Staged treatment protocol for hand, foot, and mouth disease
Hand, foot and mouth disease (HFMD) is one of the common infectious diseases caused by enteroviruses, mainly occurring in summer and autumn. The clinical manifestations are fever, rash and ulcers on the hands, feet, mouth and buttocks. The course of the disease is about 1 week, rarely recurring, and the prognosis is generally good, with no scarring after healing. Very few patients may suffer from complications such as myocarditis, pulmonary edema, aseptic meningitis and circulatory failure, which can be life-threatening in severe cases. Enterovirus 71 (EV71) infection can lead to critical illness and a high mortality rate. In our clinical work, we managed children with different stages of disease in stages and standardized treatment, and received better results. Now we introduce the following.
1.Stage of common cases of hand, foot and mouth disease
Pay attention to isolation, avoid cross-infection, proper rest, light diet, good oral and skin care, and give ribavirin orally or quietly; symptomatic treatment for fever, vomiting, diarrhea, etc.
2.Neural involvement stage
Once the child develops neurological symptoms and signs, such as headache, vomiting, poor mental health, irritability, drowsiness, limb weakness, myoclonus, convulsions or acute flaccid paralysis, etc., take the following measures immediately. Take the following measures immediately.
2.1 Closely observe respiration and pulse rate, if there is accelerated respiratory rate, irregular respiratory rhythm and sputum sound in both lungs, tracheal intubation should be performed as early as possible to remove secretions and keep the airway unobstructed, and be ready to apply ventilator.
2.2 Keep head in neutral position, elevate 15~30°.
2.3 Actively lower the cranial pressure by injecting mannitol 1.g/(kg/time), 1 time/4~6 h, 20~30 min; if necessary, alternately apply tachypnea 1~2mg/(kg/time),
1 time/8~12 h, sedation; albumin.
2.3 Early application of gammaglobulin can replenish antibodies and seal antigens in neurological involvement. The total amount of gammaglobulin 2 g/kg should be given in 2-3 days, and should be titrated slowly in poor cardiac function.
2.4 Avoid crying and sedate the child appropriately;
2.5 Actively control convulsions and hyperthermia, and limit fluid intake;
2.6 Give catheterization to those with urinary retention and avoid massage for urination;
2.7 Avoid lumbar puncture during this period to prevent brain herniation.
3. Cardiopulmonary failure stage
This stage is the most critical stage of HFMD. The clinical manifestations are sudden shortness of breath, ashen face, cold sweat, rapid heart rate, spitting of foamy sputum or bloody foamy sputum, increased pulmonary rales, obvious abnormal blood pressure, frequent myoclonus, increased convulsions and/or impaired consciousness, as well as hyperglycemia, hypertension, hypoxemia, and obvious increase in chest X-ray abnormalities or pulmonary edema and pulmonary solid manifestations on top of the original illness. Treatment is:
3.1 Keep the airway unobstructed and continue to administer oxygen.
3.2 Ensure the patency of two intravenous channels, monitor respiration, heart rate, blood pressure and oxygen saturation. 3.3 Intubate the trachea as early as possible to ensure the patency of the airway and ensure the supply of oxygen; give the ventilator for positive pressure mechanical ventilation immediately when respiratory dysfunction occurs.
The initial adjustment parameters of the ventilator: inhalation oxygen concentration is 80%~100%, PIP (peak inspiratory pressure) is 20~30 cmH2O, PEEP (positive end-expiratory pressure) is 4~8 cmH2O, f (respiratory count) is 20~40 times/min, tidal volume is 6~8
ml/kg, and later adjust the ventilator parameters according to blood gas at any time.
High-dose glucocorticosteroids were given as short-term shock therapy, with methylprednisolone 10-20 mg/(kg・d) for 3-5 days.
According to the changes of blood pressure and circulation, vasoactive drugs such as dobutamine, dobutamine, milrinone, sodium nitroprusside and phenibut were applied to relieve hypertension and improve microcirculation, and epinephrine was given to maintain effective blood circulation if blood pressure dropped.
Monitor the change of blood glucose, subcutaneous or intravenous insulin can be given to hyperglycemic patients.
Apply cimetidine, loxacillin, etc. to prevent gastrointestinal bleeding.
Antipyretic, anti-stunning, maintain acid-base balance, prevent electrolyte disorders and DIC, and protect the function of organs.
4.Stable vital signs period
During this period, the child’s vital signs are basically stable, but signs and symptoms of neurological dysfunction may remain. The child should have good respiratory management to avoid complications of respiratory tract infections, and provide supportive therapy to promote the recovery of all organ functions and neurological signs.