Saturday, 4 April 2020

The WACEM-ACAIM Joint 3rd Special Global Web Conference on Case Based Lessons from COVID19 patients across the World



4th April 2020

Telemedicine

Telemedicine for home monitoring of discharged patients and other complaints is in full use as numbers in Italy start to trend south.

Hypoxia

Point of Care Pulse Ox assessment at triage should identify silent Hypoxia Assessment via rest and stress check after one-minute walk.

Order Labs and X-ray Chest.

An inconclusive chest X-ray should prompt plain CT of the chest. If the CT is positive then the patient is admitted.

Negative CT Chest should prompt an evaluation to rule out COVID Myocarditis / PE as COVID has shown to have cardiac effects and thrombotic tendencies.

CTA is done when there is a high suspicion for PE. Additional POCUS Cardiac exam is done. D-Dimer routinely is high in COVID patients.

The PE algorithm should be followed keeping in mind that AKI and dehydration can be present.

Kidney Dysfunction

GFR and trending the creatinine in last 7 weeks is good enough to evaluate the kidney status in addition to creatinine.

Myocarditis
High Sensitivity Troponin is an efficient marker to r/o myocarditis.

Non-COVID Pathologies:
The emphasis was that other pathologies do exist and we have to keep that in mind as we evaluate COVID patients and vice versa.

Hematological / Metabolic Markers
Neutropenia, Lymphopenia, Hypokalemia and High Fibrinogen levels have been found in COVID19 patients.

LMWH
Routine dosing that the experts recommended for patients admitted.

Extra-Pulmonary manifestations of COVID19
AMS / Seizures / Delirium / Encephalopathy / Myocarditis / N / V/ D / Rhabdomyolysis / AKI / Thrombosis / Embolism were the major manifestations mentioned by experts.   








Saturday, 28 March 2020

The WACEM Second Special Global Web Conference on “ Emergency Shock , Resuscitation in COVID19”





Date: 28/3/20

With gratitude to all our global participants today for sharing your experiences and advice.


1) Multi-use Ventilator-Patient Dyssynchrony : 
Consider the major problem of ventilator triggers when optimizing use for multiple patients. Adequate sedation is key.

2) ECMO
- Should be used in conjunction with CVTS and experienced team/units.
- Consider outcome potential, with best potential in young, otherwise fit individuals. Older patients with co-morbidities and multi-organ failure are poor candidates for consideration of this limited resource.

3) Aggressive Diagnostic CT
Consider balancing the use of your CT resources with the time and resource limiting factors. 

4) POCUS 
Bedside POCUS use by trained operators.

5) CRP/Procalcitonin 
There are of more value in serial measurements than to use as absolute diagnostic or discharge criteria.

6) Neutrophil to Lymphocyte ratio

7) Co-infection
COVID-19 is being diagnosed as either the primary or the co-infection in cases of Sepsis / Trauma / Cardiology presentations. To be kept in mind. ACLS / ATLS should be done as per protocol.
Broad spectrum antibiotics for at-least 48 hours until negative cultures obtained if Sepsis protocol is being followed. Do not forget Non COVID19 Sepsis and other pathologies continue to exist and cannot be missed. Fluid management and Ventilator support should follow ARDS protocols.  

8) PCR sampling 
Of more use in milder infections and targeting health care professionals than a wider use screening tool. 

9) OP/NP sampling
Moderate sensitivities shown. Potential for late positives. Efforts should be made to reduce sampling errors.

10) Disaster preparedness
Countries/regions with good disaster preparedness protocols and experience are fairing better than those without. Successful models or successful features from developing models should be shared and inculcated into global practice.

10) Discharge Criteria
Silent Hypoxia is the major factor which can impede discharge from ED. Other factors like Fever and Low Lymphocyte count should take presence / Absence of Hypoxia as a Major criteria to discharge or admit the patient.

Please read post covering previous meeting talking points for completeness.  



Sunday, 22 March 2020

The WACEM Compilation of Open Access Resources for COVID-19 (Updated 28th March 2020)




Compilation of Open Access Resources for COVID-19

(With gratitude to all contributors for sharing your wisdom, resources, experiences and ideas)
The disease is new, thus the knowledge evolving and dynamic.

I'll be updating the list as time permits.

1) Website: OnepagerICU: https://onepagericu.com by
@nickmmark

2) Website: Propofology: https://propofology.com/covid19.html UK-based FOAMed; (twitter user Gas_Craic)

3) Society of Critical Care Medicine
https://sccm.org/…/Surviving-Sepsis-Campaign-Guidelines-on-…… Guidelines for management of the acutely unwell with COVID-19

4) Blog: New to ITU
https://whatwouldflorencedo.com/new-to-itu/ by (twitter user SamIAm_UK)
ICU basics for anyone...new to ICU.

