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Excerpt from a post by an ICU doc in the Seattle area:
A common scenario for our patients is, on admission they are put on 1L oxygen by nasal cannula. Next 12hrs, they regress to non-invasive positive pressure ventilation, the blower. Next 12-24hrs, they regress to a ventilator in the prone position with Flolan.
Interestingly, despite some needing Flolan, the hypoxia is not as refractory as with H1N1. Quite different, and quite unique. Odd enough that you’d notice and say hmmm.
Thus far many are dying of cardiac arrest rather than inability to ventilate/oxygenate.
Given the inevitable rapid progression to an endotracheal tube once respiratory decompensation begins, we and other hospitals, including Wuhan, are doing early intubation. Facemask is fine, but if needing a high-flow nasal cannula or non-invasive positive pressure ventilation, just tube them. They definitely will need a tube anyway, & no point risking the aerosols.
Multiple-organ system failure is NOT typically seen. There’s the mild AST/ALT elevation [AST/ALT is an indicator of liver damage or hepatotoxicity], maybe a small Cr bump [Creatinine, indicator of kidney damage], but no florid failure. except cardiomyopathy.
Multiple patients here have had normal cardio Ejection Fraction (EF) on formal Echocardiogram or point-of-care ultrasound (POCUS) at time of admit (or in a couple of cases EF 40ish, chronically [EF 40 or below may be evidence of heart failure or cardiomyopathy, 41-49 is borderline]). Also normal cardiac troponin from EmergencyDepartment[? troponin can be used to diagnose a heart attack, so probably measured on the way in].
Then they get the horrible respiratory failure, without sepsis or shock.
Then they turn the corner, get off Flolan, they are sitting up, weaning off the ventilator, looking good, never any pressor requirement [I think this means no blood pressure drop that would require medication to increase blood pressure].
Then over 12hrs, newly cold, clamped, multiple-pressor shock that looks cardiogenic, EF 10% or less, then either VT [ventricular tachycardia, rapid heartbeat] progressing to VF [ventricular fibrillation, heart quivering or beating erratically] progressing to death
OR, PEA [Pulseless Electrical Activity, got a waveform on ECG–or EKG for you German-loving chemists–but no pulse felt in the body] progressing to asystole [flatline ECG] in less than a day. Needless to say this is awful for families who had started to have hope.
We have actually had more asystole than VT, other facilities report more VT/VF, but same time course, a few days or a week after admit, around the time they’re turning the corner. This occurs on med-surg patients too; one today who is elderly and chronically ill but baseline EF preserved, newly hypoTN overnight, EF<10. Already no escalation, has since passed, So presumably there is a viral CM aspect, which presents later in the course of days.
Of note, no WMAs [left ventricular wall motion abnormalities, commonly seen in coronary artery disease, congestive heart failure, stress-induced cardiomyopathy, etc] on Echo, RV [right ventricular function] is preserved, Tpns [troponins] don't bump. Could be unrelated, but I've never seen anything like it before, esp in a pt who had been HD stable without sepsis.
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