Protecting health care worker is a top priority. Attention to guideline-based patient isolation and infection prevention are the primary ways that frontline providers can protect themselves. The first case series of 138 patients infected with coronavirus noted that 29 percent of patients were medical staff, suggesting a high rate of nosocomial infections.13 Recent reports suggest that this is inhibiting the ability of some Chinese hospitals to maintain staffing and care for patients.14
Explore This IssueACEP Now: Vol 39 – No 03 – March 2020
Personal protective equipment (PPE) should be worn at all times when caring for a PUI. PPE guidelines for COVID-19 are based on recommendations for previous MERS and SARS coronavirus outbreaks (these differ from Ebola virus recommendations). The components are listed in Table 2.
Table 2. Personal Protective Equipment for COVID-1920
|Gowns||Consider level 3 or 4 liquid barrier performance* (eg, surgical gown)|
|Gloves||Consider wearing two pairs of gloves so a top layer can be discarded if visibly soiled
Consider using appropriate sanitizing solution or sanitizing wipe to disinfect gloves prior to removal to reduce risk of cross-contamination
|Eye protection||Goggles or disposable face shield that protects eyes AND the sides of the face|
|Face mask||Fitted N95 mask OR power air-purifying respirator|
*American National Standards Institute/Association for the Advancement of Medical Instrumentation recognizes four levels of liquid protection. Yellow contact gowns are level 1 and not intended for protection against long, fluid-intense procedures or body fluids at pressure.
Entry into patient rooms should be limited as much as possible. Procedures producing aerosolized patient secretions (open suctioning, induction of sputum) should be avoided. Health care workers at highest risk are those who are improperly trained in infection control, inconsistently use PPE, or perform high-risk procedures (eg, endotracheal intubation).12
Diagnosis and Clinical Features
In the first case series of infected patients with COVID-19, nearly all (98 to 100 percent) had fever, and leukopenia was associated with ICU admission, acute respiratory distress syndrome (ARDS), and death.13 A retrospective review of chest CT performed in confirmed cases showed a high incidence of multilobar ground glass opacities (86 percent) with or without consolidation.14 This is comparable with radiographic findings in MERS coronavirus and SARS coronavirus infections.
Current data suggest a case fatality rate of about 2 to 4 percent, although that number is likely to drop as milder cases will be more likely to be diagnosed as testing becomes more common. So far, 26 percent of infected patients have required critical care.13 While this may seem relatively benign, especially when compared to a 60 percent case fatality rate with Ebola virus, it is worth noting that the 1918 influenza pandemic had a similar case fatality rate (5 percent). The primary difference at this stage between the two is the dispersion globally of the disease.16
COVID-19 cases are definitively diagnosed by a positive real-time polymerase chain reaction (rt-PCR) isolation of viral RNA from respiratory secretions. This is theoretically possible from any upper or lower respiratory samples (nasopharyngeal swabs, sputum, bronchoalveolar lavage, nasopharyngeal wash, or aspirate), and it should be performed in any person meeting criteria for a PUI.17 Samples should be collected, handled, and shipped under the guidance of state or regional public health departments to appropriate reference laboratories capable of performing the specific SARS-nCoV-2 rt-PCR.
The foundation of COVID-19 management is supportive care and minimizing transmission. At this time, there is no evidence-based pathogen-specific treatment available. Neuraminidase inhibitors (oseltamivir, peramivir, zanamivir), ganciclovir, acyclovir, and ribavirin are considered ineffective against coronavirus and likely have no role in management.18 Drugs considered possibly effective and currently being offered under “compassionate use” standards in multiple countries include remdesivir, lopinavir/ritonavir, interferon beta, convalescent plasma, and monoclonal antibodies.18 Extracorporeal membrane oxygenation (ECMO) has been used in multiple cases in China, although candidacy guidelines do not exist.18 Use of any of these approaches should be in communication with CDC personnel and infectious disease specialists. While antibacterial therapy is unlikely to benefit most patients with COVID-19, most patients in Chinese case series with acute respiratory distress syndrome (ARDS) or septic shock received empiric broad-spectrum antibacterial therapy. The rate of bacterial superinfection is unknown. Additionally, about 40 percent of patients with ARDS received steroid therapy, reflecting the ongoing controversy of steroid use in ARDS.13
As China reels from the COVID-19 outbreak, the world prepares to limit its spread. Emergency physicians are on the front line of any infectious outbreak and should maintain a working knowledge of the features of infection, recommendations for isolation and health care worker protection, and the local and national public health infrastructure for reporting PUIs.