Spring 2020

SPECIAL COVID-19 EDITION

I N T H I S I S S U E

EDITORCOVID-19 SPECIAL EDITION

Michael S. Beeson, MD, FACEP Dr. Beeson is a professor and the director of the Emergency Medicine Residency Program at Summa Health in Akron, Ohio.

Contributor Disclosures. In accordance with the ACCME Standards for Commercial Support and policy of the American College of Emergency Physicians, all individuals with control over CME content (including but not limited to staff, planners, reviewers, and authors) must disclose whether or not they have any relevant financial relationship(s) to learners prior to the start of the activity. These individuals have indicated that they have a relationship which, in the context of their involvement in the CME activity, could be perceived by some as a real or apparent conflict of interest (eg, ownership of stock, grants, honoraria, or consulting fees), but these individuals do not consider that it will influence the CME activity. Joshua S. Broder, MD, FACEP is a founder and shareholder of OmniSono Inc, an ultrasound technology company; his wife is employed by GlaxoSmithKline as a research organic chemist. All remaining individuals with control over CME content have no significant financial interests or relationships to disclose.

This educational activity consists of two lessons, a post-test, and evaluation questions; as designed, the activity should take approximately 5 hours to complete. The participant should, in order, review the learning objectives, read the lessons as published in the print or online version, and complete the online post-test (a minimum score of 75% is required) and evaluation questions. Release date May 1, 2020. Expiration date April 30, 2023.

Accreditation Statement. The American College of Emergency Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The American College of Emergency Physicians designates this enduring material for a maximum of 2.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Each issue of Critical Decisions in Emergency Medicine is approved by ACEP for 2.5 ACEP Category I credits. Approved by the AOA for 2.5 Category 2-B credits.

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Target Audience. This educational activity has been developed for emergency physicians.

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The American College of Emergency Physicians (ACEP) makes every effort to ensure that contributors to its publications are knowledgeable subject matter experts. Readers are nevertheless advised that the statements and opinions expressed in this publication are provided as the contributors’ recommendations at the time of publication and should not be construed as official College policy. ACEP recognizes the complexity of emergency medicine and makes no representation that this publication serves as an authoritative resource for the prevention, diagnosis, treatment, or intervention for any medical condition, nor should it be the basis for the definition of or standard of care that should be practiced by all health care providers at any particular time or place. Drugs are generally referred to by generic names. In some instances, brand names are added for easier recognition. Device manufacturer information is provided according to style conventions of the American Medical Association. ACEP received no commercial support for this publication.

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Critical Decisions in Emergency Medicine is the official CME publication of the American College of Emergency Physicians. Additional volumes are available.

EDITOR-IN-CHIEFMichael S. Beeson, MD, MBA, FACEP

Northeast Ohio Medical University, Rootstown, OH

SECTION EDITORS

Joshua S. Broder, MD, FACEP Duke University, Durham, NC

Andrew J. Eyre, MD, MHPEd Brigham & Women’s Hospital/

Harvard Medical School, Boston, MA

John Kiel, DO, MPH University of Florida College of Medicine, Jacksonville, FL

Frank LoVecchio, DO, MPH, FACEP Maricopa Medical Center/Banner Phoenix Poison

and Drug Information Center, Phoenix, AZ

Amal Mattu, MD, FACEP University of Maryland, Baltimore, MD

Lynn P. Roppolo, MD, FACEP UT Southwestern Medical Center,

Dallas, TX

Christian A. Tomaszewski, MD, MS, MBA, FACEP University of California Health Sciences,

San Diego, CA

Steven J. Warrington, MD, MEd Orange Park Medical Center, Orange Park, FL

ASSOCIATE EDITORS

Wan-Tsu W. Chang, MD University of Maryland, Baltimore, MD

Walter L. Green, MD, FACEP UT Southwestern Medical Center,

Dallas, TX

John C. Greenwood, MD University of Pennsylvania, Philadelphia, PA

Danya Khoujah, MBBS University of Maryland, Baltimore, MD

Sharon E. Mace, MD, FACEP Cleveland Clinic Lerner College of Medicine/

Case Western Reserve University, Cleveland, OH

Nathaniel Mann, MD Greenville Health System, Greenville, SC

David J. Pillow, Jr., MD, FACEP UT Southwestern Medical Center

Dallas, TX

George Sternbach, MD, FACEP Stanford University Medical Center, Stanford, CA

Joseph F. Waeckerle, MD, FACEP University of Missouri-Kansas City School of Medicine,

Kansas City, MO

EDITORIAL STAFFRachel Donihoo, Managing Editor

rdonihoo@acep.org ISSN2325-0186 (Print) ISSN2325-8365 (Online)

Lesson 1 n COVID-19 Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Critical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Lesson 2 n Personal Protective Equipment . . . . . . . . . . . . . . . . . . . . . . . 15

Critical Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

CME Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Drug Box/Tox Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

COVID-19 Special Edition n Spring 2020 3

FROM THE EM MODEL10.0 Systemic Infectious Disorders 10.7 Emerging Infections/Pandemics

n What signs and symptoms should raise suspicion for COVID-19, and which patients are at greatest risk?

n What diagnostic tests are most reliable for detecting COVID-19?

n What is the best approach to airway management in a patient with COVID-19?

n What pharmacological treatments can be used to manage COVID-19?

CRITICAL DECISIONSOBJECTIVESOn completion of this lesson, you should be able to:

1. Describe the signs and symptoms of COVID-19, and explain who is most at risk for severe disease.

2. Describe which diagnostic tests are most useful for evaluating cases of COVID-19.

3. List the considerations that must be made when providing respiratory support to patients with COVID-19.

4. Identify therapeutic interventions that should be avoided in patients with confirmed or suspected COVID-19.

5. List potential pharmacologic agents that may be used to treat COVID-19 infections.

The COVID-19 pandemic has ignited fear, frustration, and a flurry of rapidly evolving research as experts worldwide scramble to stem the morbidity and mortality caused by the novel virus. Anecdotal reports of successful treatments and models predicting the potential spread of the disease are omnipresent, yet the avalanche of often-contradictory information can make it difficult to decipher the facts. Clinicians on the front lines of this global crisis are tasked with recognizing and appropriately managing the flood of infected patients, many of whom are critically ill. Now more than ever, emergency physicians must be prepared to provide evidence-based care while bracing for the prospect of future coronavirus resurgences.

By Quentin Reuter, MD; Steven T. Haywood, MD; and Amer Aldeen, MDDrs. Reuter and Haywood are emergency physicians with US Acute Care Solutions, assistant professors of emergency medicine at Northeast Ohio Medical University in Rootstown, and staff physicians in the Department of Emergency Medicine at Summa Health in Akron, Ohio. Dr. Aldeen is the chief medical officer of US Acute Care Solutions in Canton, Ohio.

Reviewed by Michael S. Beeson, MD, MBA, FACEP

LESSON 1

COVID-19 Infections

Going Viral

Critical Decisions in Emergency Medicine4

CASE PRESENTATIONS■ CASE ONE

A 24-year-old woman presents with a dry cough that began 2 days earlier. She works at a restaurant and has been delivering takeout food to cars; the dining room has been closed for several weeks. She has had no known exposure to anyone who has been ill. She complains of a runny nose but denies a sore throat, fever, shortness of breath, and GI symptoms. She has no medical or surgical history, and the only medication she takes is an oral contraceptive. She smokes ½ pack of cigarettes per day, uses alcohol only on weekends, and denies any illicit drug use. The patient explains that she has been following the news about COVID-19 cases in the area and is terrified that she has contracted the deadly virus.

