Title: Quick Critical Care Pearls for COVID-19<br/>Author: Caleb Chan<br/><a href='http://umem.org/profiles/resident/1583/'>[Click to email author]</a><hr/><p style="margin: 0px; font-stretch: normal; line-height: normal; font-family: Arial; color: rgb(26, 26, 26);">
<span style="font-kerning: none">(<b>*</b>It is important to note that many of the percentages in these early studies will change as more asymptomatic or minimally symptomatic patients are identified with increased testing)</span></p>
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<span style="font-kerning: none"><b>Epidemiology</b></span></p>
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<span style="font-kerning: none">Among more than 44,000 confirmed cases of COVID-19 in China as of Feb 11, 2020:</span></p>
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<span style="font-kerning: none">- 30–69 years: ~78%</span></p>
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<span style="font-kerning: none">- severely or critically ill: ~19%</span></p>
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<span style="font-kerning: none">Case-fatality proportion: </span></p>
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<span style="font-kerning: none">-60-69 years: 3.6%</span></p>
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<span style="font-kerning: none">-70-79 years: 8%</span></p>
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<span style="font-kerning: none">-≥80 years: 14.8%. </span></p>
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<span style="font-kerning: none">-With </span><span style="text-decoration: underline ; font-kerning: none">no</span><span style="font-kerning: none"> underlying medical conditions: overall case fatality of 0.9%</span></p>
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<span style="text-decoration: underline ; font-kerning: none">-With</span><span style="font-kerning: none"> comorbidities: </span></p>
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<span style="font-kerning: none">-cardiovascular disease (10.5%), diabetes (7%)</span></p>
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<span style="font-kerning: none">-chronic respiratory disease, hypertension, and cancer (6% each)</span></p>
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<span style="font-kerning: none"><b>Presentation</b></span></p>
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<span style="font-kerning: none">For patients </span><span style="text-decoration: underline ; font-kerning: none">admitted</span><span style="font-kerning: none"> to the hospital, many non-specific signs and symptoms: </span></p>
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<span style="font-kerning: none">- fever (77–98%) and cough (46%–82%) were most common</span></p>
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<span style="font-kerning: none">- of note, gastrointestinal symptoms (~10%) such as diarrhea and nausea present </span><span style="text-decoration: underline ; font-kerning: none">prior</span><span style="font-kerning: none"> to developing fever and lower respiratory tract signs and symptoms.</span></p>
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<span style="font-kerning: none"><b>Diagnosis</b></span></p>
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<span style="font-kerning: none">No general lab tests have great sensitivity or specificity </span></p>
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<span style="font-kerning: none">A normal CT scan does </span><span style="text-decoration: underline ; font-kerning: none">NOT</span><span style="font-kerning: none"> rule out COVID-19 infection</span></p>
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<span style="font-kerning: none">-In an early study, 20/36 (56%) of patients imaged 0-2 days (‘early’) after symptom onset had a normal CT with </span><span style="text-decoration: underline ; font-kerning: none">complete absence</span><span style="font-kerning: none"> of ground-glass opacities and consolidation</span></p>
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<span style="font-kerning: none"><b>Treatment</b>-</span></p>
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<span style="font-kerning: none">Mainstay of treatment will be management of hypoxemia including early intubation if necessary. However, specifically:</span></p>
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<span style="font-kerning: none">-Steroid therapy is controversial and the WHO is currently recommending </span><span style="text-decoration: underline ; font-kerning: none">against</span><span style="font-kerning: none"> it unless it is being administered for another reason</span></p>
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<span style="font-kerning: none">-has not been associated with any benefit</span></p>
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<span style="font-kerning: none">-associated with possible </span><span style="text-decoration: underline ; font-kerning: none">harm</span><span style="font-kerning: none"> in previous smaller studies with SARS and MERS</span></p>
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<span style="font-kerning: none">-associated with prolonged viremia</span></p>
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<span style="font-kerning: none">-intravenous remdesivir (a nucleotide analogue prodrug with promising in-vitro results against SARS-CoV and MERS-CoV) is available for compassionate use</span></p>
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<span style="font-kerning: none"> -lopinavir-ritonavir has been used without any associated benefit</span></p>
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<fieldset><legend>References</legend>
<p>
Al-tawfiq JA, Al-homoud AH, Memish ZA. Remdesivir as a possible therapeutic option for the COVID-19. Travel Med Infect Dis. 2020;:101615.</p>
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Bernheim A, Mei X, Huang M, et al. Chest CT Findings in Coronavirus Disease-19 (COVID-19): Relationship to Duration of Infection. Radiology. 2020;:200463.</p>
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Holshue ML, Debolt C, Lindquist S, et al. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med. 2020;</p>
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Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;</p>
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Russell CD, Millar JE, Baillie JK. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. Lancet. 2020;395(10223):473-475.</p>
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Wu Z, Mcgoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72?314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020;</p>
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Young BE, Ong SWX, Kalimuddin S, et al. Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore. JAMA. 2020;</p>
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<a href="https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html">https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html</a></p>
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