The early basics...

1. Coronavirus disease 2019
SARS-CoV-2
Prepared by Myiesha Taylor, MD, FAAEM, FACEP
Emergency Medicine Attending
3/23/2020

2. Covid-19
The virus
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
The disease
COVID-19
Transmission
person-to-person via respiratory droplets and aerosols that are
produced when a source patient talks, coughs, or sneezes.
Virus can remain viable and able to infect for 3 hours as an
aerosol.
Surface transmission: viable virus can live on surfaces. Viable
virus can be detected for up to 3 days on some surfaces
(particularly plastic and stainless steel) [1]
CONTACT and AIRBORNE precautions are recommended.

3. Personal Protective Equipment (PPE)
Donning and doffing PPE is a
complex process. Often, when stakes
are high, requires THREE people.
The person, a buddy, and a site
monitor present with a checklist.
Significant number of contaminations
occur during the doffing (removal)
process of PPE [2]
Removal of PPE is a complex
procedure, with studies showing that
there are high rates of doffing errors
even with basic PPE [3]
“Specialized clothing or equipment worn
by an employee for protection against
infectious materials” - OSHA
● Gloves
● Gowns
● Masks
● Goggles
● Respiratory (N95, N99, or N100
particulate respirators)
Cloth masks are not sufficient and
may create additional risk and
exposure. [1]

4. Fun Facts
Asymptomatic people can transmit this
virus.
SARS-CoV-2 RNA and live virus has
been found in blood and stool.
Incubation period: median incubation
period is about 5 days (from exposure to
symptom onset); but thought to be up to
14 days.

5. Spectrum of illness severity
● 81% Mild with no symptoms or with a mild viral
pneumonia.
● 14% Severe disease. Trouble breathing, low oxygen,
over 50% lung involvement on CXR or CT scan.
● 5% Critical disease. Respiratory failure, multiorgan
dysfunction, shock.
Case fatality rate
5.8% Wuhan and Italy
0.9% South Korea
Italy median patient age 64y.
S.Korea median patient age 40s.
S.Korea did extensive testing which expanded their
denominator.

6. Impact of age
People of any age can acquire this infection
Symptomatic cases and severe disease are more common in
older adults.
Symptomatic infection in children is uncommon - however
they still get the virus, they are just not symptomatic (or are
mildly symptomatic).
The study, published March 13 in Nature Medicine, found
that even though children typically only exhibit mild
symptoms if infected, they can shed the coronavirus long
after symptoms disappear. [1,2]
“Children will get through this no problem...with corona
children are vectors not victims. In most epidemics young
children are the transmitters.” [3]
This is why school is canceled.

7. Clinical Presentation
Initial presentation - pneumonia characterized by
fever, cough, trouble breathing, and bilateral infiltrates
on CXR, ground-glass appearance on chest CT.
Fever 99% (possibly very low grade defined as 99.5 F)
Fatigue 70%
Dry cough 59%
Anorexia 40%
Myalgias (body aches) 35%
Dyspnea (trouble breathing) 31%
Less frequently: Headache, sore throat, nausea,
diarrhea
Healthy 40s year old man
In the ER at presentation
The next day.
Intubated on a vent.

8. Clinical Course
Day 1: Exposure
Day 5: Symptom onset
Day 10: Difficulty breathing (dyspnea)
Day 12: Hospital admission
Day 13: ARDS (acute respiratory distress syndrome).
ICU with mechanical ventilation. Heart arrhythmias,
acute cardiac injury, shock.
Recovery: 2 weeks for mild infections
Up to 6 weeks for severe disease

9. Labs and Imaging
WBCs - lymphopenia (low number of lymphocytes)
LDH - elevated (lactate dehydrogenase). LDH is the
enzyme that converts pyruvate into lactic acid in glycolysis
when oxygen is absent (anaerobic respiration). Elevation
signifies tissue damage and increased mortality in sepsis.
Procalcitonin - normal
D-dimer - elevated
SARS-CoV-2 RNA - nasopharyngeal swab. RT-PCR
(reverse-transcription polymerase chain reaction).
Positive test is confirmatory. Negative test does not rule-
out disease.
Chest CT - ground glass opacification. Tendency to be
bilateral, have a peripheral distribution, and involve the
lower lobes.

10. Management
Home care - mild infection. Focus on preventing spread and
monitor for deterioration which would prompt hospitalization.
Home isolation may be discontinued when:
At least 7 days have passed since symptom onset AND
at least 3 days have passed since symptom resolution
without the use of medications.
Limited role of glucocorticoids - steroids should not be used.
Uncertainty about NSAIDS - (ibuprofen, aspirin) anecdotal
reports of younger patients experiencing worsening disease with
their use. Further the anti-inflammatory properties of these drugs
could have a negative impact on the patient's immune response.
Therefore acetaminophen (Tylenol) is recommended.
Investigational:
Remdesivir (antiviral) IV medication developed for treatment of Ebola.
Hydroxychloroquine - reported to inhibit SARS-CoV-2 in vitro (in the
lab). It’s use was associated with a higher rate of undetectable SARS-
CoV-2 RNA on nasopharyngeal specimens at 6 days.
Azithromycin appears to add to the benefit.

11. #FlattenTheCurve
Dr. Emily Porter (board certified emergency medicine
physician) explains why everything is canceled.
Shelter-in-place for 3 months prevents hospital overload.
Social distancing for 3 months pushes critical peak/hospital overload to April 28th.
But then, shit hits the fan. So, it makes sense that cities, counties, and states will
do some form of 'shelter-in-place' pushing that May 18th peak from social
distancing down so its below hospital capacity.