Cath Lab Protocols for COVID-19

Indiana-ACC Virtual Forum: Cath Lab Protocols for COVID-19 James B. Hermiller, MD, FACC Ascension Medical Group The Heart Center of Indiana Indianapolis, IN Mladen I. Vidovich, MD, FACC University of Illinois Jesse Brown VA Medical Center Chicago, IL A.J. Voelkel, MD, MBA, FACC Ascension Medical Group Evansville, IN

Discussion Topics Evaluation of the ACS patient in the COVID-19 era Assessment - Bedside echo? CTA? DTB time changed ER sends directly to cath lab/no EMS SCAI algorithm Use of thrombolytics SCAI and ACC statements issued Where have all the STEMIs gone?

Precautions for cath lab staff Airflow considerations: Positive flow rooms (negative flow is difficult and tent outside of the door) Full PPE Cleaning room between cases Where to don & doff Potential change in strategies with rapid bedside testing (predictive value/specificity) Take outside transfers?

https://doi: 10.1002/ccd.28887

https://doi.org/10.1016/j.jci n.2020.04.001

https://doi.org/10.1016/ j.jacc.2020.03.021

9th

15th

Chapman et al. Troponin in the Fight Against COVID-19.

Circulation (In Press April 6, 2020) - https://www. ahajournals.org/ doi/pdf/10.1161/CIRCULATION AHA.120.047008

American College of Cardiology: Troponin and BNP Use in COVID-19. Available online at https://www.acc.org/latest-incardiology/articles/2020/03/18/15/25/troponin- and-bnp-use-in-covid19. Last accessed April 6th 2020.

• Echo?

• Coronary CTA? • Rapid Testing?

NSTEMI • Up to 7% of COVID-19 patients will have evidence of myocardial necrosis • In Italy, many patients presented with chest pain, mildly elevated troponin or arrhythmias. Large numbers of patients sent to cath lab without proper isolation protocols and screening.

• The highest incidence of infected physicians were cardiologists.

• In stable, suspected COVID-19 patients, defer cath until further testing and preparation for infection control • In non-COVID patients, encourage early, same day discharge following PCI to free up res

• Portable CXR? • Bedside Echo?

• Rapid Testing?

STEMI •Careful screening and • NO direct EMS to cath lab transfers • Usual care for non-COVID-19 patients.

•Known COVID-19: • Weigh risks/benefits. No direct data comparing PCI and thrombolytics in this population. Although PCI likely superior to thrombolysis, and thus should be considered primary therapy, ACC/SCAI state “fibrinolysis can be considered an option for the relatively stable STEMI patient with active COVID-19”

Precautions for Cath Lab Staff • Screen all ACS patients including transfers for COVID-19 • Maximal personal protective equipment (PPE).

• gown, gloves, goggles (or shields), and a N95 mask,

• Intubation, suction, and active CPR likely result in aerosolization of respiratory secretions increasing likelihood of exposure to personnel.

• Performing endotracheal intubation in the CCL should be avoided to the extent as possible.

• Early intubation (prior to transfer to the CCL) should be considered in order to minimize aerosolization.

• If intubation is required in the CCL, all personnel not essential to the act of intubation should exit the room

• If CPR is required in the CCL, consider using automated CPR devices

Precautions for Cath Lab Staff • A single procedure room should be designated for the care of COVID-19 • Switch to negative pressure if possible • Limited amount of dedicated supplies • Terminal cleaning

• Reduce the number of personnel who enter or exit the procedure room during each case • Vendors, visitors, observers, research coordinators, and any non-essential personnel should be restricted from the CCL

Donning and Doffing • https://youtu.be/C83AHSjcrvw

Donning and Doffing

Donning: 1. Tall disposable shoe covers 2. Covid-19 designated lead apron.

3. Leaded glasses or prescription glasses 4. First head cover (cover ears) 5. N95 Mask 6. Second head cover (cover ears) 7. PPE Mask – N95, etc 8. Eye protection: Goggles or face shield 9. Hand Hygiene: Surgical scrub 10. Non-sterile gown (Don’t tie back?)

11. Sterile gloves 1 12. Sterile gown 13. Sterile gloves 2

Doffing: 1. Hand Hygiene (HH1) 2. Remove surgical gown by breaking neck/back straps and dispose sterile gloves. (Don’t tie to begin with?)

3. HH2 with alcohol foam in room 4. Remove eye protection 5. Remove surgical mask 6. Remove second head cover in room 7. Remove PPE gown and gloves 8. HH3 with alcohol foam in room 9. Remove shoe covers at doorway in room and step out of room 10. HH4 with alcohol-based disinfectant (i.e.: Sterillium) 11. Remove N95 mask 12. Remove first head cover 13. HH5 with surgical scrub 1 14. Remove Covid-19 lead 15. Change to clean scrubs

61-yo with SOB, CP and…

Initial ED ECG… MARCH-28-2020

EMERGENT DIAGNOSTIC ANGIOGRAM

Narrow-complex tachycardia

3 days later…

MARCH-31-2020