Thread by @CELovegrove

Primed & ready.

https://twitter.com/RCSEd/status/1240307320933974016

1/n.
Atypical presentations: diarrhoea, vomiting, abdominal pain, post operative pyrexia
Pts at risk: male, elderly, comorbid, HTN, DM (NB based on tested cohort, ? bias)
Organ failure: tachypnoea, tachycardia, arrhythmias, cyanosis
Systemic shock less frequent presentation

2/n.
2 presentations.
1. Early: Slow progression hypoxic resp failure(5/7)
2. Late: acute, generalised sepsis, hypoxic, urgent intubation & ventilation required
Ix: leukopaenia/lymphopaenia, altered ALT, LDH. High CRP, Low Alb, low Hb. High trop if myocardium involved & D-dimer

3/n.
Further Ix:
-Nasal/mouth swabs often -ve, maintain high index of suspicion if clinically resembles #COVID19
-Sputum/ET aspirate more reliable
-CXR: resembles ARDS, 75% bilateral, 25% unilateral
-CT characteristic changes: ground glass, pleural thickening, effusions

4/n.
D-dimer useful in prognostication
14% admissions will need O2
5% will need ITU...prepare for ICU expansion

5/n.
Likely practical implications:
Surgical wards -> COVID isolation wards
Reallocation of roles- critical care experience highly valuable

6/n.
Initial tx:
-Paracetamol for fever
-O2
-Prepare for deterioration- early anticipatory care planning (ceiling of care, DNACPR etc) to benefit pts & staff. Consider comorbidities & frailty scale & document this
-If suitable for crit care, escalate early

7/n.
Minimal benefit from NIV/high flow O2 (& risk of aerosol)
-When >60% O2 requirement, needs crit care
-Tachypnoea concerning but its absence is not reassuring
-NEWS2 score less reliable

8/n.
In crit care:
-early arterial line for monitoring
-intubation if ongoing high O2 requirement; escalate to minimise desaturation on intubation
-PPE, PPE, PPE!
-Avoid bagging for pre-oxygenation if possible, though not always practicable
-Avoid bronchoscopy

9/n.
-Manage ARDS- prone ventilation valuable (16hours) esp if FiO2>60% & P/F <20
-Lung protective ventilation
-Limit tidal volume & pressure to minimise volume trauma & barotrauma
-PEEP to recruit more alveoli
-Beware tachyarrhythmias
-PPE, PPE, PPE!
-ECMO: potential value

10/n.
Challenges:
-Weaning off ventilation
-?role of tracheostomy
-no data for antivirals
-?chloroquine in severe cases
-ACE2r antagonists- ? role

11/n.
Infection control:
-Trust local guidelines
-PPE, PPE, PPE!
-End of life challenges: disposal via standard practice incl PPE.

12/n.
Further advice:
- icmanaesthesiacovid-19.org
- Wellbeing; look after selves, each others, family
- Marathon not a sprint

13/n.
Q&A:
-Smokers at higher risk
-Steroids?- no good data despite high-dose use in China, low-dose may change ventilatory requirements
-Role of routine CT in Dx: not recommended by UK radiologists
-May have longer intubation post-op than other pts
-No role for CPAP/BiPAP

14/14.
Q&A cont:
-Asymptomatic carriers CAN transmit! #SelfIsolation #SocialDistancing #lockdownuk highly valuable

Many thanks @McneillGregor, @agibson82 @RCSEd @surgeonsnews #alwayslearning