COVID-19: Difference between revisions

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{{AdultPage|COVID-19 (peds)}}. For pregnant patients see [[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.
*Caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)  
*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}}


==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<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
**Sudden onset anosmia has a high specificity for COVID-19 infection


==Introduction==
{| {{table}}
* The current national and international pandemic is from a virus named SARS-CoV-2 (previously 2019-nCoV), which causes a disease named COVID-19.
| align="center" style="background:#f0f0f0;"|'''Symptom<ref>World Health Organization. "Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19)" (PDF): 11–12. Retrieved 5 March 2020.</ref>'''
 
|'''%'''
=== Virology Background ===
|-
*Coronaviruses are common human pathogens
|[[Fever]]
**Cause the common cold
|87.9
**In epidemics, cause up to one-third of community-acquired upper respiratory tract infections in adults; and may cause diarrhea in infants and children
|-
*SARS-CoV-2 is a novel coronavirus (a new strain not previously identified in humans)
|Dry [[cough]]
**Likely primary source = bats
|67.7
**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
|-
*Surface survival time of SARS-CoV-2:
|Fatigue
**stainless steel: persists for 3 hours (or longer)
|38.1
**underscores the importance of environmental cleaning / disinfection
|-
***cleaning gets rid of the proteins that would interfere with a disinfectants effectiveness
|Sputum production
**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
|33.4
 
|-
 
|[[Shortness of breath]]
=== Covid19 Basic Epidemiology / Infectivity Data ===
|18.6
* Expected patient outcomes (from data so far):
|-
** 80% have mild symptoms
|Myalgia or arthralgia
** 15% have severe disease requiring hospitalisation
|14.8
** 5% require mechanical ventilation
|-
* Case fatality rate (CFR) = 2-4% (from Hubei data)
|[[Sore throat]]
** SARS ~ 10%
|13.9
** MERS ~ 35%
|-
** Seasonal flu ~ 0.1-0.2%
|[[Headache]]
** 1918 Pandemic Influenza ~ 2-3%
|13.6
* R0 = 2.2 - 4.2
|-
** Where R0 = expected number of secondary cases produced by a single typical infection in a susceptible population (basic reproductive rate)
|Chills
** R0 for seasonal flu ~ 1.3
|11.4
** R0 for pandemic flu ~ 1.5-1.8
|-
* Incubation: 5 days (median); range of 2-14 days
|[[Nausea or vomiting]]
* Serial interval duration = 7.5 days
|5.0
** Serial interval refers to the time from illness onset in successive cases in a transmission chain
|-
 
|Nasal congestion
[[File:Ro example.png|thumb|center|Ro Example]]
|4.8
|-
|[[Diarrhea]]
|3.7
|-
|[[Hemoptysis]]
|0.9
|-
|[[Conjunctivitis]]
|0.8
|}


==Clinical Features==
===Common Complications===
===Broad Testing Recommendations===
''The initial presentation can be followed by delayed and serious complications''
''The CDC has expanded testing beyond the initial travel to china recommendations<ref>Criteria to Guide Evaluation and Laboratory Testing for COVID-19 https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html</ref>''
* Pulmonary
*Test any person who has fever or respiratory illness AND had close contact with a known COVID-19 patient
**Most common complications: [[pneumonia]], [[ARDS]] (average 8 days from onset, 20% of patients in China)
*Test any person who has fever or respiratory illness AND a history of travel to CDC-classified high risk areas or areas with recent significant community spread
**"Happy Hypoxemia": many of these patients will be hypoxic without dyspnea
*Test any person who has severe respiratory illness AND is being admitted to the hospital
** Decompensation risk occurs during 2nd week of illness leading to [[respiratory failure]]
*Test any hospitalized person who has respiratory illness AND no alternative diagnosis
*Cardiac Complications<ref>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</ref>
*Consider testing any person who has respiratory illness AND lives in a residential facility such as a nursing home or recently returned from a cruise
**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)<ref>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</ref>
**acute CVA, encephalitis, Guillain-Barré syndrome, acute necrotizing hemorrhagic encephalopathy, and hemophagocytic lymphohistiocytosis


