May 4, 2020

Introduction: Emergency physicians rarely are involved in tube exchanges; I can’t remember the last time I had to do one. However, during the COVID19 surge, we found ourselves boarding intubated patients for days and even weeks as our ICUs were filled to the brim. With our ICU teams so busy, it became increasingly important for us to aid in critical care management where we could. Initially this was simply with lines and hemodynamic monitoring but, tube exchange became important. A number of our boarding patients developed considerable mucous plugging and tube obstruction that could not be cleared by suction. Reintubation with a fresh tube, while well within our scope, creates unnecessary risks - aerosol generation, increased provider exposure and possible harm to patient if intubation proves challenging. Tube exchange over a bougie seems to make a lot of sense.

Note: Due to the lack of experience most EM clinicians have with this procedure and the fact that it is a high-risk one, it may be best to consult anesthesia to help with the procedure if they are available. We acknowledge that this may not be possible if that service is stretched thin due to circumstances.

May 3, 2020

The Novel Coronavirus 2019, was first reported on in Wuhan, China in late December 2019.  The outbreak was declared a public health emergency of international concern in January 2020 and on March 11th, 2020, the outbreak was declared a global pandemic. The spread of this virus is now global with lots of media attention.  The virus has been named SARS-CoV-2 and the disease it causes has become known as coronavirus disease 2019 (COVID-19).  This post will serve as a summary of emerging available evidence in regard to neurologic manifestations associated with COVID-19.

May 1, 2020

Background: Over the past few weeks there has been a shift in the management of critically ill COVID-19 patients.  Many seem to have moved away from an intubate early strategy to the use of high flow nasal cannula (HFNC) and noninvasive ventilation (NIV).  HFNC and NIV may obviate the need for endotracheal intubation in patients with acute respiratory failure.  Mechanical ventilation is not a benign intervention as it has a number of associated complications including ventilator associated pneumonia, excessive sedation, delirium, ICU acquired weakness, as well as ventilator induced lung injury (VILI). NIV can cause lung injury from excessive negative pressure forces.  However, mechanical ventilation can cause VILI from excessive positive pressure forces.  There is a fine balance of when to use which modality, and when to transition from one modality to another that requires frequent bedside monitoring.  NIV has been used successfully for COPD exacerbations and cardiogenic pulmonary edema, but its use in acute hypoxemic respiratory failure is still rather controversial.  One of the issues with NIV through a mask device is that higher levels of positive end-expiratory pressure (PEEP), which are often needed in hypoxemic conditions, may lead to mask intolerance and air leaks around the sides of the mask.  Helmet NIV may have several advantages over face masks including better tolerability and less air leaks.  There is a dearth of evidence comparing these to NIV modalities.

April 30, 2020

Background: Currently, there are no approved medications for the treatment of COVID-19, but,  there are many investigational agents that have shown antiviral activity against SARS-CoV-2 in vitro.  Unfortunately in vitro studies do not always extrapolate to clinical care  In vitro studies of remdesivir demonstrate inhibition of  human and animal coronaviruses tested including SARS-CoV-2.  However, the clinical and antiviral efficacy of remdesivir in COVID-19 remains to be established. The title of this post is, "two more trials just published on Remdesivir," but in reality it is 1.5 trials as we don't have the full release of the 2nd trial (see discussion).

April 29, 2020

Needs Assessment: As the COVID19 pandemic continues to mount, hospitals will rapidly reach maximal capacity. As a result, patients are boarding longer in the ED and, new patients are waiting longer to be seen. This dynamic poses numerous threats to patients safety. While we are seeing a large number of patients with severe and critical COVID19 who require intense monitoring, therapy and even ICU resources, many patients are only in need of supplemental O2 while they deal with their symptoms. The ability to discharge patients home with O2 and proper follow up monitoring can help open up more beds in both the ED and the hospital in general allowing us to deliver the proper resources to patients who need them.

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