ED Muskoka Physicians - Living the Dream

COVID 19

I thought this might be a good time to review COVID 19 and coronaviruses.

Intro:

Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV)A novel coronavirus (nCoV) is a new strain that has not been previously identified in humans.  

Coronaviruses are zoonotic, meaning they are transmitted between animals and people.   SARS-CoV was transmitted from civet cats to humans and MERS-CoV from dromedary camels to humans. Several known coronaviruses are circulating in animals that have not yet infected humans. 

Best preventative strategies are: WASH YOUR HANDS; stay 1-3m away from people in social situations; cover your mouth with your elbow if you cough or sneeze; avoid touching your face,nose or eyes. Avoid close contact with people who are sick; stay home when you are sick; and clean and disinfect frequently touched objects and surfaces. Coronavirus is spread by DROPLET transmission and these steps above minimize exposure to droplets.

What about masks?

  • If you are healthy, you only need to wear a mask if you are taking care of a person with suspected 2019-nCoV infection.
  • Wear a mask if you are coughing or sneezing.
  • Masks are effective only when used in combination with frequent hand-cleaning with alcohol-based hand rub or soap and water.

What about Canada? To date there are 77 confirmed cases in Canada, 34 in Ontario. That number will go up.

How infectious is COVID 19?

It looks like it is more infectious that influenza. The R0 is a measure of how readily a virus is transmitted. The R0 for influenza ia 1-2-1.4 and the estimates for COVID 19 are around 3. This means for every one person infected they will pass it along to three other people.

What is the case fatality rate of COVID 19?

This is a moving target. Early in the outbreak when only the sickest patients were being identified, the case fatality rate (CFR) was over 10%. That number is steadily decreasing as more cases are being diagnosed and more testing is being done. The denominator now will include the MANY people who have mild symptoms. Still, the most current estimates have the CFR at 2-3%. A study in the NEJM had the mortality rate estimated at 1.4%. Some areas are reporting mortality rates of less than 1%. We won’t know for a while longer the best estimate for mortality rate but for now it looks to be more serious than seasonal influenza. On average seasonal influenza has a mortality rate of about 0.1%.

Your age matters when estimating mortality rate!

Under the age of 40, the death rate so far is only 0.2%; 0.4% for ages 40-49; 1.3% for 50-59, 3.6% for 60-69; 8% for 70-79 and 15% for 80-89.

Comorbidities Matter:

Death rate higher if you have cardiovascular disease (10.5%), respiratory disease (6.3%) , diabetes (7.3%), hypertension (6%) or cancer (5.6%). The death rate fwith no known conditions is aorund 0.9% currently.

What is the clinical spectrum of the disease?

So far, it seems that fever, dry cough and dyspnea are the commonest symptoms. However, influenza-type symptoms including sore throat, headache and myalgia have also been described in some). So far, about 80% of cases have been classified as mild, 14% severe (dyspnea, pneumonia) and 5% critical (respiratory failure, septic shock, and/or multiple organ dysfunction/failure). Sympotms can atake up to 14 days after exposure to develop.

What should you do if you see a patient with severe acute respiratory illness (SARI) and possible exposure to COVID 19?

Take precautions mentioned previously. Mask on patient. Mask on providers. Gown and eye protection on provider.

Early supportive therapy and monitoring. Give supplemental oxygen therapy immediately to patients with SARI and respiratory distress, hypoxia, or shock.

Use contact precautions when handling contaminated oxygen interfaces of patients with nCoV infection.

Use conservative fluid management in patients with SARI when there is no evidence of shock. Remarks: Patients with SARI should be treated cautiously with intravenous fluids, because aggressive fluid resuscitation may worsen oxygenation, especially in settings where there is limited availability of mechanical ventilation.

Give empiric antimicrobials to treat all likely pathogens causing SARI. Give antimicrobials within one hour of initial patient assessment for patients with sepsis. Although the patient may be suspected to have nCoV, administer appropriate empiric antimicrobials within ONE hour of identification of sepsis. Empiric antibiotic treatment should be based on the clinical diagnosis (community-acquired pneumonia, health care-associated pneumonia [if infection was acquired in healthcare setting], or sepsis), local epidemiology and susceptibility data, and treatment guidelines. Empiric therapy should be de-escalated on the basis of microbiology results and clinical judgment.

Do not routinely give systemic corticosteroids for treatment of viral pneumonia or ARDS outside of clinical trials unless they are indicated for another reason. A systematic review of observational studies of corticosteroids administered to patients with SARS reported no survival benefit and possible harms (avascular necrosis, psychosis, diabetes, and delayed viral clearance). A systematic review of observational studies in influenza found a higher risk of mortality and secondary infections with corticosteroids; the evidence was judged as very low to low quality due to confounding by indication. A subsequent study that addressed this limitation by adjusting for time-varying confounders found no effect on mortality. Finally, a recent study of patients receiving corticosteroids for MERS used a similar statistical approach and found no effect of corticosteroids on mortality but delayed lower respiratory Clinical management of severe acute respiratory infection when Novel coronavirus (2019-nCoV) infection is suspected:

Application of timely, effective, and safe supportive therapies is the cornerstone of therapy for patients that develop severe manifestations of 2019-nCoV. Understand the patient’s co-morbid condition(s) to tailor the management of critical illness and appreciate the prognosis. Communicate early with patient and family.