Her vital signs are blood pressure 110/60, heart rate 75, respiratory rate 17, temperature 37.2°C (99°F), and oxygen saturation 97% on room air. She is in no acute distress, and her oropharynx is moist and clear. Her tonsils are not enlarged and no exudates are present. Her lungs are clear to auscultation bilaterally, and her heart sounds are normal with no murmurs, rubs, or gallops. Her heart rate is regular. Her abdomen

is soft, nontender, and nondistended. Her speech is conversational with an occasional nonproductive cough. A point-of-care ultrasound examination shows good lung sliding with A-lines in all lung fields without effusion, consolidation, or B-lines.

■ CASE TWOA 45-year-old man presents with

a cough, fever, and sore throat that began 4 to 5 days ago; today, he has developed dyspnea. He takes losartan for hypertension and occasionally takes ibuprofen for ankle pain. His surgical history, social history, and review of systems are unremarkable. His vital signs are blood pressure 150/90, heart rate 95, respiratory rate 20, temperature 38.3°C (100.9°F), and oxygen satura-tion 96% on room air.

The patient is in no acute distress and is speaking in full sentences. His lung examination reveals a few crackles bilaterally. His heart rate and rhythm are regular. His oropharyngeal examination is normal, with moist membranes and no tonsillar enlargement or exudates. His abdomen is soft, nontender, and nondistended. A point-of-care ultrasound scan reveals a consolidation in the left-lower lung posteriorly and some consolidation with B-lines in the right-upper lung anteriorly. A laboratory workup

reveals a WBC count of 3.8 with 12% lymphocytes, an ALT of 250, and an AST of 312. A chest x-ray shows bilateral infiltrates.

■ CASE THREEEMS reports the impending arrival

of a 68-year-old man with slurred speech that reportedly began 2 hours earlier. A level 1 stroke team is activated in the emergency department. Upon arrival, the patient is lethargic and globally weak with no focal weakness. His initial vital signs are blood pressure 110/55, heart rate 120, respiratory rate 25, temperature 38.5°C (101.3°F), and oxygen saturation 65% on room air.

The patient is rapidly transferred to a negative-pressure isolation room, and supplemental oxygen is administered via a nonrebreather mask at 15 L/min with a surgical mask placed over the exhalation valve. A point-of-care ultrasound examination reveals multiple areas of consolidation bilaterally. His oxygen saturation improves to 85% with the mask in place. A high-flow nasal cannula is added under the nonrebreather set at 40 L/min and 100%. His oxygen saturation improves to 90%, but he remains lethargic and tachypneic. The care team discusses what further respiratory support should be used.

CRITICAL DECISION

What signs and symptoms should raise suspicion for COVID-19, and which patients are at greatest risk?

COVID-19 infections can lead to a wide range of symptoms, from mild upper-respiratory complaints to profound respiratory distress and ARDS. The average incubation period from the time of exposure to first symptoms appears to be 4 to 6 days, with one study reporting an interquartile range of 2 to 7 days.1-4 In one cohort study of 181 patients with COVID-19, 97.5% developed symptoms within 12 days.2

Most patients develop mild upper- and lower-respiratory tract disease, while a minority present with life-threatening ARDS. The exact proportion of asymptomatic patients remains unknown, but some estimates report these individuals account for 18% to 33% of COVID-19 cases.5,6 Further complicating efforts to contain the spread of the virus, emerging data suggests that presymptomatic transmission is likely (Figure 1).7-9

The average age of hospitalized patients is between 45 and 55 years; a slight predominance is male. Children, who are at much lower risk, comprise only 1.3% of the hospitalized patients reported by the Chinese Center for

Disease Control and Prevention (Chinese CDC).10 Fever (43.8%-76.5%) and a dry cough (59.4%-70.2%) are the most common symptoms at the time of admission.3,4,11 Notably, 30% to 50% of patients who present to the emergency department are afebrile; however, nearly all hospitalized patients (88.7%-98.6%) eventually develop a fever.3,12-14 Shortness of breath appears to be associated with greater disease severity when compared to milder cases (37% vs 15%).3 Other symptoms, including diarrhea, nausea, vomiting, headache, sore throat, fatigue, myalgias, and chills, are less common.14

In one cohort of hospitalized patients with relatively mild disease, hypoxia was only present in 9.4%; however, this

COVID-19 Special Edition n Spring 2020 5

TABLE 1. Common Findings in Hospitalized Patients with COVID-193,4,6,8,14

Symptom Frequency Incidence

Fever (during hospitalization) Common 88.7%-98.6%

Shortness of breath Common 31.2%-80.0%

Fever (at admission) Common 43.8%-76.5%

Dry cough Common 58.4%-70.2%

Fatigue Common 38.1%-69.6%

Hypoxia Occasional 9.4%-41.3%

Anorexia Occasional 1.0%-39.1%

Productive cough Occasional 26.8%-36.0%

Myalgias Occasional 3.4%-34.8%

Anosmia/dysgeusia Occasional 33.9%

Diarrhea Occasional 3.8%-26.7%

Nausea/vomiting Occasional 1.3%-24.4%

Sore throat Occasional 13.9%-17.8%

Headache Occasional 6.5%-16.1%

Chest pain/tightness Occasional 10.7%-15.0%

Wheezing Rare 6.7%

Altered mental status Rare 6.1%

finding has been as high as 41.3% in more severely ill populations.3,4,15 Out of 59 hospitalized patients in Italy, 33.9% reported anosmia or dysgeusia.16 Other anecdotal evidence suggests that these complaints may precede the development of more typical symptoms.17

A recent study of 204 patients with COVID-19 found that GI symptoms may be more common than initially thought, with roughly 40% of patients having anorexia and up to 17% having diarrhea.18 More recently, neurologic sequelae, such as confusion and altered mental status, have also been described (Table 1).19

Clinical CourseApproximately 81% of COVID-19

cases reported by the Chinese CDC are mild, 14% are severe (eg, dyspnea, hypoxia, tachypnea), and 5% are critical (eg, respiratory failure, shock, multiple organ failure). The overall fatality rate has been reported as 2.3%; however, mortality appears to be 14.8% for patients 80 years and older and 8% in those between the ages of 70 and 79 years.10 In a study of 1,099 admitted patients, 41.3% required oxygen therapy, 5.1% needed noninvasive mechanical ventilation, and 2.3% underwent intubation.3

In another study of 138 hospitalized patients with COVID-19, the median time from the first symptoms to dyspnea was 5 days, from the first symptoms to hospital admission was 7 days, and from the initial symptoms to ARDS was 8 days (Figure 2).13 The median time from symptom onset to death appears to be between 12 and 18 days.20,21

The mortality of patients who develop ARDS was as high as 51% in one study; for survivors, the time to hospital discharge was 22 days.21 Importantly, patients may remain infectious for 5 to 13 days after symptom resolution.22

High-Risk PopulationsIn a preliminary description of US

patients with COVID-19 published March 16, 2020, mortality was highest in those aged 85 years and above (10%-27%).23 Mortality was less than 1% for patients aged 54 years and younger. No fatalities had been reported at that time

FIGURE 1. Infectiousness of COVID-19 vs Other Pathogens

MERS Influenza Ebola

COVID-19 SARS Mumps

Rubella Smallpox Measles

How many people will catch the disease

(estimate up-to-date as of early March)

One sick person

ADAPTED FROM POPULAR SCIENCE MAGAZINE

Critical Decisions in Emergency Medicine6

in patients younger than 19 years. Of note, morbidity and mortality were also observed in younger, healthier groups. Interestingly, patients younger than 65 years accounted for 69% of cases, 55% of hospitalizations, 47% of ICU admissions, and 20% of deaths.

