ACEP NowACEP Now https://www.acepnow.com Wed, 01 Apr 2020 22:15:54 +0000 en-US hourly 1 https://wordpress.org/?v=5.3.2 Coping with COVID-19: The Puget Sound Experience https://www.acepnow.com/article/coping-with-covid-19-the-puget-sound-experience/ https://www.acepnow.com/article/coping-with-covid-19-the-puget-sound-experience/#respond Wed, 01 Apr 2020 22:15:11 +0000 https://www.acepnow.com/?post_type=article&p=23052 Author’s Note: I am not an authorized representative of any hospital but am writing broadly from my...

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Author’s Note: I am not an authorized representative of any hospital but am writing broadly from my knowledge of experiences at medical centers across the Puget Sound region, an epicenter of the recent coronavirus outbreak in the United States.

Editors’ Note: This article was accepted on March 16, 2020, and was accurate at that time. Because information about SARS-nCoV-2 and COVID-19 is evolving rapidly, please verify these recommendations and information.

The first case of COVID-19 at Providence Regional Medical Center in Everett, Washington, was diagnosed Jan. 20, 2020, in an intensive care unit patient who had recently traveled from Wuhan Province in China. We had heard about the epidemic breaking out of China, yet it came as a sobering shock to my colleagues and me when we realized the illness was at our local facility.

The real diagnostic challenge began about a week into the epidemic, when we started seeing patients with features of COVID-19 at various facilities across Puget Sound. We had large numbers of patients who had possibly been exposed, many of whom were showing symptoms that could be compatible with the disease.

Since that first case, we’ve seen a lot of patients with clinical features consistent with other descriptions that have been given—patients with cough, sore throat, and fever. Most patients had typical presentations, though some older adults did not mount a fever response. Many patients have had leukopenia, and some have had high transaminases. Some people had only mild symptoms, but we couldn’t definitively diagnose because no testing was available at that time. We had to assume that such patients might have COVID-19, so we sent them home for self-quarantine.

Triage and Treatment

We quickly learned to focus on the patients who appeared very ill. We’ve found that the clinical presentation was quite different from typical cold symptoms or common flu. Patients might present with a little labored breathing and mild hypoxia. However, the chest X-ray often looked substantially worse than the patient appeared. One could see a classic viral pattern of bilateral patchy ground-glass infiltrates.

We learned to recognize that as a highly alarming sign. In our experience, once patients develop that, the progression to severe respiratory complications is likely. For sick patients coming into the emergency department, this can often happen quickly, within hours. We’ve seen some patients who went from slight hypoxia on arrival to needing intubation eight hours later, displaying a severe viral pneumonia or even an acute respiratory distress syndrome pattern. We’ve been surprised by how dangerous this virus is, how it can make certain people very ill very quickly. That is in line with the Chinese experience, but it has still been disconcerting to see up close.

We found that common temporizing measures used for patients with respiratory distress such as bilevel positive airway pressure (BiPAP) and high-flow nasal cannula oxygen don’t seem to avert this progression. One might be able to buy a little time this way, but even with these measures, these sick patients have eventually needed intubation. This contrasts with other medical conditions, such as congestive heart failure, where such interventions might be all that are needed. More recent experience suggests that ventilator-sparing strategies may have merit; this is very much a learning process. We’ve tended to avoid both BiPAP and high-flow nasal cannula because of concerns that they might increase aerosol particle formation and thus make the virus more transmissible to health care workers.

Computed tomography scan seems to be quite sensitive to coronavirus, at least in patients having moderate or severe symptoms, probably even more sensitive than the polymerase chain reaction tests that we have. However, pragmatically, it is not very useful as a screening tool for large numbers of patients due to the time needed to perform the procedure and decontaminate the scanner between uses. It may be useful in some situations when the diagnosis of coronavirus is unclear, but we’ve mostly been treating presumptively until test results come back.

Hospital Ops Tips

Our hospitals had learned some lessons from the SARS epidemic in 2003, the H1N1 epidemic in 2009, and the Ebola crisis in 2014, lessons that had been written into their disaster plans. As the scale of the crisis became apparent, the hospitals quickly implemented these plans, which greatly helped with mitigation. Because of inability to test early on, we were unable to contain the crisis in the Puget Sound region, but we did go directly into mitigation to help flatten the disease curve.

The most-effective hospitals that have responded to this have had an internal command center staffed 24 hours a day. These staffers are knowledgeable about the plan and can coordinate different service lines, ensuring that resources are being allocated where they are needed most. That’s been a critical element.

Triaging potential coronavirus patients from other visitors to the emergency department is also essential. In one hospital, we gathered all the patients with respiratory complaints in a single area of the emergency department. Because of the high level of contagiousness of coronavirus, each emergency department in our regional hospitals has had to develop its own way to implement appropriate isolation criteria. When private rooms have not been available, some hospitals have performed triage in the waiting room and had patients wait in their cars to be notified via cellphone when a room is available. Some places have also used pop-up tents outside the department to do some prescreening.

Now that we’ve seen more community transition of the virus, some places have developed drive-through station testing, like the ones used extensively in South Korea. People can drive up, get their temperature and oxygen level tested, and get swabbed to receive the results by phone at home. I think we will see more of those as the epidemic continues.

Stellar Staff Response

As the crisis has developed, the staffing needs have changed. Fortunately, the public has received the message to stay away from the emergency department unless they are seriously ill. Recently, patient volumes in the emergency departments have been down in some cases. Because of this, we’ve been able to shift some providers from a fast-track shift to the respiratory unit so we can have extra focus on the really sick people. We’ve been very flexible in changing provider staffing based on the needs of the moment.

We all got fitted for N95 masks for seeing high-risk patients or doing high-risk procedures using full airborne precautions. Our health care workers quickly got in the habit of being very diligent with their personal protective equipment. As has been covered in the media, some clinicians have been anxious about potential shortages in personal protective equipment. At centers in our region, I don’t feel that such worries have impacted care yet. However, we all share concerns about whether the supply chain will hold up on a long-term basis.

Situations like this one bring out many fears for health care providers, just like they do in the rest of the population. However, we’ve seen that events like this also tend to bring out the best in people. People approach it as a war zone; they buckle up and get the work done. If a provider gets sick or has to self-quarantine, someone else steps up to fill the shifts.

What Comes Next

We need guidance from the federal government about how the regulatory framework of medicine is going to adapt to this widespread epidemic. According to EMTALA, any patient who comes to the emergency room must receive a screening exam and stabilizing treatment. We embrace EMTALA as emergency physicians, but it’s not clear exactly how it should be implemented in these innovative modalities of emergency screening and health care delivery. We are pleased to see clear guidance from the Centers for Medicare & Medicaid Services about how EMTALA shall be applied in these settings so that we are confident what we are doing is compliant. Some clinicians also worry about the potential for malpractice suits when delivering medical care under these difficult circumstances. Congressional action could put such concerns to rest.

In my opinion, the hospitals around the region have displayed an outstanding response to the crisis. However, we already have days in which every intensive care unit bed in the region is full, days in which a specific hospital might have used up all their ventilators. Our hospitals have been very agile in creating more capacity, canceling elective surgeries, and opening new intensive care unit wings. However, we are all very concerned about how the health care system will hold up if we see an exponential growth in transmission.


