How to warn severe cases in COVID-19, and how to use hormones and antibiotics？ Village doctors should master these points.

　　The Spring Festival is approaching, and the population is flowing in large numbers, so the number of people who work in cities and return home to visit relatives for holidays will increase rapidly. This has also brought severe challenges to the treatment of rural COVID-19.

　　"Grassroots medical and health institutions have undertaken a large number of tasks of first diagnosis of patients and classified management of key populations." On January 14th, Nie Chunlei, director of the Department of Primary Health and Health in National Health Commission, said that there was an imbalance in medical resources between urban and rural areas, with obvious differences, and health service resources in rural areas were relatively insufficient. "Grassroots village doctors urgently need to master the knowledge and skills of Covid-19 infection diagnosis, severe early warning and treatment, especially the use of antibiotics, hormones and small molecule drugs, so that patients can be effectively treated."

　　On January 11th, the General Practice Branch of Chinese Medical Association, together with several branches, issued the "Guidelines for Diagnosis, Treatment and Service of Infections in novel coronavirus (First Edition)" (hereinafter referred to as the "Guidelines"), which elaborated on diagnosis, clinical classification, identification, treatment and treatment of severe cases.

　　How to warn of moderate and severe diseases?

　　"For the grassroots, the evaluation of COVID-19’s diagnosis and clinical typing is more important, and it is also the whole of the diagnosis and treatment strategy." Wu Hao, the correspondent of the Guide and dean of the School of General Practice and Continuing Education of Capital Medical University, said.

　　In the evaluation of patients’ clinical typing, Wu Hao said that the majority of grassroots village doctors need to pay special attention, and the evaluation of vital signs can be carried out through a simple "four-piece set" of body temperature, respiration, heart rate and blood pressure; In the measurement of finger oxygen saturation, due to the low outdoor temperature in winter, the village doctor found that the patient’s limbs or skin were cold, and its oxygen saturation value may be less than 93%, but this does not mean that the patient is at risk, and it is necessary to judge by observing whether the lips are purple and dry.

　　Imaging examination can be based on chest X-ray or CT. If there is pneumonia in COVID-19, most of it occurs in the lower lungs. If there is no CT in rural medical institutions, you can auscultate whether the patient’s lower lungs are accompanied by wet rales (if there is, CT examination is not necessary); Instead of taking X-ray chest film, you need to pay attention to the patient’s posterior and anterior and lateral films, and sometimes you can see some exudative and inflammatory lesions. Although the X-ray chest film may miss the diagnosis, if the chest film shows pneumonia, the actual situation of the patient will be more serious.

　　"What needs to be repeatedly emphasized is the early warning of severe illness." Wu Hao said that the patient’s three situations indicate that it is very dangerous and may progress to severe illness. First, moderate and severe dyspnea occurred, including (meeting one of the following conditions) heart rate greater than 120 beats/min, breathing frequency greater than 30 beats/min, and breathing with an auxiliary ventilator (pay attention if the patient cannot speak a whole sentence during the consultation); Second, the oxygen saturation is lower than 93%; In addition, if the patient has chest pain, falls, changes of consciousness, low blood pressure, decreased urine output, severe vomiting or diarrhea, etc., we should also consider severe warning.

　　Zhang Wenhong, director of the Department of Infectious Diseases of Huashan Hospital affiliated to Fudan University, said during the training that after the implementation of the "Class B and Class B Management" policy, it is crucial for grassroots doctors to master the transformation from Chinese diseases to severe diseases in the process of normalizing COVID-19 treatment. In particular, the clinical classification of patients was adjusted in the "novel coronavirus Infection Diagnosis and Treatment Program (Trial Tenth Edition)", instead of ordinary type, it was medium. "Light and medium-sized should be treated at the grassroots level. Therefore, the grassroots should prevent medium-sized to heavy-duty, and heavy patients need to be referred in time. "

　　Zhang Wenhong said that in the clinical early warning of severe illness, one indicator has changed and it is necessary to be alert to the deterioration of the patient’s condition, that is, the patient is "hypoxic after activity; After slight activity, the oxygen saturation value is less than 94%, which can make the patient walk back and forth in the corridor. If his CRP(C-reactive protein), lactic acid and other indicators are normal, it means that the oxygen saturation value has decreased, which is also a signal of the progress of the disease.

