本博客文章是基于C级证据 - 共识和专家的意见,以及一些观测数据。和算法的协议,清单的例子是用于教育目的和使用在临床实践前,您的医院需要为您的特殊需要修改,以及批准。

COVID-19 prognosis and mortality rate to help guide goals of care

理查森S,赫希JS,纳拉辛汉M等人。呈现特点,合并症和结果在5700例住院COVID-19在纽约市地区。JAMA。网上公布一个pril 22, 2020. doi:10.1001/jama.2020.6775.

在北美的医疗环境中的5700例患者这个大型的观测研究发现,死亡率在所有来者从取决于年龄5-64%不等。这些人中14%是ICU的患者,12%的通风。谁是通气的患者中有一个死亡率88%(在那些年龄18-65岁76%,这些97%> 65岁以上)。这与一致以前的研究结果通风COVID-1的死亡率非常高9patients. Mortality of non-ventilated patients ages 18-65 years was 20% and mortality of non-ventilated patients >65 years old was 27%. These data are important to know when counseling patients and families about goals of care.

Score to predict likelihood of coagulopathy and mortality in COVID-19 patients on MDCalc


与患者所花费的时间可以是作为程序的用于烟雾化/类型COVID-19病毒的空气传播重要

威尔逊NM,诺顿,年轻的FP,科林斯DW。严重急性呼吸综合征冠状病毒-2机载传输到医护人员:叙事的审查。麻醉。四月,20年,2020年。

There are 3 mechanisms for the production of aerosols that, if inhaled, can deposit in the distal airways:

  1. Laryngeal activity such as talking and coughing
  2. High velocity gas flow; and
  3. 周期性的打开和关闭终端的气道

在这篇文章中,他们认为,变速箱与时间接近相关联COVID,19例有呼吸道症状,而不是每本身的程序。

气溶胶生“打喷嚏和咳嗽都有效一个tors, but all forms of expiration produce particles across a range of sizes. The 5 μm diameter threshold used to differentiate droplet from airborne is an over‐simplification of multiple complex, poorly understood biological and physical variables. The evidence defining aerosol‐generating procedures comes largely from low‐quality case and cohort studies where the exact mode of transmission is unknown as aerosol production was never quantified. We propose that transmission is associated with time in proximity to SARS‐CoV‐1 patients with respiratory symptoms, rather than the procedures per‐se. There is no proven relation between any aerosol‐generating procedure with airborne viral content with the exception of bronchoscopy and suctioning. The mechanism for SARS‐CoV‐2 transmission is unknown but the evidence suggestive of airborne spread is growing. We speculate that infected patients who cough, have high work of breathing, increased closing capacity and altered respiratory tract lining fluid will be significant producers of pathogenic aerosols. We suggest several ‘aerosol‐generating procedures’ may in fact result in less pathogen aerosolisation than a dyspnoeic and coughing patient. Healthcare workers should appraise the current evidence regarding transmission and apply this to the local infection prevalence. Measures to mitigate airborne transmission should be employed at times of risk. However, the mechanisms and risk factors for transmission are largely unconfirmed. Whilst awaiting robust evidence, a precautionary approach should be considered to assure healthcare worker safety.”

气雾化的完整的PDF /联合V2文章的空气传播

气溶胶,液滴,空气传播:一切你可能想知道在Firt10EM

Droplets spread more than 2 meters (a systematic review) at First10EM

Should a healthcare worker wear an N95 mask when providing care for a coughing, possible or confirmed COVID 19 child, when the child will not wear a surgical mask? (care of Laurie Mazurik)

Yes, if a patient is coughing and is a possible or confirmed COVID 19, and cannot keep a surgical mask on, the provider should wear an N95 mask when providing their care.咳嗽产生的气溶胶。This, is why having a coughing patient wear a surgical mask is so important. This applies to all ages. Given that we are all concerned about PPE conservation, if you have to look after these types of patients, it may be best to simply wear the N95 all shift or as long as possible along with the face shield, changing it only if you feel it is contaminated, wet etc.