Although ICU admission rates in the US were higher in the elderly, as many as 1 in 50 to 1 in 25 patients aged 20 to 44 years required ICU admission (Table 2). In another study of hospitalized patients with COVID-19, patients older than 60 years had much higher rates of critical care admission than their younger counterparts (24.26% vs 6.75%).24 Although elderly patients with comorbidities are at greatest risk, COVID-19 does not completely spare young and healthy patients. The average length of stay of recovered hospitalized patients is roughly 10 to 12 days.3,13

ComorbiditiesIn a large study of hospitalized

patients with COVID-19, only 23.7% had preexisting conditions. Only 42.8% of the patients who required ICU-level care had preexisting conditions.3 Another study reported that only 25% of more than 1,500 hospitalized patients in China had preexisting conditions.11 Conversely, early data from the US suggests that as many as 90% of hospitalized patients may have at least one underlying condition.14 The biggest risk factors for severe disease and complications from COVID-19 appear to be advanced age (≥65 years),

cardiovascular disease (eg, hypertension, coronary artery disease, congestive heart failure), chronic respiratory disease (COPD, asthma), diabetes, and obesity.

Recent data illustrates the role that comorbidities play in the outcomes of patients with COVID-19. A US analysis of 7,162 patients showed that 78% of ICU admissions and 71% of non-ICU hospital admissions involved patients with at least one underlying condition. In nonhospitalized patients, the rate of underlying conditions was 27%. Furthermore, in patients with one or more comorbidities, 28% required non-ICU hospitalization and about 14% were hospitalized in an ICU. On the other hand, only 7.5% of patients with no underlying conditions required non-ICU hospitalization, and between 2.2% and 2.4% of patients required ICU-level care. Nearly all (94%) patients who died had at least one underlying medical condition. Again, the most common comorbidities included diabetes, COPD, asthma, and cardiovascular disease.25

A recent systematic review of five population-based studies described the clinical outcomes and smoking status of patients with COVID-19. While the data is unadjusted for other factors, active smokers and those with a history of smoking appear to do worse. Notably, smokers were more likely (RR=1.4, 95% CI: 0.98–2.00) to suffer from severe COVID-19 symptoms and were more likely to be admitted to an ICU, need mechanical ventilation, or die than nonsmokers (RR=2.4, 95% CI: 1.43–4.04).3,26

MortalityOutcomes among ICU patients

appear to be poor — between 48.4% and 49% — according to two recent studies.10,27 In a United Kingdom study of 3,883 ICU patients with COVID-19, the survival rate was 75% for those aged 16 to 49 years, 58.9% for those aged 50 to 59 years, 43.6% for patients aged 60 to 69 years, and 31% for those 70 years or older.27 A BMI above 30 also appeared to portend a greater risk of death. Approximately 59% of the critically ill patients in the study were intubated within 24 hours of admission.23

Mortality in intubated patients also appears to be alarmingly high. In one study of 191 COVID-19 cases, all but one of the patients who required intubation eventually died. The median time from symptom onset to the need for mechanical ventilation was 14.5 days.27 Another study describes 52 critically ill patients (mean age 59.7 years; 67% men), only 40% of whom had a chronic underlying condition. Nearly all of these patients were febrile. Approximately 61.5% died at 28 days, and mortality was 81% among those who required mechanical ventilation.

TABLE 2. Severe Outcomes Among Patients with COVID-19

%Age group (years) (no. of cases) Hospitalization ICU admission Case fatality

0–19 (123) 1.6–2.5 0 0

20–44 (705) 14.3–20.8 2.0–4.2 0.1–0.2

45–54 (429) 21.2–28.3 5.4–10.4 0.5–0.8

55–64 (429) 20.5–30.1 4.7–11.2 1.4–2.6

65–74 (409) 28.6–43.5 8.1–18.8 2.7–4.9

75–84 (210) 30.5–58.7 10.5–31.0 4.3–10.5

≥85 (144) 31.3–70.3 6.3–29.0 10.4–27.3

Total (2,449) 20.7–31.4 4.9–11.5 1.8–3.4

*Lower bound of range = number of persons hospitalized, admitted to ICU, or who died among total in age group; upper bound of range = number of persons hospitalized, admitted to ICU, or who died among total in age group with known hospitalization status, ICU admission status, or death.

TABLE 3. Medications Used for COVID-19

Drug In Vitro Animal Human Trials

NSAIDs Possible harm68,70 No data No data

ACE inhibitors, angiotensin receptor blockers

Possible harm55,56 Conflicting data58-62 No data

Remdesivir Possible benefit75 Possible benefit74 Possible benefit76

Lopinavir–ritonavir Possible benefit77 Possible benefit No benefit79

Chloroquine, hydroxychloroquine

Possible benefit75 Possible benefit Possible benefit84

COVID-19 Special Edition n Spring 2020 7

FIGURE 2. COVID-19 Timeline: Infection to Recovery or Death

The median duration from admission to ICU to death was 7 days. Approximately 67% were determined to be suffering from ARDS, and 23% had cardiac injuries.28 In 24 critically ill patients in Seattle, 18 required intubation, but only 6 were successfully extubated.29 Finally, among 1,053 critically ill patients in the UK who received noninvasive or invasive mechanical ventilation, 66.3% died.27

Approximately 12.7% of COVID-19 cases in Italy are fatal, as are 3.9% of US cases, 2.3% of German cases, 2.0% in South Korea, and 0.3% in Singapore.30,31 As of March 17, 2020, 96.5% of fatalities in Italy are in patients older than 60 years. Mortality in patients 80 years and older is 20.2%, and it is less than 0.5% in those younger than 50 years.32

CRITICAL DECISIONWhat diagnostic tests are most reliable for detecting COVID-19?

Laboratory TestsNumerous laboratory values can

suggest COVID-19 infections. A low lymphocyte count (<1500 per mm3) may be present in more than 80% of patients admitted with COVID-19. Patients with severe infections also tend to have more prominent lymphocytopenia and leukopenia than those with milder symptoms.3,13 Thrombocytopenia also appears to portend a worse prognosis and increased risk of mortality.33

The course of the disease can run from approximately 16 days (mild case, following a short incubation period) to 10 weeks (worst-case outcome, following a long incubation period).

A person can be infectious before symptoms start until symptoms are gone, with a peak about 5 days after symptom onset. However, this timeframe is not well understood; some people can infect others despite remaining asymptomatic.

SOURCES: Mark Cameron & Robert Salata, Case Western Reserve University; Bruce Aylward, et al, WHO

Upon infection, coronavirus incubates 2-14 days, averaging 5-6.

Symptoms tend to last longer in more severe cases.

