Tag Archives: COVID-19

Newsletter Coming Soon: ATLS In The COVID Era

The next Trauma MedEd newsletter is coming soon! It is a continuation of my COVID and Trauma Professionals series.

COVID has turned our usual teaching model on its head. There are now limits on group size and time together, mask requirements, and disinfection requirements, to name a few. All of these serve to make providing an in-person, physical contact course very difficult.

We recently produced our first ATLS course at the Regions Hospital EMS Education offices. There were many hoops to jump through and several changes that were required. But it turned out to be a great success.

In the next Trauma MedEd Newsletter, I will share the details of how we did it. Hopefully this information will help your center successfully continue to produce this valuable and sought-after course.

Existing subscribers will receive automatically later this week.  It will be published on my trauma performance improvement website, TraumaMedEd.com, at the same time. All others will be able to find it on this blog next week. So subscribe now  by clicking this link right away to sign up and/or download back issues.

Tomorrow, back to the Laws of Trauma!

The April 2020 Trauma MedEd Newsletter: More On Coronavirus and Trauma Professionals

The April edition of the Trauma MedEd Newsletter will be released at the end of the week. It will provide even more practical information regarding the Coronavirus pandemic for trauma professionals.

Topics covered will include:

  • The New ACS COVID Site Visit Schedule
  • COVID And Your State Trauma System
  • COVID-19 And Your PI Meeting
  • Protecting Personnel During Intubation
  • COVID-19 And Chest Tube Insertion

Subscribers will receive this issue by Friday.  All others will be able to find it via the blog next week. So subscribe now  by clicking this link right away to sign up and/or download back issues.

And please send me your comments, updates, or tips you have found helpful at your hospital! I’ll include them in the next newsletter.

Can Chest Tube Insertion Result In Exposure To Coronavirus?

Endotracheal intubation is considered an aerosol-producing procedure. In this new age of SARS-CoV-2 and COVID-19, most hospitals are stepping up the level of personal protective equipment (PPE) used when performing this procedure. This has also resulted in modifications in the location where intubation is performed and the choice of drugs used.

But what about needle and chest thoracostomy? These are different than intubation in that the respiratory tract is usually not directly accessed. However, there is the opportunity for exposure to pleural fluid. In the case of needle thoracostomy, it is possible that air under pressure in the chest can force tiny droplets or even an aerosol out and into the air. There is less likelihood of aerosolization during tube thoracostomy, where liquid and droplet exposure can be anticipated.

What do we know about pleural fluid and the novel coronavirus? Basically nothing. And there is very little literature out there regarding other respiratory viruses in pleural fluid either. The only paper I could find (reference below) was published five years ago by a Spanish group. They compared the presence of bacteria and viruses in the pleural fluid of patients with community acquired pneumonia against an uninfected control group. They found only one incidence of virus in the pleural fluid in one patient, a human metapneumovirus. Is this comforting? Probably not.

Trauma patients with chest trauma are likely very different. Those with a hemo- or pneumo-thorax, by definition, had some violation of the surface of the lung. to cause the leak This injury is very likely to breach alveoli which are laden with coronavirus, thus contaminating the pleural fluid. Once that occurs, it is possible that the entire thorax surrounding the lung is contaminated. Note: this is one of those “common sense” assumptions with absolutely no data currently to back it up.

Bottom Line: This is yet another of the many questions about SARS-CoV-2 that we just don’t have an objective answer to. However, since we are already limiting exposure during or forgoing laparoscopic procedures altogether to avoid vaporizing viral particles in smoke, it makes sense to protect ourselves during procedures that involve pleural fluid in trauma patients.

Until we have more data, needle and tube thoracostomy procedures should be considered at least a droplet-prone procedure, if not an aerosol-producing one. This means that trauma professionals should don appropriate personal protective equipment as dictated by their local policies and procedures before performing these procedures.

Reference: Detection of bacteria and viruses in the pleural effusion of children and adults with community-acquired pneumonia. Future Microbiology 10(6):909-916, 2015.

COVID-19 Thinking Cap: How To Protect Personnel During Intubation (Video)

There is a fascinating letter in the New England Journal of Medicine submitted by authors from the Boston Medical Center and Brigham and Women’s Hospital. Like all trauma professionals, they were concerned with droplet contamination produced during the intubation process. Most hospitals have modified their intubation procedures to try to protect personnel as much as possible.

The authors designed a Plexiglas box with two holes for the arms of the intubator that is placed over the patient’s head. This should serve to shield them, and other personnel in the room if the patient unexpectedly coughs during the process. They tested this concept using an intubation mannequin. First, they placed a balloon filled with fluorescent dye in its mouth and slowly inflated until it burst. Here was the result when viewed under ultraviolet light. Sputum everywhere!

Next, they placed the intubation shield over the patient. Here is a drawing of its dimensions.

The device is open on the bottom and on the side away from the intubator. The arm holes are 10cm in diameter.

The authors then repeated the balloon experiment with the shield in place and the intubator’s arms inserted through the holes. The resulting contamination was limited to their hands and forearms, and the inside of the shield.

Bottom line: This is a very interesting yet simple and cheap device that can be built by just about anyone and should protect personnel from droplet contamination. It will not have much effect on aerosols escaping into the room, but that’s what our other PPE are for! It’s a great example of how creativity is key in keeping us all safer during this pandemic.

You can view the video on the NEJM website at:
https://www.nejm.org/doi/full/10.1056/NEJMc2007589

Reference: Barrier Enclosure during Endotracheal Intubation. NEJM DOI: 10.1056/NEJMc2007589, April 4 2020.

The March 2020 Trauma MedEd Newsletter: Coronavirus and Trauma Professionals

Welcome to the current newsletter. I am releasing this to nonsubscribers early due to the relevance of the information it contains.

Topics covered include:

  • Guidance from the American College of Surgeons
  • COVID-19 and the trauma surgeon
  • Coronavirus and your trauma service
  • Coronavirus and the trauma team
  • CT scan safety and the coronavirus
  • Changing trauma rounds for coronavirus safety
  • Coronavirus and your massive transfusion protocol (MTP)

The April issue will be released next month and will be a followup to this one. I’m sure we will learn quite a bit about the virus and our response to it in the ensuing month.

And please send me your comments, updates, or tips you have found helpful at your hospital! I’ll include them in the next newsletter.

To download the current issue, just click here! Or copy this link into your browser: http://bit.ly/TME202003.