　　How to use hormones and antibiotics?

　　Is it really effective for rural doctors to use the four-piece set of "antiviral+antibiotic+hormone+antipyretic"?

　　Wu Hao explained that, in fact, the elderly people in rural areas were not treated in time after onset, and there was malnutrition. When he went to the clinic for medical treatment, he might be in the acute pneumonia period, and even had a bacterial infection. At this time, the village doctor will give hormone and antibiotic treatment, and the effect will be more obvious.

　　Regarding whether antiviral drugs can be used for more than 7 days, Wu Hao said that the time of viremia is usually 7 days. The reason why antiviral drugs are prescribed to be used within 5 days of onset is because the earlier they are used, the greater the benefit, which also takes into account the incubation period of 1 ~ 2 days. "For the elderly and frail patients, the process of virus clearance is slow. At this time, even if the illness lasts for more than 7 days, it will still be effective to continue using antiviral drugs."

　　Wu Hao further said that the use of antibiotics should also avoid blindness and should be judged with reference to the patient’s indications. For example, if the patient coughs dry or coughs white sputum, or has less sputum in the early stage, this is a viral infection; If the patient has pus or coughs yellow sputum, it is generally a bacterial infection. If the village doctor doesn’t have the above-mentioned accurate detection means, he can write it all in combination with the patient’s situation, that is, his family members are infected and have flu symptoms, and he also has lung symptoms, which is definitely viral pneumonia, but if his family members don’t have it, it is the possibility of community-acquired pneumonia.

　　In order to facilitate the operation of primary doctors, the "Simplified Edition" published on January 4th referred to the "four-step" treatment of COVID-19 at the primary level: general treatment, oral small molecular antiviral drugs, glucocorticoid, oxygen therapy and respiratory support.

　　Therefore, Zhang Wenhong emphasized that glucocorticoid should be used with great caution. It is suitable for COVID-19 patients with high-risk factors (older, with medium-sized clinical manifestations and evidence of disease progression). At this time, low-dose and short-term corticosteroids can be given. "Specific usage, you can use dexamethasone or prednisone, 4 ~ 6 tablets a day, eat for 3 days. Within 72 hours, the patient will face a turning point. If the patient gets better quickly, it will be reduced to 2-3 tablets and taken for another 3 days. If it is relieved later, either stop taking the medicine or use another tablet for 3-4 days. If the patient progresses to severe illness, he needs to be hospitalized for observation, and the dosage of hormones can also be increased, and the treatment plan for severe patients can be started later. "

　　"On the one hand, an early British clinical study showed that the daily use of 6 mg dexamethasone in large-scale hospitalized patients in COVID-19 can reduce the mortality rate; On the other hand, our team also gives patients low doses of hormones in the early stage of severe illness, which can greatly reduce the intubation rate of patients and reduce the mortality rate. " Zhang Wenhong said.

　　The Guide stipulates that glucocorticoid can be used for patients with early onset in the community, such as high-risk factors such as basic diseases and advanced age, or medium-sized patients who need oxygen therapy, after evaluating the contraindications of hormone use.

　　Zhang Wenhong said that "prone position ventilation treatment" for COVID-19 patients can be operated regardless of the resources of rural medical institutions, and it is suitable for medium-sized patients with severe high-risk factors and rapid progress. This is also recommended by many respiratory and critical care experts.

　　"When the patient is lying on his back, the heart and lungs are under certain pressure, and there will be problems in the proportion of ventilation blood flow. After prone, the pressure on the heart and lungs is reduced, the proportion of ventilation blood flow will be more balanced, and the physiological diseases related to inflammation of patients will also get better. " Li Yingchuan, an expert in critical care medicine and vice president of Shanghai Tenth People’s Hospital, explained to reporters earlier.