Author: Charlotte Davies / Codes: / Published: 24/03/2020
Coronavirus is moving on apace, and every hospital is desperately trying to make sure that they are prepared. We’ve got some original articles here, as well as some collated experience from the @RCEMLearning team. All of this has been collated into an RCEMLearning iBook (which won’t be updated regularly) and free RCEMlearning modules and podcasts collated here.
The pressures caused by COVID have changed from acute presentations, to chronic problems, and post- vaccination problems. We’ve added sections on this, but also left the existing sessions planned for those doing unfamiliar clinical procedures. The need to critically appraise everything you read remains! If you have any resources that you’re willing to share, please email us, or post on twitter with the #rcemcovid so we can find it!
The update list was growing so much we’ve moved it into a second document – check what’s changed since you last visited here.
Last updated 16th April 2021.
by Nikki Abela
For a full reminder, look at this RCEMLearning article. For the #rcemcovid just in time update, read on. Remember, if the chest exam is normal, there still might be covid chest, or it might mean a non physiological cause – there will be a lot of anxiety. The Cambridge Breathless Intervention Service has lots of leaflets pre-prepared that might help, and some similar here.
The current climate suggests that we are going to be spending a fair bit of our time assessing people’s respiratory status. So here at RCEMLearning we thought it would be a good time to brush up on our chest assessment. This may include things you do already, probably everyday, but here are a few tips and tricks about my approach which hopefully you can learn from. Feel free to comment below so that we can all learn from each other.
The first thing is to take in the initial picture. Experienced clinicians do this automatically, but you will remember in medical school they told us to “look around the bed”.
Look for clues like: Is the patient already on oxygen? If so, how much? Nebs? Inhalers? Cigarettes coming out of their pockets?
Then look at the patient. Any immediate signs that there is an underlying or larger problem. This will include:
- Cyanosis: central and peripheral
- Oedema: think heart failure
- Signs of liver failure
- Hands for clubbing, tremor, cigarette stains
- Work of breathing: is it increased? Are they tripoding? – this is a bad bad sign
The above two things take seconds and most of the time you won’t realise you are doing it, much like driving. I like to multi-task having a look with feeling the radial pulse, but find your own time to do this. The other place to look for clues are the observations: don’t forget to check them (when I do, our excellent nurses will always prod me if they are worth looking at). Don’t forget to speak to the patient, not only because it is polite but it is also a chance to see how they are completing sentences. Then move on to the chest itself. Take note of chest movement: is it equal throughout? Is the chest rising and falling adequately? Does the patient look like they are tiring? Have a listen for air entry, is it good and the same throughout? Any added sounds like wheezes or crackles? Some questions about whether this is a good idea or not – you’re still listening for a differential, so crack on. Percuss for any hyperresonance (?pneumothorax) or dull areas (?fluid). Feel for the trachea, is it central, and also have a little feel for lymph nodes in the neck. Before you move away from the patient, look at the ankles and sacrum for oedema and feel the calves for tenderness. It is likely that if the patient is unwell you will order a CXR, which we have covered in another section. You may (or may not) need to do blood gasses too, and we have talked about how to interpret them here.
Look for clues around the patient and from the end of the bed – Speak to the patient – Check their obs – Auscultate, feel and percuss – add in any extra tests as needed.
After your chest assessment is complete you then need to create a plan. Your plan will probably be one of:
– Do nothing – their obs are normal, and everything seems OK.
– Give some treatment – oxygen (over the top of a face mask) to keep saturations OK (currently 92 – 96%), maybe some nebulisers (no-longer considered aerosol generating!) if there’s a wheeze, or some furosemide if they’re overloaded. High flow oxygen should generally be avoided. If you suspect a bacterial pneumonia, don’t forget antibiotics.
– If you’re suspecting COVID-19, supportive treatment is likely all you can do. Have a look at this lancet article (twitter here) for the curves of covid.
– Get help – if your patient is really really unwell, contact your “senior” support.
For advice on interpreting arterial blood gases, have a look at this youtube video.
by Michelle Tipping
This was going to be the topic of our next #rcemblogs blog – please accept this guide instead. NIV is considered an aerosol generating procedure – there’s a summary of some of the infection control precautions from the BTS here.
Non-invasive ventilation (NIV) can seem daunting to those who are not used to it. It is a therapeutic intervention overwhelmed with confusing abbreviations and lots of seemingly complex underlying physiology. However, in reality it is a really useful & simple tool that clinicians can instigate to make a major impact on stabilising a sick patient with respiratory failure. This guide is not intended for those who are experienced ITU types, however, if you are one of the millions of front-line staff looking to help during our latest respiratory pandemic with little experience in the use of NIV please read on. Please note; this guide does not include use of NIV in our paediatric population.
The Basics – When to
Before we get started, it is important to know when NIV may help. In simple terms NIV is a method of delivering oxygen to the lungs using pressure to reduce the amount of work the patient has to do to breathe. Therapeutically it sits between a simple facemask (the old non-rebreather by every hospital bed) and full intubation. It is delivered by a tightly fitting face mask which can induce claustrophobia and panic in the calmest of individuals so remember, even if you feel the same about setting it up, the patient needs you to seem calm, so, take a deep breath and read on. There’s some tips on how to avoid panic in your patient on #rcemblogs – explain what you are doing, take it slowly, and give the patient control. NIV can be used in a wide range of settings. If you are reading this today it is likely that you are considering its use with Covid-19. However, we will be seeing many patients with normal underlying lung diseases (COPD, bronchiectasis, pneumonia) during this time who may benefit from NIV just as they would in normal circumstances (despite having a super-added viral infection). Essentially NIV is really useful when patients are struggling to absorb enough oxygen (Type I respiratory failure) OR when you can’t get enough oxygen in and carbon dioxide out (Type II respiratory failure). Although research is still limited, initial reports from the Covid front-line suggest that the pliability of the lungs is preserved so NIV may be very useful in the combined situation. Relevant examples of Type I include pneumonia and acute respiratory distress syndrome (ARDS) and Type II include COPD. These pathologies will form the biggest extent of our work load during the Covid-19 epidemic and we should expect to see many patients with a mixed respiratory picture.
