Novel 2019 Coronavirus SARS-CoV-2 (COVID-19): An Overview for Emergency Clinicians - 5/1/20

Multi-system Inflammatory Syndrome in Children (MIS-C) with COVID-19: An Interview with Dr. Ilene Claudius and Dr. Mohsen Saidinejad.

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• What is it and when did we discover it as an entity? 
• Have either of you treated anyone with the disease? 
• Discussion of different cohorts of patients with MIS-C.
• Definition of MIS-C.
• Shock: cardiogenic and distributive shock presentations.
• Fever, is 4 days required?
• Discussion of where in the COVID-19 illness MIS-C occurs.
• Is clinical shock a requirement? 
• Screening criteria (labs) and the Children’s Hospital Of Philadelphia pathway. 
• What is available as treatment?
  • A discussion of IVIG
  • Steroids
  • Cytokine blockers
  • Remdesivir
• Why IVIG? 
•  Complications of the disease.
• Why are there more cases in New York? 
• How has MIS-C changed your practice of testing children? 
• Is there utility in testing for COVID-19 infection or antibodies in these cases? 

Children’s Hospital of Philadelphia Clinical Pathway for MIS-C.

Rural Emergency Medicine and COVID-19: An Interview with Dr. Harry Wingate and Dr. Ken Gramyk.

• The rural experience in Georgia and Idaho.
• Covering both the ED and inpatient areas.
• Transfers.
• Schedule and ED operation changes.
• Practicing in a resource limited environment.
• Volume changes during the pandemic.
• Employee furloughs and staffing changes.
• EMS availability and transfers.
• Telemedicine.

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EBMedicine Live Webinars:

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Emergency Department COVID Management Protocols: One Institution’s Experience and Lessons Learned

1. Laboratory Testing and Imaging
2. Disposition/admission Criteria
3. Cardiac Arrest Protocol
4. Medication Treatment Guidelines
   1. Anticoagulation Protocol
5. Intubation Protocol
6. Nonaerosolized Asthma Protocol
7. Acute Dyspnea/Palliative Care Treatment
   1. Death Management Talking Points
8. COVID-19 Smart Phrases / Discharge Plan for Likely COVID-19 Patients
9. Guidelines for Prone Positioning of Nonintubated Patients
10. Clinical Care for ED COVID-19 Patients

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COVID-19 Topics:

1. Triage Tent Implementation (02:35)
2. Telemedicine – In the tent, in the department, and in follow up. (08:45)
3. PPE (16:30)
   • Reusing N95s
   • using elastomeric full and half face respirators
   • CDC, FDA, Osha
4. EMS (22:44)
   • Crew Safety
   • Criteria for transport
   • Viral filters
   • Handoff to the ED

Helpful Links:

1. Reusable Facemasks and COVID-19
2. Mask Alternative - University of Florida Department of Anesthesiology
3. UF Health anesthesiology team devises respirator mask made from existing hospital materials

Please excuse typos

01:29 Dr. Andrea Duca introduction.

ER physician working in Milan.

02:05 What were your shifts like at the start of the epidemic?

Initially started seeing a few patients who had recently returned from China. They were screened in triage and isolated based on travel to china or contact with someone who had traveled to China and fever. Over the next few days the number of patients increased with mild upper airway and fever symptoms.

04:50 Were you testing patients for COVID-19 initially?

Only the patients coming from China or Caulonia Italy (First confirmed case in Italy).

05:08 Were the COVID-19 tests completed in-house or sent out to a government lab?

Test had to be sent out for confirmation.

05:35 The arrival of the first cases. Then… and now.

Initially only a few patients required admission. Around the 27th or 28th of February a lot of patients presented with lower respiratory symptoms and fever requiring increased admission rates. Around the first week of March the admission rate increased.

07:03 What percent of your daily volume is due to COVID-19 patients?

80% of patients presenting to the ED were hypoxic. 80% of those patients required oxygen and 30% of the patients required ventilatory support.

08:17 Are COVID-19 patients diverted to a regional facility?

No. 90% of our patients are COVID-19

09:13 Are you still testing patients for COVID-19 today?

We test only the patients we are admitting to the hospital

09:57 What is your current medication protocol?

