Pulmonology Book

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Corona Virus 19

Aka: Corona Virus 19, COVID-19, Covid19, SARS-CoV2, High Risk Factors in Covid-19 Infection, COVID
  1. See Also
    1. Intensive Care
    2. Cytokine Release Syndrome (Cytokine Storm)
    3. Covid-19 Vaccine
    4. COVID-19 Monoclonal Antibody
    5. Long COVID
  2. Epidemiology
    1. Originally acquired at seafood and live animal market in Wuhan, Hubei Province, China in late 2019
      1. Initial International hot-spots (Feb 2020): China, Iran, Northern Italy, South Korea, Japan
      2. Initial U.S. hot spots (Feb 2020): Washington and California (sporadic cases in other regions)
        1. By middle March, Corona Virus spread to all 50 states
        2. Limited test availability hampered the identification of true cases, especially given ongoing Influenza
    2. Many COVID-19 Variants have been identified since the start of the 2019 pandemic
      1. B.1.1.7 (alpha)
      2. B.1.351 (beta)
      3. B.1.617.2 (delta)
      4. B.1.427 and B.1.429 (epsilon)
      5. P.1 (gamma)
      6. B.1.526 (iota)
      7. B.1.1.529 (omicron)
    3. Global Pandemic Statistics in first 24 months (March 2020 to March 2022)
      1. Incidence: 500 Million confirmed cases
      2. Mortality: 6 Million attributed deaths
  3. Risk Factors: High Risk Patients for Serious Complications (criteria for emergency use Covid medications)
    1. Body Mass Index (BMI) >=35
    2. Chronic Kidney Disease
    3. Diabetes Mellitus
    4. Immunocompromised Condition
    5. Current use of immunosuppressant
    6. BIPOC (Black, Indigenous, People of Color)
    7. Pregnancy
    8. Age >=65 years old
    9. Age >= 55 years old AND Comorbidity
      1. Cardiovascular Disease
      2. Hypertension
      3. Chronic Obstructive Pulmonary Disease (or other chronic respiratory disease)
    10. Children 12 to 17 years old with at least one of the following risk factors
      1. Body Mass Index (BMI) >= 85th percentile by age and gender
      2. Sickle Cell Disease
      3. Congenital or acquired heart disease
      4. Neurodevelopmental disorders (e.g. Cerebral Palsy)
      5. Medically related device dependence (e.g. Gastrostomy, Tracheostomy, non-covid related NIPPV)
      6. Asthma, reactive airway disease or other chronic respiratory disease requiring daily medication for control
  4. Pathophysiology: Organism
    1. Corona virus that originated in bats (similar to SARS, MERS)
    2. Enveloped, single-stranded RNA novel coronavirus
  5. Pathophysiology: Infectivity
    1. Person to person transmission with viral shedding 17-24 days (median 20 days) in China survivors
      1. Infectious 5 to 13 days after symptom resolution
    2. Infectivity (R0, pronounced "R-Naught")
      1. R0 appears to be 2-3 in most cases of Corona Virus 19
        1. However, there have been "super spreader" cases in which R0>20 (e.g. large gatherings)
  6. Pathophysiology: Severe Course Timing
    1. Incubation: 4 to 7 days (mean 5 days, some cases as long as 12-14 days)
    2. Day 0: First Symptoms (see below)
    3. Day 5: Dyspnea
    4. Day 7: Hospital Admission
    5. Day 8: Acute Respiratory Distress Syndrome (ARDS)
    6. Day 12-18: Death
    7. Day 22: Survivor hospital discharge
    8. Day 30: Recovery in mild cases (although Anosmia may persist for months)
    9. Day 60-75: Recovery in severe cases
  7. Pathophysiology: Illness stages
    1. Replication Stage
      1. Virus replicates with relatively minor symptoms
    2. Immunologic Response Stage
      1. Immune response after the first few days to week is a normal adaptive response in 80% of patients
      2. Exaggerated immunopathologic response (Cytokine Storm) occurs in <20% of cases
        1. See Cytokine Release Syndrome (Cytokine Storm)
        2. Inflammatory Cytokines cause tissue damage with Pneumonia and ARDS
  8. Findings: Signs and Symptoms in Adults
    1. General and prodromal
      1. Asymptomatic in 18-33% (especially younger patients)
      2. Fever (44% at initial presentation, 83-98% on hospitalization)
      3. Chills (12%)
      4. Myalgias (11 to 45%)
      5. Fatigue (38 to 70%)
      6. Anorexia (40%)
    2. Upper Respiratory
      1. Pharyngitis (5-14%)
      2. Nasal congestion or Rhinorrhea (2 to 5%)
      3. Conjunctivitis (1%)
    3. Cardiopulmonary
      1. Cough (46-82%)
        1. Hemoptysis (1-2%)
        2. Cough is typically dry (but may be productive in up to one third of cases)
      2. Shortness of Breath (31%)
        1. Associated with more severe disease
      3. Hypoxia (9% of mild cases, 40% of severe cases)
        1. Patients often appear to be in little respiratory distress
        2. Yet patients often present with profound Hypoxia (even with O2 Sat 70-80%)
        3. Patients with significant respiratory distress may decompensate rapidly
    4. Cardiac
      1. Chest tightness, pain or pressure (2 to15%)
      2. Palpitations
    5. Gastrointestinal
      1. Decreased appetite or Anorexia (40%)
      2. Diarrhea (17%)
      3. Nausea and Vomiting (up to 19%)
    6. Neurologic
      1. Headache (3-14%)
      2. Confusion or Altered Level of Consciousness (encephalopathy)
      3. Dizziness (8%)
      4. Altered taste or smell (34-64% of patients)
        1. Loss of Smell Sensation (Anosmia)
        2. Altered Taste Sensation (Dysgeusia)
    7. Skin
      1. Rash (up to 20% of cases)
      2. Pernio-like reactions of distal digits with erythema and swelling ("Covid Toes")
      3. Acrocyanosis
      4. Livedo Reticularis
  9. Findings: Signs and Symptoms in Children
    1. Pharyngeal erythema (46%)
    2. Cough (44 to 54%)
    3. Fever (41-56%)
    4. Diarrhea (8%)
    5. Vomiting
    6. Fatigue (8%)
    7. Rhinorrhea (8%)
  10. Precautions: Red Flag Findings Prompting Emergent Evaluation (Triage Protocols, return indications)
    1. Vital Signs
      1. Heart Rate >110
