Emergency Medical Minute

Accumulating clinical evidence suggests that many patients with COVID have neurological symptoms and that some may even present with neurologic manifestations of the disease. Most COVID patients have a cough, respiratory distress, and while clinicians often speak about how similar the presentations of patients with respiratory COVID are, it's worth looking at the possibility that COVID has atypical presentations, too.There's very good evidence that coronaviruses can infect all sorts of human cells--not just those in the respiratory tract. A few weeks ago we discussed ACE inhibitors and NSAIDs and SARS COV2 and you may remember that the virus attaches to the ACE2 receptor--a receptor which is found on a wide range of human cells. What are the chances the virus can infect a patients brain cells, cranial nerves, peripheral nerves? Host: Elizabeth Esty, MD Research By: Tanisha Crosby-Attipoe & Mason Tuttle Sound Editing By: Stephen Bahmani Time Stamps: 0:23 - Numbers 1:25 - Possible Neurological Manifestations of COVID 4:15 - What are the chances the virus can infect a patients brain cells, cranial nerves, peripheral nerves? 4:55 - The neuroinvasive potential of SARS‐CoV2 may play a role in the respiratory failure of COVID‐19 patients 8:24 - early neurological research from NEJM in February 9:10 - some early research indicated possible neurological manifestations 10:05 - COVID and serious CV incidents 10:40 - Italian Neurologists urge other nations to be alert for neuro presentations of COVID 11:11 - Case report in Radiology, COVID patient with encephalopathy 12:06 - Possible link with Guillain-Barré References: Li Y-C, Bai W-Z, Hashikawa T. The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients. Journal of Medical Virology. 2020;92(6):552-555. doi:10.1002/jmv.25728 Poyiadji N, Shahin G, Noujaim D, Stone M, Patel S, Griffith B. COVID-19–associated Acute Hemorrhagic Necrotizing Encephalopathy: CT and MRI Features. Radiology. March 2020:201187. doi:10.1148/radiol.2020201187 Mao L, Jin H, Wang M, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. April 2020. doi:10.1001/jamaneurol.2020.1127 Li Y, Wang M, Zhou Y, et al. Acute Cerebrovascular Disease Following COVID-19: A Single Center, Retrospective, Observational Study. Rochester, NY: Social Science Research Network; 2020. doi:10.2139/ssrn.3550025 Zhao H, Shen D, Zhou H, Liu J, Chen S. Guillain-Barré syndrome associated with SARS-CoV-2 infection: causality or coincidence? The Lancet Neurology. 2020;19(5):383-384. doi:10.1016/S1474-4422(20)30109-5 Further reading and listening: https://www.medscape.com/viewarticle/928069 http://emguidewire.libsyn.com/rss

In this organic conversation, Nick and Dr. Helman establish a warm rapport early on as they discuss musical beginnings, life-changing mentors and the origins of Emergency Medicine Cases. Their banter includes Dr. Helman's views on FOAMed and multimodal learning and treatment hacks learned on the frontlines of COVID-19. Intro Music: Backbay Lounge Kevin MacLeod (incompetech.com) Licensed under Creative Commons: By Attribution 3.0 License http://creativecommons.org/licenses/by/3.0/

In this episode of the COVID-19 Digest, we revisit the airborne vs droplet transmission debate and analyze a highly publicized study on Remdesivir from the New England Journal of Medicine. Host: Elizabeth Esty, MD & Dylan Luyten, MD Research By: Tanisha Crosby-Attipoe & Nathan Novotny Sound Editing By: Stephen Bahmani Time Stamps: 0:00 - Numbers 0:58 - "Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center" 6:53 - "Compassionate Use of Remdesivir for Patients with Severe Covid-19" References: [1] Santarpia, J. L., Rivera, D. N., Herrera, V., Morwitzer, M. J., Creager, H., Santarpia, G. W., Lowe, J. J. (2020). Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center doi:10.1101/2020.03.23.20039446 [2]Grein J, Ohmagari N, Shin D, et al. Compassionate Use of Remdesivir for Patients with Severe Covid-19. New England Journal of Medicine. 2020;0(0):.doi:10.1056/NEJMoa2007016

In part 2 of our interview with Dr. Adam Graham, Jordan takes a deep dive into posterior circulation strokes and how to identify them in the field.

