Clinical Pearls Covid 19 for ER practitioners

331,639 Views | 254 Replies | Last: 2 yr ago by plain_o_llama
Pelayo
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AG
BCO07 said:

where did that come from?
Indian Council of Medical Research.
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DifferenceMaker Ag
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Quote:

Many thanks to the OP and DifferenceMaker Ag !!

I had nothing to do with anything. I just hope the added notes drive home how serious this is to everyone.Glad you found it helpful.

My prayers continue to go out to NawlinsAg and all of the doctors, nurses and staff who are facing this tragic challenge every day. They are true heroes, one and all. God Bless Us All.
VKint
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AG
Thanks for the superb summary. We are probably a week or two behind you. Just got a phone call from someone in NO last week, fever and cough along with parent. they will be tested, maybe get a result within a week.
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McInnis 03
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Infection_Ag11 said:

McInnis 03 said:

For those with the elevated levels of IL6, are any of the IL-6 receptor blockers being administered? If so, any results to speak of?


This editorial written yesterday has some inisghts....
https://www.sitcancer.org/research/covid-19-resources/il-6-editorial

Quote:

Emerging evidence suggests that high levels of CRP and IL-6 are observed in patients infected with COVID-19 [1, 8]. Anecdotal experience on the use of tocilizumab at doses comparable to those used for the management of CRS from investigators in Italy [9] and from China [10] has reported rapid improvement in both intubated and non-intubated patients. In these reports, expeditious administration of anti-IL-6R therapy for patients in acute respiratory distress has been critical. A recent study protocol to evaluate the efficacy of tocilizumab in COVID-19 induced pneumonitis accrued over 300 patients worldwide in less than 24 hours. Additionally, Genentech will also provide 10,000 vials of tocilizumab to the U.S. Strategic National Stockpile [11]. Tocilizumab was also approved in China in March 2020, for the treatment of patients with COVID-19 with serious lung damage and elevated IL-6. Sponsors, investigators, and regulators have moved with unprecedented speed and collaboration to initiate protocols to formally study the safety and efficacy of antiviral agents and vaccines, as well as various anti-IL-6 antibodies in patients with COVID-19. In the US, a trial of sarilumab in the COVID-19 setting is ongoing [12].




Yes, we're conducting trials with multiple IL-6 inhibitors. At my facility we're enrolling patients in a sirolumab.
I hope the results are truly remarkable.
mernaggie12
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AG
Myalgias is any muscle pain not just back pain.
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mernaggie12
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Azithromycin is used for its anti-inflammatory properties, including effects on IL-6, in other conditions. This may be the benefit of azithromycin in COVID-19.
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DifferenceMaker Ag
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mernaggie12 said:

Myalgias is any muscle pain not just back pain.
Thanks. Updated.
fullback44
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Doc,

Do you think that someone will develop some immunity after you get the virus?

I actually think I may have had it last week or so. All the symptoms you mention, especially the lower back pain after after a light fever for a few days. The back pain was some sudden type pain that I had not experienced before. Back pain lasted 3-4 days and then fever and fatigue throughout. Now feeling fine, l drank lots and lots of fluids along with taking vitamin C, D, and zinc daily
Decay
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mernaggie12 said:

Azithromycin is used for its anti-inflammatory properties, including effects on IL-6, in other conditions. This may be the benefit of azithromycin in COVID-19.
This might be a "duh" and "we'll worry about it later" situation but if half of America gets an Rx of z-packs are we going to see some issues with drug-resistant strains of all kinds of bugs?
Ag In Ok
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Shortness of breath as well?
fullback44
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Ag In Ok said:

Shortness of breath as well?
very little of that, just a couple times at night when I would lay down and my chest would get a little tight, I would get up, drink an entire bottle of water and just move around till I felt better. so maybe 2 times at night I felt a little shortness of breath. That back pain was what was so noticeable.. after fell down getting out of the car one day and that's when I knew something was up.
RandyAg98
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I hope you are isolating yourself.
fullback44
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yes, isolated from everyone, made it for a rough 12 days or so, still isolated mostly
DifferenceMaker Ag
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fullback44 said:

Doc,
Do you think that someone will develop some immunity after you get the virus?