      2. Respiratory Rate >22
      3. Oxygen Saturation <91% (<95% in pregnancy)
      4. Systolic Blood Pressure <100 mmHg
      5. Minimal to no Urine Output
    2. Cardiopulmonary
      1. Hemoptysis
      2. Severe Chest Pain or pressure
      3. Severe Shortness of Breath at rest
    3. Skin
      1. Cyanosis
      2. Cold, clammy, pale or mottled skin
      3. Non-blanching rash
    4. Mental status
      1. Lethargy or difficult to arouse
      2. New confusion
  11. Labs
    1. COVID-19 Diagnosis (efficacy varies widely by test version, technique, timing)
      1. Indications for COVID-19 Testing (Antigen or PCR)
        1. Symptomatic patients
        2. Asymptomatic patients undergoing hospitalization or procedures
        3. Asymptomatic patients with known positive exposure >15 min (esp. indoors without mask or social distancing)
          1. Avoid testing within first 48 hours (high False Negative Rate)
          2. Consider testing at 3-5 days and 7-10 days after exposure
          3. Quarantine for 10-14 days after exposure and a positive Covid test
          4. Quarantine for 7-10 days after negative Covid PCR at 5-7 days after exposure
        4. No need to re-test patients after positive test (use 10 day quarantine guidelines below)
          1. Tests may remain positive for weeks
        5. Re-exposed patients after positive COVID-19 Test need not be re-tested within first 3 months
          1. Persistent positive tests may confuse results and Immunity is likely for at least 3 months
        6. (2020) Presc Lett 27(10): 55
      2. Molecular PCR for Corona Virus 2019 (preferred)
        1. Reverse transcriptase polymerase chain reaction detects viral Nucleic Acids that are amplified in sample
        2. Obtained via Nasopharyngeal swab (deep nasal swab) or Oropharyngeal swab
        3. Test accuracy depends on an adequate swab sample
        4. In lab, FDA approved PCR tests have Test Sensitivity >95%, Test Specificity >98%
        5. In practice, Test Sensitivity (and False Negative Rate) is poor for much of the Covid19 course
          1. Day 0 (known Covid19 exposure): 0%
          2. Day 4 after exposure (pre-symptomatic): 33%
          3. Day 5 after exposure (symptom onset): 62%
          4. Day 8 to 9 after exposure (day 3 to 4 of symptoms): 80%
          5. Day 21 after exposure (day 16 of symptoms): 34%
          6. Kucirka (2020) Ann Intern Med 173(4):262-7 [PubMed]
      3. Antigen Tests for Corona Virus 2019
        1. Obtained via Nasopharyngeal swab (deep nasal swab) or Oropharyngeal swab
        2. Fast and inexpensive tests similar to Rapid Strep Test and Rapid Influenza Test (but lower efficacy than PCR)
        3. Increased risk of False Negative 5-12 days after symptom onset (falling viral loads)
          1. Molecular (PCR) tests are less effected by this timing
          2. Consider repeating as a Molecular test after initial Antigen testing is negative
        4. Lower Test Sensitivity: 70-80% in symptomatic patients
          1. Test Sensitivity drops to 35-40% in asymptomatic patients
        5. High Test Specificity: >98%
      4. Antibody Testing (IgG and IgM) for Corona Virus 2019
        1. Unclear if Antibody confers Immunity
        2. Unclear how long Antibody confers Immunity (may be short as with seasonal Influenza)
        3. FDA approved Antibody tests should have Test Sensitivity >90% and Test Specificity >95%
        4. High False Positive Rate (20-30%) in low disease Prevalence regions (much of U.S. in Fall 2020)
        5. Even spike Protein specific Antibody (Vaccine induced) is unlikely to define Immunity regardless of result
        6. Consider testing patients with repeatedly negative Antigen tests, but persistent symptoms for weeks
      5. Home Testing (OTC)
        1. Precautions
          1. Most accurate in symptomatic, non-immunized patients
          2. False Negatives may occur and unlikely to be accepted for travel requirements
          3. False Positives may occur in up to 30% of asymptomatic patients (confirm with PCR)
        2. Simple Antigen Tests (similar to home Pregnancy Test)
          1. Antigen test requiring nasal sample
          2. Similar to Pregnancy Test with result in 15 minutes
          3. Cost: $20-30 for 2 tests
          4. Devices
            1. BinaxNow (Test Sensitivity 85%, Test Specificity 99%)
            2. QuickVue (Test Sensitivity 96%, Test Specificity 99%)
        3. Ellume
          1. Rapid Antigen test approved for age > 2 years, results in 15 min, costs $40 OTC
          2. Requires a mid-turbinate sample and a smartphone (connects to analyzer via bluetooth)
          3. Test Sensitivity 80%
          4. Test Specificity approaches 100% in patients with symptoms, BUT False Positives if no symptoms
      6. References
        1. (2021) Presc Lett 28(6): 33-4
        2. (2021) Presc Lett 28(2): 10
    2. Differential Diagnosis Evaluation
      1. Influenza nasopharyngeal swab
        1. Coninfection with Influenza is unlikely but possible (may occur in 5% of cases)
      2. Respiratory Virus Panel
        1. Typically includes Influenza, parainfluenza, RSV, Metapneumovirus, Rhinovirus, Adenovirus
      3. Pertussis PCR
      4. Streptococcal Pneumoniae urine Antigen
      5. Legionella urine Antigen
    3. Other lab findings
      1. Complete Blood Count (CBC) with Platelet Count
        1. Lymphopenia (Lymphocytes <1500/mm3) is most common (63%)
          1. More common in worse disease (present in >80% of those hospitalized)
        2. Leukocytosis (24-30%)
        3. Thrombocytopenia (associated with worse prognosis)
      2. Liver Function Test
        1. Liver transaminases (AST, ALT) mildly increased (37%)
        2. Lactate Dehydrogenase
      3. Venous Blood Gas
      4. Serum Lactate
    4. Acute phase reactants (most useful markers to follow)
      1. C-Reactive Protein
        1. Consider additional immunomodulators when C-RP >75
