Pediatric Severe Acute Respiratory Syndrome
Introduction
Brief introduction of severe acute respiratory syndrome in children Severe acute respiratory syndrome in children is a human coronavirus that can cause respiratory and digestive tract diseases. Among them, human respiratory coronavirus is one of the main causes of colds, which can cause nasal congestion, runny nose, sore throat and cough, and can also cause lower respiratory tract infections. . Human intestinal coronavirus causes diarrhea. Corona and diarrhea caused by coronavirus are self-limiting, and coronavirus mainly affects respiratory tract. basic knowledge Sickness ratio: 0.0001% Susceptible people: children Mode of infection: non-infectious Complications: shock, respiratory failure
Cause
Causes of severe acute respiratory syndrome in children
Causes:
Human coronavirus can cause respiratory and digestive tract diseases. Among them, human respiratory coronavirus is one of the main causes of colds, which can cause nasal congestion, runny nose, sore throat and cough, and can also cause lower respiratory tract infection; human intestinal coronavirus diarrhea. The common cold caused by coronavirus and diarrhea is self-limiting. The coronavirus is mainly infected with the respiratory tract, a small number of infections are in the intestine, and very few have neurological symptoms. Therefore, respiratory secretions are the main route of transmission, and can also be passed through the feces. Oral route and direct contact spread.
Pathogenesis:
SARS virus is the main pathogen causing this SARS. It is understood that SARS virus is highly contagious and pathogenic. It is a brand new coronavirus or highly variant strain. New coronavirus may be transmitted through the following channels:
1. Infected by eye, nose, and mouth.
2. Close contact with the patient without taking appropriate protective measures.
3. Direct contact with the patient's secretions or contaminated objects.
4. It may be transmitted through air and unclear pathways. The virus is a new pathogen, and a large amount of research is needed in the classification, structure and function of the virus, pathogenicity, pathogenic diagnosis, epidemiological characteristics and prevention.
Prevention
Prevention of severe acute respiratory syndrome in children
1. General preventive measures Prevention of atypical pneumonia Preventive and protective measures are taken from five aspects to avoid infection:
a Keep the air in the living and working environment.
b wash your hands.
c Anyone who is in contact with the patient should wear a mask and pay attention to the cleaning and disinfection of the hand.
d According to the weather changes, pay attention to cold and warm, participate in exercise, enhance their ability to resist disease, prevent disease.
(1) Air disinfection: every time the window is opened for 10 to 30 minutes, the air is circulated, and the germs are discharged outside. If there are conditions, some air disinfectants approved by the health administrative department may be used, and sprayed or fumigated according to the instructions for use.
(2) Ground disinfection: Wet cleaning should be carried out to prevent the dust from flying and bring the bacteria into the air. At the same time, the ground should be kept dry.
(3) Object disinfection: tables, chairs, thermos, handles, switches, floors, toilets, baths, etc. can be sprayed or wiped with 500mg/L of effective chlorine disinfectant, such as faucets, toilet door handles and relatively humid places, the bacteria are easily contaminated and propagated. It is important to disinfect.
(4) Disinfection of tableware: It can be boiled for 10 to 20 minutes together with the remaining food. The tableware can be sterilized with 500mg/L of effective chlorine or 0.5% peroxyacetic acid for 0.5~1h. When the tableware is disinfected, it should be fully immersed in water. The disinfection time is from boiling. Count it up.
(5) disinfection of hands: often use running water, soap to wash your hands, before and after meals, after exposure to contaminated products, it is best to use 250 ~ 1000mg / L 1210 disinfectant or 250 ~ 1000mg / L effective iodine iodophor or use Approved commercial hand sanitizer for disinfection.
(6) Disinfection of clothes, towels, etc.: cotton cloth and diapers can be boiled and disinfected for 10 to 20 minutes, or soaked with 0.5% peracetic acid for 0.5 to 1 hour. For some chemical fiber fabrics, satin, etc. can only be used for chemical immersion disinfection. .
