COVID-19 Updates2020-05-04T11:58:46-04:00
  • EM Cases Weekly COVID update

A practical COVID-19 resource for Emergency Medicine

COVID-19 Update May 262020-05-26T11:35:17-04:00

COVID-19 Update May 26th, 2020 by Dr. Andrew Morris

Edited by Anton Helman

Epidemiology and Prevention of COVID-19

We have no idea how to prevent COVID-19 with non-pharmaceutical interventions (NPIs), but it is clear that jurisdictions that have effectively pursued a test, trace, isolate approach combined with physical distancing and mask-wearing can get COVID-19 under control.  Those that cannot do not get COVID-19 under control.  As it stands, there are no effective pharmaceutical interventions for COVID-19.  Perhaps the most hotly pursued was hydroxychloroquine prophylaxis.  We await the clinical trials.  I will discuss treatment later on.

If we talk about acquisition of disease, the epidemiology has been fairly consistent: the highest risk comes from prolonged, close contact, indoors, unmasked, ideally with shared surfaces or food.  So household contacts are important, but there have been several high-profile outbreaks, including the well-described choir practice, where 61 people attended a 2.5h choir practice where there was one symptomatic person, with an attack rate of 53-87%, resulting in 3 hospitalizations and 2 deaths.

What becomes less clear is the role of children in disease acquisition and transmission.  Epidemiologists struggle with this a bit, because children are long believed to be the source of respiratory viral evil: looking cute and cuddly, but in fact being quite deadly with all sorts of germs. We know that there have been no childhood deaths in Canada.  In fact, despite over 5M infected and 343 513 deaths, children are massively under-represented.  There have been several prior attempts to quantify this, and much of it is very reassuring.  In Europe, only about 2% of all lab-confirmed cases were under age 15.  However, this one recent report from a tertiary centre in New York City, posted online May 11, describes a somewhat uneasy picture: 46 admitted patients, of which 13 were admitted to the PICU—8 were discharged home, 4 remained on a ventilator at Day 14, and 1 (with metastatic cancer) died.

Further with children, we are starting to learn more about the PIMS-TS (dyslexically labelled Pædiatric Multisystem Inflamatory Syndrome Temporally associated with SARS-CoV-2) or Multisystem Inflammatory Syndrome in Children (MIS-C), which is the Kawasaki-like disease that appears associated with COVID-19. It is characterized by fever, inflammation, organ failure, and SARS-CoV-2 infection, but may have headache; sore throat, cough, or other respiratory symptoms; conjunctivitis; lymphadenopathy; rash; abdominal pain, vomiting and/or diarrhea; and characteristic swelling and/or redness of the hands and feet (referred to as chilblain).  The fascinating thing is that it appears to be disappearing. Regardless, it is incredibly rare, with the European CDC reporting recently that there have only been 230 suspected cases of PIMS-TS in the European Union or UK, where there are over 80 million children.

Whether or not we need N95 masks for prevention—and where we need them—continues to remain a controversy for reasons unclear to me (https://www.cidrap.umn.edu/practice/facemask-and-n95-respirator-recommendations).  Perhaps a more fascinating story is the position of the Royal College of Dental Surgeons of Ontario, who have decided that the typical dental office needs to wait 207 minutes (yup, 207) between patient appointments before cleaning a dental operatory.


 

Diagnosis of COVID-19

Diagnosis hasn’t advanced substantially. We remain beholden to the RT-PCR via nasopharyngeal swab. Just a couple of weeks ago, the FDA approved the home-collected Rutgers Clinical Genomics Laboratory test (LDT) using the Spectrum Solutions LLC SDNA-1000 Saliva Collection Device. The FDA has not had the most auspicious tract record on regulation lately, so whether this device is the real deal or not remains to be seen.

We still seem to be relying, in the acute setting, on a variety of PCR tests.

Whether or not someone has been infected (i.e. using serology) has been a story of 1 step forward and 2 steps back. There are a variety of different tests: rapid diagnostic test (uses a lateral flow assay as a point-of-care rest), ELISA, neutralization assays, and chemiluminescent immunoassay. Eleven such tests have been approved in the US, whereas there is only 2 approved in Canada:  the LIAISON test, developed by DiaSorin (an Italian biotech) and the SARS-CoV-2 IgG assay by Abbott; an additional 22 serological tests are at various stages of approval by Health Canada.


Treatment of COVID-19

Hydroxychloroquine (HCQ) continues to take a beating.  This study in mild-moderate COVID-19 failed to show a benefit in 148 patients randomized to HCQ vs. standard of care.  There was no apparent microbiological benefits, with 30% of HCQ patients getting side effects vs. 9% of those receiving standard care.  (Tang W, Cao Z, Han M, Wang Z, Chen J, Sun W, et al. Hydroxychloroquine in patients with mainly mild to moderate coronavirus disease 2019: open label, randomised controlled trial. BMJ. 2020;369:m1849.)  Similarly, an observational study published in The Lancet looked at 96,032 patients hospitalized with COVID-19, with 1,868 receiving chloroquine, 3,783 CQ + macrolide, 3,016 receiving HCQ, and 6,221 receiving HCQ + macrolide (Mehra MR, Desai SS, Ruschitzka F, Patel AN. Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis. The Lancet. 2020.)  It really doesn’t matter how you dice this study up, it is an observational study that does not favour CQ or HCQ.  We need a bigger and better RCT.

Most of the attention this past week rested on remdesivir.  More than 3 weeks after Dr. Fauci of the NIH stated publicly that remdesivir should be the standard of care, it was released online by the NEJM in what is quite remarkable: preliminary results of the halted trial. What did we learn? Well, this was an RCT of 1059 patients—538 assigned to remdesivir and 521 to placebo—with a median recovery time of 11 days in the remdesivir arm and 15 days in the placebo arm. Using Kaplan-Meier estimates of 14 day mortality, 7.1% of those on remdesivir died vs. 11.9% on placebo; adverse events favoured remdesivir.  Perhaps more striking:  the benefit was not seen in those receiving high-flow oxygen, non-invasive mechanical ventilation, mechanical ventilation, or ECMO.  So what to do with all of this?  Well, it stands in relief to the much smaller Chinese trial published in The Lancet with 237 patients that showed no difference in time to clinical improvement overall, but DID show a reduction in time to clinical improvement in those treated early. (Wang Y, Zhang D, Du G, Du R, Zhao J, Jin Y, et al. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. The Lancet. 2020;395(10236):1569-78.)  Additionally, it appears that—once you get really sick, it is of minimal benefit.  This is problematic because it is administered intravenously, and what it does is gets you better quicker, but it might not make an overall difference to your outcome. I really wish they didn’t stop this trial yet.  I am hopeful the WHO’s SOLIDARITY trial (with its Canadian CATCO arm) gives us more clarity.


References for COVID-19 update

  1. https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/covid-19/diagnostic-devices-authorized.html#wb-auto-5
  2. Hamner L, Dubbel P, Capron I, et al. High SARS-CoV-2 Attack Rate Following Exposure at a Choir Practice – Skagit County, Washington, March 2020. MMWR Morb Mortal Wkly Rep. 2020;69(19):606-610.
  3. https://www.cps.ca/en/documents/position/update-on-covid-19-epidemiology-and-impact-on-medical-care-in-children-april-2020
  4. https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-risk-assessment-paediatric-inflammatory-multisystem-syndrome-15-May-2020.pdf
  5. https://www.cidrap.umn.edu/practice/facemask-and-n95-respirator-recommendations
  6. https://www.rcdso.org/en-ca/rcdso-members/2019-novel-coronavirus/covid-19–managing-infection-risks-during-in-person-care
  7. Tang W, Cao Z, Han M, Wang Z, Chen J, Sun W, et al. Hydroxychloroquine in patients with mainly mild to moderate coronavirus disease 2019: open label, randomised controlled trial. BMJ. 2020;369:m1849.
  8. Mehra MR, Desai SS, Ruschitzka F, Patel AN. Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis. The Lancet. 2020.
  9. Beigel JH, Tomashek KM, Dodd LE, et al. Remdesivir for the Treatment of Covid-19 – Preliminary Report. N Engl J Med. 2020;
  10. Wang Y, Zhang D, Du G, Du R, Zhao J, Jin Y, et al. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. The Lancet. 2020;395(10236):1569-78.
COVID-19 Update May 3, 20202020-05-20T11:47:49-04:00

