COVID-19 (Coronavirus disease 2019), part 2
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新冠肺炎 臨床表現、診斷與防護
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COVID-19 (Coronavirus disease 2019), part 2
- 1. 弐 炎
- 2. 防護 臨床表現 診斷 炎
- 3. 臨床 表現
- 7. Symptoms The average time from exposure to symptom onset is 5 days, and 97.5% of people who develop symptoms do so within 11.5 days. Common symptoms in hospitalized patients • fever (70%-90%) • dry cough (60%-86%) • shortness of breath (53%-80%) • fatigue (38%) • myalgias (15%-44%) • nausea/vomiting or diarrhea (15%-39%) • headache, weakness (25%) • rhinorrhea (7%). • olfactory and/or gustatory dysfunctions (64%-80%)
- 8. Common Lab Abnormalities • lymphopenia (83%) • elevated inflammatory markers (eg, ESR, CRP, ferritin, TNF-α, IL-1, IL-6) • abnormal coagulation parameters (eg, prolonged PT, thrombocytopenia, elevated D- dimer [46% of patients], low fibrinogen).
- 9. Common Complications • pneumonia (75%), ARDS (15%) • acute liver injury (19%) • cardiac injury, including troponin elevation (7%-17%), acute heart failure, dysrhythmias, and myocarditis • prothrombotic coagulopathy resulting in venous and arterial thromboembolic events (10%-25%) • acute kidney injury (9%) • neurologic manifestations, including impaired consciousness (8%) • acute cerebrovascular disease (3%) • shock (6%)
- 10. Current Evidence-Based Treatments • Dexamethasone therapy reduces 28-day mortality in patients requiring supplemental oxygen compared with usual care (21.6% vs 24.6%; age-adjusted rate ratio, 0.83 [95% CI, 0.74-0.92]) • Remdesivir improves time to recovery (hospital discharge or no supplemental oxygen requirement) from 15 to 11 days. • In a randomized trial of 103 patients with COVID-19, convalescent plasma did not shorten time to recovery.
- 11. Convalescent Plasma and COVID-19 JAMA Published Online: June 12, 2020. doi:10.1001/jama.2020.10699
- 12. Timeline of Symptoms of Severe Covid-19 Severe Covid-19 N Engl J Med. 2020 May 15. doi: 10.1056/NEJMcp2009575
- 15. ✗ ✗ ✗ ✓ ? ✓ ✓
- 19. How Korea responded to a pandemic using ICT Flattening the curve on COVID-19 May 11, 2020
- 20. Flattening the curve on COVID-19 : The Korean Experience
- 25. 診斷
- 29. 6月23 日，日本籍在南部大學就讀女學生， 返日無症狀，但在機場被驗出 PCR 弱陽性 （Ct 值 37.38）。女學生後來自費抗體採 檢呈現陰性，因此本個案應為假陽性。且 接觸者的 PCR 及抗體均為陰性。
- 30. 7月29日，比利時工程師自費 PCR 弱陽性 （Ct 值 35-36），他在比利時就已有失去 嗅味覺的症狀，而且抗體檢驗 IgM 陰性 /IgG 陽性（已經罹病至少 2 周），其接觸 者的 PCR 及抗體都是陰性。
- 31. SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients N Engl J Med. 2020 Feb 19. doi:10.1056/NEJMc2001737 1) 症狀發生不久就可檢測到高 病毒載量 2) 鼻腔的病毒載量高於喉嚨 3) 無症狀感染者的病毒載量， 與有症狀者相似。代表無症 狀或症狀輕微患者在感染早 期即有病毒傳播潛力，必須 採取不同於SARS-CoV 的隔 離策略。
- 32. Saliva or Nasopharyngeal Swab Specimens for Detection of SARS-CoV-2 N Engl J Med. 2020 Aug 28. doi: 10.1056/NEJMc2016359
- 33. Infectious Diseases Society of America Guidelines on the Diagnosis of COVID-19 Published by IDSA, 5/6/2020
- 35. 建議 1~7 討論有症狀者： 有 COVID-19 症狀的病人，單靠症狀診斷易有偽陽性，建議以核酸檢測 做為診斷依據。 採檢方式：建議由鼻咽，中鼻甲 (mid-turbinate) 或前鼻孔 (nasal/anterior nares) 採檢。不建議口咽或唾液採檢。 為減少防護設備的消耗及醫護人員的曝露，有症狀的病人在經適當指導後， 可自行由鼻孔及中鼻甲採檢，敏感度不輸醫護人員採檢的 (0.95 vs 0.94)。 從上呼吸道還是下呼吸道採檢？雖然下呼吸道檢體的敏感度高於上呼吸道 檢體 (0.89 vs 0.76)，但採檢風險高。因此，一開始先採上呼吸道檢體 (例 如鼻咽)。除非一開始的上呼吸道檢體呈陰性，臨床仍高度懷疑，才採下 呼吸道檢體 (痰液，BAL，tracheal aspirate)。 第一套篩檢陰性需不需要重覆採檢？重覆採檢的敏感度比單一次採檢為高 (0.88 vs 0.71)，重覆採檢與前次採檢時間需相隔 24-48小時。若病人嚴重 度高，需住院，多個符合的臨床表現，病程符合，確診的可能性高，一採 陰性的情況下，建議重覆採檢；若臨床可能性低，則不需重覆採檢。
- 36. 建議 8~15 討論無症狀者： 無症狀者，如果有確定或疑似的接觸史，建議篩檢。 為避免院內感染，住院前是否需篩檢？ 沒有接觸史，社區盛行率低 (<2%)，不需篩檢。社區盛行率高 (≧10%) ，建議篩檢。 COVID-19 陽性病人在以下情況的預後較差：免疫低下住院或 接受免疫抑制治療，行俱時效性的重大手術 (時效性：需在3個 月內完成；重大手術：複雜需時長，需插管全身麻醉)，建議應 篩檢出並避免或延後治療。 接受 aerosol-generating procedures (AGP) (包括支氣管鏡， 氣管內管插管，抽痰，非侵入性呼吸器，ambu bagging， CPR，autopsy)，防護設備可獲得的情況下，可不篩檢；但在 防護設備供應有限，建議篩檢。因為篩檢有偽陰性，所以就算 篩檢陰性，會近距離接觸到病人呼吸道的人 (插管者，ENT) 還 是要小心。
