Clinical Pearls Covid 19 for ER practitioners

332,568 Views | 254 Replies | Last: 2 yr ago by plain_o_llama
TelcoAg
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AG
Replying direct to OP so you get the blue marker whenever you check back in:

Post to you from Wake Forest MD: https://texags.com/forums/84/topics/3102444/replies/56263949
TelcoAg
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You can email staff@texags.com to see if they'll share your message with him or give out personal details, but it'd be improper for any of us to give that out here.
hrompel
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totally agree, emailing staff email address now, thanks for that!
jcbradley3
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What is your name? NH researchers would like to contact you for further information.
jcbradley3
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Same. NH researchers want info. Can you reply to jheath9@wildcats.unh.edu
jcbradley3
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This information should be shared in the fight against this virus. He is definitely a superstar right now in ID
kyledr04
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This post is getting shared nationwide. I saw it here first and shared with several colleagues. Now I'm starting to see it pop up on other sites and boards.

Always amazed at the power of Texags.
RangerRick9211
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It's on Reddit now. Top post on the daily thread on r/Coronovirus.
elchucoag93
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Just added this to my EHR template. Thank you
Bird Poo
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Aggies saving the world.
FriscoKid
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RangerRick9211 said:

It's on Reddit now. Top post on the daily thread on r/Coronovirus.
Link? I have a hard time navigating reddit...
CT75
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PearlJammin said:

Aggies saving the world.
....always been that way!!!
Irwin M. Fletcher
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Reveille said:

vettmaster99 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.


Hopefully there isn't much indiscriminate use of azithromycin otherwise we may end up causing more bacterial resistance in the long run.
There is already significant resistance to azithromycin.
Zitrhomax had high resistance back in the late 90's. It is one of the least efficacious antibiotics to ever come out. I have no clue if it will have some effect on COVID-19 and if it does then that will be its saving grace because for the most part that drug sucked.
jetescamilla
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kyledr04 said:

This post is getting shared nationwide. I saw it here first and shared with several colleagues. Now I'm starting to see it pop up on other sites and boards.

Always amazed at the power of Texags.


I previously forwarded this post to the chief of Alaska EMS who then sent it up to the Chief Medical Officer for the State of Alaska. We're lucky because our "curve" was delayed due to our isolation. We're hoping to get ahead if it.

Im so happy that others are doing the same and experiencing the wealth of knowledge and diversity of this Aggie community
nawlinsag
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In uncertain times, we search for facts to provide comfort and clarity. Throw in the power of Texags.com and I should not be so dumbfounded by the run this is getting.


My first expanded lost draft (thanks again MacBook Touch Bar) contained the appropriate hedging, disclaimers, and uncertainty the current understanding of this pandemic deserves. Some of the more concise, unproofread, hastily rewritten original post (OP) presents itself as more definitive instead of "what I think I know". For this, my apologies. I am not performing clinical trials. I am not involved in cohorting and analyzing data. The academic physicians involved in ER, Infectious Disease and Pulmonary Critical Care are likely (hopefully) way beyond my understanding of Covid 19. Furthermore, I fail to appreciate any additional benefit I could provide to Hospital Administrators who have been preparing and communicating with each other for months; or for some already combating this daily.


Basically, several state medical licensing boards are temporarily loosening their independent practice regulations on NPs, PAs, and to a lesser extent Medical Students. I wrote the OP as much for me to collect and organize my thoughts, as it was to provide a jumping-off platform for providers who may find themselves in an ER-like setting and unknowingly be treating Covid 19 patients or will be treating them soon enough. If any of it helps some of my colleagues hit the ground running then that is something too.


The OP was a summary of thoughts from being emersed in Covid 19 for weeks, reading as much as I can, and following up on my own patients. It is not my intention for this to be taken as dogma. I do not have the answers or the algorithm everyone is searching for. I was merely looking to point the handful of people I thought would read it in a clinical direction best I could. What I think I know evolves every day with the presumption it may very well end up markedly different once this pandemic is better understood. I do not know when this crisis will ultimately be arrested, however, I maintain resolute that each one of us can help make that happen. Stay home. Be safe. Find a way not to have to visit grandma.


