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

 

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

 

 

 

Tags: Coronavirus, Coronavirus Precautions, Coronavirus Prognosis, Coronavirus Symptons, Coronavirus Treatment, Covid-19 Labs, COVID-19 Symptoms, Covid19