污黑的謝先生由救護車運送至醫院。謝先生一直大喊著『好痛!好渴!』,診察發現,心跳每分鐘162下,呼吸速率每分鐘26次,血壓70/35 mmHg,全身都是三度燒傷,體無完膚,右側腕部撓動脈摸不到脈搏。您認為對謝先生而言,下列處置何者應該最優先進行?
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建立輸液管道
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腦神經外科常見疾病(Common diseases in Neurosurgery):
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--Head injury( GCS, Brain CT, ICP and CPP)
--Brain tumor (Menigioma, astrocytoma, acoustic neuroma) -- Pediatric neurosurgery (Hydrocephalus) --Spinal disease( spinal stenosis, spondylolisthesis, metastasis, infection) --Spinal cord injury( complete and incomplete) --Peripheral nerve injury( CTS, ulnar nerve entrapment) |
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葛氏昏迷指數(Glasgow Coma Scale;GCS)
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取最佳反應
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昏迷指數(coma scale)
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睜眼反應(E): 4分 病患能自行張開眼睛
3分 聽到別人說話而張開眼睛 2分 因為檢查者施以疼痛刺激而張開眼睛 1分 完全沒有睜眼反應 語言反應(V): 5分 對時、地、人等定向問題可以正確回答 4分 雖可回答問題,但答案錯誤 3分 答非所問,但仍有語言結構 2分 能發出聲音,但無法了解其意思 1分 完全無法發出聲音 運動反應(M): 6分 可以遵從指示作動作 5分 疼痛刺激時,手腳可向刺激處移動 4分 疼痛刺激時,肢體可回縮 3分 疼痛刺激時,肢體呈屈曲反射 2分 疼痛刺激時,肢體呈伸張反射 1分 身體完全無運動反應 |
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根據Glasgow昏迷指數,若患者住院時,對任何刺激眼睛皆無睜眼,身體呈現角弓反張,且無任何語言反應,則其昏迷指數為幾分?
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4
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腦幹反射(Brainstem reflex)
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瞳孔對光反射(pupillary light reflex):
此反射是腦幹上段中腦的功能(II進III出) 眼角膜反射(corneal reflex): 此反射是腦幹中段橋腦的功能(V進VII出) |
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腦幹反射(Brainstem reflex)..
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前庭--動眼反射:
橋腦下端與位於橋腦和中腦之內側縱束 所構成(VIII進III,VI出) 作嘔反射(gag reflex): 此反射是腦幹下段延髓的功能(IX進 IX,X,XII出) |
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頭--眼反射:
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有較長之聯絡徑路,必須有相當健全之
腦幹功能才能表現出來。當病人的頭由 正前位置突然被轉至一側時,此轉動之 動作刺激前庭系統之耳石或頸部之自體 感覺或二者都參與反射,經由內側縱束 之作用使兩眼仍處於正前方之位置,在 轉動瞬間不隨著頭部之偏向而一起偏向。 |
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若以昏迷 (GCS) 指數分級,則中度頭部外傷之GCS應介於何者之間?
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9至12分
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死亡率最高的腦外傷為那一種?
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急性腦膜下出血
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Mortality of Acute SDH
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50-90%
60% in aged; 90-100% in coagulopathy Four hour rule 30% mortality if operation within 4 hrs; 90% mortality if surgery delayed > 4hrs Functional survival (GCS>4) 65% if surgery within 4 hrs |
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有關硬腦膜下血腫 (subdural hematoma) 的CT影像
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(A) 在橫切面影像呈半月狀
(B) 在冠切面影像,可呈紡錘狀 (D) 其對大腦造成的腫塊效應,通常比硬腦膜外血腫的腫塊效應大 |
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一位20歲年青人因騎機車車禍,經救護車送至急診室。到院時血壓180/60 mmHg,心跳55次/min,病人雙眼閉合,疼痛刺激時眼睛無法張開,四肢可疼痛定位,且只能發出呻吟聲,理學檢查發現右側頭皮下有血腫,右側有耳漏現象,右側瞳孔5 mm無光反應,左側3 mm有光反應,頭部X光片顯示右側顳部有線性骨折。則此病人昏迷指數 (GCS) 為幾分?