Liam Yore, MD, FACEPDr. Yore is a Past President of the Washington chapter of the ACEP and a practicing emergency physician at North Sound Emergency Medicine in Everett, Washington.

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Get Your Emergency Department Ready for COVID-19 https://www.acepnow.com/article/get-your-emergency-department-ready-for-covid-19/ https://www.acepnow.com/article/get-your-emergency-department-ready-for-covid-19/#respond Wed, 01 Apr 2020 22:07:38 +0000 https://www.acepnow.com/?post_type=article&p=23056 Editors’ Note: This article was accepted on March 13, 2020, and was accurate at that time. Because...

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Editors’ Note: This article was accepted on March 13, 2020, and was accurate at that time. Because information about SARS-CoV-2 and COVID-19 is evolving rapidly, please verify these recommendations and information.

Over the course of these past several weeks, our area hospitals have been crafting a set of rapidly evolving protocols to combat the spread of SARS-CoV-2, the novel coronavirus that causes COVID-19, and develop best practices to care for our COVID-19 patients.

Since the outbreak began, our colleagues locally and nationally have been reaching out to us for assistance as they start to see cases. We hope that by sharing our work, we can assist your teams and facilities to prepare and move more quickly.

Though protocols are frequently being revised as we learn more, there are several ways to ready your emergency departments for these patients. These include creative approaches to staff training, improvements in the physical space for isolation capacity, equipment to procure/inventory, and systems for providing patient care to minimize staff exposure.

We hope you can benefit from these recommendations while you have the time to prepare yourselves and your departments. The most important and time-critical component of COVID-19 response protocol is communication.

 

Consider Activating Your Incident Command System

Your incident command system should include communication early and often between emergency departments, hospitalist services, ICUs, local and state departments of health (DOHs), emergency medicine services (EMS), leads, and outreach leads to vulnerable populations (eg, local skilled nursing facilities [SNFs], jails, homeless shelters). In our experience, SNFs have been particularly vulnerable and have been the source of most patients and fatalities.

Developing communication links with local SNFs for the purpose of creating a transportation and hospital disposition plan prevents proximately located hospitals from being overwhelmed by a single SNF experiencing an outbreak.

The following cheat sheet is in the staff/stuff/space/systems format of simple ideas to consider for preparing.

 

Staff

Initiation of Staff Preparations

Fit testing for airborne precautions should be up-to-date within the last month for all staff, including radiology, maintenance, housekeeping, and other ancillary staff. Every physician and nurse should attest to watching the proper donning/doffing technique recommended by the Centers for Disease Control and Prevention (CDC) in the links in the “Resources” sidebar, and in-person training should be considered.

Staff should update their own home personal safety plans, including creating backup child care plans and stocking household supplies so that when work gets busy, their home plans and supplies are ready and they can concentrate on work.

Communication

Incident command structure should be followed, with centralized communication, messaging, and task delegation, including:

  • Identify a liaison to communicate regularly with the local DOH.
  • Identify a liaison for communications with the media.
  • Identify a COVID-19 hospitalist lead for admissions that are not to the ICU and an intensivist lead for those to the ICU.
  • Identify outreach leads for EMS, the homeless and shelter community, SNFs, and jails if your hospital receives these patients.

Stuff

Inventory current amounts of sanitation supplies (especially alcohol-based hand gel and bleach wipes); pulse oximeters; masks, powered air-purifying respirators (PAPRs), and shrouds for PAPR; mirrors for doffing stations; and disposable stethoscopes to anticipate increased needs. We have run short of flu swabs and personal protective equipment (PPE). Consider storing these supplies in ways that prevent hospital personnel and guests from removing them for personal use.

Assess supplies of key medications including antibiotics, sedation, analgesia, neuromuscular blockade, and crystalloid. Plan for use of metered dose inhalers with spacers instead of nebulizers to reduce infectivity.

Establish protocols for handling patient specimens (blood, urine, respiratory viral testing, etc.).

Hospitals should determine how many ventilators are available, including noninvasive positive pressure devices and anesthesia machines; reach out to ambulatory surgery centers for the possibility of using anesthesia machines; and assess the number of extracorporeal life support pumps and circuits available.

 

Space

Develop a department plan designating which areas of the emergency department will be dedicated to droplet precautions and which areas are negative pressure rooms appropriate to airborne precautions. For areas without an antechamber, consider creating a taped “warm zone” outside of the room for proper doffing. Ensure donning/doffing stations are set up with all needed supplies. Consider taking a photo of the station to post to ensure proper setup. How will you secure these supplies (especially the hand gel and wipes)?

Consider cohorting patients with mild illness who are “patients under investigation” in internal waiting rooms away from well patients or those who could be immunocompromised.

Patient Presentation

In general, patients have presented with a wide variety of symptoms, including fever, cough, upper respiratory infection symptoms, and hypoxemia. Rapid decompensation was seen in several patients. Generally, those who died were elderly, and some were immunocompromised.

Syndrome

  • Some afebrile, some with high fevers lasting more than one week
  • Shortness of breath, dry cough, some with gastrointestinal symptoms (although uncommon)
  • Risk factors: older patients, comorbidities
  • Respiratory failure: acute respiratory distress syndrome (ARDS)/pneumonitis, varying presentations on radiography
  • Cardiomyopathy, including elevated creatine kinase, has been seen

Use phones in the patient rooms to interview noncritically ill patients to reduce trips in and out of the room and to coordinate with nursing or respiratory therapy when they are at the bedside.

Movements

Consider how patients will be transported from the waiting room through the emergency department to the isolation or precautions room. What route will they take to minimize exposure from the emergency department to the floor or unit dedicated within your hospital?

What route will patients take from the emergency department to the inpatient unit? Use security to facilitate clearing the route, hold the elevator, and ensure that the elevator is cleaned after patient transport.

What route will your used supplies take to be cleaned, and how will your nasal swabs be transported to the lab (eg, we are not using our tube system)?

Diagnostics

Develop plans for terminal cleaning of CT scan rooms and other bedside diagnostic equipment (portable radiology, ultrasound, etc.). For example, will you have a dedicated ultrasound?

We have developed a process to perform portable radiographs through the door window for patients in isolation, reducing risk to staff and the need to clean portable units (see Figure 1). The radiographs have been found to be of acceptable quality for reading using this technique.

Figure 1: Radiology teams from our institution have minimized staff and equipment exposure by performing single-view portable radiographs through the windows on doors to isolation rooms. A) The patient is positioned standing or sitting in front of the door inside the isolation room with a nurse/staff wearing a lead shield, holding the plate to the patient’s chest. B) The portable machine camera is brought close to the glass, and adjustments are made to the machine to optimize the film. The film is passed by the gowned nurse outside the room with removal of the plastic sheet while passing to the X-ray staff outside the room, keeping the plate clean. C) While artifact from the window is sometimes present on the film, our radiologists have been able to read from these for multi-focal pneumonia and tube placement. Credit: University of Washington

Figure 1: Radiology teams from our institution have minimized staff and equipment exposure by performing single-view portable radiographs through the windows on doors to isolation rooms. Left: The patient is positioned standing or sitting in front of the door inside the isolation room with a nurse/staff wearing a lead shield, holding the plate to the patient’s chest. Center: The portable machine camera is brought close to the glass, and adjustments are made to the machine to optimize the film. The film is passed by the gowned nurse outside the room with removal of the plastic sheet while passing to the X-ray staff outside the room, keeping the plate clean. Right: While artifact from the window is sometimes present on the film, our radiologists have been able to read from these for multi-focal pneumonia and tube placement.
Credit: University of Washington

Systems

Staffing

Plan to have a double backup system in place ensuring that if staff members are sick, there is an easy system to call in relief without having to scramble. This system also protects against staff members feeling remorse or hesitance about calling in sick and contributing to dangerous “presenteeism” and coming to work sick.