2. Traditional Chinese medicine prevention measures Chinese medicine taken by healthy people: prescription one: fresh reed root 20g, silver flower 15g, forsythia 15g, clothing 10g, silkworm 10g, mint 6g, raw licorice 5g, decoction on behalf of tea, continuous Take 7 to 10 days, prescription 2: Atractylodes 12g, Atractylodes 15g, Astragalus 15g, windproof 10g, Musk 12g, Radix Salvia 15g, Silver Flower 20g, Guanzhong 12g, Shuijianbi, 2 times / d, continuous taking 7 ~ 10 days, prescription 3: Guanzhong 10g, silver flower 10g, forsythia 10g, Daqingye 10g, Suye 10g, Pueraria 10g, Musk 10g, Atractylodes 10g, Radix Sophora 15g, Perrin 10g, Shuijianbi, 2 times /d, for 7 to 10 days in a row, for healthy people who have contact with atypical pneumonia cases or suspected cases, under the guidance of a doctor, the prescription of traditional Chinese medicine: raw radix 15g, silver flower 15g, Bupleurum 10g, astragalus 10g, Banlangen 15g, Guanzhong 15g, Atractylodes 10g, raw coix seed 15g, musk 10g, windproof 10g, raw licorice 5g, Shuijianbi, 2 times / d, continuous taking 10 ~ 14 days.
3. Prevention and treatment of this disease The onset time of this disease is in winter and spring. This season is also a high incidence of respiratory infectious diseases. The epidemiological performance is mainly caused by close-range respiratory droplets, contact with patient secretions, and therefore, stop infection. The spread of the disease, in addition to early diagnosis, early isolation of the patient, disinfection and isolation of the patient's excrement, secretions and the environment in which the patient is exposed, is also an indispensable measure to establish an isolation ward and specialist for the treatment of such patients. Outpatient clinic, the special ward is located at one end of the ward, the ward is divided into polluted areas, semi-polluted areas, clean areas, critical rescue rooms, etc. The other facilities in each ward are the same as ordinary wards, but there are special isolation vests at the entrance. , thermometer, sphygmomanometer, stethoscope and other appliances, in addition to disinfectant for medical staff to wash hands, faucet is electric sensor switch; suspected patients and confirmed patients have different income wards, the ward is well ventilated, entering the ward requires 12 layers Cotton gauze masks, hats, good isolation gowns, isolation pants, disposable socks, shoe covers, ward ward entrance pads (including The disinfectant is soaked, the effective chlorine is 2000mg/L, to disinfect the soles when entering and leaving.) It is not necessary to supplement the spray disinfectant to keep it moist. The hospitalized children wear masks, strictly isolate and manage, and must not leave the ward and strictly visit the system. In principle, there is no escort, try not to visit. If the sick child is in critical condition, the visitor must wear a mask, a hat, a gown, and a shoe cover.
(1) Disinfection and isolation of the ward:
1 Air disinfection: The ward regularly performs air disinfection every day for 4 hours; using ultraviolet radiation, no less than 1h each time (no patient ward), fumigation with chlorine disinfectant, spray disinfection (dosage: effective chlorine 20~30ml/ M3, 1500mg / L chlorine disinfectant, role 30min), the ward should have sufficient time to open the window every day, open the door ventilation, keep the air circulation.
2 Surface and object surface disinfection: daily use chlorine disinfectant (effective chlorine 1500mg/2000m1) to mop 2 times, 24 hours cleaning, pollution, anytime mopping, tables and chairs, bedside tables, door handles, medical records and other items, Wipe with chlorine-containing disinfectant, the test list for each patient in the special ward, the medical records can only be disinfected for 30 minutes to 1 hour with the ozone generator before being sent to the hospital's medical record room for filing.
3 Disinfection of the items used by the patient: A. After the patient uses the disinfectant with 500~2 500mg/L effective disinfectant, it can be poured into the patient's toilet. B. After the patient is used to soak for 30 minutes with 1000mg/L effective chlorine disinfectant, Only after the cleaning process can be done, the domestic garbage should be packed in double-layer garbage and treated in a timely and effective manner. C. After the patient is discharged or died, the use of the substance must be terminally disinfected.
(2) Personal protection of medical personnel: The medical personnel's own protective measures must be strict and strict. In addition to providing effective protective equipment, the protection measures for medical staff should be continuously improved. Drinking heat-clearing and detoxifying Chinese medicine every day, and taking oral anti-disease Poison and mouthwash, specific measures:
1When the medical staff enters the ward for medical treatment, they need to wear 12 layers of cotton masks and N95 masks. The wearing time should not exceed 4 hours. If they are wet or contaminated, they should be replaced at any time. When performing close-up operation, wear protective glasses.
