SARS Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved. SARS Update: Focus on Airway Management Robert C. Jones, M.D. LtCol, USAF, Medical

SARSSARSCopyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved.

SARS Update: SARS Update: Focus on Airway ManagementFocus on Airway Management

Robert C. Jones, M.D.Robert C. Jones, M.D.

LtCol, USAF, Medical CorpsLtCol, USAF, Medical Corps

Staff Anesthesiologist Staff Anesthesiologist

Andrews Air Force Base, MarylandAndrews Air Force Base, Maryland

E-mail: [email protected]: [email protected]

Web site: http://www.notbob.comWeb site: http://www.notbob.com


Overview

A Brief History of the 2003 SARS epidemic The SARS Virus Diagnosis Treatment Lessons Learned from China/Canada Airway Management Guidelines Discussion Issues


Brief History of SARS

? Zoonotic spread from unknown animal reservoir



? Zoonotic spread from unknown animal reservoir Nov 02: Index case in Guangdong Province, PRC; most

early cases among food handlers (civets, raccoons…)




early cases among food handlers (civets, raccoons…) Feb 03: Hotel Metropole, HK, PRC Physician from

Guangzhou (Superspreader) massive outbreak

Hotel Metropole, Hotel Metropole, Kowloon, HK, PRCKowloon, HK, PRC





Guangzhou (Superspreader) massive outbreak Mar 03: Amoy Gardens outbreak high prevalence of

diarrheal disease due to poor sanitation design






diarrheal disease due to poor sanitation design Mar 03: SARS spreads to Beijing, Taiwan, Toronto, U.S.






diarrheal disease due to poor sanitation design Mar 03: SARS spreads to Beijing, Taiwan, Toronto, U.S. Apr 03: Virus identified, sequenced in record time



? Zoonotic spread from unknown animal reservoir Nov 02: Index case in Guangdong Province, PRC; most early

cases among food handlers (civets, raccoons…) Feb 03: Hotel Metropole, HK, PRC Physician from Guangzhou

(Superspreader) massive outbreak Mar 03: Amoy Gardens outbreak high prevalence of diarrheal

disease due to poor sanitation design Mar 03: SARS spreads to Beijing, Taiwan, Toronto, U.S. Apr 03: Virus identified, sequenced in record time July 03: Epidemic declared over by WHO


Timeline

774 Known 774 Known Dead (9.1% Dead (9.1% fatality rate)fatality rate)


The SARS Coronavirus (SARS-CoV)

Coronaviridae first identified in 1937 in chickens (avian infectious bronchitis) Crown-shaped peplomers surrounding RNA source of name (Corona = Crown in Latin) Responsible for common cold (2nd most common etiology after rhinoviridae) Exact number unknown: many don’t grow in cultures SARS virus can be grown in Vero culture (primate fibroblast cell line from 1962)


Diagnosis: CDC

Clinical Criteria Asymptomatic or mild respiratory illness Moderate respiratory illness

Temperature of >100.4°F (>38°C)*, and One or more clinical findings of respiratory illness (e.g., cough, shortness

of breath, difficulty breathing, or hypoxia). Severe respiratory illness

Temperature of >100.4°F (>38°C)*, and One or more clinical findings of respiratory illness (e.g., cough, shortness

of breath, difficulty breathing, or hypoxia), and – radiographic evidence of pneumonia, or – respiratory distress syndrome, or – autopsy findings consistent with pneumonia or respiratory distress syndrome

without an identifiable cause


Diagnosis: CDC

AreaFirst date of illness onset for inclusion as reported case‡

Last date of illness onset for inclusion as reported case†

China (Mainland) November 1, 2002 July 13, 2003

Hong Kong February 1, 2003 July 11, 2003

Hanoi, Vietnam February 1, 2003 May 25, 2003

Singapore February 1, 2003 June 14, 2003

Toronto, Canada April 1, 2003 July 18, 2003

Taiwan May 1, 2003 July 25, 2003

Beijing, China November 1, 2002 July 21, 2003

Table. Travel criteria for suspect or probable U.S. cases of SARS

Epidemiologic CriteriaTravel (including transit in an airport) within 10 days of onset of symptoms to an area with current or previously documented or suspected community transmission of SARS (see Table below),

or Close contact within 10 days (one incubation period) of onset of symptoms with a person known or suspected to have SARS.


Diagnosis: CDC

Laboratory CriteriaConfirmed

Detection of antibody to SARS-associated coronavirus (SARS-CoV) in a serum sample, or Detection of SARS-CoV RNA by RT-PCR confirmed by a second PCR assay, by using a second aliquot of the specimen and a different set of PCR primers, or Isolation of SARS-CoV.

Negative Absence of antibody to SARS-CoV in a convalescent–phase serum sample obtained >28 days after symptom onset.**

Undetermined Laboratory testing either not performed or incomplete.