Thank you to all the well-wishers and good luck to us all.



Sincerely,


NawlinsAg
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
benchmark
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My Uncle is in ICU in San Antonio with this. Hope doctors/nurses from Baptist NE have seen this information and find it helpful!
TelcoAg
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Ok but reddit says you're not a doctor because residents don't graduate in May, so there.

Thanks again, Nawlins. Praying for you to keep your sanity and health, my man.
Big Al 1992
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Again - thanks a million for this info. How is your 31 year old co worker that was sent home with symptoms?

Godspeed!
nawlinsag
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Benchmark, I pray for your Uncle.

Big Al- I hear she is improving.

Telco- I graduated from residency in May. Assuming she did too. An internship/residency year starts typically on July 1st. To make a resident in their final year work in June. That's just mean.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
KidDoc
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TelcoAg said:

Ok but reddit says you're not a doctor because residents don't graduate in May, so there.

Thanks again, Nawlins. Praying for you to keep your sanity and health, my man.
Residents are doctors (they have MD) they just aren't board certified yet.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
RangerRick9211
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FriscoKid said:

RangerRick9211 said:

It's on Reddit now. Top post on the daily thread on r/Coronovirus.
Link? I have a hard time navigating reddit...

https://www.reddit.com/r/Coronavirus/comments/fpxagz/daily_discussion_post_march_27_questions_images/flni09b/?utm_source=share&utm_medium=ios_app&utm_name=iossmf
TelcoAg
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Lol I know these things. Some guy claiming to be an ED Resident on reddit said he knew Nawlin's was lying because residents don't graduate in May.
Quote:

So let's just say I question the veracity of this based on several things, but this:
Quote:

One of my colleagues who is a 31 yo old female who graduated residency last may
Pretty much confirms it's bull*****
That's what I was referring to.
https://www.reddit.com/r/emergencymedicine/comments/fp2igx/info_from_new_orleans_er/fllpi2s/?context=8&depth=9
benchmark
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Thanks, nawlinsag. Way back in the 90s I worked as a nurse in ER at Methodist in NO East. Excellent doctors in your neck of the woods. Prayers for all of you!
BCO07
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Well then I guess my program is mean, I'll be rounding (or really just looking over the intern) the morning of graduation this year.
PJYoung
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https://threadreaderapp.com/thread/1243690469172879362.html

Quote:

I intubated my colleague today, a young, healthy ER doc like me. This is what I learned...

1. As scared as I was, I knew that I owed it to my colleague to be calm, focused, and collected. We've trained for this and with a little courage and vulnerability, we can meet any challenge.

2. This virus does not discriminate with regards to age or health status. But it does have an affinity for us. Health care workers represent more than 20% of all #COVID19 cases.

3. Use highflow, proning, and a NRB, to buy yourself some extra time. This gave our team the opportunity to set up for a safe and organized intubation.

4. PPE like you life depends upon it because it does. Limit the number of providers in the room. The most senior physician should intubate, and use video laryngoscopy.

When it's over, it's ok to be human. It's ok to show emotion for in doing so, we show that we care, we grieve, we love. In the end, our love and service to one another, may very well be the thing that gets us through this.
mystix
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Hello..
Not a physician, a former EMT that is absorbing a lot of information quickly. I signed up here after making an association that I want to put in front of qualified eyes. Someone please take a look at it and consider if it has worth.

From OP:
"An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes."

From a reply to op on first page:
"Also, some of these patients have incredible IL-6 levels. I've never seen numbers this high even in my AIDS patients with KICS. One guy had a level above assay which were pretty sure has never been reported by our lab before."

Recent reporting, such as:
https://www.washingtonpost.com/climate-environment/2020/03/19/coronavirus-kills-more-men-than-women/

"The coronavirus is killing far more men than women"
Same article:
"... Studies have also found that estrogen was protective in female mice infected with the virus that caused the 2003 SARs outbreak."

