History In The Making
We opened this week with a reminder of the history of INDUSEM, WACEM, and its connections to AAEM. As a young resident and member of AAEM, Dr. Galwankar worked to amalgamate the best principles of AAEM, as well as best practices from American and European EM while establishing INDUSEM. The crux of his mission was to start an organization for emergency medicine from the ground up within India. The urgency of placing due importance on board certified residency programs and inculcating the culture of regular reading and assessments led to the establishment of ACEE. The new residents of a fairly new specialty saw the need for networking, soon leading to the formation of the free membership organization, the EMA. Several other leadership initiatives such as FLAME (Female leadership academy for medicine and entrepreneurship) and EMCORD-India (Emergency Medicine Council of Residency Departments in India); research initiatives like INCIITE (INDUS Network of Critical Illness and Injury Translational Trial Experts) and INDUS-ARC (INDO-US Academic Research Cooperative); and journals such as JETS (The Journal of Emergencies, Trauma and Shock), JGID (The Journal of Global Infectious Diseases), etc., and many other initiatives all fall under the umbrella of INDUSEM. In 2014, INDUSEM along with several global academic partners and associates, transformed to the global congress and council, WACEM. With much to its credit already, WACEM is still hard at work with a clear vision for 2025. (More information can be found in the links included within this write-up.)
Disparities in COVID-19
Dr. Lisa Moreno-Walton,
MD, MS, MSCR, FAAEM, FACEP, FIFEM
Professor of Medicine - Emergency Medicine,
Louisiana State University Health Sciences Centre,
President, AAEM (American Academy of Emergency Medicine)
Dr. Moreno chose a topic close to her heart, important not just in her department and state, but applicable around the globe. With many graphs and stats, she showed us the disparities in case rates and mortality rates for COVID-19 by race and ethnicity. She spoke of host related predispositions to disease and worse outcomes; factors impacting spread and increased case fatality rates among minorities as well as the unfortunate but present unconscious bias, social conditioning, and historical inequities perpetrating and perpetuating poor outcomes in populations of color. Her presentation reminded us of some key facts - that living below the poverty line is associated with increased morbidity and mortality, that 40% of US households are headed by women but of US born women, of which Dominican female heads of household are most likely to live in poverty. That 35.3% of female headed households are food insecure, but because of the various considerations excluded or overlooked when studying these numbers, there's a true likelihood of underestimating that final percentage. In this pandemic where a lot of work is being carried out from home, educational disparities also play a role - of the working class there are some whose work cannot be carried out from home (the office cleaners, housekeepers, grocery clerks, cashiers, sanitation workers, mail carriers). Information disparities still exist - there are some who do not have internet, or computers; some who only consume information from selective and not necessarily validated or vetted sources.
As much as we are all focused on this new disease and pandemic, there are in fact factors that have long existed and though these are not problems easily solved by any one individual, it becomes an important part of our job as emergency physicians and responsible humans to recognize the existence of these disparities.
Government Medical College, Chandigarh
Ventilatory management of patient with severe COVID-19 induced ARDS
Dr. Selwin R Selvam,
PG Junior Resident
Dr. Selwin began his presentation with the case of a 45 year-old male patient who had been experiencing fever, chest pain, cough and shortness of breath, with a background medical history of diabetes. Following his examination which revealed tachycardia, tachypnea and profound hypoxia requiring oxygen via NRBM, chest X-ray showing diffuse bilateral consolidation, he was provisionally diagnosed with severe acute respiratory illness due to COVID-19 pneumonia with ARDS (acute respiratory distress syndrome). His respiratory failure, and potential need for mechanical ventilation was recognized early, leading to COVID ICU admission. Non-invasive ventilation was initiated, and was followed by a failed attempt at proning with NIV (ill-tolerated by the patient), however, impending type 2 respiratory failure with respiratory fatigue led to endotracheal intubation with mechanical ventilation. Dr. Selwin described the other measures taken and course of illness for this patient as well, his case choice serving to generate a discussion about ventilator management in COVID-19 ARDS. His team largely follows WHO clinical management guidelines, with regards to immediate administration of supplemental oxygen, NIV and HFNC (High flow nasal cannula), proning strategies, and ventilatory management. He ended the discussion with a review of the SCCM recommendations for initial management of hypoxic COVID-19 patients.