The indications for NIV are well documented but essentially include: pH <7.35 pCO2 >6.5 RR >23 Failure of medical therapy, Incl: steroids, nebulisers, controlled O2
These figures should be taken from an arterial blood gas (ideally with local anaesthetic!) not a point of care venous blood gas! There are a few absolute contraindications to the use of NIV that we should all be aware of: Facial Burns Fixed upper airway obstruction Facial deformity (mask won’t fit) Pneumothorax Respiratory Arrest The relative contraindications will be discussed in the last section: “should you?”.
Before you get started fitting a patient for NIV it is important to understand some basic physiology and what you are trying to achieve. (Yes, I’m going to try & explain some of those annoying abbreviations!) Firstly, there are 2 types of NIV: CPAP (continuous positive airways pressure) and BiPAP (bilevel positive airways pressure). Essentially most patients who utilise NIV at home for conditions like sleep apnoea will have a CPAP machine as they are more portable. Hospital settings tend to utilise BiPAP. BiPAP is generally better tolerated and is the ‘go-to’ for most emergency departments when starting NIV. BiPAP delivers a couple of things that can make it more useful than CPAP… 1. You can set a breathing rate – although not enough to take over breathing altogether, it can encourage a better rate. 2. You set the machine to deliver 2 pressures; one for inspiration (known as IPAP – inspiratory positive airways pressure) and one for expiration (EPAP – expiratory positive airways pressure). By having a lower positive pressure during expiration patients find it more comfortable than CPAP where they have to exhale against a high pressure system.
By constantly delivering some form of pressure (CPAP or BiPAP) then when a patient exhales the alveoli don’t completely collapse. This is obviously more energy efficient than try to open up closed airways and means oxygen delivery starts earlier because the airway is already open during inhalation…creating a win-win situation! There are lots of different machines on the market, but they are all essentially the same. Standard starting pressures for BiPAP are: IPAP – 8-10 mmHg EPAP- 2-4 mmHg Once the patient is undergoing therapy the settings can be altered to optimise ventilation.
It is recommended that the patient has a repeat blood gas after an hour to check response to therapy aiming for sats of 88-92%in COPD and 94% in the otherwise well with resolution of hypercarbia. It should also be repeated an hour after any change in settings and after 3 & 12 hours of treatment. There’s a little bit of an art too it, but generally, if PO2 still low – turn up O2 and / or turn up EPAP 2-3 cmH2O a time to max of 12cmh2o consider increasing IPAP to a max if 20cmh20 if estimated volumes are less than estimated for patients size (then expert discussion). If PO2 high – turn down O2, and then turn down EPAP. If CO2 high – consider increasing ventilatory rate and then turn up the IPAP to increase the ventilatory volume delivered. Increase the IPAP in steps of 2-3 cmh2o to avoid sensation of sudden change in pressure and improve tolerance to increases and be prepared to increase pressures to max of 20 in steps every 5mins. The rough aim is a volume of 5-7ml/kg of ideal body weight. So for your average 70kg person (!!), 350 – 490ml volume.
It is also possible to run nebulised drugs through the NIV circuit and you can give positive suggestions, as well as a light sedative (0.25mg lorazepam) to aid tolerance if your patient is agitated. Good resources to help with the simple mechanics of setting up NIV & how it works can be found here: EM3FOAMed #EM3 CLAHRC NWL ICU Advantage OME Twitter video . The second video above raises some other important points regarding good explanation to patients of what you are trying to achieve and the limits of NIV – before starting NIV it is important to have ceilings of treatment in place. i.e. should it fail or the patient start to deteriorate what would you do next? Is the patient a suitable candidate for invasive mechanical ventilation?
NIV has most definitely proven its worth over the past 20 years in everyday respiratory challenges such as COPD. It is recommended by the British Thoracic Society in most situations. Its use in isolated ARDS remains controversial but it will likely be of benefit to those with underlying respiratory physiology. Physicians should be aware that it is not a ‘quick fix’ therapy and we would expect patients on NIV to need ongoing support for several days including a weaning period. Reports from Italy are also indicating the period of respiratory support required is longer than normal in Covid-19 which puts a bigger drain on resources.
There are some standard relative contraindications to be aware of:
pH <7.15 pH <7.25 with additional adverse features
GCS < 8 Confusion/agitation Cognitive impairment.
If any of these features are present, then the use of NIV should be discussed with a senior doctor proficient in its use (ITU/HDU consultants / respiratory consultants / ED consultants), as intubation may be preferable. One of the problems with NIV is leaking of the masks and aerosolization of any pathogen increasing the risk of infection to those administering care or in the near vicinity (known as an aerosol generating procedure – AGP). This has been raised as a concern in lots of the current literature regarding treatment of potential and confirmed Covid-19 patients.
Full page version here.
The bottom line: If you do not have the resources to isolate your patient and protect yourself and others then this is not a modality you should be using to treat Covid-19 patients, although we accept CPAP may be a useful bridging tool before intubation. If you’re going to use it, deliberately practice -as practice makes perfect. CPAP and NIV hacks here.
