COVID-19: Difference between revisions
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''See also [[prevention of COVID-19 transmission in the healthcare setting]]; [[COVID-19 (peds)]]; and [[COVID-19 in pregnancy]].''
''See also [[prevention of COVID-19 transmission in the healthcare setting]]; [[COVID-19 (peds)]]; and [[COVID-19 in pregnancy]].''
==Background==
==Background==
* The current national and international pandemic is from a virus named SARS-CoV-2 (previously 2019-nCoV), which causes a disease named COVID-19 (also known as "2019 Novel Coronavirus")
*See [[COVID-19: Epidemiology and pathophysiology]]
*First detected in Wuhan, China


{{Specific Coronavirus Sub-Types of Clinical Importance}}
{{Specific Coronavirus Sub-Types of Clinical Importance}}
{{COVID virology}}
{{COVID virology}}
{{COVID epidemiology}}
{{COVID epidemiology}}
===Risk Factors for Severe Disease===
*Older age
*Underlying conditions (lung disease, Renal Failure, Malignancy, heart disease, [[diabetes]])
NOT Risk Factors
*Children: milder disease
*Pregnant patients: see [[COVID-19 in pregnancy]]


==Clinical Features==
==Clinical Features==
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* At onset of symptoms: [[fever]], dry [[cough]], myalgias, fatigue, [[shortness of breath]]
* 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 and cough start early, [[shortness of breath]] noted about 9 days into illness
** Fever not present in all adults (less common in vulnerable populations)
** Fever not present in all adults  
** Less common: cough with sputum, sore throat, headache, congestion, GI symptoms, anosmia
***Only 1/2 of patients may have fever at time of admission<ref>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</ref>
***less common in vulnerable populations
** Less common: cough with sputum, sore throat, headache, congestion, GI symptoms, anosmia, altered mental status


{| {{table}}
{| {{table}}
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* Most common complications: [[pneumonia]], [[ARDS]] (average 8 days from onset, 20% of patients in China)
* 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]]
** Decompensation risk occurs during 2nd week of illness leading to [[respiratory failure]]
*Myocarditis: elevated troponin, arrhythmias, heart failure
*According to limited ICU data (21 cases) from Washington state (Arentz et al):
*According to limited ICU data (21 cases) from Washington state (Arentz et al):
**Vasodilatory shock reported in 67% of ICU admissions
**Vasodilatory shock reported in 67% of ICU admissions
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==Evaluation==
==Evaluation==
===Workup===
*Consider minimal workup in well-appearing patients with mild disease
====Viral Testing Background (Reverse Transcriptase PCR)====
===Viral Testing===
*Internationally the WHO has distributed kits<ref>Sheridan, Cormac . "Coronavirus and the race to distribute reliable diagnostics". Nature Biotechnology https://www.nature.com/articles/d41587-020-00002-2</ref>
[[Testing+Surveillance: COVID]]
*In the United States, the US Centers for Disease Control (CDC) is distributing testing to public health labs<ref>https://www.internationalreagentresource.org/</ref>
*RT-PCR (reverse transcriptase polymerase chain reaction) is most commonly used test for confirming cases
**Testing is currently coordinated through [https://www.cste.org/page/EpiOnCall state] or [https://www.naccho.org/membership/lhd-directory local] health departments or private labs
**Sensitivity may be only 75%, but highly specific
** See [http://publichealth.lacounty.gov/acd/ncorona2019/checklist.htm Example testing checklist from LA County DPH]
**Turnaround time may be several hours to days
*BIOFIRE Respiratory Panel Corona Virus assay does NOT detect this COVID-19 subtype
*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


====Who to Test (Persons Under Investigation)====
===Labs===
*Patients should be carefully evaluated to determine if they meet Persons Under Investigation (PUI) criteria
Tests to consider
*Due to a lack of available tests, non-PUI patients (including the worried well) should not have testing performed
*Chemistry
*Clinicians are strongly encouraged to test for other causes of respiratory illness (e.g. [[influenza]], [[RSV]])
**BMP
**In many systems, testing algorithms assume patients do not have COVID-19 if influenza or RSV positive
**Mg
 
