Grand Rounds Recap - 6.15.22
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QI/KT: COVID-19 with Drs. Elizabeth Stevens and Anthony Martella
Current Testing:
Main testing assays include:
Antigen testing (“rapid tests”): affordable, allow for home testing, but lack sensitivity
PCR: higher sensitivity, longer processing time, dependent on sample obtained
Decision Rules and Diagnostics:
National Early Warning Score (NEWS2) looked at patients with COPD to determine what level of care they would need. Not appropriate to extrapolate to COVID patients given that they have hypoxic respiratory failure rather than hypercapnic respiratory failure.
PRIEST score is inconsistent with our current practice patterns and therefore not recommended
4C Mortality Score: validated for patients admitted w/ COVID, less applicable to the ED
Quick COVID-19 Severity Index (qCSI) uses vital signs to predict severity of illness, recommended to determine mild vs moderate illness.
CXR Score: each lung divided into 3 lobes, 0-2 of severity for each section (scored 0 to 6)
Independent predictors of hospitalization: CXR score 2 or greater (OR 6.2), obesity
Independent predictor of intubation: CXR score of 3 or greater (OR 4.7)
Laboratory findings associated with critical illness: lymphopenia, neutrophilia, thrombocytopenia, elevated ALT/AST, elevated LDH, elevated CRP, procalcitonin, or ferritin
Management:
Dexamethasone 6mg daily for 10 days showed overall 28-day mortality benefit in those receiving supplemental O2, mechanically ventilated, or on ECMO
Patients requiring ICU level of care for COVID-19 were found to have higher rates of VTE. There has been no demonstrated benefit of therapeutic anticoagulation compared to prophylactic anticoagulation on rate of VTE, and therapeutic anticoagulation carried higher risk of bleeding.
Outpatient treatments:
Bebtelovimab: shown to reduce symptom duration but no difference in mortality, given as single dose 175mg infusion, must start within 7 days of symptom onset
Paxlovid (nirmatrelvir+ritonavir): 300mg-150mg bid for 5 days, must be renally dosed, contraindicated in patients with eGFR <30 and severe hepatic impairment. Patients may have rebound symptoms or become PCR+ again 2-8 days after initial illness, must start within 5 days of symptom onset
Molnupiravir: alters COVID-19 virus’ codons to render its genome nonfunctional, given 200mg PO bid for 5 days, some studies show possible 50% decrease in hospitalization or death, must start within 5 days of symptom onset
For all, must have life expectancy >6 months and must meet one of these criteria to qualify:
Immunocompromised (see details on protocol)
Pregnancy (only eligible for bebtelovimab)
75+ years and unvaccinated
Category D (meeting two or more of the listed criteria-see protocol for details)
At UCMC, send these prescriptions to the Hoxworth pharmacy. Tell your patients that they will receive a phone call from the pharmacy to tell them when to come in (to avoid COVID+ patients sitting in their pharmacy lobby)
Remdesivir: some conflicting data. WHO no longer recommends, however NIH still recommends based on PINETREE study
Tocilizumab: IL-6 inhibitor used for rapidly increasing O2 requirement, CRP >75 + ferritin >1500
EMS Grand Rounds: ET-3 with Dr. Drew Williams
CMS/CMMI goal is to incorporate healthy equity and the goals of the patient
“ET3” (Emergency Triage, Treat, and Transport) Model: five-year nationwide initiative aimed to expand patient care flexibility and possible payment models to ambulance care teams. For example, ambulance crews may be able to facilitate a telehealth visit and receive funding as if they had transported the patient. The goal is to reduce costs and improve the quality of healthcare provided. Additionally, crews could transport to an outpatient office, urgent care, behavioral health facility, sober living (i.e. Talbert House in Cincinnati) based on illness severity and patient preference.
R4 Simulation: Anaphylaxis with Dr. Logan Walsh
Anaphylaxis management
Epinephrine (0.3mg IM in adults or 0.01mg/kg IM in pediatrics). Can repeat dose in 5-15 minute intervals if symptoms persist (or sooner if clinically indicated).
corticosteroids
H1 blocker
H2 blocker
IVF
epinephrine gtt for hypotension
can mix “dirty epi gtt” by placing 1mg epinephrine (1amp “code dose epi”) into 1L bag of IVF. concentration is then 1 mcg/mL. Start at 1-3mcg/min.