Mechanical Ventilation Strategies in COVID-19 induced ARDS
Dr. Dheeraj Kapoor,
Beginning at the beginning, Dr. Dheeraj reiterated the aim of ventilatory management in COVID-19 induced ARDS (CARDS): respiratory support should find a balance between airway recruitment and the risk of lung injury. NIV and HFNC ought to be used for P/F ratio of > 150mmHg for CARDS. ROX index can be used to predict HFNC failure. Lung-protective strategies should be used. Bedside measures such as PV curve and optimal PEEP settings to evaluate and improve lung recruitment. Measures to improve hypercapnia, such as optimizing ventilator settings, prone positioning, tracheal gas inflation, extracorporeal life support, can be used in different combinations. Early prone positioning may act in a number of ways, including improved V/Q, lung recruitment. ECMO used judiciously for the correct indications, with awareness of excluding factors. Administration of NMBA (neuromuscular blocking agents) for up to 48 hours may help improve oxygenation by improving ventilator adaptation. Inhaled Nitric Oxide is another treatment consideration for refractory severe hypoxemia. He ended his presentation with a review of the evidence based guidelines from UMCNO (University Medical Centre, New Orleans), which also describe extubation strategies.
Airway management in morbidly obese COVID-19 patients
Dr. Kavida Bagwat,
Dr. Kavita presented her case of a 42 year-old female patient attending the emergency department with fever and shortness of breath, and a past medical history significant for diabetes and occasional snoring. Her case served to discuss the association of obesity in COVID-19 associated with increased morbidity and mortality. Obese individuals with COVID are more at risk of hospitalization and need for intensive care unit admission. Physiologically, these patients have reduced lung and chest wall compliance, reduced FRC and vital capacity, increased oxygen consumption and carbon dioxide production. Anatomically, obesity can mean increased soft tissue in the neck, with adipose tissue deposits in the lateral pharyngeal wall, hypopharyngeal and pretracheal regions; reduced neck mobility, large tongue, short neck, anterior larynx, and restricted mouth opening. With relation to COVID-19 there is enhanced cytokine production with greater risk of cytokine storm syndrome, increased risk of ARDS, poor pulmonary recruitment, and disrupted vasoregulation. Airway assessment is a key examination focus. Various tools such as the mallampatti score, BONES MOANS, LEMON, MACOCHA score can be used to assess difficult airway. For patients with expected difficult airways, several measures such as ideal positioning (use of ramps/ positioning aids), proning, NIV, HFNC, High PEEP, and most importantly a stepwise approach with easy availability of the difficult airway trolley.
Airway management in COVID-19 patients - What's different?
Dr. Manpreet Singh,
Dr. Manpreet used an excellent combination of his wealth of knowledge and experience, and evidence based medicine for his presentation on airway management in COVID-19. He began by describing aerosol generating events referencing Brewster et al. He referred to Verdiner et al. in describing the key features of airway management in COVID-19: adequate PPE, most experienced physician and minimal personnel exposure, rapid sequence intubation, avoiding mask-ventilation, use of video laryngoscopy, and a preference for ETT intubation. He emphasized the message good airway management requires good preparation, referring to Meng et al, acronym (OH MS MAID) for intubation preparation. The most essential measures are airway assessment, planning, use of a checklist, after which the plans can be executed and anticipatory planning for extubation prepared. He described RSI in COVID-19, and ended his presentation by describing modified extubation strategies.