Contributor: Dave Rosenberg, MD Educational Pearls: White noise is all the surrounding sound frequencies mixed together that your brain tunes down so you don't get distracted while you're sleeping Pink noise, or deep soothing noises, is the accentuated bass sounds like falling rain or waves crashing your brain keys into while sleeping. Brain electrical waves during stage 4 sleep (the deepest of sleeps), cause sudden increases and decreases in cerebral blood flow allowing for CSF washing of the brain, which helps eliminate beta amyloid - the misfolded protein linked to Alzheimers Pink noise during sleep has been shown to increase stage 4, creating more CSF washout of beta amyloid. References 1. Spinedi, E. Cardinali, DP. Neuroendocrine Metabolic Dysfunction and Sleep Disturbances in Neurodegenerative Disorders: Focus on Alzhimer's Disease and Melatonin. Neuroendocrinology. 2019;108(4):354-364. doi: 10.1159/000494889. Epub 2018 Oct 28. 2. Zee, P. Papalambros NA. et al. Acoustic Enhancement of Sleep Slow Oscillations and Concomitant Memory Improvement in Older Adults. Front Hum Neurosci. 2017 Mar 8;11:109. doi: 10.3389/fnhum.2017.00109. eCollection 2017. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

The circumstances that led to the national shortage in PPE for healthcare workers, the inspiring work of New Orleans med students to equip medical providers with PPE and the science behind personal use of cloth masks are all topics covered in this special edition of the Emergency Medical Minute. Host: Elizabeth Esty, MD Research By: Julia Luyten Sound Editing By: Stephen Bahmani Time Stamps: 0:00 - The scope of the mask shortage 1:04 - What led to the shortage 5:01 - Interview with Taylor Hopper, med student from Tulane University School of Medicine (TUSOM), who's part of TUSOM COVID Response Group - an organization frantically working to adequately supply hospitals with PPE in New Orleans. 16:23 - The science behind personal use of cloth masks References and Further Reading: https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/faqs-shortages-surgical-masks-and-gowns https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2190272/?smid=nytcore-ios-share https://www.sciencedirect.com/science/article/pii/S0140673620305201?via%3Dihub https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7118603/ https://www.msn.com/en-us/news/us/how-the-worlds-richest-country-ran-out-of-a-75-cent-face-mask/ar-BB11GgLi?li=BBnbcA1 https://www.vox.com/the-goods/2020/3/20/21188369/face-masks-short-supply-coronavirus-donations https://www.nytimes.com/2020/03/26/opinion/coronavirus-doctors-hoarding.html https://columbiasurgery.org/donate-ppe https://www.vox.com/policy-and-politics/2020/3/27/21194402/coronavirus-masks-n95-respirators-personal-protective-equipment-ppe https://www.nytimes.com/article/face-masks-coronavirus.html?smid=nytcore-ios-share Photo Credit: https://flickr.com/photos/91499534@N00/49432443047

Contributor: Dylan Luyten, MD Educational pearls: Clinical management of COVID-19 is rapidly evolving, relying on case reports and clinical experience In just a month, the consensus around management of COVID patients with severe hypoxia has shifted from an early intubation strategy to other, non-invasive means Intubating early can quickly consume ventilator resources, require increased intensive care monitoring, and likely leads to longer hospital stays and once COVID patients are intubated, extubation can take days to weeks. In Italy, ventilator supplies were depleted leading to the use of helmet CPAP machines, which appeared to be effective in management of respiratory distress in COVID, though not available for use in the US Non-invasive ventilation such as CPAP/BiPAP is thought to increase risk to staff for infection via aerosolization, and has often been avoided in COVID patients High flow nasal cannulas appear to pose less of a risk of aerosolization of viral particles (especially when a surgical mask is placed over the patient's nose, mouth and apparatus) Anecdotal evidence from NYC has shown success allowing conscious patients to maintain hypoxia on HFN, where they will self prone to help with lung recruitment, and seemingly do well despite persistent saturations in the 80s or less Hospitals around the country are moving away from the intubate early methodology in favor of high flow oxygen therapy as long as they are not having issues with work of breathing or other complications The pathophysiology of respiratory distress and hypoxia in COVID patients is evolving as well, and some presentations appear similar to disease processes such as high altitude pulmonary edema (HAPE) rather than acute respiratory distress syndrome (ARDS), in that patients are quite well appearing despite phenomenally low oximetry readings. These select patients appear to be excellent candidates for non-invasive means rather than an early intubation strategy Editor's note: do not take lightly that intubation is one of the highest risk aerosolization generating procedures, along with many peri-intubation procedures like suctioning, BVM, etc. References [1]. Sorbello, M. et al. The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice. Anaesthesia. 2020 Mar 27. [2]. Giwa, AL. Desai A. Duca A. Novel 2019 coronavirus SARS-CoV-2 (COVID-19): An updated overview for emergency clinicians. Emerg Med Pract. 2020 May 1;22(5):1-28. [3]. Ather B, Edemekong PF. Airborne Precautions. [Updated 2020 Feb 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD Photo Credit: New England Journal of Medicine https://www.nejm.org/doi/full/10.1056/NEJMc2007589?query=RP

