Starting a series on clinical Pearls I am gathering in #COVID19 patients based on experiences of many experts

Will add as we go along

Feel free to add your own observations/experiences

#covidclinicalpearls /1

Anosmia is likely the most specific #COVID19 related symptom
30% of patients have anosmia as their 1st symptom
#covidclinicalpearls /2

Around 90% of patients have fever.
50% maybe afebrile at the time of presentation
Fever tends to be very resistant to routine measures in hospitalized patients
There is no consensus that NSAIDs are to be avoided in #COVID2019 patients

#covidclinicalpearls /3

Viral shedding is greatest at the time of symptom onset and declines over the course of several days
50% of patients keep shedding after complete resolution of symptoms
Viral shedding can continue for as much as 24 days

#COVID2019
#covidclinicalpearls /4

Lymphopenia is common in #COVID2019 > 80% patients
Leukopenia is seen in 1/3 of patients
Its associates with poor outcomes and poor surivival.
Recovery with Lym % > 20% at Day10 of symptoms is a + outcome marker
Lym % of <5% = poor prognosis

#covidclinicalpearls /5

Lymphopenia timeline in #COVID19

LYM% < 20% are pre-severe type
At TLM-2
If LYM% > 20% those are reclassified as “moderate”
If 5% < 20% = “severe”
If < 5% = “critical”

#covidclinicalpearls /6

Diagnosis by PCR testing has upto 30% false negative rate #COVID19
Sampling early in disease course will have lower sensitivity
CT Chest has BETTER predictive value in cases where CT findings are high probability even if PCR swab negative

#covidclinicalpearls /7

Average time from initial negative to positive PCR swab test is 5 days

Do NOT rule out #COVID19 with ONE pharyngeal swab.

Sensitivity of CT in patients with positive CT & negative PCR is 97%

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#CT Chest in #COVID19

Early #groundglass abnormality in early disease,

followed by “crazy paving,”

finally increasing consolidation

Typically peripheral
#covidclinicalpearls /9

Temporal changes of CT findings in #COVID19

Note #groundglass predominant early

#covidclinicalpearls /10

Respiratory support
#COVID19

AVOID
- Noninvasive ventilations #NPPV
- High flow O2 #HFNC

due to high risk to healthcare workers due to aerosols.

EARLY intubation

#covidclinicalpearls /11

For #intubation in #COVID19

Only Experts intubate
AVOID bag-mask ventilations
Use PEEP valve if needed
Gentle bagging via supraglottic device preferred if needed

Always use rapid sequence intubation - rocuronium preferred by some

#covidclinicalpearls /12

If using #NPPV #NIV in #COVID2019 ( #Ventilator in short supply)

Use a full face mask or helmet
Use a filter for the leak port
Use a HME Filter to provide additional safety from aerosol

Set Alarms for patient disconnect

#covidclinicalpearls /13

If using #HFNC (preferred to #NIV) in #COVID19
Use preferably low flow rates (30-40L/min) have lower rates of aerosolization
Always increase FiO2 to max before increasing flow rate >30L/min
Reassess at 1 hr and 3 hr intervals for possible intubation

#covidclinicalpearls /14

Use of Venturi mask
#COVID19
if patient requires >8L/min NC
Non humidified
Uptitrate to FiO2 35%
Then increase flow rate if needed to 12 L/min

#covidclinicalpearls /15

For mechanical #ventilation in #COVID19 #ICU

Tidal volume 6ml/kg IBW
PEEP 5 if BMI <35
(10 if BMI >35)

Avoid HIGH PEEP
#COVID19 ARDS is atypical with normal compliance & high PEEP may do more harm than good

#covidclinicalpearls /16

Use ARDSnet LOW PEEP table as a guide but try to maintain as low a PEEP as feasible early in #COVID19 disease

#covidclinicalpearls /17