COVID-19 in the Emergency Department

Last Updated: 4/29/2020

By: Noah Berland MD, Andrea Greene MD, Suvam Neupane MD, and Julian Watson MD

Reviewed By: Robert Allen MD and Monisha Dilip MD

Introduction

This post is meant to be an easily digestible and up-to-date article. The post is broken up into multiple parts, and we have tried to link out to our resources as much as possible.  We will try to keep this post as current as possible. Please feel free to comment as needed. The bulk of our management decisions are based on the WHO’s Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected¹. The NIH⁶⁰ also has a great search engine. Other useful references were EB Medicine Novel Coronavirus COVID-19: An Overview for Emergency Clinicians – EXTRA Supplement² and the CorePendium chapter³. The WHO also has an excellent search tool focused on the COVID-19 outbreak. And nearly every major journal; JAMA, The Lancet, NEJM, BMJ, etc… have focused pages for the outbreak. It is very important that you defer to your hospital’s policies.

Table of Contents

What is COVID-19?
Epidemiology
Evaluation

Signs and Symptoms
Diagnostics
Laboratory markers
Imaging Studies
Summary

ED Management

Severe Disease
Mild to Moderate
Novel therapies

Disposition
ED Self care and protection
References

What is COVID-19?

Standing for CoronaVirus Disease of 2019, it is the viral syndrome caused by the 7^th known coronavirus that is able to infect humans⁴. The virus itself is named SARS-CoV-2, which appears to be related to the coronavirus, SARS-CoV. SARS-CoV was responsible for the first Severe Acute Respiratory Syndrome (SARS) outbreak in 2003. Coronaviruses are enveloped, positive-sense, single-stranded RNA viruses with the largest known genome of all RNA viruses⁴. SARS-CoV-2 is an iteration of one of the many coronaviruses known to circulate and mutate in bats, and it is presumed to have jumped to humans through an unknown intermediate animal in one of the exotic food markets in Wuhan, China. This has yet to be substantiated⁵.

Epidemiology

Here are the global and US numbers as of April 29^th, 2020

• Total Confirmed Globally: 3,132,363
• Total Deaths Globally: 217,947
• Total Recovered Globally: 938,037
• Global Mortality Rate: 7%
• ———-
• Total Confirmed in US: 1,012,583 (295,106 in NYS, 162,338 in NYC)
• Total Deaths in US: 58,355 (17,682 in NYC)
• Total Recovered in US: 115,936
• US Mortality Rate: 6% (11% NYC)

You can stay current with the John Hopkins database⁶ which is updated daily.

Age appears to be the most important risk factor. Below are some more tables and graphics from The NNT and MDCalc⁷:

Plots of confirmed cases by age and mortality by age from Korean and Chinese CDC data. Courtesy of The NNT and MDCalc: https://www.mdcalc.com/covid-19#nnt

Graph of common risk factors and their mortality for patients with CAP compare with patients with COVID-19 from Chinese and Korean CDC, courtesy of The NNT and MDCalc, https://www.mdcalc.com/covid-19#nnt

Here is the Chinese Data from 44,415 cases as of Feb. 11, 2020, according to the WHO partner, Our World in Data^10:

This figure breaks down by percentage fatalities, critical cases, severe cases, and mild cases, Courtesy of Our World in Data https://ourworldindata.org/coronavirus

Evaluation

Testing pathways vary widely between institutions. You should refer to your institution’s guidelines but also consider clinical judgment and engage in shared decision making with your patients. China specifically established fever clinics¹¹ and some institutions, like ours, are directing febrile, well-appearing patients to specific COVID-19 workup locations. COVID-19 is considered to be spread by droplets, but due to recent research¹² and best practices¹³, many are taking airborne precautions. The WHO¹ recommends isolation with contact and droplet during standard patient encounters and escalation to airborne precautions for aerosolizing procedures.

