Category: Respiratory

Covid-19 (dexamethasone)

You may have seen in the news early results from the RECOVERY trial.

In Covid-19 patients requiring either Oxygen or Intubation, dexamethasone has been shown to reduce mortality.

  • Oxygen – 20% reduction in mortality
  • Intubation – 35% reduction in mortality
  • No respiratory support required – No benefit found

Inclusion: Covid-19 patient requiring oxygen or intubation

Medication: (RECOVERY study protocol)

  • Dexamethasone administered as an oral (liquid or tablets) or intravenous preparation 6 mg once daily for 10 days.
  • In pregnancy or breastfeeding women, prednisolone 40 mg administered by mouth (or intravenous hydrocortisone 80 mg twice daily) should be used instead of dexamethasone.

 

 

Emergency Tracheostomy/Laryngectomy Management

Occasionally patients with Tracheostomy or Laryngectomy present with difficulty breathing due to problem. As this is rare for us in ED, this situation can be very difficult for all of us. However the protocols below can help.

 

Tracheostomy

Tracheostomy is simply a passage from the neck into the trachea. In most cases the trachea will still be connected to the nose and mouth (so can breath though their mouth too).

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COVID-19 (Paediatric multisystem inflammatory syndrome)

AKA: Paediatric Inflammatory Multi-system Syndrome – Temporally associated with SARS-CoV 2 

Although COVID-19 seems a benign disease in almost all children there are increasing evidence (however rare) of a “Paediatric multisystem inflammatory syndrome”. This is a RARE and newly emerging condition and there are many questions still e.g. It is currently unclear if it is directly related to the COVID-19 pandemic.

Case definition (RCPCH)

  1. A child presenting with persistent fever, inflammation (neutrophilia, elevated CRP and lymphopaenia) and evidence of single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal or neurological disorder). This may include children fulfilling full or partial criteria for Kawasaki disease. 
  2. Exclusion of any other microbial cause, including bacterial sepsis, staphylococcal or streptococcal shock syndromes, infections associated with myocarditis such as enterovirus (waiting for results of these investigations should not delay seeking expert advice).
  3. SARS-CoV-2 PCR testing may be positive or negative

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COVID-19 (optimal use of oxygen)

As you are aware during the Covid-19 pandemic our use of oxygen has increased. However, supply is limited and most hospitals can only generate 3000-5000l/min of oxygen (i.e. enough to treat 300-500 patients on 10l/min). If you exceed this capacity the oxygen valves can freeze and the whole oxygen supply can fail (e.g Watford General closing)

In an effort to optimise our use of oxygen, so as many patients as possible can be treated, trust oxygen targets have been updated.

  • Oxygen prescribing targets
    • General Adults: oxygen saturation 92-96% (adjusted from the current range of oxygen saturation 94-98%) – inc. stroke, myocardial infarction, trauma
    • Type 2 Resp Failure: oxygen saturation 88-92%
    • Covid-19 Patients: oxygen saturation 90-94%
  • Evidence from clinical trials: suggests that hyperoxia may be harmful and lower oxygen target ranges are safe. 

Trust adapted guide – HERE

 

COVID-19 (DKA/HHS)

Experience is showing that those with diabetic patients with COVID-19 are more likely to develop DKA/HSS. However, treating them with the traditional large amount of fluid is detrimental to their chest, if they have Covid-19

Hence the following has been developed from the Guy & Thomas’ guidance – CLICK HERE

High Clinical Suspicion of Covid-19

  • Clinical: Fever ≥37.8°C plus any of; cough, short of breath, myalgia, headache, sore throat
  • CXR: consistent with Covid-19

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COVID-19 (40 Step Desaturation Test)

NHS England has introduced the use of a “40 step desaturation test” into discharge planning from the ED. You will have heard Covid -19 patients complaining of increasing SOB on exercise, and it’s important that we test this prior to discharge.

Method:

  • Is this appropriate? – Could the patient walk 40 steps before they were ill?
  • Patient remains in cubical – with mask on
  • Attach Sats probe – ensure good trace
  • Walk on spot 40 steps 
  • Monitor SaO2

 

 

COVID-19 (Talking to Relatives)

During the current Covid-19 pandemic relatives are not attending the hospital with patients, which means we are increasingly having to have difficult conversations over the phone. Chelsea and Westminster have published this helpful guide.

Remember:

  • Keep your language simple 
  • Avoid jargon/euphemism
  • Be honest
  • Pauses can be helpful
  • Don’t rush
  • Talk to your colleagues (these conversations will be difficult)

 

COVID-19 (Palliative Care)

Some patients who present with COVID-19 infection will be not suitable for escalation and actively dying when they attend the ED, for these patients the best management may be palliative care. The primary symptom that causes distress is breathlessness.

Palliative Care of COVID-19 patients will ideally be provided with a syringe driver and their symptoms well controlled using the standard guidance available via the Kirkwood Hospice Palliative Care Toolkit available HERE – Latest

However if there is no syringe driver available an alternative pathway has been produced

Injectable

Non-Injectable