      2. D-Dimer (risk increased >1 or twice normal)
        1. D-Dimer >1.5 mcg/ml may prompt full dose VTE Anticoagulation at some facilities
    5. Markers of increased mortality
      1. Serum Troponin Increased
      2. Lymphopenia (Lymphocytes <1500/mm3)
      3. Interleukin-6 (IL-6) Increased
      4. Liver Function Test increases (AST, ALT, LDH, PT/INR increased)
      5. Serum Creatinine increased
      6. Creatine Kinase (CK) increased
      7. Serum Ferritin increased
        1. Markedly increased Serum Ferritin on presentation is associated with worse outcomes
      8. Procalcitonin Increased
        1. Normal on presentation
        2. Increase may suggest Bacterial Infection or severe Covid19 infection
    6. Other testing
      1. Blood Cultures (draw and hold first set with initial lab testing)
  12. Imaging
    1. Chest XRay
      1. Bilateral infiltrates
    2. Chest CT
      1. Bilateral regions of lung consolidation and ground glass opacities
      2. Progression from scattered ground glass findings to coalescence and then lung consolidation in the most severe cases
    3. Lung Ultrasound
      1. Survey the lungs using a systematic "lawn mower" approach
      2. Ultrasound B-Line artifacts correlate with CT ground glass findings
      3. Progression from scattered b-line artifacts to b-line coalescence and then lung consolidation (liver-like appearance)
      4. https://emcrit.org/ibcc/COVID19/#lung_ultrasonography
  13. Differential Diagnosis
    1. See Hypoxia
    2. See Dyspnea
    3. Bacterial Infections
      1. Streptococcal Pneumoniae
      2. Pertussis
      3. Legionella pneumonia
      4. Streptococcal Pharyngitis
      5. Opportunistic lung infection
    4. Viral Respiratory Infections
      1. Influenza
      2. Parainfluenza
      3. Metapneumovirus
      4. Rhinovirus
      5. Adenovirus
    5. Non-Infectious Causes
      1. Pulmonary Embolism
      2. Obstructive Lung Disease (Asthma Exacerbation, COPD exacerbation)
      3. Congestive Heart Failure with Acute Pulmonary Edema
      4. Acute Respiratory Distress Syndrome
  14. Complications: Acute
    1. Precautions
      1. Complications and decompensation are more common after 7 days of illness
      2. Prolonged symptoms (>14-21 days) in up to 35% of cases
    2. Respiratory Effects
      1. Multi-lobar Pneumonia
      2. Acute Respiratory Distress Syndrome (ARDS)
    3. Secondary Infection (Bacterial, fungal)
      1. Coinfections are a major cause of morbidity and mortality in Covid19
    4. Cardiac effects
      1. Myocarditis (Cardiomyopathy with Cardiogenic Shock)
        1. May mimic Acute Coronary Syndrome (findings on EKG may be identical to STEMI)
        2. Children <16 years old have 37 fold increased Myocarditis risk associated with Covid19 Infection
          1. Boehmer (2021) MMWR Morb Mortal Wkly Rep 70(35): 1228-32 [PubMed]
      2. Acute Coronary Syndrome
        1. Like Influenza, COVID-19 creates a severe inflammatory response that precipitates Plaque rupture and MI
        2. Cardiology is unlikely to perform PCI on active COVID-19 patients
          1. May need to consider MI Thrombolysis (however, high risk in patients at risk of DIC)
    5. Thrombosis
      1. Venous Thromboembolism
      2. Mycocardial Infarction
      3. Cerebrovascular Accident
      4. Skin microthrombi such as Pernio (see dematologic findings as above)
      5. https://www.sciencedirect.com/science/article/pii/S0049384820301201
    6. Encephalopathy
      1. Filatov (2020) Cureus 12(3):e7352 +PMID:32328364 [PubMed]
    7. Multisystem Inflammatory Syndrome (similar to Kawasaki Disease)
      1. As of Fall 2021, 5500 reported cases in children in U.S.
      2. Prolonged Fever, severe illness and multiorgan involvement in children
      3. Similar Multisystem Inflammatory effects have been seen in adults
      4. Jones (2020) Hosp Pediatr +PMID:32265235 [PubMed]
    8. Acute Renal Failure
      1. Raza (2020) Cureus 12(6):e8429 +PMID:32642345 [PubMed]
  15. Complications: Chronic
    1. See ICU Follow-up Care
    2. See Long COVID
    3. Covid Phases
      1. Phase 1: Acute Illness for days to weeks (may be asymptomatic)
      2. Phase 2: Hyperinflammatory state at 2 to 5 weeks after onset (rare)
        1. Multisystem Inflammatory Syndrome (Kawasaki-like syndrome) in children (and less commonly in adults)
        2. Stems from a dysregulated immune response
      3. Phase 3: Long COVID at more than 28 days from Covid onset
  16. Management: Home - General Measures
    1. See Prevention below
      1. Includes Personal Protection Equipment (N95 Mask, gown, Eye Protection and gloves) applied with donning and doffing
    2. TeleHealth triage protocol
      1. Mild symptoms
        1. COVID testing
        2. Self-care (e.g. deep breathing Exercises and position changes - see below)
        3. Quarantine (see below)
        4. Monitor symptoms, signs and oyxgen saturation probe (if available) and return if consistently <92%
        5. Telephone Follow-up
      2. Moderate Symptoms
        1. Outpatient, in-person visit
      3. Severe Symptoms (esp. with comorbidities) or Red Flags (see above)
        1. Emergency Department evaluation
    3. Position Changes
      1. Consider awake prone position (as well as on their left and right lateral decubitus positions, and sitting upright)
      2. Direct patient to roll to prone position and other positions for as long as they are comfortable
      3. Proning obese patients may be difficult
        1. Consider pregnancy massage mattress
        2. https://prone2help.org
    4. Practice deep breathing Exercises
      1. Johns Hopkins
        1. https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-recovery-breathing-exercises#:~:text=Phase%201%3A%20Deep%20Breathing%20While%20On%20Your%20Back&text=Breathe%20in%20through%20the%20nose,deep%20breaths%20for%20one%20minute.
