Saturday 14 November 2020

The 35th WACEM-ACAIM Weekly Summit: Week 7 of e-EMINDIA2020


🎇 Happy Diwali! 🎇

Toxicological issues that have emerged during the pandemic

Dr. Ziad Kazzi, MD
Associate Professor of Emergency Medicine,
Director, International Postdoctoral Fellowship in Medical Toxicology, Emory University,
Assistant medical director, The Georgia Poison Center, 
President MENATOX, Board member, ACMT, MTF

    Dr. Kazzi started off this week's talks with a bang. He started with sharing a valuable resource, a web-series by ACMT (response to COVID-19). His talk focused on the increased exposure to poisoning from cleaning agents and disinfectants such as bleach and the more dangerous chlorine dioxide which produces severe adverse effects and death. Unfortunately there were cases of ingestion of these substances. Toxicologists play an important role in public education of correct use of equipment, procedures, types of agents, and their medical consequences. Relevant at present, was his mention of alcohol-based hand-sanitizers. Due to the pandemic, a lot of alcohol distilleries participated in production of these hand-sanitizers. These should contain a minimum of 94.9% ethanol by volume, or isopropyl alcohol, along with bittering agents such as hydrogen peroxide to dissuade ingestion. In some instances, methanol was used erroneously. Methanol, as we know, is highly toxic substance. 
    He also spoke about hydroxychloroquine/chloroquine. These become an important topic of discussion due to the initial touting for the "treatment and prevention" of COVID-19, by both clinicians who did not wait for an evidence base as well as non-medical people, particularly those in the public eye. These drugs produce sodium channel blockade, potassium channel blockade, and an intracellular shift of potassium. The trouble is unpredictable toxicity, sometimes even in therapeutic doses, potentially with multisystem adverse effects. Treatment is aggressive supportive care, high dose epinephrine, diazepam, careful use of sodium bicarbonate typically with replacement of potassium. There were also cases of oleander (a cardiac glycoside) poisoning. Interestingly, this can be treated with digoxin binding fragments, though likely to require higher doses than digoxin toxicity, and supportive care. Serum digoxin levels may also be helpful - though not targeting the exact substance, and thus likely to be inaccurate if considering quantitatively, any level at all is still suggestive of toxicity. 
    Dr. Kazzi spoke passionately about the fact that we must follow an evidence base. We must be patient in our therapeutic ventures. Undue use of any and every medicine we might think of is not the right way to practice medicine, and in fact is quite dangerous. His talk highlighted the role toxicology has and continues to play during this pandemic. 

Surviving COVID

Dr. Digambar Naik, MD
DOIH, DHA, FIAE, FAIMP (Cardiology)
Senior Cardio-metabolic physician, 
Senior Echocardiography Trainer, Goa

    Dr. Digambar spoke not only as a clinician, but as a recovered COVID-19 patient. Despite taking precautions and following the rules, Dr. Digambar found himself a victim of this terrible virus. He had been taking prophylactic medications at the time already, including hydroxychloroquine. As a patient in hospital, he was on a medication list so long it did not fit on just one page. This polypharmacy continued even upon discharge. What made a significant impact, as you could tell from the heaviness when he spoke about it, was being alone in his time of need. Due to typical institutional rules, he had no attendant, family support, contact. He learnt from this the importance of managing one's own wellbeing. He had a few thoughts that stuck with him, which he shared with us, the first of which was that COVID is not a simple flu. Accidents happen despite precautions. This is a virus that is killing the healers. Our knowledge of COVID is still incomplete. In a lot of cases, drugs are used irrationally. He also took drugs for lung fibrosis (glutathione in his case), on his own initiative and suggested that this warrants some attention. His structural ECHO was normal, but after he was discharged, he arrange a functional ECHO which revealed strain patterns. So he highlighted the importance of functional echocardiography. He closed by saying that a lot of hospital burden can be prevented by better post-COVID management. The patients have persisting symptoms which understandably cause a lot of worry, but often resolve without intervention. Follow up of these patients would reduce hospital attendance. 
    There are so many clinicians, nurses, paramedical staff who have experienced the disease themselves. It would be prudent to use their clinical experience and patient experience to improve clinical care for all.

Jubilee Mission Medical College and Research Institute, Kerala

Reimagine the Restart - The impact of COVID-19 on the wellness of Emergency Doctors

Dr. Deo Matthew, 
Senior resident, 

A pertinent topic at any time, but especially right now, Dr. Deo's presentation calmly brought some structure to wellness. His talking points followed the spokes of the ACEP wellness wheel. He brought forward the idea of considering this pandemic as being a syndemic (defined as two or more disease states adversely interacting with each other). It is, sadly, easy to envision the lasting psychological impact this pandemic is bound to have upon professionals and civilians. Emergency physicians are especially susceptible to burnout. We are shift workers in an adrenaline fueled profession seen not just the sickest of the lot but a lot of the sickest. Dr. Deo suggests we do for ourselves what we do best at work - triage. Whether it be the emotional, occupational, physical, intellectual, social or spiritual health, we must make time for ourselves too. 

