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| | The fantastic information on this page that was not site-specific has been consolidated with other COVID-19 pages on WikEM. SWLA VA Site specific information can be found at: [[WLAVA:COVID19 ED Operational Updates]] |
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| Disclaimer: Aggregation of recommendations from CDC and LA County DPH. Information is not a substitute for clinical judgement & your local infection control expertise.
| | Please join us in editing and updating all non-site-specific COVID information on the following WikEM pages: |
| https://emcrit.org/ibcc/COVID19/#key_principle:_supportive_care_for_viral_pneumonia
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| https://www.emrap.org/corependium/chapter/rec906m1mD6SRH9np/Novel-Coronavirus-2019-COVID-19?MainSearch=%22covid%22&SearchType=%22text%22
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| https://www.cdc.gov/coronavirus/2019-ncov/index.html
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| https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html
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| | | {{COVID see also}} |
| ==Introduction==
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| * The current national and international pandemic is from a virus named SARS-CoV-2 (previously 2019-nCoV), which causes a disease named COVID-19.
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| === Virology Background ===
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| *Coronaviruses are common human pathogens
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| **Cause the common cold
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| **In epidemics, cause up to one-third of community-acquired upper respiratory tract infections in adults; and may cause diarrhea in infants and children
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| *SARS-CoV-2 is a novel coronavirus (a new strain not previously identified in humans)
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| **Likely primary source = bats
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| **It is a betacoronavirus in the same subgenus as the severe acute respiratory syndrome (SARS) virus. Middle East respiratory syndrome (MERS) virus is another, more distantly related, betacoronavirusLike the SARS coronavirus, SARS-CoV-2 uses angiotensin-converting enzyme 2 [ACE2] for cell entry
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| *Surface survival time of SARS-CoV-2:
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| **stainless steel: persists for 3 hours (or longer)
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| **underscores the importance of environmental cleaning / disinfection
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| ***cleaning gets rid of the proteins that would interfere with a disinfectants effectiveness
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| **Note: studied in a simulated lab environment. Lab virions not covered in protein and mucus and other things that would mimic real life and that could prolong survival
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| === Covid19 Basic Epidemiology / Infectivity Data ===
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| * Expected patient outcomes (from data so far):
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| ** 80% have mild symptoms
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| ** 15% have severe disease requiring hospitalisation
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| ** 5% require mechanical ventilation
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| * Case fatality rate (CFR) = 2-4% (from Hubei data)
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| ** SARS ~ 10%
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| ** MERS ~ 35%
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| ** Seasonal flu ~ 0.1-0.2%
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| ** 1918 Pandemic Influenza ~ 2-3%
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| * R0 = 2.2 - 4.2
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| ** Where R0 = expected number of secondary cases produced by a single typical infection in a susceptible population (basic reproductive rate)
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| ** R0 for seasonal flu ~ 1.3
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| ** R0 for pandemic flu ~ 1.5-1.8
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| * Incubation: 5 days (median); range of 2-14 days
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| * Serial interval duration = 7.5 days
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| ** Serial interval refers to the time from illness onset in successive cases in a transmission chain
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| [[File:Ro example.png|thumb|center|Ro Example]]
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| === GENERAL PREVENTION RECOMMENDATIONS ===
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| *Exercise general infection precautions
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| **Person-to-person transmission occurs with close contact (6 feet)
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| ***Direct contact with mucous membranes or respiratory droplets
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| ***Indirect: cough —> secretions left on surface —> 2nd person touches surface secretions and touches face & mucous membranes
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| **Avoid touching your face (try it, it’s not easy)
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| **Frequent Handwashing
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| ***Alcohol based hand sanitizer
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| ***Diligent hand washing
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| ****20 seconds minimum
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| ****Correct technique video (between 2:15 and 2:45 minute mark): https://www.youtube.com/watch?time_continue=169&v=C47vExSujVs&feature=emb_logo
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| *****“How to Hand Rub” link of pdf (from WHO)
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| ****Image (right) shows commonly forgotten areas: thumb (ulnar aspect), fingertips, WRIST (Borrowed from WHO Hand Hygiene for Healthcare)
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| **Wear a mask if you develop respiratory symptoms (fever, cough, rhinorrhea, congestion) to prevent spread
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| ***Avoid unnecessary travel
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| ***Stay home if symptomatic
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| **Home means home. Do not go out to parks with other groups of people
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| **Contact your supervisor: due to expected health care worker (HCW) shortages, minor symptoms may be allowed to continue working with adequate PPE to prevent infection spread
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| [[File:hand pic.jpg|400px]]
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| === PRECAUTIONS FOR HEALTHCARE WORKERS ===
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| *PPE BOTTOM LINE: Per CDC and LAC DPH (3/12/20)
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| **1. Airborne isolation required if aerosol-generating procedure
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| ***Bag-valve mask (BMV)
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| ***CPAP/BiPAP
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| ***Intubation
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| ***Nebulizer administration (COMMONLY FORGOTTEN) - use MDI instead. E.g. 8-12 MDI puffs instead of albuterol 2.5-5mg INH.
