Sunday, 20 December 2020

The 40th WACEM-ACAIM Weekly Summit: Week 12 of e-EMINDIA2020

 

The risk of SARS-CoV-2 reinfection in an intense re-exposure setting

Dr. Hassan Al-Thani
Head of Trauma and Vascular Surgery
Hamad General Hospital, Doha, Qatar

Dr. Al-Thani started his talk by introducing CDC's guidelines on investigating the possibility of reinfection with COVID-19. He presented his review of the paper "Assessment of the risk of SARS-CoV-2 reinfection in an intense re-exposure setting". The study aims to assess the risk and incidence rate of documented reinfection in a cohort of 133,266 SARS-CoV-2 laboratory confirmed infected persons. Viral genome sequencing was conducted on retrieved samples of the first positive swab, and reinfection swab of patients with strong or good evidence for reinfection as confirmatory analysis. Results suggested conclusive evidence of reinfection, however, the risk of documented reinfection was rare, at about 1-2 reinfections per 10,000 infected persons. A significant proportion of the population has been repeatedly exposed to the infection but such re-exposures hardly led to any documentable reinfections. Nearly two-third cases were discovered accidentally, either through random testing campaigns or surveys or through contact tracing, of which none were severe, critical or fatal infections. These findings suggest that most infected persons do develop immunity against reinfection that lasts for at least few months, and reinfections (if they occur) are well tolerated and no more symptomatic than the primary infections. Dr. Al-Thani concluded his talk by suggesting that SARS-COV-2 reinfection appears to be a rare phenomenon, and that immunity develops after the primary infection and lasts for at least a few months, and that immunity protects against reinfection.

Biothreat and COVID-19 experience in Malaysia

Prof. Dr. Mohamed Alwi Abdul Rahman
HOD Emergency and Trauma,
Selayang Hospital, Malaysia
Fellowship coordinator in EM, Malaysia
General secretary WACEM 2021, Malaysia

Malaysia has experienced several types of disasters including natural and man-made ones. In order to prevent global outbreaks, it is critical for high-risk countries such as Malaysia to be prepared and have appropriate biothreat preparedness. Among some of the statistics provided by Dr. Alwi, 78 deaths from the H1N1 pandemic in 2009, and 5 suspected cases during the SARS pandemic of 2003, compared to 265 cases and 105 deaths during the 1999 Nipah virus outbreak, stood out. A study of biothreat preparedness of hospitals in Klang Valley, Malaysia published in 2019, revealed that there is room for improvement in terms of hospital preparedness to biothreats, namely regular staff education and training, space designated for airborne biothreats i.e. negative pressure rooms/isolation rooms, and plans addressing stockpiling of antibiotics and supplies, and adequate laboratory diagnostic capabilities. In order to improve biothreat preparedness, hospitals should update their emergency plans consistently, have frequent training for staff including disaster exercises, store appropriate antibiotics, improve laboratory diagnostic capability, and ensure adequate supplies of PPE and related equipment. In this COVID pandemic, Malaysia fought its own fair share of challenges, just as the rest of the world did, for instance surge capacity, adherence to PPE, dynamic guidelines and SOPs. They made sure to focus and communicate with their healthcare workers regarding coping with stress during the outbreak, and regular reiteration of safety measures. He concluded his talk with a few key messages, highlighting the need to consolidate and enhance existing pandemic plan strategies, prioritize biosafety and security of healthcare workers, need for continuous risk communication and community engagement, and developing sustainable business continuity plans. 

National Residency Programs

Government Medical College, 

Kozhikode, Kerala

Post-COVID Syndromes

Dr. R. Chandni
Professor and head,
EM member, State Expert Committee and
State Medical Board for COVID, Kerala

Dr. Chandni presented an overview of the outbreak, presentations, management concerns and long term sequelae of COVID-19. After a quick review of cytokine storm in COVID-19, Dr. Chandni reminded us that COVID-19 is unlike MERS and SARS outbreaks in having a high prevalence of VTE and its potential complications. The recovery process itself is a spectrum from short disease to longer term illness or syndromes. People continuing to experience symptoms after their initial recovery, the so-called "long-haulers" are said to have the post-COVID syndrome or "long COVID-19". For some people, some symptoms may linger or recur for weeks to months following initial recovery, while others develop medical complications that may have lasting health effects. There may be mood disorders, such as PTSD, depression, anxiety, and sleep disturbances; neurological effects such as anosmia, cognitive impairment - memory and concentration; thromboembolic disease such as DVT, PE, MI, Stroke. There is plenty still unknown with COVID-19. We have seen that it can result in prolonged illness and persistent symptoms. It can happen even in the young, the mildly symptomatic or asymptomatic. She briefly touched upon the diagnosis of MIS-C, a Kawasaki-like illness with features of toxic shock syndrome, reported in children and adolescents. She concluded her presentation by emphasizing the need to recognize red-flag features of serious disease or complications in the post-COVID syndrome, recognizing psychological impacts, as well as the need for long term rehabilitation. 

