本博客文章是基于C级证据 - 共识和专家的意见。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 evolving indications for intubation

Hypoxemia and tachypnea should not be the sole indications for intubation, but rather a complete clinical assessment including work of breathing, mental status and increasing PaCO2 and/or acidosis. Based on experience in NYC, patients who present early in the disease course with oxygen saturations in the 80’s, but who are otherwise clinically well and relatively asymptomatic, do not require intubation. There have been suggestions that these patients may benefit from prone positioning and HFNC (see below). The recommendation early in the COVID pandemic to strongly consider early intubation in all patients with oxygen saturations <90% despite non-invasive oxygenation may not be the best approach.

建议分步骤进行的呼吸支持COVID-19

随着外科口罩所有步骤和HFNC,CPAP,气管插管,其中可能产生的负面压力室

基于ED和纽约ICU经验,C级证据

COVID-19 graded respiratory support

基于呼吸,精神状态,二氧化碳分压,VBG的工作疗法的升级。考虑间断俯卧位。

网络研讨会上避免插管和初始通气COVID-19与斯科特Weingart

患者呼吸支持,COVID-19https://onlinelibrary.wiley.com/doi/pdf/10.1002/emp2.​​12071

COVID-10低氧血症上REBELEM

建议氧合策略算法AIME

氧合策略COVID

AIME氧合策略COVID由乔治·科瓦奇和亚当法

烟雾化分散

从https://onlinelibrary.wiley.com/doi/pdf/10.1002/emp2.​​12071

HFNC COVID

通过Lauren Westafer, FOAMcast

俯卧位通气

为俯卧位提出的机制

  • 前胸壁 - - 跨越诱导胸壁同质遵守纵隔的重量 - 腹部内容改进位移
  • 后/依赖性肺区的招聘更好
  • 可能导致血流的改变,更好的通气/灌注匹配
  • Improved drainage effect on respiratory secretions
  • 减少腹,背肺压力差
  • Reduced lung compression
  • 改善肺灌注

Consistently, most trials demonstrate improved oxygenation with ventilation in the prone position. One randomized trial and several meta-analyses also suggest a mortality benefit in those with severe ARDS. Trials have consistently shown that in most patients with ARDS (up to 70 percent), prone ventilation increases PaO2允许在氧合指数的降低2。谁表现出响应大多数患者这样做的第一个小时内,但超出了延迟的响应已被观察到。该PROSEVA审判和几个荟萃分析报告死亡率的好处从早期的,大剂量的重症患者ARDS俯卧位通气(由他们作为氧分压定义2:氧合指数2<150 mmHg). There is no evidence that prone ventilation prevents organ system dysfunction and reduces the intensive care unit (ICU) length of stay.

孙勤等人。“通过早期识别和干预COVID-19的死亡率较低:从江苏省的经验。”重症监护10.1(2020)的志:1-4。


对于COVID-19呼吸衰竭患者的限制性流体战略

  • 积极的复苏一般应COVID-19例可避免
  • COVID-19的患者似乎是相似的高原肺水肿患者体液过剩非常敏感。
  • Consider norepinephrine at 5-10mcg/kg/min rather than a fluid bolus to maintain MAP>65
  • 对于低血容量患者给予小晶体丸(250cL),并经常重新评估容量状态
  • 避免补液以清除euvolemic患者乳酸,作为高乳酸更可能严重低氧血症和呼吸窘迫相关的儿茶酚胺激增的结果,比低血容量

Video for procedure of prone positioningHTTPS://万维网。nejm.org/doi/full/10.1056/NEJMoa1214103

网络研讨会上避免插管和初始通气COVID-19与斯科特Weingart

患者呼吸支持,COVID-19https://onlinelibrary.wiley.com/doi/pdf/10.1002/emp2.​​12071

COVID-10低氧血症上REBELEM

使用hyperangulated VL与乔治·科瓦奇插管技巧和细微差别更新的视频


在COVID儿科考虑萨拉·里德的带回188bet安卓app家点

HTTPS://www.myrives.com/wp-content/uploads/2020/04/COVID-pediatric-considerations.pdf