    5. Disposition: Home Recommendations
      1. High Risk Patients (see Risk Factors Above)
        1. Monoclonal Antibodies (see below)
      2. Practice position changes and deep breath Exercises (see above)
      3. Monitor for Hypoxia (with portable Oxygen Saturation monitor)
        1. Return for Oxygen Saturations <92%
      4. Duration of home quarantine recommendations
        1. Asymptomatic contacts
          1. Monitor for fever and possible COVID-related symptoms daily
          2. Quarantine for 7 days after last exposure IF 2 criteria
            1. Patient remains symptom-free AND
            2. Negative Covid Antigen or PCR test on day 5-6 post-exposure
        2. Symptomatic patients or positive COVID test
          1. Quarantine >= 10 days and no fever for at least 1 day (was 3 days) AND improving symptoms (e.g. cough)
            1. Quarantine for at least 20 days if severely Immunocompromised
          2. Isolate within home, staying in sick area/room away from others and without sharing bathroom
        3. https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html
  17. Management: Home - Return to Play (Return to Sports, Children and Teens)
    1. Asymptomatic or Mild COVID-19
      1. Criteria
        1. Fever <4 days
        2. Lethargy, chills, myalgias <1 week
        3. No hospitalization
      2. Evaluation before return to play
        1. Phone, Telemedicine or In-Person Clinic Evaluation
        2. Symptomatic patients should have in person clearance exam with electocardiogram
      3. Management
        1. Asymptomatic patients may return to play
    2. Moderate COVID-19
      1. Criteria
        1. Fever >4 days
        2. Lethargy, chills, myalgias >1 week
        3. Non-ICU Hospitalization
        4. No Multisystem Inflammatory Syndrome (MIS-C)
      2. Evaluation before return to play
        1. In person clearance clinic evaluation
        2. Include Cardiovascular components from Preparticipation History (i.e. AHA 14) and Preparticipation Exam
        3. Electocardiogram (EKG)
      3. Management
        1. Positive history, exam or abnormal EKG
          1. Cardiology referral
        2. Negative history and exam
          1. Gradual return to play (5 steps of increasing intensity with symptom monitoring)
          2. Caveats
            1. Initial positive Covid Test >10 days before return to play AND
            2. Symptom resolution (without fever reducing medications) >10 days before return to play
    3. Severe COVID-19
      1. Criteria
        1. ICU Hospitalization
        2. Endotracheal Intubation
        3. Multisystem Inflammatory Syndrome (MIS-C)
      2. Evaluation before return to play
        1. In person clinic evaluation
        2. Include Cardiovascular components from Preparticipation History (i.e. AHA 14) and Preparticipation Exam
        3. Electocardiogram (EKG)
      3. Management
        1. Return to Play requires cardiology clearance
        2. Exercise restriction for 3 to 6 months
    4. References
      1. COVID-19 Interim Guidance: Return to Sports and Physical Activity (AAP)
        1. https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/?_ga=2.136178545.1962690096.1649527198-1095622219.1641358364
  18. Management: Emergency Department Overall Approach
    1. See ABC Management
    2. See Intensive Care
    3. See Pneumonia Management
    4. See ARDS Management
    5. Personal Protection Equipment (N95 Mask, gown, Eye Protection and gloves) applied with donning and doffing - see below
    6. Avoid aggressive fluid Resuscitation (do NOT use Sepsis level 30 cc/kg)
    7. Have Norepinephrine available for Hypotension
  19. Management: Oxygenation
    1. Precautions
      1. Oxygenation combined with position changes (see above) are the two most critical interventions
      2. Monitor oxygenation and ventilation closely and recheck patient every 1-2 hours (patient decompensate quickly)
      3. Review work of breathing, Respiratory Rate, Heart Rate, Oxygen Saturation, Capnography and other parameters
      4. Consider Endotracheal Intubation in those tiring, failing oxygenation strategies
    2. Indications for Supplemental Oxygen
      1. Oxygen Saturation <90 to 92% (<95% in pregnancy)
    3. Oxygenation by Nasal Cannula and Mask
      1. Oxygen by Nasal Cannula up to 5-6 L/min (humidified if available) to maintain Oxygen Saturation 92-96%
      2. Persistent Hypoxia despite Nasal Cannula up to 5-6 L/min
        1. Non-rebreather at 15 L/min may be applied over the top of the Nasal Cannula
          1. Helps prevent aerosolization
          2. Allows for adequate oxygenation for severe Hypoxia
          3. Levitan (2020) ACEP Now (see link below)
        2. Non-Invasive Positive Pressure Ventilation (esp. HHFNC, or in some cases non-vented CPAP)
        3. Endotracheal Intubation
    4. Non-Invasive Positive Pressure Ventilation (NIPPV)
      1. Use all devices with viral filter (HEPA filter)
      2. High Flow Nasal Cannula (typically 40 to 60 L/min)
        1. Appears safer than BiPAP, CPAP without significant viral dispersion
        2. Allows for the oxygenation and increased alveolar recruitment that many with corona virus require
        3. However, anecdotally at high volume sites, High Flow Nasal Cannula appears less effective than CPAP
      3. BIPAP
        1. Avoided initially in the COVID-19 pandemic due to risk of viral spread
          1. However, as of 2021, used with filters and negative airflow rooms to make use safer
        2. BiPAP appears to be effective in those failing High Flow Nasal Cannula (e.g. 60 LPM, FIO2>60%)
          1. Typical I:E progression: 10/5, 15/10, 18/12
      4. CPAP
        1. Risk of viral dispersion
        2. If done safely, CPAP could have a significant role for alveolar recruitment (decreased Atelectasis)
          1. https://emcrit.org/pulmcrit/cpap-covid/
        3. Safer options to limit viral dispersion
          1. Non-vented CPAP masks
          2. Helmet interface (used in Italy pandemic, not typically available in U.S.)
  20. Management: Endotracheal Intubation
    1. Precautions
      1. Although early intubation has been favored, NIPPV despite Hypoxia may be preferred in some patients
      2. Endotracheal Intubation is among the highest risk procedures for transmission
      3. COVID-19 patients are intubated on Mechanical Ventilation for on average 10 days
        1. See Mechanical Ventilation for potential complications
        2. Mortality of intubated patients ranges from 20-90%
      4. COVID-19 patients are difficult intubations (most experienced intubating clinician should perform)
        1. Rapid desaturation despite Apneic Oxygenation
        2. Signficant airway edema of the supraglottic region that distorts landmarks
