Emergency Medical Minute

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**Emergency Medical Minute**

Our near daily podcasts move quickly to reflect current events, are inspired by real patient care, and speak to the true nature of what it’s like to work in the Emergency Room or Pre-Hospital Setting. Each medical minute is recorded in a real emergency department, by the emergency physician or clinical pharmacist on duty – the ER is our studio and everything is live.

Latest Episodes:

Podcast 557: COVID-19 Lab Trends Apr 29, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

COVID-19 is diagnosed with a nasopharyngeal swab (q-tip). This unfortunately can be painful, but if the swab doesn't go deep into the nasal cavity the sample can be inadequate leading to false negatives (missed infections).

The sensitivity of the COVID-19 RT PCR test is low, ranging from 66-80% in various studies. Another study has shown 23% of patients who initially tested negative but had COVID-19 symptoms will test positive when re-tested. So test highly suspicious patients twice.

COVID has shown to have an effect on CBC. White blood cell counts are often normal (no leukocytosis), but there is often lymphopenia, or low lymphocytes, and thrombocytopenia. Interestingly, low platelets have appeared to have prognostic value in that lower platelets often indicate worse patient outcomes.
Coagulation studies are showing very elevated D-Dimers which has sparked the debate as to whether COVID-19 causes a hypercoagulable state. The increased incidence of MI/heart attacks and strokes in COVID patients supports this argument.
While D-Dimers can help point towards a diagnosis of pulmonary embolism, in the setting of highly likely COVID-19 infections, getting a CTA looking for a PE is probably unnecessary unless there's also suspicion for PE.
C-reactive protein (CRP) and procalcitonin are two common inflammatory markers. A CRP can help indicate how sick a patient is and procalcitonin can help determine if the infection is bacterial or viral in nature.
CRP levels are often elevated in COVID patients, and studies are showing a high CRP is linked to worse patient outcomes.
Elevations in procalcitonin can be used to see if there's a concomitant bacterial infection, meaning patients need antibiotics in addition to supportive care for the COVID-19.
Flu season is coming to a close, but data has shown a 5-10% co-infection rate of COVID-19 with influenza. As expected patient outcomes have been worse in those with both infections.

References

1) Farkas, Josh. "COVID-19." EMCrit Project, 21 Apr. 2020, emcrit.org/ibcc/covid19/#labs.

2) Guan W. et al. Clinical Characteristics of Coronavirus Disease 2019 in China. February 28, 2020, updated on March 6, 2020, at NEJM.org. DOI: 10.1056/NEJMoa2002032

3)Young BE, Ong SWX, Kalimuddin S, et al. Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore. JAMA. 2020;323(15):1488–1494. doi:10.1001/jama.2020.3204

4) Wang M. et al. Clinical diagnosis of 8274 samples with 2019-novel coronavirus in Wuhan. medRxiv 2020.02.12.20022327; doi: https://doi.org/10.1101/2020.02.12.20022327

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Podcast 556: CSF - What is it good for? Apr 28, 2020

Show notes

Contributor: Eric Miller, MD

Educational Pearls:

A cell count is performed on tubes 1 and 4 to account for changes that may occur from blood entering the first sample from the needle insertion
Tube 2 and 3 are usually used for the other studies like protein levels, glucose levels and gram staining
Protein levels are often elevated in bacterial meningitis but can be helpful in diagnosis conditions like multiple sclerosis
Glucose levels are typically low in bacterial meningitis due to the use of glucose by bacteria
Cell counts above 3-5 cells are typically abnormal, but cell counts can vary widely depending on the type of meningitis (viral vs. bacterial) and how long the infection has been present.
Cell type and differential can indicate viral vs. bacterial meningitis
- Neutrophils are more associated with bacterial causes
- Lymphocytes are more associated with viral etiologies
CSF cultures are used to identify the cause of bacterial meningitis but can take days to result.
A gram stain can help determine if any bacteria are present as well as cell types present.

References

Jain, R. Chang, WW. Emergency Department Approach to the Patient with Suspected Central Nervous System Infection. Emerg Med Clin North Am. 2018 Nov;36(4):711-722. doi: 10.1016/j.emc.2018.06.004.