**Phos
;CDC PUI Guidance<ref>Criteria to Guide Evaluation and Laboratory Testing for COVID-19. Updated March 20, 2020. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html</ref>
*CBC w/diff
''<u>Your local PUI testing guidelines may be different, depending on test availability and local epidemiology; see [https://www.cste.org/page/EpiOnCall state] or [https://www.naccho.org/membership/lhd-directory local] health departments and internal hospital resources</u>''
**Lymphopenia - common (80%)<ref>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</ref>
*"Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested."
**Thrombocytopenia - common but mild
*Priorities for testing include:
***<100 poor prognostic sign <ref>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</ref>
*#Hospitalized patients who have signs and symptoms compatible with COVID-19^ (in order to inform decisions related to infection control)
*Coagulation studies
*#Other symptomatic individuals with risk factors for severe disease
**PT/PTT/INR - DIC possible
*#*Older adults
**D-dimer, fibrinogen - markers of severity
*#*Individuals with chronic medical conditions and/or an immunocompromised state (e.g., diabetes, heart disease, receiving immunosuppressive medications, chronic lung disease, chronic kidney disease)
*LFTs - mild elevation of ALT/AST
*#Symptomatic persons who within 14 days of symptom onset had close contact with a suspect or laboratory-confirmed COVID-19 patient
*Inflammatory Markers
*#*Including healthcare personnel
**CRP - Indicates disease severity <ref>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</ref>, <ref>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</ref>
*#*INcluding history of travel from affected geographic areas
***Negative points to non-infectious cause (CHF/ESRD)
 
**Procalcitonin - normal/mild increased on admission. Normal procalcitonin makes bacterial superinfection less likely.
^Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing).
**Ferritin
 
**LDH
====Clinical Sample Collection<ref>Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19). March 19, 2020 Revision. https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html</ref>====
*Troponin <ref>https://www.covidprotocols.org</ref> - myocarditis
''Testing can be done in ambulatory setting if absolutely needed (see [[Prevention of COVID-19 transmission in the healthcare setting|precautions]])''
*Sepsis labs
#Upper respiratory tract specimen
**Lactate
#* Nasopharyngeal (NP) swab
**Blood culture x2
#**Some systems allow sending both [[flu]]/[[RSV]] and [[COVID-19]] test on the same swab to conserve testing supplies
*Swabs - Co-infection has been reported as high as 7-20%
#Additionally include lower tract specimen, if available
**Flu swab
#*''CDC does NOT recommend inducing sputum (because aerosol generating)''
**Respiratory viral panel
#* For productive cough patients: collect sputum
***Note that BIOFIRE Respiratory Panel Corona Virus assay does NOT detect this COVID-19 subtype
#*For patients for whom it is clinically indicated (e.g., those receiving invasive mechanical ventilation): collect lower respiratory tract aspirate or bronchoalveolar lavage sample
*Urine pregnancy test in reproductive-age women
#* May include in same testing tube as upper respiratory track specimen (i.e. send as a single test) in some systems
*''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