The CDC¹⁴ has stated that there is community transmission, therefore infection with COVID-19 must presently be considered in any patient with fever and/or respiratory symptoms. The median incubation period is estimated¹⁵ to be 5.1 days (95% CI, 4.5 to 5.8 days) and 97.5% of those who develop symptoms will do so within 11.5 days (95% CI, 8.2 to 15.6 days) of infection. One should maintain a high index of suspicion in patients with progressive or acutely worsening dyspnea for five days or more after onset of symptoms as these patients may progress to respiratory failure. Any patients with tachypnea and hypoxemia, particularly “silent hypoxemia” (hypoxia without signs of respiratory distress), warrant close monitoring and evaluation. All such patients should be considered for transfer to a COVID-19 designated hospital or location based on local guidelines.

Signs and Symptoms

The following table is from a meta-analysis by Sun et al out of China¹⁶ and it highlights common presentations based on the pooled data from 50,466 patients:

Clinical complaints and symptoms from Guan et al¹⁷ (1099 patients):

Diagnostics

The extent of community spread¹⁸ has spurred on the WHO Director-General¹⁹ to advocate for liberal testing of all suspected cases to maximize public health efforts in reducing transmission and minimizing morbidity/mortality. However, given the limitations in our testing capacity and the current absence of disease-specific interventions to change management, the CDC²⁰ recommends targeted testing of symptomatic patients: presumed COVID-19 admissions, patients with comorbidities that increase the risk of poor outcomes, and healthcare workers with possible exposure. The NYC DOH²¹ only recommends testing hospitalized patients. While it appears unlikely for patients diagnosed with another respiratory pathogen to be co-infected with COVID-19, Wang et al reports a rate of ~5.8%.²² If we continue to only test influenza negative patients, we will risk ruling out an important diagnosis as prevalence in the community continues to rise.²³

Laboratory Markers

The following table from Guan et al¹⁷ highlights findings that can help you risk stratify patients with significant comorbidities and those requiring admission.

Lymphocytopenia was noted in 83.2%¹⁷ and 64.5%²⁴ of patients on admission, and this seems to have the best diagnostic value in the ED. Inflammatory markers (D-dimer especially >1mg/L, ferritin, IL-6, LDH), and cardiac enzymes (troponin, BNP) seem to rise over the course of illness²⁵ in patients who expire and lateralize or downtrend in survivors. While all of these markers are non-specific, they may allow our medicine and ICU colleagues to track a patient’s clinical course and help them determine prognosis and guide resource utilization.

Imaging Studies

The following table extracted from Guan et al¹⁷ highlights common findings on Chest X-Ray and Chest CT.

Some argue for the use of chest CT in diagnosing COVID-19,²⁶ which may demonstrate a higher sensitivity (86-97%) over RT-PCR (66-80%) as well as faster detection and turnaround. There is overlap in CT findings between COVID-19 and other viral pneumonias and the overall approach to ground-glass opacities, therefore, imaging by itself is not diagnostic.

The sensitivity of CT may be overestimated²⁶ and also vary with the duration of symptoms.²⁷ The precise quantification of PCR’s true performance can be limited by insufficient specimen collection and possible variability of sample sensitivity during the disease course – there may be lower sensitivity associated with lower viral burden early in the course.

Shi et al²⁸ report CT abnormalities emerging before symptom onset but in a small sample size of healthcare workers – a population with uniquely high exposure to COVID. Thus, there is limited applicability. While asymptomatic detection is crucial in coordinating public health efforts, the clinical significance of these CT findings is unclear as there is minimal commentary about the subjects’ hospital course.

Lastly, reliance on CT imaging risks contamination of the scanners, delaying care for other patients in the ED. Additionally, your patient may already have a high pretest probability of having COVID, and a confirmatory CT may not change clinical management. Our institution is promoting portable chest radiographs. Ultrasound can be a helpful adjunct, revealing findings consistent with multifocal pneumonia, including pleural thickening with pleural line irregularity (C Lines), and B-lines in multiple lung fields^{29 30}. Ultimately, you will diagnose and treat based on the clinical presentation. Checkout the POCUS Atlas⁶¹ for visual findings and time course of point of care ultrasound and COVID-10, and remember to check all lung fields.

Summary

Using data from Zhou et al²⁵,  Liu et al³¹, and Guan et al¹⁷, the NNT and MDCalc⁷ calculated odds ratios for common diagnostic studies and their association with mortality:

ED Management

SARS-CoV 2² is a respiratory virus, and the mainstay of treatment is supportive care. However, there are some unique considerations with treatment and some novel therapies that we should be aware of.