Guide to Chest CT in COVID-19 (twitter profile PulmCCM)

CDC's Infection Control Guidance

7) Website: CDC posters on how to don/doff PPE: 
https://www.cdc.gov/niosh/npptl/pdfs/PPE-Sequence-508.pdf

8) Summary thread of SCCM guidelines by twitter user @virenkaul (New York based Pulmonologist/ICM doctor)

9) Simulations resource and experience sharing by twitter user @cliffreid (Sydney based EM/ICM/PHEM doctor)

10) Nitrates in acute pulmonary edema secondary to LVF by @cliffreid (Sydney based EM/ICM/PHEM doctor)
https://twitter.com/cliffreid/status/1241486112909955072?s=20
11) Influenza vs. COVID19 infographic by @CPSolvers

12) Airway Pressure Release Ventilation by @eddyjoemd (Intensivist, unsure where) *also has resource rich Instragram account

13) Optimizing ventilator capacity by @SJH_EM (Detroit based EM)

+ Published journal article: 
Increasing Ventilator capacity By Lorenzo Paladino et. al    https://www.resuscitationjournal.com/article/S0300-9572(07)00582-5/pdf 

14) Innovation: Plexiglass barrier, by twitter user @alison4WI https://twitter.com/alison4WI/status/1241362899899121664…

15) Experience: From Madrid, by twitter user @mgalandejuana

16) Innovation: 3D printed ventilator, by twitter user @sonalasthana

17) Experience: Document shared by Italian College of Anaesthesia/Analgesia/Resuscitation/Intensive Care, by twitter user @Yascha_Mounk

18) Indo-Pacific Management guidelines by Australasian College of Emergency Medicine: https://acem.org.au/…/Managing-COVID-19-across-the-Indo-Pac… 

19) COVID-19 and Children, Website: Don't Forget The Bubbles: https://acem.org.au/…/Managing-COVID-19-across-the-Indo-Pac…

20) Experience/Innovation: Extubation in COVID-19 by twitter user @StephenLap

21) Journal: Treatment of severed ARDS, in The Lancet: https://www.thelancet.com/…/PIIS2213-2600(20)30127…/fulltext

22) Website: COVID-19 prevention, REBELEM (laid out neatly!)
https://t.co/X1DobSoEMY?amp=1

23) Twitter: Mask Basics (From REBELEM) by twitter user: @ srrezaie
https://twitter.com/srrezaie/status/1242215792231448576?s=20



24) Mass General Hospital guidelines for management of COVID-19 shared by twitter user @HarvardPulm

https://twitter.com/HarvardPulm/status/1242108566716084226


24) Important Reminder re: caution in using Chloroquine shared by twitter user @CMichaelGibson

https://twitter.com/CMichaelGibson/status/1242235424275410948?s=20 25) NEJM Paper: SARS – COV – 2 Infection in Children https://www.nejm.org/doi/full/10.1056/NEJMc2005073
26) REBEL EM’s Airway Management (with further resources scouted within) https://rebelem.com/covid-19-airway-management/
27) FOAMcast’s COVID Timeline: https://foamcast.org/2020/03/26/covid-19-timeline-of-disease-and-viral-shedding/ 28) NHS COVID-19 Admission Guidance https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/clinical-management-of-persons-admitted-to-hospita-v1-19-march-2020.pdf 29) NebraskaMed N95 decontamination process: https://www.nebraskamed.com/sites/default/files/documents/covid-19/n-95-decon-process.pdf
--- Originally published: 22/3/20 ---
--- Updated: 28/3/20 ---


Saturday, 21 March 2020

The WACEM Inaugural Special Global Web Conference on “The Emergency Physicians Response to COVID19 across the World”




21st March 2020

The WACEM Special Global Web Conference on
“The Emergency Physicians Response to COVID19 across the World”

Eminent Academic Experts from USA, Italy, UK, Netherlands, Qatar, India and many other places participated in this specially convened Web Conference.  

The Key Take Home Points:

The Patient Care Paradigm will be the most defining as number of patients mount up.

Non-COVID19 sick patients and health care providers need protection ASAP.

Viral Load and virulence is variable across patient population. Greater the co-morbidity greater the severity even though there are healthy sick patients.

Few of the leaders on the Conference are infected and have signs of severe weakness, Diarrhea, Nausea, Vomiting and extreme myalgia and fatigue. They are healthy!

“SILENT HYPOXIA” needs to be recognized. Patients look fatigued and are low temp but are Hypoxic.

Hospitals need to consider being locked down. Exit Doors open to EXIT ONLY, no visitors, and one point entry outside the hospital in a separate tent where fully gowned personnel check vitals temperature and recognize high-risk patients for further testing in a special area in isolation.

Airborne and Droplet precautions are important.

Health Providers need PPE and that demand will rise and is paramount.

Hospitals Need for Ventilators and Critical Care beds will rise.

Qatar Model of Erecting Field Hospitals, Quarantining in Hotels and ramping up of critical Care beds was applauded.

Telemedicine to care for the STABLE SICK is recommended.

Antimalarial Chloroquine, Antibiotic Azithromycin and Anti-Viral Remesdivir are all being recommended but we still need outcomes data. THEY ARE NOT FOR PROPHYLAXIS.

POCUS Lung Ultrasound, HsTrop and D Dimer can be used to predict mortality.

Provider Safety and in-patient safety and surge management are all key.

Sharing of all protocols for Triage, Isolation, Discharge, Admission, NIV, Ventilation, and Resuscitation is needed.

Be Safe and God Bless Everyone !

Get well Soon Leaders !

Next Update very soon !

Regards
The World Academic Council of Emergency Medicine