===Diagnostic Findings===
===Imaging===
[[File:COVID one pager with links.jpg|thumb|]]
[[File:COVID one pager with links.jpg|thumb|]]
[[File:COVID one pager with links 2.jpg|thumb|]]
[[File:COVID one pager with links 2.jpg|thumb|]]
[[File:covidcxr.jpg|thumb]]
[[File:covidcxr.jpg|thumb]]
====Labs====
*Note that BIOFIRE Respiratory Panel Corona Virus assay does NOT detect this COVID-19 subtype
* Lymphopenia most common in critically ill; mildly elevated ALT, AST; normal pro-calcitonin on admission
** Elevated d-dimer and severe lymphopenia are associated with increased mortality
** RT-PCR is currently test of choice for confirming cases
*** Test kit availability is currently limited as of mid March
*** Consider viral respiratory panel to identify alternative diagnoses though co-infection has been reported as high as 7-20%
*''Other labs to consider in patients that will be admitted:''
** CBC with diff, hepatic panel, procalcitonin, CK, TnI, LDH, ferritin, HIV, HBV serologies, HCV antibody
**''Consider (as clinically indicated):'' PCP DFA, beta-d-glucan, urine legionella Ag, IL-6
====X-ray====
====X-ray====
** Portable [[CXR]] preferred in PUI to prevent spread of infection
** Portable [[CXR]] preferred in PUI to prevent spread of infection
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** More opacities correlates with worse disease
** More opacities correlates with worse disease
** GGOs may coalesce and appear as infiltrates
** 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====
====CT====
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* Uncertain role in diagnosis at this time
* Uncertain role in diagnosis at this time
**May reveal B lines, consolidation, or "ragged" appearance of pleural line
**May reveal B lines, consolidation, or "ragged" appearance of pleural line
*Useful in evaluating undifferentiated Dyspnea
**[[Ultrasound: Cardiac]]
**[[Ultrasound: Lungs]]
**[[IVC ultrasound]]
==Management by Lung Phenotypes==
{{COVID-19 Lung Phenotypes}}


==Management==
==Management==
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{{COVID PPE summary table}}
{{COVID PPE summary table}}


===Mild Cases===
===Mild Patient Management===
*Isolate all patients suspected of having COVID-19
**[[Hospital preparedness: COVID-19]]
*Supportive care is mainstay of therapy for patients with mild viral symptoms
*Supportive care is mainstay of therapy for patients with mild viral symptoms
*Most patients will do well enough for discharge home
*80% of patients do not require hospital admission
*Discuss with Dept of Public Health, who will guide testing and, if discharging, help patient remain in isolation at home
*Discuss with Dept of Public Health, who will guide testing and, if discharging, help patient remain in isolation at home
*Some define low acuity as SaO2 > 93% on RA, RR < 20, and HR < 110 (if febrile, re-check acuity determined after acetaminophen)
*[[Testing+Surveillance: COVID]]
===Moderate/Severe Patient Management===
* 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.
*Cardiovascular <ref>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</ref>
**Most patients without hemodynamic compromise
**Maintain euvolemia - hypervolemia may contribute to ARDS
**Hypoperfusion - cautious fluid resuscitation
**Vasopressors
***1st line - [[Norepinepherine]] ([[Epinephrine]] if NorEpi) not available
***2nd line - [[Vasopressin]]
*Infectious disease
**Acetaminophen for fever
**Consider empiric Abx for pneumonia
*Pulmonary <ref>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</ref>
**Supplemental O2 if Sat<90%
***Target SPO2 92%-96%
***[[Oxygen therapy]]
**"Happy Hypoxemia" Many of these patients will be hypoxic without dyspnea
**High-flow Nasal Cannula
***Some guidelines recommending HFNC over BIPAP/CPAP in those that fail low-flow O2. <ref>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</ref>
***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


===[[Respiratory failure]]===
==[[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
*[[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
**Using 2 viral filters attached to a "2-tube NIPPV circuit" in a negative pressure room may sufficiently prevent viral spread
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*See also [[deterioration after intubation]]
*See also [[deterioration after intubation]]


===Investigational Agents===
==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<ref>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</ref>
**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''
* [[Bag-valve-mask]] (BVM)
* CPAP/[[BiPAP]]
* [[Intubation]]
* Nebulizer administration (if possible, use MDI instead)
* Bronchoscopy
* Chest PT
*[[Oxygen therapy|High-Flow Nasal Cannula]]
 
