S1E1: Covid-19
Thank you all for joining us for our very first episode of TheCase.Report! We’re delighted to have you with us as we set off on this very exciting journey!
This month we’ll be looking at (what else!) COVID-19.
For our first segment, @MoHamza89, @KarlKavanagh and @drsafras will be going through a case and discussing the issues it raises.Our adult in the room this month @cianmcdermott will check our work after!
Then we’ll be joined by @DrDaraByrne, who’ll help us think about simulation, and it’s varied uses during this pandemic.
@UnaUnak will talk to us about wellness in EM and will share some great tips for looking after ourselves and each other.
Sources & resources will be linked in-line for the case material. Sim & Wellness resources all the way at the end!
Let’s get to it!
Definitions
Coronavirus disease 2019 (COVID-19) is a respiratory tract infection caused by a newly emergent coronavirus, SARS-CoV-2, that was first recognized in Wuhan, China, in December 2019. Genetic sequencing of the virus suggests that SARS-CoV-2 is a betacoronavirus closely linked to the SARS virus.
Epidemiology (in Irish context)
Daily Updated numbers:
https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/casesinireland/
Social measures
1. Stay at home
2. Exceptions
3. Essential service workplaces
4. Health Services
5. Transport and Travel
6. Legislation and Regulation
** Enforcement by Garda Siochana
PPE
· To be worn by ALL staff and visitors entering the room where a suspected, or confirmed case is being cared for
· An adequate supply of alcohol-based hand rub must be available outside and inside the patient’s room
· PPE should be available outside the patient's room for donning prior to room entry
· A buddy system to observe donning and doffing of PPE is recommended
· In addition to standard precautions, the following PPE for contact and droplet precautions should be used by all HCW involved in patient care:
o Disposable long-sleeved gown
o **Surgical mask - secure ties/straps to middle back of head and neck. Fit flexible band to bridge of nose. Fit snug to face and below chin
o Eye Protection – goggles or visor adjusted to fit
o Gloves – pull glove wrist over the gown cuff
· For aerosol generating procedures put on a minimum of a FFP2 respirator instead of surgical mask and fit check.
**Given that an accidental disconnection or extubation (AGPs) can occur at any time with intubated patients, it can be argued that a FFP2/3 should always be worn when dealing with same.
HCW burden
~25% of total cases so far! Higher than other European countries to date… I don’t really know what to do with this number/how to interpret it.
Paul Cullen in IT suggests it could be a product of insufficient PPE/late cancellation of elective procedures…
“To paraphrase Oscar Wilde, to lose one healthcare worker to this disease is a misfortune; to lose this many looks like carelessness.”
Ouch, Paul.
Mental health consequences also…
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2763229
The effects were greatest in nurses, women, those directly caring for virus patients, and those working at the epicenter in Wuhan.
Cross-sectional, geographically stratified survey of 1257 healthcare workers (39% physicians; 61% nurses; 72% of nurses had junior titles) from 34 hospitals (20 in Wuhan; 7 elsewhere inside Hubei province, and 7 outside the province).
42% were directly caring for patients with COVID-19. There were high rates of depression (50%), anxiety (45%), insomnia (34%), and distress (72%). Symptoms were higher in nurses, women, people caring for COVID-19 patients, and those in Wuhan (symptoms were lowest outside Hubei). Of these higher-risk groups, 10% to 20% scored in the moderate or severe range.
These findings are limited by the absence of clinicians' evaluations which would have allowed better determination of the severity and functional impact of symptoms. While most symptoms were in the mild range, a substantial minority of individuals in higher-risk categories had moderate-to-severe symptoms. Greater symptoms in healthcare workers geographically closer to the epicenter or having close contact with infected patients are consistent with the broader literature showing that “dose” of traumatic stress increases risk for distress. Greater effects in nurses than physicians might reflect their closer, more prolonged contact with patients and, perhaps, their greater inexperience. While it may be modestly reassuring that half the respondents on the front lines of this outbreak had minimal or no symptoms, these findings highlight the importance of being sensitive to caretaker distress and of caring for the caretakers as well as the patients.
http://www.mindthefrontline.com
Classification and presentation
WHO classification of clinical syndromes ranges from “mild illness” to ARDS, and includes sepsis and septic shock.
https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected
Two phenotypes of the disease described in this paper in ICM, with reference to specific respiratory treatment strategies each is likely ot respond to:
https://www.esicm.org/wp-content/uploads/2020/04/684_author-proof.pdf
Immediate management
Triage & department flow
Patient to be triaged as per the up to date ‘’COVID-19 Risk assessment for use in a RECEIVING HOSPITAL SETTING’’ guideline by HSE
Early recognition of suspected patients allows for timely initiation of appropriate IPC measures (see Table 1). Early identification of those with severe illness, such as severe pneumonia (see Table 1), allows for optimized supportive care treatments and safe, rapid referral and admission to designated hospital ward or intensive care unit.