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8/15
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腦壓升高(Inreased intracranial pressure, IICP)
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Symptoms
頭痛 噁心 嘔吐 視乳突水腫.. (Headache, N/V, papillary edema) Signs 瞳孔放大無光反射 (pupillary dilatation, no light reflex) 去大腦或者去皮質姿勢 (decorticate or decerebrate posture deterioration of neurologic exam) |
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嚴重的顱內高壓可能出現Cushing’s triad
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心跳下降 血壓上升 呼吸不規則(HR↓, BP↑, irregular
RP) |
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腦壓升高處置(Management for IICP)
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頭部抬高(HOB 30o)
過度換氣(HPV , PaCO2 30 mmHg) 鎮定(Sedation) 利尿劑使用(Mannitol, Glyceral and Furosemide) 類固醇(Steroids):不建議使用在頭部外傷,但是對於腦腫瘤者可使用 巴比妥鹽昏迷(Barbiturate coma) 低溫療法(Hypothermia) 腦室外引流(CSF drainage) 顱骨切除減壓 (Craniectomy) |
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如何計算求得腦灌注壓 (Cerebral perfusion pressure)?MABP為平均動脈血壓,CVP為中央靜脈壓,SABP為收縮動脈壓,DABP為舒張動脈壓,ICP為顱內壓
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MABP減ICP
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對顱內壓升高 (IICP) 的治療
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(A) 降低體溫,避免發燒
(B) 維持高換氣量,降低血中CO2分壓至35 mmHg (C) 使用Mannitol或Glycerol靜注 |
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腦瘤分類(WHO classification)
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源自於神經上皮組織 (Tumors of neuroepithelial tissue)
源自於腦膜組織(Tumors of meningothial cells) 源自於週邊神經 (Tumors of peripheral nerves) 源自於淋巴組織或者血液 (Lymphomas and hemopoietic neoplasms) 生殖細胞腫瘤 (Germ cell tumors) 蝶鞍部腫瘤 (Tumors of the sellar region) 轉移性腫瘤 (Metastatic tumors) |
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腦腫瘤手術重症照護
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一般處置(General care)
預防抽筋(Prevent seizure) : 抗癲癇藥物使用(Anticonvulsion drug) 預防腦水腫(Prevent brain edema) : Mannitol, Glyceral or furosemide Steroid 降低顱內高壓(IICP control) |
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關腦膜瘤(meningioma)的敘述
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(B)起自蜘蛛膜帽細胞(arachnoid cap cells)
(C)男女性發生率相同 (D)良性腦膜瘤,不侵犯腦部 |
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腦膜瘤(Meningioma
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Second most common primary brain tumor
Slow growing, extra-axial, usually benign, arise from arachnoid (not dura) Most commonly located along falx, convexity, or sphenoid ridge; may be multiple in 8% of cases Hyperostosis Calcification: psammoma bodies Female: male: 1.8:1 Simpson grading system for surgery |
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MRI of meningioma
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Current MRI (>0.5 tesla) will show most meningiomas on T2WI (unless it is nearly totally calcified)
Give information regarding patency of dural venous sinuses (90%) “Dural tail” is a common finding |
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下列有關腦神經膠質母細胞瘤glioblastoma multiforme(GBM)的敘述
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(A)最常見的腦瘤是神經膠質瘤(glioma)
(B)星狀細胞瘤第四級(Astrocytoma, grade 4) (C)病理切片可見細胞有絲分裂、內皮細胞增生、壞死(mitotic figure、endothelial proliferation、necrosis) |
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Survival for astrocytomas
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Grade Median survival
I 8-10 yrs II 7-8 yrs III 2-3 yrs IV <1 yr |
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一位45歲之女性病患,有數年的頭痛病史,近六個月來右側聽力逐漸減退,理學檢查發現右側臉頰感覺較差,且有輕度右側顏面麻痺,磁共振檢查發現在右側小腦橋腦角有一4公分之腫瘤,且內耳孔 (Internal auditory meatus) 擴大,為腫瘤所侵入,此一腫瘤最可能由何神經所生出?
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前庭神經
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聽神經瘤(Acoustic neuroma
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Misnomer: vestibular schwannoma as the preferred term from superior division of the vestibular nerve.
3 most common symptoms Insidious and progressive hearing loss High pitched tinnitus Dysequilibrium Antoni A (narrow elongated bipolar cells) & Antoni B fibers (losse reticulated) |
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松果體腫瘤(Pineal region tumor)
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Parinauds syndrome
Convergence, accommodation and “setting sun sign” (upgaze palsy + lid retraction) Stereotactic procedure May be used to ascertain diagnosis or to treat symptomatic pineal region cysts Radiation treatment Germinomas are very sensitive to radiation (and chemotherapy). |
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CT顯示蝶鞍 (sella) 上方單一囊性腫瘤,其邊緣有點狀鈣化,蝶鞍 (sella) 為正常大小,則下列何者為最可能的診斷?