I actually think I may have had it last week or so. All the symptoms you mention, especially the lower back pain after after a light fever for a few days. The back pain was some sudden type pain that I had not experienced before. Back pain lasted 3-4 days and then fever and fatigue throughout. Now feeling fine, l drank lots and lots of fluids along with taking vitamin C, D, and zinc daily
Dr Coates indicated that studies have shown that those who have recovered from Covid-19 carry with them antibodies that provide immunity from becoming reinfected, with the possibility of extremely rare exceptions.

https://m.facebook.com/story.php?story_fbid=2650121791937428&id=1998386763777604?sfnsn=mo

You should have yourself confirmed though, and stay quarantined just in case. Contact your primary care physician, and follow his/her instruction.


PJYoung
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fullback44 said:

yes, isolated from everyone, made it for a rough 12 days or so, still isolated mostly
From what I've heard, shortness of the breath is a big indicator.
BCO07
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Decay said:

mernaggie12 said:

Azithromycin is used for its anti-inflammatory properties, including effects on IL-6, in other conditions. This may be the benefit of azithromycin in COVID-19.
This might be a "duh" and "we'll worry about it later" situation but if half of America gets an Rx of z-packs are we going to see some issues with drug-resistant strains of all kinds of bugs?


Horse is out of the barn on this one due to years of over prescribing antibiotics for viral infections due to a customer service mentality that has developed in medicine. Azithromycin in particular has a very high resistance pattern in most areas for the bugs you traditionally treat with it.
McInnis 03
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n/m I don't want to get this thread off topic
Infection_Ag11
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mernaggie12 said:

Azithromycin is used for its anti-inflammatory properties, including effects on IL-6, in other conditions. This may be the benefit of azithromycin in COVID-19.


The evidence for the anti-inflammatory effect has always been pretty weak and even then it's really only in the acute phase of obstructive lung disease exacerbations. The pulmonologists use it chronically 3x week in really bad COPD but that's always largely been voodoo.

In general azithromycin is surrounded by lots of lore and legend with little substance.
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Infection_Ag11
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Decay said:

mernaggie12 said:

Azithromycin is used for its anti-inflammatory properties, including effects on IL-6, in other conditions. This may be the benefit of azithromycin in COVID-19.
This might be a "duh" and "we'll worry about it later" situation but if half of America gets an Rx of z-packs are we going to see some issues with drug-resistant strains of all kinds of bugs?


Apart from atypical organisms, most common bacterial respiratory pathogens already have developed significant or complete resistance to azithro. So much so that docs shouldn't be using it for monotherapy for pneumonia anymore. Nobody should be taking z-paks alone for pneumonia anymore.
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nawlinsag
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I agree, but the most common i am hearing from the patients is the back.
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Pelayo
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Infection_Ag11 said:

Decay said:

mernaggie12 said:

Azithromycin is used for its anti-inflammatory properties, including effects on IL-6, in other conditions. This may be the benefit of azithromycin in COVID-19.
This might be a "duh" and "we'll worry about it later" situation but if half of America gets an Rx of z-packs are we going to see some issues with drug-resistant strains of all kinds of bugs?


Apart from atypical organisms, most common bacterial respiratory pathogens already have developed significant or complete resistance to azithro. So much so that docs shouldn't be using it for monotherapy for pneumonia anymore. Nobody should be taking z-paks alone for pneumonia anymore.
been true since 2003
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JD Shellnut
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But does it still work on Chlamydia? Asking for a friend.....
Ag_of_08
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That's the plan actually, is to use the filter elements cut from larger ones.
AggieDO97
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Hang in there, nawlinsag !

Thank you VERY much for passing along your insight and experience with the clinical presentation of this virus! Truly very helpful for those of us in outpatient primary care setting. My staff is extremely concerned.
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maroonbeansnrice
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Ag_of_08 said:

What I'm able to print is face shield holders and masks that can take filter inserts. The ones I've been seeing used in emergency situations are cutting up filters and using them as inserts. I doubt they meet full n95 standards, but most of the people using them are taking what they can get.

I know the PLA plastic has been questioned because it can be porous, but it will hold pressure with stripping around the mouth and nose.

The face shield frames are great if I could find clear lexan, I could make them by the dozen, but I dont have a source for the guard materials.