NHS:
“EDs will change their system and will use triage at the front door and stream patients directly to inpatient areas before examination or diagnostics. Consider in-reach services that are consultant-led to pull patients needing admission to inpatient areas or facilitate rapid discharge to the community.”
“It will be necessary for each admission area for medical patients (AMU, ED) to create parallel systems to separate patients with respiratory symptoms from those with other clinical presentations.”
Note: Clinical presentations NOT requiring admission… yikes.
Reference guide very useful; interesting RCEM integrated COVID-19 care record
Our own streaming process algorithm under development is a little rougher around the edges, but is sensible and hits the key points.
General Approach
Take care donning appropriately, and then continue as per usual. It’s really important we don’t become blinkered to other pathologies. We should still expect to see the whole breadth of emergency presentations we usually do, so we need to be vigilant that we keep a wide angle view of the differentials and maintain our usual high standards for the care of the undifferentiated unwell.
Being thorough, while also being concise, i.e. maintaining standards of safety while improving throughput is going to be a challenge, but it’s one that I’m confident we’re up to.
Diagnostics
General Ix:
Pulse Ox
Blood gas )as indicated to detect hypercarbia/acidosis)
FBC
WBC tends to be normal, lymphopenia common
NLR + age may be sensitive severity predictors
Other blood tests: Renal profile, LFTs, coag, CRP, procalcitonin, troponin, LDH, CK
Swab (as per HPSC guidance)
Cultures
CXR/CT: Features of viral pneumonia
Ultrasound
Irregular pleural line
B-lines (may be irregular and even confluent)
Patchy pattern with bilateral sparing
Areas of white lung
Subpleural consolidations
hCG**
Management & Ongoing Treatment
In spite of the algorithm in that NLR paper, how sick the patient is clinically is what’ll determine disposition.
They’ll either be
Fit for home + supportive care
Ward + supportive care
ICU
Who goes home?
Mild symptoms, vitally stable; this will be the majority of patients in the community, though maybe not the majority of those presenting to EDs.
Advice RE: self-isolating (https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/selfisolationathome/Self-isolation%20(2).pdf)
Those who can’t self isolate? HPSC has guidance for patients in vulnerable groups, I know we see many homeless patients here that would not be able to self isolate adequately. Important to contact their hostel/residence with the advice here, and also maybe involve social work colleagues. (https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/vulnerablegroupsguidance/Guidance%20for%20settings%20for%20vulnerable%20groups%20V2.pdf)
Who comes in?
Abnormal vitals? Very symptomatic? Horrible x-ray?
I’m personally in favour of keeping our threshold LOW.
Who goes to ICU?
CRITICAL CARE REFERRAL (As per IAEM Covid-19 Guideline - http://www.iaem.ie/wp-content/uploads/2020/04/Covid19-guideline.pdf)
The following indicate high likelihood of need for invasive ventilatory support and should prompt urgent critical care review:
1. SpO2 < 90% on non-rebreather mask or
2. Respiratory acidosis pH <7.2 or
3. Respiratory rate > 40 or
4. Inability to protect or maintain airway
Patients exhibiting signs of shock also require urgent critical care review
1. Systolic blood pressure < 90 mm Hg
2. Clinical evidence of shock:
Altered level of consciousness
Decreased urine output refractory to volume resuscitation
Who DOESN’T go to ICU?
This is a tricky one… Too nuanced for a quick overview to do it justice. We’ll revisit this when we can dedicate the time it deserves.
How do we fix them?
Supportive care is REALLY important, for those whose care we’ll escalate as well as those who won’t require/won’t be suitable for escalation. The ERJ have a great review of common things to consider, including symptom relief, psychological support and pastoral care if that’s required. (https://erj.ersjournals.com/content/early/2020/04/07/13993003.00815-2020)
In the more immediate term:
Supplemental O2 as required
Judicious** fluid therapy
Aggressive resuscitation can exacerbate respiratory failure, while we also need to be cautious of the unwell patient who may be normotensive and dehydrated.
Consider proning if tolerated
Consider NIV
Early evidence from China not favourable, but more encouraging results for CPAP and HFNO more recently
RECOVERY-RS trial ongoing in Warwick to assess this further (https://warwick.ac.uk/fac/sci/med/research/ctu/trials/recovery-rs/)
Consider tubing early if heading in that direction
Involve experienced personnel (call ICU early!)
