Corona Virus Daily Thread #27

The Great China Plague of 2020 (daily thread #23)
http://www.freerepublic.com/focus/f-chat/3826809/posts

Corona Virus Daily Thread #24
http://www.freerepublic.com/focus/f-chat/3827099/posts

thread 25
http://www.freerepublic.com/focus/f-chat/3827443/posts

thread 26
http://freerepublic.com/focus/f-chat/3827832/posts

thread 27
http://www.freerepublic.com/focus/f-chat/3828191/posts

Good post. Arrhythmias are possible and require monitoring.

“Just the flu, y’all.”

The state chart this afternoon showed 285 for NY state. If you add the 60 new deaths you get 345. There may be a few more out there—not sure—but that is the ballpark.

Greenville, SC now has a night time curfew, 2300 to 0600

must be off the streets

Coronavirus Disease (COVID-19)
https://ourworldindata.org/coronavirus#the-symptoms-of-covid-19

https://data.vcstar.com/coronavirus/
Tracking the Coronavirus Contagion: Active Cases

Coronavirus Disease (COVID-19)
https://ncov2019.live/data

realtime corona virus updates
https://www.globaltimes.cn//content/1177737.shtml

https://bnonews.com/index.php/2020/02/the-latest-coronavirus-cases/

https://kungflu.net/

Corona Virus - COVID-19 / SARS-CoV-2: LIVE stats and graphs
https://covid2019.azurewebsites.net/

Johns Hopkins Corona Virus map
https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6

“I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know.

Clinical course is predictable.
2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias(back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.

Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.

Day 10- Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours.

81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.

Patient presentation is varied. Patients are coming in hypoxic (even 75%) without dyspnea. I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA. I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT’s of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this ***** has told all other disease processes to get out of town.

China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA in the ED and rescue PCI at 60 minutes only if TPA fails.

Diagnostic
CXR- bilateral interstitial pneumonia (anecdotally starts most often in the RLL so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.

Labs- WBC low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95%
CRP and Ferritin elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated.
Notice D-Dimer- I would be very careful about CT PE these patients for their hypoxia. The patients receiving IV contrast are going into renal failure and on the vent sooner.

Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.

A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.

An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.

Other factors that appear to be predictive of poor outcomes are thrombocytopenia and LFTs 5x upper limit of normal.

Disposition
I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won’t make it back.

We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.

Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the “lockdown”, our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.

Treatment
Supportive

worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.

Plaquenil which has weak ACE2 blockade doesn’t appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil’s potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.

We are also using Azithromycin, but are intermittently running out of IV.

Do not give these patient’s standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.

Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.

Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.

Do not use Bipap- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.

The same goes for nebulizer treatments. Use MDI. you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn’t often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.

Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis.

We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.

One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 of 92%. She will be the first of many.

I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all.”

https://texags.com/forums/84/topics/3102444?fbclid=IwAR3s13SRnw7YNgtu-7LZyrMUSMIRRWScU67lwbuwZM8fna-6R8k4tqrtO3w

Correction—add 80 new deaths—NY state estimate—365 deaths to date.

King Ralph
John Goodman

Today I ventured out to other threads and I kid you not, now it is a “sanctuary city” and/or Chinatown problem.

Nope. Vaping puts you at higher risk.

Eventually it will be a “neighbor across the street” problem.

Solipsism is really the problem. :-)

—

I am happy to report I don’t know _anyone_ in this area with the solipsism disease. _Everybody_ is stepping up around here.

“Even us knobs on FR could see fire on the horizon, and impending chaos. And we’re not paid to look for or see this stuff.”

Not all of us. Some still deny it.

And I doubt any of those folks will ever admit they were wrong or apologize for the abuse they dished out over it.

My gosh.

There is SO much valuable info in that one post, from that Doc.

God bless him/all of the docs/HC workers fighting this, in the front lines.

Incredible....the days to present/full blown shut down.

THIS -> tells it.... Somehow this ***** has told all other disease processes to get out of town.

Great find and thanks for posting.

Amazing....I hope other ER docs/HC peeps have a chance to read this.

Nope, Touching your phone puts you at a higher risk then vaping. You are cleansing the lungs when vaping super heated chemicals. Touching your phone and then your face gives you the phonavirus. Beware.

Denial Bros™

“My gosh.”

Yes, I just posted it on the main FR page. I got it from a friend in the news media here locally in Dallas, he had just had it sent to him.

Scary stuff. We need more real information like this out there.

That is the most informative, horribly descriptive account of this disease I’ve seen. Prayers up for this doc and all the patients. May God give them strength and comfort during this crisis, and may we all have someone as dedicated as this when we need them.

Best I’ve read. Marking.

“The Diamond Princess experience is most useful in determining the proportion of victims showing symptoms to victims with no symptoms (3/7 vs. 4/7).”

Exactly. Determining penetrance of the population as a whole is not something we can look to the DP for. We don’t have valid data, yet, for comparing penetrance of CCP-19 and Spanish Flu.