Tiger Board Logo

Donor's Den General Leaderboards TNET coins™ POTD Hall of Fame Map FAQ
GIVE AN AWARD
Use your TNET coins™ to grant this post a special award!

W
50
Big Brain
90
Love it!
100
Cheers
100
Helpful
100
Made Me Smile
100
Great Idea!
150
Mind Blown
150
Caring
200
Flammable
200
Hear ye, hear ye
200
Bravo
250
Nom Nom Nom
250
Take My Coins
500
Ooo, Shiny!
700
Treasured Post!
1000

YOUR BALANCE
YACP......
storage This topic has been archived - replies are not allowed.
Archives - Tiger Boards Archive
add New Topic
Replies: 16
| visibility 2,289

YACP......


Mar 26, 2020, 7:53 PM

(Yet another Covid-19 post)


Covid19 - From a ER MD in New Orleans... (not me)

I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know.

Clinical course is predictable.
2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias(back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.

Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.

Day 10- Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours.

81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.

Patient presentation is varied. Patients are coming in hypoxic (even 75%) without dyspnea. I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA. I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT's of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this ***** has told all other disease processes to get out of town.

China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA in the ED and rescue PCI at 60 minutes only if TPA fails.

Diagnostic
CXR- bilateral interstitial pneumonia (anecdotally starts most often in the RLL so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.

Labs- WBC low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95%
CRP and Ferritin elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated.
Notice D-Dimer- I would be very careful about CT PE these patients for their hypoxia. The patients receiving IV contrast are going into renal failure and on the vent sooner.

Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.

A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.

An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.

Other factors that appear to be predictive of poor outcomes are thrombocytopenia and LFTs 5x upper limit of normal.

Disposition
I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won't make it back.

We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.

Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the "lockdown", our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.

Treatment
Supportive

worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.

Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil's potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.

We are also using Azithromycin, but are intermittently running out of IV.

Do not give these patient's standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.

Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.

Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.

Do not use Bipap- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.

The same goes for nebulizer treatments. Use MDI. you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn't often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.

Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis.

We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.

One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 of 92%. She will be the first of many.

I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all.

2024 purple level memberbadge-donor-15yr.jpg flag link military_tech thumb_downthumb_up

Re: YACP......


Mar 26, 2020, 8:20 PM

“Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population. “

Plaquenil is Hydroxychloroquine, for those that don’t know.

2024 purple level memberbadge-donor-15yr.jpg flag link military_tech thumb_downthumb_up

Re: YACP......


Mar 26, 2020, 10:31 PM

Thanks for posting. Instead of POTUS spewing rethoric about "lamestream media" he needs to read this post and then look in the camera and tell everyone this could be you...

I don't give a crap if the death rate is.1 or 10%. If I'm this patient, it's 100%. Unfortunately, the last generation that isn't me first is about dead. Ghesh this is scary stuff.

badge-donor-05yr.jpg2016_pickem_champ.jpg flag link military_tech thumb_downthumb_up

Re: YACP......


Mar 27, 2020, 7:15 AM

This was not meant to be a political post. For the record I am neither Democrat or Republican. I have seen threads on here that are not in touch with the reality of the situation. I neither blame nor endorse the president nor congress. This disease process is not within their control. In a country of “free men” this is difficult to control. In China, they hauled away anyone ill to “sickness camps”. Can’t really do that in a free society.

2024 purple level memberbadge-donor-15yr.jpg flag link military_tech thumb_downthumb_up

Re: YACP......


Mar 27, 2020, 9:43 AM

I was not trying to make this a political post. I, like you, are neither dem or rep. Could careless about politics at this point. My apologies if it came across that way.

My entire reason in response to your post was a desire to emphasize the seriousness of this virus and my sincerest hope that everyone to be safe and respect what the medical experts are saying.

