EM:RAP 2020 March 20th Breaking News

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August B., III -

My husband is an ER doctor in New Orleans. Yesterday he finished his shifts & is home for his pre planned vacation x 10 days, as we have a 3 week old newborn. As this is our 7th child, all of our children (17 year old & younger) are home from school. As discussed in your previous broadcast, he wore appropriate PPE at work, immediately washed his clothes & showered before entering our household. He has no symptoms. My question is - do we know how long viruses live in his nasal mucosa & can be passed on? If passed on, when is the longest timeframe someone might show symptoms? We are staying aware from grandparents for the next 2 weeks.

Anand S., M.D. -

I'm not sure we know the answer to this. The NEJM published an article this week about how long it can live on different surfaces but, that doesn't really apply to nasal mucosa.

The best answer is that up to 14 days after exposure, people can still become symptomatic. However, with proper PPE, there shouldn't be a risk. This has been shown in Hong Kong where health care workers aren't getting COVID19

NEJM Article: https://www.nejm.org/doi/10.1056/NEJMc2004973

Maximillian Y. -

Do we know what the "appropriate PPE" they used was. The CDC, LA public health and our hospital downgraded the PPE to surgical mask. This seems very risky to me when we know this thing is highly transmissible even in the asymptomatic phase. I'm just worried that a lot of ED doctors are going to be getting sick because of this decision.

EMFreakz -

Does the team agree that proper ppe means surgical mask is fine unless intubating?

Benjamin P. -

I read that higher LDH, CRP, ferritin and d-dimer might be associated with higher mortality and poorer prognosis in COVID-19 patients. Any thoughts on how much we should rely on these lab values vs the clinical scores mentionned in this podcast?

Anand S., M.D. -

We don't know the answer to this but, I would like to rely on the lab less as it's already stressed. Likely a role for these labs in the ICU, though.

Eric S. -

Agree, at the point-of care in the ED, unlikely to make a difference in our dispo decision. Likely more useful for prognostication upstairs.

Ian L., Dr -

Great advice .
Many patients admitted with hypoxia might survive with supplemental oxygen .
What measures are in place for protection of health workers and other patients if high flow nasal cannula therapy is very likely to save a patient eg 50 year old in normally good health who develops a COVID 19 pneumonia ?

Ian L., Dr -

In staff safety during emergency airway management for COVID -19 in Hong Kong :Cheung J et al in PlumX Metrics advise AGAINST Aerosol Generating procedures until patients are cleared of COVID 19 .
They state oxygen above 6L per minute is considered high flow and ought NOT be done if there is no airborne isolation room .

Jesse D. -

What about using Absolute Lymphocyte count as a screening tool for COVID? Our some combination of other lab values? We are being asked to severely limit our use of COVID testing and an case series in the NEJM https://www.nejm.org/doi/full/10.1056/NEJMoa2002032 suggested an ALC < 1500 might be 82% sensitive for COVID. That would make it more sensitive than the PCR test itself (currently listed as 75%). Thoughts on that approach>?

Thanks

Anand S., M.D. -

Jesse - At this point, I'm simply assuming that patients with infectious symptoms have COVID19. There's too much community transmission to assume otherwise (at least in my region). My only decisions are admit, admit ICU or d/c home.
I like the idea of the ALC but need more data before I rely on it.

Eric S. -

ALC <8 is one of the heaviest-weighted criteria in the MulBSTA score, which was developed for risk stratifying viral pneumonia. Although not validated, it's quite sensitive for viral etiology. Still, nothing seems to be more important than age.

Jesse D. -

Thanks for you prompt response and all that you and the rest of the EM:RAP crew are doing to get info out. As for the MDCALC folkes I really appreciate what you do as well and think it would be awesome if you could come up with a diagnostic risk score based on a composite of lab values

Thanks

Brian T., M.D. -

UV sterilization of N95-- this could potentially increase supply of N95 by an order of magnitude

· When exposed to UVC light, "After 15 min the [SARS corona]virus was completely inactivated to the limit of detection of the assay..."

o https://www.sciencedirect.com/science/article/pii/S016609340400179X

· "This suggests that, for influenza virus, dozens of UVGI disinfection cycles could be performed on respirators without the UVGI affecting their performance."

o https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4699414/

Maria R. -

Alot of hospitals are recommending regular surgical mask unless you are intubating. I thought we have not determined if this virus is airborne vs just droplet. what do you guys recommend for PPE in screening these patients coming in with cough, fever while we examine them?