Narayana Medical College and Hospital, Nellore
"COVID-19": is it the future comorbidity; A Perspective
Dr. Ravi Sankar V,
Dr. Ravi Sankar described the challenges generated by COVID-19 - be it the panic, sudden need for change in behavior, limited knowledge, new treatment updates, or the staff training, logistical issues, biowaste disposition. Equally the medical fraternity stood up to the challenge, taking up multiple role and responsibilities, teaming up with departments. The recognition that there is not necessarily a correlation between clinical presentation and RT-PCR, RAT, CTSI. Home care due to stigma associated with hospital admission, or lack of hospital beds for admission, leading to delayed presentations. In the midst of this, staff tested positive, there was the question of recurrence or reinfection. ICUs needed expanding. There is still a need for reliable bedside testing. We must consider lung ultrasound which is more cost effective and time sparing than CT. COVID testing and CTs may need to be considered as adjuncts in patient assessments. As for clinicians, there is a recognized need for behavioral modification, importance of tending to HCP wellness, disaster training, simulation based testing, telemedicine, and preparation for future pandemics.
Biomarkers versus CT indices, prognostic significance in COVID
Dr. B S Gopala Krishna,
Predicting mortality among patients with COVID-19 who present with a spectrum of complications is difficult, further hindering prognostication and management of the disease. Therefore, there is a need for risk predictors to support management decisions. Dr. Gopala Krishna's team carried out a cohort study over a period of 3 months, of patients admitted in their high dependency unit with COVID-19 over the age of 18 years. These patients all received a fixed set of investigations including CBC, RFT, D-dimer and serum ferritin, as well as an HRCT of the chest on the day of admission. From their studies they derived interesting results. For instances, their study found both D-dimer and Serum ferritin to be 100% sensitive, however 80% and 75% specific respectively. We did not see the study in its entirety to be able to critically appraise it, however it did generate interesting results and makes us want to see larger studies addressing a similar question.
OP poisoning with SARS-COV-2: A challenging presentation
Dr. Midde Srikanth,
Dr. Srikanth presented his case of a gentleman in his 70s brought to the department following alleged ingestion of organophosphate and pyrethroid poison. He was managed appropriately with resuscitative measures and supportive care for acute poisoning, specific antidotes (pralidoxime, atropine, glycopyrrolate, introduced at various stages based on clinical need) , which resulted in a gradual improvement of his acidosis and deranged liver enzymes and general condition. However he also had an ongoing requirement for oxygen. On the day of his poisoning, the attendants had tried approaching various local hospitals, possibly due to the misjudgment of his cholinergic symptoms mimicking a viral prodrome in the midst of a pandemic. But he ended up at Narayana Medical College where his history was taken into account and syndromic presentation recognized and treated by a team of discerning emergency physicians.
Tension pneumothorax, a dreaded complication post-COVID
Dr. Siva Kumar Adoni
Dr. Adoni's patient was a gentleman in his 70s presenting with acute shortness of breath and diaphoresis, 20 days after having been diagnosed with COVID-19 and treated for it. With a past medical history remarkable for hypertension and diabetes - two of the risk factors associated with poorer outcomes in COVID-19, as well as a CABG. A systematic clinical examination was quick to reveal absent breath sounds unilaterally, with the presence of hypoxia requiring 15 L oxygen through NRBM. He also had cardiovascular signs of instability, with a heart rate in the 140s, hypotension, and feeble peripheral pulses. The team was quick to recognize the presence of a tension pneumothorax and proceeded with chest drain placement. The patient had further investigations including bedside ultrasound, quickly confirming their diagnosis, as well as a CT thorax which showed both the pneumothorax, as expected, as well as ground glass opacities on the contralateral lung. They also carried out other investigations, including D-dimer and serum ferritin that were raised.
It was notable, in my opinion, that the presence of a tension pneumothorax, though always an emergency you do not wish about any patient, is even more alarming when there is limited "good lung" in cases such as this one or other chronic respiratory illnesses, and quick recognition and action is the call of the hour to salvage these situations before it is too late.
Tune in for more next week...Until then, check out the links below:
WACEM COVID Central - for links on all our publications
INDUSEM - for links to various projects, affiliated sites, and further information