Cracking D’ Boards Review Center COVID-19 Pearls Preboard Chill-Out Sesions

Covid19
Case
 A 40-year-old man sought teleconsult with you
due to a 3-day history of low-grade fever,
anorexia and dry cough which he attributes to
his allergic rhinitis. Patient lives in Metro Manila
where COVID-19 cases are surging. He denies
any history of travel. He is a known • Family Coronaviridae
hypertensive for 4 years maintained on • Subfamily Orthocoronaviridae
Telmisartan 40 mg 1 tablet PO OD and a • Order Nidovirales
diabetic for 4 years currently on Sitagliptin +
Metformin 50/500 mg 1 tablet PO OD with poor 4 Genera of CoVs:
compliance. Currently, patient denies any • alphaCoV
difficulty of breathing, changes in sensorium • betaCoV
and anosmia. He is currently taking mega doses • deltaCoV
of Vitamin C and Zinc and is asking whether he • gammaCoV
can take Ivermectin tablets and Melatonin
which his friend recommended.
 How will you categorize this patient? COVID_19  SEVEN Co-V causes human infection
suspect/probable?  FOUR – mild, self-limiting
 Will you recommend isolation? Should you  Severe Acute Respiratory Syndrome (SARS-CoV)
recommend isolation to his workmates who he  2002-2003 Outbreak, Hongkong
saw 2 days prior to onset of symptoms?  Himalayan Palm Civet
 What laboratory tests are recommended for  Middle East Respiratory Syndrome (MERS-CoV)
this patient?  2012-2013, Saudi Arabia
 What medicines can you offer for this patient?  Dromedary Camel
 How will you monitor his response to  SARS-CoV-2
treatment?

 January 7, 2020
 WHO renamed 2019-nCoV to SARS-
CoV2 after genomic sequencing
 COVID-19 was the disease it caused
SARS-CoV 2 transmitted from Horse-shoe bat
> Civet cat> Human

• Enveloped
• Positive single-stranded
• RNA virus
• Zoonotic
Cracking D’ Boards Review Center COVID-19 Pearls Preboard Chill-Out Sesions

Incubation period
 The incubation period for COVID-19, which is
the time between exposure to the virus
(becoming infected) and symptom onset, is, on
average, 5–7 days, but can be up to 14 days.
 “Presymptomatic” period - some infected
persons can be contagious, from 1–3 days
before symptom onset
 Among symptomatic patients, the duration of
infectious virus shedding has been estimated at
8 days from the onset of any symptoms
 Shedding of SARS-CoV-2 is highest in the upper
respiratory tract (URT) (nose and throat) early in
the course of the disease
 Highest viral load in throat swabs at the time of
symptom onset, suggesting infectiousness peak
on or before symptom onset

RT-PCR positivity
 BAL 93%
 Sputum 72%
 Nasal swab 63%
 Pharyngeal swab 32%
 Feces 29%
 Blood 1%
 Urine none

Ct 40 cutoff!!!

• Env – envelope
• N - nucleocapsid
• S – spike protein
• RdRp – RNA dependent RNA polymerase
• ORF1 gene
Cracking D’ Boards Review Center COVID-19 Pearls Preboard Chill-Out Sesions

WHO SEVERITY DEFINITION

Cracking D’ Boards Review Center COVID-19 Pearls Preboard Chill-Out Sesions

Who living guidance (treatment)

 Mild COVID-19
 Suspected/confirmed mild COVID cases
 ISOLATE
 Symptomatic treatment; antipyretics for
fever and pain, adequate nutrition,
appropriate rehydration
 Counsel patients about signs and
symptoms of complications that
requires prompt urgent care (light
headedness, difficulty breathing, chest
pain, dehydration)
 Antibiotic therapy or prophylaxis should
not be used with mild COVID-19

 Moderate COVID-19
Cracking D’ Boards Review Center COVID-19 Pearls Preboard Chill-Out Sesions
 Suspected/confirmed moderate COVID
cases  ISOLATE (health facility,
community facility or at home)
 For patients at high risk for
deterioration, hospital isolation is
preferred
 For symptomatic patients  pulse
oximetry monitoring
 Antibiotics should not be prescribed
unless there is clinical suspicion of a
bacterial infection.
 Close monitoring of patients with
moderate COVID-19 for signs or
symptoms of disease progression.

