COVID-19 – Clinical Management

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Presenting Symptoms in early COVID-19 may include non-respiratory illness

Dr. Robon Clouston

March 19 2020

 

COVID-19 presents approximately 2 to 9 days after exposure, with a median of 5 days. Under conservative estimates, 99% of patients will develop symptoms within 14 days.1

The classic presenting symptoms of COVID-19 are2:

  • Fever
  • Dry cough
  • Dyspnea/SOB

However, not every patient will exhibit these classic signs. Symptoms which should raise index of suspicion for COVID-19 include3,4:

  • Fever seen in approx. 75% of hospitalized cases at some point but 50% are afebrile at time of admission
  • Cough 60 – 80% (dry or productive)
  • Dyspnea/SOB 20 – 40%
  • Myalgias or fatigue 44%
  • URTI symptoms <15% (headache, sore throat, rhinorrhea)
  • GI symptoms 3 – 10% (diarrhea, nausea, vomiting)
  • Hemoptysis 5%
  • Emerging reports of anosmia (no reference available)

COVID-19 tends to have a gradual onset, in contrast to influenza which typically has a rapid onset 4:

  • Median duration from illness onset to dyspnea: 8 days
  • Median duration from symptom onset to hospitalization: 7 days
  • Median duration from symptom onset to ARDS: 9 days
  • Median duration from symptom onset to mechanical ventilation: 10.5 days

From Martha Blum, MD, PhD attendance at Infectious Disease Association of California Winter Symposium on March 7 2020, recounting experience in Santa Clara, San Francisco and Orange County3:

“The most common presentation was one week prodrome of myalgias, malaise, cough, low grade fevers gradually leading to more severe trouble breathing in the second week of illness. It is an average of 8 days to development of dyspnea and average 9 days to onset of pneumonia/pneumonitis. It is not like Influenza, which has a classically sudden onset. Fever was not very prominent in several cases. The most consistently present lab finding was lymphopenia (with either leukocytosis or leukopenia). The most consistent radiographic finding was bilateral interstitial/ground glass infiltrates. Aside from that, the other markers (CRP, PCT) were not as consistent.” 

 

References

  1. Lauer, SA et al. (March 10 2020). The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med.  DOI: 10.7326/M20-0504

Retrieved from: https://annals-org.qe2a-proxy.mun.ca/aim/fullarticle/2762808/incubation-period-coronavirus-disease-2019-covid-19-from-publicly-reported

  1. CDC Coronavirus Disease 2019. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
  2. Coronavirus Tech Handbook Resources for Doctors. UCSF COVID-19 Clinical Working Group. March 4 2020. https://www.digital.health/covid-clinical
  3. Prof Chaolin Huang et al. (Feb 2020). Clinical Features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet. Vol. 395. Issue 10223. 15-21. 497-506.

Retrieved from: https://www-sciencedirect-com.qe2a-proxy.mun.ca/science/article/pii/S0140673620301835?via%3Dihub

 


Airway and Ventilation

Dr. Jay Mekwan

TEAM:

  • Protection – this should be full PPE with N95 and face shield in place.
  • 3-person team in room (intubator, RN, RT) 2 outside room – RN for situational awareness and second physician for assistance; both should be gowned and ready to enter the room if needed.
  • Prep the whole team with the intubation plan so that it is clear to all what the course of the procedure should be and so they can react if things go wrong. Use good, closed loop communication pre, during and post procedure.

INTUBATION:

  • Those who are hypoxic, who fail nasal cannula therapy (3-5L/min) should be intubated early, rather than using NIPPV or high flow O2. This reduces risk of aerosolized viral spread.
  • All equipment required for your intubation plan should be taken into the room (this may vary from patient to patient and plan to plan)
  • Use RSI for cases and consider increasing the dose of paralytic to reduce cough.
  • The most experienced clinician should intubate – this is not one for the trainees (unfortunately)
  • Use VL as the intubation tool
  • Use high flow O2, positive pressure ventilation and bagging only when truly necessary – these all increase risk of aerosolization
  • Use a checklist to ensure you haven’t missed any safety critical steps.
  • Pre- O2: 3-5 mins of 15L/min NRM & nasal O2 or use a NiPPV mask attached to a BVM reservoir at flush flow rate for the spontaneously breathing patient or a tightly applied BVM, attached to high flow O2 for the spontaneously breathing patient
  • Use a supraglottic device (LMA/iGel….) to reoxygenate (during RSI) rather than bagging.
  • At all interventions a HEPA filter needs to be placed when it can as close to the patient end of the intervention.
  • Once intubated, inflate the cuff before positive pressure ventilation
  • Limit ventilator disconnects, or do them at the end of expiration

 

POST PROCEDURE:

  • Disposable, soiled equipment should be placed in biohazard bag.
  • Re-usable equipment (e.g. CMAC cart) should be wiped down using usual equipment wipes. CMAC blades can double bagged and labeled as a risk and also tell SPD when they collect it.
  • Doffing of PPE should be observed to ensure no cross contamination
  • Debrief the procedure. This is a high-risk intervention and we can all learn and improve from each others experiences. Either email me or the wider group with ideas/update or if it all went well.

Checklist

Download (PDF, 121KB)

Download (PDF, 98KB)

 

 

COVID-19 Airway Management infographic from Albert Chan, Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Chinese University of Hong Kong (click image to enlarge)

 

See EMCrit for more information.

References

  • Brown, C.A., III, Mosier, J.M., Carlson, J.N. and Gibbs, M.A. (2020), Pragmatic Recommendations for Intubating Critically Ill Patients with Suspected COVID‐19. Ann. Emerg. Med.. Accepted Author Manuscript.
  • Scott Weingart, EmCrit: COVID19 Intubation Packs and Preoxygenation for Intubation https://emcrit.org/emcrit/covid19-intubation-packs-and-preoxygenation-for-intubation/
  • COVID-19 Airway Management infographic from Albert Chan, Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Chinese University of Hong Kong

SARS COVID-19 Clinical Management – SJRHEM Resource

Dr. Cherie Adams

Download (PDF, 97KB)

 


SJRHEM Guide to Ventilator Settings

Mike Campbell and Dr. Devon Webster

This guide is provided in case of exceptional circumstances, for example overwhelming numbers of patients requiring ventilation with insufficient trained Respiratory Therapists available for every patient. We would always recommend that a Respiratory Therapists should be present for all ventilated patients wherever possible. However, as has been seen in a number of countries badly affected by COVID-19, healthcare professionals are having to multitask in areas that are unfamiliar to them. This guide is provided to help physicians in these exceptional circumstances.

 

Download (PDF, 200KB)

See the videos below:

 


Horizon Infectious Diseases Guideline

Download (PDF, 243KB)

 


 

Presumed COVID-19 Admission Pathway SJRH

Download (PDF, 89KB)

 


 

Click here for the most current version


Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected – WHO – 13 March

WHO-2019-nCoV-clinical-2020.4-eng