References & Useful Resources
1. Simon Carley (2020) St.Emlyn’s Covid 19 Podcast from Italy with Roberto Cosentini
2. British Thoracic Guidelines (2016) BTS/ICS Guideline for the Ventilatory management of Acute Hypercapnic Failure in Adults
3. Josh Farkas (March 2020) COVID-19 EMCrit
4. Public Health England (March V1 2020) Covid-19 Guidance for infection prevention and control in healthcare settings.
Early reports suggest that most of the intubations will not be happening in ED, but on the wards, and as much as possible, ITU / anesthetics will be performing intubations. If you want to avoid the tube – listen to this podcast, and think about an awake intubation. Intubation is a high risk aerosol generating procedure, so the most experienced operator should do it to maximise first pass success, although most of the patients seem to be cardiovascularly stable. Make sure intubations are logged for research here.
Drawing up all the drugs needed won’t be familiar to everyone – crib sheets here.
If you need a reminder of basic airway management, look here.
There’s a video of how to intubate a ?COVID patient here, with an instructive blog from first10EM, and although at first glance these “tips for orthopaedic surgeons” may seem flippant… they remind us that speaking people’s language matters.
If you do end up intubating someone, do consider your situational awareness. Situational Awareness in COVID Intubation – a 5 minute video that might make you think about critical care RSI as a team sport.
The “intubation box” that has been widely suggested on twitter has been reviewed carefully by LITFL and is generally considered NOT a good idea.
Intubation Prep Tips and Checklists
- Create intubation packs. You need an HME filter on all your bag valve masks.
- Rapid intubation team – to give a backup 2nd opinion for ceiling of care and DNAR decisions to the ED senior. Avoids lots of difficult communications, bleeps, trying to get hold of people etc. And then, where appropriate, to intubate. Briskly.
- Don’t disconnect experiment – think about taping circuits together to prevent accidental disconnection – reviewed by EM Crit here.
- Have a respiratory precautions intubation checklist: Faculty of Intensive Care Checklist – in my view, the only one you need.
Royal London Hospital Checklist – useful.
EM Updates Checklist – does it emphasise PPE enough?
EM Crit Oldham Checklist – I like the way it splits clearly into outside the room, and inside the room.
Safe Airway Checklist Chris Hicks twitter thread and latest checklist- suspect more links coming
Collection of checklists Twitter checklist.
Used in anger checklist.
We also need to think about intubation in cardiac arrest. PPE will be needed – think about who to get it on first – the senior person might be sensible. Consider compression only CPR and how you will mimimise post arrest cleaning. Video here and resus council flow chart here. Capnography? The hats and caps might help!
ICU Trouble Shooting
You may get deployed to intensive care. It might be that not all your tasks will be clinical – doctors will still need to do admin tasks like requesting CTs! ICNARC are releasing regular data reports.
When do ITU need to review your patient? One guide here. In the ED we’re generally used to identifying the sick patient – your ITU will know whether they want to be referred all patients on 15L in-case, or not.
Non ITU staffed may end up rounding on the most well patients, highlighting problems to ITU clinicians. If you’re looking at setting up vasopressors or inotropes (yes, there is a difference), these lovely pics let you know what they squeeze.
Daily Rounds: This guide and this checklist here will be useful. The ITU one pager will be essential! St Emlyns are likely to keep their ITU updates guide regularly updated with any new rounding guides they spot. Checklists for problem solving here.
ITU Guidelines: Cork , Propofology , “summary of ITU” guideline in a tweet here, there’s a (non reviewed) video on ITU basics here. Online “basics” course here. Portsmouth guidelines, Northampton Critical care guidelines here.
Good interview about ITU care by St Emlyns here.
Some crib sheets for redeployed to ICU on “nursing care” here.
National ITU Guidelines: NICE
Ventilators: introduction here. There’s a fabulous few summary slides here. There’s some ventilation basics here, and some e-learning here and here. We anticipate beginners will be keeping an eye on the vent – crib sheet here.
Now engineers have been asked to make ventilators I’m sure we’ll be fine. But just incase…here’s a video on how to convert one ventilator to use for multiple people (although clearly we shouldn’t be doing that – alternative suggestions here), and a journal article, and one on CPAP via facemask, and one on 3D printing required valves.
Proning: Simply, proning is lying ventilated patients on their tummies to help their ventilation – beautifully explained in this video here. It’s often one of the last measures we try, and it takes a lot of people to perform it. There’s lots of resources becoming available to help specialities (well done orthopaedics) with the proning – video here, Cardiff e-learning here.
Do consider and simulate what to do if your proned patient arrests – flip them or treat them prone?
With the elderly expected to be hit more than the rest, having an escalation conversation early will be beneficial. We can never #havetheconversation too early. If you’re not used to having these discussions, I would just recommend you print this letter from Matt Morgan, and read it to your patient. Leave the copy with them. There’s a good death and dying booklet from Age UK here that focuses more on DNA CPR than ITU care. If you need convincing about why this is a good idea have a look at this or this. Have a look here for more printable posters and resources or here or here or here (see twitter) for some framework videos.
Many of us are starting to have to deliver bad news over the telephone, which is not something we’re comfortable with. There’s a twitter thread discussing it here, with this prompt sheet, and this crib sheet being really useful, with some tips about dealing with bereaved children here. Some hospitals have started to use simulation to practice this, and it’s been a useful way of not only learning about these conversations, but debriefing. At the RCEM Spring 2021 conference, we heard how this past year has really challenged the way we communicate with barriers in place. From communicating with PPE on to breaking bad news over the phone, which many of us have found really challenging. Helen Parker gave some useful tips, like taking a colleague in and call on mobile via speaker to replicate the way we always take someone in with us when we are doing face to face difficult conversations.