Remdesivir for treatment of COVID-19 by Andrew Morris

This week saw 3 trial results “announced”.  One is the Lancet trial https://doi.org/10.1016/S0140-6736(20)31022-9 posted online on April 29. This trial is a multicenter double-blind RCT with 2:1 allocation of remdesivir: placebo with a total of 237 patients with <12 days of symptom onset admitted to hospital in Hubei, China.  Patients were permitted concomitant use of lopinavir–ritonavir, interferons, and corticosteroids. Primary endpoint was time to clinical improvement up to day 28, defined as the time (in days) from randomisation to the point of a decline of two levels on a six-point ordinal scale of clinical status (from 1=discharged to 6=death) or discharged alive from hospital, whichever came first. Primary analysis was done ITT.  No improvement in mortality. Possibly improved median time to clinical improvement … although the data is very difficult to interpret, because they use this wacky ordinal scale, so that going from 4l/min O2 and hospitalized —> meeting discharge criteria (even if you stay in hospital) is given the same weight on improvement as going from ventilated in ICU—> supplemental O2 on ward. They aren’t the same.  Most importantly, the data showed no difference in mortality.  The “improvement” differences are so over the map that they are largely uninterpretable.
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We then have another study, from Gilead themselves, announced with a media release on April 29:  it is the open-label, Phase 3 SIMPLE trial evaluating 5-day and 10-day dosing durations in 397 patients. Bottom line:  no appreciable difference in 5 vs. 10 days … except more side effects with 10 days (5% vs. 10% leading to discontinuation, p=.07). Tells us nothing otherwise.
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Finally, it brings me to the Fauci-Birx-Trump press announcement—again on April 29 (boy that was a busy day for Gilead.  And me!):  I cannot express enough how disappointed I was in this.  It was a press release announcing that the DSMB of the NIAID (one of the 27 institutes of the NIH … we have Institute of Infection and Immunity for CIHR) looked at the data—as is normal in an adaptive trial—and concluded that the median time to clinical improvement (i.e moving 2 points on an ordinal scale) was 11 vs 15 days favouring remdesivir. Dr. Fauci referred to this as highly significant, emphasized that there were over 1000 patients enrolled … we then learn that the analysis has only been done on 600 patients.  He then says that the data are so compelling that remdesivir now needs to be considered the “standard of care”—meaning that all patients enrolled in COVID-19 therapeutic trials should be receiving remdesivir. At to the nuttiness of all of this, but the endpoint of the trial was switched from mortality to median time to clinical improvement literally days before the DMSB analysed the data.
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Am I incensed?  Absolutely.  The Fauci-Birx-Trump conference—held in the Oval Office—has undermined ongoing clinical trials, rational exploration of the role of remdesivir, and has seriously compromised the credibility and independence of scientific/medical expertise in the most important country for research in the world. What do I think of remdesivir?  I dunno.  We don’t have the paper yet. It could really be helpful. Or not. But cherry-picking an outcome and then saying that it is a reason for calling it the standard of care and halting one of the few trials able to give us the answer makes me question the independence of all of this. Gilead on the other hand … well their stocks went up … and then went right back down. So investors are starting to question that announcement just as much as people like me.
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Wang Y, Zhang D, Du G, et al. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. The Lancet. 2020.

Grein J, Ohmagari N, Shin D, et al. Compassionate Use of Remdesivir for Patients with Severe Covid-19. N Engl J Med. 2020.

First10EM Remdesivir: The first real trial

REBEL EM: Two More Trials Just Published on Remdesivir 

PulmCrit: First placebo-controlled RCT on remdesivir for COVID-19


Largest international observational study on clinical features of COVID-19 to date

  • Mean number of days from (first) symptom onset to hospital admission was 11.7
  • Mean duration for the number of days from hospital admission to outcome (death or discharge) was 8.7
  • Mean and median durations for non-invasive ventilation were 2 days and 0.5 days respectively
  • Duration of stay in ICU/HDU had a mean of 7.4 days and a median of 5.5
  • Mean and median for the duration of mechanical ventilation were 9.6 days, 9 days
  • 72.4% received an antibiotic and 8.8% received antivirals

International Severe Acute Respiratory and Emerging Infections Consortium (ISARIC) global federation of clinical research networks COVID-19 Report: 27 April 2020.


Updated airway management guidelines for patients with known or suspected COVID-19 infection (care of George Kovacs)

COVID oxygenation AIME

This document nicely outlines indications for early intubation:

  • Significant hypoxemia refractory to non-rebreathing mask at flows < 15 lpm in conjunction with one or more of the following:
    • Clinical signs of the patient tiring:
      • Dyspnea;
      • Tachypnea with RR > 30-35 (adult);
      • Tachycardia;
      • Agitation;
      • Accessory muscle use; paradoxical chest/abdomen movement
    • Worsening PaO2/FiO2; Increasing PaCO2;
    • Rapidly progressive disease trajectory or other clinical judgement.
  • Other standard indications for tracheal indication, e.g., failure to protect the airway or obstructing airway pathology, hemodynamic instability, sepsis, multi-organ failure.

Airway Management Guidelines for Patients with Known or Suspected COVID-19 Infection Version 3.7


Review of COVID-19 POCUS diagnosis and disinfection

http://www.emdocs.net/lung-ultrasound-in-covid-19/


Roche’s COVID-19 antibody test receives FDA emergency use authorization, but many questions still remain

https://www.roche.com/media/releases/med-cor-2020-05-03.htm

As outlined in the latest FOAMcast, cross-reactivity can cause false positives and false negatives are common early in the disease. If prevalence is very low, then a positive test probably indicates past infection, but immunity is still questionable.

Zhao J, Yuan Q, Wang H, et al. Antibody responses to SARS-CoV-2 in patients of novel coronavirus disease 2019. Clin Infect Dis. 2020.

This study suggests that reinfections with the same coronavirus are possible within one year.

COVID-19 Update April 26, 20202020-04-27T12:48:12-04:00

This blog post is based on Level C evidence – consensus and expert opinion, and some observational data. Examples of protocols, checklists and algorithms are for educational purposes and require modification for your particular needs as well as approval by your hospital before use in clinical practice.

COVID-19 prognosis and mortality rate to help guide goals of care

Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. Published online April 22, 2020. doi:10.1001/jama.2020.6775.

This large observational study of 5700 patients in a North American healthcare setting found a mortality rate in all comers ranging from 5-64% depending on age. Fourteen percent of these patients were ICU patients, 12% were ventilated. Of those patients who were ventilated there was an 88% mortality rate (76% in those aged 18-65 years, 97% on those >65 years old). This is consistent with previous findings of very high mortality rates in ventilated COVID-19 patients. Mortality of non-ventilated patients ages 18-65 years was 20% and mortality of non-ventilated patients >65 years old was 27%. These data are important to know when counseling patients and families about goals of care.

Score to predict likelihood of coagulopathy and mortality in COVID-19 patients on MDCalc


Time spent with patient may be as important as the type of procedure for aerosolization/airborne transmission of COVID-19 virus 

Wilson NM, Norton A, Young FP, Collins DW. Airborne transmission of severe acute respiratory syndrome coronavirus-2 to healthcare workers: a narrative review. Anaesthesia. April, 20th, 2020.

There are 3 mechanisms for the production of aerosols that, if inhaled, can deposit in the distal airways:

  1. Laryngeal activity such as talking and coughing
  2. High velocity gas flow; and
  3. Cyclical opening and closure of terminal airways

In this article they suggest that transmission is associated with time in proximity to COVID-19 patients with respiratory symptoms, rather than the procedures per‐se.

“Sneezing and coughing are effective aerosol generators, but all forms of expiration produce particles across a range of sizes. The 5 μm diameter threshold used to differentiate droplet from airborne is an over‐simplification of multiple complex, poorly understood biological and physical variables. The evidence defining aerosol‐generating procedures comes largely from low‐quality case and cohort studies where the exact mode of transmission is unknown as aerosol production was never quantified. We propose that transmission is associated with time in proximity to SARS‐CoV‐1 patients with respiratory symptoms, rather than the procedures per‐se. There is no proven relation between any aerosol‐generating procedure with airborne viral content with the exception of bronchoscopy and suctioning. The mechanism for SARS‐CoV‐2 transmission is unknown but the evidence suggestive of airborne spread is growing. We speculate that infected patients who cough, have high work of breathing, increased closing capacity and altered respiratory tract lining fluid will be significant producers of pathogenic aerosols. We suggest several ‘aerosol‐generating procedures’ may in fact result in less pathogen aerosolisation than a dyspnoeic and coughing patient. Healthcare workers should appraise the current evidence regarding transmission and apply this to the local infection prevalence. Measures to mitigate airborne transmission should be employed at times of risk. However, the mechanisms and risk factors for transmission are largely unconfirmed. Whilst awaiting robust evidence, a precautionary approach should be considered to assure healthcare worker safety.”

Full pdf of aerosolization/airborne transmission of Co-V2 article

Aerosols, Droplets, and Airborne Spread: Everything you could possibly want to know at Firt10EM

Droplets spread more than 2 meters (a systematic review) at First10EM

Should a healthcare worker wear an N95 mask when providing care for a coughing, possible or confirmed COVID 19 child, when the child will not wear a surgical mask? (care of Laurie Mazurik)

Yes, if a patient is coughing and is a possible or confirmed COVID 19, and cannot keep a surgical mask on, the provider should wear an N95 mask when providing their care. Coughing generates aerosols. This,  is why having a coughing patient wear a surgical mask is so important. This applies to all ages. Given that we are all concerned about PPE conservation, if you have to look after these types of patients, it may be best to simply wear the N95 all shift or as long as possible along with the face shield, changing it only if you feel it is contaminated, wet etc.

Mask decontamination and re-use

N95 masks are designed for one time use and there is no manufactured authorized method for their decontamination. National Institute for Occupational Safety and Health (NIOSH) and CDC do not recommend decontamination of respirators as standard of care; however, they outline that when shortage exists, the option of decontamination should be considered. According to the CDC, ultraviolet germicidal irradiation, vaporous hydrogen peroxide, and moist heat using an autoclave show the most promise as methods for decontamination of N95 masks. These methods do not appear to break down filtration or compromise the respirator; however, many of these methods can only be used for limited times.

Public Health Ontario. (2020, April 4). COVID-19 – What We Know So Far About Reuse of Personal Protective Equipment. https://www.publichealthontario.ca/-/media/documents/ncov/covid-wwksf/what-we-know-reuse-of-personal-protective-equipment.pdf?la=en

COVID-19 Decontamination and Reuse of Filtering Facepiece Respirators. (2020, April 9). Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html

Your ED should have a system/protocol for sterilization and reuse of N95 masks (care of Laurie Mazurik)
Sunnybrook Health Science Centre, Toronto Ontario and other hospitals are saving and sterilizing N95s for reuse.
http://health.sunnybrook.ca/navigator/some-hospitals-planning-to-sterilize-and-reuse-n95-masks-to-stretch-out-supplies-during-covid-19-pandemic/ Each provider places their N95 mask in sterilization envelope, seals it and write  their name on it, so they only get their mask back.
They  autoclave 400 masks in 1.5 hours and redo the process up to 10 times for each N95 (except molded ones). These can only be autoclaved once but if you use other methods for these it goes up to 10 times. University of Manitoba is working with the National Microbiology Lab tested different modes of sterilization and reuse for N95s, and started the whole process.

