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Skip to content. MIX Your browser does not support the audio element. ASMR Your browser does not support the audio element. This compendium summarizes the lessons learned through interdisciplinary collaborations to meet the varied challenges created by the explosive appearance of the infection in our community, and will be updated continuously as new research and best practices emerge.
It is our hope is that the collaborations and lessons learned that went into creating these guidelines and protocols can serve as a useful template for other systems to adapt to their fight against COVID The authors would like to dedicate this issue to Dr.
Lorna Breen and to recognize her contributions to our specialty and unwavering dedication to her patients. This monograph summarizes the evaluation, treatment, and disposition tactics the Mount Sinai Health System created and implemented to help manage a new disease that posed an unprecedented volume of critical patients and had no known treatment.
While by no means all-encompassing, the methods outlined here are focused on the front-line emergency clinician. We provide a rubric of how to think about major decisions regarding workup, treatment, and disposition. There is a focus on providing fundamental care in a way that maximizes safety for both patients and clinicians. Discussions regarding personal protective equipment PPE , operational flow, and nonmedical resources are beyond the scope of this monograph.
Although not discussed in detail, many of the nodal points in clinical decision-making can likely be performed by both telemedicine and advanced practice providers. Most of the protocols presented here were developed by an interdisciplinary team of emergency physicians, infectious disease specialists, and intensivists. Incorporated into the tables is a combination of information coming out of Italy and China, local information obtained within an 8-hospital system in New York City with both community and academic sites, extensive discussion with emergency medicine experts around the country, and literature searches focused primarily on acute respiratory distress syndrome ARDS and analyses from prior viral outbreaks, including SARS, MERS, and H1N1.
Disclaimer: While the recommendations presented in this monograph are based on the best evidence available at the time of their creation, we acknowledge that our understanding of COVID is changing daily. The protocols presented were developed by individuals, and though adopted by our Health System, the protocols are not necessarily endorsed by the Mount Sinai Health System, but are the independent product of the authors.
We note that there is controversy, and that some of the recommendations may be controversial. We thank our many colleagues for their input, and we have tried, to the best of our ability, to note the sources from which protocols were adapted. While laboratory testing and imaging may assist with management and prognosis, they are generally adjuncts to the history and physical examination and rarely change initial management, especially in the well-appearing patient.
While clinical management for patients with COVID continues to evolve and change on a nearly a daily basis, we have come to some clinical equipoise regarding laboratory studies and imaging. Laboratory studies are generally not required for the well-appearing patient under investigation with few or no risk factors. When drawn for concerning presentation in the emergency department ED , labs are fairly standard, with the addition of inflammatory markers if the patient is expected to be admitted to the hospital.
Although many are nonspecific, some may offer assistance in diagnosis, pending confirmatory testing. Troponins may be elevated due to myocarditis or ischemia demand or thrombosis.
The basic metabolic panel may show electrolyte abnormalities due to dehydration or medication noncompliance; renal injury due to inflammation, vasculitis, and thrombosis has also been reported. The inflammatory markers will allow the inpatient team to trend them and potentially aid in directing therapy.
Because knowledge is continuously evolving and there are often local protocols, a discussion with inpatient leadership may help guide which markers may be useful. We use imaging less as a primary diagnostic tool than to rule out other diagnoses and to measure extent and progression of disease.
Similar to lab testing, low-acuity patients without tachypnea, hypoxia, or more than minimal shortness of breath do not necessarily require imaging. In the early days of the pandemic, when the availability of PCR testing was limited, the use of CT scans was often substituted as a diagnostic modality. Discharge must also assess whether appropriate outpatient follow-up is available as well as the ability to return if the patient worsens.
Patients with suspected or confirmed COVID who are not exhibiting increased work of breathing, tachypnea, or evidence of hypoxia may be managed in the outpatient setting with follow-up as needed for any new or worsening symptoms. One useful strategy is to ambulate patients prior to discharge to confirm that their oxygen saturation remains stable.
Although this is not a proven strategy at this point, anecdotally it has been very helpful in finding unexpected hypoxia.
Patients who are admitted for respiratory distress may be considered for discharge after 48 hours if they remain clinically stable. Persistently hypoxic patients without increasing supplemental oxygen requirements who do not have other significant risk factors may also be considered for discharge on home oxygen or with an oxygen concentrator. If available, scheduling patients for hour telemedicine follow-up appointments may provide an expedient strategy for safely discharging patients with mild dyspnea or hypoxia, in order to closely monitor them for any signs of decline while reducing overcrowding and nosocomial transmission in the ED.
Table 3 provides a list of the risk factors associated with the potential for clinical deterioration and thus need for hospitalization. Table 4 provides the context for which patients might be safe for discharge with close outpatient monitoring. We are currently assessing our experience with this pathway to find whether it has been successful in both decreasing admissions and providing safe discharges.
