How to Ventilate Patients with COVID-19

Severe SARS CoV-2 diagnosis, CT Chest Findings and Management Strategies for the Intensivist

There are multiple educational resources available for prevention and management . The following 2 Webinars and the online article from ESCIM are particularly helpful in severe cases:

Above are data from Wuhan.

>>>>>> More CT findings form the Lancet article can be found here

Below are data mainly from Lombardy 

additional CT resources from Belgium and Wuhan 

EKG challenge

Both EKG's have the same diagnosis !

The Effect of Xenobiotics on the EKG

Slide presentation on the effect of xenobiotics on the 12 lead EKG. Podcast addendum to follow

ST-Elevation on the ECG in a 36 year old man (Presented at ESC Congress 2019)

The patient was a 36-year-old man who was previously healthy. He suddenly manifested squeezing left parasternal chest pain. The pain started seventeen hour before the visit. At that time, his blood pressure was 140/81 mmHg; pulse, 70 beat per minute; respiratory rate, 20 breaths/min and his oxygen saturation was 96% in room air. On electrocardiography (Figure 1), voltage was extremely low in the precordial leads, particularly in V4, V5 and V6 leads, and ST-segment elevations in V1, V2, V3, V4, II, III and aVF leads. A plain chest radiograph demonstrated a large, left-sided pneumothorax, with the collapse of nearly whole left lung area and his heart was deviated to the right side, with more than two thirds of the heart on the right side of the midline.

What test was done after chest tube placement and what were the findings ?

How to calculate actual risk of Torsades des Pointes with QT prolongation

• FACT: Computer generated QT/QTc calculations are unreliable and should not be used.
• Measure QT manually( yes use calipers!)
• There is no common agreement which QT value to use, I prefer to use the longest QT, but other advocate average of all leads( time consuming and QT cannot be measures usually in all leads), or use lead II ( QT can be measures) as this is lined up with mean QRS vector.
•  Calculate QTc according to Fredericia or Hodges formula ( Bazzett's formula over corrects QTC at higher heart rates often present in critically ill patients). 
• Example 
  
• For the above example the measured QT in leads I, II aVF, V2, V4, V6 are 320, 340, 320, 300, 340 and 320 respectively. This gives a median QT of 320ms. Note the computer generated QT is longer at 360ms, correcting with Bazett’s formula to 485 – which would be considered prolonged. However plotting this on the nomogram shows a level which is well below the risk line. Bazett’s QTc over corrects in tachycardia and under corrects for slow heart rates and should not used in toxicology patients to determine overall risk of TdP. 
  
• The QT nomogram has a sensitivity of 97% and specificity of 99% for predicting TdP following toxicological ingestions and has been found to be more accurate in predicting TdP than using Bazett’s QTc of 440ms or 500ms. 

General references:

1. Drug-Induced Prolongation of the QT Interval

2. What Clinicians Should Know About the QT Interval

Go this this website for any question , CredibleMeds,on QTc risk of drugs. Meds are classified in 4 risk categories 

VITAMINS Trial: Vitamin C and Thiamine for Sepsis and Septic Shock

I probably should not make the same mistake as Paul Marik , taking a fanatical view. Usuallly the end result does not turn out in your favor . After reading the paper quickly, there are many problems not in the least the timing of the intervention.
On the other hand, I cannot disagree with his Lacto- Bolus reflex comment and his statement that 30 ml /kg of fluid is a hoax in sepsis .....he actually published this .

Conclusion in my view is there is no conclusion "yet" . I would like to hear other comments. I posted the video of the Vitamins Trial on the blog. Even if your not interested in this trial , with Paul Marik there  it is quite entertaining.