Consider:

  • Canceling communal food in meetings and care areas and moving to tele-education and online meetings.
  • Updating staff flu shots.
  • Requiring use of scrubs instead of wearing personal clothes to work and encouraging minimization of jewelry and personal items as fomites.
  • Using gel-in/gel-out hand hygiene and redoubling efforts to ensure 100 percent compliance for all patients.
  • Creating a hospital-wide plan for backup child care so physicians, nurses, and other staff are not staying home to care for their children if schools close.
Physicians practice intubating using the glidescope while in a PAPR with a shroud.

Figure 2: Physicians practice intubating using the glidescope while in a PAPR with a shroud.
Credit: University of Washington

Training

Arrange in-person donning/doffing training by “supertrainers” for all ED staff. Once an airway plan has been established, use simulation training to get staff comfortable with new procedures and protocols (eg, intubating using the glidescope while in a PAPR with a shroud, as shown in Figure 2).

Tracking Systems

Review the current system or create a new one for tracking exposures and symptoms when a COVID-19 exposure happens for staff or when staff members are sick. For example, when will they return to work, and how will they get their test results?

Intubation and Airway Algorithms

Review plans for limiting staff exposure to aerosolization of COVID-19. Consider not using high-flow nasal cannula or noninvasive positive pressure ventilation in the emergency department unless adequate airborne isolation can be guaranteed and limiting use of nebulized medication. Intubation should occur only by those trained in how to intubate while in a PAPR with shroud. Follow a COVID-19-specific protocol for intubation developed by your hospital’s airway leads.

Consider PPE use, use of video laryngoscopy, premade medical airway bags, reentry and intubation checklists, and rapid sequence intubation to decrease aerosolization of particles with bag-valve masks.

Review methods for addressing severe hypoxemia and acute respiratory distress syndrome (ARDS) with ventilation, medication, and other maneuvers with all staff (eg, titration positive end-expiratory pressure, neuromuscular blockade, recruitment maneuvers, and proning).

Bundle Care

Plan ahead for blood draws, ECGs, and medication administration to minimize trips into and out of the patient’s room. Build kits with preassembled supplies to be used in isolation areas. Establish protocols for testing patients in conjunction with your lab’s ability to run these tests.

Create scripts for 911 call centers to ask about COVID-19 risk factors before sending EMS to a scene. Develop scripts for your transfer center to use screening questions regarding symptoms and COVID-19 status with the goal of identifying potential COVID-19 patients prior to ED arrival. Have EMS call ahead to alert emergency department to high-risk COVID-19 patients from the field. Draft outward-facing documents with clear instructions for the community to call their doctor prior to coming to the emergency department to reduce overcrowding.

Interfacility Triage

If your center is a receiving center for stroke or other transfers, ensure that there are COVID-19 screening questions being asked by all accepting physicians and services.

Extracorporeal Membrane Oxygenation (ECMO)

Consider risks and benefits of citywide and regional referral of patients to ECMO centers. Risks of transport may include disease spread, risk to transport personnel, and overwhelming ECMO centers’ general ICU resources. Develop strict criteria for ECMO initiation only to those with the highest chance of survival given the high number of potential ECMO candidates and limited capacity. If patients require transfer from low-resource hospitals, consider triaging potential ECMO candidate patients (young, otherwise healthy, single organ failure) to large urban ECMO centers. This may decrease the frequency of patient transports for eventual ECMO referral.

Consider how mobile ECMO retrieval teams may be used to maximize ICU care at referral facilities. Once patients have failed conventional hypoxemia therapies, they will be too unstable for transport without ECMO. Coordinate with neighboring ECMO centers to exchange experience and knowledge, and potentially develop care guidelines for this patient population.

Intubation and Respiratory Support

Personnel from critical care, respiratory therapy, and anesthesiology should convene to develop approaches to support for suspected or confirmed COVID-19 patients with respiratory failure. Controversy exists about the use of noninvasive positive pressure ventilation and high-flow nasal cannula, which may disperse secretions and therefore virus.

We have opted to perform early tracheal intubation for these patients with placement on mechanical ventilation with a viral filter. Intubation should occur ideally in negative pressure rooms using airborne precautions.

  • The intubating clinician should use a PAPR with shroud and follow donning/doffing procedures.
  • Additional staff should be minimized (ideally, one nurse and one respiratory therapist).
  • We favor the use of video laryngoscopy to increase the distance between the intubating clinician and patient’s aerodigestive tract along with the rapid sequence intubation technique to minimize coughing or dispersion of secretions during bag-mask ventilation.
  • Viral filters can be placed in-line with bag-valve masks.
  • If sidestreamwaveform capnography devices are used, make sure a viral filter is placed in-line proximal to the end-tidal CO2 adapter (ie, directly on the end of the endotracheal tube, mask, or laryngeal mask airway). Otherwise, contaminated secretions may theoretically leak into the end-tidal CO2 tubing and perhaps back to the monitoring module.

Code Blue/Clinical Emergency Response

A dedicated plan for response to clinical emergencies should be created for patients with suspected or confirmed COVID-19. The plan should include limiting responding personnel, ensuring isolation precautions are maintained, and limiting aerosolizing procedure.

Consider appointing a dedicated isolation “captain” to ensure only essential staff enter the room, appropriate PPE are used, and equipment is decontaminated appropriately. The plan should include early discussions about “do not resuscitate” status with next of kin for critically ill infected patients.

Resources


The authors are in the department of emergency medicine at the University of Washington, Harborview Medical Center in Seattle.

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Diabetes, Lung, and Heart Disease Common in U.S. COVID-19 Patient https://www.acepnow.com/article/diabetes-lung-and-heart-disease-common-in-u-s-covid-19-patient/ https://www.acepnow.com/article/diabetes-lung-and-heart-disease-common-in-u-s-covid-19-patient/#respond Wed, 01 Apr 2020 22:03:16 +0000 https://www.acepnow.com/?post_type=article&p=23075 Diabetes, heart disease and long-term lung problems are the most common underlying conditions among Americans hospitalized with...

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Diabetes, heart disease and long-term lung problems are the most common underlying conditions among Americans hospitalized with the illness caused by the new coronavirus, but more than one in five people requiring intensive care had no such health issues, according to a report issued on March 31, 2020.

The findings show that higher percentages of COVID-19 patients with underlying conditions were being admitted to hospitals and intensive care units (ICUs), according to the U.S. Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report. That echoes patterns seen in other countries hit hard by the pandemic.

