emDocs.net Podcast – Episode 5: JACC Consensus Statement for AMI and US in COVID-19

Today on the emDocs cast with Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER) we cover the JACC Consensus Statement on myocardial infarction in COVID-19 and use of lung ultrasound in COVID-19.

Part 1: JACC Consensus Statement on AMI in COVID-19

Key Points from the Podcast and Post:

1. Goals of article: 1) minimize EMS and healthcare provider exposure to COVID-19 while ensuring patients receive the appropriate level of cardiac care, 2) target PCI or fibrinolysis (at non-PCI capable hospitals) in STEMI patients and avoid reperfusion therapy for those with other causes of ST-segment elevation ECG, and 3) maximize the safety of medical personnel by appropriate masking of patients and use of PPE.
2. First medical contact to reperfusion time is important, and delays to primary PCI for STEMI should be avoided.
3. All STEMI patients should be evaluated in the ED prior to cath lab activation.
4. PCI remains the standard of care for patients presenting to PCI centers, including COVID-19 confirmed or probable patients.
5. The ED should focus on cath lab transfer as soon as possible in cases of confirmed STEMI. While door to balloon time of < 90 minutes from first medical contact is recommended, there may be delays due to further evaluation and management required, including ultrasound (US) for wall motion abnormalities, assessment of COVID-19 status, and respiratory support.
6. If primary PCI is not feasible, a pharmacoinvasive approach with fibrinolysis may be considered.
7. Initial fibrinolysis therapy may be used in non-PCI capable hospitals if the first medical contact to reperfusion is felt to be > 120 minutes. Additional noninvasive imaging can help determine whether ST-elevation on the ECG is due to occluded coronary artery.
8. If primary PCI is not feasible, fibrinolytics may be administered, followed by consideration of transfer to a PCI-capable center. This decision should be discussed with the physician at the PCI center. Fibrinolysis within 30 minutes of STEMI diagnosis and transfer for rescue PCI when necessary may be preferable for all COVID-19 STEMI patients at a referral hospital if STEMI is likely.
9. In patients with equivocal symptoms, atypical ECG, or delayed presentation and possible but not confirmed STEMI, further evaluation in the ED is recommended. Use US, serial ECGs, and chest x-ray, while also evaluating for other conditions such as COVID-19 myocarditis.
10. Patients with cardiogenic shock or OHCA have poor outcomes and are high risk for droplet-based spread of COVID-19. Resuscitated OHCA patients should be selectively considered for cath lab activation if persistent STEMI is present on ECG and wall motion abnormality on US is present.

Part 2: Lung Ultrasound in COVID-19

Key Points from the Podcast and Post:

1. Lung ultrasound (LUS) is a useful tool in more rapid identification of likely COVID-19 patients. Findings on LUS correlate well with computed tomography (CT) findings as long as they extend to the pleural line (most do).
2. Use a comprehensive and systematic approach to image the lungs.
3. Use linear vs phased array with lung mode setting if available.
4. COVID-19 has been described to have bilateral, patchy findings, particularly in the posterior and inferior areas. B lines, small sub pleural consolidations, pleural line abnormalities may be found.
5. CHF and bacterial PNA can be differentiated from COVID based on US findings.
6. Can scan the well and sick patient with COVID-19.
7. Have a cleaning/decontamination strategy and method for your US machines.