Special edition EM Quick Hits podcast on COVID-19 #2: Practical Tips, Pediatric COVID and Human Factors

Drs. Sara Gray, Emily Austin, Chris Keefer, Justin Morgenstern, Sarah Reid, Chris Hicks, Peter Brindley and Andrew Cameron share their experience with the COVID-19 pandemic and offer some practical tips.

Podcast production, editing and sound design by Anton Helman

Written summary & blog post by Anton Helman, April 2020

Cite this podcast as: Helman A. Gray, S. Austin, E. Keefer, C. Morgenstern, J. Reid, S. Hicks, C. Brindley, P. Cameron, A. EM Quick Hits 15 – COVID-19 Practical Tips, Pediatric COVID and Human Factors. Emergency Medicine Cases. April, 2020. https://emergencymedicinecases.com/em-quick-hits-covid-19-more-experiences-practical-tips/Accessed [date].

This podcast was recorded in late March, 2020 and the information within is accurate up to this date only, as the COVID pandemic evolves and new data emerges. 

COVID weekly updates via the EM Cases Newsletter and on the EM Cases website under ‘COVID-19’ in the navigation bar.

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

Practical tips on managing yourself, your team and your patients in the COVID-19 pandemic

Sara Gray’s 4 step COVID wellness program

  1. Normalizing: Know that your stress, anxiety and fear is normal
  2. Remember that you’re not alone; we’re all in this together – stay connected
  3. Make a happy list – a list of activities that brings you joy or comfort or peace or are refreshing including a) physical activity, b) mindfulness, c) emotional wellness
  4. Make your strategies explicit by making a schedule, tell other people about your happy list

EM Cases Episode 103 Preventing Burnout & Promoting Wellness in EM with Sara Gray

Beware of anchoring bias in the COVID era

Not every patient who presents with fever has COVID, and even those with documented COVID and get sick with another diagnosis. Keep your differential diagnosis wide as you would before the COVID era so that you don’t miss alternate important life or limb threatening diagnoses. Keep your eye out for the many diagnoses that could be masquerading as COVID-19.

Time management tips during the COVID era

  1. Limit yourself to one hour per day (with a timer set) to learn about COVID-19 using the time in a structured, deliberate and purposeful way.
  2. Choose your top 6 sources for COVID-19 information and stick with them, which can be divided into direct (correstpondance from hospital), text-based (e.g. up to date, quickicutraining.com), audio source, social media source (Forbes’ currated list of COVID experts to follow on Twitter), big picture source.
  3. Mute the noise! Use ‘do not disturb’ mode on your iphone or zenmode for android phones.

To stay connected with the medical community during COVID and find the best COVID hacks in real time try the free app developed by Andrew Cameron https://pandemos.care/

Pediatric COVID management considerations (March 30th, 2020)

  • Disease severity is low in children compared to adults perhaps due to lack of the ACE-2 receptor and/or a decreased immune response resulting in respiratory failure, however there are case reports of pediatric deaths and ARDS-like respiratory failure in teenagers
  •  There is no evidence that COVID-19 causes croup, bronchiolitis or asthma exacerbations in children
  • For these illnesses, in general, minimize nebulized treatments while maintaining standard of care
  • Data from China suggests that 10-30% of pediatric COVID-19 patients present with GI symptoms, a higher percentage than adults
  • Both ibuprofen and acetaminophen have been endorsed by the Canadian Pediatric Society for fever in children with COVID-19
  • Don’t forget to screen the parents as well as the pediatric patient!
  • Vertical transmission of COVID-19 has occurred in newborns (3/33 newborns to COVID+ mothers according to JAMA pediatrics study)

Bronchiolitis – our expert recommends avoiding nebulized epinephrine for bronchiolitis at present, maintaining current guidelines on discharge criteria (e.g. O2sat≥90%, feeding well, hydration status normal)

Croup – our expert recommends administering nebulized epinephrine with full airborne precautions for children with croup who present with stridor; there is no evidence for IM epinephrine in croup; epinephrine MDIs are available on special release in some jurisdictions and would be preferable to nebulized epinephrine. Health Canada will likely not be approving epinephrine MDIs.

Asthma – our expert recommends the use of MDIs for every asthma patient which has shown to be as effective as nebulized treatment

Ventilatory support – most children who require ventilatory support at present require it for reasons other than COVID-19, therefore there is no recommendation for “early intubation” in children as some experts have recommended for adult patients, however for teenagers, adult guidelines should be followed; in smaller children we need to balance the risk of generating aerosolized virus from intubation or CPAP with patient harm caused by inappropriate intubation of children with asthma or bronchiolitis.

EM Deliberate Practice Airway Safety Course in the COVID era

EM Deliberate Practice Free Airway Safety Training Course Materials

Curriculum pdf

Instructor’s Notes pdf

Site Director Logistics pdf

Scheduler pfd

Human Factors and A Pandemic Airway Checklist in the COVID era

Airway COVID acronym

Adapted from “A pandemic airway checklist: the basics of how to potentially increase safety during intubation, donning, and doffing” by Brindley, P, Mosier, J and Hick, C.

Protected intubation pre-brief

Example of pre-resuscitation checklist in the COVID era adapted from St. Michael’s hospital (for educational purposes only)

Post intubation departure checklist COVID

Example of post-resuscitation/pre-departure checklist adapted from St. Michael’s hospital (for educational purposes only)

Adapted from Reid C, Brindley P, Hicks C, et al. Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med. 2018;5(3):139-143.

References and Resources

  1. EM Cases Episode 103 Preventing Burnout & Promoting Wellness in EM with Sara Gray
  2. Zeng L, Xia S, Yuan W, et al. Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. JAMA Pediatr. 2020.
  3. https://dontforgetthebubbles.com/evidence-summary-paediatric-covid-19-literature/
  4. https://trekk.ca/system/assets/assets/attachments/467/original/2020-04-01_COVID_Quick_Facts_v_1.1.pdf?1585776103
  5. https://www.cps.ca/en/documents/position/can-nsaids-be-used-in-children-when-covid-19-is-suspected
  6. Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: A retrospective review of medical records. Lancet 2020;319(10226):809-15.
  7. Reid C, Brindley P, Hicks C, et al. Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med. 2018;5(3):139-143.
  8. Brindley, P, Mosier, J and Hick, C. A pandemic airway checklist: the basics of how to potentially increase safety during intubation, donning, and doffing. In print, 2020.
  9. Coronavirus Tips and Guidelines. Canadian Anesthesiologists Society. https://www.cas.ca/en/practice-resources/news/cas-articles/2020/coronavirus-tips-and-guidelines
  10. https://nationalpost.com/opinion/life-in-the-trenches-an-edmonton-icu-doctor-describes-the-war-against-covid-19
  11. https://blogs.bmj.com/bmj/2020/03/16/peter-brindley-this-is-a-chance-to-remember-that-the-team-matters-not-just-our-personal-success/
  12. https://codachange.org/covid-19/
  13. https://www.cas.ca/en/practice-resources/news/cas-articles/2020/coronavirus-tips-and-guidelines
  14. https://www.chapters.indigo.ca/en-ca/books/peak-performance-under-pressure-lessons/9781859598566-item.html

“When I was a boy and I would see scary things in the news, my mother would say to me, ‘Look for the helpers. You will always find people who are helping.'” – Fred Rogers

None of the authors have any conflicts of interest to declare