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

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 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

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

COVID-19 TELE-EDUCATION SERIES FOR HEALTHCARE PROVIDERS IN LMICS Respiratory Clinical Symptoms & Treatment Pierre P. Massion, MD Attending, Pulmonary Critical Care Medicine Service Vanderbilt University Medical Center, Nashville TN VA Medical Center, Nashville TN

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:

COVID-19 TELE-EDUCATION SERIES FOR HEALTHCARE PROVIDERS IN LMICS Managing the COVID-19 Patient in the Critical Care Setting & Ventilation Dr. Joseph J. Schlesinger, MD Vanderbilt University Medical Center Dr. Priscilla C. Hirst, MD, MSc Montefiore New Rochelle Hospital

LEARNING OBJECTIVES • ACUTE RESPIRATORY DISTRESS SYNDROME • RISK FACTORS FOR ARDS • COVID-19 CARE ESSENTIALS • COVID-19 RESPIRATORY SUPPORT ALGORITHM • PRONE POSITIONING • ANTICOAGULATION PROTOCOL

COVID-19 TELE-EDUCATION SERIES FOR HEALTHCARE PROVIDERS IN LMICS Multi-System Organ Failure and Sepsis Kyle Bruns DO, Kaitlyn Brennan DO, MPH Arna Banerjee MD, MMHC, FCCM, Kimberly Rengel MD 28/04/2020

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

COVID-19 TELE-EDUCATION SERIES FOR HEALTHCARE PROVIDERS IN LMICS Clinical Features and Management of Cardiovascular Disease (CVD) in COVID 19 Henry Okafor, MD, FACC Director of Vanderbilt-Meharry Cardiology May 1, 2020

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

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

CASE PRESENTATIONS OF CVD IN COVID-19

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.

CASE 1 TESTS EKG LABs CXR 2D-ECHO • NSR w/ • Trop 1.07 • Cardiomegaly • Biventricular PACs failure • p-BNP 22K • Pulmonary • LAD congestion • LVEF <20% • NSST -T • No • Grade 3 DD wave pneumonia changes • Small PE, no tamponade

CASE I CONTD • Clinical improvement with iv • Elevated inflammatory markers – diuresis CRP, fibrinogen, ferritin and D-Dimer • Temp spike to 101.7F on Day 3 • COVID-19 resulted positive on Day 8 • Progressive hypoxia requiring • Treated with Azithromycin x 5 days, increasing oxygen supplementation, avoided HCQ due to prolonged baseline QT • Septic w/u initiated including for SARS COV2 • Hypoxia and fever resolved and patient discharged on Day 15

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.

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%.

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.

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 Figure Legend: Mortality of Patients With Coronavirus Disease 2019 (COVID-19) With/Without Cardiovascular Disease (CVD) and With/Without Elevated Troponin T (TnT) Levels Date of download: 4/11/2020

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

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 Date of download: 4/27/2020

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

MECHANISMS OF MYOCARDIAL INJURY

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

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.

HEART FAILURE AND CARDIOGENIC SHOCK IN COVID-19 Bedside clinical assessment If in cardiogenic shock, consider • cold extremities • Inotropic support and vasopressors • Hypotension • Dobutamine • JVD • Nor-epinephrine • use POCUS vs 2 D-echo • Vasopressin • Extracorporeal Membrane Oxygenation GDMT including ACEI/ARBs are (ECMO) recommended. • Veno-Venous in intractable respiratory failure • Veno-Arterial in cardiogenic shock

THROMBOEMBOLISM IN COVID-19

PREVENTION AND MANAGEMENT OF THROMBOSIS IN COVID-19 • Assess for risk factors • Prophylaxis per usual protocol • Pre-existing need for anticoagulation • Therapeutic anticoagulation • Age with low molecular weight vs • Bed-ridden status (Stasis) unfractionated Heparin • Disease severity: Inflammatory response, endothelial injury • Hemostatic abnormalities: Elevated D- dimer, DIC, High Procalcitonin • • Confirmed DVT/PE in COVID-19

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

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

VanderbiltHeart.com

QUESTIONS?

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.