Ver el código de «COVID-19»

{{Adult top}} [[COVID-19 (peds)]]. For pregnant patients see [[COVID-19 in pregnancy]].''
==Background==
*Caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 
*See [[COVID-19: Epidemiology and pathophysiology]]

{{Specific Coronavirus Sub-Types of Clinical Importance}}

==Clinical Features==
===Initial Presentation===
*Many patients are asymptomatic
* At onset of symptoms: [[fever]], dry [[cough]], myalgias, fatigue, [[shortness of breath]]
** Fever and cough start early, [[shortness of breath]] noted about 9 days into illness
** Fever not present in all adults 
***Only 1/2 of patients may have fever at time of admission<ref>1. Zhou F, Yu T, Du R et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet. 2020;395(10229):1054-1062. doi:10.1016/s0140-6736(20)30566-3</ref>
***less common in vulnerable populations
** Less common: cough with sputum, sore throat, headache, congestion, GI symptoms, anosmia, altered mental status
**Sudden onset anosmia has a high specificity for COVID-19 infection

{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Symptom<ref>World Health Organization. "Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19)" (PDF): 11–12. Retrieved 5 March 2020.</ref>'''
|'''%'''
|-
|[[Fever]]
|87.9
|-
|Dry [[cough]]
|67.7
|-
|Fatigue
|38.1
|-
|Sputum production
|33.4
|-
|[[Shortness of breath]]
|18.6
|-
|Myalgia or arthralgia
|14.8
|-
|[[Sore throat]]
|13.9
|-
|[[Headache]]
|13.6
|-
|Chills
|11.4
|-
|[[Nausea or vomiting]]
|5.0
|-
|Nasal congestion
|4.8
|-
|[[Diarrhea]]
|3.7
|-
|[[Hemoptysis]]
|0.9
|-
|[[Conjunctivitis]]
|0.8
|}

===Common Complications===
''The initial presentation can be followed by delayed and serious complications''
* Pulmonary
**Most common complications: [[pneumonia]], [[ARDS]] (average 8 days from onset, 20% of patients in China)
**"Happy Hypoxemia": many of these patients will be hypoxic without dyspnea 
** Decompensation risk occurs during 2nd week of illness leading to [[respiratory failure]]
*Cardiac Complications<ref>Long B, Brady WJ, Koyfman A, Gottlieb M. Cardiovascular complications in COVID-19. Am J Emerg Med. 2020;38(7):1504-1507. doi:10.1016/j.ajem.2020.04.048</ref>
**Myocarditis,Acute Myocardial infarction, Dysrhythmias, cardiomyopathy, venous thromboembolism.
***Vasodilatory shock reported in 67% of ICU admissions
***Cardiomyopathy reported in 33% of ICU admissions
***Mortality reported 67% of ICU admissions
*Neurological Complications- thought to be related to the increased levels of interleukin (IL)-6, IL-12, IL-15, and tumor necrosis factor alpha (TNF-α)<ref>Bridwell R, Long B, Gottlieb M. Neurologic complications of COVID-19. Am J Emerg Med. 2020;38(7):1549.e3-1549.e7. doi:10.1016/j.ajem.2020.05.024</ref>
**acute CVA, encephalitis, Guillain-Barré syndrome, acute necrotizing hemorrhagic encephalopathy, and hemophagocytic lymphohistiocytosis

==Differential Diagnosis==
{{ILI DDX}}
{{Causes of pneumonia}}

==Evaluation==
===Workup===
''Consider minimal to no workup in well-appearing patients with mild disease''
====Viral Testing====
[[Testing+Surveillance: COVID]]
*RT-PCR (reverse transcriptase polymerase chain reaction) is most commonly used test for confirming cases
**Sensitivity may be only 75%, but highly specific
**Turnaround time may be several hours to days
*Real time RT-PCR e.g. Cepheid
**Rapid test with results in <1hr
*Serologic testing for IgM/IgG is not widely available, but likely more sensitive
**The presence of IgG with a negative RT-PCR likely confirms past exposure and some immunity
*Test kit availability varies widely by region and institution

