A Crash Course on COVID-19: Information for Today's Practitioners - LECOM

A Crash Course on COVID-19: Information for Today’s Practitioners

Thursday, 04 June 2020

Miranda Ochs, PharmD; Abbey Krysiak, PharmD, BCPP

Nearly 7 months ago, the first cluster of a flu-like illness was reported in Wuhan, China. One week later, the virus was identified as coronavirus 2019-CoV. On January 30, 2020, the World Health Organization (WHO) declared the outbreak a Public Health Emergency of International Concern. As more cases and deaths were reported around the world, WHO finally declared the new COVID-19 outbreak as a pandemic. The number of patients affected by the novel coronavirus continues to rise, and researchers are scrambling to find a cure. In the meantime, healthcare providers are seeking out any information they can to ensure they are managing patients with coronavirus effectively without placing other patients at risk.1

Patients often experience traditional flu-like symptoms at some point throughout their illness (cough with or without sputum production, shortness of breath, fever, fatigue, etc.).2 Atypical symptoms include anosmia or ageusia prior to respiratory symptom onset, and some patients present with gastrointestinal complaints, such as diarrhea. Atypical presentations may complicate diagnosis, though – especially those who are asymptomatic. It is possible for asymptomatic patients to present with the bilateral, peripheral ground glass opacities in the lungs, a common manifestation of the novel coronavirus observed through imaging.3

While a chest CT may provide evidence of infection, it is not recommended for routine screening or diagnosis of COVID-19 due to a wide differential and non-specific results.2 A stronger case for diagnosis may be built when imaging results are coupled with lab results. Patients infected with the novel virus may have various lab abnormalities, the most common of these being lymphopenia. The presence of neutrophilia, elevated liver enzymes (specifically ALT & AST), elevated lactated dehydrogenase, high C-reactive protein (CRP), and high ferritin may be indicators of worsening severity of illness.3 Patients may have a higher risk of mortality if they have an elevated D-dimer or lymphopenia. Ferritin, C-reactive protein, and D-dimer are not standard of care, but they may be useful when considering prognosis. See Table 1 for more information.

As information is limited with regards to presentation, there are various classification schemata that may be used. Patients can be classified as asymptomatic/pre-symptomatic, mild, moderate, severe, or critical. Regardless of presentation, it is important that appropriate infection-control measures are put in place to decrease risk of transmission.2,3 Institution wide policies may be put in place that limit visitors or delegate special COVID-19 units to mitigate risk of transmission from outside patients or from within an institution. Contact with patients infected with COVID-19 should be limited to medically necessary contact, when possible. It’s also important that healthcare providers take appropriate measures in order to prevent transmission. All healthcare providers should practice good hand hygiene. Those dealing directly with patients infected with COVID-19 will require personal protective equipment (PPE).

Providers should utilize a face shield or goggles, N95 or higher respirator (face mask as an alternative), non-sterile gloves, and an isolation gown when caring for those with COVID-19.2

In an outpatient setting, quarantine and isolation may be used to help prevent transmission. Patients who may have been exposed to an individual infected with COVID-19 should quarantine themselves in order to prevent possible transmission to others, even if they don’t experience symptoms.2 Quarantine should last at least fourteen days (provided the individual does not develop symptoms). Isolation is utilized when patients are infected with COVID-19. Patients may be able to end isolation once they have met the following criteria: afebrile for three days, improved symptoms, ten days since symptom onset. Asymptomatic patients with a positive test should also perform a ten day long isolation.

As we navigate this pandemic and all that comes with it, many people are left questioning what kind of world we may return to post-COVID-19. Scientists and researchers are spending countless hours studying available medications, developing new medications, and scrambling to develop a vaccine. The pandemic may be far from being over, but it’s still fair to say that our lives have all been affected.

Table 1: Initial Management of Patients with COVID-192,3

Mild Moderate Severe Critical
Symptoms Fever, cough, malaise

Absence of dyspnea

Evidence of lower respiratory disease with SpO2 >93% on room air SpO2 ≤93% on room air, RR >30, PaO2/FiO2 <300, or lung infiltrate >50% ARDS, septic shock, cardiac dysfunction
Labs Not indicated in otherwise healthy patients Standard: CBC, CMP

CRP, D-dimer, ferritin add prognostic value

Imaging Normal if taken Chest x-ray, ultrasound, or CT may be considered Pulmonary imaging and ECG if indicated
Setting for Management Telemedicine visits; outpatient Inpatient for close monitoring as they may develop severe illness in second week Inpatient Intensive care

SpO2: peripheral blood oxygen saturation; CBC: complete blood count; CMP: complete metabolic profile; CRP: C-reactive protein; CT: computerized tomography; RR: respiratory rate; PaO2/FiO2: arterial oxygen partial pressure/fractional inspired oxygen; ARDS: acute respiratory distress syndrome; ECG: echocardiogram

References:

  1. Coronavirus: A timeline of how the deadly COVID-19 outbreak is evolving. Pharmaceutical Technology. https://www.pharmaceutical-technology.com/news/coronavirus-a-timeline-of-how-the-deadly-outbreak-evolved/. Accessed 23 May 2020.
  2. Coronavirus (COVID-19). Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/index.html. Accessed 23 May 2020.
  3. COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available at https://www.covid19treatmentguidelines.nih.gov/. Accessed 23 May 2020.

 

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