这是我们在Covid-19上系列的第3部分。

第1部分筛选,诊断和管理

Part 2 Surge Capacity Strategies

Betway Sports

第5部分流行病学与预测模型

The single most important thing we can do as ED providers in this COVID pandemic is to protect ourselves, our colleagues, our patients, our families and our friends against transmission of the virus; and there is no higher risk of transmission that during the resuscitation of a sick COVID patient. In this podcast we speak with a world expert on PPE, Dr. Laurie Mazurik about protecting against transmission of the virusbefore, during一种fter你的转变。我们不仅讨论了从头保护到鞋类的所有PPE的细节,但我们也给出了同样重要的非PPE保护的提示。我们触及PPE保护策略,因为我们用耗材斗争,为您提供底线,并讨论核心原则受保护的代码蓝色

Anton Helman的播客生产,声音设计和编辑

由Anton Helman 3月,2020年3月的书面摘要和博客帖子

Cite this podcast as:a . Mazurik l . 139集大木船COVID-19第3部分– PPE: What We Know and Conservation Strategies. Emergency Medicine Cases. March, 2020. //www.mp3valve.com/covid-19-ppe访问[日期]

此播客和博客文章基于C级证据 - 共识和专家意见。协议,清单和算法的例子仅供教育目的,并要求您在临床实践中使用之前的特定需求以及您的医院的批准。

This podcast was recorded on March 20th, 2020 and the information within is accurate up to this date only, as the COVID pandemic evolves and new data emerges. The blog post will be updated regularly and we are working on a weekly update via theEM案件通讯which will be replicated on the EM Cases website under ‘COVID-19’ in the navigation bar.

Protecting against COVID-19 transmission before your shift, during your shift and after your shift

在你的班次之前和之后

改编自净化清单by Lauren Westafer

  • 避免公共交通
  • 带上自己的食物/饮料供应
  • Remove jewelry, watches
  • If you have long hair, tie it up in a tight bun
  • Obtain clean scrubs at the hospital if possible
  • Place all your work gear – stethoscope, pens, phone, clipboard etc in a freezer zip lock bag
  • 使用您在工作中留下的单独的防水鞋
  • Take an extra large freezer bag or garbage bag to place your clothes into
  • Take with you disinfectant wipes (or if they have run out in your community mix 25mL of bleech in 750mL of water in a spray bottle so that you can wipe down your car steering wheel, gear shift and seat).
  • 在你的班次之后,如果可能,在医院淋浴,让你擦洗(或把它们放在一个单独的冷冻袋中),并将你放在冷冻包里的衣服中。如果医院没有淋浴,请用肥皂洗手,手臂和脸部。从你的医院鞋改变到你家的鞋子里。消毒你的徽章和手机,将所有装备放回冰箱中。
  • 当您回家时,将工作装置留在车库或棚屋外或在外面倒置桶下。将水瓶和食品容器直接放入洗碗机,衣服用热水进入洗衣机。
  • 洗个淋浴

提示采访和擦拭低风险Covid患者:For isolated low risk patients, consider not entering the patient room initially; rather do a电话采访。Then make an assessment plan. When obtaining swabs,站在患者身边和后面,并要求他们将面具放在鼻子下方,如果他们觉得他们会打喷嚏或咳嗽,请转向你。

Personal protective Equipment (PPE)

Transmission of COVID-19 is approximately 3 x more likely to occur at the ED than elsewhere and certain procedures like intubation create the highest risk. You need to learn about PPE, and how to use it properly. Yours and the lives of others depends on it.

提示1:PPE建议经常更改。尤其是新兴疾病的情况,在可能存在关于传播方式和在Covid 19的情况下可能存在一些不确定性,所以消耗的PPE的纯粹量导致全球短缺。尽一切努力适应。

Tip 2:非PPE保护同样重要!

  • 距离为2米
  • 您与患者(墙,门等)之间的结构障碍
  • 通过电话采访患者并在可能的情况下使用远程医疗
  • 保持与患者的时间最低。避免所有不必要的程序
  • 保持环境清洁。擦拭键盘,桌面,笔等
  • Eat in designated areas, and bring your own snacks and food
  • 只穿PPE下的磨砂膏;No jewelry, watches, or street clothes under PPE.
  • 没有钢笔,图表或剪贴板应该进入房间。
  • 您可以决定是否要将听诊器带入但是随后用Cavi擦拭清洁它。
  • 如果你有胡子或小胡子,请强烈考虑剃须或修剪它,所以它不会破坏N95呼吸器的印章。
  • 避免可能在可能的情况下产生气溶胶;Nebulizers, BVM,CPAP,BiPAP, High Flow Nasal Cannula and bronchoscopy.

如何正确洗手:The COVID Scrub

Tip 3:并非所有PPE都是平等的!

礼服

礼服一种re graded in fluid resistance from: Level 1 (~no resistance to fluids), to Level 4 which is impervious. They also vary in coverage, with some covering only the front of you, like an apron with sleeves.