1 week 2 3 4 5 6 7 8 9 10

MILD 2 WEEKS

SEVERE WITH RECOVERY 2 WEEKS

DEADLY 2–8 WEEKS

Lymphopenia and elevated AST/ALT, , LDH, troponin, CK, D-dimer, serum ferritin, interleukin-6 (IL-6), PT, creatinine, and procalcitonin levels have all been associated with a greater risk of death.20,21 Multivariate regression models have linked a greater risk of in-hospital mortality with higher sequential organ failure assessment scores (5.65, 2.61-12.23; P <0.0001) and D-dimer levels above 1 mcg/mL (18.42, 2.64-128.55; P=.0033) on admission.21 Procalcitonin appears to remain normal in patients with uncomplicated viral infections, but the level may become elevated in those with severe COVID-19 disease or bacterial coinfections.34

Cardiac injury is becoming more widely recognized as a complication of COVID-19 infections; one study demonstrated that 19.7% of hospitalized patients had acute cardiac injuries. ARDS (58.5% vs 14.7%) and death (51.2% vs 4.5%) appear to be more likely in patients with cardiac injuries than in those without.35,36 The risk of coinfection with other respiratory pathogens remains unclear. Some unpublished estimates suggest as many as 5.8% to 20% or more of patients with COVID-19 have concomitant respiratory infections.37-39

Imaging StudiesChest x-rays, chest CT, and point-

of-care ultrasonography (POCUS) can all illuminate evidence of COVID-19 infections. Although bilateral infiltrates are indicative of the pathogen, this finding is neither sensitive nor specific.

In the previously cited study of 1,099 hospitalized patients with COVID-19, only 59.1% demonstrated any radiographic abnormalities; however, approximately 86.2% had suggestive CT findings.3 Imaging findings were also more prevalent in the critically ill; of the 21 patients admitted to the ICU, all but one had chest x-ray abnormalities, including local and bilateral patchy infiltrates and interstitial abnormalities.40

Early infections may show multiple small, patchy shadows on CT and interstitial changes with a pleural or bronchial distribution (rather than a parenchyma distribution). As the disease progresses, the lesions increase, enlarge, and develop into multiple ground-glass opacities and consolidations, typically in both lungs (Figure 3). Eventually, pulmonary consolidations progress and encompass large volumes of lung parenchyma.41

Lung cavitation, discrete pulmonary nodules, pleural effusions, and lymphadenopathy are typically absent.42 Ground-glass opacities were present in 56.4% of patients in the previously mentioned study of 1,099 patients. Eighteen percent of those with nonsevere disease had normal CT scans, while only 3% of those with severe disease had normal CT scans.3 In 81 patients admitted with COVID-19, the predominant abnormality observed was bilateral (79%), peripheral (54%), ill-defined (81%), and ground-glass opacification (65%).

Lesions quickly progressed to bilateral ground-glass opacities and then developed into consolidative and mixed patterns within 1 to 3 weeks.12 In 59 patients hospitalized with COVID-19, the major characteristic of the initial CT scan showed ground-glass opacities (61.3%), followed by ground-glass opacity with consolidation (35.5%), rounded opacities (25.8%), a crazy-paving pattern (25.8%), and air bronchograms (22.6%).43

POCUS is emerging as a viable modality for evaluating cases of COVID-19. Thickened pleural lines, multifocal B-lines, and small multilobar consolidations have been reported, but the sensitivity and specificity of ultrasound for the detection of

Critical Decisions in Emergency Medicine8

n Fever, shortness of breath, dry cough, and fatigue are the most common presenting symptoms of COVID-19 infections.

n Comorbidities and advanced age correlate with a greater risk of decompensation and death.

n Lymphopenia and elevated AST/ALT, LDH, troponin, CK, D-dimer, serum ferritin, IL-6, PT, creatinine, and procalcitonin levels are all associated with an increased risk of death.

coronavirus is unknown.44 As ultrasound findings of the disease become more well-described, the role of POCUS may expand, limiting the need for chest CT and perhaps enabling clinicians to diagnose these infections before definitive test results are returned.

CRITICAL DECISIONWhat is the best approach to airway management in a patient with COVID-19?

Managing Hypoxia Severe hypoxia is relatively common

among hospitalized and critically ill patients with COVID-19. Although the stabilization and optimization of oxygenation and ventilatory support in the emergency department is essential, no randomized control trials are available to dictate the best approach. In 1,099 hospitalized patients with COVID-19, 3.4% developed ARDS, 5.1% required noninvasive mechanical ventilation, and 2.3% required invasive ventilation. Overall, 41.3% required oxygen supplementation.3 In another cohort of 191 hospitalized patients, 26% required ICU admission, 21% needed high-flow nasal cannula (HFNC), 14% required noninvasive ventilation, and 17% underwent invasive mechanical ventilation.21

Although numerous consensus recommendations regarding airway management and the treatment of hypoxia exist, no definitive data pertaining to COVID-19 has been derived from high-quality studies. The approach to respiratory management outlined in this article is primarily taken from evidence pertaining to patients with ARDS and other infectious pulmonary pathologies. As more is learned, experts may discover that features of COVID-19 mandate a unique approach. Of note, aerosol-generating procedures, including noninvasive ventilation and endotracheal intubation, can put clinicians at increased risk of exposure to COVID-19. As such, all management decisions must consider potential patient benefits while simultaneously protecting front-line health care workers.

In patients who require supplemental oxygen, an oxygen saturation above 90% is recommended by the WHO, the Surviving Sepsis Campaign, and the Australian and New Zealand Intensive Care Society.45-47 Nasal cannulas, Ventimasks, and nonrebreather masks are all reasonable, low-risk interventions. If initial oxygenation techniques fail to maintain an adequate oxygen saturation, HFNC is generally recommended as the next step. High-flow nasal cannula can deliver 60 L/min and up to 100% the fraction of inspired oxygen.

Reducing Aerosolization Although the use of a negative-

pressure room is optimal for patients being treated with HFNC to avoid the aerosolization of viral particles, it may not always be feasible in high-volume emergency departments. Some data show a relatively minimal risk of aerosolization with properly fitted HFNCs.48,49 Moreover, research demonstrates that a cough generates viral particles at a rate of approximately 400 L/min compared to 40 to 60 L/min created by HFNC.50

Placing a surgical mask over the HFNC apparatus is highly recommended to minimize aerosolization. Staff should wear aerosol personal protective equipment (PPE), including powered air-purifying respirators, eye protection, gowns, and gloves, regardless of the availability of a negative-pressure room. HFNC is recommended over bilevel positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP) for the treatment of refractory hypoxia.45-47 Although a viral filter can be used with BiPAP and CPAP, leaks around the facemask are difficult to prevent

FIGURE 3. Chest CT Demonstrating Central Ground-Glass Hazy Density

COVID-19 Special Edition n Spring 2020 9

and can result in the aerosolization of viral particles. Moreover, BiPAP failed to prevent intubation in a high number of patients infected with Middle East respiratory syndrome, a pathology that is similar to COVID-19.51

Mechanical Ventilation If a patient fails HFNC, intubation

is typically the next step in treatment. CPAP can potentially be trialed and was widely used in China; however, given the risks of aerosolization, it may only be appropriate if HFNC is unavailable.3 Intubation is a high-risk procedure for clinicians and should be performed in a negative-pressure room with only minimal staff present (eg, one intubator, one nurse, one respiratory therapist). The most experienced clinician should perform the intubation.