====Labs====
''Consider in sicker patients (likely requiring admission):''
*Chemistry
*CBC w/diff
**Lymphopenia - common (80%)<ref>Yang X, Yu Y, Xu J et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. The Lancet Respiratory Medicine. 2020. doi:10.1016/s2213-2600(20)30079-5</ref>
**Thrombocytopenia - common but mild
***<100 poor prognostic sign <ref>Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med. 2020. doi:10.1007/s00134-020-05991-x</ref>
*Coagulation studies
**PT/PTT/INR - DIC possible
**D-dimer, fibrinogen - markers of severity
*LFTs - mild elevation of ALT/AST
*Inflammatory Markers
**CRP - Indicates disease severity <ref>Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med. 2020. doi:10.1007/s00134-020-05991-x</ref>, <ref>Young B, Ong S, Kalimuddin S et al. Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore. JAMA. 2020. doi:10.1001/jama.2020.3204</ref>
***Negative points to non-infectious cause (CHF/ESRD)
**Procalcitonin - normal/mild increased on admission. Normal procalcitonin makes bacterial superinfection less likely. 
**Ferritin
**LDH
*Troponin <ref>https://www.covidprotocols.org</ref> - myocarditis
*Sepsis labs
**Lactate
**Blood culture x2
*Swabs - Co-infection has been reported as high as 7-20%
**Flu swab
**Respiratory viral panel
***Note that BIOFIRE Respiratory Panel Corona Virus assay does NOT detect this COVID-19 subtype
*Urine pregnancy test in reproductive-age women
*''Other labs to consider in patients that will be admitted:''
** HBV serologies, HCV antibody
**''Consider (as clinically indicated):'' PCP DFA, beta-d-glucan, urine legionella Ag, IL-6

====Imaging====
[[File:COVID one pager with links.jpg|thumb|CXR of COVID]]
[[File:COVID one pager with links 2.jpg|thumb|CT of COVID]]
[[File:covidcxr.jpg|thumb|CT of COVID]]

=====X-ray=====
* Portable [[CXR]] preferred in PUI to prevent spread of infection
** May be normal in early disease
** Typical pattern is peripheral patchy ground glass opacities (GGO)
** More opacities correlates with worse disease
** GGOs may coalesce and appear as infiltrates
** Not every PUI needs a chest X-ray. Patients who are more likely to need one include any moderate or high acuity patient, elderly, concerning chronic conditions, BMI > 40, high risk socioeconomic situations.

=====CT=====
* Many have normal imaging early on (CDC does '''not''' recommend CT for diagnostic purposes)
** CT (86%) more sensitive than CXR (59%) for detecting GGOs
**Generally, the findings on chest imaging are not specific and overlap with other infections, including influenza, H1N1, SARS and MERS.<ref>From the American College of Radiology (3/11/20):</ref>

=====US=====
* Uncertain role in diagnosis at this time
**May reveal B lines, consolidation, or "ragged" appearance of pleural line
*Useful in evaluating undifferentiated Dyspnea
**[[Ultrasound: Cardiac]]
**[[Ultrasound: Lungs]]
**[[IVC ultrasound]]

===Diagnosis===
*Typically confirmed by viral testing (see above)

====Disease Severity====
''Some define moderate and severe acuity as follows''
* Low: SaO2 > 93% on RA, RR < 20, and HR < 110
* Moderate: SaO2 = 91-93% on RA, RR 20-24, HR 110-124 with wheezing, rales, or an otherwise abnormal lung exam.
* High: SaO2 < 91%, RR > 24, HR > 124.
^ If febrile, treat with [[acetaminophen]] and reassess acuity.