Case Classification***Probable case: meets the clinical criteria for severe respiratory illness of unknown etiology and epidemiologic criteria for exposure; laboratory criteria confirmed or undetermined.

Suspect case: meets the clinical criteria for moderate respiratory illness of unknown etiology, and epidemiologic criteria for exposure; laboratory criteria confirmed or undetermined.


Diagnosis: WHO

Suspect case Suspect case 1. A person presenting after 1 November 2002 with history of: 1. A person presenting after 1 November 2002 with history of: - high fever (>38 °C) - high fever (>38 °C) AND AND - cough or breathing difficulty - cough or breathing difficulty AND one or more of the following exposures during the 10 days prior to onset of symptoms: AND one or more of the following exposures during the 10 days prior to onset of symptoms: - close contact with a person who is a suspect or probable case of SARS; - close contact with a person who is a suspect or probable case of SARS; - history of travel, to an area with recent local transmission of SARS - history of travel, to an area with recent local transmission of SARS - residing in an area with recent local transmission of SARS - residing in an area with recent local transmission of SARS 2. A person with an unexplained acute respiratory illness resulting in death after 1 2. A person with an unexplained acute respiratory illness resulting in death after 1 November 2002, but on whom no autopsy has been performed November 2002, but on whom no autopsy has been performed AND one or more of the following exposures during to 10 days prior to onset of symptoms: AND one or more of the following exposures during to 10 days prior to onset of symptoms: - close contact with a person who is a suspect or probable case of SARS; - close contact with a person who is a suspect or probable case of SARS; - history of travel to an area with recent local transmission of SARS - history of travel to an area with recent local transmission of SARS - residing in an area with recent local transmission of SARS - residing in an area with recent local transmission of SARS


Diagnosis: WHO

Probable case Probable case 1. A suspect case with radiographic evidence of infiltrates consistent 1. A suspect case with radiographic evidence of infiltrates consistent with pneumonia or respiratory distress syndrome (RDS) on chest X-with pneumonia or respiratory distress syndrome (RDS) on chest X-ray (CXR). ray (CXR). 2. A suspect case of SARS that is positive for SARS coronavirus by 2. A suspect case of SARS that is positive for SARS coronavirus by one or more assays. one or more assays. 3. A suspect case with autopsy findings consistent with the 3. A suspect case with autopsy findings consistent with the pathology of RDS without an identifiable cause.pathology of RDS without an identifiable cause.

Exclusion criteria Exclusion criteria A case should be excluded if an alternative diagnosis can fully A case should be excluded if an alternative diagnosis can fully explain (his or her) illness. explain (his or her) illness.


Clinical Manifestations

Incubation period: 2-10 days Prodrome: 1-2 days

myalgia, fever, malaiseFever > 38°C Less commonly diarrhea

Respiratory Phase: 3-7 days after onset; lasts to day 11-14Cough, SOB, hypoxiaSeverity variesFalling SpO2 (<94%) ICU; SpO2 < 92% likely intubation

Entire illness lasts 3 weeks if you don’t die; ? long term effectsSource: Loutfy, M, SARS: The Frontline Experience; Powerpoint presentation, 20 Oct 03Source: Loutfy, M, SARS: The Frontline Experience; Powerpoint presentation, 20 Oct 03


Clinical Manifestations (cont’d)

Extreme anxiety out of proportion to hypoxia Hyperglycemia Thrombocytopenia Leukopenia Lymphopenia Increased LDH, CK, ALT, lipase Increased severity in elderly (up to 50%

mortality > age 65); rare, less severe in children


Radiologic findings

CXR: focal or multifocal CXR: focal or multifocal airspace disease/consolidation airspace disease/consolidation bilateral ground glass bilateral ground glass opacities consistent with opacities consistent with ARDS/SIRS; may be NORMALARDS/SIRS; may be NORMAL

High Contrast CT: can High Contrast CT: can determine disease in patients determine disease in patients with “normal” CXR; with “normal” CXR; parenchymal and airspace parenchymal and airspace disease evidentdisease evident


Treatment

As of Nov 03, no specific treatment supportive Antibiotics: azithromycin, ceftriaxone not useful

against virus, may help if bacterial superinfection High-dose steroids in China avascular necrosis,

other side effects Ribavirin used not recommended (hemolytic

anemia) Experimental: TNF-alpha, protease inhibitors…


Lessons Learned from China and Canada

Misinformation language issues, WHO travel warning in Toronto

Lack of Communication between countries, governments, hospitals public health authorities

Lack of Personnel underfunded health care system; unions and contracts; overtime issues

Assumptions Public health authorities assumed hospitals had adequate infection control

Transfers ED ward long term care ED other hospitals (lots of opportunities for infection)

Post-Traumatic Stress Health-care workers, civilians; stigmatization of subsets of populace (e.g., Chinese)

