Thread by @Dr_Khan

A must read thread on clinical insight, #coronavirus disease patients ..
#COVID19 #COVID2019 #COVID

Clinical course is predictable.
2-11 days after exposure (day 5 on average) flu like symptoms start.
1/25

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Common are fever, headache, dry cough, myalgias(back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.

Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.
2/25

Day 10- Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours.

81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.
3/25

Patient presentation is varied. Patients are coming in hypoxic (even 75%) without dyspnea. I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA.

I have seen bilateral interstitial pneumonia on the xray of the asymptomatic or on CT.
4/25

Seen 3 positive flu swabs in 2 weeks & all 3 had Covid 19 as well. Somehow this has told all other disease processes to get out of town.
China reported 15% cardiac involvement. I have seen present with myocarditis, pericarditis, new onset CHF & new onset atrial fibrillation.
5/25

I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA in the ED and rescue PCI at 60 minutes only if TPA fails.
6/25

Diagnostic
CXR- bilateral interstitial pneumonia (anecdotally starts most often in RLL so bilateral on CXR is not required). Hypoxia does not correlate with CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket & evaluate with your eyes & pulse ox.
7/25

Labs- WBC low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95%
CRP and Ferritin elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated.
Notice D-Dimer- I would be very careful about CT PE these patients for their hypoxia.
8/25

Patients receiving IV contrast are going into renal failure and on the vent sooner.

Basically, if you have bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP & ferritin- you have covid-19 & do not need a nasal swab to tell you that.
9/25

A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.
10/25

An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.

Other factors that appear to be predictive of poor outcomes are thrombocytopenia and LFTs 5x upper limit of normal.
11/25

Disposition
I had never discharged multifocal pneumonia before. Now I do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if patient is comfortable & oxygenating above 92% on nasal cannula.
12/25

We have contracted with a company that sends paramedic to home twice daily to check on them & record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something.
Obviously we are fearful some won't make it back.
13/25

We are small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on floor.
14/25

We now have 9 vented patients in our ER transferred down from floor after intubation. Luckily we are part of larger hospital group. Our main teaching hospital repurposed space to open 50 Covid 19 ICU beds this past Sunday so these numbers are with significant decompression.
15/25

Today those 50 beds are full. They are opening 30 more by Friday. But even with the "lockdown", our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.
16/25

Treatment
Supportive

Worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.
17/25

Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of & kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see benefit to our hospitalized patients, but we are using it & studies will tell.
18/25

With Plaquenil's potential QT prolongation & liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication.

We are also using Azithromycin, but are intermittently running out of IV.
19/25

Do not give these patient's standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.
20/25

Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.

Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.
21/25

Do not use Bipap- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.

The same goes for nebulizer treatments.
22/25

Use MDI. you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn't often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct patient on how to start it after you leave the room.
23/25

Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis.

We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.
24/25

I PPE best I have. I wear a MaxAir PAPR entire shift. I do not take it off to eat or drink during shift. The stress & exposure at work coupled with isolation at home is trying. Be nice to your nurses & staff. Show by example.
Good luck to us all.
25/25

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