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| ***Bronchoscopy
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| ***Chest PT
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| **2. If not aerosol-generating procedure, then respiratory droplet only (no airborne isolation required).
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| ***“Can collect specimens (e.g., nasopharyngeal swabs) for COVID-19 observing standard, contact, and droplet precautions including eye protection in a normal examination room with the door closed”
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| **3. Put mask on the patient.
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| Transmission
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| **Simply walking into a room is NOT a recognized risk of transmission. Must make contact with respiratory droplet (directly or indirectly)
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| **Masks: MOST IMPORTANTLY => on the coughing individual
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| ***Evidence clearly demonstrates masks decrease shedding of infectious material in the environment
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| ***Little evidence for HCWs wearing masks prophylactically outside of close contact patient care
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| **How long to shut a patient room down after a COVID patient is in there?
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| ***It’s not about the risk of contracting the infection but about the ability to clean room safely without respiratory protection precautions by the cleaner
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| ***30-40 minutes usually sufficient (for most modern facilities) as long as no aerosol-generating procedure performed (longer, time not clearly stated at this time)
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| ****Most modern rooms designed to have 12 air exchanges per hour
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| ****Ventilation symptoms vary. So, older / fewer exchanges per hour => more time.
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| === PPE Guidelines ===
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| *EVERY PATIENT CONTACT: Respiratory droplet precautions. Contact precautions also recommended but if gowns in short supply consider reserving for aerosol-generating procedures
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| **Droplet = surgical mask, eye protection
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| **Contact = gown and gloves
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| **Technique:
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| ***Mask donning (often incorrectly done):
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| ****Wash hands BEFORE touching mask
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| ****Grip mask by loops/bands/ties only
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| ****Coloured portion typically faces outward
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| ****Mold / pinch the stiff edge to the shape of your nose
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| ****Pull the bottom of the mask over your mouth AND chin
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| ****Make sure you are up to date with fit testing
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| ***Mask removal:
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| ****Wash hands BEFORE touching mask
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| ****Only make contact with the loops/bands/ties. DON’T TOUCH THE MASK ITSELF!
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| *For AEROSOL GENERATING procedures: airborne precautions (N95/PAPR)
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| **Due to higher risk of aerosolizing droplets-- infection itself doesn’t seem to be spread via airborne route)
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| **Void Aerosol generating procedures when possible
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| ***Bag-valve mask (BMV)
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| ***CPAP/BiPAP
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| ***Intubation
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| ***Nebulizer administration (COMMONLY FORGOTTEN) - use MDI instead. E.g. 8-12 MDI puffs instead of albuterol 2.5-5mg INH.
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| ***Bronchoscopy
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| ***Chest PT
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| === PPE Shortage / Limiting Usage Guidelines ===
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| *In case of PPE shortage or in an attempt to save on PPE supplies, the following guidelines were approved by CDC 3/13/20
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| **Same Powered Air-Purifying Respirator (PAPR) can be worn for multiple serial patient contacts (e.g. in between successive COVID/PUI (patients under investigation) without exchanging respirator. Therefore, in between each patient:
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| ***no need to change mask or eye protection
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| ***BUT need to change gown and gloves
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| **Respirator (PAPR) reuse?
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| ***Higher risk because of having to touch the mask and either self-inoculate or transmit to another patient (e.g. wear it for a patient, then you remove, and then you put it back on)
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| ***if you must do this because of limited supplies, don and doff properly and perform proper hand hygiene in between
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| **N95 Reuse?
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| ***Probably okay to re-use same N95 during an 8 hour shift as long as no tears or visible contamination. Store facedown in labeled re-sealable bag/container. Based on non peer reviewed reports from Washington State
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| **N95 Shelf life?