Andrew Morris COVID-19 update on epidemiology and medical treatment

Asymptomatic and presymptomatic SARS-VoV-2 infection — how do we know who is infectious?

Scripps Research have been collating all of this data, and it appears to be somewhere between 42 and 88% of people who are COVID positive, are asymptomatic.  If you look closely, the populations vary widely, and the sample sizes remain quite small, with the 3 largest populations on boats (Diamond Princess + 2 aircraft carriers).  This aligns with the very recent (and timely) NEJM article which showed that—in a Long Term Care Facility (LTCF)—56% of residents that tested positive were asymptomatic; 89% would develop symptoms; so probably best to refer to them as “presymptomatic”. (Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility. New England Journal of Medicine. 2020.)  In addition, over half of these pre-symptomatic patients were shedding live virus.

Congregant settings should be the most targeted sites in this pandemic

There has been dramatic spread of CoV-2 in LTCF, shelters and other congregant settings in Canada.  It is likely under–recognized in the US at present, but it is absolutely a recognized problem in Canada, where it continues to be a problem, especially in LTCFs in Quebec and Ontario.  An unsurprising congregant setting is a meat–packing facility in Alberta, which has furnished over 600 cases, especially involving workers originally from the Philippines who are major breadwinners for their families back home.  It has resulted in several deaths, and is the largest single outbreak in Canada.  Congregant settings should be the most targeted sites in this pandemic.

Coordination of RCTs  for COVID drugs  and organizing of science is of paramount importance

The (now hundreds of) RCTs on potential COVID drugs should be coordinated and properly conducted.  A recent article in Lancet Digital Health argued for this, and made their point based on the available data: Figure thumbnail gr1
As the rapidity of science on COVID moves, we need to organize it better. There is a move afoot to do this.  My two favourite resources are https://www.mcmasterforum.org/networks/covidend/lets-collaborate/our-guide-to-covid-19-evidence-sources and http://eppi.ioe.ac.uk/COVID19_MAP/covid_map_v6.html

COVID-19 Home testing for health care workers

FDA-approved home testing kits will soon be available for health care workers through a physician’s order, with results available online. Apparently this testing kit has proven to be as accurate as standard CoV-2 nasopharyngeal swab tests (which are not very accurate), although I can not find the data on this anywhere online. Even though this has been approved by the FDA it remains to be determined if these kits are truly reliable.

Labcorp home testing kits


Combined COVID-19 moderate physical distancing, testing and tracing strategies would reduce transmission more than mass testing or self-isolation alone according to UK mathematical models

Kucharski, A et al. Effectiveness of isolation, testing, contact tracing and physical distancing on reducing transmission of SARS-CoV-2 in different settings. Centre for Mathematical Modelling of Infectious Diseases. April 23, 2020.

This group of mathematical modelers used a model of individual-level transmission stratified by setting (household, work, school, other) based on data from 40,162 people in the UK in this non-peer reviewed paper. They simulated the impact of a few different testing, isolation, tracing and physical distancing scenarios. They estimated the reduction in effective reproduction number for a given level of COVID-19 incidence and the number of contacts that would be newly quarantined each day under different strategies. They estimated that combined testing and tracing strategies would reduce transmission more than mass testing or self-isolation alone (50–65% vs 2–30%). If limits were placed on gatherings outside of home/school/work (e.g. maximum of 4 daily contacts in other settings), then manual contact tracing of acquaintances only could have a similar effect on transmission reduction as detailed contact tracing. Strategies that combined isolation of symptomatic cases and tracing of their contacts reduced the effective reproduction number more than mass testing or self-isolation alone.

It looks like moderate physical distancing (max 4 daily contacts outside home/school/work) measures combined with contact tracing (the details of which should be regionalized) is our best bet going forward.

Full pdf of “Effectivenss of isloation, testing, contact tracing and physical distancing on reducing transmission of SARS-CoV-2 in different settings”


Dipyridamole for COVID-19? Interesting, but not ready for prime time

Liu X, Li Z, Liu S, et al. Potential therapeutic effects of dipyridamole in the severely ill patients with COVID-19. Acta Pharm Sin B. 2020.

Elevated D-dimers in patients with COVID-19 have previously been shown to be a marker of poor prognosis. Dipyridamole has been shown in vitro to suppress CoV-2 replication. In this proof of concept trial of oly 31 patients with COVID-19, dipyridamole was associated with lower D-dimers, increased lymphocyte and platelet recovery and clinical improvement (87.5% cure rate, 12.5% clinical remission). Large RCTs are required before any recommendations for clinical use of this drug can be made.


Some observational data suggests that awake self proning may improve oxygenation transiently in patients suspected of COVID-19

Caputo ND, Strayer RJ, Levitan R. Early Self-Proning in Awake, Non-intubated Patients in the Emergency Department: A Single ED’s Experience during the COVID-19 Pandemic. Acad Emerg Med. April, 22nd, 2020.

This observational pilot study of 50 patients (with hypoxia on arrival and suspected of having COVID19 who were treated with NRB and nasal cannula supplemental oxygenation), compared SpO2 at triage and after five minutes of proning and looked at post‐proning failure rates of intubation within the first 24 hours. SpO2 improved from 84% to 94%. One quarter of patients failed to improve or maintain their oxygen saturations and required endotracheal intubation within 24 hours of arrival to the ED. While this observational study looks promising for self proning suspected COVID-19 patient in the short term, the duration of potential benefit is not known. RCTs looking at longer time periods and more patient oriented outcomes are needed before routinely employing self-proning in COVID-19 patients.

IDSA COVID-19 treatment guideline recommendations

Bhimraj A, et al. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19. April, 2020.

  1. Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel recommends hydroxychloroquine/chloroquine in the context of a clinical trial. (Knowledge gap)
  2. Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel recommends hydroxychloroquine/chloroquine plus azithromycin only in the context of a clinical trial. (Knowledge gap)
  3. Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel recommends the combination of lopinavir/ritonavir only in the context of a clinical trial. (Knowledge gap)
  4. Among patients who have been admitted to the hospital with COVID-19 pneumonia, the IDSA guideline panel suggests against the use of corticosteroids. (Conditional recommendation, very low certainty of evidence)
  5. Among patients who have been admitted to the hospital with ARDS due to COVID-19, the IDSA guideline panel recommends the use of corticosteroids in the context of a clinical trial. (Knowledge gap)
  6. Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel recommends tocilizumab only in the context of a clinical trial. (Knowledge gap)
  7. Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel recommends COVID-19 convalescent plasma in the context of a clinical trial. (Knowledge gap)

Full pdf IDSA COVID-19 Guidelines

Updates to the IDSA COVID-19 Guidelines


Should we discharge patients with instructions for self monitoring of oxygen saturation or Roth Score monitoring?

Salim Rezaie, “REBEL Cast Ep80: A New War Plan for COVID-19 with Richard Levitan”, REBEL EM blog, April 24, 2020. Available at: https://rebelem.com/rebel-cast-ep80-a-new-war-plan-for-covid-19-with-richard-levitan/.

Jordan TB, Meyers CL, Schrading WA, Donnelly JP. The utility of iPhone oximetry apps: A comparison with standard pulse oximetry measurement in the emergency department. Am J Emerg Med. 2019.

Based on expert opinion, the most impactful point in the natural history of COVID-19 occurs when oxygen saturation starts to decline. This decline may occur without the patient experiencing subjective shortness of breath (“silent hypoxia”). Hence the suggestion that patients suspected of COVID-19 who are discharged from the ED with normal oxygen saturations should be instructed to monitor their oxygen saturations at home, and to return to the ED when oxygen saturations are persistently lower than baseline. Patients could be provided with a portable oxygenation saturation monitor or could buy one for about $30. If this is not an option, the Roth Score (see below) could be used to estimate oxygen saturation, although it has been criticized because sensitivity and specificity appeared to be presented incorrectly in the original article, and it has not been validated. MDCalc has removed the Roth Score “as it is no longer recommended.” Evidence for the accuracy of smartphone apps for oxygen saturation is all over the map and should probably not be recommended either.


Evidence-based review of psychological impact of quarantine and how to reduce it

Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912-920.

There were 24 articles included in this review, most of which reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. People who are quarantined are more likely to exhibit symptoms of exhaustion, detachment from others, irritability, difficulty sleeping, and poor concentration. Some healthcare workers may suffer from long term psychological consequences such as post traumatic stress, depressive symptoms or alcohol abuse, especially those quarantined > 10 days.

They suggest some ways to mitigate the effects of quarantine:

  • Provide adequate supplies
  • Communicate clearly regarding the details of the quarantine (duration, warning signs, etc.)
  • Provide ways for people to communicate and socialize from a distance

Additional COVID-19 resources and updates

EM Cases COVID-19 Part 5: Epidemiology & Prediction Models

EM Cases COVID-19 Part 4: Protected Intubation

EM Cases COVID-19 Part 3: PPE: What You Need to Know & Conservation Strategies

EM Cases COVID-19 Part 2: Surge Capacity Strategies

EM Cases COVID-19 Part 1: Screening, Diagnosis & Management

EM Quick Hits 14: You Colleagues Experiences & Tips 1

EM Quick Hits 15: Practical Tips, Pediatric Management & Human Factors

EM Quick Hits 16: Oxygenation strategies, Trauma Modifications, Addictions Considerations, Cardiac Complications & Compassionate Care

Canadian Stroke Best Practice Guidance During the COVID-19 Pandemic

ROX index for predicting need for intubation after HFNC

Amal Mattu video on cardiology articles you need to know in 2020 related to COVID-19 (starting at 7:15)

Improving mental health during COVID-19 pandemic


References

Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. Published online April 22, 2020. doi:10.1001/jama.2020.6775.