- 40. 防 護
- 41. Filtration Efficiency of Hospital Face Mask Alternatives JAMA Intern Med. Published online August 11, 2020. doi:10.1001/jamainternmed.2020.4221
- 42. Filtration Efficiency of Hospital Face Mask Alternatives JAMA Intern Med. Published online August 11, 2020. doi:10.1001/jamainternmed.2020.4221
- 43. Filtration Efficiency of Hospital Face Mask Alternatives JAMA Intern Med. Published online August 11, 2020. doi:10.1001/jamainternmed.2020.4221
- 45. Exposure to a Surrogate Measure of Contamination From Simulated Patients by Emergency Department Personnel Wearing Personal Protective Equipment JAMA. Published online April 27, 2020. doi:10.1001/jama.2020.6633 8位急診醫療人員在穿著個人防護 裝備（PPE）下，執行模擬插管後， 所有人都有頭髮染污 ；7位有皮膚 染污（頸部 6人，耳朵 1人）。
- 46. N Engl J Med 2020; 382:1957-1958 DOI: 10.1056/NEJMc2007589 with the aerosol box, the simulated cough resulted in contamination of only the inner surface of the box and the laryngoscopist’s gloves and gowned forearms
- 50. 穿防護衣 管制人員進出 使用BVM加 filter且緊扣， 提供換氣 使用BVM加 filter且 緊扣，提供換氣 或 連續壓胸加氧氣面罩 被動給氧
- 57. 防護 臨床表現 診斷 炎
- 58. Timeline of Symptoms of Severe Covid-19 Severe Covid-19 N Engl J Med. 2020 May 15. doi: 10.1056/NEJMcp2009575
- 60. 穿防護衣 管制人員進出
- 61. 弐 炎
Hinweis der Redaktion
- Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A Review. JAMA. 2020;324(8):782-793. doi:10.1001/jama.2020.12839 Published online July 10, 2020.
- JAMA Published Online: June 12, 2020. doi:10.1001/jama.2020.10699
- Invasive Mechanical Ventilation for Covid-19–Related Respiratory Failure. lung-protective ventilation with low tidal volumes (4-8 mL/kg, predicted body weight) and plateau pressure less than 30 mg Hg is recommended.7
- A：新冠病毒的病毒量與時間關係圖 1，Y 軸為病毒量 ， X軸為感染後時間 2， 發病前病毒量最高 點3 3， 病毒量在2～4缐以上，病毒量可傳播。 4，病毒量在2-4缐以下。病毒量不具備傳播能力。 5，病毒量在1~5線以上，可被PCR檢測到底
- ❶ 症狀發生不久就可檢測到高病毒載量 ❷ 鼻腔的病毒載量高於喉嚨 ❸ 無症狀感染者的病毒載量，與有症狀者相似。代表無症狀或症狀輕微患者在感染早期即有病毒傳播潛力，必須採取不同於SARS-CoV 的隔離策略。
- Samples were obtained from 70 hospital inpatients who had a diagnosis of Covid-19. Panel A shows SARS-CoV-2 RNA titers in the first available nasopharyngeal and saliva samples. The lines indicate samples from the same patient. Results were compared with the use of a Wilcoxon signed-rank test (P<0.001). Panel B shows percentages of positivity for SARS-CoV-2 in tests of the first matched nasopharyngeal and saliva samples at 1 to 5 days, 6 to 10 days, and 11 or more days (maximum, 53 days) after the diagnosis of Covid-19.
- Filtration Efficiency of Hospital Face Mask Alternatives In a study of fitted face mask alternatives, expired N95 respirators with intact elastic bands and masks that had been subjected to ethylene oxide and hydrogen peroxide sterilization had unchanged fitted filtration efficiencies (FFEs) > 95%, while N95 respirators in the wrong size had FFEs of 90%-95%. As a group, surgical and procedure masks had lower FFEs relative to N95 respirators, with masks secured with elastic ear loops showing the lowest performance. Bottom Line: When new N95 respirators are unavailable, N95 respirators past their expiration date; sterilized, used N95 respirators; and other less common respirators can be acceptable alternatives.
- 8位急診醫療人員在穿著個人防護裝備(PPE)下，執行模擬插管後，所有人都有頭髮染污 ；7位有皮膚染污（頸部6人，耳朵1人）。 After completion of the simulation and before doffing, the fluorescent markers on the participants were visualized and photographed under UV light. Of 8 participants, 6 had markers on the neck (A and B) and 1 had markers on the ear (C). Distribution of the markers on all participants is shown with each color representing 1 participant (D).