In our coverage of COVID-19 this week, we've investigated the shakey evidence for NSAID use making COVID worse, heard first-hand accounts from ED clinicians with COVID, and looked at the status of testing in the United States. Before capping our week of coverage off, we wanted to analyze some of the most recent literature on clinical interventions for COVID, particularly the recently FDA approved hydroxychloroquine. Host: Elizabeth Esty, MD Research By: Elizabeth Esty and Nathan Novotny Sound Editing By: Stephen Bahmani References Wang M, Cao R, Zhang L, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Research. 2020;30(3):269-271. doi:10.1038/s41422-020-0282-0 Gautret P, Lagier J-C, Parola P, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. March 2020:105949. doi:10.1016/j.ijantimicag.2020.105949 Molina JM, Delaugerre C, Goff JL, et al. No Evidence of Rapid Antiviral Clearance or Clinical Benefit with the Combination of Hydroxychloroquine and Azithromycin in Patients with Severe COVID-19 Infection. Médecine et Maladies Infectieuses. March 2020. doi:10.1016/j.medmal.2020.03.006 Chen Z, Hu J, Zhang Z, et al. Efficacy of hydroxychloroquine in patients with COVID-19: results of a randomized clinical trial. medRxiv. March 2020:2020.03.22.20040758. doi:10.1101/2020.03.22.20040758

A dive into how the United States responded to an emerging pandemic and the pitfalls along the way that led to stalled testing capacity across the country before community transmission was confirmed. Hear what led us to our current situation, what continues to be an issue and new technologies on the horizon as well as how the rest of the world has responded. Host: Elizabeth Esty, MD Research By: Mason Tuttle Sound Editing By: Stephen Bahmani References: Shear M, Goodnough A, Kaplan S, Fink S, Thomas K, Weiland N. The Lost Month: How a Failure to Test Blinded the U.S. to Covid-19. The New York Times. https://www.nytimes.com/2020/03/28/us/testing-coronavirus-pandemic.html?smid=nytcore-ios-share. Published March 28, 2020. Topol E. US Betrays Healthcare Workers in Coronavirus Disaster. MedScape. https://www.medscape.com/viewarticle/927811. Published March 30, 2020. Abbott. DETECT COVID-19 IN AS LITTLE AS 5 MINUTES. https://www.abbott.com/corpnewsroom/product-and-innovation/detect-covid-19-in-as-little-as-5-minutes.html. Published March 27, 2020. Abdelmalek M, David E, Margolin J. Why coronavirus antibody testing in one Colorado town could provide a way forward. ABC News. https://abcnews.go.com/Health/antibody-testing-colorado-town-provide-forward/story?id=69856623. Published March 28, 2020. Kuznia R, Devine C, Griffin D. Severe shortages of swabs and other supplies hamper coronavirus testing. CNN. https://www.cnn.com/2020/03/18/us/coronovirus-testing-supply-shortages-invs/index.html. Published March 18, 2020. Judd D, Zaslav A, Diaz D. America is ramping up Covid-19 testing, but a shortage of basic supplies is limiting capabilities. CNN. https://www.cnn.com/2020/03/28/politics/coronavirus-swabs-supplies-shortage-states/index.html. Published March 28, 2020. Haug G. "A game changer": FDA authorizes Abbott Labs' portable, 5-minute coronavirus test the size of a toaster. USA Today. https://www.usatoday.com/story/news/health/2020/03/28/coronavirus-fda-authorizes-abbott-labs-fast-portable-covid-test/2932766001/. Published March 28, 2020. Hasell J, Roser M, Ortiz-Ospina E. Data on COVID-19 testing. Our World In Data. https://ourworldindata.org/covid-testing. Published March 28, 2020. Hale T. Iceland's Prolific COVID-19 Testing Is Telling Us A Lot About The Outbreak. IFLScience! https://www.iflscience.com/health-and-medicine/icelands-prolific-covid19-testing-is-telling-us-a-lot-about-the-outbreak/. Published March 27, 2020.

Long time friends of EMM, Aaron and Bree, share their experiences on the frontlines in the ED, coping with COVID, managing anxiety and quarantining with their family.