PoCUS in COVID

Point of Care Ultrasound (PoCUS) during the Covid-19 pandemic – Is this point of care tool more efficacious than standard imaging?

Resident Clinical Pearl (RCP) May 2020

Dr. Colin Rouse– (PGY-3  CCFP Emergency Medicine) | Dalhousie University

and Dr. Sultan Alrobaian (Dalhousie PoCUS Fellow, Saint John, NB, Canada)

Reviewed by Dr. David Lewis

 


Case

A 70 year of woman present to the ED with a history of fever, cough and dyspnoea. After a full clinical assessment (with appropriate PPE), Lung PoCUS is performed.


Introduction

The Covid-19 Pandemic has created the largest international public health crisis in decades. It has fundamentally changed both societal norms and health care delivery worldwide. Changes have been implemented into resuscitation protocols including ACLS to prioritise appropriate donning of personal protective equipment (PPE) and consideration of resuscitation appropriateness prior to patient contact.1 Equipment has been removed from rooms to limit cross-contamination between patients. In this Pearl we will explore why PoCUS should not be discarded as an unnecessary tool and should be strongly considered in the assessment of a potential Covid Patient.

Disclaimer: Given the novel nature of CoVid-19 there is a lack of RCT data to support the use of PoCUS. These recommendations are based solely on expert opinion and case reports until superior evidence becomes available.


Potential Benefits of PoCUS

  • Lung PoCUS has increased sensitivity compared to conventional lung X-ray for known lung pathologies such as CHF4 and Pneumonia5 with similar specificities. Given that Pneumonia is the most common complication of Covid-19 it may help diagnose this complication in patients who have a normal CXR.
  • PoCUS can be performed by the assessing physician limiting the unnecessary exposure to other health care providers such and Radiologic Technologists and other staff in the diagnostic imaging department.
  • Lung PoCUS is low cost, repeatable and available in rural settings
  • Once pneumonia is diagnosed other potential complications can be sought including VTE and cardiovascular complications.

The assessment of the potential Covid-19 patient.

First one must consider the potential risk for coronavirus transmission at each patient encounter and ensure proper PPE2 for both oneself and the PoCUS device3.


Lung Ultrasound in the potential Covid-19 Patient

Technique

  • Appropriate level PPE
  • A low-frequency (3–5 MHz) curvilinear transducer
  • Set Focus to Pleural Line and turn off machine filters (e.g THI) to maximize artifacts
  • Scanning should be completed in a 12-zone assessment6
    • 2 anterior windows
    • 2 lateral windows
    • 2 posterior windows

Findings7

Mild Disease

  • Focal Patchy B-lines in early disease/mild infection (May have normal CXR at this point)
  • Areas of normal lung

 

Moderate/Severe Disease – Findings of bilateral Pneumonitis

  • B-lines begin to coalesce (waterfall sign)
  • Thickened and irregular pleura
  • Subpleural Hypoechoic consolidation      +/- air bronchograms

 

Other Covid-19 Pearls

  • Large/Moderate Pleural Effusion rarely seen in Covid-19 (consider another diagnosis) – Small peripleural effusions are common in COVID
  • The virus has a propensity for the base of the posterior lung windows and it imperative to include these views in your assessment.


Example COVID PoCUS Videos8

Confluent B Lines and small sub pleural consolidation

 

Patchy B lines and Irregular pleura

 

Irregular pleura

 

Air Bronchogram


CT & ultrasonographic features of COVID-19 pneumonia9

It has been noted that lung abnormalities may develop before clinical manifestations and nucleic acid detection with some experts recommending early Chest CT for screening suspected patients.10 Obviously there are challenges with this recommendation mainly regarding feasibility and infection control. A group of researchers in China compared Ultrasound and CT findings in 20 patients with COVID-19. Their findings are summarized in the table below:

Their conclusion was that ultrasound has a major utility for management of COVID-19 due to its safety, repeatability, absence of radiation, low cost and point of care use. CT can be reserved for patients with a clinical question not answered by PoCUS. CT is required to assess for pneumonia that does not extend to the pleura. Scatter artifact from aerated lung obscures visualization of deep lung pathology with PoCUS. When PoCUS is sufficient it can be used to assess disease severity at presentation, track disease evolution, monitor lung recruitment maneuvers and prone positioning and guide decisions related to weaning of mechanical ventilation.