Oxford Vaccine Trial - Critical Appraisal of the Journal

Dr. Vijay Chanchal, 
PG resident

Vaccines for COVID-19 have been the talk of the town, featuring in the news all over the world. There are several trials ongoing. For his appraisal, Dr. Chanchal chose the Lancet publication - "Safety and immunogenicity of the ChAdOx1 nCoV-19 vaccine against SARS-CoV-2: a preliminary report of a phase 1/2, single-blind, randomised controlled trial". The ChAdOx1 nCoV-19 vaccine consists of replication-deficient simian adenovirus vector ChAdOx1, containing the full-length structural surface glycoprotein of SARS-CoV-2, with a tissue plasminogen activator leader sequence. The vaccine was administered intramuscularly into the deltoid muscle, and recruited participants were followed up and required to record any adverse events. Humoral and cellular responses were assessed using various neutralization and immunoassays. Dr. Chanchal systematically reviewed the methodology in his presentation. He noted that the study was not easy to generalize, given that it was done in young healthy volunteers, a majority being Caucasians. It was limited also by short follow-ups, small number of participants, and for being a single-blinded design. He finished with the conclusion that ChAdOx1 nCoV-19 was safe, well tolerated, and immunogenic, while reactogenicity was reduced with paracetamol, and a single dose elicited both humoral and cellular responses against SARS-CoV-2, with a booster immunization augmenting neutralizing antibody titres. 

A mysterious coagulopathy

Dr. Jasmine K J
PG resident

With her case presentation, Dr. Jasmine highlighted the hypercoagulability associated with COVID-19. Her patient who presented with an ischaemic upper limb with nail bed cyanosis and absent brachial, radial and ulnar pulses. She shared two published papers referring to acute limb ischaemia in COVID-19. SARS-CoV-2 attacks endothelial cells and can activate the coagulation cascade resulting in extensive thrombosis. Studies have reported acute limb injuries in COVID-19 patients with lower rates of successful revascularization due to viral related hypercoagulable state. Addition of iv heparin has been reported with better outcomes, but there are limited studies and no established treatment protocols in such patients. 

Kasturba Medical College, Manipal

Innovation and simulation during the COVID-19 Pandemic

Dr. Freston Marc Sirur, MD
Assistant Professor
KMC Manipal

Because failure of PPE has been an important factor in healthcare COVID-19 infections, with the highest risk errors relating to hand hygiene and compromised or mishandled PPE; finding solutions for these issues played an important role in KMC's management during the pandemic. Some of their innovations included Bio-safety barrier devices, reusable PPE, and modified techniques for AGPs. Their cleverly named barrier device, B-safe, is an easy-to-install containment system which can provide high-level protection for exposure-risk procedures like endotracheal intubation, vascular access, beside ultrasound, mechanical ventilation, monitoring, and throat swab collection. The "4T" Tented Transport Trolley in Transmissibility provides them a contained transport system. Their UDUPI (Ultra-ductile Portable Interface) allows for interventions in infection - quite reminding me of similar little units from South Korean news. They took to 3D printing face shields for personnel. Simulations played a key role for KMC as well. From donning and doffing exercises for correct and safe use of PPE for all medical and auxiliary staff to practicing the MIST (Modified Intubation Sequence for Transmissibility) Bundle for infectious diseases with aerosol hazard, some of their efforts are soon to be published. Watch out of team KMC leading by example.

CV(A) Neurological complication of COVID-19

Dr. Chethana A S
PG resident

Dr. Chethana shared her case of a patient in his 50s who was admitted with typical symptoms of COVID-19, going on to develop a unilateral limb weakness on his 7th day of admission. His medical history was significant for type 2 diabetes on metformin. He was admitted under the neurology team under whom he had a CT angiography revealing a left ICA stenosis. With that, Dr. Chethana focused on the strokes in COVID-19, beginning with defining a probable versus possible association. COVID-19 is an independent risk factor for acute ischaemic stroke. Critically ill patients with SARS-CoV-2 showed elevated D-dimer levels and platelet counts, which may render patients susceptible to acute cerebrovascular disease. She delivered a few good take home messages. In view of COVID-19 and its association with hypercoagulability, the concurrent presence of anticoagulation with direct oral anticoagulants should not be reassuring as preventive. Immediate anticoagulation with LMWH has been recommended in COVID-19 patients. We need to consider multisystemic presentations of the disease including neuro and cardiovascular complications.

Acute on chronic pandemic

Dr. Mohammad Khalid
PG resident

Dr. Mohammad impressively delivered his case presentation which reminded of the all-important comorbidity of diabetes in COVID-19. His patient who presented with respiratory distress, needing high flow oxygen at the get go progressed early to intubation. His investigations quickly revealed a high blood glucose level and presence of urinary ketones. He was resuscitated in the emergency department, with vascular access and invasive monitoring established early, RSI and mechanical ventilation, iv fluids, and bedside ultrasound examination. His medical history was significant for longstanding diabetes on OHAs, having recently stopped insulin; and hypertension. A systematic review of history, examination and investigations led to developing a sensible list of differentials. Some follow up after he left the department revealed a final diagnosis of severe COVID-19, uncontrolled diabetes and a resolving acute kidney injury, and unfortunately a klebsiella VAP. Dr. Mohammad's reason to choose this topic was to remind us of the "chronic pandemic" of diabetes. These individuals represent a large vulnerable segment of the COVID-19 population. He proposed that the poorer prognosis of diabetic patients could be a consequence of the syndromic nature of the disease itself in addition to other factors like old age or comorbidities. He made a good point about people with chronic diseases not visiting hospitals, in some instances with worsening their pre-existing disease and drove the message that COVID itself and its interplay with chronic illnesses require an aggressive resuscitative pathway in EDs / ED-Crit units with equally aggressive diagnostic pathways. 

Tune in for more next week

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