COVID-19

See also prevention of COVID-19 transmission in the healthcare setting; COVID-19 (peds); and COVID-19 in pregnancy.

Background

Specific Coronavirus Sub-Types of Clinical Importance

Clinical Features

Initial Presentation

  • Many patients are asymptomatic
  • At onset of symptoms: fever, dry cough, myalgias, fatigue, shortness of breath
    • Fever and cough start early, shortness of breath noted about 9 days into illness
    • Fever not present in all adults
      • Only 1/2 of patients may have fever at time of admission[1]
      • less common in vulnerable populations
    • Less common: cough with sputum, sore throat, headache, congestion, GI symptoms, anosmia, altered mental status
Symptom[2] %
Fever 87.9
Dry cough 67.7
Fatigue 38.1
Sputum production 33.4
Shortness of breath 18.6
Myalgia or arthralgia 14.8
Sore throat 13.9
Headache 13.6
Chills 11.4
Nausea or vomiting 5.0
Nasal congestion 4.8
Diarrhea 3.7
Hemoptysis 0.9
Conjunctivitis 0.8

Common Complications

The initial presentation can be followed by delayed and serious complications

  • Pulmonary
    • Most common complications: pneumonia, ARDS (average 8 days from onset, 20% of patients in China)
    • Decompensation risk occurs during 2nd week of illness leading to respiratory failure
  • Cardiac Complications[3]
    • Myocarditis,Acute Myocardial infarction, Dysrhythmias, cardiomyopathy, venous thromboembolism.
      • Vasodilatory shock reported in 67% of ICU admissions
      • Cardiomyopathy reported in 33% of ICU admissions
      • Mortality reported 67% of ICU admissions
  • Neurological Complications- thought to be related to the increased levels of interleukin (IL)-6, IL-12, IL-15, and tumor necrosis factor alpha (TNF-α)[4]
    • acute CVA, encephalitis, Guillain-Barré syndrome, acute necrotizing hemorrhagic encephalopathy, and hemophagocytic lymphohistiocytosis

Differential Diagnosis

Influenza-Like Illness

Causes of Pneumonia

Bacteria

Viral

Fungal

Parasitic

Evaluation

Consider minimal workup in well-appearing patients with mild disease

Workup

Viral Testing

Testing+Surveillance: COVID

  • RT-PCR (reverse transcriptase polymerase chain reaction) is most commonly used test for confirming cases
    • Sensitivity may be only 75%, but highly specific
    • Turnaround time may be several hours to days
  • Real time RT-PCR e.g. Cepheid
    • Rapid test with results in <1hr
  • Serologic testing for IgM/IgG is not widely available, but likely more sensitive
    • The presence of IgG with a negative RT-PCR likely confirms past exposure and some immunity
  • Test kit availability varies widely by region and institution

Labs

Tests to consider

  • Chemistry
  • CBC w/diff
    • Lymphopenia - common (80%)[5]
    • Thrombocytopenia - common but mild
      • <100 poor prognostic sign [6]
  • Coagulation studies
    • PT/PTT/INR - DIC possible
    • D-dimer, fibrinogen - markers of severity
  • LFTs - mild elevation of ALT/AST
  • Inflammatory Markers
    • CRP - Indicates disease severity [7], [8]
      • Negative points to non-infectious cause (CHF/ESRD)
    • Procalcitonin - normal/mild increased on admission. Normal procalcitonin makes bacterial superinfection less likely.
    • Ferritin
    • LDH
  • Troponin [9] - myocarditis
  • Sepsis labs
    • Lactate
    • Blood culture x2
  • Swabs - Co-infection has been reported as high as 7-20%
    • Flu swab
    • Respiratory viral panel
      • Note that BIOFIRE Respiratory Panel Corona Virus assay does NOT detect this COVID-19 subtype
  • Urine pregnancy test in reproductive-age women
  • Other labs to consider in patients that will be admitted:
    • HBV serologies, HCV antibody
    • Consider (as clinically indicated): PCP DFA, beta-d-glucan, urine legionella Ag, IL-6