Learning Points

  • Lung PoCUS is helpful in the initial assessment of the suspected or known COVID19 Patient
  • Lung PoCUS may reveal pathology not visible on CXR
  • Lung PoCUS can provide insight into COVID19 disease severity
  • Lung PoCUS is a useful tool to track disease progression in COVID19

Lung PoCUS in COVID Deep Dive

Deep Dive Lung PoCUS – COVID 19 Pandemic

 

 


References

  1. Edelson, D. P., Sasson, C., Chan, P. S., Atkins, D. L., Aziz, K., Becker, L. B., … & Escobedo, M. (2020). Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of …. Circulation.
  2. COVID-19 – Infection Protection and Control. http://sjrhem.ca/covid-19-infection-protection-and-control/
  3. Johri, A. M., Galen, B., Kirkpatrick, J. N., Lanspa, M., Mulvagh, S., & Thamman, R. (2020). ASE Statement on Point-of-Care Ultrasound (POCUS) During the 2019 Novel Coronavirus Pandemic. Journal of the American Society of Echocardiography.
  4. Maw, A. M., Hassanin, A., Ho, P. M., McInnes, M., Moss, A., Juarez-Colunga, E., Soni, N. J., Miglioranza, M. H., Platz, E., DeSanto, K., Sertich, A. P., Salame, G., & Daugherty, S. L. (2019). Diagnostic Accuracy of Point-of-Care Lung Ultrasonography and Chest Radiography in Adults With Symptoms Suggestive of Acute Decompensated Heart Failure: A Systematic Review and Meta-analysis. JAMA network open, 2(3), e190703. https://doi.org/10.1001/jamanetworkopen.2019.0703
  5. Balk, D. S., Lee, C., Schafer, J., Welwarth, J., Hardin, J., Novack, V., … & Hoffmann, B. (2018). Lung ultrasound compared to chest X‐ray for diagnosis of pediatric pneumonia: A meta‐analysis. Pediatric pulmonology, 53(8), 1130-1139.
  6. Wurster, C., Turner, J., Kim, D., Woo, M., Robichaud, L. CAEP. COVID-19 Town Hall April 15: Hot Topics in POCUS and COVID-19. https://caep.ca/covid-19-town-hall-april-15-hot-topics-in-pocus-and-covid-19/
  7. Riscinti, M. Macias, M., Scheel, T., Khalil, P., Toney, A., Thiessen, M., Kendell, J. Denver Health Ultrasound Card. http://www.thepocusatlas.com/covid19
  8. Images obtained from. Ultrasound in COVID-19. The PoCUS Atlas. http://www.thepocusatlas.com/covid19
  9. Peng, Q., Wang, X. & Zhang, L. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic. Intensive Care Med (2020). https://doi.org/10.1007/s00134-020-05996-6
  10. National Health Commission of the people’s Republic of China. Diagnosis and treatment of novel coronavirus pneumonia (trial, the fifth version)[EB/OL]. (2020-02-05)[2020-02-06]. http://www.nhc.gov.cn/yzygj/s7653p/202002/3b09b894ac9b4204a79db5b8912d4440.shtml
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Deep Dive Lung PoCUS – COVID 19 Pandemic

SJRHEM Weekly COVID-19 Rounds – May 2020

Dr. David Lewis


 

 

Part One covers aspects of core and advanced aspects of lung ultrasound application including: Zones, Technique, and Artifacts

Part Two covers PoCUS in COVID, the recent research, PoCUS findings, Infection Protection and Control, Indications and Pathways.