Hormone replacement therepy is less common in Italy and Spain than Germany and France.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5019289/

Some research in mice shows a protective effect of Estrogen against Sars
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5450662/

My associations -

IL-6 seems to be important to the progression of Covid-19 and the cytokine storm.

Estrogen inhibits Il6.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC146754/

Estrogen levels drop quickly in menopause and Covid-19 death rate rises quickly after age 55

Could estrogen also be used as a protective tool?
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Thank you for your evaluation. Ill leave it to those more experienced with all this in the small chance that its helpful. Pardon if it was not. I won't post it further.
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McInnis 03
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Infection_Ag11
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TelcoAg said:

That's all I was asking about my man. Just know there are a lot of eyes on this thread from around the EM community.
I was able to confirm this yesterday. Several hospitals in NY are now using a more aggressive, mandatory DNR system for critically ill COVID patients not expected to survive.

It's essentially the same 2 physician consent system most states already utilize to stop futile care, but it is now being utilized pre-intubation.
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88planoAg
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I just found the OP's post on my Facebook newsfeed, shared by a friend who got it from a Colorado doctor.

The post begins:


Quote:

Here's what bad really looks like..... (**I will translate where appropriate for non-medical **)

Repost from another group. Interesting read.

Then it is word for word the OP, including "I'm class of 98"

You have become an email forward!
Diyala Nick
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I'm not a doctor, and I'm also not a believer that vitamins are some sort of panacea. That said, this is incredibly interesting:

(Synopsis: meta analysis demonstrates that high dose Vitamin C substantially reduces ventilator time in critically I'll patients)

https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-020-0432-y
lmarcus
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Patients are dying because of a cytokine storm and inappropriate autoimmune response with raised IL-6 and CRP levels. The x rays are ground glass and similar to patients with immune checkpoint induced pneumonitis.

And I found a potential answer in THIS FORUM!

EXERPT FROM PREPRESS ARTICLE:

https://www.sitcancer.org/research/covid-19-resources/il-6-editorial

In any case here is a quote from the article as there is already an FDA approved drug Tocilizumab to treat this !!!

Tocilizumab also is already FDA-approved to manage cytokine release syndrome (CRS) in patients receiving CAR T cell therapy [4, 5]. In addition, tocilizumab has been shown to reduce toxicity in patients treated with ICI who were steroid refractory [6], and has been added to the ICI agents ipilimumab and nivolumab in an ongoing US phase II study (NCT03999749) to ameliorate immune-related toxicity. In Castleman's disease, a lymphoproliferative disorder caused by Kaposi's Sarcoma Herpesvirus, a pathogen that produces viral IL-6, tocilizumab has been shown to reduce viral loads [7]. Tocilizumab is also being explored as a potential supportive care measure for the management of CRS in cancer patients treated with a number of CD3-based bispecific molecules. Now, data from the frontlines of the pandemic indicates that the agent may offer lifesaving benefit for COVID-19 patients with respiratory distress.

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

mathglot
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Thanks for posting this. I wonder if you can comment on the Vox article, "How doctors can potentially significantly reduce the number of deaths from Covid-19" , which explains about cytokine storms, and discusses treatment approaches including drugs targeting interleukin-1 (IL-1), IL-6, IL-18, and interferon-gamma. thanks.

Co-author of the article is Dr. Randy Cron, professor of pediatrics and medicine and director of Pediatric Rheumatology at the U of AL/Birmingham, and author of "Cytokine Storm Syndrome".
kyledr04
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I read a long discussion today with several ICU and infectious disease pharmacists from across several large institutions in Texas. They're experience has been that Actemra helps in severe patients but it's hard to get. Also to give it when it looks like someone is headed towards intubation. They also said that steroids seem beneficial for intubated patients despite some reports to the contrary. Others mentioned pulmonary vasodilators and need for anticoag.
ChandaKomatsu
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NawlinsAg,
I am trying to track you down to connect you with Dr. Amy Wagner of UPMC who urgently needs some information about how you are getting certain labs measured that she needs to figure out for possible cytokine storm treatment. How can I get you two connected?
 
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