SERIES FOR HEALTHCARE PROVIDERS IN LMICS PROJECT ECHO ETIQUETTE - - PowerPoint PPT Presentation

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SERIES FOR HEALTHCARE PROVIDERS IN LMICS PROJECT ECHO ETIQUETTE - - PowerPoint PPT Presentation

Oct 25, 2023 137 likes •568 views

COVID-19 TELE-EDUCATION SERIES FOR HEALTHCARE PROVIDERS IN LMICS PROJECT ECHO ETIQUETTE Foundation of love and respect -Respond kindly rather than react if you disagree It is everybodys responsibility to keep ECHO a safe space

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COVID-19 TELE-EDUCATION SERIES FOR HEALTHCARE PROVIDERS IN LMICS

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PROJECT ECHO ETIQUETTE

Foundation of love and respect

  • Respond kindly rather than react if you disagree

It is everybody’s responsibility to keep ECHO a safe space Test your equipment ahead of time Introduce yourself before speaking Body signals can be distracting Avoid making noise (i.e. potato chips, shuffling papers, whispering, cell phones, loud bags, etc.) For questions during Q&A session use the “raise hand” function or chat box

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PROJECT ECHO ETIQUETTE

Mute microphone when not speaking

  • Left bottom corner of your screen

 Remember to unmute before speaking Position webcam effectively to show your face if alone or to capture the whole group Have a light source from the front (Avoid being backlit) Test both audio and video Speak close to microphone IT issues? Send a message through chat/email

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Pierre P. Massion, MD

Attending, Pulmonary Critical Care Medicine Service Vanderbilt University Medical Center, Nashville TN VA Medical Center, Nashville TN

COVID-19 TELE-EDUCATION SERIES FOR HEALTHCARE PROVIDERS IN LMICS

Respiratory Clinical Symptoms & Treatment

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LEARNING OBJECTIVES

  • Understand SARS CoV-2 infection; Recognize pathogenicity
  • Presentation
  • Diagnosis of Pneumonia Imaging and Pathology
  • Challenges Pulmonary to ICU
  • Priorities LMICs
  • Key points/ References
  • Questions:
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Managing the COVID-19 Patient in the Critical Care Setting & Ventilation

COVID-19 TELE-EDUCATION SERIES FOR HEALTHCARE PROVIDERS IN LMICS

  • Dr. Priscilla C. Hirst, MD, MSc

Montefiore New Rochelle Hospital

  • Dr. Joseph J. Schlesinger, MD

Vanderbilt University Medical Center

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LEARNING OBJECTIVES

  • ACUTE RESPIRATORY DISTRESS SYNDROME
  • RISK FACTORS FOR ARDS
  • COVID-19 CARE ESSENTIALS
  • COVID-19 RESPIRATORY SUPPORT ALGORITHM
  • PRONE POSITIONING
  • ANTICOAGULATION PROTOCOL
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Multi-System Organ Failure and Sepsis

COVID-19 TELE-EDUCATION SERIES FOR HEALTHCARE PROVIDERS IN LMICS

Kyle Bruns DO, Kaitlyn Brennan DO, MPH Arna Banerjee MD, MMHC, FCCM, Kimberly Rengel MD 28/04/2020

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LEARNING OBJECTIVES

  • Review common organ dysfunction and initial treatment in ICU patients with sepsis

and COVID 19

  • Understand organ dysfunction specific to COVID 19 infection
  • Formulate optimal treatment plans based on your hospital’s capabilities
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Clinical Features and Management of Cardiovascular Disease (CVD) in COVID 19

COVID-19 TELE-EDUCATION SERIES FOR HEALTHCARE PROVIDERS IN LMICS

Henry Okafor, MD, FACC Director of Vanderbilt-Meharry Cardiology May 1, 2020

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DISCLOSURES

  • The speaker has no significant financial conflicts of interest to disclose
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LEARNING OBJECTIVES

  • Understand the spectrum of cardiovascular disease in Covid-19
  • Review the clinical features of CVD in Covid-19
  • Discuss the approach to therapeutic decisions in CVD complications of Covid-19
  • Highlight potential adaptations in low resource settings
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CASE PRESENTATIONS OF CVD IN COVID-19

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CASE 1

  • 55 y/o man with a h/o HTN, DM-2, severe NICM/HFrEF

(prior LVEF was <20%) and non-obstructive CAD.

  • Presents with 1 week h/o progressive dyspnea on mild

exertion and 3 days of exertional angina.

  • Bp -150/101, HR-94, T
  • 98.1F, RR-22, O2sat – 96-98% RA.
  • Positive bibasilar crackles, elevated JVD, S3 gallop and 2+

bilat pitting edema.

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CASE 1 TESTS

EKG LABs CXR 2D-ECHO

  • NSR w/

PACs

  • LAD
  • NSST
  • T

wave changes

  • Trop 1.07
  • p-BNP 22K
  • Cardiomegaly
  • Pulmonary

congestion

  • No

pneumonia

  • Biventricular

failure

  • LVEF <20%
  • Grade 3 DD
  • Small PE, no

tamponade

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CASE I CONTD

  • Clinical improvement with iv

diuresis

  • Temp spike to 101.7F on Day 3
  • Progressive hypoxia requiring

increasing oxygen supplementation,

  • Septic w/u initiated including for

SARS COV2

  • Elevated inflammatory markers –

CRP, fibrinogen, ferritin and D-Dimer

  • COVID-19 resulted positive on Day 8
  • Treated with Azithromycin x 5 days,

avoided HCQ due to prolonged baseline QT

  • Hypoxia and fever resolved and

patient discharged on Day 15

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CASE 2

  • 68 y/o woman with h/o HTN, DM-2 was hospitalized 10

days after initially testing positive for Covid-19, required mechanical ventilation for respiratory failure.