Preoxygenation should minimize aerosolization, but levels of hypoxia may be severe enough to require bag-valve-mask ventilation, despite the risk to staff. Video laryngoscopy, which can help mitigate the risk to providers by reducing the physical proximity of the intubator, is widely recommended. Airborne PPE should be worn by any care provider who is present for the intubation. Barrier enclosures, such as acrylic boxes or plastic tents, may minimize exposure during procedures, especially intubation.52

Definitive criteria for intubation indications have not been elucidated. Debate continues regarding the benefits of early intubation (predicting that patients will clinically deteriorate and potentially reducing staff exposure to aerosolizing procedures) versus late intubation (potentially avoiding the procedure altogether, given the high mortality of intubated patients and limited ventilator resources in some settings). Anecdotally, most experts are leaning toward delaying intubation for as long as possible when managing young, healthy patients.

Prone Positioning Without controlled trials to support

its use for the treatment of COVID-19, awake prone positioning is a technique that has been associated with improved mortality.53 Supplemental noninvasive oxygen (including HFNC) combined

with awake prone positioning may delay the probability of intubation; however, this has yet to be proven. The need to proceed to intubation remains a clinical decision, but many experts recommend worsening hypoxia and hypercapnia, acidemia, respiratory fatigue, hemodynamic instability, and altered mentation as indications.45-47

Ventilator ManagementOnce invasive mechanical ventilation

is initiated, little is definitively known regarding best practices for ventilator management. Low tidal volumes, higher positive end-expiratory pressure strategies, restrictive fluid resuscitation, and early prone positioning have all been recommended by leading critical care societies.45-47 One published strategy was able to reduce the need for mechanical ventilation by identifying severe COVID-19 infections early (based on low oxygen saturation, high respiratory rates, or tachycardia) and implementing aggressive treatment with positive-pressure ventilation, HFNC/CPAP, restrictive fluid resuscitation, and awake prone positioning. The strategy resulted in a rate of mechanical ventilation under 1%, a rate well below the national average of 2.3%.53

CRITICAL DECISIONWhat pharmacological treatments can be used to manage COVID-19?

ACE Inhibitors and Angiotensin Receptor Blockers

Patients with a history of hypertension have worse outcomes when infected with COVID-19; furthermore, researchers have discovered that the disease uses angiotensin-converting enzyme 2 (ACE2) as an entry point into cells.20,54-56 Because of these two findings, some have postulated that medications that interact with the renin angiotensin aldosterone system (RAAS), including ACE inhibitors (ACEi) and angiotensin receptor blockers (ARB), may be to blame for the poorer outcomes in patients with hypertension (Table 3). ACE catalyzes the conversion of angiotensin I to angiotensin II (AT II).57

ACE2 converts AT II into angiotensin 1-7. ACEi medications inhibit the action of ACE, reducing the amount of AT II. Since the substrate for ACE2 is decreasing, the amount of free ACE2 theoretically rises.

The mechanism through which ARB medications increase available ACE2 is somewhat unclear. Medications in the ARB class work by blocking AT II from binding to its receptor on the cell. Theoretically, this blocked receptor should increase the amount of free AT II. With the rise in its substrate, free ACE2 levels should decrease.

Some animal models show an increase in the levels of ACE2 after the administration of an ACEi and an ARB, while others show no increase.58-62 In human trials, the effect of ACEi and ARB and ACE2 is unclear. Although some studies show no difference, others have shown increased ACE2 levels with some RAAS medications.62-65 None of these studies evaluated patient-centered outcomes; instead, they looked at the amount of an enzyme that may or may not predict disease severity.

Multiple professional organizations, including the American Heart Association and European Society of Cardiology, strongly recommend that patients stay on their antihypertensive medications during the pandemic based on the benefits they are known to convey.66,67 There is potential danger in spreading word to the general public that these medications may worsen COVID-19 infections.

NSAIDsOn March 14, 2020, Olivier Véran,

the health minister of France, released the following tweet: “COVID-19. Taking anti-inflammatory drugs (ibuprofen, cortisone, …) could be an aggravating factor of the infection. If you have a fever, take paracetamol [acetaminophen]. If you are already on anti-inflammatory drugs or in doubt, ask your doctor for advice.” This tweet (Figure 4) initiated some debate about the use of NSAIDs in patients with COVID-19.

In the cells, membrane lipids are converted into phospholipase A2. This molecule is then converted into arachidonic acid, which in turn is

Critical Decisions in Emergency Medicine10

converted to prostaglandin G2 with the enzymatic assistance of cyclooxygenase 1 and cyclooxygenase 2 (COX-1, COX-2). Prostaglandin G2 is further converted to other prostaglandins (PG) and proinflammatory substances, including prostaglandin E2 (PGE2). When pathologic conditions exist in the kidney, the expression of COX-1 and COX-2 increases. This enzyme elevation causes an increase in PGE2, a process that can maintain the glomerular filtration rate by dilating the afferent arterioles of the glomerulus.68,69

NSAIDs inhibit the action of COX enzymes, preventing the formation of these PGs.70 Some NSAIDs selectively block COX-2, while others are nonselective in their COX blockade. If COX enzymes are blocked in a patient with pathologic kidney disease, the kidney cannot increase the production of PGE2. The loss of this protective feedback mechanism worsens kidney function.

Patients infected with COVID-19 appear to be at higher risk of acute kidney injury. Once this damage has occurred, mortality is higher than in patients without kidney injuries.71 In the setting of COX inhibition by NSAIDs, the kidneys lose the protection of PGE2. In addition to the known risk of causing and worsening kidney function,

further changes are observed in the body after the administration of NSAIDs that may worsen COVID-19 infections.

Through an unknown mechanism, ACE2 levels are known to rise with the administration of ibuprofen.72 COVID-19 is known to bind to ACE2, a process that facilitates the pathogen’s entry into the cell. The increase in ACE2 with NSAID use is hypothesized to increase the COVID-19 cell entry, which theoretically would increase the severity of infection and likelihood of death. To date, an increase in ACE2 levels has not been shown to directly affect morbidity and mortality.

According to the European Medicines Agency, “There is currently no scientific evidence establishing a link

between ibuprofen and worsening of COVID-19.” On March 18, 2020, the WHO stated they “do not recommend against NSAIDs” in cases of COVID-19. On March 19, 2020, the FDA recognized the concern for ibuprofen worsening COVID-19 symptoms, but the lack of direct scientific evidence kept the organization from making a recommendation. However, the FDA did note that NSAIDs carry a warning: “…the pharmacological activity of NSAIDs in reducing inflammation, and possibly fever, may diminish the utility of diagnostic signs in detecting infections.”

While there are postulated risks associated with the use of NSAIDs, these drugs have not been proven to worsen COVID-19 infections; however, they are associated with a significantly increased risk of adverse events in geriatric patients, a population in which COVID-19 carries a greater risk of mortality. As in any geriatric patient (with or without COVID-19), NSAIDs should be avoided to minimize the possibility of acute kidney injury, stress ulcers, stroke, and congestive heart failure exacerbation. It is important to note that acetaminophen can be used as an antipyretic while avoiding the theoretical risks of NSAIDs.

RemdesivirRemdesivir is a novel antiviral

medication that was originally developed to combat Ebola.73 In animal models, the drug has been shown to improve pulmonary function in mice infected with COVID-19.74 In addition, in vitro studies of known antiviral medications showed that remdesivir

n Assuming a patient (especially one without respiratory symptoms) is not contagious.

n Stopping antihypertensive agents, such as ACEi and ARB, when managing patients with suspected COVID-19 infections.

n Failing to minimize exposure when performing procedures that increase the risk of aerosolization (eg, noninvasive positive-pressure ventilation, intubation) and when administering nebulized medications. These procedures should be performed in a negative-pressure room with a minimal number of clinicians.

