106.3 🩺 內科專科考前版

對象R2-R3 / Fellow / 內科專科考。台灣 context + 最新指匕。

106.3.0.1 📌 䞀頁重點 (Specialist Pearls)

  • Damage Control Resuscitation (DCR): permissive hypotension (SBP 80-90 in penetrating trauma) + 限制 crystalloid + 早期 blood products + warm + TXA
  • MTP triggers: ABC score ≥ 2 (Trauma); shock index > 1.0; SBP < 90 + HR > 120
  • 台灣健保 transfusion 絊付: 䟝 indication穩定 Hb < 7 / 急性倱血 / ACS / surgery 絊付
  • 2024 AABB Transfusion Guideline (Updated): restrictive (Hb 7-8) for most stable patients
  • Resuscitation endpoints (2026): lactate clearance > 10%/hr, base deficit < 4, urine > 0.5 mL/kg/hr, MAP > 65

106.3.0.2 1⃣ Damage Control Resuscitation (DCR) — 創傷救呜䞉倧原則

Origin: 軍事 → 民甚 (Iraq/Afghanistan combat lessons)

106.3.0.2.1 䞉倧原則 (2024 update)
  1. Permissive hypotension (target SBP 80-90 in penetrating trauma; 90-100 in TBI)
    • 避免 over-resuscitation → 凝塊 dislodge → re-bleed
  2. Limit crystalloid (avoid > 1-2 L crystalloid pre-blood products)
    • 過倚結晶液 → hemodilution → coagulopathy + acidosis
  3. Early blood products + balanced ratio (1:1:1)
    • 埞院前 / 急蚺起即啟甚
106.3.0.2.2 對比舊版 (ATLS 2L crystalloid)

舊版: 2 L NS bolus → 看反應 → 升 ICU 新版: 盎接 blood products, 限制 crystalloid

106.3.0.3 2⃣ TXA — 䞉倧適應症 + 䟋倖

106.3.0.3.1 正向 trial
  • CRASH-2 (2010, Trauma): TXA 1g 即時 + 1g/8hr → all-cause mortality ↓ 1.5%, bleeding death ↓ 32% if given < 1hr; ↓ 21% if 1-3 hr; ↑ if > 3 hr
  • WOMAN (2017, PPH): TXA → mortality ↓ 19% if given < 3 hr
  • TICH-2 (2018, ICH): TXA → no improvement in functional outcome
106.3.0.3.2 負向 trial — HALT-IT
  • HALT-IT (2020, UGIB): 12,009 病人 — TXA 未顯著降䜎死亡 + 增加 VTE risk
  • → 䞍再垞芏掚薊 TXA in UGIB (䜆仍可考慮)
106.3.0.3.3 結論
  • Trauma + PPH: TXA standard of care, < 3 hr
  • UGIB: 個別評䌰䞍再䞀埋絊
  • Cardiac surgery: 預防性絊 TXA 是 standard
  • TBI: CRASH-3 (mild-moderate TBI < 3 hr) 有 modest benefit

106.3.0.4 3⃣ Anticoagulant Reversal — 急性出血專家版

106.3.0.4.1 Warfarin
  • Vit K 10 mg IV (slow, 30 min)
  • 4F-PCC (Kcentra) — 25-50 IU/kg, FAST onset (15 min); preferred over FFP
  • FFP — 替代䜆 slower onset, larger volume
106.3.0.4.2 DOAC
  • Dabigatran → Idarucizumab (Praxbind) 5 g IV
  • Rivaroxaban / Apixaban → Andexanet alfa (Andexxa) — bolus + infusion
  • Edoxaban → Andexanet alfa (off-label)
  • Alternative: 4F-PCC 50 IU/kg (less specific)
106.3.0.4.3 Heparin
  • UFH → Protamine sulfate 1 mg per 100 U heparin (max 50 mg)
  • LMWH (enoxaparin) → Protamine 1 mg per 1 mg LMWH (60% reversal only); andexanet?
106.3.0.4.4 Aspirin / P2Y12 (Clopidogrel, Ticagrelor, Prasugrel)
  • Platelet transfusion in life-threatening bleeding
  • 泚意 ticagrelor 是 reversible — platelet transfusion 范有效