2 Those who enter the hospital room are required to wear three layers of cotton isolation gowns, two layers of cotton isolation pants, and work caps.
3 Each time the medical staff contacts the patient, they must immediately disinfect and clean their hands, or use a fast hand disinfectant.
4 Work clothes are replaced every day, and there is immediate replacement of pollution.
5 After the medical staff contacts the patient and before the work, you can use the chlorhexidine acetate gargle or the compound chloroformin gargle. Before you leave work, do a good job of personal cleaning (washing your hands, washing your face, cleaning your nose), taking a shower and changing clothes before leaving the disease. Area.
6 Pay attention to reasonable arrangement of medical staff to work and rest time, avoid overwork, medical staff should strengthen nutrition, enhance physical fitness, and improve disease resistance. The labor arrangement for medical staff working in isolation wards should be twice as much as that of ordinary wards.
Complication
Complications of severe acute respiratory syndrome in children Complications, respiratory failure
Respiratory distress, respiratory and circulatory failure, multiple organ dysfunction, shock, etc.
Symptom
Symptoms of severe acute respiratory syndrome in children Common symptoms Dyspnea, acute respiratory distress syndrome, dry cough, diarrhea, cyanosis, chest tightness, lung, fatigue, relaxation, heat, heat retention
1. Age, gender, and epidemiological age ranged from 3 months to 13 years old, mostly in children over 3 years of age. There was no significant gender difference in the incidence, and there was a clear history of SARS exposure.
2. Clinical symptoms, signs similar to adults, acute onset, mainly manifested as fever and cough, high fever peak, phlegm temperature is more than 39 ° C, fever duration is more than 1 week on average, can be irregular fever, heat retention Or relaxation of heat, but irregular fever is more likely to be related to the application of antipyretic drugs in children to cause irregular heat. Most children have cough and fever at the same time. A few fevers start coughing after a few days, and cough is mostly sputum. Cough, a few are dry cough, and a small number of children have no cough throughout the course of the disease. Most children have no symptoms of typical upper respiratory tract infection such as sore throat, nasal congestion or salivation, except for some elderly children complaining of chest pain and headache. Most of them have no muscle soreness, chills, headaches, chest pains, etc. Different from adult reports, positive signs are mainly manifested in the respiratory system. Most children can hear and voice in the lungs. The voice can appear in the early or middle stage of the disease, mostly The wet and squeaky sounds, the appearance of the voices are more consistent with the lung consolidation sites displayed on the chest X-slices, and can be bilateral or unilateral, disappearing as the disease improves, and a few children have no arpeggios and the breath sounds are weakened. Tubular breath sounds and other pathological breath sounds appear.
Examine
Examination of severe acute respiratory syndrome in children
Collection and analysis of laboratory examination data for children's SARS.
1. The National Child Severe Respiratory Syndrome Treatment and Treatment Program (Trial) includes:
(1) Three routine and tuberculin experiments (blood routines must be dynamically detected for 3 consecutive days after admission).
(2) Positive, lateral chest X-ray examination (early 1 / d, 3 to 4 consecutive times).
(3) Electrocardiogram examination, positive results are reviewed regularly.
(4) Mycoplasma antibodies, detection of chlamydial antibodies, and detection of bacteria and virology.
(5) ESR, C-reactive protein, myocardial enzyme, liver function, renal function, blood electrolyte detection.
(6) Blood gas analysis for severe cases.
2. Clinical routine laboratory tests
(1) Blood routine: should be taken once every 1-2 days, once every time if necessary, and the recovery period should be appropriately extended. The dynamic change of blood routine is one of the characteristics of this disease, which is an important diagnostic basis, typical cases. The peripheral blood leukocytes showed a progressive decline in the progression of the disease, often with a decrease in lymphocyte counts.