FIGURE 4. Tweet From the Health Minister of France

COVID-19 Special Edition n Spring 2020 11

blocked viral infection at low drug concentrations with little to no cytotoxicity to cells.75 In a recent study of 61 patients who received remdesivir on a compassionate-use basis, a promising number of subjects (68%) showed clinical improvement. These outcomes are even more impressive considering that 64% of these patients required invasive ventilation.

However, it is important to note that this study had no control group, and 8 of the original 61 patients were excluded from the final analysis. While the clinical improvement rate was encouraging, the lack of a control group limits any conclusions they can be drawn from this data. Further studies with a control group of patients are needed before safety and efficacy conclusions can be made. According to clincialtrials.gov, six ongoing studies are actively recruiting patients to examine this potential treatment option for COVID-19. At this time, there is no data in humans to support the use of remdesivir for the disease, but it is commonly listed in various protocols as an experimental therapy.

Lopinavir–RitonavirDuring the 2003 SARS-CoV

pandemic, screenings showed that the HIV medication lopinavir had in vitro activity against the virus.77 A 2003 study showed that the use of lopinavir-ritonavir

decreased the viral load and adverse clinical outcomes in patients infected with SARS-CoV.78 With the emergence of this new form of coronavirus, many hoped that this lopinavir-ritonavir would improve outcomes. However, a randomized, open-label control trial showed no change in clinical improvement or mortality with the addition of lopinavir-ritonavir.

The viral load was also similar in both groups. 13.8% of patients in the medication arm had to stop the trial early due to adverse effects. The authors concluded that there was no overall benefit when adding lopinavir-ritonavir to the treatment of patients infected with COVID-19.79 However, in the trial, the drug was not administered until relatively late in the course of illness (median of 12 days), leaving open the possibility that earlier administration may have had a positive effect.

Chloroquine, HydroxychloroquineChloroquine has been the mainstay

of treatment for malaria for many years and has shown benefit in the treatment of certain malignancies.80-82 In vitro studies showed that chloroquine blocked the COVID-19 virus at relatively low concentrations and did not exhibit cytotoxicity until it achieved very high concentrations.75 This potentially wide therapeutic index created some enthusiasm for using the drug to treat

COVID-19 infections. In February 2020, the State Council of the People’s Republic of China announced that chloroquine had demonstrated efficacy and safety when used to treat the virus.83

A prospective trial in France examined the efficacy of hydroxychloro-quine for the treatment of patients infected with COVID-19. For patients in whom there was a clinical suspicion for bacterial coinfection, azithromycin was added to the treatment regimen. Participants in the treatment arm received 200 mg of hydroxychloroquine orally 3 times daily. Patients in the hydroxychloroquine arm had significantly fewer positive polymerase chain reaction (PCR) tests for COVID-19 at days 3 to 6.

Patients who were treated with both hydroxychloroquine and azithromycin had significantly lower rates of viral PCR-positive test results at days 3 to 6 when compared to the control arm and those being treated only with hydroxychloroquine. While these preliminary results are encouraging, there are many limitations to this study. The sample size was only 20 patients in the treatment arm and 16 in the control arm. Additionally, 26 patients were initially enrolled in the treatment arm, but 6 were lost to follow-up and were not included in the final results. Researchers are continuing to collect data, with more results expected in the coming weeks.84

CASE RESOLUTIONS■ CASE ONE

As there were limited COVID-19 testing kits available in the young restaurant worker’s community, she was told to self-isolate at home for 2 weeks and was advised to return to the hospital for shortness of breath or fever. The emergency physician explained that, while her normal lung ultrasound was reassuring, many patients with COVID-19 present with minimal symptoms.

■ CASE TWOThe 45-year-old man tested

positive for COVID-19. He was

advised to self-quarantine for 3 weeks, continue his current blood pressure medications, and consult his primary care physician through a virtual visit. He was advised to return to the emergency department for worsening of his condition — most importantly, shortness of breath.

■ CASE THREEThe decision was made to

intubate the elderly man with slurred speech. The physician, respiratory therapist, and registered nurse all donned PPE and took aerosol precautions. After full

preparation, the nurse injected a

hypnotic agent followed by a fast-

acting paralytic. A clear plastic

drape was placed over the patient’s

head and chest, and the physician

quickly secured the man’s airway

using video laryngoscopy. He was

immediately placed on a ventilator

equipped with a viral filter. Tube

placement was confirmed by breath

sounds and waveform capnography,

which was already in place on the

ventilator circuit. The patient was

then transferred to the ICU for

further care.

Critical Decisions in Emergency Medicine12

Five clinical trials are actively recruiting patients to further study chloroquine and hydroxychloroquine for the treatment of COVID-19. While the data regarding this therapy are initially encouraging, it is paramount to be cautious about side effects, including QTc prolongation, before broadly adopting this unproven treatment.

Summary As the scientific community develops

a deeper understanding of COVID-19, it is essential for emergency physicians to update their understanding of the disease. Clinicians on the front line must be able to appropriately evaluate those who are potentially infected, recognize patients who are likely to decompensate, and understand the risks and benefits of all available treatments and supportive therapies.

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83. Gao J, Tian Z, Yang X. Breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies. Biosci Trends. 2020 Mar;14(1):72-73.

84. Gautret P, Lagier JC, Parola P, et al.  Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. 2020 Mar. doi: 10.1016/j.ijantimicag.2020.105949.

Critical Decisions in Emergency Medicine14

TECHNIQUE

Risks and BenefitsThe primary benefit of this technique

is the capacity to ventilate more patients than traditionally allowed.

Primary risks stem from differences in the patients’ lungs and pathologies; it is possible to under-ventilate and under-oxygenate one patient or cause barotrauma to another. Some patients may also be difficult to monitor; in such cases, progression of the lung pathology can cause death or anoxic brain injury. Additional hypothesized risks include the cross-contamination of patients with various infectious etiologies. Otherwise, the risks are similar to those associated with single-patient ventilator use.

AlternativesAlternatives to ventilator sharing

include repurposing certain equipment, including anesthesia machines from the operating room or positive-pressure devices, to create ventilators. Of note, this author cautions against using every available device in a 1:1 manner (ie, with out a slack of extra equipment); a number of these devices should remain available in the emergency department for acute traumatic or medical events that require a solo ventilator.

Other alternatives for patients who are not amenable to other oxygenation and ventilation methods include using a bag-valve-mask and initiating palliative measures to provide comfort care only.

Special ConsiderationsAlthough ventilator sharing should

not be done routinely, it is a tactic with which emergency physicians should be familiar. Consider evaluating your institution’s ventilator supply and locating splitters or adapters in advance. When using this technique, the tidal volume should be doubled (for two patients) or quadrupled (for four patients).

Reducing Side EffectsClinicians should attempt to identify

patients with comparable lungs by considering factors such as compliance and tidal volumes. Patients sharing a ventilator are likely to require deep sedation or even paralysis so they remain inactive and in dyssynchrony with one another. Close monitoring is also required, as lung pathology and mechanics can change over time.