Loss of visual cues is such a problem, she said, for example permissive use of silence may be a dropped line, so simulation may help you become better at quickly recognising which is the latter or the former.
Clarity, honesty and empathy are central to allowing an authentic conversation to take place, she pointed out. It’s also important to avoid euphemisms, although “death or dying” might be hard initially, they are kinder in the longer term. Do try to stop using the words like “popping” (popping in a tube, a cannula, pop to CT etc) and other terms which may trivialise the situation.
If you are looking for some simulation scenarios, EM3 have got this covered.
There’s a useful cartoon here.
None of the Wuhan workers wearing appropriate PPE got COVID. So the PPE works, if we wear it properly. The St Emlyns “bubble” analogy is good to think about how to protect yourself. Follow PHE guidelines as to what PPE to wear (and hope they’re evidence based), and FOAM cast have blogs and podcasts about general infectivity. Government guidelines on obtaining PPE here and some consideration about the ethics of seeing patients without PPE here. There’s a whole podcast segment on it here – the fact that its one of three, means it’s so so so important. Important enough that one hospital has got a PPE officer. Do have a look at the EM3 drills for PPE communication.
Coronavirus is believed to be droplet spread, although now we’re considering airbourne again.
Coronavirus is killed by alcohol and soap.
There’s some evidence coronavirus is spread via ocular fluids so watch out for those patients presenting with “conjunctivitis”(Twitter thread). There’s evidence it lives in the faeces for five weeks after infection, although unlikely to be infections, still follow standard/ normal precautions of closing the toilet lid before flushing, and washing your hands after visiting the toilet!
General Infection Control Reminders
Social (or physical) distancing applies to ED docs too!
Standard infection control measures should be followed, with excellent hand hygiene, and frequent wiping down of surfaces. All patients with suspected COVID-19 will ideally be in negative pressure side rooms. As this isn’t possible, consider cohorting, and consider splitting your ED into “dirty respi” and “clean” or “hot” and “cold” areas. If you’re lucky enough to have two sites, maybe one will cease emergency operations. Remain vigilant even in the clean areas – many positive corona cases have presented without chest symptoms – even with the dreaded “acopia”.
Have extra caution in aerosol generating procedures – intubation, NIV, CPAP, chest physio, epistaxis management, NG tube placement, possibly farting. Even though there has been much debate, nebulisers are not considered aerosol generating – read here or twitter to see why.
Have a process for what to do before you go home.
Scientifically tested barriers may be useful. What we call FFP3, Americans call N95. Not all N95 masks are the same so be careful interpreting information from abroad. Wikipedia has a good summary of the differences and this video runs through why you can’t just use the vacuum bag.
There’s a nice poster here about which PPE to wear when. Which ever you wear, make sure you don and doff properly – a lot of the healthcare infections abroad are not because of the wrong PPE, but the wrong PPE technique. Here’s how to remove your gloves. If you wear your PPE properly, and remove it properly, chances are high you won’t get PPE – in Wuhan, providers didn’t get covid.
There’s some really good tips from actors who wear a lot of restrictive costumes here.
This incredible bunch! Difficult times always with a smile! Qe aem! pic.twitter.com/GHTePu409Y
— Phil (@Phil2_LGT) March 15, 2020
Note the facemask has the blue side outwards. The mask goes tight under the chin – you might need to tie the bottom tie over the top of the top tie, and is squeezed in over the nose. Hair is tied back. All helps the mask to do its job of filtering nicely.
FFP3 – aerosol generating precautions
Scottish video here. Donning Doffing . Practice donning and doffing, and practice intubating in PPE. Lots of checklists and prompt sheets here. Really important to practice doffing – what will you do when someone faints in the hot zone? Other considerations here. When people are in PPE hard to see their faces – lots of suggestions including stickers or pictures pinned to the PPE. It’s also hard to understand and hear them – medical makaton has been suggested – it’s important for your patients to know who you are behind the mask! It’s also hard to communicate from the cold zone to the hot zone – a role for baby monitors?
Epistaxis management probably requires AGP protection – statement from ENTUK here.
Staffing, Education, Research
HEE have issued guidance and have a COVID-19 specific website as have AOMRC. They no longer want to approve re-deployments, but are clear we should provide support, supervision, and teaching. There are guidances on ARCPs here. If you are redeploying anyone, please please please please let your DME know – HEE will still need to approve the swap and your DME is likely to want to emphasise that they are happy to be the point of contact for any trainee with concerns. We are in discussion about how to reimburse trainees for any likely extra unsocial hours. We are working very closely with the guardian of safe working. We don’t have any answers yet about how we’ll work this out. Let us know what your hospital has decided – #rcemcovid.
Rotas will potentially be difficult to manage. Good practice ideas we have seen:
- Daily ‘head counts’ and re-allocation of staffing across the medical wards
- Creation of “houses” – you may move your ward, but you’ll stay in your house.
- Plan A rota is “business as usual”.
- Plan B rota produced – change to 8 hours on, 16 hours off.
- Plan C rota produced – change to 8 hours on, 8 hours off
- “No contact” days pencilled in so staff allowed to rest
- Pyramid groups of supervision with ITU oversight.
- Healthrota has created the option of providing emergency availability. If you’re not on healthrota…maybe now’s the the time to see if you can get a free trial!