I will print anything that could be helpful at this point with the supplies I have *shrug*
It is probably sold out like so many other things, but I routinely buy sheets of Lexan at Home Depot FWIW. Good luck and God Bless.
“It ain’t like it used to be.”
-Jimbo Fisher
Ag_of_08
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maroonbeansnrice said:

Ag_of_08 said:

What I'm able to print is face shield holders and masks that can take filter inserts. The ones I've been seeing used in emergency situations are cutting up filters and using them as inserts. I doubt they meet full n95 standards, but most of the people using them are taking what they can get.

I know the PLA plastic has been questioned because it can be porous, but it will hold pressure with stripping around the mouth and nose.

The face shield frames are great if I could find clear lexan, I could make them by the dozen, but I dont have a source for the guard materials.

I will print anything that could be helpful at this point with the supplies I have *shrug*
It is probably sold out like so many other things, but I routinely buy sheets of Lexan at Home Depot FWIW. Good luck and God Bless.


I'm leery about going in to one right now but may slip in and see what I can find. Hobby lobby usually has some thin enough, but that's a place I'm def not interested in wandering in.
Reveille
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Praying for Nawlinsag!

Hang in there. Unfortunately, I am hearing stories similar to this in areas around New Orleans. Let's hope things get better. Praying for you. This virus is just a bad monster. Once you go into cytokine storm it is so hard to survive.

People asking about the hydroxycholoroquine combination, once you are this sick it is very unlikely to help. Way too much viral replication and inflammation has already occurred. It's purpose the way I see it is for us doctors in the community to get it started as soon as possible to hopefully slow down viral replication and inflammation so they never get to ventilator stage. Also hopefully it will be proven to successful in prophylaxis to protect the physicians like Nawlinsag from getting too much viral exposure.

God Bless you and I have been praying for New Orleans for many days.
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TSUAggie
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Have either of you guys treated asthma patients that tested positive for COVID-19? My son has asthma and I'm scared as hell about him getting it.
SchizoAg
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nawlinsag said:

We are currently out of Versed, Fentanyl, and intermittently Propofol.
Anybody got any leftovers in the medicine cabinet you can donate to your local hospital?
PJYoung
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TSUAggie said:

Have either of you guys treated asthma patients that tested positive for COVID-19? My son has asthma and I'm scared as hell about him getting it.


From another thread

Based on what I'm hearing from colleagues in peds ID it seems like asthma is the theme of severe presentations under 20. Kids with asthma are the ones getting intubated, but thankfully this is more related to reactive airway disease and less so parenchymal lung disease. It basically causes a severe asthma exacerbation which is easy enough to fix once they're intubated.
TSUAggie
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PJYoung said:

TSUAggie said:

Have either of you guys treated asthma patients that tested positive for COVID-19? My son has asthma and I'm scared as hell about him getting it.


From another thread

Based on what I'm hearing from colleagues in peds ID it seems like asthma is the theme of severe presentations under 20. Kids with asthma are the ones getting intubated, but thankfully this is more related to reactive airway disease and less so parenchymal lung disease. It basically causes a severe asthma exacerbation which is easy enough to fix once they're intubated.


So intubation, but then no big deal? Help me understand as I am a medical idiot.
OverSeas AG
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Every knee shall bow and every tongue shall confess
Slaytebeling
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Thanks for the info and all that you do nawlingsag

I've passed this information to my wife (critical care anesthesiologists working in the COVID19 ICU) and she found the ratio of the absolute neutrophil count very interesting. Some good news is the first patient that she intubated about 6 days ago was extubated and is doing well(they are watching closely for the viral cardiomyopathy). Trying to figure out the right time for extubation has been discussed a great deal but no good guidelines have been established yet.
ThatOneGuy
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Bumping my own question - ER doc here

ThatOneGuy said:

Thanks for posting this. I'm working at a rural Texas ER currently, but I trained EM in Baton Rouge so I have been following the South Louisiana situation. It hasn't hit here yet but I am sure it's coming. It's in every county around us. We have no ICU at my hospital so we will be tubing and attempting transfers. This may prove difficult once all the ICU beds in Houston and Austin are filled to capacity before it even hits out here. Do you have any experience with how rural ED that are critical access without ICU care are handling things in your area? As a typically transfer accepting hospital what is your situation regarding transfers for higher level care?


Ag In Ok
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I had flu a earlier in the year and it did a number on my lungs. Is there any relation between negative outcomes and previous flu illness?
 
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