Wilson NM, Norton A, Young FP, Collins DW. Airborne transmission of severe acute respiratory syndrome coronavirus-2 to healthcare workers: a narrative review. Anaesthesia. April, 20th, 2020.

Zayas, G., Chiang, M.C., Wong, E. et al. Cough aerosol in healthy participants: fundamental knowledge to optimize droplet-spread infectious respiratory disease management. BMC Pulm Med 12, 11 (2012). https://doi.org/10.1186/1471-2466-12-11.

Thorlund K, et al. A real-time dashboard of clinical trials for COVID-19. The Lancet – Digital Health. Published online April 24, 2020. 

Arons MM, Hatfield KM, Reddy SC, et al. Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility. N Engl J Med. 2020.

Kucharski, A et al. Effectiveness of isolation, testing, contact tracing and physical distancing on reducing transmission of SARS-CoV-2 in different settings. Centre for Mathematical Modelling of Infectious Diseases. April 23, 2020.

Liu X, Li Z, Liu S, et al. Potential therapeutic effects of dipyridamole in the severely ill patients with COVID-19. Acta Pharm Sin B. 2020.

Caputo ND, Strayer RJ, Levitan R. Early Self-Proning in Awake, Non-intubated Patients in the Emergency Department: A Single ED’s Experience during the COVID-19 Pandemic. Acad Emerg Med. April, 22nd, 2020.

Bhimraj A, et al. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19. April, 2020.

Salim Rezaie, “REBEL Cast Ep80: A New War Plan for COVID-19 with Richard Levitan”, REBEL EM blog, April 24, 2020. Available at: https://rebelem.com/rebel-cast-ep80-a-new-war-plan-for-covid-19-with-richard-levitan/.

Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912-920.


Daily COVID-19 affirmation

I am in the present moment.  I believe in myself and in the strength of the human spirit.  Our society, country, and the world will overcome this.  I am an essential part of the process.  Even if things are difficult now, I trust the overall path that my life is taking.  I’ll start with what I can do today.  I accept the situation I am facing.  I am confident in my ability to take necessary precautions.  Even if I don’t see them now – there are solutions to my problems.  I embrace all of my emotions.  I let go of the past.  I practice gratitude and forgiveness.  I look for examples of kindness around me.  My level of motivation is increasing.  I feel greater amounts of happiness.  I trust my intuition.  I am doing my best.  I effectively handle stress.  I adapt and focus on solutions.  I persevere.  I act from a place of love, compassion, and peace.” 

-Dr. Jerome Perera

COVID-19 Update Apr 19, 20202020-04-21T11:12:55-04:00

JACC Guidelines for anticoagulation in patients with COVID-19

Outpatient

  • Consider prophylactic dose anticoagulation in patients at high risk of venothromboembolsim and low risk of bleeding,
  • Avoid immobilization
  • Consider transitioning patients taking warfarin to a DOAC

Inpatient

  • Prophylactic dose anticoagulation for all patients without specific contraindications who are not in DIC
  • There is limited evidence to guide which patients require empiric full dose anticoagulation
  • Elevated D-dimer is common in COVID-19 patients; investigation for PE/DVT should be considered in:
    • those with symptoms of DVT
    • acute unexplained RV dysfunction or
    • hypoxemia out of proportion to COVID-19 and/or other underlying lung pathology

Bikdeli, B et al. COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up.

St. Emlyn’s on COVID-19 – Clotting: Diagnosis, D-dimers & Dilemmas

REBELEM on COVID-10 Thrombosis & Hemboglobin


Andrew Morris Update on diagnosis and treatment of COVID-19

Asymptomatic infections are common
We now have two interesting cohorts, out of Iceland  and Italy that about 43% of infections are in people with documented infection are asymptomatic.  We don’t know how well this pairs with “infectious”, but it is a pretty impressive number nonetheless.
————
Diagnosis and preventing spread with serology
This is one of these holy grails that has been, unfortunately ignored:  people assume that serology will be really helpful, but experts keep telling us that it won’t be as useful as the epidemiologists think.  There is a real chasm there.  Here is one of several commentaries highlighting that very fact. It is not the most optimistic.
————
Medications: we are still at exactly nowhere 
No high quality studies reported, but multiple trials in Canada and beyond.  I think the real problems moving forward are: duplication of efforts, poor coordination, lack of peer review of research, and lack of rationale even.
————
Running out of medications for sick patients
Health Canada has a long list of drugs used in critical care on Tier 3 status (i.e. running out!).  This is emerging to be as big a deal (if not bigger) than PPE. It turns out that some COVID-19 patients require massive amounts of intravenous agents:  paralytics, sedative, anxiolytics, and opiates.  It is much more than we anticipated. This will not only affect, potentially, management of patients, but also ability to open up hospitals , and get back to operating.
————
Serum therapy
The first serum therapy treatment trials are just starting in Canada: CONCOR-1 and CONCOR KIDs.  A little known fact—you cannot collect or administer serum/plasma therapy in Canada outside of Canadian Blood Services.  This trial is the only way you can get it.
————
WHO Prerequisites for ending lockdown and “opening up” economies
The WHO and various countries came out with pre-requisites for coming out of lockdown and opening up their economies. It includes:
  • having the disease under control
  • capacity to test, trace and isolate
  • consideration and assessment of vulnerable populations
  • control of bringing the disease into communities

————

Two parallel epidemics
The COVID-19 tragedy has moved from community—> hospitals, to a) long-term care and b) congregant settings (e.g. Shelters, Group Homes, Prisons, etc.).  There are increasingly 2 epidemics in Canada, one being in these congregant settings.  What we really have is an epidemic in the generally central society, and then another one in the marginalized society.  This second epidemic is what will make our struggle to control COVID-19 all that much greater.

AHA Protected code blue algorithm and guideline

AHA Algorithm Protected Code Blue

AHA Protected Code Blue Guidelines


ACEi/ARBs may decrease mortality in patients with COVID-19

Preclinical studies suggest that ACEi/ARBs inhibitors may increase ACE2 expression in the CoV-2 virus, but it is unknown if this occurs in humans or is clinically relevant. The WHO has recommended not stopping ACE/ARBs in patients with COVID-19 despite some earlier recommendations to hold these drugs as a precaution.  Newer evidence suggests that ACEi/ARBs may decrease mortality in patients with COVID-19. This recent retrospective, multi-center observational study in China of 1128 admitted patients with hypertension diagnosed with COVID-19, compared 188 patients taking ACEI/ARB to 940 patients not taking ACEI/ARB, found that the mortality rate was lower in the ACEI/ARB group versus the non-ACEI/ARB group after adjusting for age, gender, comorbidities, and in-hospital medications (adjusted HR, 0.42; 95% CI, 0.19-0.92; P =0.03). Remember, this is an observational study – we should not be starting all COVID patients on ACEi/ARBs based on this one study.

Zhang P, Zhu L, Cai J, et al. Association of Inpatient Use of Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers with Mortality Among Patients With Hypertension Hospitalized With COVID-19. Circ Res. 2020.

Thanks to David Juurlink for for the tip on this article


IO is probably a very good option for quick vascular access when wearing full PPE

A recent analysis of RCTs suggests that the use of PPE significantly reduces the efficacy of placing peripheral IVs (RR = 1.0; 95% CI, 0.93–1.08; I2 = 88%; p = 0.006) and extends the time to obtain access (MD = 9.37; 95% CI, 0.81–17.93; I2 = 98%; p < 0.001). They found that IO access was more effective (100% vs 90%) and faster (MD = −17.60; 95%CI,−19.44 to −15.76; I2 = 99%; p < 0.001). They also point out that IO may be associated with a lower risk of stabbing compared to IV.

Smereka J, Szarpak L, Filipiak KJ, Jaguszewski M, Ladny JR. Which intravascular access should we use in patients with suspected/confirmed COVID-19?. Resuscitation. 2020.


The combination of hypogeusia and hyposmia may be helpful in ruling in COVID-19

In an observational study of 452 patients out of France who tested positive for CoV-2 by nasopharyngeal swab hypogeusia (lessened sense of taste) and hyposmia (lessened sense of smell) were strongly associated with COVID-19 diagnosis, separately and combined, in patients with and without a medical history of ENT disorders. A combination of hypogeusia and hyposmia in patients with no medical history of ENT disorders had a sensitivity of of only 42% but had and a specificity of 95%!

Bénézit F, Le turnier P, Declerck C, et al. Utility of hyposmia and hypogeusia for the diagnosis of COVID-19. Lancet Infect Dis. 2020.


Should older healthcare workers and pregnant healthcare workers be excused from work during the COVID-19 pandemic?

People over the age of 60 (especially those with a history of heart/lung disease or cancer and those who are in an immunocompromised state) are at higher risk for both severe disease and mortality from COVID-19, with mortality rates as much 10 times higher in those between the ages of 60 and 69. The literature also suggests that pregnancy is a risk factor for severe disease and adverse fetal effects. ED administrators may consider offering shifts for these staff that do not include the “hot” and “warm” zones of their departments or suggesting that they refrain from ED shifts during the height of the pandemic.

Adapted from CJEM Just the Facts


Other #COVIDfoam Sources of note this week

First10EM deep dive into aerosol and surface distribution of Co-V2

St. Emlyn’s on COVID-19 – Clotting: Diagnosis, D-dimers & Dilemmas

FOAMcast VTE Guidelines & MI

REBELEM Why COVID Screening Protocols Won’t Work

LiTFL Imaging of COVID-19 Pneumonia: A Critical Care Perspective

ERCast COVID-19 Lessons from New York City

EMCrit More COVID Airway

References

Bikdeli, B et al. COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up.

