Thread by @Gas_Craic

What is CORONAVIRUS? How might it affect ICU? Let's go back to basics and look at the emerging evidence bases, protocols and risks. #FOAMed #FOAMcc #WuhanCoronavirus #CoronavirusWho

Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV). #FOAMcc #FOAMed

A novel coronavirus (nCoV) is a new strain that has not been previously identified in humans.... which is what the virus that is widely reported on the media, and via the WHO and CDC etc are talking about. #FOAMed #FOAMcc

Human CoVs have long been
considered inconsequential pathogens, causing the
“common cold” in otherwise healthy people. However,
in the 21st century, 2 highly pathogenic HCoVs - SARS and MERS - came from animal reservoirs -->
global epidemics with alarming morbidity and mortality

Coronaviruses are large, enveloped, positive-strand RNA viruses that can be divided into 4 genera:
alpha, beta, delta, and gamma, of which alpha and
beta CoVs are known to infect humans.. We believe the current virus is a BETA virus. #FOAMed #FOAMcc

These viruses are ZOONOTIC - which means they pass from animals to people. Interestingly, the WHO report that SARS-CoV was transmitted from cats to humans and MERS-CoV from camels to humans. #FOAMed #FOAMcc

A great, Biophysics article about how viruses actually invade cells --> ncbi.nlm.nih.gov/pmc/articles/P… #FOAMed #FOAMcc

@WHO have published information on a NEW 2019-Coronavirus from #WuhanCoronavirus in China. It's called 2019-nCoV because it was reported on 31st December 2019, in Wuhan China and is a Novel Coronavirus as mentioned above. who.int/emergencies/di…

The @WHO have also done a brilliant online course (cursory - for beginners) for those wishing to learn more about the novel respiratory viruses: openwho.org/courses/introd… #FOAMed #FOAMcc

Before going further - it's worth signposting the great CDC collection of articles on the 2019-nCoV --> cdc.gov/coronavirus/20… #FOAMed #FOAMcc

The clinical features of Coronavirus - essentially look like what SARS originally looked like... As described here: cdc.gov/coronavirus/20… #FOAMed #FOAMcc #WuhanCoronavirus

If working in clinical areas - beware of what the evidence shows about DECONTAMINATING AREAS.. it's a rather persistent virus #FOAMed #FOAMcc #WuhanCoronavirus ncbi.nlm.nih.gov/pubmed/32035997

Going back to SARS-CoV... Classic public health measures brought the SARS pandemic to an end, but not before 8098 individuals were infected and 774 died. It cost the global economy an estimated $30 billion to $100 billion... link.springer.com/chapter/10.100… and nature.com/articles/nrmic…

A number of very interesting observations occurred with SARS... nature.com/articles/nrmic… #FOAMed #FOAMcc

Comorbidities = important in SARS and MERS. A few RF --> progression to ARDS, especially advanced age and male sex. For MERS, additional RFs of severe disease= chronic conditions such as diabetes mellitus, hypertension, cancer, renal and lung disease, and co-infections. #FOAMed

Pts do not shed large amounts of virus until well after the onset of symptoms, when patients are most probably already seeking medical care. Analysis of hospital surfaces after the treatment of patients with MERS showed the ubiquitous presence of infectious virus. #FOAMed #FOAMcc

Although several treatments for SARS and MERS (based on inhibition of viral replication with drugs or neutralizing antibodies, or on dampening the host response) have been identified in animal models and in vitro studies... not yet good data from human studies #FOAMed

This trial from 2003 = The first 54 patients admitted with SARS to an intensive care unit (ICU). All were treated with corticosteroids, ribavirin, broad spectrum antimicrobials and supportive therapy.... aic.cuhk.edu.hk/web8/SARS%20ou… #FOAMed #FOAMcc

They estimated that 20% of their cases needed intubation via respiratory failure. Mortality amongst critically ill patients with SARS = high. It causes predominantly severe respiratory failure, with little other organ failure + barotrauma amongst those requiring mechanical vent

Interestingly - we can learn from those who put surviving patients on a post-SARS (/ARDS) recovery pathway, back in 2004.. thorax.bmj.com/content/60/5/3… #FOAMed #FOAMcc #wuhancoronovırus

We know that during ICU (for SARS) we can see that: "Persistent and increasing elevations of CK, lactate dehydrogenase and transaminases levels are common" (2004) Lymphocytopaenia, neutrophilia and thrombocytopenia are frequently seen too #FOAMed #FOAMcc ncbi.nlm.nih.gov/pmc/articles/P…