Imaging

COVID one pager with links.jpg
COVID one pager with links 2.jpg
Covidcxr.jpg
X-ray
    • Portable CXR preferred in PUI to prevent spread of infection
    • May be normal in early disease
    • Typical pattern is peripheral patchy ground glass opacities (GGO)
    • More opacities correlates with worse disease
    • GGOs may coalesce and appear as infiltrates
    • Not every PUI needs a chest X-ray. Patients who are more likely to need one include any moderate or high acuity patient, elderly, concerning chronic conditions, BMI > 40, high risk socioeconomic situations.
CT
  • Many have normal imaging early on (so CDC DOES not recommend CT for diagnostic purposes at this time)
    • CT (86%) more sensitive than CXR (59%) for detecting GGOs
    • 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.”
US

Diagnosis

  • Typically confirmed by viral testing (see above)

Disease Severity

  • Some define moderate and severe acuity as follows:
    • Moderate: SaO2 = 91-93% on RA, RR 20-24, HR 110-124 with wheezing, rales or an otherwise abnormal lung exam.
    • High: SaO2 < 91%, RR > 24, HR > 124.
    • If febrile, treat with acetaminophen and reassess acuity.

Management

See prevention of COVID-19 transmission in the healthcare setting for PPE recommendations
See COVID-19: Medication therapy for investigational agents
 Template:COVID PPE summary table

Mild

  • Supportive care is mainstay of therapy
    • 80% of patients do not require hospital admission
  • Some define low acuity as SaO2 > 93% on RA, RR < 20, and HR < 110 (if febrile, re-check acuity determined after acetaminophen)
  • Dexamethasone has not demonstrated benefit in patients not requiring oxygen and may be potentially harm

Moderate/Severe

  • Dexamethasone 6mg Qday PO or IV
    • Improves 28d mortality in patients requiring oxygen (NNT = 29) or mechanical ventilation (NNT = 8.5)
    • Use should be for up to 10 days or until stable for discharge, whichever comes first.
  • Pulmonary [10]
    • "Happy Hypoxemia" Many of these patients will be hypoxic without dyspnea
    • Supplemental oxygen therapy if Sat<90%
      • Target SPO2 92%-96%
    • High-flow Nasal Cannula
      • Some guidelines recommending HFNC over BIPAP/CPAP in those that fail low-flow O2. [11]
      • Requires patient to be on airborne isolation.
    • Non-Invasive Ventilation if no HFNC
    • Consider Awake proning to improve oxygenation
    • Bronchodilators if bronchospasm present
      • avoid nebulizers
      • Use Metered-dose inhaler
  • Infectious disease
  • Cardiovascular [12]
    • Most patients without hemodynamic compromise
    • Maintain euvolemia - hypervolemia may contribute to ARDS
    • Hypoperfusion - cautious fluid resuscitation
    • Vasopressors

Respiratory failure

  • NIPPV may increase the spread of viral particles via droplets, making early intubation the preferred airway management strategy in patients with respiratory distress/failure
    • Using 2 viral filters attached to a "2-tube NIPPV circuit" in a negative pressure room may sufficiently prevent viral spread

Template:COVID-19 intubation

Lung Protective Mechanical Ventilation

Lung Protective Ventilator Settings[13] should be the default for all intubated patients, unless contraindicated. It has demonstrated mortality benefit for ARDS-like pulmonary conditions; limits barotrauma and decreases complications of high FiO2[14][15]