Severe Disease

As with all emergency care, assessing ABCs is your first step. Early intubation is considered the mainstay for patients presenting in respiratory failure. There are some concerns that non-invasive positive pressure ventilation (NIPPV) and high-flow nasal cannula/oxygen (HFNC/O) may increase the spread of the virus via aerosolization, though viral filters with NIPPV can help to reduce the risk. Confronting a growing shortage of ventilators, however, Italian providers have used NIPPV effectively to buy time until ICU beds become available². Yuan et al³² describe using HFNC/O to delay or reduce the need for intubation in patients with mild to moderate hypoxic respiratory failure (300> PaO ₂ / FiO ₂ ≥150). WHO guidelines¹ allow for a trial of NIPPV while closely monitoring patients for the development of respiratory failure. All of these patients should be cultured and receive broad-spectrum antibiotics.

Our institutions are supporting early intubation and avoiding NIPPV and HFNC/O. Vent settings for patients in ARDS (Acute Respiratory Distress Syndrome) should follow ARDSnet³³ protocol with tidal volumes of 4-8 cc/kg and a fluid restrictive strategy. The WHO¹ and American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline³⁴ recommend proning patients³⁵ in severe ARDS. The most critically ill patients might require V-V ECMO³⁶, however, 83% of these patients may still die. One thing that is important to remember is utilization of resources. Multiple sources, including Dr. Rosenbaum in the New England Journal of Medicine³⁷, have been reporting rationing of ventilators in Italy. This is actually an issue that has previously been explored with the idea that we weren’t prepared to handle these ethical dilemmas.³⁸ One possible solution is using a vent for multiple patients³⁹, however multiple authors have challenged the utility.^{40 41} You should follow your institution’s guidelines, but remember to consider access to ventilators prior to intubating a patient.

Currently, the WHO¹ does not recommend the use of steroids unless they are indicated for specific reasons (asthma or COPD exacerbation, septic shock). Chen et al⁴² showed hat steroids may be effective in inhibiting the cytokine storm and provide some benefit in a subset of patients suffering from haemophagocytic lymphohistiocytosis. The Hscore can be used to risk stratify and identify patients who might benefit from anti-inflammatory and anti-cytokine targeted therapy⁴³. Tocilizumab, an anti IL-6 monoclonal antibody, has showed potential benefit in one case series.⁴⁴

Mild to Moderate

Most patients with COVID-19, who are young and have limited comorbidities, will present with mild to moderate symptoms. The mainstay of treatment here is supportive care; yet, 10-20% of patients may require ventilatory support.⁴⁵

If your patient has shortness of breath, a history of asthma, and is wheezing, the WHO still recommends beta-agonist and antimuscarinic therapy along with corticosteroids¹. The clinician should strongly consider giving these therapies through an MDI with a spacer rather than a nebulizer to reduce aerosolization. Even though we predominantly rely on nebulizers in the ED, numerous reviews^{46 47}  and a meta-analysis⁴⁸ have demonstrated no clinical difference in efficacy between the two modalities. Lastly, fevers can be treated with acetaminophen (APAP) or nonsteroidal anti-inflammatory drugs (NSAIDs); there are rumors to avoid NSAIDs but no evidence to support this claim.