          1. Elastic Bougie has been less helpful in these patients (not firm enough given edema)
      5. Maximize Endotracheal Tube first pass success
        1. Slow down and expect desaturation with intubation
        2. Exercise caution in Laryngoscope introduction, rotating around the Tongue
        3. Use the Levitan technique of gradual exposure of the uvula, epiglottis, aryepiglottic fold, Larynx
      6. Avoid Awake Nasotracheal Intubation
        1. Higher risk of aerosolization
        2. Nasal Intubation duration limit of 3 days is too short for COVID-19 patients
      7. Have rescue airway at bedside
        1. Attach I-Gel or LMA with HEPA Filter to ambubag with PEEP Valve
    2. Early intubation was initially advocated over NIPPV (other than High Flow Nasal Cannula) for less viral transmission
      1. However, intubation puts healthcare staff at significant transmission risk
      2. Ventilators are a limited resource (Italian providers placed up to 4 patients on the same Ventilator)
        1. https://emcrit.org/pulmcrit/split-ventilators/
    3. Have a lower threshold for intubation when failing High Flow Nasal Cannula and BiPaP
      1. COVID-19 patients may give less warning (Hypoxemia without increased resp. effort) before rapid decompensation
      2. Rising FIO2 requirements (>75% FIO2) and high Respiratory Rate >26/min
    4. Personal Protection Equipment (PPE)
      1. See Donning and Doffing Personal Protection Equipment
      2. Providers are using Powered Air Purifying Respirator (PAPR) for intubation where available
      3. Surgical hat and gown
      4. N95 Mask beneath a surgical mask with Face Shield
        1. Ideally uses a full Face Shield or goggles
      5. Double gloves
    5. Intubation Equipment
      1. Video Laryngoscopy is preferred (allows for distance from airway) over Direct Laryngoscopy
        1. However, supraglottic inflammation or restricted mouth opening may require Direct Laryngoscope backup
        2. Consider Macintosh-Shaped Video Laryngoscopy blades (may also be used with Elastic Bougie)
      2. Endotracheal Tube with stylet and 10 cc syringe
      3. HEPA Filter
      4. CO2 Detector
      5. Dirty equipment bucket at feet of intubating provider
      6. Rescue Airway (e.g. I-Gel or LMA with HEPA Filter)
      7. Preoxygenation equipment (see below)
        1. Bag-Valve Mask (BVM) with PEEP Valve
        2. EtCO2 adapter (inline between Bag and Mask)
          1. Oxygen tubing attached and oxygen flow set at 6 L/min
        3. Viral Filter (inline between Bag and Mask)
        4. Mask
          1. Use NIPPV mask if available for better seal
    6. Rapid Sequence Intubation (with K-ROC)
      1. Ketamine and Rocuronium is the a common Sedative and paralytic combination used in these intubations
      2. Ketamine 1.5 to 2 mg/kg
      3. Rocuronium 1.5 to 2 mg/kg
    7. Preoxygenation
      1. Preoxygenation for 5 minutes without Positive Pressure Ventilation
      2. Continue Apneic Oxygenation throughout intubation, despite with expect rapid oxygen desaturation
      3. Use Rapid Sequence Intubation with Apneic Oxygenation, but avoid PPV (Bag Valve Mask or Bipap)
        1. However, Scott Weingart, MD has an innovative approach to safe preoxygenation with CPAP
        2. https://emcrit.org/emcrit/covid19-intubation-packs-and-preoxygenation-for-intubation/
    8. Safe PPE Procedure after passing Endotracheal Tube
      1. Inflate ET Tube cuff and dispose of syringe
      2. Drop stylet and Laryngoscope Blade into the dirty equipment bucket
      3. Place Laryngoscope Handle onto work surface now considered dirty
      4. Remove outer gloves
      5. Attach HEPA Filter to ET Tube (will remain in place throughout Mechanical Ventilation period)
      6. Attach CO2 detector and ambubag to confirm color change
      7. Remove only the CO2 detector (leave HEPA Filter in place) and continue ventilation
      8. Carefully evaluate ET Tube Depth (CXR may be delayed)
    9. Mechanical Ventilator settings
      1. See Mechanical Ventilation
      2. Follow ARDSnet protocols
        1. See PEEP Table
      3. Initial Setting
        1. Use low Tidal Volumes (e.g. 6 ml/kg Ideal Body Weight)
        2. Use high Respiratory Rates (e.g. 20/min)
          1. However monitor closely for Breath Stacking (Auto-PEEP)
          2. Monitor for Hypotension (decreased Preload)
        3. May start with high FIO2 but rapidly decrease FIO2 while increasing PEEP
          1. See PEEP Table
          2. Goal Oxygen Saturation 92 to 96%
          3. FIO2 <0.4, Start with PEEP 5 cmH2O
            1. Consider Ventilator Weaning if stable on low FIO2 and low PEEP (see below)
          4. FIO2 0.4 to 0.6, Start with PEEP 10 cmH2O
            1. See Ventilator Troubleshooting (evaluate for mucous plugging, Pneumothorax, VAP)
          5. FIO2 >0.6, Start with PEEP 15 cmH2O
            1. Prone patient for 16 hours of every 24 hours if FIO2 >0.6 and PEEP >10 cmH2O
            2. Consider ECMO if persistent FIO2 and PEEP requirements
        4. Inspiratory to Expiratory Ratio (I:E) to 1:2 or 1:1.5
      4. Consider a lung recruitment maneuver at start of Mechanical Ventilation
        1. See Proning
        2. Increase Tidal Volume to 8-10 ml/kg for 10 minutes and then return to 6 ml/kg OR
        3. Increase pressure to 30 cm H2O for 30 seconds
      5. Ventilator Weaning
        1. Consider when FIO2 <0.5 and PEEP <10 cmH2O
        2. Decrease sedation and trial pressure support
      6. Monitoring
        1. Permissive hypercapnea, but keep pH >7.2 (permissive hypercapnea)
        2. Plateau pressure <30 cm H2O
        3. Follow ABG every 12 hours (and as needed for clinical worsening)
      7. Inadequate Ventilators available
        1. See Ventilator Sharing
    10. Post-Intubation Sedation and Analgesia
      1. Inadequate sedation risks Post-Traumatic Stress Disorder
      2. Expect to use higher doses of sedation
        1. Patients have Respiratory Failure, but intact mentation
        2. Plan to sedate to RASS -3 to -5 (Deep Sedation )
      3. Start with Propofol and Fentanyl
      4. Add Dexmedetomidine or Midazolam
  21. Management: Lines and Fluids
    1. Left Internal Jugular Central Line
      1. Reserve right internal jugular for ECMO
    2. Arterial Line
    3. Nasogastric Tube or Orogastric Tube
    4. Urinary Catheter
    5. Maintain negative flud balance
      1. Avoid maintenance Intravenous Fluids
      2. Supply fluids through enteral feedings and the fluid in delivered medications
      3. Consider IV Furosemide (lasix) 20 mg every 8 hours
      4. If fluid bolus is required, use 20% Human Albumin
    6. Enteral Feedings (Nasogastric Tube)