==Differential Diagnosis==
==Differential Diagnosis==
*[[Pneumonia]]
*[[Sinusitis]]
{{ILI DDX}}
{{ILI DDX}}
{{Causes of pneumonia}}
{{Causes of pneumonia}}


==Evaluation==
==Evaluation==
[[File:COVID one pager with links.jpg|thumb|]]
===Workup===
[[File:COVID one pager with links 2.jpg|thumb|]]
''Consider minimal to no workup in well-appearing patients with mild disease''
===Patient rooming===
====Viral Testing====
*Evaluation of patients does not need to occur in the hospital and can easily occur outside the ED if the patient is not in extremis
[[Testing+Surveillance: COVID]]
*Although negative pressure rooms are preferred due to the droplet precautions, a non-negative pressure room is acceptable
*RT-PCR (reverse transcriptase polymerase chain reaction) is most commonly used test for confirming cases
===Viral Test===
**Sensitivity may be only 75%, but highly specific
*In the United States, the US Centers for Disease Control is distributing the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel to public health labs through its International Reagent Resource<ref>https://www.internationalreagentresource.org/</ref>
**Turnaround time may be several hours to days
*Internationally the WHO has distributed kits based on the RT-PCR platform<ref>Sheridan, Cormac . "Coronavirus and the race to distribute reliable diagnostics". Nature Biotechnology https://www.nature.com/articles/d41587-020-00002-2</ref>
*Real time RT-PCR e.g. Cepheid
*BIOFIRE RESP PANEL Corona Virus assay does NOT detect this subtype - DO NOT USE
**Rapid test with results in <1hr
 
*Serologic testing for IgM/IgG is not widely available, but likely more sensitive
==Management==
**The presence of IgG with a negative RT-PCR likely confirms past exposure and some immunity
===Personal Protective Equipment===
*Test kit availability varies widely by region and institution
====Clinical Assessment====
''PPE for evaluating a patient clinically should include:''
*N95
*Face mask
*Surgical Gown and gloves
*The video below indicates the proper order for donning and doffing PPE for clinical evaluation of a patient
 
====During Intubation====
*N95 or PAPR
*Surgical Mask over N95
*Goggles that surround eyes with facial contact, face shield, or full joint-replacement-hood with visor
*Bunny suit, preferably with hood or disposable fluid-proof gown
**If no hooded suit available, sterile disposable cap
*2 pairs gloves, 1 under sleeves of bunny suit or gown and 1 over, under-layer gloves would ideally be long cuffed
 
===Mild Cases===
*Supportive care is mainstay of therapy for patients with mild viral symptoms
*Most patients will do well enough for discharge home
*Discuss with Dept of Public Health, who will guide testing and, if discharging, help patient remain in isolation at home
 
===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
*During [[BVM]], if needed, use a viral filter
*Due to the viral spread risk early intubation is the preferred means of airway managment
 
==Disposition==
*Mild cases for perons under investigation for Covid19 awaiting a positive test result can self quarantine at home in conjunction with the local Public Health Dept
*If admitting, needs to be placed in negative pressure isolation room with airborne and droplet precautions
 
==Complications==
*[[ARDS]]
*[[Respiratory failure]]
*[[Renal failure]]
 
==See Also==
*[[Coronavirus]]
*[[Harbor:Infectious Disease Threats]]
*[[WLA_VA:COVID19]]
 
==External Links==
*https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html
*https://emcrit.org/emcrit/some-additional-covid-airway-management-thoughts/
 