{{COVID-19 intubation}}
 
==Investigational Agents==
<p>''See [[COVID-19: Medication therapy]] for the latest recommendations''</p>
''Generally not started in ED setting; CDC does not recommend for or against any investigational therapies at this time''
''Generally not started in ED setting; CDC does not recommend for or against any investigational therapies at this time''
*'''[[Remdesivir]] (IV)'''
*'''[[Remdesivir]] (IV)'''
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*** 3 clinical trials across country (one is NIH adaptive trial)
*** 3 clinical trials across country (one is NIH adaptive trial)
*** 2 other trials are investigational open-label trials testing different dosages for moderate or severely hospitalized patients  
*** 2 other trials are investigational open-label trials testing different dosages for moderate or severely hospitalized patients  
* Limited data on [[Ritonavir]], [[chloroquine]], and hydroxychloroquine
* Lopinavir/ritonavir
**anti-retroviral protease inhibitor (old HIV drug combo)
* [[Chloroquine]], and [[hydroxychloroquine]]
** In vitro activity against SARS-CoV-2, perhaps some anti-inflammatory benefit
*Azithromycin
**Macrolide antibiotic (protein synthesis inhibitor)
**Purported anti-inflammatory mechanisms. Possibly inhibits neutrophil proliferation/lymphocyte activation
*Glucocorticoids
**Binds nuclear receptor and regulates gene expression of several inflammatory molecules (e.g. SLPI)
**May blunt cytokine storm in critically ill patients
**Caution: also inhibits viral clearance
*Tocilizumab
**May blunt cytokine storm in patients with elevated IL-6
 
*Convalescent plasma (plasma/antibodies from healthy survivors)
*Convalescent plasma (plasma/antibodies from healthy survivors)
**Has been used in prior viral epidemics with success
**Has been used in prior viral epidemics with success
**No proven benefit, but actively being researched
**No proven benefit, but actively being researched


===Contraindicated===
==Contraindicated Therapies==
*Avoid steroids unless strong non-COVID indication (due to progression of viral replication reported from prior coronaviruses; e.g. [[MERS]], [[SARS]])
*Avoid steroids unless strong non-COVID indication (due to progression of viral replication reported from prior coronaviruses; e.g. [[MERS]], [[SARS]])
**Possible benefit in severely ill patients to treat cytokine storm
* Avoid nebulizers as they are generally ineffective and may aerosolize virus
* Avoid nebulizers as they are generally ineffective and may aerosolize virus
** [[Albuterol]] with spacer is safer, though probably ineffective unless co-occuring reactive airway disease  
** [[Albuterol]] with spacer is safer, though probably ineffective unless co-occuring reactive airway disease  
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****<20 kg or 5yrs old: 4-5 puffs with a spacer every 20 minutes. 4 breaths between puffs.
****<20 kg or 5yrs old: 4-5 puffs with a spacer every 20 minutes. 4 breaths between puffs.
****>20 kg or 5yrs old: 8-10 puffs with a spacer every 20 minutes. 4 breaths between puffs.
****>20 kg or 5yrs old: 8-10 puffs with a spacer every 20 minutes. 4 breaths between puffs.
* Generally avoid [[BiPAP]] and high-flow nasal [[oxygen]] as these may increase viral spread
* Caution with [[BiPAP]] and high-flow nasal [[oxygen]] as these may increase viral spread
** WHO cautiously states that high flow [[oxygen]] may be occasionally indicated.
** WHO cautiously states that high flow [[oxygen]] may be indicated. If used, cover HFNC with surgical mask.
*There is anecdotal concern about [[NSAID]] use; some have suggested preferentially using [[acetaminophen]] however, there are no formal recommendations to avoid NSAIDs at this time
*There is anecdotal concern about [[NSAID]] use; some have suggested preferentially using [[acetaminophen]] however, there are no formal recommendations to avoid NSAIDs at this time
*There is anecdotal concern about ACEi/ARB use, however no formal recommendations to avoid use at this time
*There is anecdotal concern about ACEi/ARB use, however no formal recommendations to avoid use at this time
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==Special Situations==
==Special Situations==
*For pregnant patients see: [[COVID-19 in pregnancy]]
*For pregnant patients see: [[COVID-19 in pregnancy]]
*For pediatric patients see: [[COVID-19 (peds)]]
*For pediatric patients see: [[COVID-19 in pediatrics]]


