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Basic FAMMed: COVID-19

Basic FAMMed: COVID-19

  • Updated: 20 April 2020

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INTRODUCTION:

The Novel Coronavirus 2019, was first reported on in Wuhan, China in late December 2019.  The outbreak was declared a public health emergency of international concern in January 2020 and on March 11th, 2020, the outbreak was declared a global pandemic.  The spread of this virus is now global with lots of media attention.  The virus has been named SARS-CoV-2 and the disease it causes has become known as coronavirus disease 2019 (COVID-19).  This new outbreak has been producing lots of hysteria and false truths being spread, however the data surrounding the biology, epidemiology, and clinical characteristics are growing daily, making this a moving target.  

RebelEM

EPIDEMIOLOGY:

  • Incubation period: 3 – 14 days

Severity:

  • 80% Mild
  • 15 % Severe (Hypoxic / Hospitalized)
  • 5 % Critical (Ventilation)

Age:

  • 0-14 years – 1%
  • 15 – 49 years – 55%
  • 50 – 64 years – 28%
  • > 65 years – 15%

Mortality Rate:

  • Higher mortality rate than Influenza
  • Moving target
  • Young people can get affected

TRANSMISSION

  • Droplet and Fomites
  • Airborne ? NOT CONFIRMED
  • Aerosol generating procedures
  • Infectious period: 10 – 14 days

Asymptomatic Carriers

SYMPTOMS:

CLINICAL PICTURE

  • Fever in 88%
  • Fatigue in 38%
  • Dry cough in 67%
  • Myalgias in 14.9%
  • Dyspnea in 18.7%
  • Headache
  • Sore Throat
  • Rhinorrhea
  • Gastrointestinal Symptoms
  • Sputum production
  • Agnosmia, Aguesia
  • Hemoptysis

COURSE OF DISEASE:

  • Stage 1 (Viral Response Phase)
    • Viral Incubation and replication
      • Mild symptoms – cough, fever, malaise (+- diarrhea)
  • Stage 2 (Pulmonary Phase)
    • Adaptive Immune Response
      • Hypoxia, Dyspnea, Abnormal Labs, Abnormal CXR
      • Admission
  • Stage 3 (Hyperinflammation Phase)
    • Disregulated cytokine storm
      • ARDS
      • Shock
      • DIC
      • Multiorgan Failure
      • DIC

CLINICAL COURSE:

  • Fever
  • Cough
  • Dyspnea
  • +- Diarrhea
  • Sepsis
  • DEATH
  • Recovery
  • Early stage (0-4 days after the onset of the symptoms), in which ground glass opacities (GGO) are frequent, with sub-pleural distribution and involving predominantly the lower lobes. Some patients in this stage could have a normal CT.
  • Progressive stage (5-8 days after the onset of the symptoms), the findings usually evolved to rapidly involvement of the two lungs or multi-lobe distribution with GGO, crazy-paving and consolidation of airspaces.
  • Peak stage (9-13 days after the onset of the symptoms), the consolidation becomes denser and it was present in almost all of the cases. Other finding was residual parenchymal bands.
  • Absorption stage (>14 days after the onset of the symptoms), no crazy paving pattern was observed, the GGO could remain.

DIAGNOSTIC CRITERIA:

  1. New or acutely worsening cough (duration < 2 weeks) OR
  2. New or acutely worsening shortness of breath OR
  3. Fever OR
  4. Other viral symptoms that the clinician deems compatible with COVID-19

*Initially travelling was included, but this was removed as COVID became a community disease.