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

Podcast 555: Anticoagulation vs. Antiplatelet Apr 27, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

When do we give antiplatelet drugs or anti-coagulation drugs?
- Arterial issues get antiplatelet therapy
- Venous issues, or slow flow states, get anticoagulation therapy.
High flow areas (arteries) are more prone to platelet clotting while the venous system is more prone to allowing blockages caused by coagulation factors.
The main side effect with antiplatelet and anticoagulants is bleeding. Typically antiplatelet drugs cause more bleeding issues because platelets are made in the bone marrow, while coagulation factors are made in the liver, so it takes longer for the bone marrow to replete platelets versus the liver which is a fast synthesizer of clotting factors.
Reversal of antiplatelet drugs can take a while, so patients on these drugs (ex. Plavix) may need a week of withholding the drug to get surgery, while anti-coagulation drugs (ex. Xarelto) can be stopped a day or two prior to surgery.

References

1. Altiok, E. Marx, N. Oral Anticoagulation: Update on Anticoagulation With Vitamin K Antagonists and Non–Vitamin K–Dependent Oral Anticoagulants. Dtsch Arztebl Int. 2018 Nov; 115(46): 776–783. Published online 2018 Nov 16. doi: 10.3238/arztebl.2018.0776

2. Kapil, N. Et al. Antiplatelet and Anticoagulant Therapies for Prevention of Ischemic Stroke.

Clin Appl Thromb Hemost. 2017 May;23(4):301-318. doi: 10.1177/1076029616660762. Epub 2016 Jul 26.

3. Ostergaard, L. Fosbol EL. Roe MT. The Role of Antiplatelet Therapy in Primary Prevention. A Review. Curr Pharm Des. 2017;23(9):1294-1306. doi: 10.2174/1381612822666161205115540.

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

COVID-19 Digest: Neurological Manifestations of COVID-19 Apr 23, 2020

Show notes

Accumulating clinical evidence suggests that many patients with COVID have neurological symptoms and that some may even present with neurologic manifestations of the disease. Most COVID patients have a cough, respiratory distress, and while clinicians often speak about how similar the presentations of patients with respiratory COVID are, it's worth looking at the possibility that COVID has atypical presentations, too.There's very good evidence that coronaviruses can infect all sorts of human cells--not just those in the respiratory tract. A few weeks ago we discussed ACE inhibitors and NSAIDs and SARS COV2 and you may remember that the virus attaches to the ACE2 receptor--a receptor which is found on a wide range of human cells. What are the chances the virus can infect a patients brain cells, cranial nerves, peripheral nerves?

Host: Elizabeth Esty, MD

Research By: Tanisha Crosby-Attipoe & Mason Tuttle

Sound Editing By: Stephen Bahmani

Time Stamps:

0:23 - Numbers

1:25 - Possible Neurological Manifestations of COVID

4:15 - What are the chances the virus can infect a patients brain cells, cranial nerves, peripheral nerves?

4:55 - The neuroinvasive potential of SARS‐CoV2 may play a role in the respiratory failure of COVID‐19 patients

8:24 - early neurological research from NEJM in February

9:10 - some early research indicated possible neurological manifestations

10:05 - COVID and serious CV incidents

10:40 - Italian Neurologists urge other nations to be alert for neuro presentations of COVID

11:11 - Case report in Radiology, COVID patient with encephalopathy

12:06 - Possible link with Guillain-Barré

References:

Li Y-C, Bai W-Z, Hashikawa T. The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients. Journal of Medical Virology. 2020;92(6):552-555. doi:10.1002/jmv.25728
Poyiadji N, Shahin G, Noujaim D, Stone M, Patel S, Griffith B. COVID-19–associated Acute Hemorrhagic Necrotizing Encephalopathy: CT and MRI Features. Radiology. March 2020:201187. doi:10.1148/radiol.2020201187
Mao L, Jin H, Wang M, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. April 2020. doi:10.1001/jamaneurol.2020.1127
Li Y, Wang M, Zhou Y, et al. Acute Cerebrovascular Disease Following COVID-19: A Single Center, Retrospective, Observational Study. Rochester, NY: Social Science Research Network; 2020. doi:10.2139/ssrn.3550025
Zhao H, Shen D, Zhou H, Liu J, Chen S. Guillain-Barré syndrome associated with SARS-CoV-2 infection: causality or coincidence? The Lancet Neurology. 2020;19(5):383-384. doi:10.1016/S1474-4422(20)30109-5

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