EM Mindset: COVID-19 Edition – A Community EM Doc’s Perspective

Author: Salim Rezaie, MD (@srrezaie, EM/IM Doc; Founder of REBEL EM & REBEL Cast) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Manny Singh, MD (@MPrizzleER); and Brit Long, MD (@long_brit)

For this edition of the EM Mindset series, we are honored to have Salim Rezaie from REBEL EM provide some perspectives on COVID-19. If you would like to contribute to the EM Mindset series, please feel free to reach out to us.



Down in San Antonio, TX, we have not been hit as hard with the SARS-CoV-2 pandemic like New York City, Detroit, and New Orleans to name a few places, but we have still had our share of sick patients.  The whole process of preparation, awaiting the surge, lack of enough personal protective equipment, lack of testing, learning about a new disease in real time, and major swings in management have all been scary, frustrating, and everything in between to say the least.  However, I have never been so proud to be a board-certified emergency medicine physician, alongside so many others as we have shown the world, when the shit hits the fan, we will stand up and fight despite putting ourselves and our families at risk.  Our greatest strengths in emergency medicine include innovation and adaptability in the setting of the unknown.  These traits have never been more important than now.

 

FOAMed/Social Media

Much like the virus, the amount of information published and posted daily is fast and furious.  This has its pros and cons.  In lieu of bigger studies, the real time information available at our fingertips is unprecedented. Doctors from around the world discussing what has been working and not working is absolutely amazing. Emergency medicine has been on the cutting edge of knowledge translation via multiple platforms (blogs, podcasts, social media) for some time now. However, despite the influx of information exchange, we must not let our anxieties abandon our scientific method. We cannot simply grasp for straws and in some cases act like we have lost our minds. We must slow down, and practice good medicine. We must ensure that we hold to the same standards as before, as we read through this massive influx of information. Case in point in the past few weeks we have debunked the NSAID argument, as well as the fact that ACEI and ARBs are still fine to use. Had we abandoned ship with these previous practices with little or no evidence to support it, we could have been led astray very quickly

 

Intubate Early or Maybe Don’t

Initially, in the COVID-19 pandemic the paradigm was, “intubate early.” This was driven by two main factors: high flow nasal cannula (HFNC)/noninvasive ventilation (NIV) are destined to fail anyways and our own concern over aerosolization. Both of these were based on expert opinion, and almost no data. The first reality was that patients intubated on mechanical ventilation were having long courses in the ICU and that there may have been an association of ventilator induced lung injury occurring.  This led to many facilities running out of ventilators and ICU beds. As time has gone on, we have realized that HFNC with a surgical mask on the patient produce minimal additional aerosolization compared to nasal cannula up to 6LPM with a surgical mask.  All of this has now shifted our mindset to trying to avoid intubating early and learning to accept oxygen saturations that none of us are accustomed to. Concepts such as awake proning and frequent re-positioning have gone from novel to commonly utilized and integrating them into protocols to stave off intubation.  In the end this is a balance of multiple complicated factors.  We don’t want to intubate too early for those who don’t need it, but also don’t want to intubate too late for those who do need it.  Not everyone will decompensate, but we currently don’t have any good predictors of who will and won’t decompensate, therefore careful monitoring is essential.

 

Thrombosis

As our knowledge of SARS-CoV-2 continues to grow, we are starting to find out that this is a demon virus that can do whatever it wants.  More and more evidence is starting to indicate patients have some form of hypercoagulability, however the prevalence of acute venothromboembolism (VTE) is still an evolving area.  Some early histopathological data indicate that pulmonary microvascular thrombosis may play a role in progressive respiratory failure.  Unfortunately, most of the evidence is limited to retrospective and small trials.  Almost all major societies now recommend prophylaxis dose low molecular weight heparin (LMWH) for admitted patients.  Some clinicians are using intermediate-dose or full dose therapeutic parenteral anticoagulation, but there is very limited to no evidence for this practice at this time.  The optimal dosing in patients with severe COVID-19 still remains elusive.

 

D-Dimer

Another issue is many critically ill patients have elevated d-dimers.  D-dimer also happens to be a non-specific acute phase reactant which can be elevated in any acute inflammatory condition. The conundrum comes with who do we image?  There is no need to CT all patients who are getting admitted as all patients without contraindications, should be on some form of anticoagulation whether you have definitively diagnosed a PE or not.  For example, at my shop this is the current regimen we are using:

  • For Inpatients:
    • High Risk: D-Dimer >6x ULN (>3ug/L) = Therapeutic Anticoagulation (TAC)
    • Low Risk: D-Dimer <6x ULN (<3ug/L) = Prophylactic Dosing
  • For Outpatients (Deemed High Risk for DVT/PE Discharge Plan):
    • If no DVT/PE and on TAC during hospital stay + High risk (D-Dimer Still >6x ULN) –> 2 weeks of AC post discharge
    • If no DVT/PE and on TAC during hospital stay + High risk (D-Dimer <6x ULN) –> No AC post discharge
    • If confirmed DVT/PE, then normal provoked protocol –> AC for 3 – 6mos

 

More to Learn

The more we learn about SARS-CoV-2 the more we realize there is a lot that we still don’t know. Nobody has all the answers and certainly no one has everything figured out.  Much like life, there is a process of making mistakes and learning from them. We are just at the tip of the iceberg of this pandemic with much more still to come and waiting to be discovered. As we continue to unveil new revelations about this disease process and its sequelae, let’s do our best to keep our anxiety at arms-length and be mindful of how to proceed and change our practices.  Just like every forerunner, as we lead the world in the FOAMed/social media exchange, let’s keep up the good work, continuing on with our common sense and scientific questioning.

This was a potpourri of my thoughts, and I hope you found it helpful.  Thank you for everything you do to help humanity. Stay safe, one day at a time, one patient at a time, and remember we are all in this together. Oh…and don’t forget to wash your hands a lot.

 

Sincerely,

A humble ED trench doc

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