Novel Therapies

Important note, new data mentioned at the bottom essentially argues against use of these medications. Chloroquine and Hydroxychloroquine have been included in the treatment and prevention of COVID-19 pneumonia. Gao et al⁴⁹ note apparent clinical efficacy for patients with COVID-19. There is in-vitro data⁵⁰ and one systematic review⁵¹ supporting the use of chloroquine 500 mg PO q12 (expert consensus statement out of china⁵²) or hydroxychloroquine PO up to 600 mg/day⁵³. These treatments have been considered for patients who have simply been exposed or those who are critically ill. These are generally inexpensive medications but also in limited supply, so they should likely be reserved for patients with severe comorbidities and the critically ill. In one study by Gautret et al⁶² shows decreasing viral loads with 600 mg/day of hydroxychloroquine, and even better improvement when combines with azithromycin, when compared to the literature. An important update, from the VA, we have some pre-publication data on hydroxychloroquine vs no hydroxychloroquine, based on retrospective data is now out from Magagnoli et al⁶³. In this study the authors performed a retrospective chart review across all VAs and looked at rate of intubation, rate of death after intubation, and rate of death, comparing being exposed to hydroxychloroquine or not. In summary, even after taking into account the fact that patients receiving hydroxychloroquine alone had more severe disease, the authors still noted increased mortality, possibly based on side-effects or the involvement of other organs, such as cardiac toxicity, as noted by Mehavas et al⁶⁴.  This data is obviously based on retrospective data, so is not of the greatest quality, and as noted patients who received hydroxychloroquine were sicker, and VA data is often problematic for populations generalization, but at this time it is probably best to avoid hydroxychloroquine and chloroquine unless new compelling data comes out.

Remdesivir, an anti-ebola drug, has also demonstrated some efficacy in reducing RNA viral titers for other coronaviruses including MERS-CoV and SARS-CoV in in-vitro and non-human primate models.⁵⁴

Lopinavir/ritonavir, two antiretrovirals for the treatment of HIV, have been used and recommended for severe disease. Lopinavir, has shown potential benefit in one systematic review⁵⁵ mostly of animal and in-vitro studies of SARS-CoV 1 and MERS-CoV. There have also been case reports of lopinavir/ritonavir being potentially effective. The combination with interferon-alpha was recommended by the Chinese CDC.

Favipiravir, an anti-influenza drug, has also been proposed as a possible treatment⁵⁶ but has not undergone trials with COVID-19. It is approved and used in China⁵⁷ and Japan with potentially beneficial results.

And finally, convalescent plasma has also been proposed⁵⁸ as one potential treatment.

Disposition

Right now, ED flow – which is affected by ED volume and boarding, hospital occupancy, and staffing – is critical to the care of all patients. Further resource utilization is key. There are the easy choices: the severe patients either requiring intubation, NIPPV, or HFNC/O go to the MICU, and the people who are young and healthy and don’t require any interventions go home. But what do you do with the patients in the middle?

If the patient requires supplemental oxygenation or frequent nebs or has other high-risk features such as end-organ damage or anion gap metabolic acidosis, then admission may be required. However, other patients who you maybe previously would have placed in a stepdown or observation unit previously might now need to be admitted to a lower level of care or even discharged home. It is very important to understand the potential challenges of self-monitoring at home. If a patient has significant comorbidities and lacks the ability to care for themselves you might consider admitting a patient, doing the work up as above, or sending home on chloroquine or hydroxychloroquine. In NYC, the department of homeless services has specifically created units for Patients Under Investigation (PUIs) that do not need hospitalization. One should consider getting an ambulatory pulse oxygenation saturation prior to discharge.

Directly from the WHO¹:

Older patients and those with comorbidities, such as cardiovascular disease and diabetes mellitus, have increased risk of severe disease and mortality. They may present with mild symptoms but have high risk of deterioration and should be admitted to a designated unit for close monitoring.

In terms of risk stratification, The NNT and MDCalc⁷ have provided some very good information from some studies we’ve already covered.

Odds ratios and 95% Confidence Intervals, † In South Korea CDC Dataset the odds ratio for death in age group ≥ 60 is 30.7 (95% CI, 14.7 – 64) and the odds ratio for death in male gender is 1.95 (95% CI, 1.23 – 3.07). South Korea has very robust testing, in which case fatality rates were significantly lower across all age groups as compared with the Chinese data, but even more so in patients < 60 where there seem to be many positive patients with mild symptoms.

See the Epidemiology section for more details. Italy’s mortality rate may be high due to its relatively old population. However, it is important to note that older people almost always have a higher mortality rate than younger people, and the same can be said for people with significant comorbidities. This is apparent when looking at the pneumonia severity index (PSI), which gives a point for each year of life. This is clearly a virulent disease, but one should have the same conversations about the risks of hospitalization with the elderly.

