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]].''
{{AdultPage|COVID-19 (peds)}}. For pregnant patients see [[COVID-19 in pregnancy]].''
==Background==
==Background==
*See [[Epidemiology+Pathophysiology - COVID-19]] for more in-depth information
*Caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)  
* 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 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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***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>
***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 in vulnerable populations
** Less common: cough with sputum, sore throat, headache, congestion, GI symptoms, anosmia
** 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


{| {{table}}
{| {{table}}
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===Common Complications===
===Common Complications===
* Most common complications: [[pneumonia]], [[ARDS]] (average 8 days from onset, 20% of patients in China)
''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]]
** Decompensation risk occurs during 2nd week of illness leading to [[respiratory failure]]
*According to limited ICU data (21 cases) from Washington state (Arentz et al):
*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>
**Vasodilatory shock reported in 67% of ICU admissions
**Myocarditis,Acute Myocardial infarction, Dysrhythmias, cardiomyopathy, venous thromboembolism.
**Cardiomyopathy reported in 33% of ICU admissions
***Vasodilatory shock reported in 67% of ICU admissions
**Mortality reported 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==
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==Evaluation==
==Evaluation==
===Workup===
===Workup===
====Viral Testing Background (Reverse Transcriptase PCR)====
''Consider minimal to no workup in well-appearing patients with mild disease''
*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>
====Viral Testing====
*In the United States, the US Centers for Disease Control (CDC) is distributing testing to public health labs<ref>https://www.internationalreagentresource.org/</ref>
[[Testing+Surveillance: COVID]]
**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
*RT-PCR (reverse transcriptase polymerase chain reaction) is most commonly used test for confirming cases
** See [http://publichealth.lacounty.gov/acd/ncorona2019/checklist.htm Example testing checklist from LA County DPH]
**Sensitivity may be only 75%, but highly specific
*BIOFIRE Respiratory Panel Corona Virus assay does NOT detect this COVID-19 subtype
**Turnaround time may be several hours to days
 
*Real time RT-PCR e.g. Cepheid
====Who to Test (Persons Under Investigation)====
**Rapid test with results in <1hr
*Patients should be carefully evaluated to determine if they meet Persons Under Investigation (PUI) criteria
*Serologic testing for IgM/IgG is not widely available, but likely more sensitive
*Due to a lack of available tests, non-PUI patients (including the worried well) should not have testing performed
**The presence of IgG with a negative RT-PCR likely confirms past exposure and some immunity
*Clinicians are strongly encouraged to test for other causes of respiratory illness (e.g. [[influenza]], [[RSV]])
*Test kit availability varies widely by region and institution
**In many systems, testing algorithms assume patients do not have COVID-19 if influenza or RSV positive
 
;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>
''<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>''
*"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."
*Priorities for testing include:
*#Optimize care for hospitalized patients and lessen risk of nosocomial infections
*#*Hospitalized patients
*#*Symptomatic healthcare workers
*#Identify highest risk of complications
*#*Symptomatic patients in long-term care facilities
*#*Symptomatic patients ≥ 65 with symptoms
*#*Symptomatic patients with chronic medical conditions and/or an immunocompromised state
*#*Symptomatic first responders
*#Decrease community spread
*#*Symptomatic critical infrastructure workers
*#*Healthcare workers and first responders
*#*Any symptomatic individual
*#Non-priority
*#*Any individual without symptoms
 
====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>====
''Testing can be done in ambulatory setting if absolutely needed (see [[Prevention of COVID-19 transmission in the healthcare setting|precautions]])''
#Upper respiratory tract specimen
#* Nasopharyngeal (NP) swab
#**Some systems allow sending both [[flu]]/[[RSV]] and [[COVID-19]] test on the same swab to conserve testing supplies
#Additionally include lower tract specimen, if available
#*''CDC does NOT recommend inducing sputum (because aerosol generating)''
#* For productive cough patients: collect sputum
#*For patients for whom it is clinically indicated (e.g., those receiving invasive mechanical ventilation): collect lower respiratory tract aspirate or bronchoalveolar lavage sample
#* May include in same testing tube as upper respiratory track specimen (i.e. send as a single test) in some systems