With the ongoing pandemic, there are inevitably cardiac arrests associated with caring for the COVID-positive patient. Cardiopulmonary resuscitation CPR , by its very nature, is an aerosolizing procedure.
Whether this is from intubation, compressions, or bagging the airway, they all pose a real risk to staff. Also, given that a resuscitation can often be labor-intensive, it becomes even more important to minimize exposure.
Therefore, a protocol to ensure the best care of the patients while protecting front-line staff must be followed. We do not have enough local or critical US data to make any clear recommendations regarding in-hospital arrest. Again, while the studies for mCPR have been mixed, at best, the balance between safety and treatment must be maintained. Equipment shortages are inevitable when dealing with a pandemic, and resources must be guarded.
Although many pharmacologic agents are undergoing urgent investigation for use in patients with COVID, no curative or preventative treatments have been confirmed. ED treatments are typically focused on symptom control and treatment of the manifestations of the disease eg, shortness of breath, fever, pain.
An electrocardiogram ECG , basic coagulopathy biomarkers, and an assessment of kidney and liver function are generally performed in the ED, as some of the inpatient treatment may affect or be affected by other organs. Advanced treatments are not usually started in the ED. Patients admitted should be screened for additional or research studies. For severe cases of COVID, convalescent plasma, immunomodulators tocilizumab and sarilumab , and antivirals such as remdesivir should be considered in the setting of clinical trials.
Recommendations for the use of alternate or adjuvant therapies may change, as the literature on COVID continues to evolve rapidly.
Please note that in this document, The Mount Sinai Health System is currently recommending steroids and full anticoagulation in the most critical patients who do not have contraindications. These both remain highly debated and controversial and are based on expert opinion, early evidence, and theoretical considerations.
The evidence is constantly changing, and we recommend regular review of practice. The exact mechanisms and pathophysiology of how COVID attacks the human body are incompletely understood. However, there is an increasing amount of evidence that COVID patients are in a hypercoagulable state, with autopsy evidence of microthrombi seen throughout the body, including the lungs, brain, heart, kidneys, and other organs. These patients may show abnormalities including elevated D-dimer, fibrinogen, and abnormal thromboelastography.
It is believed that heparins bind tightly to COVID spike proteins 3,4, and that heparins also downregulate IL-6 and directly dampen immune activation. COVID is a disease with multiple manifestations; however, the common manifestation of acute respiratory disease is what leads to most concerning ED presentations. A minority—but concerning number—of patients will have profound acute hypoxic respiratory failure and ARDS. When intubation is being contemplated, it is also very important to address goals of care with the patient and family, as current data show high mortality for intubated patients, especially with increased age and medical comorbidities.
Patients with pure hypoxemia will be up-titrated from room air, to nasal canula, to non-rebreather, and HFNC. A room with a closed door or within a full COVID unit with all providers using N95 masks, is an option if negative pressure is not available. Additionally, a surgical mask can be placed over the HFNC to help decrease the amount of aerosolization. If intubation is necessary, the Mount Sinai Health System has developed a systemwide protocol for airway management as a collaboration between the Department of Emergency Medicine, the Institute for Critical Care Medicine, and the Department of Anesthesiology.
They have been updated regularly, with both new data and experience gained taking care of COVID patients. EDs in the United States see over 1. Should a patient require respiratory support with noninvasive ventilation, this should ideally be done within the confines of a negative pressure room. While palliative care should not be equated with hospice or immediate end-of-life care, providing palliation to ill patients with COVID implies a low chance of survivability.
Interventions should be titrated to observed or reported symptoms and not based on specific physiologic parameters. The flow sheet in Figure 1 represents a simple approach to dyspnea and agitation. Given the high mortality with COVID in the critically ill, an early discussion with patients and their families is highly recommended. Although increasing mortality is associated with underlying chronic medical conditions such as pulmonary, renal, and cardiac conditions, the absolute mortality is still unclear and studies may have incomplete data, given the relative newness of the disease.
Special thanks to Dr. Claire Akuna and Dr. Christopher Richardson and the Brookdale Department of Palliative Care at the Icahn School of Medicine at Mount Sinai who provided invaluable help with this guideline and review of palliative care assistance. The COVID pandemic has caused a radical shift in the practice of emergency medicine, and operational and communication issues have emerged that had not been encountered previously.
Emergency physicians have quickly had to have many goals-of-care discussions as well as breaking bad news to family members. While emergency clinicians are familiar with these types of discussions, the large numbers in a short period of time can become overwhelming. In addition, New York and other hard-hit areas have also had the number of deaths exceed morgue and funeral home capacity.
