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COVID-19 Overview by Seattle Intensivist, Nick Mark, MD

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Nomenclature
Infection. Coronavirus Disease 2019 a.k.a. COVID-19
Virus. SARS-CoV-2, 2019 Novel Coronavirus
NOT “Wuhan Virus”

Biology

  • 30 kbp, +ssRNA, enveloped coronavirus
  • Likely zoonotic infection; source/reservoir unclear (Bats? / Pangolins?-> people)
  • Now spread primarily person to person;
  • Can be spread by asymptomatic carriers!
  • Viral particles enter into lungs via droplets
  • Viral S spike binds to ACE2 on type two pneumocytes
  • Effect of ACE/ARB is unclear; ACE vs ARBs may even have opposite effects
  • Other routes of infection (contact, enter c) possible but unclear if these are significant means of spread

Epidemiology

  • Attack rate = 30-40%
  • R0 = 2-4 (similar to influenza)
  • CFR = 3.4% ( worldwide num bers)
  • Incubation time = 4-14 days typically (up to 24 days)

Timeline:

  • China notifies WHO 2019-12-31
  • First US case in Seattle 2020-1-15
  • WHO declared pandemic 2020-3-11
  • National emergency 2020-3-12
  • Disease clusters: SNFs, Conferences, other
  • Strategies: contact tracing, screening, social distancing

Diagnosis / Presentation

Symptoms:

  • 65-80% Cough
  • 45% febrile on presentation(85% febrile during illness)
  • 20-40% dyspnea
  • 15% URI Symptoms
  • 10% GI Symptoms

Labs

  • CBC:Leukopenia & lymphopenia (80%+)
  • BMP: BUN/CR ( Increased )
  • LFTs: AST/ALT/Tbili (Increased)
  • D-dimer (Increased), CRP (Increased), LDH (Increased)
  • IL-6 (Increased), Ferritin (Increased)
  • Procalcitonin (Decreased)

* PCT may be high w/bacterial superinfxn*

Imagine

  • CXR: hazy bilateral, peripheral opacities
  • CT: ground glass opacities (GGO), crazy paving, consolidation, *rarely may be unilateral*

  • POCUS: numerous B-lines, pleural line thickening, consolidations w/air bronchograms

Isolation

  • Phone call is the best isolation(e.g. move to telemed)
  • Place patient in mask, single room, limit/restrict visitors

Precautions

  • STANDARD + CONTACT (double glove)+
  • Either AIRBORNE (for aerosolizing procedures: intubation, extubation, NIPPV, suctioning, etc) or DROPLET (for everything else)
  • N95 masks must be fit tested; wear eye protection
  • PPE should be donned/doffed with trained obsesrver
  • Hand hygiene: 20+ seconds w/ soap/water or alcohol containing hand gel

Treatment

  • Isolate & send PCR test early (may take days to result)
  • GOC discussion /triage
  • Notify DOH,CDC,etc
  • Fluid sparing resuscitation
  • +/- empiric antibiotics
  • Intubate early under controlled conditions if possible
  • Avoid HFNC or NIPPV (aerosolizes virus) unless individualized reasons exist(e.g. COPD, DNI Status, etc); consider helmet mask interface (if available) if using NIPPV
  • Mechanical ventilation or ARDS
    • LPV per ARDSnet protocol
    • 7P’s for good care of ARDS patients e.g. PEEP/Paralytics/Proning/inhaled Prostacyclins, etc
    • ?High PEED ladder may be better
    • ?ECMO in select cases (unclear who)
  • Consider using POCUS to monitor/evaluate lungs
  • Investigational therapies:
    • Remdesivir –| block RNS dependent polymerase
    • Chloroquine –| blocks viral entry in endosome
    • Tocilizumab –| block IL-6
    • Corticosteroids –| reduce inflamation
  • None of these investigational therapies are proven, but literature is evolving quickly.

Prognosis

  • Age and comorbidities (DM, COPD, CVD) are significant predictors of poor clinical outcome; admission SOFA score also predicts mortality
  • Lab findings also predict mortality
    • d-dimer(increased),
    • ferritin(increased)
    • troponin (increased)
    • cardiac (increased)
    • myoglobin
  • Expect prolonged MV
  • Watch for complications:

Secondary infection VAP, Stress CM, etc

 

 

 

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