Angioedema/Airway Management
Pretreatment with glycopyrrolate for secretion management, oxymetazoline for vasodilation, viscous lidocaine and atomized aqueous lidocaine for topical anesthesia
Can place a nasal airway to dilate the naris and help determine the size of the ETT you will use. Can either remove the nasal trumpet prior to insertion of the fiberoptic scope (caution, this could result in bleeding) or use it as a channel for fiberoptic intubation.
If you chose to use the nasal trumpet as a channel, you may cut the nasal trumpet lengthwise prior to placement, which will allow you to peel the nasal trumpet off of the scope to then pass the ETT.
Alternatively, subtotal intubation with ETT (placement of the ETT through the naris into the mouth-shown below) allows for dilation of the naris, provides a clean channel for fiberoptic scope, and eliminates the step of removing the nasal trumpet (*this method is preferred).
Prepare for surgical airway if fiberoptic nasal intubation is unsuccessful and orotracheal intubation is not possible. Use 4.0-4.5 ETT for females (with pediatric bougie) and 6.0 ETT for males (can use adult or pediatric bougie with this size ETT).
Oral Boards: Croup with Dr. Christa Pulvino
Etiology/Epidemiology: laryngotracheobronchitis which typically occurs in children ages 6 months to three years due to infection with parainfluenza virus. Can use the Westley croup score to assess illness severity.
Diagnostics: neck XR can show steeple sign indicative of upper airway edema. Imaging is not necessary to diagnose croup but could be beneficial to evaluate for other more serious etiologies of stridor.
Management: dexamethasone, racemic epinephrine for stridor at rest, treatment of fever
Differential diagnosis: includes epiglottitis, bacterial tracheitis, retropharyngeal abscess, peritonsillar abscess, airway foreign body
Disposition: can discharge home if SpO2 is stable on room air, stridor is resolved, appropriate mental status and aeration, and PCP agrees and can follow-up closely
Oral Boards: Lemierre’s Syndrome with Dr. Colleen Laurence
Pathophysiology: Suppurative thrombophlebitis of the internal jugular vein that occurs as a result of hematogenous spread of bacteria (33% Fusobacterium necrophorum, Fusobacterium nucleatum, GAS) from oropharyngeal infection via tonsillar vein or lymphangitis. Typically occurs after tonsillitis (37%), pharyngitis (30%)
Epidemiology: Incidence of 3.6 cases per 1 million persons; predominantly in 15-24 year old; increased incidence with antibiotic resistance, decreased tonsillectomies, and use of rapid Strep pharyngitis testing
Presentation: classic triad of pharyngitis, anterior neck tenderness/swelling, cough and non-cavitary pulmonary infiltrates on chest x-ray/CT, typically occurs > 7 days after pharyngitis with transient improvement; exam with unilateral overlying erythema on neck in 52% of patients; presentation may vary depending on where septic emboli disseminate to (ie, pulmonary, septic arthritis, neurologic 6% of patients)
Evaluation: CT neck with IV contrast is study of choice to evaluate clot and potential abscess formation around it; consider extending to chest to evaluate for pulmonary emboli; US can help, but reduced sensitivity for recently formed thrombus or deeper infections
Management:
Airway: 37% of patients may require intubation
Antibiotics: Ampicillin-sulbactam, Piperacillin-Tazobactam, or Carbapenem
Anticoagulation: Often cautioned against, especially in the context of septic emboli given potential for hemorrhage; however, no consensus on AC based on recent meta-analysis, which did not demonstrate mortality difference with anticoagulation. Discuss with Hematology
May require surgical thrombectomy, but only considered typically after weeks of antibiotic therapy
Mortality was previously 90%, but more recent rates are 5-10% with early antibiotics
Oral Boards: Ramsey Hunt Syndrome with Dr. Colleen Laurence
Presentation/Etiology: herpes zoster oticus presents as a triad of ipsilateral facial paralysis, ear pain, and vesicles in the auricle or canal. Can affect ipsilateral taste and may have tongue lesions present. Often preceded by viral syndrome which causes reactivation of VZV in the geniculate ganglion.
Epidemiology: elderly females are at higher risk
Presentation: paralysis is often more severe than in Bell’s palsy and carries a lower chance of complete recovery
Treatment: valacyclovir 1g tid x 7-10d and prednisone 1mg/kg x5d. Best outcome with both tx started within 72 hours of symptom onset (70-86% full recovery if w/in 72 hrs vs ~20% or more if not). All will improve somewhat; more severe cases see less improvement.
Additional considerations: corneal abrasions and ulcers if eyelid closure impaired (prescribe artificial tears, consider taping eye shut at night).