References

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Effect of high-flow nasal cannula oxygen therapy in adults with acute hypoxemic respiratory failure: a metaanalysis of randomized controlled trials. CMAJ 2017;189:E260-E7. 25. Lee MK, Choi J, Park B, et al. High flow nasal cannulae oxygen therapy in acute-moderate hypercapnic respiratory failure. Clin Respir J 2018;12:2046-56. 26. Luo Y, Ou R, Ling Y, Qin T. The therapeutic effect of high flow nasal cannula oxygen therapy for the first imported case of Middle East respiratory syndrome to China [Chinese]. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2015;27:841-4. Clinical management of severe acute respiratory infection when Novel coronavirus (2019-nCoV) infection is suspected: Interim Guidance 10 27. Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017;50. 28. Arabi YM, Arifi AA, Balkhy HH, et al. Clinical course and outcomes of critically ill patients with Middle East respiratory syndrome coronavirus infection. Ann Intern Med 2014;160:389-97. 29. Leung CCH, Joynt GM, Gomersall CD, et al. Comparison of high-flow nasal cannula versus oxygen face mask for environmental bacterial contamination in critically ill pneumonia patients: a randomized controlled crossover trial. J Hosp Infect 2019;101:84-7. 30. Hui DS, Chow BK, Lo T, et al. Exhaled air dispersion during high-flow nasal cannula therapy versus CPAP via different masks. Eur Respir J 2019;53. 31. Hui DS, Chow BK, Lo T, et al. Exhaled air dispersion during noninvasive ventilation via helmets and a total facemask. Chest 2015;147:1336-43. 32. Detsky ME, Jivraj N, Adhikari NK, et al. Will This Patient Be Difficult to Intubate?: The Rational Clinical Examination Systematic Review. JAMA 2019;321:493-503. 33. Fan E, Del Sorbo L, Goligher EC, et al. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017;195:1253-63. 34. Rimensberger PC, Cheifetz IM, Pediatric Acute Lung Injury Consensus Conference G. Ventilatory support in children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015;16:S51-60. 35. ARDS Network Tools. 2014. (Accessed 25 July, 2018, at http://www.ardsnet.org/tools.shtml.) 36. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 2015;372:747-55. 37. Messerole E, Peine P, Wittkopp S, Marini JJ, Albert RK. The pragmatics of prone positioning. Am J Respir Crit Care Med 2002;165:1359-63. 38. Guerin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368:2159-68. 39. National Heart L, and Blood Institute Acute Respiratory Distress Syndrome Clinical Trials Network,, Wiedemann HP, Wheeler AP, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006;354:2564-75. 40. Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA 2010;303:865-73. 41. Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial Investigators, Cavalcanti AB, Suzumura EA, et al. Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA 2017;318:1335-45. 42. Goligher EC, Kavanagh BP, Rubenfeld GD, et al. Oxygenation response to positive end-expiratory pressure predicts mortality in acute respiratory distress syndrome. A secondary analysis of the LOVS and ExPress trials. Am J Respir Crit Care Med 2014;190:70-6. 43. Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 2010;363:1107-16. 44. National Heart L, Blood Institute PCTN, Moss M, et al. Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome. N Engl J Med 2019;380:1997-2008. 45. Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med 2018;378:1965-75. 46. Goligher EC, Tomlinson G, Hajage D, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome and Posterior Probability of Mortality Benefit in a Post Hoc Bayesian Analysis of a Randomized Clinical Trial. JAMA 2018;320:2251-9. 47. Alshahrani MS, Sindi A, Alshamsi F, et al. Extracorporeal membrane oxygenation for severe Middle East respiratory syndrome coronavirus. Ann Intensive Care 2018;8:3. 48. Combes A, Brodie D, Bartlett R, et al. Position paper for the organization of extracorporeal membrane oxygenation programs for acute respiratory failure in adult patients. Am J Respir Crit Care Med 2014;190:488-96. 49. Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign Bundle: 2018 update. Intensive Care Med 2018;44:925-8. 50. Lamontagne F, Meade MO, Hebert PC, et al. Higher versus lower blood pressure targets for vasopressor therapy in shock: a multicentre pilot randomized controlled trial. Intensive Care Med 2016;42:542-50. 51. Rochwerg B, Alhazzani W, Gibson A, et al. Fluid type and the use of renal replacement therapy in sepsis: a systematic review and network metaanalysis. Intensive Care Med 2015;41:1561-71. 52. Rochwerg B, Alhazzani W, Sindi A, et al. Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med 2014;161:347-55. 53. Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care 2015;30:653 e9-17. 54. Schmidt GA, Girard TD, Kress JP, et al. Official Executive Summary of an American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Am J Respir Crit Care Med 2017;195:115-9. 55. Muscedere J, Dodek P, Keenan S, et al. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: prevention. J Crit Care 2008;23:126-37. 56. Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:915-36. 57. Marschall J, Mermel LA, Fakih M, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:753-71. © World Health Organization 2020. All rights reserved. This is a draft. The content of this document is not final, and the text may be subject to revisions before publication. The document may not


