Wednesday, March 18, 2020

COVID-19 (Coronavirus) notes and summary for Interns, residents, emergency medicine doctors and physicians

Disease progression

  • 1st week : Fever, non-productive cough, Vomiting , nausea, diarrhoea.
  • 2nd Week : Deterioration – Dyspnoea , SOB , Chest tightnes


  • Typical evolution :
                 -Day 6 post exposure – Dyspnoea
                 -Day 8 - Admission
                 -Day 10 - ICU admission / Intubation
  • Deterioration or recovery most commonly occurs at Day 6-7 of illness

Characteristics

  • The most associated co-morbidities with ICU admission were diabetes and hypertension.
  • Most patients are around 70 years old
  • Obesity is a frequent co-morbidity
  • Net prevalence in the male population
  • Note: Interstitial pneumonia / Reps failure +/- Flu like symptoms treat as COVID +ve  DO NOT BLINDLY trust negative swab if symptoms / pneumonia with suggestive CXR

Organ failure

  • Hypoxaemic respiratory failure > 90 %
  • Shock 30 %
  • AkI 10 – 30% (RRT 20%)

Bloods

  • ABG – Mild acidosis with normal lactates, severe base deficit, high AG.
  • Raised CK especially in younger patients
  • Lymphopenia common
  • Very elevated CRP
  • Often thrombocytopenic (mild ) <100 rare
  • WBC tends to be normal
  • LFTs abnormal ~ 30 %
  • Difficult glycaemic control – frequent ketoacidosis

Imaging


Image 1: Chest x ray PA view :Interstitiopathy, Bilat infiltrates common and gravitational distribution.

  • Chest CT – NOT indicated due to high difficulty in transportation, high risk of spreading the contagion
                   - Ground glass appearances, crazy paving , bilat infiltrates , atelectasis .
  • Lung USS – Diffuse B-line profile – Responds well to PEEP Consolidation / parapneumonic / atelectasis.
  • ECHO – Attention to dyskinesias – Proportion of patients have troponin rise. Thought to be secondary to stress cardiomyopathies secondary to virus . Not ACS.


Airway

  • Pre Oxygenate with C-Circuit and tight fitting face mask / two handed grip to minimise leak
  • Avoid bagging if able (Aerosalising) – If required insert LMA
  • Consider videolaryngoscopy as first line
  • Do not postitive pressure ventilate until cuff inflated – Attach to ventilator immediately post intubation
  • Use closed suction system
  • Airway management by most experienced practitioner
  • Cricoid pressure case dependant – avoid if able
  • Avoid unnecessary circuit disconnection – clamp ETT and place ventilator on standy
  • Use out-of-room and in-room checklists and formulate plan

Ventilation

  • PRVC
  • Lung Protective Ventilation – 6mls/kg
           - Often High PEEP required >15cmH20.
           - Patients usually have good compliance
           - PRONING – 18-22hr - Often 7 rotations necessary - Fio2 >0.60
           - NEGATIVE fluid balance
           - NMBA’s and Deep sedation
  • Worsening of ventilatory failure with refractory hypercapnia in week 3 – Secretion retention /dead space ventilation
  • Consider early tracheostomy <7 days – reduce sedation requirement / aid weaning
  • Be careful with early spontaneous ventilation due to risk of de-recruitment
  • Patients requiring 14-21 days invasive ventilation
  • Note: HFNO / NIV not recommended


Interventions

  • NG tube post intubation – early enteral nutrition
  • CVC line – Recommended USS guided ( Dedicated USS for COVID-19 lines ) – Needs decontamination .
  • 1st line vasopressor : Noradrenaline (4mg/50ml 5% Glucose)
  • In event of increased numbers of patients / limited numbers of pumps – Move to peripheral noradrenaline – (8mg/250ml ) (see separate policy / ICU Cons decision)

Renal

  • CRRT – approx. 20% pts
  • Reserve for patients with favourable outcomes:
          - Filtration / dialysis teams
          - Logistics of disposal of waste
          - Increased nursing load


Medications

  • Steroids – No benefit in Steroid use. May increase viral shedding
  • Antibiotics – Not unless severe disease with potential of bacterial overlay – Yes in late infection
  • Antivirals – Consider in deterioration – scant evidence base.

Personal Protective Equipment (PPE) for Covid-19 
Image 2 : Personal Protective Equipment (PPE) for Covid-19


The swabbing process:

Gather 3 red topped nasopharyngeal swab packets, get 6 microbiology sample bags, remove the paper from 3 of the bags (leaving just the colourless plastic pouches), attach patient labels to remaining 3 sample bags, place all 6 sample bags and 3 swabs in a white tray with sharps bin. Gather one of the large white cylindrical transport containers and place everything on a silver trolley with wheels.

  1. Get PPE ready and don (see trust guidance)
  2. Buddy unpeels swab packet
  3. Swabber takes out swab and swabs the throat
  4. Buddy takes red lid off container
  5. Swabber places swab in container and snaps end of stick off
  6. Swabber places end of stick in sharps bin with no-touch-technique
  7. Buddy screws red lid on container
  8. Buddy labels the container
  9. Buddy places the container in an empty plastic pouch, seals the pouch then places that in
  10. to the 1st labelled sample bag and seals it
  11. This process is repeated for sample 2 and 3.
  12. Once all 3 samples have been taken and bagged, buddy places them inside the transport container (everything else that was in the transport container needs to stay in there too) and screws closed the lid.
R Ferguson
York ICU
March 2020 Version 1.0



 Principles of Airway management in Coronavirus for suspected/Reportable or Confirmed cases of covid-19 infographic 
Iinfographic 1: Principles of Airway management in Coronavirus for suspected/Reportable or Confirmed cases of covid-19

In-room Intubation checklist for suspected #covid 19 Patiennt Infographic 
Infographic 2: In-room Intubation checklist for suspected covid 19 Patient


Outside room checklist for suspected for covid 19 patient Infographic 
Infographic 3: Outside room checklist for suspected for covid 19 patient