Preliminary data from 7,162 COVID-19 patients for whom the CDC had complete information as of Saturday show that 37.6% had one or more underlying health condition. Widespread testing to identify the full extent of the U.S. outbreak has not been available.

Most people infected with the coronavirus develop mild but persistent symptoms such as fever or cough. But difficulty breathing is a symptom sending many people to the hospital, and the new data show how underlying health conditions heighten the odds of complications requiring hospitalization.

Researchers found that 78% of ICU patients with COVID-19 had at least one underlying health problem, including diabetes (seen in 32% of patients), cardiovascular disease (29%) and chronic lung disease (21%). Twelve percent had long-term kidney disease and 9% had a weakened immune system.

Among hospitalized patients who were not sick enough to need intensive care, 71% had at least one underlying condition, the CDC analysis found.

In contrast, among people with COVID-19 who did not need to be hospitalized, only 27% had one or more long-term health issues.

But being free of chronic conditions offers no guarantees against serious illness as 22% of COVID-19 patients who ended up in an ICU had no history of underlying health problems.

“It is not yet known whether the severity or level of control of underlying health conditions affects the risk for severe disease associated with COVID-19,” according to the report by the CDC’s COVID-19 Response Team.

“Many of these underlying health conditions are common in the United States” with an estimated 10.1% of U.S. adults diagnosed with diabetes, 10.6% with heart disease, and 5.9% with chronic obstructive pulmonary disease (COPD), along with 7.9% of people of all ages who suffer from asthma.

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Loss of Taste and Smell Key COVID-19 Symptoms, App Study Finds https://www.acepnow.com/article/loss-of-taste-and-smell-key-covid-19-symptoms-app-study-finds/ https://www.acepnow.com/article/loss-of-taste-and-smell-key-covid-19-symptoms-app-study-finds/#respond Wed, 01 Apr 2020 21:51:34 +0000 https://www.acepnow.com/?post_type=article&p=23073 Losing your sense of smell and taste may be the best way to tell if you have...

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Losing your sense of smell and taste may be the best way to tell if you have COVID-19, according to a study of data collected via a symptom tracker app developed by scientists in Britain and the United States to help monitor the coronavirus pandemic.

Almost 60% of patients who were subsequently confirmed as positive for COVID-19 had reported losing their sense of smell and taste, data analyzed by the researchers showed.

That compared with 18% of those who tested negative.

These results, which were posted online but not peer-reviewed, were much stronger in predicting a positive COVID-19 diagnosis than self-reported fever, researchers at King’s College London said.

The app, which the researchers say could help slow the outbreak and identify more swiftly those at risk of contracting COVID-19, can be downloaded via the URL covid.joinzoe.com.

If enough people participate in sharing their symptoms, the scientists said, the app could also provide healthcare systems with critically valuable information.

“This app-based study is a way to find out where the COVID-19 hot spots are, new symptoms to look out for, and might be used as a planning tool to target quarantines, send ventilators and provide real-time data to plan for future outbreaks,” said Andrew Chan, a professor of medicine at Harvard Medical School in the United States who is co-leading the study.

Of 1.5 million app users between March 24 and March 29, 26% reported one or more symptoms through the app. Of these, 1,702 also reported having been tested for COVID-19, with 579 positive results and 1,123 negative results.

MATHEMATICAL MODEL

Using all the data collected, the research team developed a mathematical model to identify which combination of symptoms – ranging from loss of smell and taste, to fever, persistent cough, fatigue, diarrhoea, abdominal pain and loss of appetite -was most accurate in predicting COVID-19 infection.

“When combined with other symptoms, people with loss of smell and taste appear to be three times more likely to have contracted COVID-19 according to our data, and should therefore self-isolate for seven days to reduce the spread of the disease,” said Tim Spector, a King’s professor who led the study.

Trish Greenhalgh, a professor of primary care health sciences at Britain’s Oxford University and who is not involved in the study, said it was the first to demonstrate scientifically and in a large population sample that loss of smell is a characteristic feature of COVID-19.

Spector’s team applied their findings to the more than 400,000 people reporting symptoms via the app who had not yet had a COVID-19 test, and found that almost 13% of them are likely to be infected.

This would suggest that some 50,000 people in Britain may have as yet unconfirmed COVID-19 infections, Spector said.

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Becton Dickinson, BioMedomics Launch Test to Detect Past, Current Coronavirus Exposure https://www.acepnow.com/article/becton-dickinson-biomedomics-launch-test-to-detect-past-current-coronavirus-exposure/ https://www.acepnow.com/article/becton-dickinson-biomedomics-launch-test-to-detect-past-current-coronavirus-exposure/#respond Wed, 01 Apr 2020 21:44:45 +0000 https://www.acepnow.com/?post_type=article&p=23071 Becton Dickinson and Co and diagnostics company BioMedomics on March 31, 2020, said they will launch a...

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Becton Dickinson and Co and diagnostics company BioMedomics on March 31, 2020, said they will launch a diagnostic test that can detect current or past exposure to the coronavirus within minutes, and can be used in doctors’ offices, as well as other settings.

The test is the latest to join an arsenal of diagnostic tools for the coronavirus that can be used in community health settings such as doctors’ offices and urgent care clinics.

“This is a simple blood test that can be done at the point of care without the need to involve a large laboratory,” David Hickey, president of Becton Dickinson’s diagnostics division, told Reuters in a phone interview.

Abbott Laboratories on Friday won U.S. marketing approval for another coronavirus test that can deliver results to patients within minutes and be used in physicians offices and urgent care clinics. A week earlier, the U.S. Food and Drug Administration approved a test made by Cepheid that can be used at the point of care.

The United States now has more cases of the coronavirus than any other country, and hospitals have struggled to meet the demand to test thousands of people for the often-deadly virus.

The test from Becton Dickinson and privately-held BioMedomics is being released under the FDA’s recently relaxed rules for coronavirus tests, allowing the distribution of some tests before they receive regulatory clearance or without clearance entirely.

Becton Dickinson said it will begin distributing tests in April. It said it will have the capacity to produce 1 million tests and can scale up production further if necessary.

Point-of-care tests reduce the burden on laboratories to process samples of potential coronavirus patients and on hospitals to administer the tests. They also allow patients to be tested in a wider array of locations and receive results in as little as a few minutes.

The test can also play a role in understanding the process through which the disease spreads in the United States because of its ability to identify people who had a previous case of the coronavirus, Hickey said.

In some cases, patients who test positive for the coronavirus may need additional testing in a laboratory to determine the best course of treatment for the disease, Hickey said.

The FDA has also approved coronavirus tests on an emergency basis made by companies including Roche Holding AG and Thermo Fisher Scientific Inc.

With the expansion of testing has come a surge in confirmed cases of COVID-19, the disease caused by the coronavirus. Reuters reported on Friday that the United States now has more than 100,000 cases.

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Simulations can Reveal Deficiencies in PPE Coverage https://www.acepnow.com/article/simulations-can-reveal-deficiencies-in-ppe-coverage/ https://www.acepnow.com/article/simulations-can-reveal-deficiencies-in-ppe-coverage/#respond Wed, 01 Apr 2020 21:39:00 +0000 https://www.acepnow.com/?post_type=article&p=23069 Simulations to test the effectiveness of personal protective equipment (PPE) may reveal shortcomings in both the equipment...