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| ***CDC / NIOSH will allow certain N95s to be used beyond manufacture-designated shelf life
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| ***See list of appropriate models here (manufactured between 2003-2013)
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| === Healthcare Worker Monitoring ===
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| *Every HCW should check temperature with thermometer BID at home (and especially before work).
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| *Facilities should screen their HCW prior to shifts.
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| *If symptomatic, notify supervisor.
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| **If febrile, STAY HOME.
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| **If other symptoms, discuss with supervisor / clinical experts. Due to expected HCW shortages, minor symptoms may be allowed to continue working with adequate PPE to prevent infection spread
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| === Clinical Findings ===
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| * At onset: fever, dry cough, myalgias, fatigue, shortness of breath
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| ** Fever and cough start early, SOB noted about 9 days into illness
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| ** Fever not present in all adults (less common in vulnerable populations)
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| ** Less common: cough with sputum, sore throat, headache, congestion, GI symptoms
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| * Most common complications: pneumonia, ARDS (avg 8 days from onset, 20% of patients in China)
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| ** Decompensation risk occurs during 2nd week of illness
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| * Risk factors: older adults, underlying conditions (lung disease, heart disease, diabetes)
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| ** Children: milder disease
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| ** Pregnant patients: don’t appear to be at increased risk of infection or adverse outcomes (limited data - see #Pregnant Women [[https://www.wikem.org/wiki/WLA_VA:COVID19#Special_Population:_Pregnant_Women]])
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| ==== Laboratory Findings ====
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| * Lymphopenia most common in critically ill; mildly elevated ALT, AST; normal pro-calcitonin on admission
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| ** Elevated d-dimer and severe lymphopenia are associated with increased mortality
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| ** RT-PCR is currently test of choice for confirming cases
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| *** Test kit availability is currently limited as of mid March
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| *** Consider influenza/viral respiratory panel to identify alternative diagnoses
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| **** Although co-infection is possible
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| ==== Imaging ====
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| '''XRay:'''
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| ** Portable CXR preferred in PUI to prevent spread of infection
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| ** May be normal in early disease
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| ** Typical pattern is peripheral patchy ground glass opacities (GGO)
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| ** More opacities correlates with worse disease
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| ** GGOs may coalesce and appear as infiltrates
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| '''CT:'''
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| * Many have normal imaging early on (so CDC DOES not recommend CT for diagnostic purposes at this time)
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| ** CT (86%) more sensitive than CXR (59%) for detecting GGOs
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| ** Radiopaedia COVID-19 Resources (https://radiopaedia.org/articles/covid-19)
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| ** From the American College of Radiology (3/11/20): “Generally, the findings on chest imaging in COVID-19 are not specific, and overlap with other infections, including influenza, H1N1, SARS and MERS. Being in the midst of the current flu season with a much higher prevalence of influenza in the U.S. than COVID-19, further limits the specificity of CT.”
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| * Reinfection (after recovery from COVID19): unclear if possible
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| ** Limited data. Unlikely to be reinfected shortly after but unknown about later on
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| [[File:covidcxr.jpg|400px]]
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| ==== ISOLATION ====
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| *Persons diagnosed with COVID-19 are considered cleared after 14 days from symptom onset or 3 days after resolution of fever and improvement of other symptoms, whichever is longer.
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| *CDC: Reasonable to isolate patients with unexplained fever and respiratory symptoms (and no travel history) at this time
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| ==Isolation==
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| * Persons diagnosed with COVID-19 are considered cleared after 14 days from symptom onset or 3 days after resolution of fever and improvement of other symptoms, whichever is longer.