      1. Use calorie dense feedings, targeting 25 kcal/kg/day
      2. Use senna 15 ml twice daily to promote regular stooling once enteral feeds are established
        1. Consider adding Lactulose
  22. Management: Adjunctive Measures in Hospitalized Patients
    1. Bronchodilators
      1. Avoid nebulizer use due to dispersion of virus
      2. Albuterol HFA Inhaler as needed
    2. Corticosteroids
      1. Dexamethasone
        1. Indicated in COVID-19 Patients on Supplemental Oxygen or Mechanical Ventilation
        2. Dosing: Dexamethasone 6 mg daily for up to 10 days
        3. https://www.covid19treatmentguidelines.nih.gov/dexamethasone/
        4. Horby (2020) N Engl J Med +PMID:32678530 [PubMed]
      2. Other Corticosteroid indications
        1. May also use Corticosteroids in those with Asthma Exacerbation or COPD exacerbation
        2. Intensivists have also used Methylprednisolone 60 mg IV daily for 3-6 days in severe ARDS
      3. Corticosteroids are not recommended early in COVID-19 course for those not with indications above
        1. Risk of increased viral shedding, worse outcomes
    3. Remdesivir
      1. Viral RNA Polymerase Inhibitor (Nucleotide analog prodrug) that inhibits viral RNA synthesis
        1. Originally developed for use in Ebola
        2. May speed COVID-19 Recovery, but unclear if affects mortality
        3. As of 2021, no evidence of benefit in Covid19
          1. Ansems (2021) Cochrane Database Syst Rev (8):CD014962 [PubMed]
      2. Indicated in moderate Covid with Hypoxia, bilateral lung involvement, or severe cases
      3. Dosing: 200 mg IV (or 10/mg/kg) for first dose, then 100 mg daily for 4-9 days
      4. https://www.niaid.nih.gov/news-events/nih-clinical-trial-shows-remdesivir-accelerates-recovery-advanced-covid-19
      5. https://www.nejm.org/doi/full/10.1056/NEJMoa2007764
    4. Immunomodulators
      1. Indications
        1. C-RP>75
        2. Worsening oxygenation despite Dexamethasone or Mechanical Ventilation
      2. Tocilizumab (Actemra)
        1. Anti-IL6 Monoclonal Antibody used as immunomodulator in Cytokine Release Syndrome
        2. Dosing 8 mg/kg up to 400 to 800 mg IV for 1 dose
        3. Studied in COVID-19 as of March 2020 (phase 3 trial)
          1. https://www.cancernetwork.com/news/fda-approves-phase-iii-clinical-trial-tocilizumab-covid-19-pneumonia
        4. Does not appear effective in severe COVID-19
          1. Stone (2020) N Engl J Med 383:2333-44 [PubMed]
      3. JAK Inhibitor
        1. Indicated as alternative to Tocilizumab as immunomodulator in refractory Covid19
        2. Baricitinib (Olumiant)
        3. Ruxolitinib (Jakafi)
    5. Venous Thromboembolism Prophylaxis in hospitalized patients
      1. Low Risk
        1. Enoxaparin (Lovenox) 40 mg SQ daily OR
        2. Heparin 5000 units (if eGFR < 30 ml/min) OR
        3. Mechanical Prophylaxis (if Platelets <30,000 or active bleeding)
      2. Moderate Risk (D Dimer > 10x upper normal limit, ICU, active cancer, VTE history)
        1. Enoxaparin (Lovenox) 0.5 mg/kg SQ every 12 hours OR
        2. Low Intensity Heparin infusion with loading dose (if eGFR < 30 ml/min) OR
        3. Mechanical Prophylaxis (if Platelets <30,000 or active bleeding) and start Heparin when stable
      3. High Risk (Confirmed or highly suspected VTE)
        1. Enoxaparin (Lovenox) 1 mg/kg SQ every 12 hours
        2. High Intensity Heparin infusion with loading dose (if eGFR < 30 ml/min) OR
        3. Mechanical Prophylaxis (if Platelets <30,000 or active bleeding) and start Heparin when stable
  23. Management: Adjunctive Measures in Non-hospitalized Patients
    1. Bronchodilators
      1. Avoid nebulizer use due to dispersion of virus
      2. Albuterol HFA Inhaler as needed
    2. Specific measures under investigation
      1. Overall approach as of February 2022 in high risk patients (see above, MASSBP Score) with confirmed Covid19
        1. Best efficacy is when these medications are started early
        2. Consider Monoclonal Antibody if 5 to 10 days from symptom onset
        3. If symptom onset <5 days
          1. Nirmatrelvir/Ritonavir (Paxlovid, Pax) is preferred (but many Drug Interactions, Renal Dosing required)
          2. If Paxlovid is not available, consider Monoclonal Antibody
          3. If neither Paxlovid nor Monoclonal Antibody are available, consider Molnupravir
      2. Monoclonal Antibodies
        1. See Covid19 Monoclonal Antibody
      3. Fluvoxamine (Luvox)
        1. May reduce Covid-related emergency department visits and hospitalizations (but variable study results)
        2. Does not reduce mortality, and not routinely recommended by IDSA for Covid19
        3. Dosing: 100 mg orally twice daily for 10 days
        4. See Fluvoxamine (Luvox) for adverse effects
        5. Reis (2021) Lancet Glob Health 10(1): e42-51 +PMID: 34717820 [PubMed]
      4. Nirmatrelvir/Ritonavir (Paxlovid, Pfizer)
        1. Oral Protease Inhibitor specific to SARS-COV-2 viral replication (Ritonavir slows nirmatrelvir metabolism)
        2. FDA emergency use in 2022 for high risk outpatients age >12 years (and >40 kg) within 5 days of onset
        3. Reduces risk of hospitalization or death at 28 days by 89% if started within first 3 days
          1. NNT 18 unvaccinated, high risk patients to prevent one hospitalization or death
        4. Dosing (distributed in Blister pack, which pharmacist adjusts based on eGFR)
          1. eGFR>=60 ml/min: Nirmatrelvir 300 (2 tabs) AND Ritonavir 100 mg twice daily for 5 days
          2. eGFR 30 to 59: Nirmatrelvir 150 (1 tab) AND Ritonavir 100 mg twice daily for 5 days
        5. Avoid in eGFR <30 ml/min or severe liver disease
        6. Adverse effects include Dysgeusia, Diarrhea, Hypertension, myalgias
        7. Risk of COVID-19 rebound (recurrent symptoms within 1 week after finishing Paxlovid)
          1. Do not repeat Paxlovid course, but re-quarantine 5 days and mask for 10 days
        8. Numerous Drug Interactions, esp. for Ritonavir (esp. CYP3A)
          1. Important interactions include Salmeterol, DOACs (esp. Rivaroxaban) and Clopidogrel
          2. Use a Drug Interaction checker
        9. LoVecchio (2022) Crit Dec Emerg Med 36(1): 28
      5. Molnupiravir (Lagevrio)
        1. Under FDA review in early 2022, emergency approved for age 18 years and older
        2. Blocks Covid19 replication by inserting into the viral RNA
        3. Dose: 4 capsules twice daily for 5 days (and start within 5 days of onset)
        4. NNT: 35 unvaccinated patients to prevent one hospitalization (similar to Monoclonal Antibody efficacy)
        5. Consider in high risk patients over age 18 years (see above, esp. if unvaccinated)