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Simulations to test the effectiveness of personal protective equipment (PPE) may reveal shortcomings in both the equipment and in the manner that PPEs are used, a new study suggests.

Canadian researchers testing PPEs in an airway-management simulation scenario found the equipment they were using might not adequately protect medical personnel caring for a real patient with COVID-19, according to the report in the Canadian Journal of Anesthesiology.

With the help of a mannequin that could “cough” up a mixture containing Glo Germ powder, the study team ran a series of simulations involving different types of protective attire. The Glo Germ powder is a product designed to mimic the spread of microorganisms.

The powder was brushed onto the surface of the simulation mannequin and also loaded into the mannequin’s nostrils. While health care workers were working on the mannequin, it coughed up droplets containing the powder. When the workers wore reusable yellow gowns that were permeable to liquid, six out of six had visible soilage on their scrubs beneath their gowns.

During one simulation, an airway assistant wearing a disposable Advancement of Medical Instrumentation level-3 surgical gown showed no contamination of the scrubs beneath the gown, but there was significant contamination on that health care worker’s neck, on the base of the wrist, and on the lower pants and shoes.

“While skin contamination is not a method of transmission for the severe acute respiratory syndrome coronavirus-2 responsible for causing COVID-19, these areas of soilage increase the risk for self-contamination (e.g., during doffing) via mucous membranes,” write the authors, led by Dr. Shannon Lockhart, of the department of anesthesiology at St. Paul’s Hospital and the University of British Columbia in Vancouver.

The study authors did not respond to requests for comment.

Contamination could also occur while health care workers disrobed, Dr. Lockhart and her team found. The researchers suggested that the doffing process be adjusted to the types of PPEs used, and it must be practiced, they said.

In their simulations, Glo Germ was found on faces, necks, forearms and shoes after participants disrobed.

The new study underscores the importance of practicing with simulations, said Dr. Jennifer Arnold, a neonatologist and medical director of simulation at Johns Hopkins All Children’s Hospital in Baltimore.

“One critical message is that identification of the proper PPE coverage is key to protection and testing this with simulation is a safe and effective way to optimize safety for our clinicians,” Dr. Arnold said in an email. “Additionally, this article demonstrates the challenge of performing effective donning and doffing procedures”

Even for a simulation expert, some of the findings were unexpected.

“I was surprised to learn just how much contamination of exposure particles can occur in areas we don’t think of covering – the neck, the feet,” Dr. Arnold said.

While the article was aimed at anesthesiologists, anyone providing care for patients with COVID-19 can learn from it, said Dr. Paul Phrampus, a professor in the department of emergency medicine and director of the Winter Institute for Simulation, Education and Research (WISER) at the University of Pittsburgh.

“What’s nice about it is it informs the entire medical community that when these procedures are being done, you need to pay strict attention to what PPE is recommended and also to the procedures for putting on and, most important, the procedures for taking off since this is when most contaminate themselves.”

“As a simulation professional as well as a practicing physician, I would like to continue to advocate for simulation centers to be doing these kinds of studies to inform us as we move forward during these trying times,” Dr. Phrampus said.

Dr. Phrampus and his team have been running through simulations themselves.

“All day yesterday and today we were looking at system sequences involved in the intubation of patients – who goes in the room and when, choreographing movements,” he said. “We probably ran the drill 20 times to refine the sequences so that we do them better and safer.”

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U.S. Companies, Labs Rush to Produce Blood Test for Coronavirus Immunity https://www.acepnow.com/article/u-s-companies-labs-rush-to-produce-blood-test-for-coronavirus-immunity/ https://www.acepnow.com/article/u-s-companies-labs-rush-to-produce-blood-test-for-coronavirus-immunity/#respond Wed, 25 Mar 2020 18:29:45 +0000 https://www.acepnow.com/?post_type=article&p=23041 As the United States works overtime to screen thousands for the novel coronavirus, a new blood test...

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As the United States works overtime to screen thousands for the novel coronavirus, a new blood test offers the chance to find out who may have immunity—a potential game changer in the battle to contain infections and get the economy back on track.

Several academic laboratories and medical companies are rushing to produce these blood tests, which can quickly identify disease-fighting antibodies in people who already have been infected but may have had mild symptoms or none at all. This is different from the current, sometimes hard-to-come-by diagnostic tests that draw on a nasal swab to confirm active infection.

“Ultimately, this (antibody test) might help us figure out who can get the country back to normal,” Florian Krammer, a professor in vaccinology at Mount Sinai’s Icahn School of Medicine, told Reuters. “People who are immune could be the first people to go back to normal life and start everything up again.”

Krammer and his fellow researchers have developed one of the first antibody tests in the United States for COVID-19, the disease caused by the new coronavirus. Krammer said his lab is busy distributing key ingredients for the tests to other organizations and sharing the testing procedure. He is transferring the work to Mount Sinai’s clinical lab this week so it can begin testing patient samples.

Antibody tests won’t face the same bureaucratic hurdles diagnostic testing initially did. The U.S. Food and Drug Administration relaxed its rules last month, and body-fluid tests can proceed to market without full agency review and approval.

Several private companies have begun selling blood tests for COVID-19 antibodies outside the United States, including California-based Biomerica Inc and South Korean test maker Sugentech Inc. Biomerica said its test sells for less than $10 and the company already has orders from Europe and the Middle East. Chembio Diagnostics Inc of New York said it received a $4 million order from Brazil for its COVID-19 antibody test, and it plans a study of the test at several sites in the United States.

Such tests are relatively inexpensive and simple, usually using blood from a finger prick. Some can produce results in 10 to 15 minutes. That could make ramping up screening much easier than for diagnostic tests.

Many questions remain, including how long immunity lasts to this new virus, how accurate the tests are and how testing would roll out, according to researchers and infectious disease experts. For now, the number of people who have been able to fight off the virus is unknown.

If testing goes forward on a wider scale, some public health experts and clinicians say healthcare workers and first responders should take priority.

Detecting immunity among doctors, nurses and other healthcare workers could spare them from quarantine and enable them to keep treating the growing surge of coronavirus patients, they say. It could also bolster the ranks of first responders, police officers and other essential workers who have already been infected and have at least some period of protection from the virus, the experts say.

“If I ever get the virus and then get over it, I’ll want to get back to the front lines ASAP,” said Dr. Adams Dudley, a pulmonologist and professor at the University of Minnesota School of Medicine. “I would have a period in which I am immune, effectively making me a ‘corona blocker’ who couldn’t pass the disease on.”

‘VERY ATTRACTIVE’

Other workers sidelined by lockdowns also could potentially return to their jobs, providing a much-needed boost to the foundering U.S. economy. The number of Americans filing for unemployment benefits has soared, and business activity slumped to a record low this month as the pandemic battered the manufacturing and service sectors.

Dr. William Schaffner, a professor of infectious diseases at the Vanderbilt University School of Medicine, said companies, schools, colleges and professional sports teams could all flock to these tests. He also said a broad sample of testing could give a governor or mayor enough confidence to lift certain restrictions on businesses and schools if there is a strong level of immunity.

“These tests would be very attractive if they’re cost effective, readily available and easy to do,” he said.