==Video==
{{#widget:YouTube|id=exV5hEG62CY}}


==References==
====Labs====
<references/>
''Consider in sicker patients (likely requiring admission):''
*Chemistry
*CBC w/diff
**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>
**Thrombocytopenia - common but mild
***<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>
*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 <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>
***Negative points to non-infectious cause (CHF/ESRD)
**Procalcitonin - normal/mild increased on admission. Normal procalcitonin makes bacterial superinfection less likely.
**Ferritin
**LDH
*Troponin <ref>https://www.covidprotocols.org</ref> - 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====
[[File:COVID one pager with links.jpg|thumb|CXR of COVID]]
[[File:COVID one pager with links 2.jpg|thumb|CT of COVID]]
[[File:covidcxr.jpg|thumb|CT of COVID]]


=== Clinical Findings ===
=====X-ray=====
* At onset: fever, dry cough, myalgias, fatigue, shortness of breath
* Portable [[CXR]] preferred in PUI to prevent spread of infection
** Fever and cough start early, SOB noted about 9 days into illness
** Fever not present in all adults (less common in vulnerable populations)
** Less common: cough with sputum, sore throat, headache, congestion, GI symptoms
* Most common complications: pneumonia, ARDS (avg 8 days from onset, 20% of patients in China)
** Decompensation risk occurs during 2nd week of illness
* Risk factors: older adults, underlying conditions (lung disease, heart disease, diabetes)
** Children: milder disease
** 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]])
 
==== Laboratory Findings ====
* 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 influenza/viral respiratory panel to identify alternative diagnoses
**** Although co-infection is possible
 
==== Imaging ====
'''XRay:'''
** Portable CXR preferred in PUI to prevent spread of infection
** May be normal in early disease
** May be normal in early disease
** Typical pattern is peripheral patchy ground glass opacities (GGO)
** Typical pattern is peripheral patchy ground glass opacities (GGO)
** 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
'''CT:'''
** 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.
* Many have normal imaging early on (so CDC DOES not recommend CT for diagnostic purposes at this time)
 
=====CT=====
* Many have normal imaging early on (CDC does '''not''' recommend CT for diagnostic purposes)
** CT (86%) more sensitive than CXR (59%) for detecting GGOs
** CT (86%) more sensitive than CXR (59%) for detecting GGOs
** Radiopaedia COVID-19 Resources (https://radiopaedia.org/articles/covid-19)
**Generally, the findings on chest imaging are not specific and overlap with other infections, including influenza, H1N1, SARS and MERS.<ref>From the American College of Radiology (3/11/20):</ref>
** 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.”
* Reinfection (after recovery from COVID19): unclear if possible
** Limited data. Unlikely to be reinfected shortly after but unknown about later on


==General Prevention Recommendations==
=====US=====
* Exercise general infection precautions
* Uncertain role in diagnosis at this time
** Person-to-person transmission occurs with close contact (6 feet)
**May reveal B lines, consolidation, or "ragged" appearance of pleural line
*** Direct contact with mucous membranes or respiratory droplets
*Useful in evaluating undifferentiated Dyspnea
*** Indirect: cough —> secretions left on surface —> 2nd person touches surface secretions and touches face & mucous membranes
**[[Ultrasound: Cardiac]]
** Avoid touching your face (try it, it’s not easy)
**[[Ultrasound: Lungs]]
** Frequent Handwashing
**[[IVC ultrasound]]
*** Alcohol based hand sanitizer
*** Diligent hand wasing
**** 20 seconds minimum
**** Image shows commonly forgotten areas: thumb (ulnar aspect), fingertips, WRIST (Borrowed from WHO Hand Hygiene for Healthcare)
** Wear a mask if you develop respiratory symptoms (fever, cough, rhinorrhea, congestion) to prevent spread
* Avoid unnecessary travel
* Stay home if symptomatic
** Home care does not mean being out in the parks with other groups of people
** Contact your supervisor: due to expected HCW shortages, minor symptoms may be allowed to continue working with adequate PPE to prevent infection spread


[[File:Hand Hygiene.png|thumb|center]]
===Diagnosis===
*Typically confirmed by viral testing (see above)


==Precautions For Healthcare Workers==
====Disease Severity====
=== PPE Bottom Line: Per CDC and LADPH (3.12.20) ===
''Some define moderate and severe acuity as follows''
* “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”
* Low: SaO2 > 93% on RA, RR < 20, and HR < 110
* No airborne isolation required (unless aerosol-generating procedure)
* 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.


