Constitutional symptoms, URI, LRI, and GI
Most patients will have fever and cough
Fever with variable frequency (43-98%) [absence does not exclude]
GI symptoms in up to 10%
Especially in the elderly, hypoxemia without dyspnea
Who should receive NPS testing?
Physical examination is of limited value.
Minimize your exposure to close contact.
Laboratory and Radiographic Findings
NP swab may be negative, especially early in the course.
Any and all respiratory symptoms can be COVID. Protect yourself.
If pretest likelihood is high, a negative swab does not rule out COVID
Lymphopenia is common; if prolonged and severe predictive of poor outcome.
Mild thrombocytopenia common, lower = poor prognostic sign.
Elevated transaminases (AST/ALT) (not useful)
Elevated D-dimer – do not send for CT PE, do not order. It is not helpful.
Common to see + troponin. Strong prognostic indicator for mortality.
Acute kidney injury not uncommon.
A word about CRP – At this time not helpful to order.
Young and Ruan both found low CRP levels in people not requiring oxygen.
Ruan found CRP tracked with mortality (those that died often had >100, survivors 10-60).
Knowing this changes nothing. Do not follow this unless ID or ICU requests.
CXR – Repeat if significant deterioration
Bilateral or unilateral opacities, often peripheral
Looks like pulmonary edema to some
Looks like peripheral infiltrates that make people suspect PE (Hampton’s Hump)
Follow oxygen levels not CXR or CT.
If suspect bacterial super-infection (not typically before 9-11 days), CXR and Abx.
CT Thorax – DO NOT ORDER
CT scan can show signs before PCR (NPS) positivity.
CT findings are patchy ground-glass opacities that may coalesce into dense consolidation.
Sufficiently not specific that this test is not helpful.
Do not do this test because curious. The risk of infecting others is too high.
- Anti-virals: Not recommended at this time. None have been shown to be beneficial in SARS MERS or SARS-CoV2 (COVID-19).
- Antibiotics: Like in influenza, may consider early antibiotics but stop early.
- Delayed bacterial superinfection is uncommon (11/68 in one series)
- In immunocompetent and immunocompromised hosts, the same regimen.
- If severe (ICU) – consider Ceftriaxone 1 g IV q24h x 5 days
- If allergy: Moxifloxacin 400 PO q24h x 5 days
- Antibiotics did not help in Wuhan, China.
- Avoid steroids (may increase viral shedding).
- Limit IV Fluid
- For hypovolemia, we recommend crystalloid administration.
- The cause of death is nearly always ARDS. This can be exacerbated by excessive fluid administration so a directed approach is appropriate. Target euvolemia.
- Antiplatelets not indicated.
- 5-10% die of fulminant myocarditis (CHF, + trop, shock).
- Very severe cases or comorbid illness may warrant experimental treatment. Consult ID.
Use of prone positioning in patients not on mechanical ventilation
There is equipoise over this practice however we have developed a discussion document as well as several resources for staff to use if this therapy is considered.
When to call ICU
Avoid uncontrolled intubation.
CCRT calling criteria are a good guide.
Tachypnea and hypoxia will likely be the reason most people will need ICU.
Patients on 50% oxygen or higher need critical care co-management, maybe transfer.
BiPAP does not work. Do not use it.