- Once you have your rota, your team can join the whatsapp group for that day and that day only – via a QR code. (Easily generatorble)
Have a think about where your “hidden staff” may be. What will your resus officers be doing when they’d normally be teaching life support? What will your clinical skills facilitators be doing now medical student placements have ceased? Where are your education fellows? Are your occupational health doctors helping, or will their screening processes pause – could they help clinically? Can anyone on maternity leave come back early rather than tagging annual leave on the end? Are your recently retired doctors fit to return – could they do non front line work (as they’re increased risk)? And can your self isolating staff who are well, do any virtual appraisals to help other doctors get back on the front line? Think about transport – would a minibus to get people from the isolation hotel to work be useful?
The government is encouraging volunteers and medical students. What about your local St John Ambulance unit?
Child or Adult Care Support
All staff may need to not be at work because they have to look after children or relatives. Do not make them feel guilty for this. Arrangements may be able to be made- but think about them now.
- NHS supporters network
- Many nurseries are prioritising health care workers
- Find your medical students! Edinburgh people volunteering here.
- Have a baby sitting ring – 3 parents can take it in turns.
- Medical parents co-op. Sign up here.
- See if your local village has made arrangements to share small groups.
- Lanyards to highlight the respiratory assessment practitioners
- HEROS – merging efforts to help people
Whats app is difficult to use, as people may be bombarded with messages and unable to switch off. Having said that, NHSX have said using it is OK. Alternatives like slack are easier to categorize messages, but may not work for a whole large department. A trust intranet page or mobile app for clear communication is essential. A pre-shift briefing for two way flow of information will be useful (whilst maintaining social distance!) – checklist here. If you have daily briefings from the command team, it will be worth making sure your Junior Doctors forum is represented.
Its worth thinking about communication in your department too. RCEM have released a safety briefing around PPE – have look on twitter here or on RCEM here. PPE makes hearing difficult for staff and patients. Think about learning BSL /creating hand gestures and having some team drills. Have some mindful communication. The NHS nightingale prepared a crib sheet for standardised gestures.
Your department needs to have a clear way of documenting sickness, and checking the wellbeing of staff. We have created this table for documenting only. Whether self isolation counts towards sickness leave etc. will depend on government and hospital policy. Think about your bank and agency staff – they won’t be entitled to sick pay, and may be hesitant to put themselves on the front line. Your hospital may be able to expedite bank registration, and temporarily provide bank staff with sickness pay.
Staff who have contracted covid from work probably need reporting to RIDDOR. Return to work is controversial – if people are well enough in seven days, then they can return, although they are probably still shedding the virus (tweet, and journal).
There’s also lots of ways to provide education without face to face components, and without re-inventing the wheel. RCEMLearning have a fantastic series of re-released corona related modules here. Lots of other people have done similar, with free modules available on e-lfh and SCRIPT. There’s a list of e-learning resources for each subject here you can direct people too, and corona specific videos here. Leeds med school have shared loads of resources here. The ALSG have shared their hospital MIMMS e-learning, which is very useful (tweet).
For education – don’t forget human factors training!
For teaching techniques and resources, ALIEM have a list here about techniques, whats app questionning, and distance assessments. Google classroom will be easy to set up, and DFTB have created a teaching anywhere tip post. We’ve created a special #weecpd. All the corona simulations are (non-core) learning opportunities. We expect to see lots of reflections on pandemic medicine, and those trainees wanting to do public health will be shining. Kings have good good resources on corona simulation, as have EM3.
This will have shaped innovation and education for the future – log it and your thoughts here.
Research & Innovation
Everyone needs a chest x-ray in the ED to check there is no alternative diagnosis. We don’t want to be labelling all of the pneumothoraces as COVID – but the x-ray may be normal in COVID. Some COVIDs will need a CT to aid risk stratification. Images and instructions here. Some will benefit from ultrasound. Draft protocols are flying around. Have a look at this flowchart.
Specific Lung ultrasound findings have been shown to have a good correlation with findings on CT in patients with COVID-19 and has been successfully used as a risk stratification tool.
Here are some narrated slides about how to use ultrasound for chest assessment – with thanks to Michael Trauer. This YouTube video provides an introduction to lung ultrasound A profile- the horizontal lines parallel to the pleural line are A lines they are reverberation artifacts from the pleura and become fainter the further down the image the go. This is a “dry” ultrasound appearance that you might get in a patient with COPD or asthma rather than pulmonary oedema or ARDS B profile- this image shows bright “flashlight-like” beams coming off the pleural lines and extending all the way to the bottom of the screen without attenuation. These are “lung rockets” or significant B lines. Different names have been used for B lines – comet tails, ring down artifacts.
If your department is already well set up for ultrasound, it could be really useful. If you’ve never used an ultrasound before, it might be a bit tricky to start from scratch. If you’d like to refresh your ultrasound knowledge, all of RCEMLearning’s ultrasound modules are here.
To learn more about USS, we’d recommend looking at RCEM image acquisition and then jumping to 5min sono. You will need to be able to carefully decontaminate your ultrasound machine – you may need one in the dirty zone, and one in the clean zone. There’s a useful article on ultrasound appearances of COVID19 here. FASSGEM group have built a resource center to house relevant information on the role that POCUS can play with affected patients. There’s lots of other e-learning resources here, here and here.
Non Radiology Diagnostics
Make sure you don’t pod / air chute any potentially infected samples. Your laboratories will also be working flat out, and your clinical information will be essential to help them prioritise sample analysis. A troponin will be useful for risk assessment. A lymphocyopenia on diagnosis is likely – no fever, and no low lymphocytes…double check it’s really COVID19.
The basic physiology is well covered in other places: EmCrit, Rebel EM and LITFL for adults
DFTB for children (with light hearted tips for paediatricians seeing adults here). Both these sites are going to try and keep their links up to date.