===Prediction of Need for Intubation===
*ROX Index for intubation after high-flow nasal cannula (HFNC}
**Predicts HFNC failure/need for intubation
**https://www.mdcalc.com/rox-index-intubation-hfnc

==Management==
{{COVID PPE summary table}}

===General Supportive Care===
====Pulmonary <ref>Alhazzani W, Møller M, Arabi Y et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. 2020. doi:10.1007/s00134-020-06022-5</ref>====
*Supplemental [[oxygen therapy]] if Sat<90% 
**Target SPO2 92%-96%
*High-flow Nasal Cannula
**Some guidelines recommend HFNC over BIPAP/CPAP, in those that fail low-flow O2. <ref>Alhazzani W, Møller M, Arabi Y et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. 2020. doi:10.1007/s00134-020-06022-5</ref>
**Requires patient to be on airborne isolation. 
*[[Non-Invasive Ventilation]] if no HFNC
*Consider awake proning to improve oxygenation 
*Bronchodilators if bronchospasm present
**Use metered-dose inhaler (avoid nebulizers due to aerosolization)

====Other====
*Infectious disease 
**[[Acetaminophen]] for fever
**Consider antibiotics for bacterial [[pneumonia]] coverage
*Cardiovascular <ref>Alhazzani W, Møller M, Arabi Y et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. 2020. doi:10.1007/s00134-020-06022-5</ref>
**Most patients without hemodynamic compromise
**Maintain euvolemia - hypervolemia may contribute to ARDS
**Hypoperfusion - cautious fluid resuscitation
**Vasopressors
***1st line - [[Norepinepherine]] (alternative: [[epinephrine]]) 
***2nd line - [[Vasopressin]]
*Vascular
**Consider [[COVID-19:_Medication_therapy#Anticoagulation|anticoagulation]]

===Medications by Patient Category===
[[File:Outpatient Fig 1.png|thumb|NIH consensus guidelines for COVID treatment.<ref>https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/clinical-management-summary/</ref>]]
[[File:Inpatient Fig 2.png|thumb|NIH consensus guidelines for COVID treatment.<ref>https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/clinical-management-summary/</ref>]]

====Outpatients Not Requiring Admission<ref>https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/clinical-management-summary/</ref>====
*High risk patients (one of the following, if available):
**Ritonavir-boosted nirmatrelvir ([[Paxlovid]])
**[[Sotrovimab]]
**[[Remdesivir]]
**[[Molnupiravir]]
''[[Dexamethasone]] has '''not''' demonstrated benefit in this patient category and may be potentially harmful''

====Outpatients Requiring Home Oxygen (New or Increased)<ref>https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/clinical-management-summary/</ref>====
*[[Dexamethasone]] 6mg PO daily x the duration of supplemental oxygen (not to exceed 10 days)
*Consider [[Remdesivir]]

====Hospitalized Not Requiring Oxygen====
*Consider [[Remdesivir]]
''[[Dexamethasone]] has '''not''' demonstrated benefit in this patient category and may be potentially harmful''

====Hospitalized Requiring Oxygen====
*[[Dexamethasone]] 6mg PO daily x 10 days
*[[Remdesivir]] 200 mg IV once, then 100 mg IV once daily for 4 days or until hospital discharge (whichever comes first).
*If requiring High-Flow or NIV, add [[baricitinib]] or IV [[tocilizumab]]
**If not available, IV [[sarilumab]] can be used

==[[Respiratory failure]]==
{{COVID-19 intubation}}
{{Lung Protective Ventilator Settings}}
*See also [[deterioration after intubation]]
{{COVID-19 Lung Phenotypes}}
{{COVID contraindicated therapies}}

==Disposition==
*80% of patients do not require hospital admission
*Mild cases for persons under investigation for Covid-19 awaiting a positive test result can self quarantine at home in conjunction with the local Public Health Dept
*"Silent hypoxemia" is now reported in patients with oxygen saturations ranging in the 80s-90s without respiratory distress. Hypoxia is not recommended as an absolute indication for emergent intubation.
** Note: symptoms may worsen over 2nd week of illness