面膜净化和再利用

N95口罩是专为一次性使用,并且有他们的去污没有授权的制造方法。美国国家职业安全和健康研究所(NIOSH)和CDC不建议作为呼吸器护理标准的净化;然而,他们勾勒出的是,当存在不足,去污的选项应该被考虑。根据CDC,紫外线杀菌辐射,蒸气过氧化氢,并使用高压釜湿热显示最有希望成为对于N95口罩的去污方法。这些方法似乎并没有打破过滤或危及呼吸;然而,许多这些方法只能用于有限的时间。

公共卫生安大略省。(2020年,4月4日)。COVID-19 - 也就是我们目前所知关于个人防护设备的再利用。https://www.publichealthontario.ca/-/media/documents/ncov/covid-wwksf/what-we-know-reuse-of-personal-protective-equipment.pdf?la=en

COVID-19 Decontamination and Reuse of Filtering Facepiece Respirators. (2020, April 9). Retrieved fromhttps://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html

你ED应该有N95口罩(护理劳瑞Mazurik的)的消毒和重复使用的系统/协议
Sunnybrook Health Science Centre, Toronto Ontario and other hospitals are saving and sterilizing N95s for reuse.
http://health.sunnybrook.ca/navigator/some-hospitals-planning-to-sterilize-and-reuse-n95-masks-to-stretch-out-supplies-during-covid-19-pandemic/ Each provider places their N95 mask in sterilization envelope, seals it and write their name on it, so they only get their mask back.
它们高压釜400层的掩模在1.5小时,并重新进行处理直到为每个N95 10倍(除了模制的)。这些只能在高压灭菌一次,但如果你使用其他方法对这些它上升到10倍。 曼尼托巴大学正在与国家微生物实验室测试N95s口罩消毒和重复使用的不同模式,并启动了整个过程。

安德鲁·莫里斯COVID-19流行病学和医疗更新

无症状,症状前SARS-VOV-2感染 - 我们怎么知道谁是传染?

斯克里普斯已经整理所有数据,并且它似乎42的人谁是COVID阳性,无症状88%之间的某处。如果你仔细观察,种群变化很大,样本量仍然相当小,与3个人口最多的船(钻石公主+ 2艘航母)。这会将与最近才(及时的)新英格兰医学杂志文章这表明,在长期护理设施(LTCF)-56居民反映测试正面为无症状的%;89%的人会出现症状;所以可能最好把它们称为“症状前”。(症状发生前的SARS-COV-2感染和传播在专业护理机构。新英格兰医学杂志。2020年)此外,这些症状前的患者超过一半的人脱落的活病毒。

Congregant设置should在这一流行病最有针对性的网站

There has been dramatic spread of CoV-2 in LTCF, shelters and other congregant settings in Canada. It is likely under–recognized in the US at present, but it is absolutely a recognized problem in Canada, where it continues to be a problem, especially in LTCFs in Quebec and Ontario. An unsurprising congregant setting is a meat–packing facility in Alberta, which has furnished over 600 cases, especially involving workers originally from the Philippines who are major breadwinners for their families back home. It has resulted in several deaths, and is the largest single outbreak in Canada. Congregant settings should be the most targeted sites in this pandemic.

Coordination随机对照试验的COVID药物和科学的组织是非常重要的

(现在几百)的随机对照试验对潜在COVID药物应协调,适当地进行。一个近期柳叶刀数字医疗保健品主张这一点,并提出根据现有的数据自己的观点: 图缩略图GR1
作为COVID移动科技的迅速,我们需要更好地组织它。有一个正在酝酿做这个举动。我最喜欢的两个资源是https://www.mcmasterforum.org/networks/covidend/lets-collaborate/our-guide-to-covid-19-evidence-sources一个ndhttp://eppi.ioe.ac.uk/COVID19_MAP/covid_map_v6.html

COVID-19家188bet安卓app庭测试医护人员

FDA-approved home testing kits will soon be available for health care workers through a physician’s order, with results available online. Apparently this testing kit has proven to be as accurate as standard CoV-2 nasopharyngeal swab tests (which are not very accurate), although I can not find the data on this anywhere online. Even though this has been approved by the FDA it remains to be determined if these kits are truly reliable.

Labcorp home testing kits


联合CO​​VID-19中度身体疏远,检测和跟踪战略将根据英国的数学模型超过质量测试或单独自我孤立降低传输

库哈尔斯基,A等人。隔离,测试接触追踪和物理疏远的减少在不同的设置SARS-CoV的-2的传输的有效性。传染病中心的数学模型。2020年4月23日。

这组数学建模的使用设置基于这个非同行评议的论文从40162人在英国的数据(家庭,工作,学校等)分层个体层次的传输模型。他们模拟的几个不同的测试,隔离,追踪和物理疏远场景的影响。他们估计COVID-19发生一定水平,并且会在每一天的新隔离在不同的策略触点的数量在有效繁殖数量的减少。他们估计,联合检测和跟踪策略,将更多的降低比质量测试或单独自我隔离(50-65%和2-30%)传输。如果限制被放置在聚会以外家/学校/工作(例如最大的在其他设置每日触点4),然后手动接触熟人跟踪188bet安卓app只可能对传输还原为详细追踪接触类似的效果。战略的症状的病例组合的分离和他们的联系人的跟踪减少有效再现次数超过单独质量测试或自隔离。