===Diagnostic Findings===
[[File:COVID one pager with links.jpg|thumb|]]
[[File:COVID one pager with links 2.jpg|thumb|]]
[[File:covidcxr.jpg|thumb]]
====Labs====
====Labs====
*Note that BIOFIRE Respiratory Panel Corona Virus assay does NOT detect this COVID-19 subtype
''Consider in sicker patients (likely requiring admission):''
* Lymphopenia most common in critically ill; mildly elevated ALT, AST; normal pro-calcitonin on admission
*Chemistry
** Elevated d-dimer and severe lymphopenia are associated with increased mortality
*CBC w/diff
** RT-PCR is currently test of choice for confirming cases
**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>
*** Test kit availability is currently limited as of mid March
**Thrombocytopenia - common but mild
*** Consider viral respiratory panel to identify alternative diagnoses though co-infection has been reported as high as 7-20%
***<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:''
*''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
** HBV serologies, HCV antibody
**''Consider (as clinically indicated):'' PCP DFA, beta-d-glucan, urine legionella Ag, IL-6
**''Consider (as clinically indicated):'' PCP DFA, beta-d-glucan, urine legionella Ag, IL-6


====X-ray====
====Imaging====
** Portable [[CXR]] preferred in PUI to prevent spread of infection
[[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]]
 
=====X-ray=====
* 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
** 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=====
* Many have normal imaging early on (so CDC DOES not recommend CT for diagnostic purposes at this time)
* 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
** 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.”
**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>


====US====
=====US=====
* 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]]
===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===
*ROX Index for intubation after high-flow nasal cannula (HFNC}
**Predicts HFNC failure/need for intubation
**https://www.mdcalc.com/rox-index-intubation-hfnc


==Management==
==Management==
''See [[prevention of COVID-19 transmission in the healthcare setting]] for PPE recommendations''
{{COVID PPE summary table}}
{{COVID PPE summary table}}


===Mild Cases===
===General Supportive Care===
*Supportive care is mainstay of therapy for patients with mild viral symptoms
====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>====
*Most patients will do well enough for discharge home
*Supplemental [[oxygen therapy]] if Sat<90%
*Discuss with Dept of Public Health, who will guide testing and, if discharging, help patient remain in isolation at home
**Target SPO2 92%-96%
*High-flow Nasal Cannula
**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>
**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)


===[[Respiratory failure]]===
====Other====
*[[NIPPV]] may increase the spread of viral particles via droplets, making early [[intubation]] the preferred airway management strategy in patients with respiratory distress/failure
*Infectious disease
**Using 2 viral filters attached to a "2-tube NIPPV circuit" in a negative pressure room may sufficiently prevent viral spread
**[[Acetaminophen]] for fever
**Consider antibiotics for bacterial [[pneumonia]] coverage
*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]] (alternative: [[epinephrine]])
***2nd line - [[Vasopressin]]
*Vascular
**Consider [[COVID-19:_Medication_therapy#Anticoagulation|anticoagulation]]


{{COVID-19 intubation}}
===Medications by Patient Category===
[[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>]]
[[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>]]


{{Lung Protective Ventilator Settings}}
====Outpatients Not Requiring Admission<ref>https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/clinical-management-summary/</ref>====
*See also [[deterioration after intubation]]
*High risk patients (one of the following, if available):
**Ritonavir-boosted nirmatrelvir ([[Paxlovid]])
**[[Sotrovimab]]
**[[Remdesivir]]
**[[Molnupiravir]]
''[[Dexamethasone]] has '''not''' demonstrated benefit in this patient category and may be potentially harmful''


===Investigational Agents===
====Outpatients Requiring Home Oxygen (New or Increased)<ref>https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/clinical-management-summary/</ref>====
''Generally not started in ED setting; CDC does not recommend for or against any investigational therapies at this time''
*[[Dexamethasone]] 6mg PO daily x the duration of supplemental oxygen (not to exceed 10 days)
*'''[[Remdesivir]] (IV)'''
*Consider [[Remdesivir]]
**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
* Limited data on [[Ritonavir]], [[chloroquine]], and hydroxychloroquine
*Convalescent plasma (plasma/antibodies from healthy survivors)
**Has been used in prior viral epidemics with success
**No proven benefit, but actively being researched