I have a family member that's a hospital administrator in the NY/NJ/PA area. She read your post and texted me and pretty much said the same thing I posted. Very few understand exactly what it takes to put one patient with your description... Not a pretty site, and tons of man hours. Do the math.

badge-donor-05yr.jpg2016_pickem_champ.jpg flag link military_tech thumb_downthumb_up

*opens Google*


Mar 26, 2020, 11:19 PM

Gonna need some time to translate this one

badge-donor-05yr.jpg flag link military_tech thumb_downthumb_up


Like maybe a month just to pretend to understand...***


Mar 27, 2020, 12:23 AM



2024 white level memberbadge-donor-10yr.jpg flag link military_tech thumb_downthumb_up


Proning vented patients...***


Mar 27, 2020, 3:22 AM



2024 orange level memberbadge-donor-10yr.jpg flag link military_tech thumb_downthumb_up


Re: Proning vented patients...***


Mar 27, 2020, 7:08 AM

Bellydown venting.

2024 purple level memberbadge-donor-15yr.jpg flag link military_tech thumb_downthumb_up

Thanks for the thread, Doc!


Mar 27, 2020, 9:27 AM

Much appreciated. Very much so!

2024 orange level member flag link military_tech thumb_downthumb_up

Re: Thanks for the thread, Doc!


Mar 27, 2020, 10:09 AM

Yeah, this post hit really close to home. I witnessed first hand my wife go through a similar situation 5 years ago... And that didn't include complications from a virus. Point being, I saw what it took from the doctors and nurses and they didn't need the ppe that is required in this situation.

I can't relate enough how appreciative I am of doctors and nurses and cleaning staff etc. They're worth every penny they make and then some.

badge-donor-05yr.jpg2016_pickem_champ.jpg flag link military_tech thumb_downthumb_up

Oh boy, now everyone is getting dr lessons.***


Mar 27, 2020, 9:33 AM



flag link military_tech thumb_downthumb_up

Thanks for the post. This is useful stuff, especially about the


Mar 27, 2020, 11:41 AM

Sepsis protocol/fluids. Disappointed that bipap isn’t working I thought it might. Good tip on the negative pressure room for respiratory treatments.

Any data yet on ACE inhibitors? I’m sure it’s hard to separate out because a lot of those folks are going to be diabetic, CHF, CAD etc. but early on saw some small numbers that ACEi make worse but then we are recommended to not stop or switch.

I did see that this was not you but a colleague. Just curious if you’ve heard anything different.


Message was edited by: lovingit®


military_donation.jpg flag link military_tech thumb_downthumb_up

The most discouraging points...


Mar 27, 2020, 12:57 PM

Among a number, frankly:
1. worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%.

2. pneumonia in symptomatic patients.

3. We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.


When it's bad...it's really, really bad.

2024 orange level member flag link military_tech thumb_downthumb_up

Re: Thanks for the post. This is useful stuff, especially about the


Mar 27, 2020, 3:21 PM [ in reply to Thanks for the post. This is useful stuff, especially about the ]

The questions about ACE inhibitors Go back to SARS for the same reasons. I would love to see a statistical Analysis of outcomes for patients on ACE inhibitors vs not in Covid-19 patients. Should be an easy study to perform. As yet I have not seen any hard data on that. It is interesting that hypertensives and diabetics seem to have poorer outcomes, knowing that a large percentage of hypertensives and diabetics in America and worldwide are on ACE inhibitors.

2024 purple level memberbadge-donor-15yr.jpg flag link military_tech thumb_downthumb_up

Re: YACP......


Mar 27, 2020, 4:09 PM

Thanks for taking the time to provide this valuable first hand information. Many of us may not understand all of the medical terminology but we can understand the seriousness of this virus. My son-in-law is a retired MD. He recognized the seriousness of this virus when it was first appeared in our news outlets. Due to my age (98), he outlined several safety measures I should follow, He also checks on me by ZOOM on a regular basis.

Thanks to you and all of those in the medical field who are on the front lines fighting for our lives.

badge-ringofhonor-joe21.jpgmilitary_donation.jpg flag link military_tech thumb_downthumb_up


Thanks for sharing


Mar 27, 2020, 4:58 PM

We in SC are fairly behind the timeline curve, to a slightly shocking degree so far. It is nice to see detailed observations of what those out there are seeing. What’s scary is it seems like when things go downhill; they seem to go downhill fast - having to send home borderline hypoxic PNA patients has gotta be tough in those circumstances. Glad you/they’ve got PAPRs

flag link military_tech thumb_downthumb_up

Replies: 16
| visibility 2,289
Archives - Tiger Boards Archive
add New Topic