Part 1

 


Part 2

 

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COVID-19 Testing in New Brunswick

COVID Journal Club Rounds – April 2016

Dr Jo-Anne Talbott


Key Questions

  • Who should we test for COVID
  • Who can we test with the Rapid COVID test
  • What is the sensitivity and specificity of the tests
  • What are the rates of positive tests in New Brunswick
  • Will we move to testing serum for IgG, IgM

RT-PCR Test

Reverse transcription polymerase chain reaction (rRT-PCR) test

ID Microbiologists at the George Dumont used  recommended processes to develop a test for the qualitative detection of nucleic acid from SARS-CoV-2 in upper and lower respiratory specimens

Their results were validated by the National Microbiology Lab in Winnipeg, Manitoba


Rapid COVID Test

  • Xpert Xpress SARS-CoV-2 assay is performed on the GeneXpert platform
  • Rapid test used in SJRH Microbiology Lab
  • Clinically suspected COVID-19 in
    • patient currently in the ICU or being admitted to the ICU
    • pregnant patient currently in labour and being admitted
    • your clinical judgement a rapid test is required
  • Call Microbiology MD

Full Presentation

Download (PDF, 19.97MB)

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COVID-19 – SJRH and New Brunswick

This post is provided as an information resource specifically for HealthCare Professionals within the Saint John Region and New Brunswick Emergency Departments

This post is updated regularly

SJRHEM COVID-19 Pages


COVID-19

New Brunswick Public Health – Link

Trauma New Brunswick Program

WorkSafe New Brunswick


Academic Activity – Dal, DMNB, Residents, News, Cancellations


Staff Wellness

 


What is COVID-19

  • A novel betacoronavirus first reported in Wuhan, China on December 31st 2019
  • Symptoms for the novel coronavirus are similar to those for influenza or other respiratory illnesses.
  • New Brunswick Case Definition – see below– Note this continues to evolve
  • Current assumptions are that spread is via droplet and/or fomite to face
  • Infection Prevention and Control = Contact and Droplet precautions

COVID-19 – SOURCES OF INFORMATION

SJRHEM GRAND ROUNDS

 


SJRHEM Activity During the Pandemic


NB Health Screening Tool and Referral forms to Community Assessment Centres – 27 May 2020 

For community referral for COVID-19 screening and testing:

Referral Form – Combined Referral and Order Form

FAX Number = 506 462-2040

 


Horizon Screening Questions – May 29

Download pdf

 


Self-Isolation Information Leaflet for Patients

Self-Isolate and Alternative Self-Isolate Leaflet

Self Management COVID

 

 


 

COVID-19 Testing – Public Health Advice and Viral Swabs 

Summary of Current Guidance (May 26)

“Every New Brunswicker should remain vigilant,” said Dr. Jennifer Russell, chief medical officer of health. “Please continue to limit your close contacts to prevent the chance of spreading the virus, especially to those who are more vulnerable to complications of COVID-19. Although community transmission has not been confirmed, it is important to be aware that it remains a possibility.”

Up-to-date information about COVID-19, including the latest data on confirmed cases and laboratory testing in New Brunswick is available online.

New Brunswick is currently in Phase 3 (Yellow) of the COVID-19 recovery. Information on public health recovery phases, measures and guidelines is available online.

Dr. Jennifer Russell, chief medical officer of health, announced that testing would now be recommended for people exhibiting at least two of the following five symptoms:

  • fever above 38°C or signs of fever;
  • a new cough or worsening chronic cough;
  • sore throat;
  • runny nose;
  • headache:
  • New onset fatigue;
  • New onset muscle pain;
  • Diarrhea;
  • Loss of sense of taste or smell; and
  • In children, purple markings on fingers or toes

Those who are exhibiting at least two of these symptoms are advised to immediately self-isolate and contact 811 or their family physician for further direction. Symptoms can range from relatively mild (runny nose and sore throat) to severe such as difficulty breathing.

Summary of Current Guidance  (April 2):

The COVID-19 pandemic is rapidly evolving around the world and within Canada. At variable points in the last few weeks, many parts of Canada including Quebec have started seeing community transmission. This had led to additional concern and control measures applied to travel outside of the province. In addition, New Brunswick is now also entering the community transmission phase.