===Covid-19 and [[STEMI]]===
===Covid-19 and [[STEMI]]===
*Preference is for thrombolytic therapy to avoid [[PCI]] personnel exposoure
*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 [[Retavase]] 10u Retavase (reteplase) IV bolus ([[reteplase]])followed by a second bolus at 30 minute rather than PCI.  OR
**Administer [[Retavase]] 10u Retavase (reteplase) IV bolus ([[reteplase]])followed by a second bolus at 30 minute rather than PCI.  OR
**[[Tenectoplase]] (TNKase) 30 mg IV bolus       
**[[Tenectoplase]] (TNKase) 30 mg IV bolus       
**If [[Tenectoplase]] 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).
**If [[Tenectoplase]] 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).
*Followed [[thrombolytics]]  by 40u/kg [[heparin]] (max dose 4,000 units) IV and 600mg [[clopidogrel]] PO and [[ASA]] 325 mg PO
**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


==Disposition==
==Disposition==
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===Admission===
===Admission===
* Hospitalize: Respiratory distress/failure, multi-organ failure, rapid disease progression requiring escalating supportive care
* 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.  
**PSI/PORT, MuLBSTA, and CURB65 scores have all been proposed criteria for admission and predicting outcomes.  
***These scores are not externally validated. Use with caution. https://www.mdcalc.com/covid-19#calcs
***These scores are not externally validated. Use with caution. https://www.mdcalc.com/covid-19#calcs
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==Prognosis==
==Prognosis==
{{COVID Risk Factors}}
===All-Comers===
===All-Comers===
* Case fatality rate (CFR) = 2-4% (from Hubei data)
* Case fatality rate (CFR) = 2-4% (from Hubei data)
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==See Also==
==See Also==
{{COVID see also}}
{{Special:Prefixindex/COVID-19 |hideredirects=1}}


==External Links==
==External Links==

Revision as of 06:24, 5 May 2020

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

Template:COVID epidemiology

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

  • Most common complications: pneumonia, ARDS (average 8 days from onset, 20% of patients in China)
  • Myocarditis: elevated troponin, arrhythmias, heart failure
  • According to limited ICU data (21 cases) from Washington state (Arentz et al):
    • Vasodilatory shock reported in 67% of ICU admissions
    • Cardiomyopathy reported in 33% of ICU admissions
    • Mortality reported 67% of ICU admissions

Differential Diagnosis

Influenza-Like Illness

Causes of Pneumonia

Bacteria

Viral

Fungal

Parasitic

Evaluation

  • Consider minimal workup in well-appearing patients with mild disease

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
    • BMP
    • Mg
    • Phos
  • CBC w/diff
    • Lymphopenia - common (80%)[3]
    • Thrombocytopenia - common but mild
      • <100 poor prognostic sign [4]
  • 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 [5], [6]
      • Negative points to non-infectious cause (CHF/ESRD)
    • Procalcitonin - normal/mild increased on admission. Normal procalcitonin makes bacterial superinfection less likely.
    • Ferritin
    • LDH
  • Troponin [7] - 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




Management by Lung Phenotypes

COVID Lung Phenotypes and Their Management

Hypoxemic patients can be divided into two general phenotypes[8]

COVID L Lung Phenotype

  • Characterized by Low elastance (i.e., high compliance), Low ventilation to perfusion ratio, Low lung weight and Low recruitability
  • Often referred to as the “happy hypoxemic”
  • Normal lung volumes and low lung recruitability.
  • Hypoxemia may be due to loss of regulation of perfusion and loss of hypoxic vasoconstriction.
  • These patients can be damaged iatrogenically if you respond to their pulse ox with standard vent modes
  • Do poorly with low tidal volume (TV) and high PEEPs
  • Best managed with high FiO2 which allows you to limit the PEEP
  • Recommended initial vent settings:
    • 8 ml/kg TV, 100% FiO2
    • Increase the PEEP only if the patient is desaturating on a high FiO2.
    • Can turn into COVID H patients on the vent.

