Podcast production, editing and sound design by Anton Helman
Podcast content, written summary & blog post by Andrew Petrosoniak, Brit Long and Anton Helman
Cite this podcast as: Helman, A. Swaminathan, A. Klaiman, M. Sommer, L. Long, B. Gottlieb, M. Petrosoniak, A. EM Quick Hits 16 – COVID-19 – Oxygenation Strategies, Trauma Care, Addictions Considerations, Cardiovascular Complications & Compassionate Care. Emergency Medicine Cases. April, 2020. https://emergencymedicinecases.com/em-quick-hits-covid-19-oxygenation-trauma-addictions-cardiovascular-complications/. Accessed [date].
This blog post and podcast are 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.
This podcast was recorded in early April, 2020 and the information within is accurate up to this date only, as the COVID pandemic evolves and new data emerges. The blog post will be updated regularly and we are working on a weekly update via the EM Cases Newsletter which will be replicated on the EM Cases website under ‘COVID-19’ in the navigation bar.
Oxygenation strategies for COVID-19: New York City experience
There appears to be three phenotypes of COVID-19 patients:
The well COVID-19 patient – URI/flu-like illness +/- abnormal CXR, but normal/near normal vital signs
“Happy hypoxic” – relatively asymptomatic and appearing comfortable but oxygen saturation <90% despite 5-6L NP and 15L NRB, consider HFNC with covering surgical mask or CPAP in negative pressure room, both of which may prevent the need for intubation
Respiratory failure – severe hypoxia and tachypnea who appear to be tiring; consider early intubation and preoxygenation with CPAP or gentle controlled BVM 2 person (6-10 breaths/min)
Awake proning in the ED for “Happy Hypoxic” COVID-19 patients
For patients requiring NP and/or NRB oxygenation simply instruct patient to roll over into the prone position taking care not to disturb their IV or NP/NRB, wait a few minutes and assess their oxygenation and subjective symptoms; if either improve, remain prone – if not, return to supine position.
Proning may be beneficial to those COVID-19 patients on HFNC, CPAP or intubated, however this requires trained providers and is better suited for the ICU where they have experience proning patients.
Update 2021: Randomized, open-label clinical trial assessing high-flow oxygen nasal cannula versus conventional supplemental oxygen in ED’s and ICU’s across 3 hospitals in Colombia, including 220 patients with respiratory distress due to severe COVID-19 (PaO2/FiO2 <200). At the end of 28 days, found that the high-flow oxygen group displayed a significantly decreased need for intubation and was more likely to sustain clinical recovery. Abstract
Tips on trauma care in the COVID era
Streamline your trauma teams with an active and stand-by team
Integrate an infectious screen that is prompted during your team pre-brief
Use FAST exams only when it will change your management
Procedures like chest tubes might be aerosol generating while EDT should really be restricted to penetrating chest trauma with signs of life
Liberal use of CT scans might help you discharge those patients that you otherwise would admit for observation
Cardiovascular complications of COVID-19: Myocarditis vs ACS, CHF and dysrhythmias
Myocarditis: Up to one third of patients have troponin elevation in severe COVID-19. While this might be due to demand ischemia, there is evidence suggesting that certain patients also develop acute myocarditis due to direct infiltration by the virus. Studies have suggested a 5 to 10-fold higher mortality rate among COVID patients who have troponin elevations. Myocarditis can overlap with ACS.
ACS: Systemic inflammation increases risk of atherosclerotic plaque disruption, increases demand on the heart, and reduces oxygen supply. There’s a 6 fold increase in rates of acute MI within 7 days after diagnosis of influenza in hospitalized patients, which may occur in other infections too. Differentiating myocarditis and ACS is tough; obtain an echo and speak with cardiology. For those with STEMI, as per the ACC, fibrinolysis “may be considered” in those who are “relatively stable”, but they acknowledge that PCI is more commonly performed in most centers.
Heart Failure: Acute heart failure may be part of the initial presentation in one-quarter of patients and is associated with increased mortality.
Dysrhythmias: Palpitations may be a presenting symptom in over 7%. There is a wide range of dysrhythmias in patients with COVID-19 infection. Sinus tachycardia is the most common, but ventricular dysrhythmias can occur. Keep in mind that hydroxychloroquine, chloroquine, and azithromycin prolong the QT.
Offer patients to video-chat with their loved ones before intubation if time permits, as it might be the last chance they get.
Organizations supporting people in need during the COVID-19 crisis for consideration of donation
Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.