SOCRATES Special Operations CoVID19 Rapid Assessment, Treatment

and Emergency Support

8 HOURS

3 PARTS (Assessment, Overview, LAB)

CAO 24MAR20

Outcome: 18Ds/68WW1s are competent in assessing, providing initial treatment and triage, and providing supportive assistance for critical care and ventilator management to COVID19 patients in hospital or field setting, in order to sustain life in contingency event where existing medical resources are exhausted.

CAUTION: All information is subject to change as evidence and clinical care for COVID19 rapidly evolves. Always consult your local medical director and stay abreast of latest developments from the CDC, DOD JTS, and other recognized authorities.

SOCRATES CRASH COURSE – PART 1 – PATIENT ASSESSMENT

Approximately 3 hours online learning

1. Go to https://covid19.sccm.org2. Click the orange button, “Access Resources” (you will be required to sign up. Use a civilian

email, don’t worry, they won’t spam you or sell your information. SCCM is a reputable organization.)

3. Go through each of the online learning modules for the following:a. “Recognition and Assessment of the Seriously Ill Patient”b. “Airway Management”c. “Airway Assessment and Management”d. “Diagnosis and Management of Respiratory Failure”e. “Sustained Mechanical Ventilation Outside of Traditional Intensive Care Units”

For extra credit: “Mechanical Ventilation 1” and “Biohazard Disasters: Natural and Intentional Outbreaks”

4. CONGRATULATIONS – you’ve completed Part 1. Now, move onto Part 2 – “Overview of COVID19”. You will need to plan on clicking the weblinks and reading through the embedded PDFs.

PART 2SOCRATES CRASH COURSE – PART 2 – OVERVIEW of COVID19

Approx 1-2 hours online/reading

SOCRATES - Special Operations CoVID19 Rapid Assessment, Treatment and Emergency Support (references include https://emcrit.org/ibcc/covid19/, https://www.uwmedicine.org/coronavirus, https://www.cdc.gov/coronavirus/2019-ncov/publications.html , JTS COVID-19 CPG 20MAR20 DRAFT, PFCare.org, and Wayne’s Ragged Edge SAVeII class)

CAO: 24MAR20

1. What is COVID19, and where the heck did it come from?

Coronavirus disease 2019 (COVID-19) is a respiratory virus originating in Wuhan, China caused by the SARS-CoV-2 virus and is now pandemic. Most of those affected have milder illness (80%), 15% will be severely ill (require oxygen) and 5% will require ICU care. Of those who are critically ill, most require early intubation and mechanical ventilation. Other complications include septic shock and multi-organ failure, including acute kidney injury and cardiac injury. Older age and comorbid diseases, such as COPD, hypertension and diabetes increase risk of death. The virus is, highly contagious and spread via respiratory droplets, direct contact, and if aerosolized, airborne routes (if aerosolized). The most common symptoms include fever, fatigue, dry cough, and shortness of breath but also can present with gastrointestinal symptoms in some cases. SARS and MERS – these caused epidemics with high mortality which are somewhat similar to COVID-19. COVID-19 is most closely related to SARS.

https://ourworldindata.org/coronavirus#growth-of-cases-how-long-did-it-take-for-the-number-of-confirmed-cases-to-double

2. How is it transmitted and how do we protect ourselves as healthcare workers?

- large droplet transmission (risk limited to 6 feet from the patient), similar to influenza; also “fomite to face” where droplets settle on surfaces and remain viable for hours to days.

- Transmission appears to occur over roughly ~8 days following the initiation of illness; & may be transmitted before the patient is symptomatic

PPE

MIN-Cover eyes, nose, mouth and body (gown, mask, eyepro)

-standard surgical mask is acceptable but not optimal if you don’t have N95, and not performing any aerosol generating procedures.

BETTER – N95, full gown and gloves, full head coverage, sealable eye pro (tight fit to face); gown changed between patients.

BEST - head to toe Tyvek, face shield and n95's which remain on during entire shift. A disposable gown is placed over the Tyvek and discarded in between patients, and outer gloves are changed.When it's time for Tyvek removal, spray lightly with a disinfectant prior to removal.

(https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html)

- shoes don’t need to be covered, but recommend something easy to clean

DON/DOFF: https://www.youtube.com/watch?v=08XRYOE6CAw&feature=share&fbclid=IwAR3ZDvxdylOtHME5wbAbW7FDMt5vSWnN_b7ZeXOln5tTugLC1eczn0A06a8

3. What are the signs and symptoms, and when does a patient start to exhibit them?

Incubation period: ~4 days (interquartile range: 2 to 7 days). Some studies have estimated a wider range for the incubation period; data for human infection with other coronaviruses (e.g. MERS-CoV, SARS-CoV) suggest that the incubation period may range from 2-14 days.