安德鲁·莫里斯更新

1.早期经历血清疗法看起来很有希望。
2。COVID Rheumatolgy registry显示病人谁长期都在hydroxychloroquine仍处于感染和死亡的风险。
3.我们仍然不知道“真实”ICU死亡率- 因为不同的体验是...变化。中国:很多非通气患者。意大利:灾难性的场景。英格兰:数据的手段右审查,他们排除了患者的通风口比以往更长。对于所有:不清楚没有。带下宣泄治标不治本,甚至配给。
4。Transmission routes– Looks like pseudo-droplet spread in some manner. Also looks like “infected” can reduce spread by surgical mask—which justifies asymptomatic population wearing masks to protect infecting others. We don’t know if it will reduce acquisition. The difference between public masking to reduce spread vs. reducing acquisition is an important one. Probably what motivates most people is not getting infected, but we don’t have great evidence masking will do that, and it probably de-emphasizes hand hygiene.
5。COVID-19疗法– we are still lacking helpful information on pretty well anything. More and more case series with different treatments. None of them game-changing yet. Paper out of Australia suggests that伊维菌素反对COVID-19理论上的有效 - 陪审团仍然是完全脱离的那一个,太。阅读完整的纸抗病毒研究标题为:美国食品药物管理局批准的药物伊维菌素抑制SARS-CoV的-2在体外的复制:HTTPS://万维网。sciencedirect。com/科学/文章/PII /S0166354220302011

CAEP建议ED出院标准(基于C级证据)

1.具有获得食物,水,通信,安全住所
2.在功能基线水平
3。O2 saturation >94% on RA
4. RR <20,HR <110,BP在基线或预期年龄/性别
5。Does not appear clinically decompensated
6. Walk test: can walk 30 meters with <10% drop in O2 saturation (even if CXR or POCUS +ive)
考虑出院指导病人在家里进行步行试验(最好用O2坐在探头),如果O2sat返回ED <95%188bet安卓app

来源:https://caep.ca/wp-content/uploads/2020/04/Complete-COVID-AdmissionVentilation-Decision-Tree-Formatted-1.pdf


你执行NP拭子COVID-19时,需要一个N95口罩?

Use of N95 mask is not warranted for NP/OP swab

  • 存在与NP / OP棉签擦拭程序导致通过气溶胶传播的风险增加产生咳嗽没有证据。
  • HCW conducting this procedure should do so in a separate/isolation room, be well trained in the procedure, wear droplet precaution PPE, and request the patients to cover their mouth with a medical mask or tissue during NP swab.

从http://emergentc.ca/index.php/2020/03/30/summary-of-evidence-and-guidelines-for-the-use-of-n95-masks/#_ftn2


COVID-19病理生理学和临床特征相似,高原性肺水肿:我们是否应该考虑高原肺水肿治疗方法COVID-19的病人?

高原肺水肿(HAPE)和COVID-19有很多相似之处:

  • 动脉血氧分压的分馏吸入氧比例降低伴随缺氧和呼吸急促
  • 倾向低的二氧化碳水平
  • 毛玻璃混浊和片状浸润的CT表现
  • 升高的纤维蛋白原水平,其可能的浮肿形成的附带现象,而不是凝血激活
  • Bilateral diffuse alveolar damage associated with pulmonary edema, pro-inflammatory concentrates
  • Lead to ARDS

已经有研究对高原肺水肿有效的疗法的COVID-19的患者,如乙酰唑胺,nifedpine和磷酸二酯酶抑制剂的功效的建议。

Solaimanzadeh一,乙酰唑胺,硝苯地平和磷酸二酯酶抑制剂:理由他们作为辅助对策冠状病毒病2019(COVID-19)的处理利用。Cureus。2020; 12(3):e7343。


COVID-19保护的代码蓝

Excellent overview: Protected Code Blue https://rebelem.com/covid-19-protected-code-blue/

Reuben Strayer’s video on protected transfer of cardiac arrest patient from EMS to resuscitation room


COVID /非COVID的ED分离是关键

完全独立的
单独的入口,出口;之间NO道口,完全彼此独立的。
通过一种方法路径进入,评估/治疗出一种不同的方式(如果可能)
独立的员工
分配高风险人员(年龄,共病)到非COVID侧。即使无症状患者COVID来自那里,病毒载量将降低,传输给他人的变化更小。
Whether you are in the COVID or non-COVID areas all staff and patients get surgical masks, social distancing and isolation where possible still applies.
Telemedicine
分诊为COVID和非COVID。

COVID-19实验室徐大淦

实验室预后的优势比死亡率COVID

从MDCalc


报价一周

有些时候,你可以召唤,
有些时候,你必须调用。
You can take a lot of reckoning,
But you can’t take it all.

有些时候,我可以帮你,
和时间,当你必须下降。
有些时候,你必须住在疑问
我不能在所有的帮助。

三个蓝色恒星上升山丘上
也不歌唱,现在只是还
All these trials soon be past
寻找基业长青的东西。

Built to last till time itself falls tumbling from the wall
建立持续,直到阳光失败,所有的黑暗移动
基业长青,而岁月的流逝过去一样在天空中cloudscapes
告诉我基业长青什么东西建成试

-Jerry加西亚/罗伯特·亨特

本博客文章是基于C级证据 - 共识和专家的意见。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。