(2) Determination of throat swab coronavirus antigen and determination of blood coronavirus antigen: Establishing RT-PCR for detection of coronavirus antigen, its clinical diagnostic value needs to be verified by more clinical practice, pay attention to the early stage of fever, viremia period, specimen, pharynx Swab virus isolation for respiratory syncytial virus, influenza A virus, influenza B virus, enterovirus, Lassa fever virus, hantavirus, adenovirus, throat swab mycoplasma PCR, blood sampling for mycoplasma antibody (MP-IgM ), Chlamydia antibodies (CP-IgM) are necessary to rule out other pathogenic pneumonia.
(3) bacteria culture plus drug sensitivity, blood culture pathogenic cocci plus drug sensitivity: help to rule out or diagnose bacterial infection.
(4) diarrhea patients: plus stool coronavirus, rotavirus, adenovirus antigen determination.
(5) PPD skin test: It helps to eliminate or diagnose tuberculosis infection in the lungs.
(6) check the erythrocyte sedimentation rate, C-reactive protein, condensation test, fever for more than 1 week plus fat test, external Fiji test, anti-hemolytic streptococcus "O", rheumatoid factor (RF), help differential diagnosis .
(7) Immune function: Checking T cell function and immunoglobulin levels can help to understand the changes in immune function in children.
(8) Heart, liver, kidney function related examination: check the organ function index at the beginning of the onset and regularly review, including alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, -glutamyl transpeptidase, total protein, white Protein, globulin, albumin/globulin ratio, total bilirubin, indirect bilirubin, direct bilirubin, glucose, urea nitrogen, uric acid, creatinine, creatine kinase isoenzyme (CK-MB), lactate Hydrogenase, amylase.
(9) blood gas analysis and electrolytes: help to determine respiratory failure and electrolyte imbalance, pay attention to the acute phase and recovery period of double serum, prepared for detection of coronavirus antibodies.
1. Positive, lateral chest X-ray examination Regular examination of chest X-ray has important diagnostic significance, early should be 1 / d, continuous 3 to 4 times; after every 1 to 2 days, the recovery period should be extended appropriately Time, characteristics:
(1) Unilateral or bilateral focal asymmetrical infiltrates, patchy, flocculent or round-like shadows, more common in the lower lobe, hilar and lung field, special attention should be paid to the paraspinal , after the shadow of the shadow of patchy shadows.
(2) Chest X-ray changes can occur early in the course of the disease, progress is faster than general pneumonia, and the shadow range rapidly expands or changes from one side to both sides.
(3) lung shadow, pleural effusion, hilar lymphadenopathy is less common in children with SARS.
2. ECG examination should be routinely checked for EKG. Some children with SARS have heart damage. For those with heart damage, bedside dynamic ECG monitoring should be performed.
Diagnosis
Diagnosis and diagnosis of severe acute respiratory syndrome in children
diagnosis
The Diagnostic Criteria for Severe Respiratory Syndrome in Children (Trial) established by the Department of Respiratory Medicine of the Chinese Medical Association Pediatrics Branch is as follows:
Diagnostic regulations
(1) History of epidemiology:
1 Close contact with the affected person or from the affected area; one of the group's morbidity; there is evidence to clearly infect others (close contacts refer to living with SARS patients within 2 weeks, learning, playing, or having contact with SARS The patient's respiratory secretions or body fluids).
2 Those who have been to or live in the SARS epidemic area within 4 weeks before the onset of illness.
(2) symptoms and signs: acute onset, fever as the first symptom, body temperature is generally higher than 38.5 ° C, occasionally chills; often no upper respiratory tract symptoms; cough, mostly dry cough, less sputum; may have chest tightness , shortness of breath, lung auscultation can smell dry and wet voice, severe cases can appear respiratory distress, older children can complain of headache, joint and muscle soreness, fatigue, etc., may have diarrhea.
(3) laboratory examination: peripheral blood white blood cell count is generally not high, or reduced; often lymphocyte count reduction; C-reactive protein <8mg / L.
(4) Chest X-ray examination: see auxiliary examination.
(5) Antibiotic drug treatment has no obvious effect.
(6) Conditional units can be used for SARS virus antibody and/or RT-PCR to aid diagnosis.