  • 大多数透视礼服都是1级礼服,这在对Covid 19的充分保护中是一个。
  • 礼服理想地应该是耐抗体,长袖和完全覆盖你的背部
  • A washable, (reusable) Level 2 gown is the minimum requirement for high risk procedures

March 28th update:一些透明礼服是2级礼服。每个人都应该在本地确认并阅读一种ll the specs在他们的礼服上确认这一点。

大多数透明礼服是1级礼服,这在对Covid 19的情况下不适当保护;一种washable, (reusable) Level 2 gown is the minimum requirement for high risk procedures.

Eye Protection

眼睛保护有护目镜或眼镜的形式。这些可能是个人问题并通过清洁不蚀刻表面的解决方案来重复使用。它们保护您的眼睛免受被触摸或喷洒成它们的分泌物。

面罩

  • 面罩为护目镜或眼镜提供卓越的保护,因为他们遮住了你的脖子和所有面具。有可用的面罩屏蔽,通常是个人问题,必须用玻璃可以用不蚀刻表面的解决方案清洁。
  • 围罩面罩可以使用。他们有一个小窗帘,挂在盖上你的脖子,
  • 如果您正在考虑将脸部护罩与护目镜或眼镜组合,想三思,因为这种组合经常雾,导致您触摸设备调整它。

可重复使用的面罩为护目镜或眼镜提供卓越的保护。

头发覆盖或牛孔

这些不是世卫组织的目前的指导方针前线员工表示担心他们的头发,面部和颈部的侧面暴露于患者的咳嗽。牛油饼似乎捕获了一些喷雾。

颈部保护和引擎盖

Hoods are not currently recommended and are hard to find. They provide additional head and neck cover.

您可以做的两件事以提供颈部保护

  1. Tie your gown as high on your neck as possible
  2. After doffing, clean your neck with hand sanitizer or soap and water (and take a shower if there may have been a significant breach during the procedure)

鞋子

  • Boot or shoe covers目前尚未推荐谁。您将在中国使用高病毒负荷区域使用,即Covid 19病房,ICU等。
  • Rubber shoes目前尚未推荐谁。Wear closed shoes, and always leave them at work.

Gloves

Nitrile gloves come in 2 lengths extended and regular. Reserve the extended if for some reason the others don’t cover the cuff of your gown. Should you wear 1 pair or 2 pairs? Well that depends if you have to wear PPE all shift, you may end up washing your hands so much that your skin breaks down. Some people may choose to wear two pairs, disposing of the outer pair between patients and washing the under pair the same way they would their hands. Check with your IPAC to decide what’s best for you.

面具

  • 手术口罩旨在保护患者免受您的保护,并具有模拟的工作场所保护系数(SWPF)。它们是松散的装配。这些应给予患者以防止它们传播病毒。对于像Covid 19这样的液滴传播疾病,它们也含有足够的呼吸系统保护,如果产生气溶胶。
  • N95 respirators安装有SWPF ~ 10,并提供airbo吗rne protection, stopping particles as small as ~0.3 microns. Although COVID 19 is droplet spread (~10 microns), aerosol generating procedures such as BVM, BiPAP, CPAP, HFNC, Bronchoscopy and Intubation, will create smaller droplet nuclei, which are suspended in the air for a period of time. This puts you at greater risk of inhaling and contracting the virus.
  • 动力净化呼吸器provide the highest level of respiratory protection (SWPF 1000+) and are not currently recommended and extremely difficult to obtain in Canada.

牛津Covid-19证据服务“标准面罩与呼吸器面具相比,预防初级保健人员的Covid型呼吸道疾病的疗效是什么?”

PPE保护strategies

全球PPE短缺和策略正在开发保存,使用更长并重复使用PPE。例如,员工被要求尽可能长时间使用单个面具或N95呼吸器,仅在湿或污染时更换。有测试查看使用紫外线或微波以消毒面膜或N95,但此时没有明确的指示是安全的。有建议,如果有人用完呼吸系统保护,他们应该使用班班瓜。但是,我们绝对可以做得更好。科学家和面具/呼吸器专家需要合作提供更好的选择。采用可水面可重复使用的长袍,面部屏蔽和眼镜或护目镜也是保护策略的一部分。

Manufacturers retooling to make PPE:例如Bauer Hockey设备制作卫生保健提供者面部盾牌:https://globalnews.ca/news/6734828/coronavirus-bauer-face-shields/

Using industrial protective equipment:cleanable and re-usable face shields from big box hardware stores

DIY Masks:Cambridge University analysis of materials to filter viruses

绗缝材料可能是最佳的,因为它们是透气,并且纤维网格优于一层。

Extended use of N95 masks:CDC指南

重新使用N95 Masks:putting an N95 in a conventional oven at 70C (158F) for 30 minutes should be effective in killing SARS CoV2 and does not degrade the mask itself (see chart below)

reusing N95

来自斯坦福的“寻址Covid-19面罩短缺”https://m.box.com/shared_item/https%3a%2f%2fstanfordmicicine.box.com%2fv%2fcovid19-ppe-1-1

Update 4月6日,2020年4月6日CDC PPE去污再利用策略https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html

PPE.donning/doffing sequence

这需要实践,并且最好在一个监督下完成指定伙伴or safety officer who uses a清单为了确保您在没有防护的情况下正确执行此操作。

The only hard rules to remember for PPE donning/doffing:

1. Mask/N95 should always be FIRST ON & LAST OFF.
2. Take your dirtiest PPE off first.

在监督covid下脱毁

来自ecuus.

