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Treatment for COVID19

Treatment Initial/Prep/Goals CDC currently recommends quarantine/universal precautions Patients wear surgical mask when identified Evaluate in private room with door closed (airborne infection isolation room) Healthcare personnel use standard precautions (i.e., contact precautions, airborne precautions, eye protection) Immediately notify infection control personnel and local health dept IV access, Oxygen, monitor High Flow Nasal Oxygen or non-invasive ventilation Intubation Considerations COVID-19 may cause hypoxemia even in the setting of little respiratory distress May be profoundly hypoxemic without dyspnea (patients may "look" fine) Work of breathing cannot be relied upon to detect patients who are failing on high flow nasal cannula Consider a lower threshold for intubation indications Patients can develop worsening "silent" atelectasis and decline quickly and abruptly without lots of symptoms Oxygenation techniques to maintain saturation during intubation may increase virus aerosolization (e.g., mask ventilation) "Pure" rapid sequence intubation without bagging is preferred Consider viral filter to BMV This will be safer if the patient is starting out with more oxygenation reserve Consider semi-elective intubation over crash intubation (decreases prep time) Intubation procedure can place healthcare workers at risk of acquiring the virus Endotracheal tube confirmation could pose inoculation risk to practitioner Pulmonary complications by COVID-19 Atelectasis (consider PEEP, APRV, ARDSnet) Alveolar fluid filling (drain fluid- prone positioning with ventilation, APRV, coughing or "dumping" breaths to help clear lungs) WHEN TO INTUBATE? Physician clinical decision Consider if Progressively rising FiO2 requirements (e.g. > 75% FiO2 - again, based on patient's status) High flow cannula does not improve oxygenation Comorbid conditions (e.g., COPD, asthma, cardiovascular disease, etc.) Medical/Pharmaceutical Supportive therapy IV fluid resuscitation as needed Antipyretics as needed Oxygen as needed Monitors Surgical/Procedural Possible intubation/mechanical ventilation as needed Complications Under investigation Very young, elderly, immunocompromised may be asymptomatic Prevention Avoid endemic areas and persons who've traveled to endemic areas Universal precautions Disposition Admission Criteria Decision to monitor inpatient vs outpatient setting should be made on a case-by-case basis; consider Clinical presentation, patient's ability to self-monitor, home isolation, and risk of transmission in home environment Patients with mild clinical presentation may not initially require hospitalization Clinical signs/symptoms may worsen (e.g., lower respiratory illness progression due to comorbidities) All patients should be monitored closely Consult(s) Local health dept and CDC Discharge/Follow-up Instructions Per CDC interim guidance recommendations