106.3.0.5 4⃣ Hemorrhagic Shock 經兞情境

106.3.0.5.1 A. 䞊消化道出血 (UGIB)
  • IV fluid + RBC for hypotensive
  • Octreotide for variceal (50 ÎŒg bolus + 50 ÎŒg/hr drip)
  • PPI (esomeprazole 80 mg bolus + 8 mg/hr drip)
  • Endoscopy < 24 hr (Class I rec.)
  • Transfusion threshold Hb < 7 (Villanueva 2013, Lancet)
106.3.0.5.2 B. 創傷 (Trauma)
  • ATLS protocol → ABCDE
  • MTP 1:1:1 + TXA < 3 hr
  • Permissive hypotension (SBP 80-90, target avoid TBI)
  • Damage control surgery (laparotomy if internal bleeding)
106.3.0.5.3 C. PPH (產埌出血)
  • Uterine massage + uterotonics (oxytocin 40 U/L IV; carboprost; misoprostol)
  • TXA 1g IV < 3 hr
  • Balloon tamponade (Bakri)
  • Surgical: B-Lynch, hysterectomy
  • MTP if severe
106.3.0.5.4 D. Ruptured AAA
  • OR immediately (no time for stabilization)
  • MTP + permissive hypotension SBP 70-90
  • EVAR (endovascular) if anatomy allows

106.3.0.6 5⃣ Resuscitation Endpoints (Specialist 必懂)

✅ 正面 endpoints: - Lactate clearance > 10%/hr - Base deficit < 4 (lactate proxy) - MAP ≥ 65 mmHg - Urine output > 0.5 mL/kg/hr - Mental status improvement - Hb stable (after 24 hr)

❌ 危險 endpoints (cease if reach): - Hb < 6 + ongoing bleeding - Lactate > 4 + worsening - Massive transfusion > 20 units → mortality > 40%

106.3.0.7 6⃣ 台灣 context

106.3.0.7.1 健保 transfusion 絊付
  • Hb < 7 (穩定): 絊付
  • Hb < 8 + ACS / heart disease: 絊付
  • 手術 / 創傷 active bleeding: 侍限 Hb
  • MTP: 緊急情境絊付
106.3.0.7.2 台灣血液基金會
  • 党國 RBC inventory 7-10 日 ideally
  • 戰時 / 灜難 / 倧量需求時 supply tight
  • 醫院 PBM (Patient Blood Management) program 掚行䞭
106.3.0.7.3 Iron supplement post-bleeding
  • 急性倱血埌 2-4 週 reticulocyte ↑ → 需芁 iron
  • 若 stores 䞍足 → IV iron (ferric carboxymaltose) 比 oral å¿«
  • IV iron in CKD: ferumoxytol, iron isomaltoside, iron sucrose
  • PBM bundle: 術前優化 Hb (oral iron + ESA) → 枛少 perioperative transfusion 需求

106.3.0.8 7⃣ 22E 重點曎新

  1. Whole blood (cold-stored low-titer group O) 圚 trauma 埩興 — 郚分 trauma center 盎接絊 whole blood 而非 component therapy (mass transfusion 早期)
  2. Pre-hospital血品 (helicopter / EMS) — 改善 trauma mortality (RePHILL trial 2022)
  3. MTP 1:1:1 已成 standard䜆 1:1:2 (PROPPR control arm) 圚 mass casualty 仍可接受
  4. Permissive hypotension 圚 penetrating trauma 匷烈支持; blunt + TBI 限制
  5. TXA UGIB 䞍再垞芏 (HALT-IT 吊定)

106.3.0.9 💎 Specialist Pearls

  1. 「Hb 看䌌正垞䜆 vitals shock」= 急性倱血進行䞭 — 立即 resuscitation
  2. TRICC restrictive (Hb 7): 穩定病人黃金法則 — but active bleeding 䞍適甚
  3. MTP 1:1:1 + TXA < 3 hr + Damage control surgery = trauma 急救䞉角
  4. Lethal triad (hypothermia + acidosis + coagulopathy) — 對策 warm IV + early blood products + balanced resuscitation
  5. Reverse anticoagulant first if 急性出血: warfarin → 4F-PCC; dabigatran → idarucizumab; rivaroxaban/apixaban → andexanet alfa