Similarities are being noted between COVID and HAPE (disproved here), and COVID and dengue. There’s a lot of coagulopathy, and even neurological effects.
There is thought to be two phenotypes (article here, webinair here, tweet here and here).
Proposed COVID-19 Pathophysiology [Part 1 of 3]
The answers have significant potential clinical implications in COVID-19.
Buckle up. It's a long one.
Coronavirus mostly presents with a cough and fever. But may also present with GI symptoms, or cutaneous manifestations. Reports of covid induced trigeminal neuralgia aren’t clear if its coincidence or not. There’s a great thread on this, and the first response said it mimics everything, and co-exists with everything, including “generally unwell“.
The medical care needed will generally be supportive – if you’re sending people home and English isn’t their first language these leaflets will help, as will these translations. Not sure whether to send them home or not? Your hospital will have a guideline – this “TICC” protocol is clear and easy to read.
All of this clinical treatment is basically summarised here.
Provide oxygen as needed. Using a nasal cannulae will allow for a surgical mask to be placed over the top of the oxygen. Check NOW what your department’s O2 delivery capability is. Newer departments report about 2000litres per minute in ED, and lower down the line on the wards about 200L per minute. That’s about 14 patients on 15L/min. If your low flow alarm is going…maybe that’s why! How oxygen gets to your patient is described here.
CPAP / NIV may be needed – but as this is aerosol generating, many departments are being cautious in its use.
Awake proning or intubation may be needed (see ITU section for explanations).
Circulation Care: Cautious IV fluids. Early vasopressors – probably noradrenaline followed by vasopressin.
Other: Antibiotics aren’t needed unless you think there’s bacterial cause. GP guidelines here.
Stick to inhaled steroids etc. for asthma exacerbations – but remember oral steroids may increase viral shedding, so avoid unless essential. Dexamethasone or hydrocortisone should only be given to “severe COVID” patients with signs of severe respiratory distress.
Penthrox and Entonox is hypothetically considered an “avoid if possible“.
Paracetamol should be used in preference to ibuprofen, but ibuprofen is probably OK. Most hospitals are probably starting to run out of paracetamol and ibuprofen stocks… so don’t be giving out TTOs unless its absolutely essential!
Don’t change your antihypertensives.
Sickle chest crisis may present similarly with hypoxia, chest pain, shortness of breath, infiltrates on CXR but is treated differently and an exchange transfusion may be needed. South London guidelines here (with generic sickle and covid here).
A reaction to the virus may also cause HLH -get your haematology and rheumatology teams involved! Tweetorial here.
COVID may also cause delirium. BGS guidelines here – in summary… 4AT, and look for other causes (PINCH ME).
Chloroquine probably isn’t very helpful.
People with covid seem to have a higher risk of hyperglycaemia with ketones. Diabetes guideline here.
COVID summary inforgraphic version 2. This week our academics have reviewed recent publications on viral mechanisms, timelines and trial data. We hope this helps. Version 3 out next week. @InflamAge_UoB @BHPComms @unibirm_MDS @uhbtrust @kyliebelchamber @HDR_UK pic.twitter.com/lOUbA1bXZx
— Liz Sapey (@e_sapey) March 25, 2020
Resuscitation: The resus council has some really clear guidelines here. They’re the same as before with added emphasis on when to wear PPE (ie before you go in). First 10 EM has some discussion around resuscitation.
Flow and “Sensible Decisions”: Less is More is a movement mostly based in the US -but time to think about what we’re doing and why. We’ve talked a lot on the podcast before about crowding, and this pandemic will put all of that knowledge to good use. Refresh yourself here and here and here and here.
The surgeons say if you’re doing a CT AP, you might as well look for corona in the chest too. Makes sense to me! I’ve never wanted to CT scan on mechanism alone (COI…not in a MTC!), and this covid guideline supports it!
Read the AHEAD study (or listen about it here).
Consider whether CT KUBs for all are needed.
Think about CT guidelines for SAH – appraise the literature.
Read the BTS guidelines and only do CXRs in asthmatics if indicated.
Remember your ottawa and knee guidelines, and canadian c-spine rules.
In the first wave, the whole world was with us, the NHS. The freebies heading our way persist and some support still exists, but a lot is different. We know it is hugely demanding both physically and mentally for all staff, with lots of moral injury, on a background of exhaustion. As individuals we need to look after ourselves, and our team, whilst recognising the positive effects of stress! We’re in the active phase, and what we do there will help in the recovery phase. RCEMLearning has lots of wellbeing resources available here and RCEM has an excellent whole page of resources highlighted here, as well as many key documents from the sustainable working group including the wellness compendium, when a colleague dies – and much more.
There’s many resources already in existence – one of many twitter threads starts here, liason psych advice here, fabulous learning from excellence summary, pre-hospital advice here, and there’s a useful BMJ summary of self care here too. Even HEE have a separate wellbeing programme, and the London School of Paediatrics created a wellbeing book! Other places have released lots of guidance too including Cardiff intensive care here, and there’s an e-learning package on psychological wellbeing from WRAPEM, and another from University of Nottingham here.
Here are our top tips for advice to give your team, and yourself.
- Be in top physical form
We know sleep (here and here covid specific here) nutrition and rest are really important, especially as we have a lot of video call fatigue. They probably have a good effect on our immunity. View our previous articles (compendium here) already and highlight them to your non EM colleagues. RCEM is really clear that now, more than ever, we need to look after ourselves, and everyone else, including our patients.
It’s also worth mentioning that all the hand washing can cause havoc with your skin (although what all these people were doing beforehand I do not know)! Moisturise well! If your hands have started to crack, these tips from a dermatologist are fab, and BAD released a statement too.