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| * CDC: Reasonable to isolate patients with unexplained fever and respiratory symptoms (and no travel history) at this time
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| ==Testing==
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| * LA County DPH checklist (http://publichealth.lacounty.gov/acd/ncorona2019/checklist.htm)
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| * Mild illness: DO NOT send for testing (increased risk of exposure to COVID-19)
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| * ER: DO NOT go unless hospital level of care is needed (increased exposure of other patients and staff)
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| * Testing can be done in ambulatory setting if absolutely needed (see precautions)
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| ===Guidelines: Epidemiologic Factors===
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| * Persons (including HCW) within 14 days of travel (domestic/international), or
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| * Close contacts with lab-confirmed COVID19 patient within 14 days
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| ====Criteria For Sending Specimen to PHL====
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| [[File:Screen Shot 2020-03-17 at 7.27.23 PM.png|thumb|center|LAC DPH Public Health Lab (PHL) COVID-19 Testing Criteria]]
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| ====Criteria For Sending Specimen to Commercial Lab====
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| * Patients with fever and cough/shortness of breath not requiring hospitalisation who have:
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| ** History of travel from affected geographic areas (domestic / international) within 14 days of symptom onset
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| **Other exposure risk indicated by the patient’s history and clinical judgement (and no alternative diagnosis -- e.g. negative flu test)
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| [[File:Screen Shot 2020-03-17 at 8.06.03 PM.png|thumb|center|Suggested Criteria for Commercial Clinical Laboratory COVID-19 Testing, if Available]]
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| ====Decision To Obtain Imaging====
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| * CXR: no significant issues with contamination/disinfection
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| * CT: Temporarily out of commission after COVID19 patient in scanner
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| ====Clinical Sample Collection====
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| * Best way to collect:
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| ** Upper respiratory tract and lower tract specimens (if available).
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| *** NP swabs
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| *** Put both of them in the same tube and send for a single test
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| ** For productive cough patients: can collect sputum to send for testing. CDC does NOT recommend inducing sputum (because aerosol generating)
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| ====Testing: Turnaround Time====
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| * LA County Public Health Lab (PHL) = ~ 2 business days
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| * Commercial lab = ~ 3-4 business days
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| ====DECISION TO OBTAIN IMAGING====
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| *CXR: no significant issues with contamination/disinfection. Low threshold.
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| *CT: Temporarily out of commission after COVID19 patient in scanner
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| ====DECISION TO HOSPITALISE====
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| *Mild symptoms may go home and self-isolate/quarantine
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| **Note: symptoms may worsen over 2nd week of illness
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| *Hospitalise: Respiratory distress/failure, significant hypoxia, multi-organ failure, rapid disease progression requiring escalating supportive care
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| *May consider discontinuation of hospital isolation when:
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| **Resolution of fever without anti-pyretic, resolution of symptoms, and negative COVID19 testing
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| ==Treatment==
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| '''General:'''
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| * No specific treatment currently available
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| *Epidemiology interventions will be most important
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| **Spread Prevention
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| **Mitigation strategies
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| *High-dose corticosteroids should be AVOIDED (due to progression of viral replication reported from prior coronaviruses; e.g. MERS, SARS)
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| *Avoid nebulizers as they are generally ineffective may aerosolize virus
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| **Albuterol with spacer is safer, though probably ineffective unless co-occuring reactive airway disease
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| *Generally avoid BiPAP and high-flow nasal oxygen as theseaerosolize the virus)and may increase spread
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| **WHO cautiously states that high flow oxygen may be occasionally indicated.
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| Intubation
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| *High risk procedure for aeresolization
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| **Patient ideally in negative pressure room. Limit individuals in room to essential staff only.
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| **PPE for all in room: N95, gown, gloves, eye shield
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| **PPE for provider intubating: Consider PAPR, double glove, double gown
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| **BVM with viral filter. If not viral filter do NOT BVM
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| *Use sufficient paralytics to prevent coughing gagging
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| *Most experienced provider should perform intubation.
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| *Ventilator settings for Covid-19 Patients => ARDSnet protocol (see table below)
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| **Mode: Volume-Assist Control
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| **Volume: 6-8ml/kg of Ideal Body Weight (based on height/sex). NOT actual Body weight.
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| **Respiratory Rate: 15 breaths/min
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| ***Increase if pre-intubation ABG/VBG shows significant acidosis
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| ***Adjust based on ABG PaCO2/pH results
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| **PEEP: 5 (titrate via ARDSnet)
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| **FiO2: 40% after intubation and monitor O2 saturation.
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| ***Goal SaO2 > 88%
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| ***If SaO2 < 88% on FiO2 of 40%, see ARDSnet and increase PEEP first.
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| *Alarming Vent? See (https://rebelem.com/rebel-cast-ep-46b-vent-management-crashing-patient-haney-mallemat/)
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| **DOPES = Displaced ET tube or cuff, Obstructed ET tube: pt biting tube, kink in tube, mucous plug, Pneumothorax, Equipment: Tube from ETT to Vent, Stacked breaths: auto-PEEP (typically asthma/COPD, results from decreased ability to expire air)
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| **DOTTS = Disconnect from vent (can push down on pt’s chest if concern for auto-PEEP), FOR COVID-19 SKIP Oxygenate with 100% BVM (evaluates for ETT dislodgement, bilateral breath sounds, cuff leak, crepitus, difficulty bagging), Tube check for mucous plug or kink or dislodgement, Tweak vent for autoPEEP (decreased RR, decreased inspiratory time with changing E:I ratio), Sonography for pneumothorax.