Gudbjartsson DF, Helgason A, Jonsson H, et al. Spread of SARS-CoV-2 in the Icelandic Population. N Engl J Med. 2020.

https://t.co/4mrsdpQL4V?amp=1

https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930788-1

https://www.canada.ca/en/health-canada/services/drugs-health-products/compliance-enforcement/covid19-interim-order-drugs-medical-devices-special-foods/information-provisions-related-drugs-biocides/tier-3-shortages.html

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30894-1/fulltext?fbclid=IwAR1lz0MBx_yXL4fN3YPmfaxOnB-

Zhang P, Zhu L, Cai J, et al. Association of Inpatient Use of Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers with Mortality Among Patients With Hypertension Hospitalized With COVID-19. Circ Res. 2020.

Chen L, Li Q, Zheng D, et al. Clinical Characteristics of Pregnant Women with Covid-19 in Wuhan, China. N Engl J Med. 2020.

Smereka J, Szarpak L, Filipiak KJ, Jaguszewski M, Ladny JR. Which intravascular access should we use in patients with suspected/confirmed COVID-19?. Resuscitation. 2020.

Bénézit F, Le turnier P, Declerck C, et al. Utility of hyposmia and hypogeusia for the diagnosis of COVID-19. Lancet Infect Dis. 2020;

COVID-19 Update April 12, 20202020-04-12T17:28:50-04:00

This blog post is based on Level C evidence – consensus and expert opinion. Examples of protocols, checklists and algorithms are for educational purposes and require modification for your particular needs as well as approval by your hospital before use in clinical practice.

Reuben Strayer’s oxygenation strategy algorithm based on NYC experience

Strayer oxygenation COVID

This algorithm is based on expert opinion and is for educational purposes only. In clinical practice, follow your hospital-based protocols.

3 weeks of coronavirus in New York City by Reuben Strayer on EMupdates

Proning instructions for patients from New York City

awake proning instructions for patients

Example of proning instructions for awake patients. Care must be taken to avoid dislodgement of oxygenation therapies, monitors and IVs. This example is for educational purposes only. Follow your hospital-based protocols.


Anticoagulation for COVID-19 patients who are admitted to hospital

Prothrombosis is one of the many not-yet-understood but repeatedly observed aspects of COVID-19. Many hospitals are using aggressive anticoagulation algorithms based on trending D-dimers. At a minimum, everyone admitted should probably be prophylaxed to prevent thrombosis with the following exceptions: active bleeding or platelet count < 25,ooo.

A single center retrospective study of 81 ICU patients with COVID-19 found that a D-dimer >1,500 ng/ml had an 85% sensitivity and 89% specificity for predicting PE, however because of the weaknesses of this study, a D-dimer cutoff should not be used alone to make anticoagulation decisions.

COVID-19 Anticoagulation Algorithm

Example of anticoagulation decision algorithm for COVID-19. This algorithm is based on expert opinion and is for educational purposes only. In clinical practice, follow your hospital-based protocols.

REBELEM COVID-19 Thrombosis and Hemoglobin April 9, 2020

PulmCrit D-dimer cutoffs to predict thrombosis in COVID-19


COVID-19: a synthesis of clinical experience in UK intensive care settings – delayed intubation, proning, nitric oxide, upper airway edema, judicious antibiotics and fluids

A rapid dissemination summary report of a facilitated ‘Knowledge Sharing Session’ between UK clinicians with considerable experience of ICU management of COVID-19 infected patients by the Intensive Care Society as part of the National Emergency Critical Care Committee.

Early aggressive ventilation may adversely affect outcomes

Aggressive ventilation in the early phase may adversely affect later outcomes. The starting PEEP and tidal volumes should be lower than previously recommended; PEEP=10 appears satisfactory for many.

Proning patients should be considered early, to support the vasculature

  • Proning on admission if in early phase (predominantly perfusion) can be done irrespective of PF ratio, and if response is +ve, this may avoid aggressive ventilation
  • Using cut off P/F ratio ≤16 for proning
  • Using ‘proning teams’ to manage turning, e.g. by engaging orthopaedic nursing teams

Pulmonary vasodilatation with nitric oxide may provide short-term benefit

  • Using nitric oxide in early stages – it can help but may become refractory after 96 hours

Published findings from the 2004 SARS-CoV infection suggest the potential role of inhaled nitric oxide as a supportive measure for treating infection in patients with pulmonary complications. Treatment with iNO reversed pulmonary hypertension, improved severe hypoxia, and shortened the length of ventilatory support compared with matched control patients with SARS.

A phase 2 study of iNO is underway in patients with COVID-19 with the goal of preventing disease progression in those with severe ARDS. The Society of Critical Care Medicine recommends against the routine use of iNO in patients with COVID-19 pneumonia. Instead, they suggest a trial only in mechanically ventilated patients with severe ARDS and hypoxemia despite other rescue strategies. The cost of iNO is reported as exceeding $100/hour.

Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Critical Care Medicine. March 2020. [Full Text].

Chen L, Liu P, Gao H, Sun B, Chao D, Wang F, et al. Inhalation of nitric oxide in the treatment of severe acute respiratory syndrome: a rescue trial in Beijing. Clin Infect Dis. 2004 Nov 15. 39 (10):1531-5. [Medline].

Nitric Oxide Gas Inhalation for Severe Acute Respiratory Syndrome in COVID-19. ClinicalTrials.gov. Available at https://clinicaltrials.gov/ct2/show/NCT04290871. 2020mar06.

Severe upper airway swelling in some patients may make intubation and extubation difficult

Antibiotic usage should be judicious. There are some reports of subsequent aspergillosis and candida infections.

  • Stopping antibiotics in COVID patients unless clearly indicated, using procalcitonin (PCT) and other inflammatory markers to monitor for bacterial infection and restarting as required*
  • Using procalcitonin as a ‘stop’ signal to guide when to stop antibiotic use**False negative PCTs seem less of an issue than false positives in determining antibiotic use – anecdotally, rising procalcitonin has also been seen in patients without evidence of bacterial infection, perhaps in relation to ‘cytokine storm’, and so a low PCT may be more helpful (true negative) than a high PCT (false positive)

Renal failure, fluid balance and PEEP

Renal failure has been more common in UK cases than anticipated (20-35% of ICU patients). Careful attention to adequate hydration, and use of lower PEEP, may help.

While many experts have been advocating for judicious fluid administration and avoidance of hypervolemia, hypovolemia may contribute to renal failure.


Pain control may help oxygenation in “happy hypoxic” COVID patients

In patients who are hypoxic, dyspneic and who have chest pain, but are not tiring with CO2 in the 20’s, consider pain control with a combination of NSAIDs and acetaminophen and/or low dose ketamine. Anecdotal evidence suggest that adequate pain control may improve oxygenation.


Andrew Morris COVID-19 Update April 12th, 2020

Diagnosis — we still don’t know the sensitivity nor specificity of the PCR test.  There is an emerging challenge around what IS COVID-19 disease:  for example, we are seeing case reports of antiphospholipid antibody syndrome/hyprecoaguability (Zhang Y, Xiao M, Zhang S, Xia P, Cao W, Jiang W, et al. Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19. N Engl J Med. 2020; https://www.sciencedirect.com/science/article/pii/S0049384820301201) and neurological outcomes (Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurology. 2020).  We will continue to see this over time:  everyone will come up with a case series of biochemical abnormalities, GI abnormalities, psychiatric abnormalities, etc.  which are not helpful:  as the disease becomes more prevalent—and as we recognize the phenomenon of asymptomatic disease—one starts to see the challenge of identifying what is baseline presence of difference symptoms/signs/complications, vs. COVID-attributable disease.  Additionally, people will make preventative therapeutic recommendations based on responding to observational data, which is not advisable.

Medical treatment — the real emerging concern is that the public are getting information that (to the uninformed) appears to be encouraging:  great outcomes with patients on HCQ + azithromycin (https://t.co/mTWj6aGpTk?amp=1) or remdesivir (Grein J, Ohmagari N, Shin D, Diaz G, Asperges E, Castagna A, et al. Compassionate Use of Remdesivir for Patients with Severe Covid-19. New England Journal of Medicine. 2020).  But these studies are so flawed as to be useless.  Fortunately, there are numerous clinical trials out there that will help answer some of these questions very quickly, with some results expected in the next 5-10 days!  Unfortunately, almost everyone is studying the same drugs  So we will have wasted tremendous opportunity and research capacity by not considering different paradigms—and so many trials include HCQ, that it may be very difficult to tease out if it even makes a difference.  I hope we get that answer soon.

Prognosis — still very uncertain.  Global fatality rate ~7%, but it is so sensitive to the denominator (i.e. What is a case?) that populations with plenty of screening tests will have a lower case fatality rate than those with lower screening tests.  Additionally, there is emerging information from the UK that getting into the ICU with COVID is pretty bad (https://www.icnarc.org/About/Latest-News/2020/04/10/Report-On-3883-Patients-Critically-Ill-With-Covid-19)  It is always difficult to know if what is going on in a different country or jurisdiction is entirely the same as yours, but I think the UK experience probably translates pretty well to the Canadian experience.  I think the most important figure in the whole document is Figure 9, which shows that there is an early bias favouring mortality (i.e. suggesting high mortality), that diminishes over time, as we see more people surviving longer stays in the ICU.  This is a testimony to good ICU care.  It still ends up with a 50% mortality, though, which ain’t great. I also want to highlight how this comes from a reasonably healthy population.


What is the most appropriate infection control strategy for using ultrasound to minimize the risk of transmission of COVID-19?

