clinicalsars

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Information about clinicalsars
Travel-Nature

Published on March 11, 2008

Author: bruce

Source: authorstream.com

SARS WARS GUIDELINES ON MANAGEMENT:  SARS WARS GUIDELINES ON MANAGEMENT Mediadora C. Saniel, MD April 11, 2003 “The terror of the unknown is seldom better displayed than by the response of a population to the appearance of an epidemic, particularly when the epidemic strikes without apparent cause.”:  “The terror of the unknown is seldom better displayed than by the response of a population to the appearance of an epidemic, particularly when the epidemic strikes without apparent cause.” Edward Kass, 1977 Clinical picture in SARS patients:  Clinical picture in SARS patients Acute respiratory distress syndrome approx 10% None /very low Low Very high Recovery approx 90% Infectivity Prince of Wales Hospital, Hong Kong :  Prince of Wales Hospital, Hong Kong Clinical features of 138 secondary & tertiary cases Fever – 100% (high grade, persistent) Chills/rigor – 73% Myalgia – 61% Dry cough – 57% Headache – 56% Dizziness – 43% Lee N et al. www.nejm.org April 7, 2003 Laboratory findings:  Laboratory findings Chest x-ray appearances:  Chest x-ray appearances Opacities are predominantly found in the lower lung zones Pleural effusions not seen Could be rapidly progressive and might need twice daily CXRs Tsang K et al www.nejm.org March 31, 2003 Slide7:  Hospitals and major health facilities should prepare a strategy for the triage, isolation, and barrier nursing of a patient(s) with SARS Enhanced Surveillance for SARS:  Enhanced Surveillance for SARS Sensitive system in place for ID of SARS cases  isolation/barrier nursing  limit local spread Countries without previous SARS cases should use a more sensitive suspect case definition  early implementation or control measures System for verifying or dispelling rumours & anecdotal accounts of SARS cases Early notification of National/WHO authorities SARS Suspect Case Definition:  SARS Suspect Case Definition High fever (>38OC); AND Cough, shortness of breath or difficulty of breathing AND 1. Close contact within 14 days of onset of symptoms, with a person diagnosed with SARS or 2. History of travel to SARS area within 14 days of onset of symptoms Probable SARS case:  Probable SARS case Suspect case plus pneumonia or respiratory distress syndrome (RDS) OR Suspect case + unexplained respiratory illness leading to death with autopsy finding of RDS without an identifiable cause. SARS case requiring public health action: enhanced sensitivity definition for previously unaffected and low risk, high support countries:  SARS case requiring public health action: enhanced sensitivity definition for previously unaffected and low risk, high support countries A person presenting with a history of: high fever (>38oC); AND one or more of the following: close contact within 14 days of onset of symptoms, with a person who has been diagnosed with SARS history of travel within 14 days of onset of symptoms, to an area in which there are reported foci of transmission of SARS Slide12:  Does the patient have a recent history of travel to an affected area or close contact with a SARS patient Has fever (>38oC) developed within 14 days of leaving affected area, or contact with known SARS patient? ISOLATE AND INVESTIGATE Treat as possible SARS case; isolate/barrier nursing; implement local SARS plan; notify local health authorities and WHO country representative about possible SARS case Is the patient still within known incubation period for SARS (14 days) following travel/contact with SARS case? Give information about personal surveillance for fever during incubation period; treat nonSARS medical illness Provide information about SARS; treat nonSARS medical illness Yes No No No Yes Yes Suggested algorithm for contacts/travellers TRIAGE GUIDELINES:  TRIAGE GUIDELINES Task Force on SARS Clinical Guidelines 2003 Slide14:  Flow Chart for the Screening of SARS Suspect & Probable Cases Travel history to identify SARS areas or close contact w/ SARS suspect (+) fever (-) respiratory symptoms (+) fever (+) respiratory symptoms (-) fever (+) respiratory symptoms (-) fever (-) respiratory