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| **Peak Vs Plateau Pressure
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| ***Super important to keep alveolar pressure low to prevent barotrauma
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| ***Peak Pressure is pressure of entire system (vent, ET tube, trachea, bronchus, bronchioles, alveoli). High peak pressure does not equal barotrauma
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| ***Plateau pressure - check with button on vent (may say plateau pressure or end-inspiratory hold)
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| ***High Peak and Normal Plateau - problem with vent, ET tube, bronchoconstriction (reactive airway disease/asthma/COPD).
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| ***High Peak and High Plateau - Compliance issue (pneumothorax, problem with alveoli like ARDS, fluid overload). Need to decrease pressure to prevent barotrauma.
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| ***Plateau pressures should be kept < 30mmHg if possible.
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| [[File:ardsnet.jpg|400px]]
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| http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf
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| [[File:ardsnet2.png|400px]]
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| Vent basics resource: https://emcrit.org/wp-content/uploads/2010/05/Managing-Initial-Vent-ED.pdf
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| '''Experimental/compassionate use treatments:'''
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| * Remdesivir (IV)
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| ** CDC does not recommend for or against any investigational therapies at this time
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| ** Contact Gilead directly for use: compassionateaccess@gilead.com
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| ** Background: novel antiviral nucleotide analog. Initially developed for Ebola and Marburg (has since been found to show activity against other single stranded RNA viruses such as RSV, Lassa fever virus, Nipah virus and the coronaviruses including MERS and SARS)
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| *** 3 clinical trials across country (one is NIH adaptive trial)
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| *** 2 other trials are investigational open-label trials testing different dosages for moderate or severely hospitalized patients
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| * Ritonavir also being used but no data available. Same for chloroquine.
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| ==Decreasing Hospital Transmission==
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| * Examples that decrease need for PPE:
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| ** Telemedicine eval
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| **Barriers (plexiglass partitions) so triage individuals don’t have to wear PPE and be protected
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| * Masks: MOST IMPORTANT is to put it on the coughing/sick individual (don’t have HCWs wearing masks around the department prophylactically due to risk of self-inoculation)
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| * Cohort patients (all COVID +ve/PUI) in same part of department / hospital / clinic
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| ** Put a mask on them at ALL times
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| * Limit patient visitation:
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| * Barring visits except for end-of-life, case-by-case
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| * Restrict non-essential workers (painters, pet therapy)
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| * Limit patient movement within hospitals/clinics
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| ==CHILDREN==
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| === Epidemiology among Children ===
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| *2% of cases amongst < 2 years of age (NOTE: 13% in only one major city in China)
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| *Mostly because of household exposures (from adults)
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| *Vast majority of cases in US are in adults
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| === Symptoms in children ===
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| *Fever (50-80%), cough, congestion, rhinorrhea, sore throat
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| *GI in some cases (at least one case with GI sx first then respiratory symptoms after)
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| *50% of peds cases with fever, 30% with cough
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| Disease Course
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| *Mostly mild (for unclear reasons) except for only 2 cases:
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| **13 month developed ARDS and ICU care
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| **3 year old needed ICU
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| *No deaths in children under 10 (from china so far)
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| *Radiographic: same as adults (bilateral, pulmonary lesions, GGO; some with unilateral).
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| === Q&A ===
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| *Are children with underlying medical conditions (asthma, or special healthcare needs) at increased risk?
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| ** No data exists
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| === Labs ===
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| *Mild CRP or AST elevations
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| *No consistency on WBC (mild leukocytosis, leukopenia)
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| *Few coinfections have been reported (with RSV, Influenza, mycoplasma).
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| **Coinfection unlikely (but possible) at this time
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| Treatment
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| *Supportive care, isolation at home best unless needing hospitalisation
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| *Infection prevention and support!!! handwashing and PPE
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| *No remdesavir trials in children
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| === Transmission in Paediatrics ===
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| *Shedding for longer than adults (up to 22 days, some up to 30 days)
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| *Mostly goes from adults to children (not the other way around)
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| === HCW pediatric visits===
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| *CDC recommends decreased face-to-face triage
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| *nurse -directed triage and telehealth visits
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| ==Special Population: Pregnant Women==
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| ===Background Epidemiology===
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| * 34 pregnant women reported with COVID, 0 deaths reported.