Hypertension in the Emergency Department

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Hypertension In The Emergency Department (Pierre Mikhail)

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Great Ultrasound Tips from Castlefest

If you’re an ultrasound geek these tips are da bomb

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Process Improvements in The Emergency Department

A good read from an Ontario ED

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Bedside US For The Win?

We’ve been talking a lot about things we can do to improve efficiency/flow in our emergency department and I was thinking that there is a role for bedside sonography to help.  I thought maybe this could stimulate discussion.  I don’t expect everyone to agree with me. In general bedside sonography costs the MD some time while usually saving patients time in the department, which can still potentially help flow. In no particular order:

  1. In a patient with a history of prior ureteral colic, there are a few goals of care.  First, analgesia.  Then rule out a complicated presentation (ie septic patient), then rule out severe hydronephrosis.  You don’t need a CT to rule out hydronephrosis and you don’t even need a formal scan since we know appropriately trained ED docs can diagnose hydronephrosis. We know from 1st trimester and focused RUQ bedside US studies that doing the scan yourself saves patients on average 180 minutes in the department.  So it may cost you time but should help flow.  And if you have a pain free patient without severe hydronephrosis they can go home.  And even if you think they still need formal sonography (I’d argue they don’t) it could be done as an outpatient.
  2. Patients with RUQ pain.  This is a no-brainer for me.  Bedside US saves patients 180 minutes in the ED on average.  It is EASY to look for stones and again we know ER studies of US show we are really good at it if trained appropriately.  The diagnosis of cholecystitis is a CLINICAL one, not an ultrasound one, so continue to be good clinicians and you won’t miss this diagnosis.  If you get a patient comfortable re-pain and prove they do or do not have a stone, they can go home.  Again, if you feel they need a formal scan (I think they do not) this can be done as an outpatient with PCP follow up.
  3. AAA.  You do not need a formal US or a CT to rule out AAA. Bedside US has superb +LR and -LR.  Rupture cannot be diagnosed on US.  Unstable patient with AAA  = rupture and stable patient needs CT to rule out rupture.  Save time and do your own bedside US to rule out this diagnosis.
  4. Pneumothorax and Hemothorax.  There is excellent literature showing that bedside US has great +LR and -LR for these diagnoses.  In fact for a supine (ie trauma) patient US preforms much better than plain films and very similarly to CT for these diagnoses.  I think it probably could be argued that when the department is not busy maybe an Xray can happen as fast but I’d guess most times this is not the case.
  5. FAST exam in trauma.  In unstable patients there is evidence that patients get to the OR quicker.
  6. DVT and PE.  So, here is where people start getting uncomfortable.  There is decent evidence that bedside compression sonography performs well compared to formal sonography re DVT and can be done in less than 3 minutes.  But I have heard many MDs feel uncomfortable relying on their bedside answer for such an important diagnosis and I can’t quibble with this.  You can still get a formal scan if you must but perhaps can avoid a dose of anticoagulant when we don’t have US available and while awaiting a formal scan if your compression scan is negative for DVT.  Also, if you are worried about PE and bedside ECHO shows a big, hypokinetic RV then the +LR for PE is VERY high.
  7. Fluid overload.  A big IVC, a hypokinetic LV and multiple B lines (3 or more) in multiple chest quadrants suggests LV dysfunction.  The DDx for multiple B lines is anything that increases intertsitial fluid (interstitial diseases, some pneumonias, CHF, ARDS).
  8. Fracture reduction, especially long bones like wrist.  You;ve reduced a fracture.  Splint applied. Send for xray and patient comes back with an unreduced fracture.  Consider doing post reduction US before applying splint.  It is true they could lose the reduction in xray department but if bedside US shows the fracture is not reduced, perhaps you save some time.

There’s more but that’s all I’ve got for now. I wonder what everyone thinks?  It would be nice if we had a machine that was easy to move, started up quickly, didn’t lose its battery charge immediately……

The Nitty Gritty On Stroke Thrombolysis

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Low Risk Chest Pain

There’s been a lot written lately about low risk chest pain and I thought I’d open a discussion about the HEART Score because it’s here.

First, let’s review what we consider to be an acceptable miss rate for MACE (major adverse coronary event) within 90 days.  In Canada, it seems like getting miss rates under 2% seems to be acceptable.  Salim Rezaie from R.E.B.E.L EM asked this question on the Twitterverse and got this answer from a predominantly American audience.

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FOAM Tour

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Literature Drive By

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