Tony Mazzulli, chief microbiologist with Toronto’s Sinai Health system, sounded a note of caution. It is uncertain whether antibodies would be sufficient protection if a person were to be re-exposed to the virus in very large amounts. That could happen in an emergency room or intensive-care unit, for instance.

The timing of a return to work and normal life also matters, he said. Some people who have antibodies to the virus could still be contagious, even if their symptoms have eased. Patients begin to make antibodies while they are still sick, Mazzulli said, and they continue to shed the virus for a few days after they have recovered.

It would be “a bit premature” to use the tests to make staffing decisions now, Mazzulli said. “The hope is . . . (antibodies) do confer protection and they can go to work, ride the subways, whatever they do. But there’s no guarantee.”

Meantime, at the Mayo Clinic in Rochester, Minnesota, researchers are preparing to start a clinical trial in which patients who test positive for COVID-19 would have their blood collected at the time of diagnosis, and again 15 to 20 days after that in the patient’s home.

The trial is designed to show when people who have COVID-19 infections “seroconvert” – when antibodies produced by the body begin to show up in blood tests. That information will be useful in determining the best time to conduct the tests.

“You don’t want to do it too soon because of the risk of false negatives,” said Elitza Theel, director of Mayo’s Infectious Diseases Serology Laboratory.

Mayo also is evaluating the performance of antibody tests from several companies, including two from China.

The U.S. Centers for Disease Control and Prevention said it is working on its own version of antibody tests, but it has not given a timetable. The agency has said extensive research is underway. One challenge for the CDC and other labs is to get enough blood samples from people who have already been infected to verify the antibody results.

The agency faced heavy criticism for sending a faulty diagnostic test to state and local labs early in the coronavirus epidemic and then taking weeks to fix it. The federal government is still trying to expand diagnostic testing capacity.

MONTHS OF IMMUNITY

The potential for antibody testing arises as U.S. President Donald Trump is considering scaling back “social distancing” and stay-at-home advisories in the weeks ahead. His political allies argue that the toll on the U.S. economy is too severe. About half of Americans have been ordered to shelter in place as many schools and businesses remain shuttered indefinitely.

On Tuesday, Trump said: “I would love to have the country opened up and just raring to go by Easter.”

Reopening offices and businesses without fear of triggering more infections, however, has been complicated by the lack of testing to diagnose COVID-19 cases across much of the country.

On Monday, Dr. Deborah Birx, a member of the White House coronavirus task force, said simple, finger-prick antibody tests could play an important role, and she suggested the federal government is not waiting on the CDC’s version.

“Some are developed now. We are looking at the ones in Singapore,” Birx said Monday at a White House press briefing. “We are very quality-oriented. We don’t want false positives.”

False positives are erroneous results that, in this case, could lead to a conclusion that someone has immunity when he or she does not.

Researchers at the Duke-National University of Singapore Medical School said they quickly developed one antibody test that had about 90% accuracy and later introduced a more sophisticated version that was more reliable, according to a report in the Straits Times of Singapore.

Infectious disease experts say immunity against COVID-19 may last for several months and perhaps a year or more based on their studies of other coronaviruses, including Severe Acute Respiratory Syndrome (SARS), which emerged in 2003. But they caution that there is no way to know precisely how long immunity would last with COVID-19, and it may vary person to person.

“You are likely to have immunity for several months,” said Dr. Stanley Perlman, a professor of microbiology and immunology at the University of Iowa. “We just don’t know. This is an incredibly important question.”

Perlman said many of the new antibody tests coming on the market now may be highly effective, but researchers want to see data to back that up.

“You want them to be sensitive enough to detect everyone who has had the infection,” Perlman said, “but not so nonspecific that you are picking up other coronaviruses.”

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Summer Heat Unlikely to Halt Coronavirus, EU Body Says https://www.acepnow.com/article/summer-heat-unlikely-to-halt-coronavirus-eu-body-says/ https://www.acepnow.com/article/summer-heat-unlikely-to-halt-coronavirus-eu-body-says/#respond Wed, 25 Mar 2020 18:24:33 +0000 https://www.acepnow.com/?post_type=article&p=23039 Summer heat is unlikely to stop the spread of the coronavirus, and every country in Europe is...

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Summer heat is unlikely to stop the spread of the coronavirus, and every country in Europe is forecast to run out of intensive care beds by mid-April unless it acts fast, the European Union’s disease control agency said on Wednesday.

The European Centre for Disease Control (ECDC) cited research which it said suggests that the virus does not become less dangerous in hot and humid conditions, reducing hope that the northern hemisphere could get a respite when the summer arrives.

“There is no evidence to date that SARS-CoV-2 will display a marked winter seasonality, such as other human coronaviruses in the northern hemisphere,” the ECDC said in a report.

The document cited preliminary analyses from the outbreak in China which found the virus was able to maintain high levels of reproduction in tropical places with high humidity, such as Guangxi and Singapore.

That “emphasises the importance of implementing intervention measures such as isolation of infected individuals, workplace distancing, and school closures,” the agency said.

EXCEEDED CAPACITY

Healthcare systems in Europe face a high risk of being saturated, the report said. Its model forecast that existing capacity for intensive care beds would be exceeded in all European countries by mid April, unless steps were taken such as boosting capacity and reducing the spread of the disease.

The ECDC revised up its assessment of the risk posed by the virus to the elderly and those with chronic diseases in Europe to “very high” from “high.” It maintained its assessment that the rest of the public faces a “moderate” danger from the virus.

Overall risks for countries are “moderate” if they take mitigation measures, such school closures, but “very high” in absence of such measures, said the report, which covers the 27 EU countries, plus Britain, Norway, Iceland and Liechtenstein.

Authorities should provide protective gear and set up proper procedures to protect healthcare workers, who are increasingly exposed to the virus, and could further spread the disease to other patients.

The ECDC said that in China up to 10% of total reported infections were among medics and nurses, far above the nearly 4% rate that has been reported so far in other studies.

In Italy and Spain, the two EU countries most affected so far by the epidemic, the rate is respectively at 9% and around 13%.

The ECDC also cited scientific research saying the virus can survive up to 3 hours in the air, up to 4 hours on copper, up to 24 hours on cardboard, and up to 2-3 days on plastic and stainless steel, although with significantly decreased power.

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Tips for Managing Suspected Occult Fractures https://www.acepnow.com/article/tips-for-managing-suspected-occult-fractures/ https://www.acepnow.com/article/tips-for-managing-suspected-occult-fractures/#respond Wed, 25 Mar 2020 17:39:36 +0000 https://www.acepnow.com/?post_type=article&p=23034 When assessing a patient with a suspected radiographically occult fracture, there are two options for the emergency...

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A 3-year-old girl fell while running. An X-ray the day of the fall (LEFT) showed no fracture, but her arm was splinted for possible occult fracture. A follow-up X-ray at three weeks (RIGHT) confirmed the fracture (arrows). Credit: Arun Sayal

When assessing a patient with a suspected radiographically occult fracture, there are two options for the emergency physician: more tests or more time.

More tests equates to additional X-ray views or advanced imaging (CT or MRI).

More time means treating the patient for the suspected diagnosis and arranging for a serial assessment.