- Recognise and manage your stress
Read the RCEMLearning Stress Blog. Don’t just read it though, talk about stress and how to manage it with all your colleagues both in EM and out of EM. I delivered the simple stress lecture – and opened by saying “How do you know when I’m stressed”. At least 5 accurate signs were presented. When I asked “how do you help when I’m stressed”, the room went silent. By talking about it, it really helped normalise the potential of stress. Everyone in the room was stressed about coronavirus on about a 7-8/10 – apart from one person who hadn’t been in the clinical environment, so maybe we’re not helping ourselves! A stress management course online starts soon!
Remind People to be Kind: Some stress comes from not being able to help. Encourage non front line staff to think about their neighbours and community initiatives. Initiative to help GP services could be used in hospitals – engage your patient participation group? It’s not just everyone else that needs to be kind – leaders need to be kind too.
There’s lots of mindfullness apps available here with discounts / freebies for NHS staff, and a summary for “NHS people” here. There’s a new twitter handle just for wellness – @19_wellness with a supporting facebook group, and an fab overview of everything with bags of awesome resources from NHS in mind. There’s a new PHP supportline available too.
There’s some specific resources around reducing coronavirus related anxiety here and some meditations here (found from twitter). The “young person” resources might be good for the young or the old, and this imagined section resources is ideal for children.
There’s also some more generic wellbeing tips available from “live life to the full” with some lovely posters for HCPs here, and there will be some regular caring4nhspeople webinairs, as well as lots of blogs and resources from the Maudsley. You’d be surprised if we didn’t mention resilience – have a look at this resilience blog from T2 here.
- Recognise and manage everyone else’s stress
Consider why people are anxious – just because you’re not (although you probably are!), doesn’t mean they shouldn’t be – read this article on recognising anxieties. Maybe they don’t know from a patient perspective how ventilation works? This is discussed by St Emlyns here. Children might have different anxieties – discussed here. People might just be in a different spot to you – I think most people in EM have moved through the fear zone into the learning or growth zones – not everyone is there yet.
— Dr Shweta Gidwani (@Global_EM) March 29, 2020
There’s a useful leaflet from Mind about reducing general anxiety, and an excellent article on managing your own mental health from BBC coronavirus. These resources will also be useful for your patients COVID related anxiety.
This from the intensive care society starts by reminding us to make sure you only get updates once or twice a day. Encourage this from your team, to help them help themselves. Have some good email and especially whatsapp management strategies – remember whats app is often on people’s personal mobiles, so they can’t ignore it. If you check for updates every five seconds, you will burden yourself with anticipatory stress. Whilst you do this, only contact your nosey friends once or twice. We all know the people we mean – those who are only in touch when something bad happens, or they want “inside information”. They’ll take your time away, and suck you into making this a bigger drama than it is.
It’s also worth remembering your wider team. Clinicians are aware of all the resources being thrown at them, but make sure the non clinical staff are too. The effects of stress on teams are widely known – do what you can to minimise it.
- Keep Laughing and Keep Leading
It’s OK to laugh. These are challenging times, yes, but Laughter can enhance immunity– and we know it reduces stress.
Social distancing doesn’t mean emotional distancing. Your team need you now more than ever – some great tips here. Who is self isolating and needs to check in? Who is poorly and needs a 5 min check in chat?
- Debrief Often
Debriefing is everyone’s responsibility, and you need to encourage your team to start doing it now – debriefs shouldn’t just be after cardiac arrest. Check in and debrief with yourself – some great tips here, and a non covid related debrief podcast here.
Most of us have been debriefing for a while, but might run out of time, and the headspace. Contact your chaplaincy service, and any psychology services – ours are going to be running a daily debrief drop in session with our psychology colleagues to make sure night and day shift can attend. A “4 o-clock club” is a similar approach.
For people new to debriefing, the “TAKE STOCK” principle will be useful, and there’s another useful COVID specific prompt here. There’s a trial of an online debriefing service here. A hot debrief is recommended, but not compulsory. It is an emotional release and a “lessons learned” review carried out there and then after the incident or exercise, when all the key people are still present and any lessons learned can immediately influence future events. Minor details aren’t lost because of time delay, or a later emphasis on the bigger issues.
We have prompts available on our ED bereavement checklist to attempt to normalise the debrief process – often starting is the hardest part!
The cold debrief structure is often similar to the simulation “debrief diamond” or an after action review. The resus team may be able to help arrange this. An alternative model for a cold debrief is one which focuses on the emotional impact of the event and the ways in which participants are coping with this, and potential lessons to be learnt are not addressed, to enable people to speak freely in a non-judgemental environment. This model might be particularly useful to support the psychological well-being of staff.
- Arrange Practical and Wellbeing Support
It’s the little things that make a day at work better or worse. Worrying about whether your period will start, or if you’ve got enough food at home won’t make it better. But what about if you need to shower after a patient coughs all over you? What about if you’re too tired to travel home? Practical ideas like a “fare box“, “too tired to travel home” box, peer support for all things, including grocery supply are useful. Of course, if there’s space in your hospital some porta-homes would be useful for staff isolating from family, or who can’t get transport to work. The extroverts might like some interaction – maybe a zoom quiz or something?
We at LGT, had to go one step further, and our period SOS box has got organic supplies (thank you Freda), and a nice little bit of period specific relaxing (slow version here – if it helped you let us know!).
The doctor sickness record we’ve been keeping has tick boxes for when you last completed a welfare check. Ideally we’ll do that every day. Pragmatically, we’re not sure. We’re encouraging our junior doctors to form welfare groups, so they can check in on themselves.
