Tonight I had a chance to chat with Dr. Blair Schwartz, intensivist at the Jewish General Hospital in Montreal, Canada, one of the ministry-designated COVID centers, in part due to their ICU which was designed with pandemics in mind and able to physically be divided in sealed-off halves. Impressive stuff.
Here is our chat:
So thus far, the small Montreal experience parallels what we have heard from the Chinese and Italian experiences: they crash fast, so intubate them early, then deal with a high compliance ARDS that is difficult to oxygenate, and prone them. Oh yeah and the critically ill are not the very elderly at least so far…
Oh yes and I also questioned Blair on whether they were re-using N95s or staying completely protected for the day – seems to have been a practice in some of the dedicated areas in China, but so far, given “only” 3 patients they are keeping the general unit “clean” and disposing of all PPE between patients.
We’ll keep tabs on the evolution of the critically ill cases and try to share anything useful.
So I’ve yet to take care of any COVID patients, but we are ramping up, and it’s just a matter of time. In the meantime, practical issues such as where we will cohort patients and how we protect non-COVID patients and HCPs are happening, and one of the challenges in infection control is imaging, which is a staple of severe respiratory illness.
Evidence has been steadily coming out that lung ultrasound is carving itself a pivotal role in the diagnosis and management of COVID infection. Here are some of the things I’ve gathered and I think are worth sharing. I will be adding to this as I collect from others and eventually generate a COVID POCUS database and experience.
a. Lung US is more sensitive than CXR for interstitial patterns, small effusions and subpleural thickening.
b. COVID seems to have some particular ultrasound features:
c. POCUS can be used to detect worsening or improvement of disease – by personal communication of Italian and Chinese ER/ICU docs. No published data yet, but several self-scanning infected physicians corroborate clinical improvement with resolution of POCUS lung findings.
d. POCUS can also detect the usual pathologies! Pneumothorax is not a rare occurence in ventilated patients, and there may be an increased rate related to the parenchymal damage resulting in the unusually high compliance respiratory failure.
COVID POCUS DATA
Here is a good example from Marco Garrone with COVID B line pattern on the left, along with pleural thickening and small sub-pleural consolidations, note also the clustering of B lines, compared to the left, B lines of CHF with a relatively smooth and even pleural line:
This is a great article by Yi et al, a Chinese radiology group, with some great CT/POCUS comparative images:
COVID19 has made for a rough start to 2020 for humans. Now ramping up in Canada, we can only hope that lessons learnt in China and Italy by governments and medical teams can be applied in a timely enough fashion to flatten the curve and allow our already stretched-thin healthcare system to absorb it without dire consequences for both COVID and non-COVID patients.
At my shop we have started our (re)organizational plan for the potential storm that may hit us.
So here is my chat with Marco (@drmarcogarrone)
And here is the vidconf audio with Dr. Zhiyong
I apologize for the prolonged ending there were technical difficulties and we ended up losing Dr. Zhiyong’s connection at the end.
Some clinical points from these and other discussions:
– high compliance ARDS
– needs peep, but avoid hi peep as seems to have high risk of pneumothorax. This may make sense given high compliance may reflect alveolar wall elastic fiber damage.
– avoid NIV including HFNC unless negative pressure room to prevent aerosolization.
– may need to use N95 for entire duration of rounds in hot zone ICU to save stock
– personally, I would/will consider early proning or modified proning for spontaneously breathing patients (not on NIV either, just face mask).
Also, as this will undoubtedly be a time for stress for HCPs caring for COVID patients, a respirologist friend of mine shared a link to a wellness/meditation tool, the coronavirus survival guide which has been made freely available to us. Now I have not tried it yet but I trust Andy.
Comment from anaesthetist Dr. Marco Vergone who is on the front line in Turin, Italy:
We are using prone positioning in almost all of our patients that require invasive mechanical ventilation, we’re trying alternate lateral position for patients on CPAP (helmet), and personally I find very promising prone positioning for patients in spontaneous breathing during weaning from CPAP, before discharge from the ICU. I can confirm that diagnostic (CT and XR) is really burdensome when you have many isolated ICU patients, so lung US becomes paramount for bedside daily evaluation. We’re working on standardized protocols for different levels of expertise of colleagus (pro level, basic skills, beginners). For intubation procedures, we perform rapid sequence with ketamine + rocuronium or fentanil+propofol+rocuronium and ALWAYS videolaryngoscope. We always clamp the tube before disconnections and we always sop gas flow before removing helmets of masks. Apart from correct use of PPE, it is paramount to reduce aerosolization and contamination of the environment. Get prepared ASAP, and stay strong! Best, M
hope some of this can help other HCPs in these trying times.
