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 OUTSIDE OF A CLINICAL PROTOCOL
CT scan can show signs before PCR (NPS) positivity.
Do not do this test because curious.
This should only be part of an organized, systematic institutional protocol.
Link: Specialized Treatments
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 be the reason most people will need ICU.
Patients on 50% oxygen or higher need critical care co-management, maybe transfer.
BiPAP in patients with suspected or confirmed COVID-19 infection carries high risk of viral dispersion. Do not use it.