COVID H Lung Phenotype

  • Characterized by High elastance, High right-to-left shunt, High lung weight and High recruitability.
  • Increased permeability of the lung leads to edema, atelectasis, decreased gas volume, and decreased TV for a given inspiratory pressure.
  • High degree of lung recruitability.
  • 20 – 30% of patients fit ARDS criteria:
    • Hypoxemia
    • Bilateral infiltrates
    • Decreased the respiratory system compliance
    • Increased lung weight and potential for recruitment
  • The ARDS ladder applies only to this subset of COVID patients.

Management

See prevention of COVID-19 transmission in the healthcare setting for PPE recommendations

COVID-19 PPE Summary Table

Example summary flow chart for determining PPE use














Contact Category Precations Room Type
General (all persons) Social distancing; meticulous hygiene; basic mask NA
Undifferentiated patients at risk (e.g. prior to evaluation or testing) Contact and droplet precautions, including eye protection Negative-pressure NOT required
Persons Under Investigation Contact and droplet precautions, including eye protection Negative-pressure NOT required
Aerosol-Generating Procedures Contact and airborne precautions, including eye protection Negative-pressure required

See prevention of COVID-19 transmission in the healthcare setting for full PPE recommendations

Mild Patient Management

  • Isolate all patients suspected of having COVID-19
  • Supportive care is mainstay of therapy for patients with mild viral symptoms
  • 80% of patients do not require hospital admission
  • Discuss with Dept of Public Health, who will guide testing and, if discharging, help patient remain in isolation at home
  • Some define low acuity as SaO2 > 93% on RA, RR < 20, and HR < 110 (if febrile, re-check acuity determined after acetaminophen)
  • Testing+Surveillance: COVID

Moderate/Severe Patient Management

  • 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.
  • Cardiovascular [9]
    • Most patients without hemodynamic compromise
    • Maintain euvolemia - hypervolemia may contribute to ARDS
    • Hypoperfusion - cautious fluid resuscitation
    • Vasopressors
  • Infectious disease
    • Acetaminophen for fever
    • Consider empiric Abx for pneumonia
  • Pulmonary [10]
    • Supplemental O2 if Sat<90%
    • "Happy Hypoxemia" Many of these patients will be hypoxic without dyspnea
    • 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

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

Intubation of Potential COVID-19 Patients

Aerosol-generating procedure: see this link for PPE recommendations and related precautions

  • Use checklist if available (see example: File:Harbor COVID Airway Management v3-16-20.pdf)
  • Use BVM with viral filter or avoid BVM altogether, if possible
  • Use RSI to prevent coughing gagging; consider higher dosing of paralytics.
  • Use video laryngoscopy to keep provider face further away from patient (afterwards, clean with grey wipes, observe 3 min wet time)

Lung Protective Mechanical Ventilation

Lung Protective Ventilator Settings[12] 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[13][14]

  1. Mode
    • Volume-assist control
  2. Tidal Volume
    • Start 6-8cc/kg predicted body weight[15]
      • 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

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[16]
    • 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

Intubation of Potential COVID-19 Patients

Aerosol-generating procedure: see this link for PPE recommendations and related precautions

  • Use checklist if available (see example: File:Harbor COVID Airway Management v3-16-20.pdf)
  • Use BVM with viral filter or avoid BVM altogether, if possible
  • Use RSI to prevent coughing gagging; consider higher dosing of paralytics.
  • Use video laryngoscopy to keep provider face further away from patient (afterwards, clean with grey wipes, observe 3 min wet time)

Investigational Agents

See COVID-19: Medication therapy for the latest recommendations

Generally not started in ED setting; CDC does not recommend for or against any investigational therapies at this time