不要忘记在N95上进行海豹检查。

你在哪里脱屁股?

If you have a room with an anteroom,除非你的礼服或手套严重弄脏,否则你在旁边的房间里。在患者的房间里脱离污染的泪花板或手套,距离它们至少2米。然后在前厅拍摄你的面具/ n95。

如果你没有赌注房,take everything off except your N95/Mask (and hair cover if you have one) off in the room (at least 2 m/ 6ft from the patient). Take your N95/Mask off outside the patient’s room as it is your most important defence against respiratory infection when you are exposed to the patient.

然而,有时候,房间很小,你不能距离病人2米,所以可能必须在房间外脱开,清洁你在那里落下的地方。

PPE落下例子

PPE落落如果没有前台示例

The risk of transmission is related to the viral load and duration of exposure

病毒载荷在非常生病的患者中最高,如果通过:曝光产生气溶胶

  • 触发咳嗽即没有麻痹或吸力的插管
  • Bipap,CPAP.
  • 高流量氧气系统,如高流量鼻腔插管
  • 雾化器
  • 袋子遮阳篷通风,密封差

PPE.for high risk procedures that generate aerosols

The员工的最高风险是插管

据估计,有9%的工作人员参与在一个多伦多医院收缩的SARS中加入SARS患者。没有死亡。预计,在患者护理环境中,SARS-COV-2将与2003年的SARS相同的方式蔓延到医疗保健工作者。

PPE.

来自ecuus.

The current recommendation in Canada for performing an aerosol generating procedure is: N95, eye or face protection, gown and gloves.

No head or neck protection is recommended at present. From doing informal glo-germ tests (blow a small amount of florescent powder at someone in PPE before they doff from ~ 1 m away,) we found contamination of neck, ears and hair. In the Middle East where they intubate the much more lethal corona virus MERS, part of their protocol after removing PPE it to always wash their face and neck.

之后戴头和颈部盖,然后洗脸,然后洗脸。如果您有违规行为不容易解决,请洗个澡。

为个人保护建议做好准备,以改变或各种地区或国家之间变化。供应链问题正在发生。了解不同类型的PPE,并准备好找到降低风险的新方法。集体适应你的方式。

PPE.pearls, videos, errors from EM Delibrate Practice

Basic protected intubation and code blue principles

  1. 尽可能避免所有气溶胶产生程序
  2. Keep both the number of people and the duration of exposure to a minimum
  3. 在监督下佩戴正确的PPE和DOFF
  4. 尽可能使用明确的计划和清单
  5. 认为A-B-C不是心脏骤停的驾驶室。保护气道先保护团队。

Reuben Strayer的视频从EMS到4月1日从EMS到复苏室的心脏骤停患者转移的视频

Protected Code Blue

让您和您的团队安全,您必须培训火车列车;练习,练习实践 - 请使用以下免费资源开发快速培训课程,以便安全复苏在您的ed中的Covid-19患者

EM Deliberate Practice Free Airway Safety Training Course Materials

CurriculumPDF.

教练的笔记PDF.

站点导演物流PDF.

SchedulerPFD.

下一个in the COVID-19 podcast series Anton interviews George Kovacs on Airway, Resuscitation and The Protected Code Blue

References

  1. David J Brewster,Nicholas C Chrimes,Thy Bt Do等,等等。共识声明:安全气道协会气道管理和气管插管原则,对Covid-19成人患者组。澳大利亚医学杂志。2020。
  2. 安全气道协会气道管理和气管插管的原则,特定于Covid-19成人患者组
  3. Weber RT, Phan LT, Fritzen-pedicini C, Jones RM. Environmental and Personal Protective Equipment Contamination during Simulated Healthcare Activities. Ann Work Expo Health. 2019;63(7):784-796.
  4. Macintyre CR, Seale H, Dung TC, et al. A cluster randomised trial of cloth masks compared with medical masks in healthcare workers. BMJ Open. 2015;5(4):e006577.
  5. 罗米,曹思,威尔等。插管Covid-19患者的预防措施。麻醉学2020; 1。
  6. 蜡rs,christian md。关注新型冠状病毒(2019-NCOV)患者的关键护理和麻醉团队的实用建议。可以j恩斯特2020;
  7. Caputo Km,Byrick R,Chapman Mg,Orser Bj,Orser Ba。SARS患者的插管:医疗工作者的感染与视角。可以j Anaesth 2006; 53(2):122-9。
  8. Viscusi DJ, Bergman MS, Eimer BC, Shaffer RE. Evaluation of five decontamination methods for filtering facepiece respirators. Ann Occup Hyg. 2009;53(8):815-27.

Drs. Helman and Mazurik have no conflicts of interest to declare