===Admission===
* Hospitalize: Respiratory distress/failure, multi-organ failure, rapid disease progression requiring escalating supportive care. Meets criteria for high acuity above. Moderate acuity with extra risk factors (pneumonia, immunosuppressed, elderly, comorbidities), complicated social situation, worsening symptoms > 10 days out.
**PSI/PORT, MuLBSTA, and CURB65 scores have all been proposed criteria for admission and predicting outcomes. 
***These scores are not externally validated. Use with caution. https://www.mdcalc.com/covid-19#calcs
* May consider discontinuation of hospital isolation when:
** Resolution of fever without anti-pyretic, resolution of symptoms, and negative COVID19 testing

==Special Situations==
*For pregnant patients see: [[COVID-19 in pregnancy]]
*For pediatric patients see: [[COVID-19 in pediatrics]]

===COVID-19 and [[STEMI]]===
*According to ACC consensus statement "During the [[COVID-19]] pandemic, PCI remains the standard of care for STEMI patients"
*If [[thrombolytics]] are indicated options include:
**Administer 10u [[Retavase]] (reteplase) IV bolus followed by a second bolus at 30 minute rather than PCI.  OR
**[[Tenecteplase]] (TNKase) 30 mg IV bolus      
**If [[Tenecteplase]] is not available, it is acceptable to administer a lower dose of [[alteplase]] (tPA) at 50 mg (8 mg bolus, followed by 42 mg infusion over 90 minutes).
**Follow [[thrombolytics]] by 40u/kg [[heparin]] (max dose 4,000 units) IV and 600mg [[clopidogrel]] PO and [[ASA]] 325 mg PO

===COVID-19 and CPR===
*Interim AHA Guidance
**Don all PPE prior to initiating CPR. CPR is aerosol generating. 
**Intubate early, video laryngoscopy preferred
**Pause chest compressions during intubation
**If patient is on ventilator at time of arrest consider leaving patient on ventilator
***Adjust ventilator to allow for asynchronous ventilation 
**If using BVM then attach high efficiency particulate air (HEPA) filter
**Use of mechanical compression device (e.g. LUCAS) is encouraged
* Use auto CPR device if available

==Prognosis==
{{COVID Risk Factors}}

==See Also==
{{Special:Prefixindex/COVID-19 |hideredirects=1}}

==External Links==
*https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/hospitalized-adults--therapeutic-management/
*WHO COVID-19 Situation Dashboard (Live): https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd
*[https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html CDC Main Healthcare Page]
*[https://emcrit.org/emcrit/some-additional-covid-airway-management-thoughts/ EMCrit Covid Airway Management]
*Johns Hopkins COVID Case Map (Live):https://coronavirus.jhu.edu/map.html
*California Emergency Medical Services Authority Resource Portal https://emsa.ca.gov/covid19/
*Oxford Journal of Travel Medicine COVID19 Resources https://academic.oup.com/journals/pages/coronavirus?cc=gb&lang=en&
*EM:RAP Corependium COVID-19 (open access) https://www.emrap.org/corependium/chapter/rec906m1mD6SRH9np/Novel-Coronavirus-2019-COVID-19?MainSearch=%22covid%22&SearchType=%22text%22
*[https://connect.medrxiv.org/relate/content/181 MedRxiv Covid-19 SARS]
* Additional DPH Guidance: http://publichealth.lacounty.gov/acd/nCorona2019.htm
*Seattle ICU doctor's one page info on mgmt of COVID from ACEP website [[:File:COVID19 seattle one pager.pdf]]
*Harbor DEM COVID airway management guide [[:File:Harbor COVID Airway Management v3-16-20.pdf]]
*Proper donning and doffing from CDC  [[:File:Doffing PPE CDC.pdf]]
*Radiopaedia COVID-19 Resources (https://radiopaedia.org/articles/covid-19)
*Literature review https://reacting.inserm.fr/literature-review/
*COVID related trials: https://covid.inato.com/analysis

==References==
<references/>

[[Category:ID]]