We start antibiotics on almost all of COVID-19 patients. If the patient has severe respiratory failure, we start hydroxychloroquine. We have started using an antiviral also.

10:54 Hydroxychloroquine

Only if in severe respiratory failure

11:14 Do you use non-invasive ventilation?

We do not have the resources to intubate all of these patients. We start most patients on non-invasive ventilation, mostly helmet ventilation which works very well for most of the patients. This helps us buy some time to get an ICU bed

13:35 What kind of isolation do you use, airborne or droplet?

We only have one isolation room in the ED and usually about 100 patients needing it.

14:46 Do you put on new PPE as you go room to room?

We do not have enough supplies to change for every patient, so we just change the gloves.

15:21 What PPE do you currently use?

Gown, gloves, shoe covers, head cover and glasses

15:38 When did you create dirty and clean zones in the emergency department?

We created a dirty zone very early

16:45 Do you have a dirty and clean side in the waiting room?

Yes. They are screened and separated upon arrival

17:03 What is your annual emergency department volume? Daily volume?

100,000/year

18:04 How many treatment rooms are in your emergency department?

We have a lot of space

18:38 What percent of patients are admitted? Do you have boarders?

80%- 90% right now. Yes, we have boarders

19:54 Where do discharged patients go?

They go to a convalescent home

20:14 Have you personally been infected?

I got tested and I was negative and went back to work

20:58 Do you test your staff who are ill? What is your protocol for infected staff?

We do not test staff anymore. We cannot afford to stay home for 14 days and we all have some mild symptoms. If we have fever, we wait 7 days and then go back to work.

22:46 What percent of the ED staff were sick at any given time? And inpatient nurses?

Rates are low in the ED (10%) and much higher in the inpatient units (40%-50%)

24:00 How did you deal with so many inpatient nurses being sick?

Cancel elective procedures so everyone can treat COVID patients 24:36 What are your surgeons, who cannot operate, currently doing?

Surgeons are treating COVID patients in the inpatient wards not the ED. They started courses on how to use helmet CPAP and they follow these patients.

25:35 Are you running out of non-invasive ventilation equipment?

Not really. We have a lot of helmets.

26:20 Summary of current workflow for infected staff.

If staff get sick with a fever, they go home and after the fever is gone, they wait 7 days and then return to work.

26:36 How do you use ultrasound for COVID-19 patients in the ED?

We use ultrasound because we cannot CT scan everyone.

29:50 What criteria must a patient meet to be discharged?

Normal vitals, unremarkable labs, normal CXR, normal pulmonary chest US, O2 sat does not Drop by more than 3 points with ambulation

31:00 EMS and their role in community screening

EMS is field screening all patients. If the patient is not in distress and the oxygen saturation is Above 90%, they are not transported to the ED.

32:20 What are you looking for on ultrasound examination?

Minor abnormalities and lung consolidation

34.42 What size chest tube are you utilizing for a pneumothorax in a patient with positive pressure ventilation?

24 Fr

26:33 What inpatient location are patients sent to? By what criteria?

ICU is reserved for intubated patients. Chest tubes and CPAP are sent to regular floors

37:05 Have you seen any infected pregnant patients or staff?

Have not seen pregnant patient or staff infected with COVID 19 in the ED

38:02 Have you seen any infected children?

No. The ED sees only critically ill otherwise they would be seen by pediatricians

38:43 Are you still testing patients? How many times are you testing them?

Now the testing in completed in house. It takes about 8-10 hours. We test them on admission and 2-3 days later

39:21 What psychological support do you have for staff?

Staff have a number that they can call to organize a meeting and they are in the department every day. The stress is very high due to isolation at the hospital and at home

42:25 What would you have liked to know early on?

The rates of patients needing ventilation was going to be so high. Preparation is the key to managing this.

This episode, designed specifically for emergency clinicians, discusses Coronavirus COVID-19, including:

• The cause and history of the virus
• How it’s transmitted/spread and prevention methods
• Tools for management and treatment in the ED
• Which patients should be tested for Coronavirus
• The role of telehealth, and when patients should go to the ED
• Using vital signs to triage patients in the ED