=== Transmission ===
===Prediction of Need for Intubation===
* Simply walking into a room is NOT a recognized risk of transmission. Must make contact with respiratory droplet (directly or indirectly)
*ROX Index for intubation after high-flow nasal cannula (HFNC}
* Masks: MOST IMPORTANT utility is to put on the coughing individual
**Predicts HFNC failure/need for intubation
** Research clearly demonstrates it decreases shedding of infectious material in the environment
**https://www.mdcalc.com/rox-index-intubation-hfnc
** This is more effective than HCWs wearing masks prophylactically to prevent catching the infection when not actually performing close contact patient care
* How long to shut a patient room down after a COVID patient is in there?
** 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
** 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)
*** Most modern rooms designed to have 12 air exchanges per hour
*** Ventilation symptoms vary. So, older / fewer exchanges per hour => more time.


=== PPE Guidelines ===
==Management==
* EVERY PATIENT CONTACT: Respiratory droplet precautions. Contact precautions also recommended but if gowns in short supply consider reserving for aerosol-generating procedures
{{COVID PPE summary table}}
** Droplet = surgical mask, eye protection
** Contact = gown and gloves
* For AEROSOL GENERATING procedures: airborne precautions (N95/PAPR)
** Due to higher risk of aerosolizing droplets-- infection itself doesn’t seem to be spread via airborne route)
** Aerosol generating procedures (avoid when possible)
*** Bag-valve mask (BMV)
*** CPAP/BiPAP
*** Intubation
*** Nebulizer administration (COMMONLY FORGOTTEN) - use MDI instead. E.g. 8-12 MDI puffs instead of albuterol 2.5-5mg INH.
*** Bronchoscopy
*** Chest PT
** 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!


=== PPE Shortage/Limiting Usage Guidelines ===
===General Supportive Care===
In case of PPE shortage or in an attempt to save on PPE supplies, the following guidelines were approved by CDC 3/13/20
====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>====
* Same respirator 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:
*Supplemental [[oxygen therapy]] if Sat<90%
* No need to change mask or eye protection
**Target SPO2 92%-96%
* BUT need to change gown and gloves
*High-flow Nasal Cannula
* Respirator reuse possible? 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)
**Some guidelines recommend 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>
* If you must do this because of limited supplies, don and doff properly and perform proper hand hygiene in between
**Requires patient to be on airborne isolation.
* CDC / NIOSH will allow certain N95s to be used beyond manufacture-designated shelf life
*[[Non-Invasive Ventilation]] if no HFNC
** See list of appropriate models here (manufactured between 2003-2013)
*Consider awake proning to improve oxygenation
* N95 Reuse? 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.
*Bronchodilators if bronchospasm present
** Based on non peer reviewed reports from Washington State
**Use metered-dose inhaler (avoid nebulizers due to aerosolization)


=== Healthcare Worker Monitoring ===
====Other====
* Every HCW should be keeping a thermometer at home
*Infectious disease
* Self-monitor BID (and especially before work). Facilities should screen their HCW prior to shifts.  
**[[Acetaminophen]] for fever
* If symptomatic, notify supervisor.
**Consider antibiotics for bacterial [[pneumonia]] coverage
* If febrile, STAY HOME.
*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>
* 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
**Most patients without hemodynamic compromise
**Maintain euvolemia - hypervolemia may contribute to ARDS
**Hypoperfusion - cautious fluid resuscitation
**Vasopressors
***1st line - [[Norepinepherine]] (alternative: [[epinephrine]])
***2nd line - [[Vasopressin]]
*Vascular
**Consider [[COVID-19:_Medication_therapy#Anticoagulation|anticoagulation]]


