COVID-19 Update May 26

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 [...]

By |2020-05-26T11:35:17-04:00May 26th, 2020|Categories: |0 Comments

COVID-19 Update May 3, 2020

Remdesivir for treatment of COVID-19 by Andrew Morris This week saw 3 trial results “announced”.  One is the Lancet trial 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. [...]

By |2020-05-20T11:47:49-04:00May 4th, 2020|Categories: |0 Comments

COVID-19 Update April 26, 2020

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 [...]

By |2020-04-27T12:48:12-04:00April 27th, 2020|Categories: |0 Comments

COVID-19 Update Apr 19, 2020

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. J Am Coll Cardiol. 2020 Apr 17. 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 [...]

By |2020-04-21T11:12:55-04:00April 19th, 2020|Categories: |0 Comments

COVID-19 Update April 12, 2020

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 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 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 [...]

By |2020-04-12T17:28:50-04:00April 12th, 2020|Categories: |0 Comments

COVID-19 Update April 5, 2020

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 Escalation of therapy based on [...]

By |2020-04-12T17:28:28-04:00April 5th, 2020|Categories: |1 Comment

COVID-19 Update March 29, 2020

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 VE grip with aggressive jaw thrust for BVM We know that BVM can aerosolize virus particles, [...]

By |2020-04-12T17:29:06-04:00March 29th, 2020|Categories: |1 Comment

COVID-19 Update March 23, 2020

Clinical COVID-19 update by Andrew Morris 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. 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. Anosmia is common in upper respiratory tract infections.  Data is limited and is almost certainly not the real deal.  Let’s wait and see. 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). There is [...]

By |2020-04-05T23:05:54-04:00March 23rd, 2020|Categories: |0 Comments

COVID Surviving Sepsis Guidelines Summary

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

By |2020-03-31T08:15:44-04:00March 31st, 2020|Categories: |0 Comments

COVID Series Podcasts & Show Notes

Part 5: Epidemiology & Prediction Models Part 4: Protected Intubation Part 3: PPE: What You Need to Know & Conservation Strategies Part 2: Surge Capacity Strategies Part 1: Screening, Diagnosis & Management Quick Hits 14: You Colleagues Experiences & Tips 1 Quick Hits 15: Practical Tips, Pediatric Management & Human Factors Quick Hits 16: Oxygenation strategies, Trauma Modifications, Addictions Considerations, Cardiac Complications & Compassionate Care

By |2020-04-07T14:41:04-04:00March 31st, 2020|Categories: |0 Comments