Quarantine Legal issues: Canada had no legal definition of quarantine pre-SARS; difficulties enforcing home

quarantine (e-mail, phone, videophone to read thermometer); people will cheat and go to work if not given paid leave

No wakes, ritual washing of body caused stress

Meta-Issues: Meta-Issues:


Lessons Learned from China and Canada

Wash your hands! Alcohol denatures proteins– good vs. enveloped viruses Single entry point for staff separate from patients Guard with personal protective equipment (PPE) to prevent unauthorized entry Non-critical hospital staff (med students) stay home Strict no visitor policy (difficult to enforce with hospital personnel patients) N95 mask + gown + no beards among ED staff for all patients during outbreak Change PPE after every high-risk encounter (respiratory dz vs. ankle fracture) Care with pens/cell phones/computers/pagers No hallway stretchers No humidified oxygen or nebs or BiPAP in ED send to ICU Limit staff contacts to minimum required for care (hard with sick colleagues)

Hospital Infection Control:Hospital Infection Control:


Airway Management

High risk of transmission of SARS virus during airway manipulation/intubation

5/50 intubations in Toronto SARS transmitted 20 healthcare workers infected

Conflicts among staff to avoid being the laryngoscopist for high-risk patients

Intubation rarely emergency in SARS gradual decompensation over 12 hours should NOT be stat procedure (takes 5 minutes minimum to don appropriate protective equipment)

10-20% of patients will need to be intubated


High Risk Procedures

laryngoscopy intubation airway suctioning neb treatment (use MDIs instead) bronchoscopy (including fiberoptic intubation) bagging via mask emesis care anything that causes patient to cough


Intubation Guidelines

Plan ahead! Will take at least 5 minutes to… Apply N95 mask, goggles, disposable footwear,

gown, gloves, belt-mounted PAPR (powered air purifying respirator), head cover, extra gown, extra gloves; if no PAPR N95 mask, googles, disposable surgical cap, disposable full-face shield

Most experienced intubationist (not resident)

Reference: Anaesthesia and SARS, British Journal of Anaesthesia 90: 6, June 2003, 715-718Reference: Anaesthesia and SARS, British Journal of Anaesthesia 90: 6, June 2003, 715-718


Intubation Guidelines (cont’d)

Avoid awake fiberoptic intubation; consider surgical airway Plan for rapid sequence induction with skilled assistant available

for cricoid pressure; be generous with sux unless contraindicated Minimal bagging pre-intubation: 5 mins preox with 100% FiO2 High-efficiency filter between facemask and bag Intubate and confirm correct placement Airway equipment sealed in double zip-locked bag and removed

for decon Careful degowning/gloving with help of assistant Wash hands with alcohol-based cleanser prior to touching hair

or faceReference: Anaesthesia and SARS, British Journal of Anaesthesia 90: 6, June 2003, 715-718Reference: Anaesthesia and SARS, British Journal of Anaesthesia 90: 6, June 2003, 715-718


Discussion Issues

Everyone should read intranet resource: HCW Surveillance Protocol for SARS– MGMC (links to CDC sources)

PAPR availability at MGMC: Ortho space suits are kept where? Available to ED? Do we need to buy more for ICU, ED?

Infectious Disease consultants: WRAMC. Phone #s in ICU, ED? ICU beds rate limiting step– 22 beds in Toronto’s North York

hospital maxed out…Transfer MOU with other hospitals? Ambulance personnel trained/equipped (N95 masks, ?PAPR)? Quarantine issues: If hospital quarantined, policies for paying

contractors, etc.? Sleeping arrangements, food, water? Training: Should we try a SARS drill starting from ED ICU

OR to see how we do? Probably as important as mock code blue


Conclusions

“The only thing we have to fear is LACK of fear itself”

--former Deputy Treasury Secretary Lawrence Summers• SARS will recur– and may recur foreverSARS will recur– and may recur forever

• SARS is a disease of healthcare workers out of proportion to the communitySARS is a disease of healthcare workers out of proportion to the community

• Until there is an effective treatment or vaccine, SARS will remain a life-Until there is an effective treatment or vaccine, SARS will remain a life-threatening diagnosisthreatening diagnosis

• The intangible costs of SARS (economic, post-traumatic) may rival the obvious The intangible costs of SARS (economic, post-traumatic) may rival the obvious effects (morbidity, mortality); unknown long-term effectseffects (morbidity, mortality); unknown long-term effects

• Protecting healthcare workers from SARS is difficult– takes time, Protecting healthcare workers from SARS is difficult– takes time, money, communication, planning, training, communication…money, communication, planning, training, communication…

Documents

SARS Copyright (C) 2004 Robert C. Jones, M.D. All Rights Reserved. SARS Update: Focus on Airway Management Robert C. Jones, M.D. LtCol, USAF, Medical