==Isolation==
===Medications by Patient Category===
* 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.
[[File:Outpatient Fig 1.png|thumb|NIH consensus guidelines for COVID treatment.<ref>https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/clinical-management-summary/</ref>]]
* CDC: Reasonable to isolate patients with unexplained fever and respiratory symptoms (and no travel history) at this time
[[File:Inpatient Fig 2.png|thumb|NIH consensus guidelines for COVID treatment.<ref>https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/clinical-management-summary/</ref>]]


==Testing==
====Outpatients Not Requiring Admission<ref>https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/clinical-management-summary/</ref>====
* LA County DPH checklist (http://publichealth.lacounty.gov/acd/ncorona2019/checklist.htm)
*High risk patients (one of the following, if available):
* Mild illness: DO NOT send for testing (increased risk of exposure to COVID-19)
**Ritonavir-boosted nirmatrelvir ([[Paxlovid]])
* ER: DO NOT go unless hospital level of care is needed (increased exposure of other patients and staff)  
**[[Sotrovimab]]
* Testing can be done in ambulatory setting if absolutely needed (see precautions)
**[[Remdesivir]]
**[[Molnupiravir]]
''[[Dexamethasone]] has '''not''' demonstrated benefit in this patient category and may be potentially harmful''


===Guidelines: Epidemiologic Factors===
====Outpatients Requiring Home Oxygen (New or Increased)<ref>https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/clinical-management-summary/</ref>====
* Persons (including HCW) within 14 days of travel (domestic/international), or
*[[Dexamethasone]] 6mg PO daily x the duration of supplemental oxygen (not to exceed 10 days)
* Close contacts with lab-confirmed COVID19 patient within 14 days
*Consider [[Remdesivir]]


====Criteria For Sending Specimen to PHL====
====Hospitalized Not Requiring Oxygen====
[[File:Screen Shot 2020-03-17 at 7.27.23 PM.png|thumb|center|LAC DPH Public Health Lab (PHL) COVID-19 Testing Criteria]]
*Consider [[Remdesivir]]
''[[Dexamethasone]] has '''not''' demonstrated benefit in this patient category and may be potentially harmful''


====Criteria For Sending Specimen to Commercial Lab====
====Hospitalized Requiring Oxygen====
* Patients with fever and cough/shortness of breath not requiring hospitalisation who have:
*[[Dexamethasone]] 6mg PO daily x 10 days
** History of travel from affected geographic areas (domestic / international) within 14 days of symptom onset
*[[Remdesivir]] 200 mg IV once, then 100 mg IV once daily for 4 days or until hospital discharge (whichever comes first).
**Other exposure risk indicated by the patient’s history and clinical judgement (and no alternative diagnosis -- e.g. negative flu test)
*If requiring High-Flow or NIV, add [[baricitinib]] or IV [[tocilizumab]]
**If not available, IV [[sarilumab]] can be used


[[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]]
==[[Respiratory failure]]==
{{COVID-19 intubation}}
{{Lung Protective Ventilator Settings}}
*See also [[deterioration after intubation]]
{{COVID-19 Lung Phenotypes}}
{{COVID contraindicated therapies}}


====Decision To Obtain Imaging====
==Disposition==
* CXR: no significant issues with contamination/disinfection
*80% of patients do not require hospital admission
* CT: Temporarily out of commission after COVID19 patient in scanner
*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.
***These scores are not externally validated. Use with caution. https://www.mdcalc.com/covid-19#calcs
* May consider discontinuation of hospital isolation when:
** Resolution of fever without anti-pyretic, resolution of symptoms, and negative COVID19 testing


====Clinical Sample Collection====
==Special Situations==
* Best way to collect:
*For pregnant patients see: [[COVID-19 in pregnancy]]
** Upper respiratory tract and lower tract specimens (if available).
*For pediatric patients see: [[COVID-19 in pediatrics]]
*** NP swabs
*** Put both of them in the same tube and send for a single test
** For productive cough patients: can collect sputum to send for testing. CDC does NOT recommend inducing sputum (because aerosol generating)


====Testing: Turnaround Time====
===COVID-19 and [[STEMI]]===
* LA County Public Health Lab (PHL) = ~ 2 business days
*According to ACC consensus statement "During the [[COVID-19]] pandemic, PCI remains the standard of care for STEMI patients"
* Commercial lab = ~ 3-4 business days
*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