它看起来像轻微的身体接触(每日最高接点4家外/学校/工作)措施,接触者追踪(详细应区域化)相结合,是我们最好的选择前进。188bet安卓app

“减少在不同的设置SARS-CoV的-2的传输isloation,测试接触追踪和物理疏远的Effectivenss”的完整的PDF


Dipyridamole for COVID-19? Interesting, but not ready for prime time

刘X,李Z,刘S等人。在病情严重的患者COVID-19双嘧达莫的潜在治疗效果。ACTA医药罪B. 2020

患者升高d二聚体与COVID-19先前已被证明是不良预后的标志物。潘生丁已被证明in vitroto suppress CoV-2 replication. In this proof of concept trial of oly 31 patients with COVID-19, dipyridamole was associated with lower D-dimers, increased lymphocyte and platelet recovery and clinical improvement (87.5% cure rate, 12.5% clinical remission). Large RCTs are required before any recommendations for clinical use of this drug can be made.


Some observational data suggests that awake self proning may improve oxygenation transiently in patients suspected of COVID-19

Caputo ND, Strayer RJ, Levitan R. Early Self-Proning in Awake, Non-intubated Patients in the Emergency Department: A Single ED’s Experience during the COVID-19 Pandemic. Acad Emerg Med. April, 22nd, 2020.

50例患者观察这种试验性研究(缺氧抵达和怀疑COVID19的谁用NRB治疗,鼻导管补充氧),血氧饱和度比较2在分流和proning的五分钟后,看着插管后proning故障率的第一个24小时内。血氧饱和度2提高从84%至94%。患者一季度未能改善或维持其血氧饱和度和24小时内到达的ED内需要气管插管。虽然这种观测研究看起来很有希望自proning在短期内疑似COVID-19的患者,潜在益处的持续时间尚不清楚。随机对照试验看着更长的时间内,更面向患者的预后通常采用自proning COVID-19例之前需要。

IDSA COVID-19治疗指南推荐

Bhimraj A,等人。传染病的治疗和患者的管理与COVID-19美国准则的社会。四月,2020年

  1. 在谁已经承认与COVID-19医院的患者,IDSA指南小组建议在临床试验的背景下羟氯喹/氯喹。(知识间隙)
  2. 在谁已被送往医院与COVID-19的患者,IDSA指南小组建议羟氯喹/氯喹加上阿奇霉素仅在临床试验的背景下。(知识间隙)
  3. 在谁已经承认与COVID-19医院的患者,IDSA指南小组建议仅在临床试验的背景下洛匹那韦/利托那韦的组合。(知识间隙)
  4. 在谁已被送往医院与COVID-19的肺炎患者中,IDSA指南小组建议对使用糖皮质激素。(有条件的推荐,证据非常低确定性)
  5. 一个mong patients who have been admitted to the hospital with ARDS due to COVID-19, the IDSA guideline panel recommends the use of corticosteroids in the context of a clinical trial. (Knowledge gap)
  6. 一个mong patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel recommends tocilizumab only in the context of a clinical trial. (Knowledge gap)
  7. 在谁已被送往医院与COVID-19的患者,IDSA指南小组建议在临床试验的背景下COVID-19恢复期血浆。(知识间隙)

完整的PDF IDSA COVID-19指南

更新的IDSA COVID-19指南


Should we discharge patients with instructions for self monitoring of oxygen saturation or Roth Score monitoring?

Salim Rezaie, “REBEL Cast Ep80: A New War Plan for COVID-19 with Richard Levitan”, REBEL EM blog, April 24, 2020. Available at:https://rebelem.com/rebel-cast-ep80-a-new-war-plan-for-covid-19-with-richard-levitan/

乔丹TB,迈尔斯CL,Schrading WA,唐纳利JP。iPhone应用程序血氧饱和的效用:在急诊室标准脉搏血氧饱和度测量比较。牛J Emerg(紧急)医学。2019。

根据专家的意见,在COVID-19的自然历史上最有影响力的点血氧饱和度开始时出现下降。没有病人经历呼吸急促主观(“沉默缺氧”)可能会出现此下降。因此,建议,怀疑COVID-19的患者谁是从正常的血氧饱和度ED出院应指示在家里监视他们的血氧饱和度,并返回到ED时,血氧饱和度都持续低于基线水平。188bet安卓app患者可以配备便携式血氧饱和度监测仪或可以买一个约$ 30。如果这不是一个选项,罗斯得分(见下文),可以用来估计血氧饱和度,虽然它一直被人诟病,因为敏感性和特异性似乎是原来的文章中提出了不正确的,到现在也没有得到证实。MDCalc去掉了罗斯得分“,因为它是不再推荐。”证据为智能手机应用程序的氧饱和度的精度更是遍布地图,大概不会有任何建议。


Evidence-based review of psychological impact of quarantine and how to reduce it

Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912-920.

