Sandbox:huda

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in red signify that an urgent management is needed.

Abbreviations: CAD: coronary artery disease; DVT: deep venous thrombosis; ECG: electrocardiogram; ICU: intensive care unit; JVD: jugular venous distension; LBBB: left bundle branch block; NSTEMI: non-ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction; TEE: transesophageal echocardiography

❑ Order ECG ❑ Order serial cardiac biomarkers (troponins) and CK MB ❑ Perform a bedside echocardiography (if available)

Does the patient fulfill the criteria of myocardial infarction? ❑ Rise and/or fall of cardiac biomarker, preferably troponin, with at least one of the measurements >99th percentile of the upper limit of normal PLUS at least one of the following ❑ Symptoms of ischemia ❑ New ST-T wave changes ST-T wave changes in STEMI: ❑ ST elevation in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads, OR ❑ ST depression in at least two precordial leads V1-V4 (suggestive of posterior MI), OR ❑ ST depression in several leads plus ST elevation in lead aVR (suggestive of occlusion of the left main or proximal LAD artery) ST-T wave changes in NSTEMI: ❑ No changes ❑ Non specific ST- T wave changes ❑ T wave inversion ❑ ST depression in at least 2 contiguous leads ❑ New LBBB ❑ New Q wave ❑ New regional wall abnormality or new myocardial loss

Yes

No

Click here for STEMI resident survival guide Click here for NSTEMI resident survival guide

Rule out the following life-threatening conditions

Aortic dissection

Pulmonary embolism

Tension pneumothorax

Esophageal rupture

Look for supportive symptoms and signs: ❑ Sudden onset of chest pain radiating to the back or interscapular pain ❑ Acute heart failure ❑ Syncope ❑ Low pitched early diastolic murmur best heard at the 2nd right intercostal space ❑ Asymmetric blood pressure in the upper extremities ❑ Coma ❑ Diminution or absence of pulse ❑ Altered mental status ❑ Evidence of ischemia ❑ Splanchnic ischemia ❑ Renal insufficiency ❑ Lower extremity ischemia ❑ Focal neurologic deficits

Look for supportive symptoms and signs: ❑ Pleuritic chest pain ❑ Dyspnea ❑ Anxiety ❑ History of: ❑ DVT ❑ Recent surgery ❑ Malignancy ❑ Immobility

Look for supportive symptoms and signs: ❑ Sudden onset of shortness of breath ❑ Cyanosis ❑ Penetrating chest wound ❑ Flopping sound ❑ Recent medical procedure ❑ Patient on mechanical ventilation ❑ Tracheal deviation towards the unaffected side ❑ Absent heart sound on the affected side ❑ Hyperresonance on the affected side

Look for supportive symptoms and signs: ❑ Vomiting ❑ Lower chest pain ❑ Hematemesis ❑ Cervical subcutaneous emphysema ❑ Overindulgence in alcohol ❑ Overindulgence in food

Click here for the detailed management

Click here for the detailed management

Click here for the detailed management

Click here for the detailed management

Acidosis

Historical perspective

PH = 7.3-7.5

COVID-19 and DM

Diagnosis

• The gold standard test for the diagnosis of DM in covid-19 microbiologic analysis

The diagnosis of COVID-19 cannot be made without microbiologic analysis.

COVID-19 Microchapter outline

Pulmonary Complications

Pulmonary complications

COVID-19 approach to hypoxia/hypoxemia

ARDS

Pulmonary embolism

Bacterial pneumonia/super-infection

Co-infection (e.g. flue)

Pulmonary hypertension

Microchapter Template

Microchapter Template

Microchapter Template

Microchapter Template

Microchapter Template

Sumanth Khadke, MD[1]

Rana Aljebzi, MD[2]

Nuha Al-Howthi, MD[3]

Eman Alademi, MD[4]

Tayyaba Ali, M.D.[5]

Asia Alriashi, MD[6]

Medication

Hydroxychloroquine

215 studies worldwide 55 studies in the USA Placebo: Vitamin D, Pacebo: Calcium citrate, Vit C, Mannitol, glucose tablets, Folic Acid, Ascorbic Acid Combination/comparison: Drug: Vitamin D, Zinc sulfate, Azythromycin, Doxycycline,Indomethacin, Zithromax Oral Product, Ivermectin, Camostat Mesilate, Bromhexine, Nitazoxanide, Lopinavir/ritonavir, Sirolimus, Telmisartan, Active Comparator (Ciclesonide inhalor), Favipiravir, diltiazem and niclosamide, Clevudine, Lopinavir/ritonavir, Favipiravir, Interferon-β 1a, Bromhexine, Baricitinib, Nitazoxanide,