 Severe COVID-19
 All areas where severe patients may be
cared for should be equipped with pulse
oximeters, functioning oxygen systems
and disposable, single-use, oxygen-
delivering interfaces (nasal cannula,
Venturi mask and mask with reservoir
bag).
 Immediate administration of
supplemental oxygen therapy to any
patient with emergency signs during
resuscitation to target SpO2 ≥ 94% and
to any patient without emergency signs
and hypoxaemia (i.e. stable hypoxaemic
patient) to target SpO2 > 90% or ≥ 92–
95% in pregnant women.
 Closely monitor patients for signs of
clinical deterioration, such as rapidly
progressive respiratory failure and
shock and respond immediately with
supportive care interventions.
(NEWS2/PEWS score) Who living guidance (treatment)
 Severe COVID-19
 Awake prone positioning of severely ill
patients hospitalized with COVID-19
requiring supplemental oxygen
(includes high-flow nasal oxygen) or
non-invasive ventilation (conditional,
low certainty evidence).
Cracking D’ Boards Review Center COVID-19 Pearls Preboard Chill-Out Sesions
 Patients with ARDS, especially young
children or those who are obese or
pregnant, may desaturate quickly
during intubation. Pre-oxygenation with
100% FiO2 for 5 minutes, and use of a
face mask with reservoir bag is
preferred. When possible, avoid bag-
valve mask ventilation to reduce
exposure to aerosols. Rapid-sequence
intubation is appropriate

 Severe COVID-19  Critical COVID-19

 Use cautious fluid management in  Mechanical ventilation using lower tidal
patients with COVID-19 without tissue volumes (4–8 mL/kg predicted body
hypoperfusion and fluid responsiveness. weight [PBW]) and lower inspiratory
pressures (plateau pressure < 30
 Critical COVID-19 cmH2O).
 In selected patients with COVID-19 and  In adult patients with severe ARDS
mild ARDS, a trial of High Flow Nasal (PaO2/FiO2 < 150) prone ventilation for
Oxygen (HFNO), non-invasive 12–16 hours per day is recommended.
ventilation – continuous positive airway  Use a conservative fluid management
pressure (CPAP), bilevel positive airway strategy for ARDS patients without
pressure (BiPAP) may be used. tissue hypoperfusion and fluid
responsiveness.
 In patients with moderate or severe
ARDS, a trial of higher positive end-
expiratory pressure (PEEP) instead of
lower PEEP is suggested and requires
consideration of benefits versus risks. In
COVID-19, we suggest the
individualization of PEEP where during
titration the patient is monitored for
effects (beneficial or harmful) and
driving pressure