==Treatment==
===COVID-19 and CPR===
'''General:'''
*Interim AHA Guidance
* No specific treatment currently available
**Don all PPE prior to initiating CPR. CPR is aerosol generating.
* Non-pharmaceutical interventions will be most important
**Intubate early, video laryngoscopy preferred
** Spread Prevention
**Pause chest compressions during intubation
** Mitigation strategies
**If patient is on ventilator at time of arrest consider leaving patient on ventilator
* High-dose corticosteroids should be AVOIDED (due to progression of viral replication reported from prior coronaviruses; e.g. MERS, SARS)
***Adjust ventilator to allow for asynchronous ventilation
* Avoid nebulizers as they are generally ineffective may aerosolize virus
**If using BVM then attach high efficiency particulate air (HEPA) filter
** Albuterol with spacer is safer, though probably ineffective unless co-occuring reactive airway disease
**Use of mechanical compression device (e.g. LUCAS) is encouraged
* Generally avoid BiPAP and high-flow nasal oxygen as these may increase viral spread
* Use auto CPR device if available
** WHO cautiously states that high flow oxygen may be occasionally indicated.


'''Intubation:'''
==Prognosis==
* High risk procedure for aeresolization
{{COVID Risk Factors}}
** Patient ideally in negative pressure room. Limit individuals in room to essential staff only.     
** PPE for all in room: N95, gown, gloves, eye shield
** Minimum PPE for provider intubating: same as above (N95, gown, gloves, eye shield)
** Optional PPE for provider intubating: PAPR, double glove, double gown, shoe covers, buddy system for donning/doffing
* Use BVM with viral filter
* Use sufficient paralytics to prevent coughing gagging
* Most experienced provider should perform intubation.
* Ventilate using ARDSnet protocol (https://www.wikem.org/wiki/EBQ:ARDSnet_Trial)


'''Experimental/compassionate use treatments:'''
==See Also==
* Remdesivir (IV)
{{Special:Prefixindex/COVID-19 |hideredirects=1}}
** CDC does not recommend for or against any investigational therapies at this time
** 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
* Ritonavir also being used but no data available. Same for chloroquine.


==Decision To Hospitalize==
==External Links==
* Mild symptoms may go home and self-isolate/quarantine
*https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/hospitalized-adults--therapeutic-management/
** Note: symptoms may worsen over 2nd week of illness
*WHO COVID-19 Situation Dashboard (Live): https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd
* Hospitalize: Respiratory distress/failure, multi-organ failure, rapid disease progression requiring escalating supportive care
*[https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html CDC Main Healthcare Page]
* May consider discontinuation of hospital isolation when:
*[https://emcrit.org/emcrit/some-additional-covid-airway-management-thoughts/ EMCrit Covid Airway Management]
** Resolution of fever without anti-pyretic, resolution of symptoms, and negative COVID19 testing
*Johns Hopkins COVID Case Map (Live):https://coronavirus.jhu.edu/map.html
*California Emergency Medical Services Authority Resource Portal https://emsa.ca.gov/covid19/
*Oxford Journal of Travel Medicine COVID19 Resources https://academic.oup.com/journals/pages/coronavirus?cc=gb&lang=en&
*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
*[https://connect.medrxiv.org/relate/content/181 MedRxiv Covid-19 SARS]
* Additional DPH Guidance: http://publichealth.lacounty.gov/acd/nCorona2019.htm
*Seattle ICU doctor's one page info on mgmt of COVID from ACEP website [[:File:COVID19 seattle one pager.pdf]]
*Harbor DEM COVID airway management guide [[:File:Harbor COVID Airway Management v3-16-20.pdf]]
*Proper donning and doffing from CDC  [[:File:Doffing PPE CDC.pdf]]
*Radiopaedia COVID-19 Resources (https://radiopaedia.org/articles/covid-19)
*Literature review https://reacting.inserm.fr/literature-review/
*COVID related trials: https://covid.inato.com/analysis