Use a Covid-19 RSI checklist; you may have a local one, but if not, IAEM have a great one, have a look! (http://www.iaem.ie/wp-content/uploads/2020/03/Appendix-3-RSI-checklist_AMcC.pdf)
High PEEP may be required
Use lung protective settings (4-6ml/kg ideal body weight)
Monitor plateau pressures; this is the number to keep an eye on to prevent barotrauma. Some machines will tell you this, others you’ll need to do an inspiratory hold. Have a look at the vents in your department and figure out how to do this before you need to do it.
Specific therapies
Chloroquine or Hydroxychloroquine
“Use of these drugs is premature and potentially harmful” - BMJ
Hydroxychloroquine/Azithromycin
No evidence that combination is more effective than HCQ alone
Lopinavir/ritonavir
No benefit vs. standard care; 199 patient RCT - NEJM
Remdesivir
Compassionate care only; some improvement
Tocilizumab
Experimental IL-6 inhibitor for patients with Covid-19 with suspected hyperinflammation (“Cytokine Storm” as it’s dramatically called sometime)
There are currently around 600 clinical trials registered worldwide looking at different aspects of Covid-19! But even at that, we’ve only got very sketchy evidence for everything we have at our disposal.
We’ll have to come back and do a deeper dive into the therapeutics and the evidence behind them at a later stage. 4 months ago no one would have thought about adopting a treatment regimen based on the studies around Az/HCQ, but here we are… Brave new world etc…
I’m personally holding out hope for the trials studying turmeric oil injections, the 5 trials studying different herbal remedies in PO IV and even topical form, and the 4 (yes 4!) individual trials studying honeysuckle decoctions.
Good HSE Advice document, gives quick summary of major trials at the end
http://hse.drsteevenslibrary.ie/ld.php?content_id=32903083
**hCG:
Females of child bearing age, as ever, need pregnancy status determined. There have been case reports of women with severe COVID-19 at the time of birth who have required ventilation and extracorporeal membrane oxygenation.
More severe symptoms such as pneumonia and marked hypoxia are widely described with COVID-19 in older people, the immunosuppressed and those with long-term conditions such as diabetes, cancer and chronic lung disease. These same severe symptoms could occur in pregnant women and so should be identified and treated promptly. The absolute risks are, however, small.
RCOG Covid-19 guidelines (https://www.rcog.org.uk/globalassets/documents/guidelines/2020-04-09-coronavirus-covid-19-infection-in-pregnancy.pdf)
Clinical Course & Prognosis
Image from IAEM Covid-19 Guideline (http://www.iaem.ie/wp-content/uploads/2020/04/Covid19-guideline.pdf)
Those that do go to ICU, and especially those that end up requiring mechanical ventilation, they seem to have very high mortality rates. I’ve heard numbers as low as 10-15% in some places, but generally they seem to be higher.
Lancet case series from February (https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30079-5/fulltext) 61.5% overall and 94% for those requiring mechanical ventilation.
Closer to home, the ICNARC report (https://www.icnarc.org/DataServices/Attachments/Download/c31dd38d-d77b-ea11-9124-00505601089b) of ICUs in England, Wales and NI showed a 66.3% mortality rate in those requiring mechanical ventilation, which is much more encouraging! Numbers for mortality vs survival to ICU discharge look about even.
Summary & Take-Aways
This is scary, no doubt about it, but what I’m taking from it is that we’re collectively learning how to manage this a little better as each day goes by. Is this maybe a positive side effect of our habitual voracious consumption of information on the internet and social media? Or maybe that’s too hot a take…
And I don’t know about you guys, but what’s definitely encouraging for me though is how we see everyone pulling together for this common purpose. Tribalism in healthcare has always been one of my major bugbears, and all it took was a global pandemic to fix it!
Sim Resources:
https://www.ssih.org/COVID-19-Updates/-Helpful-Links-and-Information
http://simulationpodcast.com/covid-19-simulation/
Both above have tonnes of great resources for COVID-19 sims
Wellness Resources:
RCEM EM-POWER: A Wellness Compendium for EM: https://www.rcem.ac.uk/docs/Sustainable%20Working/0.%20Wellness%20Compendium%20(Apr%202019).pdf
RCEM Wellbeing App; at the moment, only available for members and fellows of the college, and EM nurses in ROI:https://www.rcem.ac.uk/RCEM/Membership/RCEM_Wellbeing_app.aspx
IEMTA EM Wellbeing Poster:
http://www.iaem.ie/wp-content/uploads/2020/03/Appendix-2-EM-wellbeing.pdf
Mind The Frontline:
https://www.mindthefrontline.com/
Employee Assistance Programme:
