Clinical Pearls Covid 19 for ER practitioners

289,454 Views | 253 Replies | Last: 2 mo ago by lfis492a
nawlinsag
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I just spent an hour typing a long post that erased when I went to change the title so I apologize to the grammar and spelling police. This one will not be proofread and much shorter.

I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know.

Clinical course is predictable.
2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias(back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.

Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.

Day 10- Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours.

81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.

Patient presentation is varied. Patients are coming in hypoxic (even 75%) without dyspnea. I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA. I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT's of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this ***** has told all other disease processes to get out of town.

China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA in the ED and rescue PCI at 60 minutes only if TPA fails.

Diagnostic
CXR- bilateral interstitial pneumonia (anecdotally starts most often in the RLL so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.


Labs- WBC low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95%
CRP and Ferritin elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated.
Notice D-Dimer- I would be very careful about CT PE these patients for their hypoxia. The patients receiving IV contrast are going into renal failure and on the vent sooner.

Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.

A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.

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

Other factors that appear to be predictive of poor outcomes are thrombocytopenia and LFTs 5x upper limit of normal.

Disposition
I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won't make it back.

We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.

Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the "lockdown", our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.


Treatment
Supportive

worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.

Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil's potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.

We are also using Azithromycin, but are intermittently running out of IV.

Do not give these patient's standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.

Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.

Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.

Do not use Bipap- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.

The same goes for nebulizer treatments. Use MDI. you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn't often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.

Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis.

We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.

One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 of 92%. She will be the first of many.

I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all.



***************************************************************************************************************************


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.
Athanasius
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AG
nawlinsag said:



I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all.

God bless you.
ham98
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damn. Hang tough Doctor.
rosie2012
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Praying for strength and safety for you and your staff..........
Diyala Nick
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AG
Hang in there, the world is in your corner.
archangelus2
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AG
You are a hero doc, thank you for answering the call.
cowenlaw
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AG
Praying for you.
Moxley
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AG
Hang in there. Crazy how this is affecting different areas of the country completely differently from others.
Sandman98
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AG
That's one of the most incredible things I've ever read. The kind of post that we'll be bumping in 20 years. One that makes me feel incredibly inadequate.

Stay safe brother. Thank you.
FunkyKO
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AG
What was the dosage of plaquinil?

Surely you gotta drink something.....isn't there a way?
Infection_Ag11
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AG
I agree that it is striking how fast they crash when they do. It happens right in front of you in very short order.

The rate of superimposed bacterial PNA is very low, less than 1% based on Chinese data, and so I really don't feel there is any benefit to azithromycin. Especially given even strep pneumo in major population centers laughs at azithro these days.

CXR findings in general have little correlation with disease severity in pneumonia, and that goes for COVID as well. A patient <65 who isn't hypoxic or hypotensive with a RR <30 essentially never needs to be admitted for pneumonia outside of unique circumstances (regardless of imaging), and even then it's usually "just in case". I will say this disease does make one hesitate because of its unique course, but there are predictors other decompensation as you said that can guide you.

I don't love the Plaquenil option and the data sucks to be honest, but I have used it some. Remdesivir really seems to work well in the severe cases from my anecdotal perch.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
FunkyKO
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AG
When you say severe.....how bad is severe?
Infection_Ag11
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AG
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.

Obviously we dont know what they were for Spanish flu patients 100 years ago but the cytokine storm was the hallmark of that disease. We're seeing something similar here.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
Infection_Ag11
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SteveMedina said:

When you say severe.....how bad is severe?


Patients requiring supplemental oxygen beyond regular nasal cannula, which in COVID usually ends up being a ventilator. We don't really try NIPPV as the OP said because it doesn't help much and risks aerosolizing the virus. I've had one patient saved from a vent by high flow nasal cannula, which in terms of pure oxygen delivery is the most we can provide prior to intubation, but generally these people are either on NC or getting intubated because the hypoxia becomes so profound so quickly if they crash.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
FunkyKO
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AG
That damn severe. Got it. Thank you.
Moxley
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AG
Correct if I'm interpreting this wrong, but extubation is occurring (on average) day 10 of being on the vent?
TAMUallen
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AG
Prayers sent your way nawlins and to all other doctors, nurses and healthcare professionals
nawlinsag
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That is correct. Once on the vent if they survive expect them to be on 10-11 days.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
nawlinsag
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400mg bid day one then 400mg qd for 4 more days is the goal. But my goal is for the patient to be managed by someone else after the first dose. Although our ER group is helping with floor intubations, central lines, and art line placements so I am seeing some of the longer term treatments.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
TelcoAg
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AG
Man needs a tag, mods

Thank you for taking the time to put this out with all you got going on
Pelayo
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AG
nawlinsag said:

400mg bid day one then 400mg qd for 4 more days is the goal. But my goal is for the patient to be managed by someone else after the first dose. Although our ER group is helping with floor intubations, central lines, and art line placements so I am seeing some of the longer term treatments.
Hang in there.

So glad I only do three ed shifts a quarter now.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
Ag_of_08
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AG
Nawlins, I have a 3-d printer going with a mask setup.... I'm trying to equip local responders, but can try to crank out stuff for yall. I can also put it out to our printing groups if there's any of it that can help.

Let me know, and I'll hit up the groups I'm in
TelcoAg
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AG
Is it n95? If so, how given the material requirements?
kyledr04
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AG
Thanks for the detail. Wild stuff. Will share with colleagues. Prayers for you, co-workers, and family.
HeardAboutPerio
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AG
God bless you and all on front lines.
Ag_of_08
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AG
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*
58-7
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AG
Stay strong, come here for support! You are are a frontline hero!
Mark Fairchild
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AG
We are constantly praying for you and your co-workers. God's protection cover you.
Gig'em, Ole Army Class of '70
Southlake Ag
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AG
God bless you and your staff!
Tailgate88
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AG
You are a hero doc. We are praying for you and your colleagues and of course patients.
ttu_85
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I'm but a lowly tard with a CS background. We too have our own unique terminology, acronym etc. I understand the OP was rushed and had to use his instinctive terminology to get this out to the masses with the time available to him.

This document is critically important and the best I have heard anywhere regarding this crisis. If a medical professional could edit it for the medical layman that would be appreciated.

God bless the OP for taking the time to share this critical information and for their work in the trenches.
PJYoung
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AG
The last part brought tears to my eyes.

God bless all of our people on the front lines.
Aggie Spirit
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AG
Godspeed through the storm.
Mateo84
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Staff: This might be a good one to pin to the top of the page for the other docs and nurses out there reading this forum.
Palovic
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Thanks for posting this. Lots to take in but very good data. Would be great to have a spot aggregating this data from all the posters on front lines that are providing similar data.
 
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