Brit: Welcome to the emDocs.net podcast. I'm Brit Long, and today, Manny Singh and I are going to discuss some vital aspects of the novel COVID-19 illness. You can access the podcast from our homepage on emDocs.net and subscribe in iTunes. We have included a summary of all of these points with respective links for further reading. Manny, what is our first post?

Manny: The first post is something that is often underappreciated in the ED setting: Personal Protective Equipment (PPE). This post published on March 25 looks at pearls of PPE use. We really have to protect ourselves during this pandemic so we can take care of our patients and more importantly, not put our loved ones in jeopardy. First, understanding how the virus can be transmitted is important. It is primarily transmitted through droplet transmission, but it can also be picked up by contact with fomites, where this virus can live on surfaces from hours to days depending on the surface composition. When any aerosolization occurs, may it be through intubation or BVM, it can be transmitted through airborne. This is key in choosing the type of mask when there is droplet vs. airborne precaution. For any airborne isolation, you have to wear a properly fitted N95 mask. If you have a beard, consider shaving. Otherwise, you will need a power air purrifying respirator (PAPR).  Finally, and most importantly, the post exame donning and doffing procedures is crucial. There are so many ways to do this, but doing it with a partner is key as they can guide you and keep you calm. If you don’t have one, do so looking in a mirror if possible. The CDC has one of your best resources for this and it is listed in the post.

Brit: My favorite part of the post comes at the end, which has some great points that you can use for your shift. First….

1. Limit exposure to the patient (limited number of providers in the room) and remove watches and jewelry on the upper extremities before starting your shift.
2. Use a constructed checklist and a partner to assist in donning and doffing.
3. If no partner is available, use a checklist and don and doff in front of a mirror if able.
4. Ensure the cuff is tucked into the gloves. The gloves should cover the gown, and there should be no gaps. Longer cuffed gloves are preferable, as they allow you to remove the gown and gloves in a single motion.
5. Aerosol generating procedures are high risk. Wear a respiratory mask with hood or cap.
6. Sanitize before donning and before each step when doffing. Clean your gloved hands before doffing (We recommend in between steps of the doffing process).
7. Have a decontamination process when you leave your shift (to include cleaning your phone and badge).

Manny, what’s next?

Manny: The second COVID post we are covering today evaluates the new Society of Critical Care Medicine guidelines for the sick COVID-19 patient. This guideline provides some key information on how to manage these difficult patients. The guideline is open access, so if you have the time, please go to the SCCM site. We aren’t going to cover all 50 recommendations here, but there were several that stand out. Brit, what were some points that stuck out to you?

Brit: There are so many great points from this post. My first key points link back to the PPE post, specifically using video laryngoscopy and a respirator mask for aerosol-generating procedures. Also the most experienced provider should intubate. My next big takeaway was the resuscitation component. The recommended target may is 60-65, with a conservative fluid resuscitation strategy using balanced crystalloids rather than normal saline. When it comes to vasopressors, the evidence is poor. The vasopressor of choice is norepinephrine, but rather than increasing the infusion to reach the target MAP, vasopressin should be added. If cardiac dysfunction is present, add dobutamine. For those with refractory shock, hydrocortisone can be administered. Manny, there was a lot on ventilation. What did you takeaway from this section?

Manny: We really need to consider ventilatory support in these patients who can become hypoxic rather quickly, but do so in a safe way that prevents exposure to the front line providers. The guidelines recommend a stepwise approach highlighted in an algorithm seen in the post. Start with some oxygen supplementation through NC if <90% and don’t titrate higher than 96%. If oxygen therapy is not working, consider starting HFNC. The guidelines do mention a trial of NIPPV if HFNC is not available, but this should be done safely in a negative isolation room with proper viral filters. There is a lot of great ventilation and airway advice with nuances from Josh Farkas and Scott Weingart from emCrit, so I would highly recommend you visit their site. The best practice right now is to closely monitor the respiratory status of these COVID-19 patients and prepare to intubate early if any worsening.

Brit: Finally, there was a section on therapies. For mechanically ventilated patients with COVID-19 and respiratory failure but no ARDS, they suggest against routine use of systemic corticosteroids. For those with ARDS, they suggest using systemic corticosteroids. You may have heard of a prior WHO recommendation to avoid NSAIDs, though this has been removed. The SCCM recommends using acetaminophen for temperature control, and for mechanically ventilated patients with COVID-19 and respiratory failure, they suggest using empiric antibiotics. They don’t make clear recommendations due to lack of data on chloroquine or hydroxychloroquine, but these medications may be beneficial based on several recent trials. We won’t delve into it here into too much detail, but these medications can reduce viral load and potentially reduce pneumonia severity.

Manny: This rounds out our summary of the key emDOCs posts. Thanks for joining us, and stay tuned for our next episode where we talk about SJS and TEN, the 5 minute rapid neuro hand exam, and penile injuries. Feel free to comment on our site and let us know if you have any feedback. Stay safe and healthy everyone!