2. SARS diagnostic criteria
(1) Clinically established diagnostic criteria: a child with one of the following 2 can establish a diagnosis:
1 Diagnostic Regulations 1. (1) + (2) + (3) + (4).
2 Diagnostic Regulations 1. (1) 2+(2)+(3)+(4)+(5), plus the sixth helps to finally establish the diagnosis.
(2) Clinical suspected diagnostic criteria: The child meets one of the following 3 to diagnose suspected cases:
1 Diagnostic Regulations 1. (1) + (2) + (3).
2 Diagnostic Regulations 1. (1) 2+(2)+(3).
3 Diagnostic Regulations 1. (2) + (3) + (4).
(3) Medical observation case determination criteria: Cases that meet the diagnostic criteria 1.(1)2+(2)+(3) can be observed.
3. Diagnostic criteria for severe SARS can be diagnosed if any of the following conditions are met:
(1) Difficulty breathing, cyanosis.
(2) hypoxemia, oxygen inhalation 3 ~ 5L / min, arterial oxygen partial pressure <70mmHg, or pulse volume oxygen saturation (SpO2) <0.93; or can be diagnosed as acute lung injury (AL1) , oxygenation index 300, or acute respiratory distress syndrome (ARDS) 200.
(3) There are multi-leaf lesions in the lungs or X-ray films showing a lesion area >50% in 24 to 48 hours.
(4) Those who have a shock performance.
(5) Those with multiple organ dysfunction syndrome (MODS).
(6) Those with serious underlying diseases.
Differential diagnosis
Clinical attention should be paid to the exclusion of other viral pneumonia, mycoplasma, chlamydia, bacterial, fungal pneumonia. Tuberculosis, epidemic hemorrhagic fever, pulmonary eosinophilic infiltration, etc. For patients with similar clinical manifestations of respiratory diseases, the conditional unit should promptly carry out relevant pathogen examination. For clinical suspected cases, the peripheral blood phase and chest positive and lateral X-ray films should be observed continuously for 3 consecutive days. Children's SARS should be combined with the following respiratory tracts. Identification of infectious diseases:
1. Upper respiratory tract infection (cold, tonsillitis, pharyngitis, laryngitis, etc.): Upper respiratory tract infections generally include sneezing, runny nose, stuffy nose, sore throat, tonsil enlargement, hoarseness, etc., but also fever, cough, around some cases White blood cells can also be reduced, but the lungs are auscultated without a voice, chest X-rays have no pneumonia, and the condition improves and heals after a few days.
2. Bacterial pneumonia: may or may not have primary infection, cough is often accompanied by white sputum, purulent sputum, or small infants with laryngeal rhythm, fever, increased peripheral white blood cell count, nuclear left shift, bilateral lung auscultation Smell dry and wet voice, chest X film and lungs have patchy blurred shadows, especially in the lower lungs, severe cases can be combined with pleural effusion or empyema, antibiotic treatment is effective, no strong contagious.
3. Mycoplasma pneumoniae pneumonia: more common in older children, but also can be prevalent, initially dry cough, then turned into intractable cough, may have fever, headache, lung signs are often not obvious, chest X-sheet changes but not signs Consistently, interstitial pneumonia, which is characterized by a thickening of the shadow around the hilar, is a prominent change, or a uniform solid image. In severe cases, there may be systemic multi-system clinical manifestations, and macrolide antibiotics are effective.
4. Respiratory syncytial virus pneumonia: more common in 2 years old, especially in 2 to 6 months, more common in infants, acute onset, no fever or moderate, low fever, cough, wheezing, difficulty breathing, early signs of lungs You can hear the full lungs wheezing sound and the fine wet voice at the bottom of the lungs. The X-rays of the chest show small-like shadows, which are accompanied by obvious signs of emphysema. The antibiotic treatment is ineffective. After symptomatic support therapy for 3 to 5 days, the wheezing stops. The condition gradually improved and the prognosis was good.
5. Adenovirus pneumonia: more common in children from 6 months to 2 years old, often have high fever, severe symptoms of systemic poisoning, apathetic, pale, cough, difficulty breathing, cyanosis, lung signs appear later, high fever 4 ~ After 5 days, the two lungs were wet and squeaky. The lung lesions were merged with signs of lung consolidation. Chest X-ray changes appeared earlier, showing flaky shadows of varying sizes, or merging into large lesions. Swelling, serious condition, the course of disease can be extended for 4 to 6 weeks, often irreversible lung injury, sequelae of atelectasis, pulmonary fibrosis, bronchiectasis, recurrent pneumonia.