  1. Mode
    • Volume-assist control
  2. Tidal Volume
    • Start 6-8cc/kg predicted body weight[16]
      • Predicted/"ideal" body weight is used because a person's lung parenchyma does not increase in size as the person gains more weight.
    • Titrate down if plateau pressure >30 mmHg
  3. Inspiratory Flow Rate (comfort)
    • More comfortable if higher rather than lower
    • Start at 60-80 LPM
  4. Respiratory Rate (titrate for ventilation)
    • Average patient on ventilator requires 120mL/kg/min for eucapnia
    • Start 16-18 breaths/min
    • Maintain pH = 7.30-7.45
  5. FiO2/PEEP (titrate for oxygenation)
    • Move in tandem to achieve:
    • SpO2 BETWEEN 88-95%
    • PaO2 BETWEEN 55-80mmHg

Template:COVID-19 Lung Phenotypes

Aerosol-Generating Procedures

Due to higher risk of aerosolizing droplets; infection itself doesn’t seem to be spread via airborne route

Recommended Provider PPE

Contact (including eye protection) and airborne precautions

  • N95 mask or higher-level respirator (e.g. PAPR), plus eye protection, gloves, and gown[17]
    • Consider head coverage: sterile disposable cap with gown or bunny suit
    • Consider two pairs gloves, one under sleeves of gown and one over
    • Consider shoe covers
    • Consider buddy system for donning/doffing
      • If using PAPR, then need pre-assigned RN outside the room to help decontaminate it by wiping it down with purple wipes before you take it off
  • Negative pressure room required, if at all possible
  • Limit personnel in room to only those essential for patient care

Mask Use Technique

  • Mask donning (often incorrectly done):
    • Wash hands BEFORE touching mask
    • Grip mask by loops/bands/ties only
    • Coloured portion typically faces outward
    • Mold / pinch the stiff edge to the shape of your nose
    • Pull the bottom of the mask over your mouth AND chin
    • Make sure you are up to date with fit testing
  • Mask removal:
    • Wash hands BEFORE touching mask
    • Only make contact with the loops/bands/ties. DON’T TOUCH THE MASK ITSELF!

Aerosol-generating procedures list

Avoid these procedures when possible

Template:COVID contraindicated therapies

Disposition

  • Mild cases for persons under investigation for Covid-19 awaiting a positive test result can self quarantine at home in conjunction with the local Public Health Dept
  • "Silent hypoxemia" is now reported in patients with oxygen saturations ranging in the 80s-90s without respiratory distress. Hypoxia is not recommended as an absolute indication for emergent intubation.
    • Note: symptoms may worsen over 2nd week of illness

Admission

  • Hospitalize: Respiratory distress/failure, multi-organ failure, rapid disease progression requiring escalating supportive care. Meets criteria for high acuity above. Moderate acuity with extra risk factors (pneumonia, immunosuppressed, elderly, comorbidities), complicated social situation, worsening symptoms > 10 days out.
    • PSI/PORT, MuLBSTA, and CURB65 scores have all been proposed criteria for admission and predicting outcomes.
  • May consider discontinuation of hospital isolation when:
    • Resolution of fever without anti-pyretic, resolution of symptoms, and negative COVID19 testing

Special Situations

Covid-19 and STEMI

  • According to ACC consensus statement "During the COVID-19 pandemic, PCI remains the standard of care for STEMI patients"
  • If thrombolytics are indicated options include:
    • Administer 10u Retavase (reteplase) IV bolus followed by a second bolus at 30 minute rather than PCI. OR
    • Tenecteplase (TNKase) 30 mg IV bolus
    • If Tenecteplase is not available, it is acceptable to administer a lower dose of alteplase (tPA) at 50 mg (8 mg bolus, followed by 42 mg infusion over 90 minutes).
    • Follow thrombolytics by 40u/kg heparin (max dose 4,000 units) IV and 600mg clopidogrel PO and ASA 325 mg PO

Covid-19 and CPR

  • Interim AHA Guidance
    • Don all PPE prior to initiating CPR. CPR is aerosol generating.
    • Intubate early, video laryngoscopy preferred
    • Pause chest compressions during intubation
    • If patient is on ventilator at time of arrest consider leaving patient on ventilator
      • Adjust ventilator to allow for asynchronous ventilation
    • If using BVM then attach high efficiency particulate air (HEPA) filter
    • Use of mechanical compression device (e.g. LUCAS) is encouraged