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顱咽瘤 (craniopharyngioma)
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顱咽瘤(Craniopharyngioma)
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From anterior superior margin of the pituitary
Solid and cystic components Cholesterol crystals Do not undergo malignant degeneration Calcification Plain x-ray: 85% in childhood; 40% in adults Microscopy: 50% |
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Sources of cerebral metastases
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Adults
Lung ca (44%) breast (10%) kidney (7%), GI (6%) melanoma (3%), undetermined (10%) Peds Neuroblastoma, rhabdomyosarcoma, Wilm’s tumor |
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腦血管疾病(Cerebrovascular disease)
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中風(Stroke, Hemorrhagic stroke)
動脈瘤 (Aneurysm, Subarachnoid hemorrhage) 動靜脈畸形 (Arteriovenous malformation) 頸動脈靜脈竇廔管 (Carotic-cavenous fistula) Moyamoya disease |
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腦出血(Intracerebral hemorrhage)
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Putamen : 50%
Thalamus : 15% Pons : 10-15% Cerebellum : 10% Cerebral white matter 10-20% |
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一位高血壓腦內出血(hypertensive intracerebral hemorrhage)的病人,臨床症狀出現嚴重的一側感覺喪失及輕微的運動功能損害,推斷最有可能的出血位置在何處?
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視丘(thalamus)
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病人突然出現頭暈、頭痛、噁心、嘔吐,理學檢查顯示步態不穩,共軛性眼凝視異常 (conjugate diplopia)。則最可能的出血部位為:
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小腦
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小腦症候群(Cerebellar syndrome)
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Lesions in cerebellar hemisphere
Ataxia of the extremities Dysmetria Intention tremor Lesions in cerebellar vermis Wide based gait Truncal ataxia Titubation |
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腦出血重點提示
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Putamen : 50%
Thalamus : 15% Pons : 10-15% Cerebellum : 10% Cerebral white matter 10-20% |
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一位65歲的女性,覺得腰酸背痛及兩側坐骨神經痛已一年多。最近兩個多月來症狀加重,而且走不遠,站不久。走沒100步,就必須蹲下來或坐下來休息,症狀才得以緩解。而且越走愈駝背。身體往後仰症狀會更惡化。但騎腳踏車則沒有問題。則下列何者是最可能之診斷?
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腰椎狹窄症 (lumbar spinal stenosis)
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脊椎狹窄(Spinal stenosis)
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Hypertrophy of facets and ligmentum flavum
Most common at L4-5 and then at L3-4 Neurogenic claudication Gradually progressive back and leg pain Relieved at rest regardless of position Responds to decompressive surgery |
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腰椎椎管狹窄(lumbar spinal stenosis)在何種姿勢時會使神經性跛行症狀減緩?
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腰椎彎曲(Flexion)
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Arthropoid posture
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Neurogenic claudication
Exaggerated waist flexion, possibly reduces lumbar lordosis, thereby reducing inward buckling of ligamentum flavum and also distracting facet joints |
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下列關於脊椎滑脫症 (Spondylolisthesis) 的敘述,何者為是?
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脊椎滑脫是由於一塊脊椎骨相對其下脊椎骨滑動的狀況
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脊椎滑脫症(Spondylolisthesis)
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Anterior subluxation of one vertebral body on another, usually L5 on S1.
Grade I,II,III & IV: <25%, 25-50%, 50-75% & 75%-complete of subluxation Spondylolysis: isthmic spondylolisthesis Defect in the pars interarticularis Defect in the neck of the “Scotty dog” on oblique LS-spine x-ray |
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腰椎彎曲或伸展時,L4-L5和L5-S1的活動範圍約佔全部活動範圍多少比例?
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80%~90%
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Odontoid fractures分類
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Type Characteristics Stability
I Through tip, rare stable II Through base of neck, most common Unstable IIA Type II + large bone chips at fracture site Unstable III Through body of C2 Stable |
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某人綁著安全帶(seat belt)開車,與來車對撞發生第一腰椎骨析,其骨折最可能是屬於:
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屈曲-牽開性骨折(flexion-distraction fracture)
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下列為脊椎內硬脊膜外腫瘤(intra-spinal, extra-dural tumor)之臨床症狀檢查發現
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(A)神經痛
(B)運動乏力(motor weakness) (D)痙攣(spasticity) |
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脊椎腫瘤的分類
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Extradural: 55%
metastases Intradural extramedullary: 40% Meningioma Neurofibromas Intramedullary: 5% Astrocytoma Ependymoma |
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下列何種癌症若轉移到脊椎時,會造成骨頭增生的現象?
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攝護腺癌
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脊椎轉移
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Most cause osteolyic
Lymphoma Lung Breast Prostate May be osteoblastic In men: prostate Ca In women: breast Ca |
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下述何種腰椎疾病,最為適合以經脊椎骨弓螺釘固定及脊椎後側融合術(Transpedicular screws and posteriolateral fusion)來治療?
