小逸文筆記

死亡及併發症討論會有個印象深刻的是抽脂後併發敗血性休克而死亡的案例， 有趣是她的腹水和膿瘍培養菌中長產氣單胞桿菌屬(Aeromonas hydrophila)，怎麼會長這菌呢？ 這支革蘭氏陰性桿菌，醫療上會遇到問題是牠所造成的傷口感染（因在淡水中被刺傷刮傷等）和腸胃炎腹瀉（因會分泌類霍亂毒素）。 來勢洶洶 若蜂窩性組織炎或壞死性筋膜炎是因在海水或淡水中受傷引起， 最常見的細菌還是S. auerus、Group A streptcocci， 但還是要考慮有可能的致病菌Aeromonas hydrophila(淡水)及Vibrio vulnificus(海水)， 需盡早給經驗性抗生素， 病情常常快速惡化，必要時盡早施行筋膜劃開術甚至截肢，才能控制感染。 若出現在肝硬化的病患，病情會快速惡化，進展成嚴重敗血性休克。 第三代抗生素cover GNB 經驗性抗生素第三代Cefalosporins+ tetracyclines。 例如Ceftriaxone 2gm IV QD,+ minocycline 100mg IV Q12H或Fluoroquinolones(Levofloxacin 500mg IV QD) 參考資料 臨床使用抗生素手冊 第三版

Maxillary fracture 1. LeFort classification Le Fort I Fracture = Horizontal Fracture Clinical finding: Facial edema Malocclusion of the teeth Motion of the maxilla while the nasal bridge remains stable 2. Le Fort II Fracture = Pyramidal Fracture Clinical finding: Marked facial edema Nasal flattening Traumatic telecanthus Epistaxis or CSF rhinorrhea Movement of the upper jaw and the nose. Le Fort III Fractures = Craniofacial Separation Clinical finding: Dish faced deformity Epistaxis and CSF rhinorrhea Motion of the maxilla, nasal bones and zygoma Severe airway obstruction

Fracture of Zygoma 1. Symptoms Enophthalmos(眼球內陷): avoid compressing infraorbital nerve Malar asymmetry: Palpable bony defect over the arch Diplopia Trismus: Pain in cheek and jaw movement Impingement on coronoid process Flame sign: Intraoral hematoma, ecchymosis Epistaxis Inferior displacement of globe Inferior displacement of lateral canthus Infra-orbital never injury: numbness 2. Diagnosis: CT scan 3. Classification Group 1. No significant displacement. Group 2. Arch fractures. Group 3. Unrotated body fractures. Group 4. Medially rotated body fractures. Group 5. Laterally rotated body fractures. Group 6. Include all cases with fracture lines cross the main fragment. 4. Five places to align the zygoma 1) zygomatico‐maxillary buttress 2) lateral wall of the orbit 3) infraorbital rim 4) zygomatic arch 5) zygomatico‐frontal suture 5. Treatment 1) Isolated arch fracture Gillies approach 2) Displaced zygomatic fracture: ORIF(open reduction internal f...