symptoms SARS SUSPECT Admit to holding area while awaiting transfer to a DOH- identified hospital for SARS cases. (See Flowchart #1). See Flowchart # 2 See Flowchart #3. See Flowchart # 4. Slide15:  FLOWCHART # 4 Screening of Patients with Travel History / Contact within 14 days without Symptoms seen at Ambulatory Care & ER Settings Patients with travel history/contact without symptoms Provide hotline numbers and advice regarding personal surveillance which includes monitoring for fever and respiratory symptoms. Fill out contact form Slide16:  FLOWCHART # 1 Screening of Patients with Travel History / Contact within 14 days with Fever & Respiratory Symptoms seen at Ambulatory Care & ER Settings Patients with fever and respiratory symptoms SARS SUSPECT Admit to holding area while awaiting transfer to a DOH identified hospital for SARS cases. (See Flowchart #1). Slide17:  FLOWCHART # 3 Screening of Patients with Travel History / Contact within 14 days with Cough but without Fever seen at Ambulatory Care & ER Settings Patients with travel history/contact with cough but without fever Treat as non-SARS cases and manage accordingly. Provide hotline numbers and advice regarding personal surveillance which includes monitoring for fever and worsening respiratory symptoms Fill out contact form Slide18:  Flowchart # 2 Screening of Patients with Travel History/Contact within 14 days with fever but without Cough seen at Ambulatory Care & ER Settings Travel history to identify SARS areas or close contact w/ SARS suspect Fever < 7 days Admit to designated isolation area. Do Chest x-ray & pulse oximetry (if available). POSSIBLE SARS Refer to DOH for further monitoring of onset of respiratory symptoms and further work-up Treat as non-SARS case & give advice. Do chest x-ray & pulse oximetry (if available) Pneumonia infiltrates on cxr OR hypoxemia? NO Fever >7 days Pneumonia infiltrates on cxr OR hypoxemia? NO PROBABLE SARS Refer to DOH identified facilities YES YES INITIAL DIAGNOSTIC EVALUATION:  INITIAL DIAGNOSTIC EVALUATION CBC ALT, AST, CK, LDH Blood culture & sensitivity Sputum GS, C&S Chest x-ray Pulse oximetry Save specimens (serum, respiratory) for additional tests SARS LABORATORY TESTS:  SARS LABORATORY TESTS Serology Enzyme immuno-assay Indirect immunofluorescent antibody assay RT-PCR in serum, stool, nasal secretions Electron microscopy Viral culture Treatment of SARS:  Treatment of SARS Efficacy of ribavirin and other antiviral agents against coronavirus is unknown In-vitro preliminary results indicate that ribavirin concentrations that inhibit ribavirin-sensitive viruses do not inhibit replication or cell-to-cell spread of the novel coronavirus (MMWR April 11, 2003) Ribavirin is a known teratogen, may cause severe hemolytic anemia More tests & clinical information on outcome of patients treated with ribavirin is needed Slide22:  Dose of ribavirin: 400 mg IV q 8h for 14 days Steroids IV methylprednisolone is recommended 3 mg/kg/d for 5 days, then 2 mg/kg/d for 5 days, then 1 mg/kg/d for 5 days, then taper off with oral prednisolone INFECTION CONTROL in SARS:  INFECTION CONTROL in SARS Overall Aim of Infection Control Measures in SARS:  Overall Aim of Infection Control Measures in SARS Minimize probability of transmission to healthcare workers, family and the public At a glance: Essential Principles of Infection Control:  At a glance: Essential Principles of Infection Control Isolation and avoidance of unnecessary contact Use of personal protective equipment (PPE) for all in close proximity Strict personal hygiene Masking of patient to reduce respiratory spread Public Awareness:  Public Awareness Information is your ally Stay informed and keep the public informed Check DOH and WHO websites every day The Global Challenge of SARS:  The Global Challenge of SARS “ If we are extremely lucky, the epidemic will be curtailed, develop a seasonal pattern . . . . or evolve more slowly . . . If the virus moves faster than our scientific, communication & control capacities we could be in for a long, difficult race. In either case, the race is on. The stakes are higher, and the outcome cannot be predicted.” J. Geberding, CDC 2003

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