The Emergency Medicine Academic Group based out of Leicester have given us another fantastic directors cut. Check out their work here! Professor Tim Coates and Dr Mohammed Elwan have searched every COVID-19 publication, and summarised the literature of everything published from the first week of August. Here they have highlighted those papers that will be of interest to EM clinicians on the front line.
This is part of a package of FOAMed for the pandemic, check out their RCEM Top 5 here!
We have kept it short and sweet and laid out the ten papers that deserve your attention..
- FYI – Worth having on the radar, but not yet ready for the prime time
- Worth a peek – Interesting, but not yet ready for prime time
- Head Turner – New concepts
- Game Changer – this paper could/should change practice
Highlights
- Fennelly1 postulates that aerosol spread from talking is possible
- Pagano et al2 signalled that CPAP might improve short-term outcomes
- Seeliger et al3 highlighted that most COVID-19 associated surgical complications happen at 19 days.
- Mitrani et al4 warn of the potential resource and human cost of COVID-19’s long term sequealae
- Moores et al5 recommend admitted cases of COVID-19 should have VTE prophylaxis (where there is no contra-indication)
- Song et al6 found a quarter of staff had depressive symptoms
- Woodford et al7 demonstrated that vulnerable groups were no more likely to contract COVID-19 than anyone else.
Particle sizes of infectious aerosols: implications for infection control by Fennelly1.
- Topic: PPE
- Rating: Head turner
- Scout: Tim Coats
This ‘Viewpoint’ in the Lancet Respiratory Medicine reflects a view that is becoming more prevalent among virologists and should be a cause for concern for those working in Emergency Departments. This paper details evidence to support the theory that there is likely to be aerosol spread of infectious particles from patients who have COVID-19 and are coughing, talking or breathing. There is no evidence for or against this theory – as the research has not been undertaken. Fennelly suggests, working on the precautionary principle, that protection against aerosols should be routinely worn when treating patients with COVID-19 (FFP3 or respirator). The paper goes on to question the effectiveness of FFP3 masks due to the absence of research about the effectiveness of mask fit testing. When coupled with the evidence of high infection rates among frontline health workers in this week’s ‘Top 5’ this Viewpoint raises concerns that need to be urgently addressed.
Non-invasive CPAP in mild and moderate ARDS secondary to SARS-CoV-2 by Pagano et al2.
- Topic: PPE
- Rating: Worth a peek
- Scout: Tim Coats
In this case series of only 18 patients treated with CPAP about half improved PaO2/FiO2 by one hour. The investigators assessed lung recruitment by ultrasound and found that only half of these responders had an improvement in lung aeration detectable on ultrasound. The authors suggest that the other half of responders may be due to vascular effects of blood redistribution and reverse of hypoxic vasoconstriction.
Acute abdomen in patients with SARS-CoV-2 infection or co-infection Seeliger et al3.
- Topic: Treatment
- Rating: Worth a peek
- Scout: Tim Coats
The underlying hypothesis is trivial (that acute surgery has worse outcomes in patients with severe COVID-19), however this paper is worth a peek for the information about the timing and the range of acute surgical conditions suffered by patients with COVID-19. Most of the complications needing surgical intervention were related to gut ischaemia (perforation or dead bowel) and occurred long after leaving the Emergency Department (median 19 days after admission). The authors noted the high prevalence of minor gastrointestinal symptoms earlier in the disease – which mirrors what we are seeing in the ED, particularly in older patients.
- Topic: Outcomes
- Rating: Head turner
- Scout: Tim Coats
Given the high incidence of myocardial injury in COVID-19 patients, as evidenced by the raised troponins which are often seen, this paper is a timely reminder of the potential for long term cardiac sequelae and the need for research involving long term monitoring of patients. The authors point out that in similar conditions long term myocardial dysfunction and arrhythmias can occur. With so many infections even if long term problems occur in a low proportion of patients this could create a significant disease burden. Long term follow-up will define the post-covid syndromes.
- Topic: Treatment
- Rating: Game Changer
- Scout: Mohammed Elwan
Moores et al. undertook a systematic review which provided little new evidence. They resorted to expert consensus to issue 22 recommendations on VTE diagnosis and treatment. The authors acknowledge there are >10 other international guidelines on this topic and their recommendations are consistent with most of these. What could be game changing here? The authors suggest AGAINST individualized VTE risk assessment and suggest anticoagulant thromboprophylaxis in ALL hospitalized patients with COVID-19 in the absence of contraindication. There is no guideline about timing of this treatment – but it seems sensible to start it in the ED.
- Topic: Staff Wellbeing
- Rating: Worth a peek
- Scout: Mohammed Elwan
It looks like 2020 might not be a great year to be an older male. Here is a cross-sectional, questionnaire-based study of 14,825 staff working in ED in 31 provinces in China. Song et al. found approximately a quarter of participants with depressive symptoms and one in 10 with PTSD. Risk factors included; male sex, age, fewer years of experience and longer daily working hours. Good social support seemed to be the greatest protective factor. Interestingly, married staff were more likely to have depressive symptoms, but less likely to have PTSD and nurses were at greater risk of PTSD than physicians.
- Topic: Geriatric emergency care
- Rating: Worth a peek
- Scout: Tim Coats
In this study of half a million patients enrolled in the UK Biobank, frailty and multimorbidity do not appear to aid risk stratification in terms of positive versus negative results of COVID-19 testing. In other words, frail and multimorbid patients were no more likely to catch COVID-19 than the rest of the population. This may be important in understanding exactly what we mean by ‘vulnerable’ populations. The vulnerability is in the impact of COVID-19 on the individual, not a susceptibility to catch it in the first place.
Remember that you can review recent Journal Clubs from RCEM on their COVID-19 site here.
References
1. Fennelly KP. Particle sizes of infectious aerosols: implications for infection control. The Lancet 2020 doi: 10.1016/S2213-2600(20)30323-4
2. Pagano A, Porta G, Bosso G, et al. Non-invasive CPAP in mild and moderate ARDS secondary to SARS-CoV-2. Respiratory physiology & neurobiology 2020;280:103489. doi: 10.1016/j.resp.2020.103489
3. Seeliger B, Philouze G, Cherkaoui Z, et al. Acute abdomen in patients with SARS-CoV-2 infection or co-infection. Langenbeck’s archives of surgery 2020 doi: 10.1007/s00423-020-01948-2
4. Mitrani RD, Dabas N, Goldberger JJ. COVID-19 cardiac injury: Implications for long-term surveillance and outcomes in survivors. Heart rhythm 2020 doi: 10.1016/j.hrthm.2020.06.026
5. Moores LK, Tritschler T, Brosnahan S, et al. Prevention, Diagnosis, and Treatment of VTE in Patients With Coronavirus Disease 2019. Chest 2020 doi: 10.1016/j.chest.2020.05.559
6. Song X, Fu W, Liu X, et al. Mental health status of medical staff in emergency departments during the Coronavirus disease 2019 epidemic in China. Brain, behavior, and immunity 2020;88:60-65. doi: 10.1016/j.bbi.2020.06.002
7. Woolford SJ, D’Angelo S, Curtis EM, et al. COVID-19 and associations with frailty and multimorbidity: a prospective analysis of UK Biobank participants. Aging Clinical and Experimental Research 2020 doi: 10.1007/s40520-020-01653-6