So a lot of people have been asking for a VExUS tutorial, and since our paper was just accepted, I figured it’s a pretty good time to do it! Thanks to Dr. Ian Ajmo of FrancoFoam fame who put on his Hollywood director’s hat and filmed it!
Here is the classification that has been validated:
I’m attaching our chapter on venous congestion below as well.
Of course, Andre Denault, William Beaubien Souligny, Rory Spiegel, Korbin Haycock and myself will be running VExUS workshops at H&R2020. There aren’t many spots left!
So I love the UVM EM Update at Stowe. It’s a great little conference, run by my good friend and all around awesome guy Peter Weimersheimer (VTEMsono) ED Pocusologist, and his super team including Kyle DeWitt (@emergpharm), Meghan Groth (ENpharmgirl) and Mark Bisanzo (@mbisanzo). It’s a smooth running show with some really amazing speakers where I always learn a bunch. Had the chance to finally meet Sergey Motov (@painfreeED) and learn from an awesome opioid lecture. And it’s always great to hang with Josh (@PulmCrit) and listen to the pearls!
So here is my fluid talk. The Keynote pdf is just below. Hope there’s a useful tidbit or two in there!
So recently a colleague asked me about one of my twitter posts where I had put a clip of doing venous congestion assessment using a handheld – which is without pulsed Doppler (PW). Since VEXUS is predominantly based on Doppler findings, seems like 2D and colour might not cut it, but can it be done in a screening or “lite” fashion?
Definitely. Here is a mini-discussion about it, and some clips below to illustrate.
Clearly Pulsatile PV likely near 100%
Ascites, plethoric IVC, pulsatile PV, markedly abnormal HV with “police siren” appearance due to substantial retrograde flow – likely VExUS 3 or C.
Normal looking HV
Markedly abnormal HV
Love to hear some questions or comments!
of course, lots of VExUS discussions with William Beaubien Souligny, Andre Denault, Rory Spiegel, Korbin Haycock and myself at H&R2020!
So I’ve had the pleasure of knowing Zack for a few years now, ever since he and Joe Bellezzo (the EDECMO Team – along with Scott Weingart) came up to Montreal to teach at CCUS 2013 where they first told us about ECPR. I was instantly hooked, and after the CHEER Study came out in 2014, have been on the path to get this going in my shop, Santa Cabrini Hospital in Montreal, Canada. A tall order for a Canadian community hospital, but hey, I’m in the business of saving lives, and always felt and will feel that any patient crossing thru into a hospital I work in should get the best care that my team and I can possibly put together.
I think any invasive procedure is within the reach of any dedicated resuscitationist with reasonable procedural experience, with the proper training, and inserting ECMO cannulae, and Joe and Zack, a couple of awesome ED docs, showed this clearly. Its use is now spreading, and though there are – as always – many pundits, there is little question that this technique can save lives – the key being selection and subsequent management.
So here Zack tells me of another potential use for a tool I really like. We have recently acquired this technology and I’m looking forward to using it. REBOA is a tool used to control bleeding – a non-surgical cross-clamping of the aorta. But here, we explore how it might be used in another, more common setting… and I love the physiology of it!
Here you go – and apologize if it may be a bit choppy as we had connectivity issues, but I think Zack’s message comes out nonetheless!
This is what a REBOA looks like:
You can see how aortic occlusion beyond the takeoff of the left subclavian will concentrate CPR-generated blood flow to coronaries, cerebral circulation and arms, none being “lost” to the viscera and lower extremities. This makes ROSC more likely by improving coronary perfusion pressure and may improve neurological outcome by improving cerebral perfusion pressure.
Oh yeah, and anyone who enjoyed this, going beyond the cutting edge, don’t miss H&R2020, whose ethos is just that. Physiology and going beyond the cutting edge. A REBOA workshop will be part of the Resus Toolbox – one of the pre-conf courses!