Zydus Hospital and Healthcare Research,

Ahmedabad, Gujarat

Administrative Modifications for COVID-19

Dr. Ketan Patel,
Consultant and Head, EM

Dr. Patel had an excellent presentation, short and sweet, and loaded with photographs as he described the administrative modifications by his department during the pandemic. Their focus was on creating safe and clear areas, and allowing the best safety standards for both patients and staff. He particularly highlighted the use of the lightweight abrasive blasting helmet - among their modification to a PAPR (powered air purifying respirator). The PAPR allowed for circulation of cool purified air within the PPE suit, while the blasting helmet, in his experience, reduced the unfortunate problem of fogging. With the need to use full PPE for aerosol generating procedures, having a device and get-up that provides both safety and clarity of vision is a boon for the clinician. 

Aftershocks of sweet COVID

Dr. Rignesh Patel
Consultant, EM

Dr. Rignesh opened with his case of a male patient in his 60s, with a background of diabetes, who attended with acute unilateral visual loss following three days of decreased vision and redness in the ipsilateral eye, and five days of reduced ipsilateral facial sensation. His vitals on arrival were significant for a mild fever, hypertension, tachypnea and moderately elevated random blood glucose reading. Review of systems demonstrated a normal systemic examination, while his facial examination was grossly abnormal. He had a swollen, red, right eye with non-reactive pupils, ophthalmoplegia and periorbital edema extending to the cheek area. His labs were significant for elevated white cell count, and D-dimer. His COVID IgG was reactive, though RT-PCR was negative, explained by a recent history of COVID-19 infection just 10 days prior to this attendance. He had been treated with remdesivir and steroids. After further tests, including CTs of his brain and paranasal sinuses which revealed significant soft tissue swelling, eye involvement, mastoiditis, and importantly, bony erosion of the maxillary sinus, he received his diagnosis of mucormycosis. Mucormycosis is a highly invasive and often fatal disease, in this case infecting the susceptible patient who was immunocompromised by his diabetes, recent COVID infection and steroid treatment. 

EDAC in the ED

Dr. Arjun J V
PGY3 EM

Dr. Arjun presented his case of a female patient in her 30s who attended with acute respiratory distress and reduced consciousness, who had pink frothy secretions requiring frequent suctioning. After promptly recognizing the need for a definitive airway, she was intubated. She had bi-basal crepitations, and type 1 respiratory failure, tachycardia with feeble peripheral pulses, and so she was duly resuscitated. The team provisionally diagnosed respiratory failure due to COVID, but also considered other differentials such as a major cardiac event, aortic catastrophe, cerebrovascular accident, sepsis, shock, endocrine emergency, and poisoning. A collateral history revealed that she had been experiencing an expectorating cough for two days, and that she had a background history of hypothyroidism for which she was not medicated. Initial investigations were conducted, including POCUS and CT brain which were reassuring, CT Thorax which revealed bilateral congestive changes, a negative urine toxicology report, and labs significant only for raised white cell count and mildly elevated CRP. In the midst of this, the patient developed a gross swelling of her neck. It was initially thought to be due to iatrogenic injury caused during intubation. Specialty consultations were sought, and further investigations conducted. A USG of the neck revealed the clinically detected mass to be a diffuse enlargement of the thyroid gland suggestive of nodular goiter, and a CT neck further revealed retro-clavicular extension of the left thyroid lobe, and tracheal compression (further increased by neck flexion). The patient thus had a further diagnosis of large multinodular goiter with dynamic obstruction of the upper airway, and type 2 respiratory failure. This initiated Dr. Arjun's discussion of his interesting topic, EDAC (excessive dynamic airway collapse) i.e. a pathological collapse and narrowing of the airway lumen by 50% or more (some suggest 70% or more) of the sagittal diameter. The emergency clinician must be quick to recognize the signs of airway obstruction, and anticipate difficult bag-mask ventilation and intubation, thus getting ready for direct laryngoscopy, using a supraglottic airway device, and potentially even front of neck access, due to distortion of anatomy and obscuring of landmarks. Notably, stridor is a late sign of airway compromise, thus we should recognize other signs, such as subtle voice change, hoarseness, dyspnea, agitation.  Because of the unpredictability of a partial obstruction transforming into complete obstruction, one must be prepared at all times. 






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