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| * Median age: 30 years (mostly 2nd and 3rd trimester -- median gestation 36 weeks)
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| * Symptom onset within 13 days prior to, and 3 days after, delivery
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| * Infants of affected mothers all tested negative
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| ===Bottom Line for Pregnant Patients===
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| * Reported data and outcomes for pregnant patients similar to non-pregnant patients
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| ** Physiologic and immunologic changes in pregnancy may make them more susceptible to contracting viral respiratory illness but symptoms and outcomes demonstrate no significant differences from non-pregnant COVID19
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| ===Q&A Scenarios===
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| * Are pregnant women at increased risk of adverse pregnancy outcomes?
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| ** No data exists on this (regarding pregnancy loss, misscarriage, etc)
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| ** High fevers in early pregnancy previously demonstrated (in SARS and MERS) to increase risk of birth defects. May be possible here. But no data.
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| * Lactation
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| ** No evidence of virus found in breastmilk. (but no good data on this). Most transmission noted to be due to close respiratory droplet contact during feeding
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| * Should pregnant patients not be out and about in the community?
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| ** Prenatal care still encouraged
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| ** Usual precautions encouraged (as with general population)
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| ===Infection Prevention===
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| * Applies to broader infection prevention
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| * Isolation of pregnant patients with COVID19 and PUIs
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| * Pre-hospital (for confirmed COVID19 or PUI):
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| ** Notify OB unit prior to arrival
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| ** EMS: driver should contact receiving unit to follow local protocols
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| ** Hospitalization: usual hospital protocols for isolation
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| * Infants born to mothers with COVID should be considered PUI
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| ** Prevention of mother-to-child transmission (PMTCT): may temporarily separate mother from baby until mother’s transmission based isolation precautions are discontinued (due to respiratory secretions)
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| *** No data on vertical transmission
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| **** Thought to spread mostly by close contact with respiratory droplet
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| *** Very limited data on routes of transmission other than contact with respiratory droplet - however small cohorts tested didn’t demonstrate transmission via these others routes (note amniotic fluid and other sources were not tested)
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| *** Discontinuation of isolation made on local ID guidance and case-by-case
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| *** Discontinuation criteria same as for other COVID19
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| **** Resolution of fever without anti-pyretic, resolution of symptoms, and negative COVID19 testing
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| *** Face mask, hand hygiene before each feeding
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| **** Dedicated breast pump if nursing
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| **** Entire pump should be entirely disinfected per manufacturer recommendations between each feed
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| ==RESOURCES==
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| *Johns Hopkins COVID Case Map (Live):https://coronavirus.jhu.edu/map.html
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| *WHO COVID-19 Situation Dashboard (Live): https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd
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| *CDC https://www.cdc.gov/coronavirus/2019-ncov/index.html
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| *California Emergency Medical Services Authority Resource Portal
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| https://emsa.ca.gov/covid19/
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| *Oxford Journal of Travel Medicine COVID19 Resources https://academic.oup.com/journals/pages/coronavirus?cc=gb&lang=en&
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| *EM:RAP Corependium COVID-19 (open access) https://www.emrap.org/corependium/chapter/rec906m1mD6SRH9np/Novel-Coronavirus-2019-COVID-19?MainSearch=%22covid%22&SearchType=%22text%22
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| *Uptodate COVID 19: https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19?search=covid%2019%20imaging&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H3937614273
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| *Reporting Los Angeles County DPH Acute Communicable Disease Control:
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| **Positive COVID-19 lab results from clinical labs (not PHL) must be reported by healthcare providers within one day.
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| **Complete and fax a Medical Provider COVID-19 Report form to 888-397-3778 or 213-482-5508 or call 888-397-3993.
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| **For consultation call 213-240-7941.
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| *Long Beach Health and Human Services:
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| **Weekdays 8am-5pm: call 562-570-4302.
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| **After hours: call the duty officer at 562-500-5537.
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| *Pasadena Public Health Department:
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| **To report a case of COVID-19, fill out the COVID-19 Report Form here and fax to 626-744-6115, and call 626-744-6089 [Weekdays 8am-5pm (closed every other Friday) or after hours call 626-744-6043].
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| [[Category:Admin]]
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