Frequently reported symptoms of patients admitted to the hospital:

Fever (77–98%) - Some afebrile, some with high fevers lasting >1 week. The Italians have noted that there is a diurnal pattern to the fevers with many patients arriving to the ER between 1100-1400 daily with fevers.

Cough (46%–82%)

Myalgia or fatigue (11–52%) Shortness of breath (3-31%)

Fever - controversy: o The best available data suggests that only about half of patients are febrile at the time of admission

(Zhou et al. 3/9/20, Arentz et al. 3/19/20).o Absence of a fever does not exclude COVID-19.o Also some data showing temperature elevation without true fever (99-100 degrees F) can be

common Acute respiratory distress syndrome (ARDS) developed in 17–29% of hospitalized patients, and

secondary infection developed in 10%. In one report, the median time from symptom onset to ARDS was 8 days.

Respiratory Failure: ARDS/Pneumonitis, varying presentations on radiography. Cardiomyopathy including elevated CKs has been seen.

*Adapted from the Center for Disease Control: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

4. How do we test for COVID19?

Collect specimens from the upper respiratory tract (URT; nasopharyngeal AND, where clinical suspicion remains and URT specimens are negative, collect specimens from the lower respiratory tract when readily available (LRT; expectorated sputum, endotracheal aspirate,) for COVID19 virus testing by RT-PCR and bacterial strains. Additionally, testing for other viral

infections such as influenza should be obtained or if available a respiratory viral panel (i.e. Biofire).

Ultrasound Lung exam: https://vimeo.com/398253608

5. What Happens to the Positives? (NOTE: this WILL change, general guidance only!)

https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html

6. TREATMENT (JTS CPG, also courtesy Dr. Joe Cooper, WAMC)

TESTING – evaluate for influenza or CAP if clinically indicated; again, do not rule out COVID-19 solely based on positive test for other infection as co-infection is potentially

present in significant number of patients. Currently U.S. data is showing up to 6% coinfection rate with influenza A/B.

MILD: STAY HOME (as long as no “High Risk” family members) – HIGH RISK = aged ≥ 60 years and/or with underlying medical comorbidities that may increase their risk for disease progression, to include: cardiovascular disease, cerebrovascular disease, chronic respiratory diseases, chronic kidney disease, chronic liver disease, diabetes, hypertension, cancer, immunocompromising conditions, and pregnancy.

Although 81% of patients in a Chinese case series had mild symptoms, those who progressed to more severe disease were hospitalized a median of 7-11 days after the onset of illness. As such, close monitoring for symptomatic progression through the second week of illness is important

Evaluate for hypoxemia early as asymptomatic hypoxemia is a relatively common finding; Supplemental O2 if necessary

SEVERE

Patients may deteriorate rapidly, so continuous monitoring is critical.

Conservative fluid resuscitation as over-resuscitation can increase likelihood of ARDS in severe cases; •Target even or negative fluid balance.

Recommend rapid sequence intubation (RSI) to minimize bagging for staff safety. Early ventilation is associated with better outcomes in severe cases. ARDSNet strategy!

For adults, initiate oxygen therapy during resuscitation at 5-6 L/min and titrate flows to reach target SpO2 >93% during resuscitation. If persistent requirement for 5-6 L/min and lacking resources for invasive ventilation, consider use high flow nasal oxygen (HFNC) or a face mask with a reservoir bag at 10-15 L/min if the patient is in critical condition. –Recommend no HFNC unless all are in PAPR/N95 +gown + enclosed eye pro given risk of aerosolization and instead would give oxygen via non-rebreather.

7. Any drugs that help?? What about Hydroxychlroquine/Chloroquine?

-CAUTION - Hydroxychlroquine/Chloroquine- Check ECG for QT prolongation (if baseline QTc 450-500 ms, consider daily EKG; maintain adequate Mg and K levels)

Hydroxychloroquine/Chloroquine shown in in vitro studies to significantly decrease cell reception as well as significantly inhibit intracellular processes necessary for both replication as well as release of new virions. (Liu, J., Cao, R., Xu, M. et al. Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting

SARS-CoV-2 infection in vitro. Cell Discov 6, 16 (2020). https://doi.org/10.1038/s41421-020-0156-0)

Hydroxychloroquine – 400 mg initial dose for first day; 200 mg BID for 4 days (Clin Infect Dis. 2020 Mar 9. pii: ciaa237. doi: 10.1093/cid/ciaa237)

ALTERNATIVE: Hydroxychloroquine 600 mg/day (may add Azithromycin 500 mg 1st day, then 250 mg x 4 days) (Gautret et al. (2020) Hydroxychloroquine and azithromycin as a treatment of COVID 19: results of an ‐open label non randomized clinical trial. International Journal of‐ ‐ Antimicrobial Agents – In Press 17 March 2020 – DOI : 10.1016/j.ijantimicag.2020.105949)

Remdesivir?? May use acetaminophen 1 gram enterally q6hr for antipyretic and analgesic effects. Melatonin 5 mg QHS for sleep.