  • Day 5 on the vent, she became acutely more tachycardic

and hypotensive requiring vasopressors.

  • Septic w/u initiated although she was already on HCQ

and Azithromycin.

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CASE 2 CONTD

  • Stat 2 d-Echo revealed severely impaired LV systolic

function with severe global hypokinesis and LVEF of 25- 30%.

  • Inotropic support with low dose dobutamine was

initiated and hemodynamics stabilized over 24-48hours.

  • Repeat echo after 7 days showed almost normal LVEF of

45-50%.

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COVID-19 EPIDEMIOLOGY

  • COVID-19 pandemic caused by SARS – COV2.
  • Primarily respiratory disease
  • Has extensive interaction with CVS.

– Patients with CVD are at higher risk of getting infected – Outcomes are worse in CVD patients

  • CVD complications are common in patients with COVID-19 even in the absence of premorbid

CVD.

  • Some of the current treatment for Covid-19 may cause CVD complications such as arrhythmias.
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Date of download: 4/11/2020

From: Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)

JAMA Cardiol. Published online March 27, 2020. doi:10.1001/jamacardio.2020.1017 Mortality of Patients With Coronavirus Disease 2019 (COVID-19) With/Without Cardiovascular Disease (CVD) and With/Without Elevated Troponin T (TnT) Levels Figure Legend:

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SPECTRUM OF CVD IN COVID-19

Pre-existing CVD SARS-COV-2 related Treatment-related Heart Failure/CMP Cardiogenic shock/HFrEF Arrhythmias Coronary Artery Disease Acute MI, Myocarditis Cardiotoxicity Hypertension Arrhythmias, CMP Arrhythmias Thromboembolism

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Date of download: 4/27/2020

From: Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China

  • JAMA. 2020;323(11):1061-1069. doi:10.1001/jama.2020.1585
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PATHOGENESIS

  • SARS-CoV2 - single-strand RNA
  • enters human cells mainly by binding

the angiotensin converting enzyme 2 (ACE2)

  • highly expressed in lung alveolar cells,

cardiac myocytes, the vascular endothelium, and other cells.

  • Leads to a mild to moderate viral

illness or progress to systemic inflammatory response syndrome, acute respiratory disease syndrome (ARDS), multi-organ involvement, and shock

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MECHANISMS OF MYOCARDIAL INJURY

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CVD MANAGEMENT PRINCIPLES IN COVID-19

ACC recommendations:

  • Establish protocols for effective clinical triage, diagnosis, and isolation of

Covid-19 patients with CVD or CVD complications.

  • Individualize and limit diagnostic testing to essential tests that could

facilitate management.

  • Consider point of care testing where available.
  • Universal precautions including masks for both patient and healthcare

worker.

  • Use of Telemedicine where possible
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ACS MANAGEMENT IN COVID-19

  • Universal precautions including masks for patients and healthcare workers.
  • Early Testing for COVID-19
  • STEMI
  • Consider Fibrinolytic Therapy
  • High risk primary PCI in dedicated COVID-19 Cath lab in full PPE
  • Unstable Angina and NSTEMI
  • Medical Therapy and consider CT Coronary angiogram for high risk patients.
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Bedside clinical assessment

  • cold extremities
  • Hypotension
  • JVD
  • use POCUS vs 2 D-echo

GDMT including ACEI/ARBs are recommended.

If in cardiogenic shock, consider

  • Inotropic support and vasopressors
  • Dobutamine
  • Nor-epinephrine
  • Vasopressin
  • Extracorporeal Membrane Oxygenation

(ECMO)

  • Veno-Venous in intractable respiratory

failure

  • Veno-Arterial in cardiogenic shock

HEART FAILURE AND CARDIOGENIC SHOCK IN COVID-19

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THROMBOEMBOLISM IN COVID-19

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PREVENTION AND MANAGEMENT OF THROMBOSIS IN COVID-19

  • Assess for risk factors
  • Pre-existing need for anticoagulation
  • Age
  • Bed-ridden status (Stasis)
  • Disease severity: Inflammatory

response, endothelial injury

  • Hemostatic abnormalities: Elevated D-

dimer, DIC, High Procalcitonin

  • Confirmed DVT/PE in COVID-19
  • Prophylaxis per usual protocol
  • Therapeutic anticoagulation

with low molecular weight vs unfractionated Heparin

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MALIGNANT ARRHYTHMIAS

  • Mitigate risk by:
  • check baseline EKG and avoid QT prolonging drugs if QTC >500ms
  • correct electrolyte abnormalities (K+, Mg and Ca) prior to treatment
  • caution with diuretics
  • permissive tachycardia (HR of 90-110 bpm)
  • DCCV if hemodynamic instability occurs
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SUMMARY

  • Diverse manifestations of CVD in Covid-19
  • Establish, rehearse and follow protocols
  • Maintain consistent universal precautions
  • Tailor care to individual needs
  • Avoid unnecessary testing
  • Adapt care to available resources I
  • Use Telemedicine where possible
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VanderbiltHeart.com

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QUESTIONS?

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JOIN OUR WHATSAPP GROUP! WhatsApp Chat

If you have more questions following this session, we have created a WhatsApp chat group for sharing relevant information about caring for COVID-19 patients. A link has been sent to your email with the registration link. Please reach out to ECHO@assistinternational.org with any questions.