  1. Normal respiratory rate can often be seen as lung compliance remains normal
  2. Walking challenge suggested to assess for desaturation.
    • Relevant for Telehealth
  1. Respiratory rate > 30/min
  2. SPo2- <93%
  3. PaO2/FiO2 <300 mmHg or < 40 kpa (Converter)
  4. Lung infiltrates >50% within 24- 48 hours
  1. Mild
  2. Silent Hypoxia – “Happy Hypoxic” (can cause iatrogenic injury when intubated in this phase)
  3. Indolent – Fine then not
  4. Hyperacute
  1. The well COVID-19 patient – URI/flu-like illness +/- abnormal CXR, but normal/near normal vital signs
  2. “Happy hypoxic” – relatively asymptomatic and appearing comfortable but oxygen saturation <90% despite 5-6L NP and 15L NRB, consider HFNC with covering surgical mask or CPAP in negative pressure room, both of which may prevent the need for intubation
  3. Respiratory failure – severe hypoxia and tachypnea who appear to be tiring; consider early intubation and preoxygenation with CPAP or gentle controlled BVM 2 person (6-10 breaths/min)

Clinical diagnosis of COVID-19 is cough and/or fever, lymphocytpenia and bilateral ground glass opacities on chest x-ray. Unilateral radiological signs can also indicate COVID.

  • ONLINE TOOLS

    • CAP – Community Acquired Pneumonia Score
    • SOFA – Sequential Organ Failure Assessment Score

PROGNOSIS

  1. Low Risk: These are well patients who are likely safe to be discharged home. When numbers are low this will be done with the approval of IP&C and Public Health (PH). If numbers get high, you will likely have a process put in place to discharge patients without IPC/PH approval just like you would do for influenza now. IPC/PH will likely want to know the patient’s name and contact information so they can track them. You should also have written instructions for patients about how to self-isolate and a telephone hotline they can call for advice to avoid a return visit.

     

  2. Medium Risk:  High CAP Score or supplemental 02< 50% needed to keep 02 sat >90. Admit to hospital or COVID-19 treatment site (possible, if numbers are high).

     

  3. High Risk: High CAP Score or Fi02> 50 % needed to keep sat >90% OR signs of respiratory fatigue or hemodynamic instability. Early referral or transfer to a hospital with ICU capacity to perform controlled intubation is key. If this is not rapidly available, your team must have a process in place to manage this patient and perform airway management safely. Video or teleconsulting may be available in some areas.

Emergency Medicine Cases

  • Risk Factors for severe disease and increase mortality rate: (1)

    • Older Age (> 60 years)
    • Male sex
    • Medical comorbidities
    • Chronic pulmonary diseases (COPD…)
    • Cardiovascular disease (HTN, CAD)
    • Chronic kidney disease
    • Diabetes
    • HIV
    • Organ Transplant or immunosuppressants
    • Cancer
    • Smoking (Small increase risk)
    • Obesity (weak evidence)
    • Elevated SOFA score
  • Poor Prognostic Indicators:

    • Vital Signs
      • Respiratory rate >24 breaths/min
      • Heart rate > 125 b/m
      • Oxygen saturation <90% on room air
    • Labs
      • Lymphycytopenia
      • Elevated D-Dimer

DIAGNOSIS:

TESTING:

  • Nasopharyngeal Swab
    • Red Top Swab
    • Blue Aptima Unisex Swab
  • Oropharyngeal Swab
    • Blue Top Copan Throat Swab (Only if swab shortage)
  • Tracheal Aspirate – Intubated Patients
  • If initial testing is negative but the suspicion for COVID-19 remains, the WHO recommends re-sampling and testing from multiple respiratory tract sites
  • Sensitivity +- 70%: ensure symptoms > 24 hours prior to testing

Imaging:

  • CXR
    • The findings on CXR are not specific, and in the initial phases of the disease the studies could be normal. The most common features include lobar/ multi-lobar / bilateral lung consolidation.
  • CT
    • Early stage (0-4 days after the onset of the symptoms), in which ground glass opacities (GGO) are frequent, with sub-pleural distribution and involving predominantly the lower lobes. Some patients in this stage could have a normal CT.
    • Progressive stage (5-8 days after the onset of the symptoms), the findings usually evolved to rapidly involvement of the two lungs or multi-lobe distribution with GGO, crazy-paving and consolidation of airspaces.
    • Peak stage (9-13 days after the onset of the symptoms), the consolidation becomes denser and it was present in almost all of the cases. Other finding was residual parenchymal bands.
    • Absorption stage (>14 days after the onset of the symptoms), no crazy paving pattern was observed, the GGO could remain.
  • Lung Ultrasound
    • The findings include: Irregular pleural lines, sub-pleural areas of consolidation, areas of White lung and thick B lines [67]. It is a tool that could be used at bed side avoiding the need for shifting infected patients to a Radiology suite.
    • Learn more.