By Steven Warrington MD, MEdOrange Park Medical Center, Orange Park, Florida

Ventilator SharingThe Critical Procedure

While criticized by various medical societies, the sharing of one ventilator among multiple patients has been successfully reported, both theoretically and in response to mass casualty crises. Several hospital systems have been sharing ventilators in response to the COVID-19 pandemic. Although nonemergency providers may argue that a ventilator should be dedicated to a single patient with

the best chance of survival, many patients are alive today thanks, in part, to the maneuver. Ventilator sharing was originally accomplished using a T tube (Y-connector tubing) with adapters, but there are

reports of success with 3D-printed adapters and the recent development of a commercial device.

1. Confirm that the short-term need for ventilators is greater than the available supply. Consider requesting ventilators from an outside institution if available; even if ventilator sharing is required as a bridge, each patient should ideally have their own.

2. Obtain T tubes (including adapters) from respiratory, central supply, or intensive care.3. Identify two patients in need of a ventilator who have similar lung “requirements,”

such as expected tidal volume, body habitus, and pathology.4. Attach a T tube and adapter to the inspiratory and expiratory input of the ventilator.

Attach commercial ventilator filters (if available) between the branch point and the patient to limit cross-contamination. Use ventilator tubing from the patient to one side of the T tube.

Note: If needed, one ventilator may be split between four patients by using additional T tubes and adapters. In such cases, there should be three T tubes connected to each inspiratory and expiratory location of the ventilator.

EXP

INSVENTILATOR

COVID-19 Special Edition n Spring 2020 15

FROM THE EM MODEL19.4.5 Systemic Infectious 19.4.5.1 Personal Protection (Equipment and Techniques)

n What type of PPE is required when taking standard precautions?

n What type of PPE is required when taking expanded precautions?

n What PPE should be donned when evaluating and/or treating a patient with suspected or confirmed COVID-19?

n What safety measures should first responders take when approaching a scene?

n Should PPE be worn even if its preparation delays patient care?

CRITICAL DECISIONSOBJECTIVESOn completion of this lesson, you should be able to:

1. Describe the proper sequence of donning and doffing PPE.

2. Explain the types of PPE required for specific clinical situations.

3. List some of the current PPE protocols recommended by the CDC.

4. Explain the PPE required when managing a patient with confirmed or suspected COVID-19.

5. Identify the safety measures that first responders should take in the prehospital setting.

The active SARS-CoV-2 (COVID-19) pandemic has heightened awareness about the importance of infection control, both in and out of the emergency department. Environmental and biological exposures are a well-known occupational hazard for emergency physicians and EMS personnel, who are contaminated by drug-resistant bacteria in an estimated 20% of patient encounters.1 While most health-care professionals are familiar with the use of personal protective equipment (PPE), the evolving nature of global PPE guidelines and institutional protocol differences can breed uncertainty.

By Christina Campana, DO, FACEPDr. Campana is an assistant professor at Northeast Ohio Medical University and a core faculty physician at Cleveland Clinic Akron General.

Reviewed by Michael S. Beeson, MD, MBA, FACEP

LESSON 2

Personal Protective Equipment

Going Undercover

Critical Decisions in Emergency Medicine16

CASE PRESENTATIONS■ CASE ONE

A 26-year-old woman with no medical history presents with fever, chills, shortness of breath, and a cough. She is a caregiver at a nursing home and states that several of her patients have been identified as +COVID-19. She denies recent travel outside of the United States. Her vital signs are blood pressure 101/50, heart rate 123, respiratory rate 24, temperature 40.2°C (104.4°F), and oxygen saturation 92% on room air.

■ CASE TWOA 76-year-old man presents via

ambulance after drinking an unknown amount of pesticide. His wife called 911 after she found him seizing in the garage next to an empty container. EMS reports finding a noxious odor at the scene and emesis down the front of the patient’s shirt, noting that his clothes appeared to be saturated with the suspected chemical. On arrival, the patient’s vital signs are blood pressure 154/88, heart rate 108, respiratory rate 22, and oxygen saturation 96% on room air. He responds

to deep pain and is maintaining his airway; a gag reflex is present.

■ CASE THREEA 52-year-old man with no medical

history presents with a fever and chills; he complains that he “just doesn’t feel right.” A triage questionnaire reveals that he returned 4 days ago from a trip to Italy, where the ongoing transmission of COVID-19 has been reported. His vital signs are blood pressure 92/40, heart rate 141, respiratory rate 32, temperature 39.8°C (103.6°F), and oxygen saturation 86% on room air.

The large-scale use of PPE first emerged during World War I, when respirators were used to neutralize the effects of chemical warfare.2 Since that time, technological advancements have resulted in better protection against a wide variety of life-threatening chemical and biological exposures.3 The long-held belief that PPE could offer full immunity from disease was challenged in 2014 to 2015 when several US health-care providers tested positive for Ebola despite taking hospital-mandated precautions.

Subsequent investigations found that these caregivers were infected after making the most common of all PPE-related errors: failing to don and doff their equipment in the proper order.4 Unsurprisingly, the devastating effects of the Ebola epidemic were felt in Africa’s three poorest countries, where proper protective equipment was scarce and education about infection control and the appropriate use of PPE was inadequate.4

The US is not above such problems. Ill-informed or untrained providers can unwittingly put themselves and others at risk by carrying infected blood or bodily fluids on their skin and clothing. Complications can also occur when health-care workers do not change facemasks or gloves between patients — a mistake that can lead to cross-contamination. In any high-risk situation, practice and knowledge are the keys to preparedness.5

It is essential for hospitals to provide designated areas for donning, doffing, and storing PPE, with clearly identified spaces for both clean and contaminated supplies. A disorganized environment can compromise infection control, lead to life-threatening procedural errors, and add substantial time to the process of donning and doffing PPE.

COVID-19 was first reported in China in December 2019; it has since become a worldwide contagion. Public health officials and infectious disease specialists are continually receiving evolving information about this novel virus and its disease process. The current global pandemic highlights the need for continued training and education about the correct use — and limitations — of PPE.

PPE BasicsThe key to proper PPE selection

and use is to understand the hazards and risks of exposure: the source, modes of transmission, pressure and methods of contact, and the duration and types of tasks to be performed by the user of the PPE.6 Precautions and standards are developed by the American Society for Testing and Material.6 The smaller the organism, the likelier it is to permeate the PPE. For example, the miniscule Ebola virus is notoriously adept at infiltration. Only 80 nm in diameter, Ebola calls for an extensive level of protection.7

Protective surgical and isolation gowns or coveralls, including hazardous materials (HAZMAT) suits made up of impermeable material, should be standard components of any PPE inventory. The types of microorganisms and fluids involved with the care of the

TABLE 1. Viruses/Bacteria with Droplet or Airborne Transmission8

Droplet Transmission

Airborne Transmission

Diphtheria (pharyngeal)

Measles (rubeola)

Haemophilus influenzae type B

Monkeypox (animal to human)

Influenza (pandemic)

Severe acute respiratory syndrome (SARS)

Neisseria meningitidis

Smallpox

Mumps TuberculosisRubella Varicella-zoster

virusMycoplasma pneumoniae

Aspergillosis

Parvovirus B19PertussisAdenovirusMycoplasmaGroup A StreptococcusRhinovirusSevere acute respiratory syndrome (SARS)Viral hemorrhagic fevers (eg, Lassa, Ebola, Marburg, Crimean-Congo)

COVID-19 Special Edition n Spring 2020 17

patient will dictate the type of protective clothing that should be worn. For example, surgical gowns are classified by four levels of barrier protection; level 4 is the most impermeable and is recommended for blood and viral protection from Ebola, HIV, and hepatitis C.7