===Contraindicated===
====Hospitalized Not Requiring Oxygen====
*Avoid steroids unless strong non-COVID indication (due to progression of viral replication reported from prior coronaviruses; e.g. [[MERS]], [[SARS]])
*Consider [[Remdesivir]]
* Avoid nebulizers as they are generally ineffective and may aerosolize virus
''[[Dexamethasone]] has '''not''' demonstrated benefit in this patient category and may be potentially harmful''
** [[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.
* Generally avoid [[BiPAP]] and high-flow nasal [[oxygen]] as these may increase viral spread
** WHO cautiously states that high flow [[oxygen]] may be occasionally indicated.
*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==
====Hospitalized Requiring Oxygen====
*For pregnant patients see: [[COVID-19 in pregnancy]]
*[[Dexamethasone]] 6mg PO daily x 10 days
*For pediatric patients see: [[COVID-19 (peds)]]
*[[Remdesivir]] 200 mg IV once, then 100 mg IV once daily for 4 days or until hospital discharge (whichever comes first).
*If requiring High-Flow or NIV, add [[baricitinib]] or IV [[tocilizumab]]
**If not available, IV [[sarilumab]] can be used


===Covid-19 and [[STEMI]]===
==[[Respiratory failure]]==
*Preference is for thrombolytic therapy to avoid [[PCI]] personnel exposoure
{{COVID-19 intubation}}
**Administer [[Retavase]] 10u Retavase (reteplase) IV bolus ([[reteplase]])followed by a second bolus at 30 minute rather than PCI.  OR
{{Lung Protective Ventilator Settings}}
**[[Tenectoplase]] (TNKase) 30 mg IV bolus     
*See also [[deterioration after intubation]]
**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).
{{COVID-19 Lung Phenotypes}}
*Followed [[thrombolytics]]  by 40u/kg [[heparin]] (max dose 4,000 units) IV and 600mg [[clopidogrel]] PO and [[ASA]] 325 mg PO
{{COVID contraindicated therapies}}


==Disposition==
==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
*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.
*"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.
Line 223: Line 236:


===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
Line 229: Line 242:
** Resolution of fever without anti-pyretic, resolution of symptoms, and negative COVID19 testing
** Resolution of fever without anti-pyretic, resolution of symptoms, and negative COVID19 testing


===Legal Considerations===
==Special Situations==
*HIPPA: in USA relaxation of HIPPA rules for telehealth
*For pregnant patients see: [[COVID-19 in pregnancy]]
**“HHS…will waive potential HIPAA penalties for good faith use of telehealth during the nationwide public health emergency due to COVID-19.”
*For pediatric patients see: [[COVID-19 in pediatrics]]
***This includes “non-public facing” products including Facetime/Skype:
 
****www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html
===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==
==Prognosis==
===All-Comers===
{{COVID Risk Factors}}
* 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===
{| class="wikitable"
|+ style="font-size:11pt;" |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<ref>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.</ref>
|14.8
|8.0
|3.6
|1.3
|0.4
|0.2
|0.2
|0.2
|0.0
|-
!Italy as of 16 March<ref>Epidemia COVID-19. Aggiornamento nazionale 16 marzo 2020" (PDF) (in Italian). Rome: Istituto Superiore di Sanità. 16 March 2020. Retrieved 18 March 2020.</ref>
|19.2
|11.8
|3.2
|1.0
|0.3
|0.2
|0.0
|0.0
|0.0
|-
!South Korea as of 21 March<ref>"코로나바이러스감염증-19 국내 발생 현황 (3월 21일, 정례브리핑)". Korea Centers for Disease Control and Prevention. 21 March 2020. Retrieved 21 March 2020.</ref>
|10.24
|6.28
|1.52
|0.42
|0.08
|0.11
|0.0
|0.0
|0.0
|}


==See Also==
==See Also==
{{COVID see also}}
{{Special:Prefixindex/COVID-19 |hideredirects=1}}


==External Links==
==External Links==
*https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/hospitalized-adults--therapeutic-management/
*WHO COVID-19 Situation Dashboard (Live): https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd
*WHO COVID-19 Situation Dashboard (Live): https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd
*[https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html CDC Main Healthcare Page]
*[https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html CDC Main Healthcare Page]
Line 310: Line 288:
*Literature review https://reacting.inserm.fr/literature-review/
*Literature review https://reacting.inserm.fr/literature-review/
*COVID related trials: https://covid.inato.com/analysis
*COVID related trials: https://covid.inato.com/analysis
==Video==
{{#widget:YouTube|id=exV5hEG62CY}}


==References==
==References==
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[[Category:ID]]
[[Category:ID]]
[[Category:COVID-19]]

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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