        6. Contraindicated in pregnancy (birth defect risk) and affects mutagenesis in sperm
          1. Women should use reliable Contraception for at least 4 days after use
          2. Men should use Condoms for 3 months after use
        7. References
          1. (2022) Presc Lett 29(1): 1
      6. Convalescent Plasma
        1. Largely replaced by monoclonal antibodies
        2. Shen (2020) JAMA +PMID:32219428 [PubMed]
    3. Specific measures that do not appear effective (or for which risk is worse than benefit)
      1. Ivermectin
        1. See Ivermectin for toxicity
        2. As of October 2021, with the exception of one retracted article, there is NO compelling evidence for Ivermectin
          1. https://www.fda.gov/consumers/consumer-updates/why-you-should-not-use-ivermectin-treat-or-prevent-covid-19
          2. https://www.nature.com/articles/d41586-021-02081-w
        3. NOT recommended by numerous agencies including CDC, AMA, Ivermectin Manufacturer
        4. Risk of medical board censure for prescribing in some states
          1. Lack evidence of benefit, adverse effects and diversion from real indications (e.g. Parasitic Infection)
          2. Fringe doctor groups continue to recommend despite lack of evidence
          3. https://www.scientificamerican.com/article/fringe-doctors-groups-promote-ivermectin-for-covid-despite-a-lack-of-evidence/#
      2. Chloroquine or Hydroxychloroquine
        1. Mortality may be higher (low efficacy, adverse effects) with these drugs despite promising results in early studies
        2. Chloroquine and Hydroxychloroquine have numerous adverse effects (e.g. QTc Prolongation)
        3. https://www.medrxiv.org/content/10.1101/2020.04.16.20065920v2
        4. https://wattsupwiththat.com/2020/03/17/an-effective-treatment-for-coronavirus-covid-19-has-been-found-in-a-common-anti-malarial-drug/
      3. Azithromycin
        1. Not recommended
          1. Does not improve 28 day mortality or affect adult hospitalization course
          2. In mild Covid19, does not affect progression, hospitalization risk or mortality
          3. Popp (2021) Cochrane Database Syst Rev (10): CD015025 [PubMed]
        2. Initial trials combined with Chloroquine showed possible improved outcomes
          1. Gautret (2020) Int J Antimicrob Agents +PMID:32205204 [PubMed]
        3. There is also risk of Ventricular Arrhythmia related to QTc Prolongation with some Azithromycin combinations
          1. https://www.acc.org/latest-in-cardiology/articles/2020/03/27/14/00/ventricular-arrhythmia-risk-due-to-hydroxychloroquine-azithromycin-treatment-for-covid-19
      4. Lopinavir/Ritonavir (Kaletra, LPV/r)
        1. As of May 2020 studies demonstrate no significant efficacy, and risk of Drug Interactions
          1. Ritonavir has many Drug Interactions
          2. Cao (2020) N Engl J Med +PMID: 32187464 [PubMed]
        2. Was initially considered when Chloroquine was not available
          1. Young (2020) JAMA
          2. https://jamanetwork.com/journals/jama/fullarticle/2762688
    4. Other measures that have been used with poor evidence
      1. Zinc Supplementation
      2. Vitamin C 1.5 g IV every 6 hours
      3. Thiamine 200 mg IV every 12 hours
    5. Medications with unclear risk
      1. NSAIDs
        1. Early in COVID-19 course, some postulated risk of NSAIDs, but no current evidence of risk as of May 2020
        2. Use Acetaminophen as a first-line Analgesic, but NSAIDs are not currently contraindicated in COVID-19
      2. ACE Inhibitors and Angiotensin Receptor Blockers (ARBs)
        1. Coronavirus targets ACE-2 Receptors as an entry into cell
        2. Postulated that ACE Inhibitors might up-regulate ACE Receptors
        3. No evidence as of significant benefit or harm of these agents as of May 2020
    6. Indications for empiric Community Acquired Pneumonia treatment
      1. Imaging consistent with Pneumonia
      2. Procalcitonin >0.26 ng/ml
  24. Prognosis: Severe Cases
    1. Severe disease in 14% of patients
      1. ICU admission in 5% of adults and 2% of children
        1. Of children requiring hospitalization, 1 in 3 require ICU level care
    2. Risks for complications or more serious, progressive infection or death
      1. Male gender
      2. Older age (60 years and older)
      3. Comorbidity (e.g. Hypertension, Diabetes Mellitus, Cardiovascular Disease, Renal Disease, Liver Disease, COPD)
        1. Hospitalized patients: 23 to 71% have at least one comorbid condition
        2. ICU Patients: 43 to 78% have at least one comorbid condition
        3. Mortality: >94% have at least one comorbid condition
      4. Body Mass Index (BMI>30)
      5. Obstructive Sleep Apnea
      6. Tobacco Abuse
        1. Smoking confers more severe case (RR 1.4)
        2. Smoking confers increased risk of ICU admission, Mechanical Ventilation and death (RR 2.4)
        3. Vardavas (2020) Tob Induc Dis 18:20 [PubMed]
      7. Immunocompromised patients (e.g. HIV, Autoimmune Disease, cancer, immunosuppressants)
      8. Pregnancy (or first 2 weeks postpartum)
        1. Consider hospital admission for Oxygen Saturation <95%
      9. Sickle Cell Anemia
      10. D-Dimer >1 on admission
      11. SOFA Score high
    3. Age-Related Prognosis
      1. Age <20 years
        1. Hospitalizations: 1.6 to 2.5%
        2. ICU admissions: 0
        3. Deaths: 0
      2. Age 20-44 years
        1. Hospitalizations: 14.3 to 20.8%
        2. ICU admissions: 2.0 to 4.2%
        3. Deaths: 0.1 to 0.2%
      3. Age 45 to 54 years
        1. Hospitalizations: 21.2 to 28.3%
        2. ICU admissions: 5.4 to 10.4%
        3. Deaths: 0.5 to 0.8%
      4. Age 55 to 64 years
        1. Hospitalizations: 20.5 to 30.1%
        2. ICU admissions: 4.7 to 11.2%
        3. Deaths: 1.4 to 2.6%
      5. Age 65 to 74 years
        1. Hospitalizations: 28.6 to 43.5%
        2. ICU admissions: 8.1 to 18.8%
        3. Deaths: 2.7 to 4.9%
      6. Age 75 to 84 years
        1. Hospitalizations: 30.5 to 58.7%
        2. ICU admissions: 10.5 to 31.0%
        3. Deaths: 4.3 to 10.5%
      7. Age >85 years
        1. Hospitalizations: 31.3 to 70.3%
        2. ICU admissions: 6.3 to 29.0%
        3. Deaths: 10.4 to 27.3%
    4. Post-ICU Survivor Care (and post-hospitalization)
      1. See ICU Follow-up Care
      2. See Chronic Complications as above
      3. Consider virtual visit for initial follow-up
      4. Isolate patients severe Critical Illness or Immunocompromised state should quarantine for 20 days (instead of 10)
      5. Gradual return to activity once patient is asymptomatic for 2 weeks and reassuring Troponin, ekg, Echocardiogram
        1. Consider post-ICU physical rehabilitation (may be directed by Telemedicine)