NSAIDS???? There is theoretical concern that the use of non-steroidal anti-inflammatory drugs (NSAIDs) may

lead to complications of COVID-19 due to NSAID-induced upregulation of angiotensin-converting enzyme 2 (ACE2), which is the cellular binding target for SARS-COV-2. However, there is no clinical evidence that the use of non-steroidal anti-inflammatory drugs (NSAIDs) for symptomatic relief lead to complications of COVID-19. The Food and Drug Administration (FDA) is investigating this theoretical further, but the World Health Organization currently warns to use caution when use is avoidable.

8. How do I ASSIST managing a ventilated patient? (**it is beyond the scope of most SOF Medics to independently manage ICU and ventilator patients; below is intended as FAMILIARIZATION to optimize care)

REVIEW THIS FIRST:

Vent (see addendums and google drive folder; courtesy Paul Loos, PFCare.org and Ragged Edge Medical)

o Ventilator settings & synchrony with ventilator.

o Confirm ETT depth at the upper teeth (ensure no migration of the tube).

o Tighten connections between ETT, connecting tubing, and ventilator (to prevent accidental disconnection).

o Include regular suction of ETT, oral hygiene (swabs with chlorhexidine mouth rinse or listerine), routine nursing care including moving the patient every 30-60 mins.

o Some recommend proning the patients 10 hours/day to optimize ARDS recovery

Three principles / goals of mechanical ventilation in ARDS patients (EACH COVID-19 Guidance, Phillip B Hitchcock, MD.)

○ ACCEPTABLE OXYGENATION

■ PaO2 > 55 mmHg (SaO2 > 88%)

■ While avoiding O2 toxicity ( FiO2 < 0.6 generally acceptable )

■ Increasing PEEP can help with alveolar recruitment - can start with a PEEP of 5 and

increase by 2-3 cm H20 q15-30 minutes until SaO2 > 88%

■ Decrease FiO2 as soon as patient improves

○ MINIMIZE BAROTRAUMA/VOLUTRAUMA

■ Tidal Volume of 4-6 ml/kg predicted body weight

■ Plateau pressure < 30 cm H20

■ May need to allow for permissive hypercapnia to achieve

■ Increase the RR to 35 breaths as needed

○ MINIMIZE ALVEOLAR COLLAPSE

https://www.nejm.org/doi/full/10.1056/NEJMoa1214103 (includes videos)

Neurologic status.

Cardiac and lung ultrasonography (may perform Q48 or Q72hr if stable).

Avoid stethoscope use (this is a fomite and poses risk of disease transmission).

NG tube care and feeding (use muscle milk or equivalent)

REMEMBER:

https://emcrit.org/wp-content/uploads/vent-handout.pdf

SOME SPECIFICS on SAVeII (God help us if we are using this device on our COVID19 Patients…this would only be as a last resort)

CONGRATULATIONS, you’ve finished PART2 (COVID19 OVERVIEW). Next step is proceeding to 3 hour hands-on LAB.

Three principles / goals of mechanical ventilation in ARDS patients (EACH COVID-19 Guidance, Phillip B Hitchcock, MD.)

○ ACCEPTABLE OXYGENATION

■ PaO2 > 55 mmHg (SaO2 > 88%)

■ While avoiding O2 toxicity ( FiO2 < 0.6 generally acceptable )

■ Increasing PEEP can help with alveolar recruitment - can start with a PEEP of 5 and

increase by 2-3 cm H20 q15-30 minutes until SaO2 > 88%

■ Decrease FiO2 as soon as patient improves

○ MINIMIZE BAROTRAUMA/VOLUTRAUMA

■ Tidal Volume of 4-6 ml/kg predicted body weight

■ Plateau pressure < 30 cm H20

■ May need to allow for permissive hypercapnia to achieve

■ Increase the RR to 35 breaths as needed

○ MINIMIZE ALVEOLAR COLLAPSE