7. Allow grief
Many trusts have banned visitors, even for the dying. This is leaving a lot of HCPs as the last person speaking to a dying patient- and this is taking a toll. We deliver people out of this world, as much as a midwife delivers them in – but it isn’t always easy. Take a moment to honour, and grieve for your patient who has died.
We hope none of you have to grieve for friends or relatives, but you might have to. Un-doubtably you will have to support grieving relatives of patients. There are plenty of tips here from thegoodgrieftrust, and tips for for grieving children here. Not all deaths will be due to coronavirus, and other support societies do exist eg. brake for victims of road traffic accidents.
8. Support Family
Acknowledging that your doctor’s family is supporting them too is useful. This is a great letter from one trust.
9. Rest Well
Resting is more than sleeping well. Resting is a chance to give everything to recover. We’ve made some suggestions on how reading can help, and some suggestions of what to do to help with holidays and we look forward to hearing your suggestions and additions too.
Other RCEM Learning Wellbeing Resources: We’ve signposted to the fabulous RCEM wellbeing compendium already. Do have a look at some of our other wellbeing resources – all available free of charge here.
Other Resources: HEE have created a wellbeing induction and strategy that piloted for the new transition to FY years. Some of the links they’ve highlighted are fabulous. We like:
Intensive Care Society
and have used some of their suggestions to update noticeboards with healthy eating and financial wellbeing contributions – instead of just focussing on mental health.
National Guidelines and Basic Science including Paediatrics
Patient Resources: Translated patient information leaflets are available via Doctors of the World and this google link.
NICE guidelines here
BMJ best practice guidelines here.
Learning from excellence collated evidence here.
Resus council statement here. (Summary: wear PPE first)
Delirium in covid times here (Summary: 4AT, look for other causes)
Rheumatology research and guidelines here.
Ethical guidelines here
Pregnant worker (twitter commentary here) guidelines here and RCOG here.
NHS PPE guidelines here
We can’t express enough how awesome DFTB is: their evidence summary on paediatric covid 19 is well worth a look at for covid in children. We started by believing that although children didn’t transmit COVID, it didn’t affect children, and that was largely true, and then we started seeing cases of PIMS-TS, MIS-C in the US. The RCEM 2021 Spring 2021 CPD conference highlighted that not all abdominal pain and serious illness is due to PIMS-TS, and be really careful you’re not succumbing to confirmation bias. Health inequalities have a huge impact here too – with PIMS-TS more common in deprived children, and BAME children.
Social deprivation led to a 5 x increased risk of admission with PIMS-TS. 15-fold increase in black children.
Also, 15% of PIMS-TS admissions were related to keyworkers in the @EvelinaLondon study
— Matt (@themattmak) April 14, 2021
PIMS-TS- what do we know?
Miriam Fine-Goulden, who works in PICU in Evelina, talked at the RCEM Spring 2021 conference about the unprecedented cluster of children presenting with hyperinflammatory syndrome, which started round about started this time last year. We were seeing children with CRPs up to 400 and evidence of cardiovascular dysfunction- something like Kawasaki and toxic shock overlap.
As time moved on, we were able to review the data of children presenting with PIMS-TS, and there is lots of it on the fantastic DFTB website. Although initially, we saw mainly older children, we now know that it although it still has a median age of 9years, but range is really large – from few months to older teens, usually fit and well. Definitely higher risk in some ethnic groups and lower socio-economic status.
If you want to dilute the evidence down to when you should think of PIMS-TS, you basically need to have alarm bells running in those with fever (generally high and prolonged) , systemic upset and no clear cause. Skin and mucosal membrane involvement is common, as are GI symptoms.
Moving on to the important stuff, you have sussed the kid out as potentially having PIMS-TS, you are going to call a friend, for help, and also to help rule out the differentials (any concern of abdominal pathology for example may not be PIMS, may also be malignancy), and now how to treat:
RCPCH have guidance here.
Your ED Planning Checklist
- Department layout:
- Flow through – do you go through hot to get to cold?
- Streaming processes – who goes to the ?COVID section
- Department equipment
- Do you need duplicates equipment in hot and cold
- Are the radios and phones charged and ready to go?
- Have you got enough trollies, PPE, signs, aprons, drugs, NIV machines
- Have you got enough scrubs, easily accessible?
- Are you cleaning communal areas with extra vigour?
- Do you have enough wi-fi signal, and enough iPads for communication.
- How are you managing predicted absences?
- Are your risk assessments for staff up to date?
- Has everyone been encouraged to have the flu jab?
- Are your wellbeing and psychological strategies reviewed, and ready to go. Are your staff as well rested as they can be?
- Is your policy clear, and well disseminated
- Do you have enough oxygen?
- When will you give dex? When will you give antibiotics? Do your juniors know/
- When will patients go home and when should they be admitted? Does the whole team know?
- Does the whole team feel confident in managing covid, delivering bad news, end of life discussions, NIV and PPE or do you need some top up education?
- When you run out of space, what’s the strategy? Will you mix ?covid and unlikely COVID?
- How can you prevent crowding – are there any quick wins for your department now?
- How many visitors are you going to allow – and will they be allowed at the end of life?
There’s ongoing research as to what helps COVID. Some find carbocysteine helps reduce the mucus plugging. Steroids (after the initial dexamethasone) may also help.
Your COVID recovery will be the website to point people towards.
Mark Campbell from the University of Oxford talked at RCEM Spring 2021 about the RECOVERY trial, a UK wide RCT for hospitalised COVID-19 patients, there is so much about this trial already, as it has really impacted how we care for our patients with COVID-19. St. Emlyn’s have blogs here and here and there is more on the Recovery trial website.