Purpose of study:

Primary prevention Post-exposure prophylaxis Treatment Clinical improvement Viral load clearance from Nasopharyngeal sample

Design/Strategy:

Phase 2 vs 3 vs 4 2 arm study vs 4 arm study Dose-based (200 vs 400 vs 600 mg) Frequenc-based ( Once vs twice vs trice per day) Duration-based (5 vs 10 vs 14 ... days)

Hydroxychloroquine

Country	Intervention	Objective	Design&Date	Strategy	Outcome
Renmin Hospital of Wuhan University, China	Hydroxychloroquine (HCQ) (Preprint article)	Treatment efficacy evaluation	February 4 to February 28, 2020 62 patients with confirmed COVID-19 diagnosis Participants were randomized in a parallel-group trial Males: 46.8%; Female: 53.2%; Mean age: 44.7 years. age and sex were adjusted between the control group and the HCQ group 31 patients treatment group	A 5-day HCQ (400 mg/d) treatment The HCQ effect was evaluated at baseline and 5 days after treatment by assessing the following: Time to clinical recovery (TTCR), clinical characteristics, and radiological results	TTCR, the body temperature recovery time and the cough remission time were significantly shortened in the HCQ treatment group (80.6%, 25 of 31of patients with improved pneumonia in the HCQ treatment group compared with the control group (54.8%, 17 of 31) 4 patients progressed to severe illness that occurred in the control group 2 patients with mild adverse reactions in the HCQ treatment group Conclusion: The use of HCQ could significantly shorten TTCR and promote the absorption of pneumonia in patients with COVID-19
Méditerranée Infection University Hospital Institute in Marseille, France	Hydroxychloroquine and azithromycin	Treatment efficacy evaluation	Early March to March 16th 36 out of 42 patients meeting the inclusion criteria 6 lost to follow up 20 hydroxychloroquine-treated patients 16 control patients Patients were included in a single-arm protocol Inclusion criteria: Age >12 years PCR documented SARS-CoV-2 carriage in nasopharyngeal sample at admission regardless of the clinical status Control was untreated patients from another center and cases refusing the protocol Endpoint: presence and absence of virus at Day6-post inclusion	600mg of HCQ daily 200 mg, three times per day for ten days Viral load in nasopharyngeal swabs was tested daily in a hospital setting Azithromycin: Added depending on the clinical presentation 500mg on day1 followed by 250mg per day, the next four days To prevent bacterial super-infection under daily electrocardiogram control	There was a statistically significant difference between treated patients and controls at days 3-4-5 and 6 (negative PCR) At day 6, 70% of HCQ-treated patients were virologically cured comparing with 12.5% in the control group (p= 0.001) HCQ vs HCQ-Azithromycin combination There was a statistically significant difference between treated patients and controls at days 3-4-5 and 6 (negative PCR) At day 6, 100% of patients treated with HCQ and azithromycin combination were virologically cured comparing with 57.1% in patients treated with HCQ only, and 12.5% in the control group (p < 0.001) Conclusion: HCQ is significantly associated with viral load reduction/disappearance in COVID-19 patients and its effect is reinforced by azithromycin
Marqués de Valdecilla University Hospital, Cantabria, Spain	HDQ	Chemoprophylaxis	Start scheduled for the second week of May 2020 Prospective, single center, double blind, randomised, controlled trial (RCT) 450 Adult health-care professionals (18-65 years) Working in areas of high exposure and high risk of transmission of SARS-COV-2	Oral Hydroxychloroquine 200mg, once-daily, for two months (HC group) or placebo (P group) Intervention: (n = 225): One 200 mg hydroxychloroquine sulfate coated tablet once daily for two months. Comparator (control group) (n = 225): One hydroxychloroquine placebo tablet (identical to that of the drug) once daily for two months In addition to the protective measures appropriate to the level of exposure established by the hospital. A serological evaluation every 15 days with PCR in case of seroconversion, symptoms or risk exposure.
Eight hospitals in Spain	Melatonin	Prophylaxis	Recruitement (May 21-31) 450 participants 225 in the experimental arm 225 in the placebo arm.	Experimental: Melatonin (Circadin®, 2 mg of melatonin orally before bedtime for 12 weeks. Comparator: Identical looking placebo, orally before bedtime for 12 weeks.