==Decreasing Hospital Transmission==
==References==
* Examples that decrease need for PPE:
<references/>
** Telemedicine eval
B** arriers (plexiglass partitions) so triage individuals don’t have to wear PPE and be protected
* 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)
* Cohort patients (all COVID +ve/PUI) in same part of department / hospital / clinic
** Put a mask on them at ALL times
* Limit patient visitation:
* Barring visits except for end-of-life, case-by-case
* Restrict non-essential workers (painters, pet therapy)
* Limit patient movement within hospitals/clinics
 
==Special Population: Pregnant Women==
===Background Epidemiology===
* 34 pregnant women reported with COVID
* Median age: 30 years (mostly 2nd and 3rd trimester -- median gestation 36 weeks)
* Symptom onset within 13 days prior to, and 3 days after, delivery
* Infants of affected mothers all tested negative
* No maternal/pregnant deaths reported from COVID
 
===Bottom Line for Pregnant Patients===
* Reported data and outcomes for pregnant patients similar to non-pregnant patients
** 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
 
===Q&A Scenarios===
* Are pregnant women at increased risk of adverse pregnancy outcomes?
** No data exists on this (regarding pregnancy loss, misscarriage, etc)
** High fevers in early pregnancy previously demonstrated (in SARS and MERS) to increase risk of birth defects. May be possible here. But no data.
* Lactation
** 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
* Should pregnant patients not be out and about in the community?
** Prenatal care still encouraged
** Usual precautions encouraged (as with general population)


===Infection Prevention===
[[Category:ID]]
* Applies to broader infection prevention
* Isolation of pregnant patients with COVID19 and PUIs
* Pre-hospital (for confirmed COVID19 or PUI):
** Notify OB unit prior to arrival
** EMS: driver should contact receiving unit to follow local protocols
** Hospitalization: usual hospital protocols for isolation
* Infants born to mothers with COVID should be considered PUI
** 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)
*** No data on vertical transmission
**** Thought to spread mostly by close contact with respiratory droplet
*** 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)
*** Discontinuation of isolation made on local ID guidance and case-by-case
*** Discontinuation criteria same as for other COVID19
**** Resolution of fever without anti-pyretic, resolution of symptoms, and negative COVID19 testing
*** Face mask, hand hygiene before each feeding
**** Dedicated breast pump if nursing
**** Entire pump should be entirely disinfected per manufacturer recommendations between each feed

Latest revision as of 18:15, 16 January 2026

This page is for adult patients. For pediatric patients, see: COVID-19 (peds)

. For pregnant patients see 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
    • Sudden onset anosmia has a high specificity for COVID-19 infection
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)
    • "Happy Hypoxemia": many of these patients will be hypoxic without dyspnea
    • 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

Workup

Consider minimal to no 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

Consider in sicker patients (likely requiring admission):

  • 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

CXR of COVID
CT of COVID
CT of COVID
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 (CDC does not recommend CT for diagnostic purposes)
    • CT (86%) more sensitive than CXR (59%) for detecting GGOs
    • Generally, the findings on chest imaging are not specific and overlap with other infections, including influenza, H1N1, SARS and MERS.[10]
US

Diagnosis

  • Typically confirmed by viral testing (see above)

Disease Severity

Some define moderate and severe acuity as follows

  • Low: SaO2 > 93% on RA, RR < 20, and HR < 110
  • 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.