For this novel CoV outbreak - the CDC continue to call for open data sharing on all matters that involve a potential global pandemic... cdc.gov/coronavirus/20… #FOAMed #FOAMcc

We can look back at 2015 to see what the CDC recommended at the time for Infection Prevention and Control for MERS: cdc.gov/coronavirus/me… #FOAMed #FOAMcc

And today - there are concerns over the shortage of PPE for healthcare workers... aha.org/news/headline/… and cidrap.umn.edu/news-perspecti…

The @DHSCgovuk have a great twitter feed for up to date information on 2019-nCoV:

https://twitter.com/DHSCgovuk/status/1227239412683005952?s=20

Back to 2019-nCoV for Intensive Care... there are reports of infection spreading outside China, to countries including Hong Kong, Macau, Taiwan, Australia, France, Malaysia, Nepal, Singapore, Thailand, South Korea, Vietnam, UK and USA.... and more #FOAMed #FOAMcc

@FICMNews has released more info here: ficm.ac.uk/safety-and-cli… #FOAMed #FOAMcc

What are we looking out for?
1. Fever, cough and shortness of breath
2. Symptoms may appear between 2-14 days after exposure.
#FOAMed #FOAMcc

All staff need to be fit tested for FFP3 masks or other suitable PPE (EN149 conforming) #FOAMed #FOAMcc

We can look at their efficacy from research etc compiled by the HSE back in 2008: hse.gov.uk/research/rrpdf…

2019 heralded a new report = Those who have stubble may have problems! hse.gov.uk/research/rrhtm…

Recent case report of 138 pts hospitalised --> 36 (26.1%) were transferred to ICU. Of the 36 cases in the ICU, 4 (11.1%) received HFNO, 15 (41.7%) received NIV, and 17 (47.2%) received ETT and 4 were switched to #ECMO. #FOAMed ja.ma/2SoLbbu

Perhaps we can look at MERS-CoV, back in 2017 to see how we could predict mortality in ICU? #FOAmed #FOAMcc bmcinfectdis.biomedcentral.com/articles/10.11…

Should we be preparing for #ECMO in ICU for our 2019-nCoV Patients? Or other forms of extracorporeal support too? #FOAMed #FOAMcc #WuhanCoronavirus thelancet.com/journals/lanre… @jlvincen @FOAMecmo

@jlvincen @FOAMecmo We can see how the @DHSCgovuk and @PHE_uk advises us to prepare for 2019-nCoV: gov.uk/government/pub… involving infection prevention and control measures #FOAMed #FOAMcc

We have a High Consequence Infectious Diseases unit of the government in the UK: gov.uk/guidance/high-… #FOAMed #FOAMcc

Together with HCID above, the @ICS_updates have given guidance to UK ICU's to help prepare for any patients with Coronavirus. Aside from the HCID FAQ's, they have added:

1. PPE
2. Buddy system
3. Identify the people you need in an emergency

#FOAMed #FOAMcc

Can also see @PHE_uk secondary care flowchart here: cas.mhra.gov.uk/ViewandAcknowl… #FOAMed #FOAMcc

But now let's explore the @ICS_updates advice for UK ICUs... #FOAMed #FOAMcc - there are FIVE HCID Airborne Centres in the UK...

Do you know where you might place your patient in ICU? #FOAMed #FOAMcc Or, indeed - how to transfer them?

Specific Treatment Considerations WRT NIV/HFNC and Steroids... #FOAMed #FOAMcc @ICS_updates

ECMO? --> Call relevant regional ECMO centre and involve the HCID Unit for retrieval. #FOAMed #FOAMcc

After much consideration - @WHO have found a better name for the 2019-nCoV virus! --> COVID19

https://twitter.com/WHO/status/1227248333871173632?s=20

#COVID19

More lessons from 2015 about how ICU can prepare... This was is in respect to MERS-CoV but principles likely to be similar healthmanagement.org/c/icu/issueart… #COVID19 #FOAMed #FOAMcc

Let's look at specific WHO (interim) guidance for ICU specific management #COVID19 #foamed #foamcc who.int/docs/default-s…

Early recognition #COVID19 #foamed #FOAMcc

Clinical syndromes associated with #COVID19 #FOAMed #FOAMcc

Control spread of infection #COVID19 #foamed #FOAMcc

Early supportative therapy and monitoring #coronavirusuk #COVID19 #foamed #FOAMcc

Specimens for lab testing #COVID19 #foamed #FOAMcc

ARDS specific advice. #COVID19 #foamed #FOAMcc

Septic shock specific guidance #COVID19 #FOAMed #FOAMcc

Prevention of complications and special considerations with #coronavirusuk #COVID19 #FOAMed #FOAMcc