Adapted from CJEM ‘Just the Facts’

  • Designate a specific ultrasound machine for suspected COVID-19 patients
  • Handheld ultrasound devices can be completely encased with a probe cover, can be easily cleaned, and do not have a cooling fan
  • Machines with touch screens are preferable to machines with keyboards or buttons
  • Employ single-use gel packets instead of gel bottles
  • The United States Environmental Protection Agency (EPA) updated list of disinfectants for use against COVID-19: https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars- cov-2
  • Health Canada list: https://www.canada.ca/en/health- canada/services/drugs-health-products/disinfectants/covid-19/list.html.

CDC recommended mask repurposing options in COVID-19 era: 4 options

  1. Autoclave – use autoclave pouches labelled by name and unit to place mask into that can be returned to the provider after autoclaved
  2. Sterrad – hydrogen peroxide vapour
  3. UV
  4. Five days in dry paper bag

Domestic abuse rates increasing in COVID-19 era – hypervigilance in the ED required

Domestic violence goes up whenever families spend more time together, such as the Christmas and summer vacations.

The United Nations has recently called  for urgent action to combat the worldwide surge in domestic violence.

Secretary-General’s message on gender-based violence and COVID-19


Lab evaluation considerations in suspected or confirmed COVID-19

  • CBC with differential: WBC usually normal, lymphopenia and mild thrombocytopenia common.
  • Liver enzymes: ALT, AST commonly elevated
  • Coagulation studies: PT/PTT/INR is usually normal on initial presentation; the D-dimer is commonly elevated; the higher the D-dimer, the more likely a DVT/PE.
  • COVID PCR: (RVP if you suspect alternate viral etiology, though coinfection is possible); false-negative COVID testing in up to 10% of cases.
  • Procalcitonin: usually not elevated above 0.5ng/mL in patients with COVID-19; an elevated procalcitonin in the ED should lead you to consider an alternative or additional diagnosis more strongly.
  • CRP: usually elevated in COVID-19 patients; seems to trend upward with the progression of the disease having some prognostic value.
  • LDH and troponin elevation: may be best predictors of mortality

Suggestions for inclusion in ED COVID order set for patients likely to be admitted to hospital

*Consult your local antibiotic biogram for specific antibiotic choices

This order set is based on expert opinion and is for educational purposes only. In clinical practice, follow your hospital-based protocols.

Airborne precautions/Negative pressure room
Droplet precautions

Place surgical mask on patient


COVID + other viral swabs (RSV, influenza)


portable CXR

ECG


Blood work
    • CBC, chem panel
    • Troponin (COVID associated myocarditis and ACS)
    • VBG (consider advanced airway management for rising PCO2 and academia)
    • Lactate (for septic shock; do not attempt to clear the lactate with fluid boluses unless septic shock is suspected)
    • D-dimer (for anticoagulation decision making for admitted patients)
    • Consider LDH, CRP in consultation with admitting team
    • Blood cultures x2 (for suspected bacterial sepsis/septic shock)

Hemodynamics (target euvolemia/slight hypovolemia, avoid excessive fluid resuscitation)
RL 250mL bolus
RL 500mL bolus
IV Norepinephrine 5-10mcg/kg/min if MAP<65, q1h line check for signs of extravasation
Ins & Outs

Antibiotics*
For suspected bacterial pneumonia
Ceftriaxone 1g IV or Clavulin 875mg po
    • MRSA risk (ICU admit, cavitary infiltrates,Empyema): add vancomycin or linezolid
    • Pseudomonas risk (Structurally abnormal lungs / Septic shock / antibiotics for >7 days past month / Hospitalization past 3 months / Immunocompromised / Nursing home resident with poor functional status): piperacillin-tazobactam or miropenem

Oxygenation

NP 6L/min MAXIMUM with surgical mask (target O2 sat 88-92%)
NRB 10L/min MAXIMUM with surgical mask (target O2 sat 88-92%)
Tavish/HiOx NRB 15L/min MAXIMUM; target O2 sat 88-92%
Call RT for HFNC 20-40 with surgical mask; target O2 sat 88-92% ONLY IN NEGATIVE PRESSURE ROOM
Awake proning: patient to change position from supine to prone to lateral decubitus q30 mins; can sit in chair if preferred
Ventolin 100mcg MDI 8 puffs q20 mins x3 then q3–4h
Atrovent 20mcg MDI 4 puffs q20mins x3 then q20 mins prn up to 3 hours

Pain, nausea and anxiety control (may improve oxygenation, avoid opioids whenever possible due to potential respiratory complications)
    • Acetaminphen 1g po
    • Ibuprofen 400mg po
    • Ketorolac 10mg IV
    • Ketamine 0.15mg/kg-0.3mg/kg IV
    • Ativan 1mg IV for anxiety/agitation
    • Ondansetron 8mg SL or IV (avoid in patients taking hydroxychloroquine and other QT prolonging agents)

Consults
ED Palliative consult
ED Medicine/ICU consult

Code Status

ACOG COVID-19 algorithm assessment and management of pregnant patient

pregnancy COVID


A cognitive aid for the pandemic airway: the basics of how to increase safety and team cohesion during intubation, donning, and doffing

By PG Brindley, JM Mosier, CM Hicks

Viruses such as the SARS-CoV-2, which causes covid-19, can be associated with performance-retarding anxiety and information-overload; especially for those performing stressful procedures like intubation, and especially if there are unfamiliar steps. We offer this simple airway-management mnemonic/checklist/cognitive-aid that utilizes the five letters: C.O.V.I.D. Our goal is to allay fears, expedite action, decrease viral spread, and highlight what has changed. This aide-memoire can also be used for future highly infectious aerosol generating viruses, or whenever enhanced PPE is required. After all, we need to protect our staff, as well as patients, now and always; and other infectious pandemics are predicted.

An easy to remember cognitive aid may help because it can enhance shared mental models (especially if personal protective equipment (PPE) impairs communication), maintain cognitive bandwidth (via a common aide-memoire), increase safety (by decreasing time in infected rooms, increasing first-pass success, and optimizing donning and doffing technique) and make it routine to cross-monitor team members using ‘buddy checks’.

Even without COVID-19, airway management is more dangerous and complex when performed away from Operating Rooms, or if it includes unfamiliar staff (1). Cognitive aids with fewer than seven steps, and those that ask questions (i.e. “what will you do, and when”) appear to be superior to those that are long or passive (2). Moreover, checklists should facilitate safe teamwork not just individual taskwork (3).

In the case of highly infectious diseases such as COVID-19, safety requires undoing years of muscle memory (e.g. avoiding bagging, high flows, etc to prevent aerosolization). To date, much of the work on airway management has focused on the anatomical difficult airway, or the physiologically difficult airway (i.e. low blood pressure, right ventricular pathology) (4). While both are important, pandemics require increased attention to situational difficulty (personal fear, situational unfamiliarity) (1-5). Because of the increased need for coordination, role clarity, and shared safety, we offer a 5-step acronym using five unforgettable letters.

Step 1: C-

Coordinate who will do what and when. Perform a pre-brief (3) where roles are assigned before entering the room, and assign “buddies” to check that PPEs offer body coverage

Collect all equipment at bedside, so that you do not have to doff and leave room.

Colleague outside of the room. Available to help if needed and already wearing PPE.

Step 2: O-

Only have three people in the room and use most experienced intubator and techniques that increase first pass success (i.e. full-dose paralysis).

Outside the room until your PPE has been checked by your buddy, and negative pressure turned on (if available).

Obstruct the ETT with a clamp prior to connecting the ventilator

Step 3: V-

Videolaryngoscopy is preferable to decrease intubator’s exposure to aerosols.

Voice communication with those outside the room (activate a microphone or walkie-talkie)

Verify tube placement with ETC02 and that the ETT cuff is inflated before initiating positive pressure breaths.

Step 4: I:

Inflate the endotracheal tube cuff prior to bagging or placement on the ventilator.

Interrupt the circuit as infrequently as possible and only at end expiration.

Insert a supraglottic airway rather than using vigorous bag-mask ventilation.

Step 5: D:

Don and Doff safely (include a buddy check and 15-second hand-washing whenever gloves, gowns or masks are touched).

Double glove (intubator only) and apply sanitizer to outside of soiled gloves before removal.

Don’t leave the room prematurely i.e. before your buddy has given the “okay”.

While this mnemonic has not been tested empirically, it received iterative multi-professional input (MD, RN, RT) and multidisciplinary input (Critical Care, Emergency Medicine, Anesthesia). It was finessed during 10 drafts and over 20 iterative high fidelity mannikin simulations, and until no further changes were requested. It was deemed robust enough to serve throughout the hospital, and to benefit all members of the airway team. It was associated with an increased in subjective team cohesion and interdisciplinary esprit de corps. It was also associated with individual and shared safety: regardless of one’s specialty or role.

Airway COVID acronym

Protected Code Blue in COVID-19 era

Resuscitation Council UK Advanced Life Support for COVID-19 Patients

ILCOR Treatment Recommendations and COVID-19 infection risk to rescuers from patients in cardiac arrest

“We suggest it may be reasonable for healthcare providers to consider defibrillation before donning personal protective equipment for aerosol generating procedures in situations where the provider assesses the benefits may exceed the risks (good practice statement).”

“Given the potential for defibrillation within the first few minutes of cardiac arrest to achieve a sustained return of spontaneous circulation and uncertainty of the likelihood of defibrillation generating an aerosol, we suggest healthcare providers consider the risks versus benefits of attempting defibrillation prior to donning personal protective equipment for aerosol generating procedures.”

“Once [PPE is]donned we identified evidence that there is a risk of mask slippage during chest compression delivery rendering the protective equipment less effective.”

“The practical implementation of these recommendations will require regional and national resuscitation councils to consider the values and preferences of their local communities, the prevalence of disease, availability of PPE, training needs of their workforce and infrastructure / resources to provide on-going care for patients resuscitated from cardiac arrest.”