I will discuss three cases and explore the ED management options.

Case 1: Occult Scaphoid Fracture

A 26-year-old female fell on an outstretched hand and has isolated wrist pain, tender snuff box, and scaphoid tubercle. X-rays of the wrist with scaphoid views are normal.

Diagnosis: suspected occult scaphoid fracture.

Follow-up studies have shown that 75 to 80 percent of patients with an ED diagnosis of a “suspected scaphoid fracture” do not have a fracture.1,2 There is concern that many patients are unnecessarily immobilized and require a low-yield follow-up appointment. These concerns have led some emergency departments to institute a wrist CT protocol during the initial visit in an attempt to definitively rule in or rule out a scaphoid fracture. A meta-analysis showed the sensitivity and specificity of CT for occult scaphoid fractures were 0.72 (95% CI, 0.36–0.92) and 0.99 (95% CI, 0.71–1.00), respectively.3 Even the CT may not definitively rule out a fracture and may be falsely reassuring. Additionally, if a patient’s radial-sided wrist pain comes from a partial scapholunate ligament (SLL) injury, the CT may be normal. If a patient subsequently falls during SLL healing (which may take weeks to months), the second force may convert a partial tear to a complete one, requiring operative management.

MRI is often considered the best advanced imaging option, as it shows the bone and soft tissues. A meta-analysis reported the sensitivity and specificity of MRI for occult scaphoid fractures were 0.88 (95% CI, 0.64–0.97) and 1.00 (95% CI, 0.38–1.00), respectively.3 Another smaller study showed early MRI missed 20 percent of radiographically occult scaphoid fractures.4 Therefore, normal MRI may not definitively rule out a fracture either. Additionally, high cost and low access prevent MRI from playing a role as an advanced imaging option for suspected occult scaphoid fractures during ED visits.

A bone scan may be considered due to a high sensitivity, though this modality is fading from common use. The sensitivity and specificity of bone scan for occult scaphoid fractures were 0.99 (95% CI, 0.69–1.00) and 0.86 (95% CI, 0.73–0.94), respectively, but there are many downsides to this imaging modality in the emergency department.3 For fracture detection, a bone scan generally requires 48 to 72 hours after injury to become reliably positive (though modern bone scans may need less time). Given its high sensitivity, a negative bone scan at 48 to 72 hours essentially rules out a fracture, but as with CT, a normal bone scan does not rule out a SLL tear. Unfortunately, a positive bone scan is hampered by low specificity. False positives can be generated by any condition that increases metabolic activity in bone, such as a bone contusion, infection, inflammation, degenerative joint disease, and tumors. Additionally, bone scans are associated with significant ionizing radiation (equivalent to 50 chest X-rays). Bone scans are fairly time-consuming and only available during certain working hours, and they require isotope availability. Bone scans miss important information including fracture pattern and/or precise location, making prognosis for that fracture difficult to assess. Therefore, a positive bone scan is often followed by a form of 3-D imaging (typically CT). As a result, radionuclide bone scans for suspected scaphoid fractures in the emergency department are largely impractical.

Similarly, ultrasound (US) is of limited value for occult fracture confirmation. Certainly, US may be helpful with some soft tissue injuries. It is less helpful in fractures. The sensitivity and specificity of ultrasound in diagnosing radiographically occult scaphoid fracture ranged from 77.8 to 100 percent and from 71.4 to 100 percent, respectively, with pooled estimates of 85.6 percent (95% CI, 73.9–92.6%) and 83.3 percent (95% CI, 72.0–90.6%), respectively.5

While there are suggestions in the literature that US may be an option for suspected scaphoid fractures, it is not considered sensitive enough to reliably alter ED management decisions.3,4

Case 2: Occult Lateral Tibial Plateau Fracture

A 78-year-old male presents with valgus stress to left knee, immediate pain, non-weight-bearing, and swelling within an hour. On exam, the knee is swollen, there is tenderness along the lateral joint line, the ligaments are stable, and soft tissues are intact. X-rays of the knee (four views) show effusion only.

Diagnosis: suspected occult lateral tibial plateau fracture.

Valgus stress with immediate pain, rapid swelling (implying acute hemarthrosis), and non-weight-bearing suggest a lateral tibial plateau fracture, especially in older patients with osteoporosis. On exam, the swollen knee, lateral joint line pain, and inability to bear weight are consistent with a likely tibial plateau injury. Even in the face of normal X-rays, the high clinical suspicion should make one pause and consider occult fracture. Such fractures are at risk of displacing if the diagnosis is missed in the emergency department and the patient is allowed to weight-bear.6

More tests? Or “treat and more time?” The option for treat and more time means immobilization, crutches, and non-weight-bearing. In many older patients, this proposition is very risky, so the push would be for advanced imaging (a CT scan) as soon as can be reasonably arranged. The patient should be kept non-weight-bearing until the diagnosis is clarified. A younger patient with a similar assessment may be more likely to manage crutches. Therefore, the option of immobilization, crutches, strict non-weight-bearing, and close follow-up (ideally within a week) may be more reasonable, depending on your local resources and preferences.

Case 3: Occult Hip Fracture

A 74-year-old female slips and falls. She has pain to the right hip and is non-weight-bearing. There is no limb-shortening or external rotation. She has a tender right hip and significant decreased range of motion (passive and active). X-rays of the hip and anteroposterior pelvis are normal.

Diagnosis: suspected occult hip (neck of femur) fracture.

The incidence of radiographically occult hip fracture (neck of the femur) is estimated to be between 5 and 10 percent—and more likely in elderly patients.

A few important warnings about ED patients with hip fractures. The “classic” patient with a hip fracture has fallen and cannot walk, and their leg is short and externally rotated. Shortening and external rotation indicate a displaced fracture. However, an undisplaced hip fracture will not have the classic short and externally rotated presentation—it will have symmetric alignment to the contralateral leg. While most patients with a hip fracture are unable to walk, a minority of patients with an impacted, undisplaced hip fracture may be able to, albeit with a painful limp. In some cases, history (or lack thereof) can mislead us; hip fractures can occur without falling. In patients with an osteoporotic (weak), arthritic (stiff) hip, a vigorous twist can produce enough torque to cause a fracture. Not realizing this can be a diagnostic pitfall.

Often, an occult hip fracture needs surgical management. Delay in diagnosis increases morbidity as diagnostic delay is associated with greater displacement and more extensive surgery.3 Even mortality increases with delay to surgery.7 A 13 percent increase in the risk of mortality for every day of delay in surgery has been reported.8 Ideally, patients with a hip fracture should be operated on within 24 to 28 hours. However, the decision to operate cannot be made until the diagnosis is confirmed.

This case highlights that a greater imperative exists to diagnose these injuries, requiring more tests on the index visit. However, if the clinical setting is such that advanced imaging is not available, then bed rest and non-weight-bearing are mandated until a diagnosis is confirmed. Ideally, arrangements for advanced imaging should be made.

Two additional points: Older patients with osteoarthritis can have marginal osteophytes. On CT, these marginal osteophytes can simulate fractures in their periphery. Osteoporosis can also accentuate lucencies and nutrient vessels, again mimicking fractures and leading to false positive reads.