Some systems are designating specific hospitals for the admission and workup of PUIs for COVID-19. Understanding your hospital’s and your local government’s plan to handle the COVID-19 pandemic is crucial. As such, any patient who requires further testing or admission for COVID-19 might need to be transferred to another facility. Most patients you send home will either not be tested or have a pending test result. It is important that you as a clinician are aware of your hospital’s policy on callbacks for positive results.

If you discharge a patient home, it is important to give the patient recommendations of home-quarantine and social distancing. The entire transmission characteristics aren’t well known as of yet. Here are the official guidelines from the WHO for home management⁵⁹. At present, the WHO is actually recommending that all laboratory-confirmed patients should be admitted to a COVID-19 specific facility, but this is not feasible. Defer to your local and national policies.

ED Self care and protection

COVID-19 has changed the world in just under three months, threatening lives, economies, and education, altering workplace and family dynamics, and exacerbating forces of social inequality. U.S. healthcare workers are uniquely vulnerable to the physical, mental, and social impacts of the virus. This article (https://www.nytimes.com/interactive/2020/03/13/world/asia/coronavirus-death-life.html) in the NYT is about two 29-year-old healthcare workers in Wuhan who became severely ill from COVID-19. Despite widespread reassurance that young people will generally suffer mildly from COVID-19 infection, there remains uncertainty regarding factors that predict those rare cases of severe disease in otherwise healthy, young individuals.

To combat stress during the Coronavirus pandemic, Dr. Sue Varma, psychiatrist at NYU Langone recommends the “four m’s of mental health: mindfulness, movement, mastery, and meaningful engagement”. For mindfulness, check out Headspace, now offering free membership for anyone with an NPI number. For movement, make sure you’re still making time to be outside, moving around and staying active. For mastery, consider spending free time doing things you’re good at, like cooking, writing, or photography. And finally, even though social distancing makes it hard to connect with others, find ways to meaningfully engage with those close to you or shoot for more meaningful connections with your patients. This may be as simple as spending the time to chat about nutrition with a diabetic patient or discussing goals of care with family members of a terminally ill patient. https://www.msnbc.com/msnbc/watch/reducing-anxiety-amid-coronavirus-pandemic-psychiatrist-shares-tips-80626245971

Ok, so we know how to stay sane in the COVID-19 pandemic. What can we do to try to prevent transmission? The risk to healthcare workers varies from specialty to specialty. In the ICU, risk comes from prolonged contact with infected patients. In the ED, the risk arises from the urgency with which we must face the unknown. Sometimes, medical interventions are needed before we have time to determine that the patient we are treating may have COVID-19. Additionally, recommendations about PPE, protocols for triage, and treatment of suspected COVID-19 patients seem to change hourly. Confusion and misinformation about the survival of the virus in the environment and the need for respirators versus surgical masks are leading to skepticism and distrust among healthcare workers and other hospital employees. Finally, some data has shown that compared to the regular population, healthcare workers may have an increased risk of COVID-19 infection. There is even speculation that healthcare workers are at higher risk of more serious disease compared to lay people, perhaps due to the greater viral load in a healthcare-related exposure.

For now, the CDC recommends droplet and contact precautions for treating COVID-19 patients. This includes a gown, gloves, eye protection, and a surgical mask for any suspected COVID-19 infected patient. In other words, no shoe or hair covers needed. The question of N95 vs surgical mask is a bit more muddled. If you have it, N95 is the preferred option, as there is concern from prior experiences that droplet and contact precautions alone are insufficient to prevent nosocomial spread of COVID-19, especially during high-risk procedures (think: lots of aerosolized secretions). An N95 or respirator equivalent should be worn by healthcare workers during high-risk procedures including CPR, bronchoscopy, and airway management. If you have a beard, your options are limited as an N95 will not fit tightly over facial hair and not all hospitals have a respirator faceshield.

The lack of available PPE for emergency room providers may become our biggest downfall in our nation’s fight to flatten the curve. Reusing N95s, recycling face shields, wearing gowns from room to room is the antithesis to preventing spread. These practices threaten our health and that of our patients. If we do not see meaningful changes with regard to PPE in the next few days, we will likely look back on this pandemic with deep remorse that our government failed to protect those most willing and able to fight back against COVID-19-related morbidity and mortality.

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