Category: Respiratory

Covid-19 (4C Mortality Score)

The 4C mortality score has been developed by ISARIC[BMJ], based on 35.463 UK Covid-19 patients.

If cases climb prognostication may become more important and this appears to be a good tool developed on a UK population.

4C Mortality Score tool – Click HERE

Factors:

  • Age: <50(0), 50-59(2), 60-69(4), 70-79(6), ≥80(7)
  • Sex: Female(0), Male(1)
  • Comorbidities*: None(0), 1(1), ≥2(2)
  • Respiratory Rate: <20(0), 20-29(1), ≥30(2)
  • Oxygen Saturations (Air): ≥92(0), <92(2)
  • GCS: 15(0), <15(2)
  • Urea: ≤7(0), 7-14(1), >14(3)
  • CRP: <50(0), 50-99(1), ≥100(2)

*Comorbidities inc:  Chronic cardiac disease; chronic respiratory disease (excluding asthma); chronic renal disease (estimated glomerular filtration rate ≤30); mild-to-severe liver disease; dementia; chronic neurological conditions; connective tissue disease; diabetes mellitus (diet, tablet or insulin-controlled); HIV/AIDS; malignancy; clinician-defined obesity.

 

Risk Score (sum of the factor scores)

  • Low 0-3: 1.2% mortality
  • Intermediate 4-8: 9.9% mortality
  • High 9-14: 31.4% mortality
  • Very High ≥15: 61.5% mortality

4C Mortality Score tool – Click HERE

 

Trust Dalteparin dosing

Trust Guidance varies slightly from BNF for those patients over 100kg

Non-Pregnant PE/DVT treatment

Dalteparin Cr Clearance >29ml/minDalteparin Cr Clearance 20-29ml/min
Weight (kg)DoseWeight (kg)Dose
<45kg7,500 units OD<63kg5,000 units am
2,500 units pm
45-56kg10,000 units OD63-80kg5,000 units BD
57-68kg12,500 units OD81-98kg7,500 units am
5,000 units pm
69-82kg15,000 units OD99-116kg7,500 units BD
83-100kg18,000 units OD117-134kg10,000 units am
7,500 units pm
101-115kg10,000 units BD135-152kg10,000 units BD
116-140kg12,500 units BD
>140kg15,000 units BD

Pregnant PE/DVT treatment

Weight (kg)Dose
<50kg10,000 units OD
50-69kg12,500 units OD
70-79kg15,000 units OD
80-89kg18,000 units OD
90-109kg20,000 units OD
110-124kg22,500 units OD
125-139kg12,500 units BD
140-154kg15,000 units am
12,500 units pm
155-169kg15,000 units BD

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.

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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