LABORATORY:

  1. Portable CXR
  2. ER Panel (CBC, lytes, BUN, Cr, Glucose)
  3. LDH
  4. Troponin
  5. INR
  6. ALT
  7. CRP
  8. VBG
  9. Influenza Swab – Co-infection is common.

Add other investigations at physician’s discretion: Blood Cultures, EKG, ABG, D-Dimer etc.

Spectrum 

Lymphocytopenia is present in >80% in patients and is probably the most useful lab test in distinguishing COVID-19 from other causes of respiratory infection.

Nonspecific lab abnormalities include elevated LDH, AST, ALT, elevated D-dimer, abnormal WBC.

Troponin and CRP may be a predictor of mortality and severe illness, and should be considered in patients who are going to be admitted.

While influenza co-infection has been reported with COVID-19, our expert recommends leaving the decision to test for influenza to the inpatient team, your local infection control specialists or public health authorities. There may be a role for testing for influenza for all ICU patients admitted with suspected COVID-19, as some patients may benefit from neuraminidase inhibitors.

Emergency Medicine Cases

  • Pro-Calcitonin:
    • Significantly elevated in bacterial infection rather than covid
  • CRP: 
    • In a patient with severe respiratory failure and a normal CRP, consider non-COVID etiologies (such as heart failure). (Farkas)

MANAGEMENT

Outpatient

  • Consider prophylactic dose anticoagulation in patients at high risk of venothromboembolsim and low risk of bleeding,
  • Avoid immobilization
  • Consider transitioning patients taking warfarin to a DOAC

Inpatient

  • Prophylactic dose anticoagulation for all patients without specific contraindications who are not in DIC
  • There is limited evidence to guide which patients require empiric full dose anticoagulation
  • Elevated D-dimer is common in COVID-19 patients; investigation for PE/DVT should be considered in:
    • those with symptoms of DVT
    • acute unexplained RV dysfunction or
    • hypoxemia out of proportion to COVID-19 and/or other underlying lung pathology

Bikdeli, B et al. COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up.

Emergency Medicine Cases

PERSONAL PROTECTIVE EQUIPMENT

  • Surgical Mask, Eye Protection and gloves for ALL patient interaction
  • Droplet and contact precautions
    • All suspected or confirmed cases.
  • Airborne and Droplet precautions
    • Use in a negative pressure room
    • N95 mask, Eye Protection, Gloves, Gown, Bouffant Cap
    • Any aerosol generating medical procedures
      • Intubation
      • HFNC
      • CPAP
      • NC O2 > 6L
      • Chest Tube
      • Code Blue (Cardiac Arrest)
  • Cover your cellphone in protective bag and wipe often. 