6. Fungal pneumonia: often occurs on the basis of many systemic diseases, such as blood diseases, malnutrition, tuberculosis, immune function defects, etc., can also be secondary to infantile pneumonia, bronchiectasis, slow onset, prolonged course Replacement of a variety of antibiotics is ineffective, the condition is getting worse, often combined with thrush, skin or digestive tract fungal infections, may have fever, cough, shortness of breath, cyanosis, listlessness, older children may have colorless gelatinous Coughing out, lung auscultation breath sounds weakened, can smell tubular breath sounds and small and medium bubble sounds, chest X-slices have a bit of shadow, can be like miliary tuberculosis changes, can also have cotton-like shadows or large solid lesions, anti-fungal Drug treatment is effective, such as Dafukang, fluconazole, ketoconazole and so on.
7. Chlamydia pneumonia: Chlamydia is classified into four types according to the antigen structure: sulfonamide sensitivity and inclusion body properties: C. trachomatis (CT), Chlamydia pneumoniae (Cpn), and Chlamydia psittaci (C. Psittaci), C. pecorum, the first three are associated with human disease.
(1) Chlamydia trachomatis pneumonia: accounting for 18.4% of infant pneumonia, more common in infants aged 1 to 4 months, the mother infected with Chlamydia trachomatis can be transmitted vertically to the baby, the onset is slower, first symptoms of upper respiratory tract infection, nasal congestion, flow Hey, most of them have no fever or only low fever, and later have increased breathing and obvious cough. More than 50% of cases have abnormal appearance of eardrum, 50% are accompanied by conjunctivitis, and physical examination can smell the sound of both lungs or Wheezing, chest X-ray showed extensive pulmonary interstitial and alveolar infiltration, often over-inflated.
(2) Chlamydia pneumoniae pneumonia: It is a new type of chlamydia that was officially named in 1989. It is now recognized as one of the most important pneumonia pathogens in children and adults over 5 years old. Chlamydia pneumoniae has a slow onset of symptoms and generally mild symptoms, often accompanied by pharyngitis. Laryngitis and sinusitis, common cough, and long duration, up to 3 weeks, chest auscultation can smell dry and wet voice, chest radiograph without specific changes, more common unilateral inferior lobe infiltration, can be complicated by pleural effusion .
(3) Chlamydia pneumoniae pneumonia: It is a zoonotic disease. People are infected mainly by inhaling bird droppings containing Chlamydia psittaci, dust or contact with sick birds, which is more common in older children and adults. Symptoms of systemic poisoning, often chills, high fever, headache, myalgia, joint pain, cough, obvious dry cough, frequent cough, sputum purulent sputum, occasional blood sputum, vomiting, hepatosplenomegaly, anemia Both lungs can be heard and voiced. The chest X-ray has a diffuse pulmonary interstitial infiltration in the early stage. It extends from the hilum to the surrounding area especially down the lung field. Laboratory examination: direct optometry of pharyngeal secretions, sputum and other smears Or by chlamydia isolation, serological examination, PCR techniques, etc., treatment with macrolide antibiotics, Chlamydia trachomatis pneumonia can also be used sulfamethoxazole, fluoroquinolones for older children and adults well.
8. Pediatric Legionnaires' Disease: China first reported Legionnaires' disease in 1982. This disease is an infectious disease caused by Legionella. Children are prone to pneumonia after infection with Legionella, and the system is mainly based on pneumonia. Organ damage, which has a variety of clinical manifestations, the initial stage of the disease like a cold or a bad cold, showing general malaise, headache, myalgia, fatigue, fever, cough, runny, if you can quickly self-restricted, then healed, if The course of the disease is not self-limiting, and further deteriorated. The child has chills, high fever, difficulty in breathing, cough and sputum to hemoptysis, dry and wet voices and signs of consolidation in the lungs, and white blood cells in the laboratory are significantly elevated. The secretions are cultured with Legionella, serum-specific antibodies IgM and IgG positive, PCR detection sensitivity can be as high as 100%, treatment with erythromycin as the first choice, treatment for 3 weeks.