Prognosis

Template:COVID Risk Factors

All-Comers

  • Case fatality rate (CFR) = 2-4% (from Hubei data)
    • SARS ~ 10%
    • MERS ~ 35%
    • Seasonal flu ~ 0.1-0.2%
    • 1918 Pandemic Influenza ~ 2-3%

Relation to Age

Case fatality rates by country, age, and percent (%)
Age 80+ 70–79 60–69 50–59 40–49 30–39 20–29 10–19 0–9
China as of 11 February[18] 14.8 8.0 3.6 1.3 0.4 0.2 0.2 0.2 0.0
Italy as of 16 March[19] 19.2 11.8 3.2 1.0 0.3 0.2 0.0 0.0 0.0
South Korea as of 21 March[20] 10.24 6.28 1.52 0.42 0.08 0.11 0.0 0.0 0.0

See Also

External Links

Video

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References

  1. ↑ 1. Zhou F, Yu T, Du R et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet. 2020;395(10229):1054-1062. doi:10.1016/s0140-6736(20)30566-3
  2. ↑ World Health Organization. "Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19)" (PDF): 11–12. Retrieved 5 March 2020.
  3. ↑ Long B, Brady WJ, Koyfman A, Gottlieb M. Cardiovascular complications in COVID-19. Am J Emerg Med. 2020;38(7):1504-1507. doi:10.1016/j.ajem.2020.04.048
  4. ↑ Bridwell R, Long B, Gottlieb M. Neurologic complications of COVID-19. Am J Emerg Med. 2020;38(7):1549.e3-1549.e7. doi:10.1016/j.ajem.2020.05.024
  5. ↑ Yang X, Yu Y, Xu J et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. The Lancet Respiratory Medicine. 2020. doi:10.1016/s2213-2600(20)30079-5
  6. ↑ Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med. 2020. doi:10.1007/s00134-020-05991-x
  7. ↑ Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med. 2020. doi:10.1007/s00134-020-05991-x
  8. ↑ Young B, Ong S, Kalimuddin S et al. Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore. JAMA. 2020. doi:10.1001/jama.2020.3204
  9. ↑ https://www.covidprotocols.org
  10. ↑ Alhazzani W, Møller M, Arabi Y et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. 2020. doi:10.1007/s00134-020-06022-5
  11. ↑ Alhazzani W, Møller M, Arabi Y et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. 2020. doi:10.1007/s00134-020-06022-5
  12. ↑ Alhazzani W, Møller M, Arabi Y et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. 2020. doi:10.1007/s00134-020-06022-5
  13. ↑ The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-1308.
  14. ↑ ARDSnet
  15. ↑ O'Brien J. Absorption Atelectasis: Incidence and Clinical Implications. AANA Journal. June 2013. Vol. 81, No. 3.
  16. ↑ Brower RG, et al. "Ventilation With Lower Tidal Volumes As Compared With Traditional Tidal Volumes For Acute Lung Injury And The Acute Respiratory Distress Syndrome". The New England Journal of Medicine. 2000. 342(18):1301-1308.
  17. ↑ https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html#take_precautions
  18. ↑ The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team (17 February 2020). "The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020". China CDC Weekly. 2 (8): 113–122. Retrieved 18 March 2020.
  19. ↑ Epidemia COVID-19. Aggiornamento nazionale 16 marzo 2020" (PDF) (in Italian). Rome: Istituto Superiore di Sanità. 16 March 2020. Retrieved 18 March 2020.
  20. ↑ "코로나바이러스감염증-19 국내 발생 현황 (3월 21일, 정례브리핑)". Korea Centers for Disease Control and Prevention. 21 March 2020. Retrieved 21 March 2020.
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