Families are understandably upset by these occurrences. We have included scripting that is designed to help with these difficult conversations. In order to rapidly chart and provide an overview with common ED patient presentations, smart phrases based on common presentations were developed. These were developed for use in the Epic electronic health records system, but can be adapted for any system.
Local DOH. Centers for Disease Control. For hypoxemic patients, there are many physiologic benefits to the prone position.
These include better matching of pulmonary perfusion to ventilation, better recruitment of dependent areas of the lung, and improved arterial oxygenation. In addition, there is evidence that the prone position results in a more homogenous distribution of stresses in the lung and thus may prevent patients with hypoxemia from developing frank respiratory failure.
Prone positioning is used extensively in the ICU to treat intubated patients with hypoxemic respiratory failure, 34,35 but the benefits cited above may also apply to nonintubated patients as well. For this reason, patients presenting with hypoxemia should be encouraged to adopt the prone position, where practical. Prone positioning may be tried as a rescue therapy in patients with escalating oxygen needs, although this will require close monitoring.
Susan Wilcox and Dr. Despite being confronted with a novel virus where evidence-based treatments are still lacking, it must be emphasized that proper critical care remains the cornerstone of current management. COVID has an observed case-fatality ratio of 4. Although this is based on sicker patients who are tested, at a minimum it should emphasize that the provision of high-quality critical care is imperative. Norepinephrine and vasopressin are the vasopressors of choice as per standard of care.
Ventilator management is largely grounded in a lung-protective strategy. While debates rage regarding the nature of the disease and best practices for ventilatory management, we recommend the ARDS Clinical Network Ventilation protocol.
Patients must be synchronized with the ventilator to maximize our ability to oxygenate them; a RASS score of -2 to -3 is to be targeted. Should the patient remain hypoxic, a trial of paralysis can be attempted to improve oxygenation. If rescue maneuvers fail, ECMO should be considered, if available. Ilene Claudius and Dr. Mohsen Saidinejad. Have questions or comments on the podcast? Leave us a voicemail at , ext or write us at emplify ebmedicine. Harry Wingate and Dr.
Ken Gramyk. Initially started seeing a few patients who had recently returned from China. They were screened in triage and isolated based on travel to china or contact with someone who had traveled to China and fever. Over the next few days the number of patients increased with mild upper airway and fever symptoms.
Initially only a few patients required admission. Around the 27th or 28th of February a lot of patients presented with lower respiratory symptoms and fever requiring increased admission rates. Around the first week of March the admission rate increased.
If the patient has severe respiratory failure, we start hydroxychloroquine. We have started using an antiviral also. We do not have the resources to intubate all of these patients. We start most patients on non-invasive ventilation, mostly helmet ventilation which works very well for most of the patients.
This helps us buy some time to get an ICU bed. We do not have enough supplies to change for every patient, so we just change the gloves. What is your protocol for infected staff? We do not test staff anymore. We cannot afford to stay home for 14 days and we all have some mild symptoms. If we have fever, we wait 7 days and then go back to work. And inpatient nurses?
Cancel elective procedures so everyone can treat COVID patients What are your surgeons, who cannot operate, currently doing? They started courses on how to use helmet CPAP and they follow these patients. If staff get sick with a fever, they go home and after the fever is gone, they wait 7 days and then return to work. EMS is field screening all patients. By what criteria? ICU is reserved for intubated patients. Chest tubes and CPAP are sent to regular floors.
How many times are you testing them? Now the testing in completed in house. It takes about hours. We test them on admission and days later. Staff have a number that they can call to organize a meeting and they are in the department every day. The stress is very high due to isolation at the hospital and at home. The rates of patients needing ventilation was going to be so high.
Preparation is the key to managing this. Ashoo is a practicing emergency physician, board-certified in emergency medicine and clinical informatics. Get quick-hit summaries of hot topics in emergency medicine. EMplify summarizes evidence-based reviews in a monthly podcast. Highlights of the latest research published in EB Medicine's peer-reviewed journals educate and arm you for life in the ED. It also allows clinicians to more closely monitor patients nearing a critical action point eg, Level 3—possibly nearing the need for intubation.
Patients with tachypnea and patients who require significant levels of oxygen or ventilatory support are at very high risk for clinical decompensation and death. This scale has not been externally validated and has been published by MDCalc as a possible method to easily assess and compare patients in a time of crisis. This review is based on incomplete data and reviews some newer calculators that have not yet been externally validated.
As we learn more, this review may quickly become outdated. It is being published in order to provide potentially helpful information, even if incomplete, to clini-cians at the frontlines of the pandemic.
Even well-validated calculators should never be used alone to guide patient care, nor should they substitute for clinical judgment. Jnana Records , Durtro. Soyuz Music , Durtro. Durtro , Jnana Records , 10 To 1 Records. Live At Bar Maldoror Album 4 versions.
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