Category: Covid-19

COVID-19 Vaccine Induced Thrombosis/Thrombocytopenia (VITT)

Inclusion Criteria [Both of]:

  1. Received AstraZeneca (AZ) COVID 19 vaccination within 42 days (typically 5-42 days from immunisation)
  2. New Onset thrombocytopenia (PLTs <150×109/L) – with or without Thrombosis
    • 5% of cases have had a “Normal” Platelet count at presentation
      • High index of suspicion repeat bloods next day
      • ‘High index of suspicion’ in this context is day 5- 28 post AZ vaccine with new onset headache or abdominal pain which is atypical and severe in nature.

Initial Investigations:

  • FBC– specifically to confirm thrombocytopenia <150x 109/L
  • Coagulation screen and D Dimers
  • Blood film to confirm true thrombocytopenia and identify alternative causes

PROBABLE CASE: (ALL 3 criteria)

  1. Received AZ COVID 19 vaccination within 42 days
  2. New Onset thrombocytopenia (PLTs <150×109/L)
  3. D Dimers > 2000 mcg/L

URGENT Scan to confirm the suspected clot.

[If patient doesn’t fit “PROBABLE CASE” proceed to usual treatment]


Condition specific advice:

Central clot:

  • inc. Cerebral Venous Sinus Thrombosis (CVST), Pulmonary Embolis (PE), Splenic, Proximal DVT
  • Discuss with Haematologist
  • Admit Medicine

Suspected DVT (scan unavailable):

  • Treat with Rivaroxaban (Do Not use Dalteparin/LMWH)
  • Request Ultrasound
  • Return AAU Next Day
  • Safety-net Advice

Confirmed Distal DVT (Not above inguinal ligament)

  • Platelets  <100×109/L – Discus with Haematology
  • Platelets ≥100×109/L – Treat as normal

Thrombocytopenia only

  • Platelets  <100×109/L – Discus with Haematology
  • Platelets ≥100×109/L – Treat as normal

Treatment (will be directed by Haematology & Specialist teams):

Avoid:

  • Heparin Based anticoagulants
  • Antiplatelets
  • Platelet Transfusion

May Require:

  • IV immunoglobulin
  • Steroid
  • Anticoagulation with: DOAC, Fondaparinux, Argatroban

Further reading

 

COVID-19 (Which Covid Test)

Once the “Decision to Admit” has been made, an appropriate Covid-19 Test will need to be performed

  1. Select the appropriate patient group below
  2. Perform Test
  3. Clearly document which test was performed

Suspected Covid-19 Positive Patient

Patients with Covid-19 symptoms should have 2 swabs taken immediately

  1. PCR Testing – sent to lab
  2. Lateral Flow Devices – in ED for result after 30mins.

Record result on EPR as “Covid-19 Antigen Lateral Flow – POCT”

Patients Admitted To: Stroke (HASU), Paeds (HDU) OR Requires “URGENT” Result

Any patients identified by site commander as needing urgent result for flow reasons

(This also includes direct ward admissions to gastro and oncology)

  • Test swabs on ROCHE LIAT machine (performed by)
    • Site Commander
    • Night Matron
    • Stroke nurses
  • In ED prior to transfer – Results are in 90mins.

Record result on EPR as “Covid-19 RNA PCR – POCT”

NO Covid-19 Symptoms Present

A swab MUST be taken and sent to the lab for PCR testing.

Patient does not wait in ED for result.

CPAP Set-Up

NIPPV 3 machines are used throughout the trust to deliver NIV and CPAP – and should be commenced in ED if transfer to ward/ICU is adding significant delay

  • NIV/CPAP  is an Aerosol Generating Proceedure (AGP)
    • Staff must wear full APG PPE
    • In Side room with a door
    • Door Marked with APG sign – HERE
  • CPAP/EPAP levels of 8-15cmH2O

This video demonstrates how to set up CPAP on the NIPPV 3

 

Covid-19 (4C Mortality Score)

Warning: this score was developed on non-immunised patients

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

 

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.

Post Dex Glucose monitoring:

  • Glucose should be checked every 6hrs (ideally fasted i.e. before meal)
  • If Glucose ≥12, follow the chart below either guided by their normal Total Daily Dose (TDD) of insulin, or weight if insulin nave, or unknown.
  • Full protocol – HERE

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.

Read more

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

Read more