Anand S., M.D. -

Maria - check something of the segments with Dr Bogoch. For standard contact, droplet precautions fine (surgical mask, face shield) + contact. For aerosolizing procedures like intubation, airborne + contact.

Ian L., Dr -

If you are doing intubation the safest is PAPR or Srtyker T4 or The Total Shield TM Surgical Helmet And The Negative Pressure room .
A team ought be walking around with at least the Face Visor N95 Mask Full gown and double gloves for the codes and then doff (take off ) PPE with one or two gowned helpers .
CDC has a stringent donning and doffing y tube demo .

Ian L., Dr -

The Stryker T4 seem impressive as does the TotalShield Helmet but CDC quoted a report in 2004 by James L Derrick and Charles D Gomersall that the solid looking Stryker T4 Failed to filter particles as well as a N100 mask and Face Shield .
In Surgical Helmets and SARS infection :Emerging Infectious Diseases Vol,10 February 2004 .

John W. -

I am a medical director of a 50,000 visit ED. We had the first case of COVID in our region and unfortunately the first COVID death in our state (PA). We are in the midst of scenario planning and one likely scenario would involve non-EM personnel providing care in the ED environment. Do you know of any good resources (or could you develop such resources) for such providers? Specifically, the workup and treatment/disposition of common ED presentations? These providers will all be competent and boarded in their fields and preference will be given to FM and IM providers but there will be a wide range of capability. There are resources out there for medical students and off service rotators but they are education/testing oriented. I am looking for a practical guide to the care of the EM patient.

Anand S., M.D. -

This may be helpful: https://www.emrap.org/episode/rop2020march25/covid
Also: https://www.stemlynsblog.org/covid-19-a-primer-on-icu-care-for-the-non-intensivist-st-emlyns/

Greg J. -

Nice job, all of you. I'd love to hear Jerry Hoffman's thoughts on this virus and response if EMRap can make that happen.

Sarah A. -

Seems fantastical to refer to mortality-based decision making for ECMO as useful only in a hypothetical "disaster situation". How many patients in the world actually have access to ECMO? The reality of weighing futility of care and allocating limited resources among patients is a routine, daily choice faced by thousands of providers in emergency departments around the world. Yet they are vulnerable to blame and self-doubt because there are not protocols or evidence to back up the decisions they are forced to make. They are held to the "standard of care" in the textbooks and guidelines from high-resource settings, even when they are not humanly possible locally. The psychological effect of taking that responsibility on yourself is immense, particularly when there is not any evidence to guide you and take some of the uncertainty off your shoulders. Can you please help us locate decision making tools to predict who is most/least likely to benefit not just from ECMO, but from intubation, mechanical ventilation and CPR in low-resource settings? Most of these patients will never make it to a center with an ICU. So how do we decide which one is worth trying to get there? When we have only 1 ventilator, 1 ambulance, 1 suction catheter, limited PPE, limited staff and space, when the cost of transport may be devastating to the patient's family. It would be nice to know whether someone has a 10% or 90% chance of survival in those cases, based on easy-to-obtain parameters that can be obtained in the ED such as history and physical exam findings.

Joe H., MD -

Hi Sarah,

Thanks for your thoughtful comment and question. There are a number of CDTs that aim to estimate the chances of survival of different treatment modalities - some of which are captured in our COVID-19 Resource Center (https://www.mdcalc.com/covid-19). They aren't always looking at who is *most likely to benefit* from a treatment, which is a related but different question - which may be important to consider when coming to a treatment decision.

Also - before incorporating any score for the decisions we're contemplating - it's important to first differentiate if the decision falls within Crisis Standards of Care structures (scarce resource allocation structures), when the question truly is who of several patients are most likely to benefit and which of them gets a scarce resource, versus the standard decision making structure, which should ideally be a patient-centered decision of which of several treatment paths is most beneficial for the individual patient (not factoring in other patients).

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EM:RAP 2020 March 20th Breaking News Full episode audio for MD edition 12:06 min - 17 MB - M4A