        2. Avoid competitive or strenuous Exercise in recovery period (Covid risk of Myocarditis or Cardiomyopathy)
      6. Discharge to Nursing Home
        1. Staff must have appropriate PPE to care for patient
        2. Facility must have capacity to quarantine patient per CDC guidelines without exposing other residents
    5. References
      1. (2020) MMWR Morb Mortal Wkly Rep 69(12):343-6 [PubMed]
      2. Wilbur (2021) Am Fam Physician 103(10): 590-6 [PubMed]
  25. Prognosis: Mortality
    1. Large number of asymptomatic and undiagnosed cases makes mortality estimate difficult
      1. Mortality overall 0.6 to 0.9% based on extrapolated undiagnosed cases
    2. Mortality (Worldwide) - Original 2020 Pandemic
      1. France: 15.3%
      2. Italy: 14.4%
      3. U.K.: 14.1%
      4. Mexico: 11.7%
      5. Sweden: 10.4%
      6. Ecuador: 8.4%
      7. Canada: 8.1%
      8. U.S.: 5.7%
      9. Johns Hopkins Coronavirus Resource Center (accessed 6/9/2020)
        1. https://coronavirus.jhu.edu/data/mortality
    3. Mortality: Cohorts - Original 2020 Pandemic
      1. See Severe Cases above for comorbidity related mortality risks
      2. By Age
        1. Age <=54 years old: <1% Mortality
        2. Age 70-79 years old: 8% Mortality
        3. Age >80 years old: 10-27% Mortality
      3. By Age in ICU
        1. Age 16 to 49 years old: 25%
        2. Age 50 to 59 years old: 41%
        3. Age 60 to 69 years old: 56%
        4. Age >70 years old: 69%
        5. (2020) MMWR Morb Mortal Wkly Rep 69(12):343-6 [PubMed]
      4. By Severity
        1. Hospitalized patients with Pneumonia have a 4-15% risk of death
        2. Acute Respiratory Distress Syndrome (ARDS) is associated with 51% mortality
        3. Intubated patients have mortality rates as high as 81%
  26. Prevention: General Measures
    1. Social distancing
      1. Keep at least 6 foot (1.8 m) distance between others (greater distance may be required indoors)
    2. Wearing masks (cloth or surgical masks) prevents COVID-19 transmission
      1. Wearing in indoor public spaces helps protect both the wearer and especially those around them
        1. Cloth Mask if asymptomatic
        2. Surgical mask if symptomatic and in healthcare facility
      2. Infectious persons may be contagious days before symptoms manifest
        1. Consider masking in any indoor space including home when virus exposure is possible
        2. Mask should cover both mouth and nose
      3. Consider outdoor masks when social distancing (6 feet) cannot be maintained
      4. Evidence for masking as primary prevention is strong
        1. Brooks (2020) JAMA
          1. https://jamanetwork.com/journals/jama/fullarticle/2768532
        2. Hendrix (2020) MMWR Morb Mortal Wkly Rep 69:930-2 [PubMed]
    3. Surgery
      1. Postpone any non-urgent surgery due to 50% risk of pulmonary complications in first 30 days after diagnosis
        1. (2020) Lancet 396(10243):27-38 +PMID: 32479829 [PubMed]
  27. Prevention: Vaccination
    1. See Covid-19 Vaccine
    2. Influenza Vaccine (October)
      1. Does not protect against COVID-19, but also does not lower Immune System or make COVID-19 more likely
      2. Patients have been infected with both Influenza and COVID-19 with higher morbidity and mortality
      3. Reduces clinical visits for Influenza
      4. Reduces potential COVID-19 exposures (while seeking healthcare)
      5. Reduces risk of lung injury from Influenza (and possible risk for worse outcome in COVID-19)
      6. Reduces diagnostic confusion in differentiating Influenza presentations from COVID-19 presentations
  28. Prevention: Transmission
    1. Move patient to airborne infection isolation room or unit with negative airflow
    2. Personal Protection Equipment (N95 Mask, gown, Eye Protection and gloves) applied with donning and doffing
      1. https://www.youtube.com/watch?v=bG6zISnenPg
      2. Doffing is the highest risk time and should follow a careful protocol (consider assigned staff to help direct)
      3. See Donning and Doffing Personal Protection Equipment
      4. See Personal Protection Equipment
      5. See Respiratory Personal Protective Equipment (includes N95 Mask, PAPR)
    3. Hand Hygiene with soap and water (or >60% Alcohol hand cleanser)
    4. Disinfect surfaces
  29. Prevention: Social Isolation Precautions
    1. Social distancing is helps to slow COVID-19 infection spread, but it does have mental health risks
    2. Social distancing is associated with Increased rates of depressed mood, anxiety, Substance Abuse
    3. See Psychological First Aid
    4. Reduce Excessive Worry
      1. Avoid over-checking the news or Social Media (limit to once or twice daily)
      2. Choose reliable resources for information
    5. Perform regular Exercise
    6. Practice Relaxation Techniques
    7. Stay connected via phone and video conferencing with friends and family
    8. Patient Resources
      1. See Suicide Risk
      2. Disaster Distress Help Line
        1. https://www.redcross.org/get-help/disaster-relief-and-recovery-services/recovering-emotionally.html
    9. References
      1. (2020) Presc Lett 27(5): 25-6
  30. Resources
    1. Johns Hopkins Coronavirus Resource Center
      1. https://coronavirus.jhu.edu/
    2. BMJ
      1. https://www.bmj.com/coronavirus
    3. Infectious Disease Society of America (IDSA)
      1. https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/
    4. National Institutes of Health (NIH)
      1. https://www.covid19treatmentguidelines.nih.gov/
    5. EM:Rap Covid19 Update (March 31)
      1. https://www.youtube.com/watch?v=GLbKyc31XhM
    6. EM:Rap Covid19 Update (March 25)
      1. https://www.youtube.com/watch?v=e51V9M2avrw
    7. CDC COVID-19
      1. https://www.cdc.gov/coronavirus/2019-ncov/index.html
    8. COVID-19 (EM-CRIT: Internet Book of Critical Care)
      1. https://emcrit.org/ibcc/covid19/
    9. Corependium (Mason and Herbert)
      1. https://www.emrap.org/corependium/chapter/rec906m1mD6SRH9np/Novel-Coronavirus-2019-COVID-19
  31. References
    1. (2021) Presc Lett 28(1): 1-3
    2. (2021) Presc Lett 28(5):28
    3. Reuter (2020) Crit Dec Emerg Med, Covid19 Edition, 3-13
    4. Fei Zhou (2020) Lancet , pre-publication online
      1. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext
    5. Levitan (2020) ACEP Now
      1. https://www.acepnow.com/article/covid-19-lessons-learned-by-an-emergency-physician-in-new-york-city/
    6. COVID-19 Ventilation: Quick Reference Guide (Bolton Critical Care Team)
      1. https://www.stemlynsblog.org/covid-19-a-primer-on-icu-care-for-the-non-intensivist-st-emlyns/
    7. Nettleton (2021) Am Fam Physician 103(8): 465-72 [PubMed]

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