有24篇包括在本次审查,其中大部分负面报道的心理影响,包括创伤后应激症状,困惑和愤怒。压力源包括更长的时间隔离,感染的恐惧,沮丧,苦闷,供应不足,信息不足,经济损失和耻辱。谁被隔离的人更容易表现出疲惫,从他人,烦躁,入睡困难脱离,注意力不集中的症状。一些医务工作者可能从长期心理后果遭受如创伤后应激,抑郁症或酗酒,特别是那些被隔离> 10天。

They suggest some ways to mitigate the effects of quarantine:

  • 提供充足的耗材
  • 沟通清楚有关隔离的详细信息(时间,警示标志等)
  • Provide ways for people to communicate and socialize from a distance

其他COVID-19的资源和更新

EM案例COVID-19第5部分:流行病学及预测模型

EM案例COVID-19第4部分:保护插管

EM Cases COVID-19 Part 3: PPE: What You Need to Know & Conservation Strategies

EM案例COVID-19第2部分:浪涌能力策略

EM案例COVID-19第1部分:筛查,诊断和管理

EM快速点击14: You Colleagues Experiences & Tips 1

EM快速点击15: Practical Tips, Pediatric Management & Human Factors

EM快速点击16: Oxygenation strategies, Trauma Modifications, Addictions Considerations, Cardiac Complications & Compassionate Care

加拿大行程的最佳实践指南在COVID-19大流行

ROX指数HFNC后预测插管需要

心脏病学文章阿迈勒Mattu视频,您需要在2020年与COVID-19知道(7:15开始)

COVID-19大流行期间,提高心理健康


参考

理查森S,赫希JS,纳拉辛汉M等人。呈现特点,合并症和结果在5700例住院COVID-19在纽约市地区。JAMA。网上公布一个pril 22, 2020. doi:10.1001/jama.2020.6775.

威尔逊NM,诺顿,年轻的FP,科林斯DW。严重急性呼吸综合征冠状病毒-2机载传输到医护人员:叙事的审查。麻醉。四月,20年,2020年。

Zayas的,G.,蒋,M.C.,黄,E.等。在健康受试者咳嗽气雾剂:为优化液滴传播呼吸道传染病管理的基础知识。BMC Pulm Med12,11(2012)。https://doi.org/10.1186/1471-2466-12-11。

Thorlund K, et al. A real-time dashboard of clinical trials for COVID-19. The Lancet – Digital Health.网上公布一个pril 24, 2020.

阿龙斯MM,哈特菲尔德KM,雷迪SC等人。症状发生前的SARS-COV-2感染和传播在专业护理机构。新英格兰医学杂志。2020年

库哈尔斯基,A等人。隔离,测试接触追踪和物理疏远的减少在不同的设置SARS-CoV的-2的传输的有效性。传染病中心的数学模型。2020年4月23日。

刘X,李Z,刘S等人。在病情严重的患者COVID-19双嘧达莫的潜在治疗效果。ACTA医药罪B. 2020

Caputo ND, Strayer RJ, Levitan R. Early Self-Proning in Awake, Non-intubated Patients in the Emergency Department: A Single ED’s Experience during the COVID-19 Pandemic. Acad Emerg Med. April, 22nd, 2020.

Bhimraj A,等人。传染病的治疗和患者的管理与COVID-19美国准则的社会。四月,2020年

Salim Rezaie, “REBEL Cast Ep80: A New War Plan for COVID-19 with Richard Levitan”, REBEL EM blog, April 24, 2020. Available at:https://rebelem.com/rebel-cast-ep80-a-new-war-plan-for-covid-19-with-richard-levitan/

Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912-920.


Daily COVID-19 affirmation

I am in the present moment. I believe in myself and in the strength of the human spirit. Our society, country, and the world will overcome this. I am an essential part of the process. Even if things are difficult now, I trust the overall path that my life is taking. I’ll start with what I can do today. I accept the situation I am facing. I am confident in my ability to take necessary precautions. Even if I don’t see them now – there are solutions to my problems. I embrace all of my emotions. I let go of the past. I practice gratitude and forgiveness. I look for examples of kindness around me. My level of motivation is increasing. I feel greater amounts of happiness. I trust my intuition. I am doing my best. I effectively handle stress. I adapt and focus on solutions. I persevere. I act from a place of love, compassion, and peace.”

-Dr. Jerome Perera