  • Remdesivir (IV)
    • Consider for severely hypoxemic (Mechanical vent, high PEEP, FiO2 requirements >40%,).
    • Contact Gilead directly for use: compassionateaccess@gilead.com
    • 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)
      • 3 clinical trials across country (one is NIH adaptive trial)
      • 2 other trials are investigational open-label trials testing different dosages for moderate or severely hospitalized patients
  • Lopinavir/ritonavir
    • anti-retroviral protease inhibitor (old HIV drug combo)
  • Chloroquine, and hydroxychloroquine
    • In vitro activity against SARS-CoV-2, perhaps some anti-inflammatory benefit
  • Azithromycin
    • Macrolide antibiotic (protein synthesis inhibitor)
    • Purported anti-inflammatory mechanisms. Possibly inhibits neutrophil proliferation/lymphocyte activation
  • Glucocorticoids
    • Binds nuclear receptor and regulates gene expression of several inflammatory molecules (e.g. SLPI)
    • May blunt cytokine storm in critically ill patients
    • Caution: also inhibits viral clearance
  • Tocilizumab
    • May blunt cytokine storm in patients with elevated IL-6
  • Convalescent plasma (plasma/antibodies from healthy survivors)
    • Has been used in prior viral epidemics with success
    • No proven benefit, but actively being researched

Contraindicated Therapies

  • Avoid steroids unless strong non-COVID indication (due to progression of viral replication reported from prior coronaviruses; e.g. MERS, SARS)
    • Possible benefit in severely ill patients to treat cytokine storm
  • Avoid nebulizers as they are generally ineffective and may aerosolize virus
    • Albuterol with spacer is safer, though probably ineffective unless co-occuring reactive airway disease
      • MDI equivalents: Albuterol or ipratropium
        • <20 kg or 5yrs old: 4-5 puffs with a spacer every 20 minutes. 4 breaths between puffs.
        • >20 kg or 5yrs old: 8-10 puffs with a spacer every 20 minutes. 4 breaths between puffs.
  • Caution with BiPAP and high-flow nasal oxygen as these may increase viral spread
    • WHO cautiously states that high flow oxygen may be indicated. If used, cover HFNC with surgical mask.
  • There is anecdotal concern about NSAID use; some have suggested preferentially using acetaminophen however, there are no formal recommendations to avoid NSAIDs at this time
  • There is anecdotal concern about ACEi/ARB use, however no formal recommendations to avoid use at this time

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 Retavase 10u Retavase (reteplase) IV bolus (reteplase)followed by a second bolus at 30 minute rather than PCI. OR
    • Tenectoplase (TNKase) 30 mg IV bolus
    • If Tenectoplase 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

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

Legal Considerations

  • HIPPA: in USA relaxation of HIPPA rules for telehealth
    • “HHS…will waive potential HIPAA penalties for good faith use of telehealth during the nationwide public health emergency due to COVID-19.”
      • This includes “non-public facing” products including Facetime/Skype:
        • www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html

Prognosis

COVID-19 Risk Factors for Severe Disease [17]

See VACO calculator

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. ↑ 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
  4. ↑ 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
  5. ↑ 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
  6. ↑ 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
  7. ↑ https://www.covidprotocols.org
  8. ↑ Gattinoni L et al. Covid-19 pneumonia: different respiratory treatment for different phenotypes. Intensive Care Medicine. 2020. https://www.esicm.org/wp-content/uploads/2020/04/684_author-proof.pdf
  9. ↑ 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
  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. ↑ 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.
  13. ↑ ARDSnet
  14. ↑ O'Brien J. Absorption Atelectasis: Incidence and Clinical Implications. AANA Journal. June 2013. Vol. 81, No. 3.
  15. ↑ 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.
  16. ↑ 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
  17. ↑ Massachusetts General Hospital COVID-19 Treatment Guide Version 1.36 04/05/2020. https://www.massgeneral.org/assets/MGH/pdf/news/coronavirus/mass-general-COVID-19-treatment-guidance.pdf. Published 2020. Accessed April 8, 2020.
  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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