Prediction of Need for Intubation

Management

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

General Supportive Care

Pulmonary [11]

  • Supplemental oxygen therapy if Sat<90%
    • Target SPO2 92%-96%
  • High-flow Nasal Cannula
    • Some guidelines recommend HFNC over BIPAP/CPAP, in those that fail low-flow O2. [12]
    • Requires patient to be on airborne isolation.
  • Non-Invasive Ventilation if no HFNC
  • Consider awake proning to improve oxygenation
  • Bronchodilators if bronchospasm present
    • Use metered-dose inhaler (avoid nebulizers due to aerosolization)

Other

Medications by Patient Category

NIH consensus guidelines for COVID treatment.[14]
NIH consensus guidelines for COVID treatment.[15]

Outpatients Not Requiring Admission[16]

Dexamethasone has not demonstrated benefit in this patient category and may be potentially harmful

Outpatients Requiring Home Oxygen (New or Increased)[17]

Hospitalized Not Requiring Oxygen

Dexamethasone has not demonstrated benefit in this patient category and may be potentially harmful

Hospitalized Requiring Oxygen

Respiratory failure

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[18] 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[19][20]

  1. Mode
    • Volume-assist control
  2. Tidal Volume
    • Start 6-8cc/kg predicted body weight[21]
      • 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


COVID Lung Phenotypes and Their Management

Hypoxemic patients can be divided into two general phenotypes[22]

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.


Contraindicated Therapies

  • NSAIDS
    • There is anecdotal evidence to suggest that NSAIDs could potentially harm patients infected with COVID-19.[23]
    • Some experts suggest avoiding NSAIDs altogether while recommending the use of paracetamol/acetaminophen instead. [24]
    • It is important to note that there is no strong evidence to suggest NSAIDs should be avoided in general in COVID-19 patients[25]
  • ACEi/ARBs
    • There is an increase in mortality in patients with both hypertension and COVID-19 infection. [26]
    • ACEi and ARBs, used in the treatment of hypertension, has been postulated to contribute to the increased mortality by upregulating membrane-bound angiotensin-converting enzyme 2 (ACE2) which allows COVID-19 entry into human cells. [27]
    • Currently, however, there is insufficient evidence to recommend against using ACEi and ARBs in patients with COVID-19. [28]
  • Nebulizers
    • 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.

Disposition

  • 80% of patients do not require hospital admission
  • 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
  • Use auto CPR device if available

Prognosis

COVID-19 Risk Factors for Severe Disease [29]

See VACO calculator

See Also

External Links

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. ↑ From the American College of Radiology (3/11/20):
  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. ↑ 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
  14. ↑ https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/clinical-management-summary/
  15. ↑ https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/clinical-management-summary/
  16. ↑ https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/clinical-management-summary/
  17. ↑ https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/clinical-management-summary/
  18. ↑ 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.
  19. ↑ ARDSnet
  20. ↑ O'Brien J. Absorption Atelectasis: Incidence and Clinical Implications. AANA Journal. June 2013. Vol. 81, No. 3.
  21. ↑ 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.
  22. ↑ 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
  23. ↑ Willsher, Kim. “Anti-Inflammatories May Aggravate Covid-19, France Advises.” The Guardian, Guardian News and Media, 14 Mar. 2020, www.theguardian.com/world/2020/mar/14/anti-inflammatory-drugs-may-aggravate-coronavirus-infection.
  24. ↑ Day, Michael. “Covid-19: Ibuprofen Should Not Be Used for Managing Symptoms, Say Doctors and Scientists.” Bmj, 2020, p. m1086., doi:10.1136/bmj.m1086.
  25. ↑ Pergolizzi JV Jr, Varrassi G, Magnusson P, et al. COVID-19 and NSAIDS: A Narrative Review of Knowns and Unknowns. Pain Ther. 2020;9(2):353-358. doi:10.1007/s40122-020-00173-5
  26. ↑ Wu C, Chen X, Cai Y, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med. Published online March 13, 2020. doi:10.1001/jamainternmed.2020.0994
  27. ↑ Fang, Lei, et al. “Are Patients with Hypertension and Diabetes Mellitus at Increased Risk for COVID-19 Infection?” The Lancet Respiratory Medicine, vol. 8, no. 4, 2020, doi:10.1016/s2213-2600(20)30116-8.
  28. ↑ Patel AB, Verma A. COVID-19 and Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers: What Is the Evidence? JAMA. Published online March 24, 2020. doi:10.1001/jama.2020.4812
  29. ↑ 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.
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