Other recommended COVID-19 resources

Updated safe first pass protected intubation from George Kovacs AIME

References
  • Cui S, Chen S, Li X, Liu S, Wang F. Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia. J Thromb Haemost. April 2020.
  • Chen J et al. Findings of Acute Pulmonary Embolism in COVID-19 Patients. Lancet 2020.
  • Zhang Y et al. Coagulopathy and Antiphospholipid Antibodies in Patients with COVID-19. NEJM 2020.
  • COVID-19: Attacks the 1-Beta Chain of Hemoglobin and Captures the Porphyrin to Inhibit Human Heme Metabolism. ChemRxiv Preprint 2020.
  • Zhou F et al. Clinical Course and Risk Factors for Mortality of Adult Inpatients with COVID-19 in Wuhan, China: A Retrospective Cohort Study. Lancet 2020.
  • Tang N et al. Anticoagulant Treatment is Associated with Decreased Mortality in Severe Coronavirus Disease 2019 Patients with Coagulopathy. J Thromb Haemost 2020.
  • Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Critical Care Medicine. March 2020.
  • Chen L, Liu P, Gao H, Sun B, Chao D, Wang F, et al. Inhalation of nitric oxide in the treatment of severe acute respiratory syndrome: a rescue trial in Beijing. Clin Infect Dis. 2004 Nov 15. 39 (10):1531-5.
  • The United States Environmental Protection Agency (EPA) updated list of disinfectants for use against COVID-19: https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars- cov-2
  • https://www.canada.ca/en/health- canada/services/drugs-health-products/disinfectants/covid-19/list.html.
This blog post is based on Level C evidence – consensus and expert opinion. Examples of protocols, checklists and algorithms are for educational purposes and require modification for your particular needs as well as approval by your hospital before use in clinical practice.
COVID-19 Update April 5, 20202020-04-12T17:28:28-04:00

This blog post is based on Level C evidence – consensus and expert opinion. Examples of protocols, checklists and algorithms are for educational purposes and require modification for your particular needs as well as approval by your hospital before use in clinical practice.

COVID-19 evolving indications for intubation

Hypoxemia and tachypnea should not be the sole indications for intubation, but rather a complete clinical assessment including work of breathing, mental status and increasing PaCO2 and/or acidosis. Based on experience in NYC, patients who present early in the disease course with oxygen saturations in the 80’s, but who are otherwise clinically well and relatively asymptomatic, do not require intubation. There have been suggestions that these patients may benefit from prone positioning and HFNC (see below). The recommendation early in the COVID pandemic to strongly consider early intubation in all patients with oxygen saturations <90% despite non-invasive oxygenation may not be the best approach.

Suggested stepwise approach to respiratory support for COVID-19

With surgical mask for all steps and negative pressure room for HFNC, CPAP, Endotracheal intubation where possible

Based on ED and ICU experience in New York, Level C evidence

COVID-19 graded respiratory support

Escalation of therapy based on work of breathing, mental status, PaCO2, VBG. Consider intermittent prone positioning.

Webinar on avoiding intubation and initial ventilation in COVID-19 with Scott Weingart

Respiratory support for patients with COVID-19 https://onlinelibrary.wiley.com/doi/pdf/10.1002/emp2.12071

COVID-10 Hypoxemia on REBELEM

Suggested oxygenation strategies algorithm AIME

Oxygenation Strategies COVID

AIME Oxygenation Strategies COVID by George Kovacs & Adam Law

aerolization dispersion

From https://onlinelibrary.wiley.com/doi/pdf/10.1002/emp2.12071

HFNC COVID

By Lauren Westafer, FOAMcast

Prone position ventilation

Proposed mechanisms for prone positioning

  • Induces homogeneous compliance across the chest wall – Anterior chest wall – Weight of mediastinum – Improved displacement of abdomen contents
  • Better recruitment of posterior/dependent lung zone
  • May lead to an alteration of blood flow and better ventilation/perfusion matching
  • Improved drainage effect on respiratory secretions
  • Reducing ventral-dorsal transpulmonary pressure difference
  • Reduced lung compression
  • Improved lung perfusion

Consistently, most trials demonstrate improved oxygenation with ventilation in the prone position. One randomized trial and several meta-analyses also suggest a mortality benefit in those with severe ARDS. Trials have consistently shown that in most patients with ARDS (up to 70 percent), prone ventilation increases PaO2 allowing a reduction in the FiO2. Most patients who demonstrate a response do so within the first hour but delayed responses beyond that have been observed. The PROSEVA trial and several meta-analyses have reported mortality benefits from early, high-dose prone ventilation in patients with severe ARDS (defined by them as PaO2:FiO2 <150 mmHg). There is no evidence that prone ventilation prevents organ system dysfunction and reduces the intensive care unit (ICU) length of stay.

Sun, Qin, et al. “Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province.” Annals of Intensive Care 10.1 (2020): 1-4.


Restrictive fluid strategy for COVID-19 patients with respiratory failure

  • Aggressive fluid resuscitation should generally be avoided in COVID-19 patients
  • COVID-19 patients seem to be very sensitive to fluid overload similar to HAPE patients.
  • Consider norepinephrine at 5-10mcg/kg/min rather than a fluid bolus to maintain MAP>65
  • For hypovolemic patients give small crystalloid bolus (250cL) and reassess volume status frequently
  • Avoid fluid resuscitation to clear the lactate in euvolemic patients, as the high lactate is more likely a result of the catecholamine surge associated with severe hypoxemia and respiratory distress, than hypovolemia

Video for procedure of prone positioning https://www.nejm.org/doi/full/10.1056/NEJMoa1214103

Webinar on avoiding intubation and initial ventilation in COVID-19 with Scott Weingart

Respiratory support for patients with COVID-19 https://onlinelibrary.wiley.com/doi/pdf/10.1002/emp2.12071

COVID-10 Hypoxemia on REBELEM

Updated video on intubation tips and nuances using hyperangulated VL with George Kovacs


Sarah Reid’s take home points on COVID pediatric considerations

https://emergencymedicinecases.com/wp-content/uploads/2020/04/COVID-pediatric-considerations.pdf

Andrew Morris updates

1.  Early experience with serum therapy looks promising.
2.  COVID Rheumatolgy registry shows patients who are chronically on hydroxychloroquine are still at risk of infection and death.
3.  We still don’t know “real” ICU mortality—because the various experiences are … varied.  China:  lots of non-vented patients.  Italy: catastrophic scenario.  England:  right-censoring of data means that they excluded patients on a vent for longer than usual.  For all: unclear about no. taken off vent for palliative or even rationing.
4.  Transmission routes –  Looks like pseudo-droplet spread in some manner.  Also looks like “infected” can reduce spread by surgical mask—which justifies asymptomatic population wearing masks to protect infecting others.  We don’t know if it will reduce acquisition.  The difference between public masking to reduce spread vs. reducing acquisition is an important one. Probably what motivates most people is not getting infected, but we don’t have great evidence masking will do that, and it probably de-emphasizes hand hygiene.
5. COVID-19 therapies – we are still lacking helpful information on pretty well anything.  More and more case series with different treatments.  None of them game-changing yet. Paper out of Australia suggests that ivermectin is theoretically effective against COVID-19 – jury is still totally out on that one, too. Read the full paper in Antiviral Research titled: The FDA-approved Drug Ivermectin inhibits the replication of SARS-CoV-2 in vitro: https://www.sciencedirect.com/science/article/pii/S0166354220302011

CAEP suggested ED discharge criteria (based on Level C evidence)

1. Has access to food, water, communications, safe shelter
2. Is at baseline level of function
3. O2 saturation >94% on RA
4. RR<20, HR<110, BP at baseline or expected for age/sex
5. Does not appear clinically decompensated
6. Walk test: can walk 30 meters with <10% drop in O2 saturation (even if CXR or POCUS +ive)
Consider discharge advice for patient to perform walk test at home (ideally with O2 sat probe) and return to ED if O2sat<95%

From: https://caep.ca/wp-content/uploads/2020/04/Complete-COVID-AdmissionVentilation-Decision-Tree-Formatted-1.pdf


Do you need an N95 mask when performing an NP swab for COVID-19?

Use of N95 mask is not warranted for NP/OP swab

  • There is no evidence that cough generated with NP/OP swab procedure leads to increased risk of transmission via aerosols.
  • HCW conducting this procedure should do so in a separate/isolation room, be well trained in the procedure, wear droplet precaution PPE, and request the patients to cover their mouth with a medical mask or tissue during NP swab.

From http://emergentc.ca/index.php/2020/03/30/summary-of-evidence-and-guidelines-for-the-use-of-n95-masks/#_ftn2


COVID-19 pathophysiology and clinical features similar to HAPE: Should we consider HAPE treatments for COVID-19 patients?

High Altitude Pulmonary Edema (HAPE) and COVID-19 have many similarities:

  • Decreased ratio of arterial oxygen partial pressure to fractional inspired oxygen with concomitant hypoxia and tachypnea
  • Tendency for low CO2 levels
  • CT findings of ground glass opacities and patchy infiltrates
  • Elevated fibrinogen levels which are likely an epiphenomenon of edema formation rather than coagulation activation
  • Bilateral diffuse alveolar damage associated with pulmonary edema, pro-inflammatory concentrates
  • Lead to ARDS

There has been a suggestion to study the efficacy of proven therapies for HAPE in COVID-19 patients such as acetazolamide, nifedpine and phosphodiesterase inhibitors.

Solaimanzadeh I. Acetazolamide, Nifedipine and Phosphodiesterase Inhibitors: Rationale for Their Utilization as Adjunctive Countermeasures in the Treatment of Coronavirus Disease 2019 (COVID-19). Cureus. 2020;12(3):e7343.


