Dr. Paul Atkinson
Tag Archives: covid
Vaccine induced immune thrombotic thrombocytopenia (VITT)
COVID Update
SJRHEM EM Rounds February 2021
Dr. James French
PoCUS & COVID Severity
Dal PoCUS Fellowship Journal Club March 2021
PoCUS Fellow
Dalhousie University Department of Emergency Medicine
COVID 19 Update
Saint John EM Rounds – November 2020
Dr Cherie Lee Adams
COVID-19 and Pregancy
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
References
- 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.
- COVID-19 – Infection Protection and Control. https://sjrhem.ca/covid-19-infection-protection-and-control/
- 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.
- 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
- 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.
- 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/
- Riscinti, M. Macias, M., Scheel, T., Khalil, P., Toney, A., Thiessen, M., Kendell, J. Denver Health Ultrasound Card. http://www.thepocusatlas.com/covid19
- Images obtained from. Ultrasound in COVID-19. The PoCUS Atlas. http://www.thepocusatlas.com/covid19
- 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
- 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
Deep Dive Lung PoCUS – COVID 19 Pandemic
SJRHEM Weekly COVID-19 Rounds – May 2020
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
COVID-19 Testing in New Brunswick
COVID Journal Club Rounds – April 2016
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
COVID-19 – Saint John 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 Infection Prevention and Control
- COVID-19 Screening Pathways
- COVID-19 Clinical Management
- Internal Communication Daily Update Thread Password has been emailed to all staff and is posted on Closed Group FaceBook SJRHEM Education page.
- COVID Cover – for medical staff only
COVID-19
- What is COVID-19
- COVID-19 Cases in Canada by Province – Updated Daily
- Johns Hopkins COVID-19 Dashboard
- World COVID Data- FT – Infographic – Updated daily
- CAEP and CJEM COVID resources
New Brunswick Public Health – Link
- COVID-19 Community Assessment Centres
- Horizon Visitor Guidelines
- NB Self-Isolation Information and Leaflet for Patients
Trauma New Brunswick Program
- Link to TNBP – COVID-19 Page
WorkSafe New Brunswick
Academic Activity – Dal, DMNB, Residents, News, Cancellations
- Dalhousie University – COVID-19 Resource for Students
- Medical Learners – Travel – NB/NS/PEI/NL – Jan 7 – HHN Letter to Learners and Faculty_Jan 7 2021
- Dalhousie and MUN Undergraduate Clinical Learning Guidelines during COVID-19 – Nov 2
Staff Wellness
- Protecting Frontline Medical Clinicians during COVID
- Horizon – Dealing with Anxiety
- SJRHEM Wellness Newsletter – Dr. Chandra – March 20
- COVID – Healthcare Worker – Safe at work and home – March 21
- CAEP -Hospitals must always provide a safe working environment – especially in Covid-19 pandemic context – Mar 21
- Canadian Society of Physician Leader – COVID Wellbeing Bulletin- March 22
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.
- 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
- Links to reliable COVID-19 Information: New Brunswick, Horizon, Canada, CDC, WHO
- Canadian Association of Emergency Physicians – COVID Page
- Other COVID -19 respected resources: EMCrit, RebelEM
SJRHEM GRAND ROUNDS
- COVID-19 Rounds – Dr. Duncan Webster (Infectious Disease Physician)
- COVID-19 Testing in NB – Dr. Jo-Anne Talbott
- COVID-19 Lung PoCUS – Dr. David Lewis
How to Collect NP Swab
COVID-19 Rounds
Dr. Duncan Webster
Infectious Disease Physician
Saint John Regional Hospital
March 10th 2020