 Critical COVID-19
 In patients with moderate-severe ARDS
(PaO2/FiO2 < 150), neuromuscular
 Critical COVID-19 blockade by continuous infusion should
 Patients may continue to have not be routinely used.
increased work of breathing or  Avoid disconnecting the patient from
hypoxaemia even when oxygen is the ventilator, which results in loss of
delivered via a face mask with reservoir PEEP, atelectasis and increased risk of
bag (flow rates of 10–15 L/min, which is infection of health care workers. Use in-
typically the minimum flow required to line catheters for airway suctioning and
maintain bag inflation; FiO2 0.60–0.95). clamp endotracheal tube when
 Hypoxaemic respiratory failure in ARDS disconnection is required.
commonly results from intrapulmonary  Techniques for airway clearance and
ventilation-perfusion mismatch or shunt secretion management include
and usually requires mechanical positioning with gravity-assisted
ventilation drainage, active cycle of breathing
Cracking D’ Boards Review Center COVID-19 Pearls Preboard Chill-Out Sesions
techniques, positive expiratory pressure
therapy, and assisted or stimulated  Critical COVID-19: Septic Shock
cough manoeuvres  In adults, administer vasopressors when
 In settings with access to expertise in shock persists during or after fluid
ECMO, consider referral of patients who resuscitation. The initial blood pressure
have refractory hypoxaemia (e.g. target is MAP ≥ 65 mmHg in adults and
including a ratio of partial pressure of improvement of markers of perfusion.
arterial oxygen [PaO2] to the fraction of  In children, administer vasopressors if
inspired oxygen [FiO2] of < 50 mmHg signs of fluid overload are apparent or
for 3 hours, a PaO2:FiO2 of < 80 mmHg the following persist after two fluid
for > 6 hours) despite lung protective bolus:
ventilation.  • signs of shock such as altered
mental state;
 Critical COVID-19: Septic Shock  • bradycardia or tachycardia
 Septic shock in adults when infection is (HR < 90 bpm or > 160 bpm in
suspected or confirmed AND infants and HR < 70 bpm or >
vasopressors are needed to maintain 150 bpm in children);
mean arterial pressure (MAP) ≥ 65  • prolonged capillary refill (> 2
mmHg AND lactate is ≥ 2 mmol/L, in the seconds) or feeble pulses;
absence of hypovolaemia  • tachypnoea; mottled or cool
 Septic shock in children with any skin or petechial or purpuric
hypotension (SBP < 5th centile or > 2 SD rash; increased lactate; oliguria
below normal for age) or two or more persists after two repeat
of the following: altered mental status; boluses;
bradycardia or tachycardia (HR < 90  • or age-appropriate blood
bpm or > 160 bpm in infants and HR < pressure targets are not
70 bpm or > 150 bpm in children); achieved
prolonged capillary refill (> 2 sec) or
feeble pulses; tachypnoea; mottled or THROMBOPROPHYLAXIS
cold skin or petechial or purpuric rash;  Suggested dosing of standard
increased lactate; oliguria; thromboprophylaxis is as follows:
hyperthermia or hypothermia.  Enoxaparin 40 mg by subcutaneous injection
every 24h:
 Critical COVID-19: Septic Shock  - Prophylactic dosages (non-weight
 In resuscitation for septic shock in adjusted) in low body weight (women <
adults, give 250–500 mL crystalloid fluid 45 kg, men < 57 kg) may lead to a
as rapid bolus in first 15–30 minutes. higher risk of bleeding. Careful clinical
 In resuscitation for septic shock in observation is advised.
children, give 10–20 mL/kg crystalloid  - If BMI > 40 kg/m2 or weight > 120 kg:
fluid as a bolus in the first 30–60 enoxaparin 40 mg by subcutaneous
minutes. injection every 12h.
 Fluid resuscitation may lead to volume  Unfractionated heparin (UFH) 5000 units by
overload, including respiratory failure, subcutaneous injection every 8 or 12h: - If BMI
particularly with ARDS. If there is no > 40 kg/m2 or weight > 120 kg: 7500 units q12h
response to fluid loading or signs of or 5000 units every 8h.
volume overload appear (e.g. jugular  Tinzaparin 4500 units/day if BMI < 40 kg/m2 or
venous distension, crackles on lung weight < 120 kg; 9000 units/day if BMI > 40
auscultation, pulmonary oedema on kg/m2 or weight > 120 kg.
imaging, or hepatomegaly), then reduce  Dalteparin 5000 units/day BMI < 40 kg/m2 or
or discontinue fluid administration. weight < 120 kg; 5000 units every 12h if BMI >
 Do not use hypotonic crystalloids, 40 kg/m2 or weight > 120 kg.
starches or gelatins for resuscitation.
Cracking D’ Boards Review Center COVID-19 Pearls Preboard Chill-Out Sesions
 Fondaparinux 2.5 mg by subcutaneous injection
every 24h.

Isolation and discharge

 Criteria for discharging patients from isolation
(i.e. discontinuing transmission-based
precautions) without requiring retesting:
 For symptomatic patients: 10 days after
symptom onset, plus at least 3 additional days
without symptoms (including without fever and
without respiratory symptoms).
 For asymptomatic cases: 10 days after positive
test for SARS-CoV-2.