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腰椎骨脫位(Spondylolithesis)
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脊髓橫斷損傷 (Spinal cord transection)
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Complete transection – loss of all sensibility and voluntary movement below the lesion
Tetraplegia, paraplegia |
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不完全脊髓損傷(Incomplete spinal cord injury)
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Anterior cord syndrome
Posterior cord syndrome Central cord syndrome Brown-Séquard syndrome |
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Anterior cord syndrome
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Hyperflexion
Ant. Two thirds of the cord injury (ant. Spinal artery supply) Paraplegia (bilateral) Dissociated sensory loss : loss of pain & temperature with preserved posterior column function The poorest prognosis |
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Posterior cord syndrome
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Direct penetrating contusion impaction, spondylosis with hyperextension
Preserve pain, temperature, and motor Loss of joint position, vibratory, two point discrimination, and deep pressure; but light-touch preserved Good prognosis |
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Central cord syndrome
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Acute hyperextension with pre-existing spinal stenosis
Weakness of upper limbs, lesser lower limbs Acute sphincter dysfunction Varying degree of sensory disturbance Most frequent |
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腳工反張 motor
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2 分
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Brown-séquard syndrome
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Spinal cord hemisection (penetrating, epidural compression)
Contralateral finding : loss of pain & temperature Ipsilateral Motor paralysis, proprioception loss |
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脊髓損傷重症照護
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First goal is to protect the spine
Spinal shock High dose methylprednisolone Acute spinal cord injury within 8 hrs of trauma, loading dose 30mg/kg and maintenance dose of 5.4mg/kg/hr for 23 hrs Major goal of the surgical procedures is to achieve adequate neural decompression and stabilization |
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一位80 歲老先生騎車車禍受傷前額著地,送至急診室時上肢肌力約2 分,下肢約3-4 分,病人原本就有頸椎退化疾病病史。理學檢查雙側均有Hoffmann's sign 及雙側深部肌腱反射(DTR)增強情形,並仍保有肛門縮肛功能(anal tone preserved)。則這位老先生最可能是何種脊椎損傷?
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中央脊髓症候群(central cord syndrome)
過度伸張損傷(hyper extension injury) 如果症狀未持續惡化,則可以先用下列何種藥物治療? (A)大劑量methylprednisolone |
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對於完全性高位頸椎脊髓損傷病患而言,病發數週內呼吸功能的進步與下列何者最有相關?
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胸廓痙攣(Spasticity)
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Sacral sparing 是代表不完全脊髓損傷(Incomplete spinal cord injury
屬於Sacral sparing |
(A)肛門周圍有感覺(Perianal sensation)
(B)肛門可自主收縮(Voluntary anal contraction) (C)大拇趾可屈曲(Great toe flexion) |
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不完全性的脊髓損傷
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Any residual motor or sensory function more than 3 segments below the level of the injury
Sacral sparing Sensation around anus Voluntary rectal sphincter contraction Voluntary toe flexion |
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Osteomyelitis高危險群
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IV drug abuse
DM Hemodialysis Immunosuppression: AIDS, chronic steroids use, ethanol abuse Infectious endocarditis Following spine surgery or invasive procedure Elderly patients |
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周邊神經病變(Peripheral Nerves)
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Carpal tunnel syndrome ( median n. )
Tardy ulnar palsy Nerve injuries, entrapments Peripheral nerves tumors Facial nerve palsy Hemifacial spasm ( AICA vs. CNVII ) Trigeminal neuralgia ( SCA vs CNV ) Brachial plexus injury ( C4 ~ T1 ) Thoracic outlet syndrome ( subcl a, v, bra plexus ) |
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手腕腹側有一個腕隧道(Carpal tunnel),內有那一條神經通過?
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正中神經(Median nerve
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有關腕隧道症候群(carpal tunnel syndrome)的敘述
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(A)患者夜眠時常因手掌麻痛醒來,甩動手部可以減緩症狀
(C)手腕極度屈曲或伸展可以誘發症狀 (D)嚴重者會有拇指外展短肌之無力 |
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下列有關尺神經(Ulnar nerve)被壓迫之敘述
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(A)最常見的位置在手肘
(B)在手肘處的尺神經壓迫必須和內側肱上髁炎(medial epicondylitis)區分 (D)尺神經在手肘部位受壓迫的幾種開刀方式中,並沒有那一種方式較好 |
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Surgery for tardy ulnar palsy
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Options
Simple nerve decompression Nerve decompression and transposition Medial epicondylectomy Result not as good as with CTS, possibly due in part to the fact that patients tend to present much later (good 60%, fair 25%, poor 15%); |
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病人手術平躺時,如長時間前臂內轉 (pronation) 容易造成那一條神經壓迫性損傷?
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尺神經
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Ulnar nerve entrapment
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Wasting of the first dorsal interosseous
Wartenberg’s sign: abducted little finger due to 3rd palmar interosseous weakness Froment’s prehensile thumb sign: Adductor pollicis weakness Claw deformity of the hand: 4th & 5th fingers hyperextended at the MCP joints and flexed at the interphalyngeal joints |