Analysis

In determining a management strategy (more tests versus more time), three main factors should be considered for patients with a suspected occult fracture:

  • Diagnosis in question
  • Patient in question
  • Available resources
  • Diagnostic Factors

For some occult fractures, the plan of immediate immobilization and delaying diagnostic confirmation is reasonable since this strategy would not adversely affect outcome. However, diagnostic delay of other radiographically occult fractures can be harmful.9 Suspected scaphoid fractures with negative X-rays are the classic example. Suspected distal radius fractures can be approached similarly. Most pediatric cases of suspected occult fractures can be managed this way.

Suspected occult hip fractures, tibial plateau fractures, and cervical spine fractures, however, require immediate further evaluation, as they are more likely to displace if missed in the emergency department and not managed appropriately.9 These displacements can lead to more extensive surgery or surgery that may have been avoided altogether.9 In these cases, the need for advanced imaging during the index visit is evident.

Patient Factors

Patient factors also play a role. Because of the tendency to displace with weight-bearing, patients with suspected tibial plateau fractures should be kept non-weight-bearing until confirmed or reassessed. For older patients, the strategy to immobilize, provide crutches, and require no weight-bearing can be a dangerous combination; fall risks are high. But younger patients may safely tolerate this approach, permitting immobilization and delayed advanced imaging in many instances. Patient factors around compliance and availability for follow-up should also influence our choice between more tests and more time.

Imaging Modalities

Advanced imaging for occult fractures in the emergency department generally refers to CT and MRI. Each has respective pros and cons.

A CT scan generally has high sensitivity for detecting fractures, and especially with 3-D reconstruction, it is an excellent tool for assessing bony alignment. CT provides little value for soft tissue injuries.

Musculoskeletal CT scans expose patients to ionizing radiation, but that exposure is far less than chest, abdomen, and pelvic protocols. A wrist CT is equivalent to the radiation of just 1.5–3 chest X-rays.10,11 A chest CT is equivalent to around 70; an abdomen/pelvis CT is equivalent to up to 100.12

MRI has advantages over CT. In addition to high sensitivity for fractures, MRIs can assess soft tissue structures—and without any radiation. However, high cost, long scan and radiology reading times, and poorer availability limit its role in the emergency department for occult fractures.

Bone scans and ultrasound in assessing suspected occult fractures are discussed above.

As a final consideration, the ED workup and treatment can vary from hospital to hospital based on local orthopedic preferences. Knowing how your local orthopedic surgeons prefer to manage the spectrum of suspected occult fractures from the outset optimally aligns initial ED care with the follow-up care patients will receive.

Summary

When considering advanced imaging, we are guided by the post-test probability for fracture; knowing the limits of plain films; understanding the complications of the suspected injury; the pros, cons, and indications for advanced imaging; and the proper ED treatment. Combining these helps optimize care.

“X-ray normal” is not a diagnosis. While most ED patients with negative extremity X-rays do not have a fracture, a few will. As clinicians, we see normal X-rays routinely on every shift. We should neither be falsely reassured by them nor unduly afraid of them. Combining the patient’s history with risk factors and the physical exam will determine our proper level of concern.

If significant concern for a fracture remains after negative X-rays, the ideal ED management strategy depends on the diagnosis, the patient, and available resources.

Worrisome diagnoses in less physically robust patients tend to require more urgent diagnostic confirmation. However, in many cases, sturdy patients with a suspected occult fracture can be safely and appropriately managed with an ED plan to treat for the fracture and arrangement of close follow-up.

References

  1. Baldassarre R, Hughes T. Investigating suspected scaphoid fracture. BMJ. 2013;346:f1370.
  2. Suh N, Grewal R. Controversies and best practices for acute scaphoid fracture management. J Hand Surg Eur Vol. 2018;43(1):4-12.
  3. Mallee WH, Wang J, Poolman RW, et al. Computed tomography versus magnetic resonance imaging versus bone scintigraphy for clinically suspected scaphoid fractures in patients with negative plain radiographs. Cochrane Database Syst Rev. 2015;(6):CD010023.
  4. Beeres FJ, Rhemrev SJ, den Hollander P, et al. Early magnetic resonance imaging compared with bone scintigraphy in suspected scaphoid fractures. J Bone Joint Surg Br. 2008;90(9):1205-1209.
  5. Kwee RM, Kwee TC. Ultrasound for diagnosing radiographically occult scaphoid fracture. Skeletal Radiol. 2018;47(9):1205-1212.
  6. Kiel CM, Mikkelsen KL, Krogsgaard MR. Why tibial plateau fractures are overlooked. BMC Musculoskelet Disord. 2018;19(1):244.
  7. Lewis PM, Waddell JP. When is the ideal time to operate on a patient with a fracture of the hip? a review of the available literature. Bone Joint J. 2016;98-B(12):1573-1581.
  8. Weller I, Wai EK, Jaglal S, et al. The effect of hospital type and surgical delay on mortality after surgery for hip fracture. J Bone Joint Surg Br. 2005;87(3):361-366.
  9. Je S, Kim H, Ryu S, et al. The consequence of delayed diagnosis of an occult hip fracture. J Trauma Injury. 2015;28(3):91-97.
  10. Iordache SD, Goldberg N, Paz L, et al. Radiation exposure from computed tomography of the upper limbs. Acta Orthop Belg. 2017;83(4):581-588.
  11. Biswas D, Bible JE, Bohan M, et al. Radiation exposure from musculoskeletal computerized tomographic scans. J Bone Joint Surg Am. 2009;91(8):1882-1889.
  12. Radiation dose to adults from common imaging examinations. American College of Radiology website. Available at: https://www.acr.org/-/media/ACR/Files/Radiology-Safety/Radiation-Safety/Dose-Reference-Card.pdf. Accessed Feb. 13, 2020.

Dr. Sayal is a staff physician in the emergency department and fracture clinic at North York General Hospital in Toronto, creator and director of CASTED ‘Hands-On’ Orthopedic Courses, and associate professor in the department of family and community medicine at the University of Toronto.

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U.S. Awards $100 Million to Health Centers to Boost Coronavirus Response https://www.acepnow.com/article/u-s-awards-100-million-to-health-centers-to-boost-coronavirus-response/ https://www.acepnow.com/article/u-s-awards-100-million-to-health-centers-to-boost-coronavirus-response/#respond Tue, 24 Mar 2020 19:06:22 +0000 https://www.acepnow.com/?post_type=article&p=23043 The U.S. Department of Health and Human Services (HHS) said on Tuesday it had awarded $100 million...

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The U.S. Department of Health and Human Services (HHS) said on Tuesday it had awarded $100 million to 1,381 health centers across the nation to bolster their response to the coronavirus pandemic.

The health centers may use the funds to meet screening and testing needs, acquire medical supplies and boost telehealth capacity, the HHS said.

“The new grants we’re releasing today are a rapid injection of resources secured by President Trump from Congress in the supplemental funding bill,” HHS Secretary Alex Azar said in a statement.

President Donald Trump had signed an emergency spending bill for $8.3 billion on March 6, which included the $100 million funding.

HHS is making this funding for health centers available immediately, recognizing the urgency of the situation.

The coronavirus outbreak has spread to over 46,000 people in the United States and led to over 500 deaths, according to a Reuters tally.

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