Coronavirus thread

[Sensei]

Discussion of the day (one of many) at work is how we do the CPR on COVID19 patients or strongly suspected ones.

Background: CPR is a high risk procedure from a transmission standpoint due to aerosolization. There's a massive shortage of N95 masks. We can't run in them at all times because we'll use them up. Cardiac arrests usually come unannounced. If we have some level of anticipation, we plan on using N95s and PAPRs ahead of the time. If we don't have correct PPE on when arrest happens, then things might become interesting.

The take-home point for all of you: if you're ACLS trained and see yourself as a bystander CPR-capable and willing, you might wanna have a properly fit N95 with you.

There is no reason to do CPR on patients who die due to complications from SARS/ARDS. Mechanical circulatory support such as CPR is a bridge treatment for patients with a single failing organ system until definitive treatment can be established. The quintessential example is a V-fib cardiac arrest bridge to defibrillation. Patients with ARDS die from multisystem organ failure, not just hypoxia, and there is no definitive treatment once they lose their pulse. The odds of you resuscitating a patient with ARDS to a good neurologic outcome is probably less than you infecting a member of your team in the process. You need to start having a frank and honest conversation with your medical director now about futile treatments for SARS patients that are also high-risk for your team.

[Arbninftry]

Nevada's governor has ordered the closing of all non-essential businesses as of noon Wednesday, lasting for 30 days. Not the more typical two weeks: a whole month. https://www.kolotv.com/content/news/...568789201.html .
From the linked story: "The closures will take effect Wednesday, March 18 at noon and will be in place for at least the next 30 days.
The closures include bars and restaurants, though restaurants are encouraged to offer curbside delivery, home delivery, and takeout.
"Non-essential businesses have two options," he said. "Find other ways to serve your customers, or close your doors."
Essential services will remain open including fire, police, transit, and healthcare, in addition to businesses that provide food, shelter, and social services for disadvantaged populations.
Pharmacies, grocery stores, banks, hardware stores, and gas stations will also stay open, as well as truck stops to allow the delivery of supplies."

Is the Bunny Ranch essential or non-essential

[YVK]

@Sensei and @TQP We were talking about COVID patients with arrest due to non-COVID causes. Example: I am working on an MI patient and they code on my cath table, they have COVID or are suspected. While this may sound like a low probability scenario, aerosolization of the lab may take out the entire cath team to infection or quarantine, leaving the facility with a compromised ACS capability.

[YVK]

Is the 1 month survival rate of those administered CPR still only 5%?

I admit I have not looked at recent data but I think it was better than that. Also depends if in hospital or out of hospital.

[Jakus]

Kansas cancels all K-12 school through the rest of the school year.

https://www.foxnews.com/us/kansas-go...he-school-year

[Dog Guy]

I admit I have not looked at recent data but I think it was better than that. Also depends if in hospital or out of hospital.

Also depends on witnessed vs unwitnessed, time to defib, time to cath lab after pulses are restored.

[Sensei]

Survival with neurologic recovery for in-hospital cardiac arrest is 20-40% and out of hospital cardiac arrest is 5-15% depending on municipality. Some EMS agencies (LA, Seattle, etc.) have posted high out of hospital cardiac arrest but those are outliers. Those numbers are a range because different studies have variable enrollment criteria and produced inconsistent results.

Having said that, I’d recommend the least invasive reasonable treatment for co-morbid illnesses that happen to occur in COVID cases. That means TPA for MI in the vast majority of STEMIs and interventional therapies over open procedures whenever possibles. Keep in mind that Italy has converted the ORs to ICUs to handle the overflow so the decision may soon be made for you. I have no idea if they are going the same thing with cath labs and IR suits.

Bottom line - avoid CPR in the vast majority of COVID cases unless you are convinced that the cause of the arrest is isolated to a failing circulatory system AND the patient has a reasonable chance of recovery (good pre-morbid condition).

Also, all of the institutions in my old neck of the woods just cancelled all elective surgeries until further notice. All face-to-face research studies are also cancelled unless they involve life-sustaining therapies.

[Tom Duffy]

Is the 1 month survival rate of those administered CPR still only 5%?

I know decades ago CHP taught petite female officers to use their foot to apply sufficient force for chest compressions - perhaps we should bring that back?

In Jersey, that was known as "Newark CPR".

[Chance]

Also, all of the institutions in my old neck of the woods just cancelled all elective surgeries until further notice.

Is there a strict definition for what constitutes "elective procedure"?

[YVK]

Survival with neurologic recovery for in-hospital cardiac arrest is 20-40% and out of hospital cardiac arrest is 5-15% depending on municipality. Some EMS agencies (LA, Seattle, etc.) have posted high out of hospital cardiac arrest but those are outliers. Those numbers are a range because different studies have variable enrollment criteria and produced inconsistent results.

Having said that, I’d recommend the least invasive reasonable treatment for co-morbid illnesses that happen to occur in COVID cases. That means TPA for MI in the vast majority of STEMIs and interventional therapies over open procedures whenever possibles.

I need a refresher. I was under impression that the in hospital arrest had a worse prognosis.

Chinese have already published a paper on moving to TPA for stemi. We so far decided not to. TPA has been associated with longer hospital stays, among other things. We're trying to send them home in 24 hours. Our plan is to wear N95 and PAPR on every stemi pci to protect cath lab personnel.

Is there a strict definition for what constitutes "elective procedure"?

Not really, not in this situation. Ordinarily everything that's not emergent (immediate time frame) or urgent (within day-two) is elective. With the COVID and attempts to minimize non-urgent stuff and push the elective stuff out by 2 months this definition is breaking down. I've a patient who under normal circumstances would have had a bypass on Monday. He's elective but not really an elective that I can push out by 2 months.
We at our place are leaving the final decision to a discretion of an operator but we've set up an internal "pre-authorization" process to avoid truly elective cases being sneaked in. Other places have taken it out of hands on individual providers and written down specific rule sets.