Because of these dynamics, we will be transitioning from focusing on identifying cases imported into the province as a control measure to focusing testing priorities in our province on protecting our most vulnerable populations/settings and maintaining critical health system capabilities.

Given this transition, the following are key points when clinically evaluating patients (virtually or in person) and deciding on testing:

  • Conduct a clinical assessment – clinical case definition still includes fever/history of fever and/or new onset/exacerbation of chronic cough. Other symptoms may include headache, sore throat or coryza.
    • Test those with moderate to severe symptoms (such as signs of pneumonia, dyspnea, blood O2 saturation <94%) including those who require hospitalization.
    • Recommend testing patients with risk factors such as age 60 +, hypertension, cardiovascular disease, chronic respiratory disease, diabetes, and cancer.
    • People living in crowded settings or limited capacity to self-isolate due to same

Assessment centers will be testing all referrals moving forward, and not providing secondary screening, so please ensure referrals have been clinically assessed appropriately, virtually or in person, prior to completing a referral form.

  • Test Priority groups (even with mild symptoms) – to maintain the integrity of the health care system and prevent transmission in clinical and other vulnerable group settings
    • Symptomatic health care professionals, such as physicians, nurse practitioners, nurses, pharmacists, laboratory technologists, Ambulance NB, first responders, emergency medical dispatchers, Extra Mural program
    • Staff in hospitals, nursing homes, and other institutional or group living settings with direct patient care/contact
    • Patients/residents in institutional and group living settings with vulnerable populations (including within RHA, long term care, shelters, correctional facilities, adult residential facilities)
  • Consider and inquire about exposure criteria (travel outside New Brunswick or close contact/group exposure setting (ie gathering, work setting), either within the last 14 days), but absence of such no longer excludes a patient from testing. Identification of exposure risks and clusters remains a critical public health strategy in managing COVID-19 even in the context of community transmission.
  • There are no specific directives to NOT test certain individuals or groups of individuals at this time, continue to use your professional judgement but please be aware that the situation may change quickly in the coming days to weeks, depending on capacity.
  • Full Document Here – April 2
  • 5 Hospitals across NB, only SJRH in R2
  • 5 per day of those being discharged
  • 5 per day of those being admitted
  • Use pre labeled ‘sentinel swab’
  • Fever or Cough but NO travel or contact hx

 

How to Collect NP Swab

 


Case Definition – New Brunswick

based on the Canada Public Health  –  NB Interim national case definition  – March 24

Person under investigation (PUI)

A person with fever and/or cough who meets the exposure criteria and for whom a laboratory test for COVID-19 has been or is expected to be requested.

Probable

A person:

  • with fever (over 38 degrees Celsius) and/or new onset of (or exacerbation of chronic) cough
    AND
  • who meets the COVID-19 exposure criteria
    AND
  • in whom laboratory diagnosis of COVID-19 is inconclusive,negative (if specimen quality or timing is suspect), or
    positive but not confirmed by the National Microbiology Laboratory (NML)

Confirmed

A person with laboratory confirmation of infection with SARS-CoV-2 as a result of nucleic acid amplification testing (NAAT).

 

SJRHEM ADVICE – 19 March 2020

Consider any patient who presents with an Influenza Like Illness – irrespective of above case definition as being suspicious for COVID-19 and take appropriate PPE precautions.


Exposure Criteria

In the 14 days before onset of illness, a person who:

  • Traveled to an affected area i.e. anyone who travelled outside New Brunswick. OR
  • Had close contact with a person with acute respiratory illness who has been to an affected area (anyone who travelled outside NB within 14 days prior to their illness onset) OR
  • Had laboratory exposure to biological material (e.g. primary clinical specimens, virus culture isolates) known to contain COVID-19.

Close contact = A close contact is defined as a person who provided care for the patient, including healthcare workers, family members or other caregivers, or who had other similar close physical contact or who lived with or otherwise had close prolonged contact with a probable or confirmed case while the case was ill.


Affected Areas

Public Health Canada Affected Area List

UPDATEAll travel outside New Brunswick


 

 

 

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