DISPOSITION

  • Decide on care goals early
    • MOST
    • Frailty Score
    • Cognitive Function
    • Comorbidities
    • Severity of Disease
  • Who?
    • SATS > 93%
    • Mild symptoms
    • Normal Labs/ CXR
    • Consider Swab if risk factors
  • Other considerations
    • 3rd trimester
    • ADL / Support
    • Age
    • Healthcare Worker
  • Rx
    • Self Isolate
    • Telehealth follow-up 48 hours and 72 hours (COVID team or primary care)
  • Who?
    • Signs of COVID + hypoxic (at rest or with exertion)
    • Risk factors for severe disease
    • Abnormal CXR
    • Abnormal Labs
  • Rx:
    • Admission
      • O2 supplementation
  • Who?
    • Refractory Hypoxia (more than 4L and Sats < 93%)
    • Respiratory Acidosis = pH < 7.2
    • Clinical Respiratory Failure
    • Hypotension (SBP < 90)
    • Myocardial Injury
      • Troponin rise initially or 4 days after
  • Rx
    • Consult ICU
  • Who?
    • Not coping with HFNC or BiPAP and Proning
    • Respiratory fatigue
    • Altered Mental Status
    • Increased Dyspnea
  • How:
    • Most Experienced Intubator
    • Advanced PPE
    • Place plastic over patient
    • Glidoscope
    • RSI
    • NO Bagging, direct connection to Ventilator
    • Viral Filter
    • Watch for VT or VF

Associated with high mortality

COMPLICATIONS

  • Observation only:
    • Myocarditis
    • Myocardial Infarction
    • Sepsis
    • Coagulopathy – DIC
    • Ketoacidosis
    • Pericarditis
    • Encephalopathy
    • Cardiomyopathy

See post on Palliative Care and COVID

TEMPLATES

COVID CORE ON-CALL: Admission / Assessment

IDENTIFICATION:

[]

MOST: []

PRESENTING COMPLAINT:

[]

Specific Symptoms: 

  • Myalgia: []
  • Headache: []
  • Sneezing: []
  • Anosmia: []
  • Cough: []
  • Fever: []
  • GI Symptoms: []
  • Sore Throat: []
  • Chest Pain: []
  • Fatigue: []
  • Dyspnea: []
  • Rhinorrhea: []
  • Hemoptysis: []
  • Ear Pain: []
  • Atralgia: []
  • Seizures: []
  • Conjunctivitis: []
  • Skin Rash: []
  • Lymphadenopathy: []

Other:

  • Travel: [Mention start and end date of travel. Where? How?]
  • Contacts:
    • Confirmed: []
    • Suspected case: []
    • HCW: []
  • Indigenous: []

Vaccinations:

  • Influenza: []
  • Pneumovac: []

PREVIOUS MEDICAL HISTORY:

[]

PREVIOUS SURGICAL HISTORY:

[]

SOCIAL:

  • Living Conditions: []
  • Smoking: [daily use? pack years?]
  • Vaping: []
  • Alcohol: []
  • Elicit Drug Use: []
  • Marijuana: []

MEDICATIONS:

[]

ALLERGIES: 

[]

VITAL SIGNS:

[]

EXAMINATION: (PPE)

General: []

Chest: []

CVS: []

Neuro: [GCS]

Abdominal: []

ENT: []

BEDSIDE INVESTIGATIONS:

POCUS: [Deferred]

SPECIAL INVESTIGATIONS: []

CXR: []

LABS: []

Other: []

ASSESSMENT: (Create a problem list for ongoing notes)

  1. []

PLAN:

  1. COVID Protocol Initiated

COVID: 

PROGRESS NOTE:

IDENTIFICATION:

[]

MOST: []

OVERVIEW:

[Stipulate key aspects from the history and clinical parameters and provide the next physician with the key problem]

PROBLEM LIST:

Active:

[Paste problem list from assessment notes – document assessment and plan for each problem in this list. Trend parameters within this section for example labs etc]

Chronic:

[List medical problems]

CARE PARAMETERS:

Diet: []

VTE: []

IV Fluids: []

Physio: []

Oxygen: []

MEDICATIONS/ TREATMENTS:

  1. []

 

VENTILATION:

[]

TODAY:

[Provide an overview of subjective findings]

VITAL SIGNS:

[]

EXAMINATION:

[]

DISCHARGE PLANNING:

[]

REFERENCES

  1. INTERNATIONAL PULMONOLOGIST’S CONSENSUS ON COVID-19,  Dr. Tinku Joseph (India), Dr. Mohammed Ashkan (Iran)

TAGS

  • COVID
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