COVID-19 protected code blue

Excellent overview: Protected Code Blue https://rebelem.com/covid-19-protected-code-blue/

Reuben Strayer’s video on protected transfer of cardiac arrest patient from EMS to resuscitation room


ED separation of COVID/Non-COVID is critical 

Completely separate
Separate entrance, exit; NO CROSSING between, fully independent of each other.
One way path through enter-assess/treat-out a different way (where possible)
Separate staff
Assign high risk staff (age, co-morbidities) to Non-COVID side. Even if an asymptomatic COVID patient comes there, the viral load will be lower, less change of transmission to others.
Whether you are in the COVID or non-COVID areas all staff and patients get surgical masks, social distancing and isolation where possible still applies.
Telemedicine
Triage as COVID and non-COVID.

COVID-19 Lab Prognostication

Lab prognostic odds ratios mortality COVID

From MDCalc


Quote of the week

There are times when you can beckon,
There are times when you must call.
You can take a lot of reckoning,
But you can’t take it all.

There are times when I can help you out,
And times when you must fall.
There are times when you must live in doubt
And I can’t help at all.

Three blue stars rise on the hill
Sing no more now just be still
All these trials soon be past
Look for something built to last.

Built to last till time itself falls tumbling from the wall
Built to last till sunshine fails and darkness moves on all
Built to last while years roll past like cloudscapes in the sky
Show me something built to last or something built to try

-Jerry Garcia/Robert Hunter

This blog post is based on Level C evidence – consensus and expert opinion. Examples of protocols, checklists and algorithms are for educational purposes and require modification for your particular needs as well as approval by your hospital before use in clinical practice.

COVID-19 Update March 29, 20202020-04-12T17:29:06-04:00

High Flow Nasal Cannula (HFNC) to prevent intubation in COVID patients with respiratory failure?

High Flow Nasal Cannula (HFNC), (set at lowest flow to maintain adequate oxygen starutation), while thought to aerosolize virus particles, are being used in the US in patients with COVID-19 who cannot maintain oxygen saturations ≥90% with a NRB, and are included as weak recommendations in the WHO guidelines as well as the Surviving Sepsis Guidelines (our quick summary of surviving sepsis guidelines).

Here are some ideas on how to use High Flow Nasal Cannula (i.e. optiflow, airvo, etc) safely, that we’d like community feedback on:

What about  using a NRB mask over HFNC AND putting suction on the port you would normally put the 02 tubing? Any virus suctioned out will get trapped in suction bag for disposal.

What about combining a BiPAP Mask, feeding the HFNC through the 02 entry and  then adapting the suction from an ordinary vacuum with a HEPA filter to the exhalation port?

For more on innovative ideas for provider safety: Stanford Medicine Anesthesia Informatics & Media Lab https://m.box.com/shared_item/https%3A%2F%2Fstanfordmedicine.box.com%2Fv%2Fcovid19-PPE-1-1

VE grip with aggressive jaw thrust for BVM

We know that BVM can aerosolize virus particles, especially when bagging (which is generally not recommended in the COVID era), however BVM (as reviewed in Episode 140 COVID Part 4 Protected Intubation) is recommended as an option for pre-oxygenation and re-oxygenation after a failed first attempt. A key aspect of the technique to minimize the chances of aerosolization is the type of grip. The “CE” grip is the one handed grip which is not recommended and the “VE” 2-handed grip (with aggressive jaw thrust and the thenar eminences almost touching) is recommended (see image). Note that the majority of the force should up from the fingers directly up towards the provider (as apposed to pushing down with the thumbs)

VE grip BVM

Left: “CE” one handed grip not recommended. Right” 2 handed “VE” grip with thenar eminences almost touching is recommended for BVM in the protected RSI

Convalescent Plasma for critically ill patients with COVID-19?

In a tiny uncontrolled study in JAMA of only 5 critically ill vented patients with COVID-19 they transfused 400mL of ABO compatible plasma from patients who recovered from COVID-19 and found that at 12-14 days, they had lower SOFA scores, increased PaO2/FiO2 ratio, 3 out of 5 patients were extubated and 4 out 5 patients’ ARDS resolved. Certainly not ready for prime time and further study is needed, but keep your eyes open for further developments.  Thanks to FOAMcast for the heads up on this one.

False negative rate of nasopharyngeal swabs

We still have zero reliable information on false-negative rate of nasopharyngeal swabs.  We will know once we pair it with serological testing, or have some other comparator.  As the prevalence and incidence of disease rises, the negative predictive value of a negative test will decline, so we will be jumping to just treating everyone as COVID+, test + or not.

Best predictors of survival in patients with COVID-19

We are learning increasingly that Case Fatality Rate is impossible to pinpoint, but as the disease rolls through the world, the best predictors of survival are
a) comorbidity
b) age
c) if your healthcare system is overwhelmed or not

Shorter shifts…or at least breaks?

Health care workers can and will catch SARS Co V2 in the community, but the risk is always greater where the viral load  is higher and duration of exposure is longer (on shift).
The Chinese Manual on COVID 19 Prevention and Treatment has many levels of HCW protection, including 4 hour shifts for people working in dedicated COVID 19 areas.
They have the manpower to do this. Many EDs don’t, but perhaps we could up-staff and schedule shift breaks?

Suggested algorithm for triaging patients in the COVID era

From CAEP ED flow in the era of COVID-19
First triage into stay or go
Second triage into respiratory or not
  •  First and second triage are decision points (not separate areas or people); define criteria for discharge ahead of time
Scaleable dirty and clean zones
  • Clean area must be able to accommodate all levels of care (monitors, lab, procedures), and patients should all be masked
Defined triggers to scale up and down
Care protocols (delegated tasks)

Are young people COVID-19 at risk for severe morbidity/mortality?

CDC data suggests that patients 20-44 years of age are not as immune to significant disease as previously reported and have up to a 20% hospitalization rate and comprise 12% ICU admissions. While mortality increases with age, among adults aged 20–64 years mortality is as high as 20% of hospital admission.  However, children aged < 19 years generally have a good prognosis. 

Coronavirus disease 2019 (COVID-19) hospitalizations,* intensive care unit (ICU) admissions, and deaths,§ by age group — United States, February 12– March 16, 2020

The figure is a bar chart showing the number of coronavirus disease 2019 (COVID-19) hospitalizations, intensive care unit admissions, and deaths, by age group, in the United States during February 12– March 16, 2020.

End of life care for COVID-19 patients

Infographic from EM Ottawa Blog

Original article from CJEM https://caep.ca/wp-content/uploads/2020/03/EOL-in-COVID19-v5.pdf

End of life care COVID

Contributors to this COVID update: Daniel Kollek, Laurie Mazurik, Andrew Morris, Anton Helman
This blog post is based on Level C evidence – consensus and expert opinion. Examples of protocols, checklists and algorithms are for educational purposes and require modification for your particular needs as well as approval by your hospital before use in clinical practice.
COVID-19 Update March 23, 20202020-04-05T23:05:54-04:00

Clinical COVID-19 update by Andrew Morris

  1. Diagnosis hasn’t changed substantially, other than recognizing that a) travel history is now totally irrelevant, and b) we anticipate nosocomial spread to arrive soon in Canada, so should consider COVID infection in hospital-acquired illness.
  2. We are starting to see new tests get up and running.  Overall, this will help us, but it makes understanding sensitivity and specificity very challenging—it is something that will need to be addressed over time.
  3. Anosmia is common in upper respiratory tract infections.  Data is limited and is almost certainly not the real deal.  Let’s wait and see.
  4. The evidence for all the various empiric therapies is very poor:  HCQ study was of poor quality, a small number of patients, and comparators were uncontrolled.  If this were anything but COVID, we would think it was Gwyneth Paltrow recommending.  We have ZERO data on remdesivir (which has temporarily become unavailable except for children and pregnant women).  Tocilizumab has a retrospective case series of 21 patients who seemed to respond miraculously well. And the lopinavir-ritonavir trial was a mixed bag—no clinical improvement or virological improvement, but mortality seemed lower (with a VERY WIDE confidence interval).
  5. There is lots of talk about increased mortality with high BMIs, but the quality of evidence is sorely lacking at present.

Global online meeting 5pm MST Wednesday 25 March 2020

Led by The International Federation for Emergency Medicine

This meeting will be held using Zoom. To join the meeting please click this link: //zoom.us/j/855206316.

If you’re having trouble you can also dial into the meeting. A list of international numbers is available here: //zoom.us/u/adsfME57JG. Webinar ID: 855 206 316

Topics covered will range from PPE preservation, ED design strategies, advocacy opportunities and caregiver well-being and psychological support.

This will be an interactive meeting including a live chat-box mediated Q & A.

This blog post is based on Level C evidence – consensus and expert opinion. Examples of protocols, checklists and algorithms are for educational purposes and require modification for your particular needs as well as approval by your hospital before use in clinical practice.

COVID Surviving Sepsis Guidelines Summary2020-03-31T08:15:44-04:00

Surviving Sepsis Campaign­­ Guidelines on COVID-19­ (Published March 20, 2020)

Summary for EM Cases
Prepared by Winny Li

Summary of 54 statements on: 1) Infection control, 2) Lab diagnosis and specimens, 3) hemodynamic support, 4) ventilatory support, 5) COVID-19 therapy

  • 4 best practice statements
  • 9 strong recommendations
  • 35 weak recommendations
  • 6 no recommendations

Full summary can be found: https://www.esicm.org/ssc-covid19-guidelines/

COVID surviving sepsis

COVID surviving sepsis 2

COVID surviving sepsis 3

Summary of recommendations on hemodynamic and pharmacologic therapy in patients with COVID-19

HFNC and NIPPV COVIDCOVID do and dont ARDS

COVID Series Podcasts & Show Notes2020-04-07T14:41:04-04:00
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