Covid 19

COVID 19 admission

The patient presents not feeling well for a few days. It can be 4-5 days. They may or may not have a known exposure as it can be contacted from an asymptomatic patient.

Patient could have dry cough, high fever, shortness of breath, Chills, repeated shaking with chills, muscle pain, headache, sore throat and a loss of taste or smell.

COVID 19 attacks the endothelial cell lining of blood vessels all over the body causing multiorgan failure per Study published in Lancet 20 April 2020.

Use proper PPE: Contact, droplet, airborne  Isolation

EMS:

IV line

Oxygen

ER:

Routine labs plus CRP, LDH, D-Dimer, Ferritin, Troponin, CK, LDH, Pro-Calcitonin, CXR, EKG, Respiratory Panel PCR,

Rapid COVID 19 test -Naso-Pharyngeal swab. Few false negative tests are reported so if patient has suspicion to be infected with COVID 19, discuss with ID specialist.

Hypoxia could be out of proportion to CXR findings

Normal WBC +/- low lymphocyte

Most ERs would have given Ceftriaxone by the time hospitalists see.

Call ICU if patient is on more than 6 LPM of oxygen or if any other ICU indication is seen.

Hospitalist:

Discuss about code status at the time of admission especially if CT shows ARDS picture

Isolation room, negative pressure rooms [some hospitals have], in a Separate [COVID] floor admission

Use Telemedicine to minimize exposure.

Do not enter the room even in emergency without proper PPE.

Supportive care.

Use treatment protocol per your hospital as there is no established standard treatment protocol at this time.

ID Consult to help with treatment based on Hospital Specific protocol. Involve Pulmonary if SOB worsens.

DVT prophylaxis with SQ Lovenox.

Hydroxychloroquine -removed from treatment protocol.

Ceftriaxone and Azithromycin for 5 days is suspecting superadded bacterial pneumonia.

IV antibiotic /Ceftriaxone can be discontinued after 72 hours if no evidence of superadded bacterial pneumonia.

Titrate Oxygen as needed including using high flow nasal cannula. 

Properly fit tested N95 is a must for aerosolizing procedures like CPR, intubation, bronch etc.

Some hospitals recommend IV Heparin for full anticoagulation for those with very high d-dimer. Some hospitals avoid DOACs due to interaction with Tocilizumab.

Restrict fluids due to increased risk of ARDS.

Monitor: Kidney function [as they can develop AKI], CRP, Ferritin, CXR, QT interval if on Hydroxychloroquine, Oxygen requirements

Myocarditis, Encephalopathy can develop.

Patients rapidly deteriorate if Cytokine storm sets in. They may need intubation.

Steroids can be associated with prolonged viral shedding but can be used if patient has severe asthma or COPD with wheezing. Talk to pulmonary first.

Tocilizumab/IL6 inhibitor treatment in trials for Cytokine Release Syndrome patients. Dose is 4mg/Kg iv X 1.

Convalescent COVID 19 plasma is most affective earlier in the disease after getting FDA authorization via either email or by phone by filling Form 3926.

ECMO for really sick patients with desaturation despite being on ventilator.

Every hospital has their own treatment protocols depending on resources. Talk to your ID specialist before discharging any patient if they improve.

If patient is better in terms of having no fever for 3 days and no respiratory symptoms after the patient had been having symptoms for more than 10 days total, one could think of discharging the patient.

ACEI/ARBs can be continued in patients who are on these chronically unless there is contraindication.

Proning helps with better gas exchange in lungs.

Remdesevir-Preliminary results show that patients given Remdesevir recovered 31% faster than those given a placebo.

As the treatment for COVID is evolving, updated guidelines should be followed from CDC.

You can see EVMS Critical Care COVID 19 Management Protocol or their 2 page COVID protocol summary.

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