Droplet size is a variable that remains under debate. Although droplets have been traditionally defined as larger than 5 μm, droplet nuclei have been associated with airborne transmission (defined as ≤5 μm) and can present challenges to the assignment of isolation categories.8 For example, COVID-19 is transmitted primarily via direct contact and droplets, but transmission has been associated with aerosolizing procedures, including endotracheal intubation, noninvasive positive-pressure ventilation, and cardiopulmonary resuscitation.8

Facemasks, which are commonly used in the evaluation of patients who require respiratory droplet precautions, can protect the examiner from pneumonia, meningitis, and other viruses (Table 1). Respirators, which are warranted under specific circumstances, help filter the air that is being breathed or can supply clean air from another source, such as a compressed oxygen tank.9 Disposable face shields should be worn in situations where high-impact hazards are likely. A full-filtering face respirator is required when there is a possibility of exposure to hazardous chemicals or infectious agents.10

Ocular exposure should be considered when dealing with bodily fluids, microorganisms, and potentially toxic airborne particles, including fumes. Safety glasses or goggles offer minimal protection and are appropriate

for general, low-risk procedures, such as suturing, which can expose the provider’s eyes to blood.10 Gloves, the most common form of PPE, provide barrier protection from virtually any form of contact.

Regardless of the type of PPE chosen, it is essential for the gear to be donned and doffed in the proper order (Figure 1).

CRITICAL DECISIONWhat type of PPE is required when taking standard precautions?

“Standard” precautions describe the minimum practice requirements that apply to all clinical care settings, regardless of a patient’s medical history or probability of exposure. These include hand hygiene, the use of adequate PPE, safe injection

FIGURE 1. CDC Guideline for Donning and Doffing PPE11

1. GOWN AND GLOVES • Gown front and sleeves and the outside of gloves

are contaminated!• If your hands get contaminated during gown or

glove removal, immediately wash your hands or use an alcohol-based hand sanitizer.

• Grasp the gown in the front and pull away from your body so that the ties break, touching outside of gown only with gloved hands.

• While removing the gown, fold or roll the gown inside-out into a bundle.

• As you are removing the gown, peel off your gloves at the same time, only touching the inside of the gloves and gown with your bare hands. Place the gown and gloves into a waste container.

2. GOGGLES OR FACE SHIELD • Outside of goggles or face shield are

contaminated!• If your hands get contaminated during goggle

or face shield removal, immediately wash your hands or use an alcohol-based hand sanitizer.

3. MASK OR RESPIRATOR • Front of mask/respirator is contaminated —

DO NOT TOUCH!• If your hands get contaminated during mask/

respirator removal, immediately wash your hands or use an alcohol-based hand sanitizer.

4. WASH HANDS OR USE AN ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING ALL PPE

PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE

Here is another way to safely remove PPE without contaminating your clothing, skin, or mucous membranes with potentially infectious materials. Remove all PPE before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient room and closing the door. Remove PPE in the following sequence:

HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 2

• Remove goggles or face shield from the back by lifting head band and without touching the front of the goggles or face shield.

• If the item is reusable, place in designated receptacle for reprocessing. Otherwise, discard in a waste container.

• Grasp bottom ties or elastics of the mask/respirator, then the ones at the top, and remove without touching the front.

• Discard in a waste container.

SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE)

USE SAFE WORK PRACTICES TO PROTECT YOURSELF AND LIMIT THE SPREAD OF CONTAMINATION

• Keep hands away from face• Limit surfaces touched• Change gloves when torn or heavily contaminated• Perform hand hygiene

The type of PPE used will vary based on the level of precautions required, such as standard and contact, droplet or airborne infection isolation precautions. The procedure for putting on and removing PPE should be tailored to the specific type of PPE.

1. GOWN • Fully cover torso from neck to knees, arms to end of

wrists, and wrap around the back• Fasten in back of neck and waist

2. MASK OR RESPIRATOR • Secure ties or elastic bands at middle of head and

neck• Fit flexible band to nose bridge• Fit snug to face and below chin• Fit-check respirator

3. GOGGLES OR FACE SHIELD • Place over face and eyes and adjust to fit

4. GLOVES • Extend to cover wrist of isolation gown

Critical Decisions in Emergency Medicine18

FIGURE 2. COVID-19 PPE for Health-Care Personnel15

TABLE 2. PPE for COVID-1915

Component CommentsGowns Consider wearing a level 3 or 4 liquid barrier performance gown (eg,

surgical gown).*Gloves Consider wearing two pairs of gloves so a top layer can be discarded

if visibly soiled. Consider using an appropriate sanitizing solution or sanitizing wipe to disinfect gloves prior to removal to reduce the risk of cross-contamination.

Eye protection Wear goggles or a disposable face shield that protects the eyes and the sides of the face.

Face mask Wear a fitted N95 mask or a PAPR.

*The American National Standards Institute/Association for the Advancement of Medical Instrumentation recognizes four levels of liquid protection. Yellow contact gowns (level 1) do not protect against long, fluid-intense procedures or bodily fluids at pressure.

practices, safe handling of potentially contaminated equipment or surfaces, and respiratory hygiene.12-14

Hand hygiene should always be the first and last step in any situation that requires standard precautionary measures.14 Hands must be washed before touching a patient or performing an aseptic procedure and after being exposed to bodily fluids or touching any surface in the patient’s surroundings. The CDC recommends the use of alcohol-based hand sanitizers with greater than 60% ethanol or 70% isopropanol in health-care settings.15

Gloves and gowns should be worn when there is a potential for exposure to blood or bodily fluids, nonintact skin, or infectious materials. Eye and face protection, including masks, should be donned before initiating any procedure that carries a risk of spraying blood or bodily fluids in the examination area.

CRITICAL DECISIONWhat type of PPE is required when taking expanded precautions?

The distinct criteria that warrant “expanded” precautions are limited to a patient’s isolation status and the PPE required in each particular circumstance. In addition to standard precautions, contact isolation safety

measures should be taken when caring for any patient known or suspected to have a serious illness that can be transmitted through direct or indirect contact. In such circumstances, the patient should be placed in a private room and providers should wear fluid-resistant gowns and gloves, which must be discarded before touching other patients or non-contaminated surfaces.

Droplet isolation precautions are required when treating patients for suspected pertussis, influenza, diphtheria, and invasive Neisseria meningitidis, among other infectious diseases that produce coughing and sneezing. Providers should wear facemasks any time they are within close proximity to the patient (approximately 3 feet).16

Patients who require airborne isolation (eg, those with smallpox, measles, severe acute respiratory syndrome, varicella, tuberculosis, etc) must be confined to a filtrated negative-pressure isolation room. Caregivers should don an N95 filtering face respirator (FFR) or powered air-purifying respirator (PAPR) prior to entering the room.16 As previously emphasized, hand hygiene should remain a priority both before and after PPE use.

CRITICAL DECISIONWhat PPE should be donned when evaluating and/or treating a patient with suspected or confirmed COVID-19?

Patients can be properly screened for COVID-19 exposure in the emergency department or prehospital setting with simple triage questions that address recent travel to areas with widespread, ongoing transmission; direct contact with +COVID-19 individuals; and signs of infection. These signs can be mild or severe and include a cough, shortness of breath, and a fever of 38°C (100.4°F) or more.17 Physicians should use their clinical judgement and screening questions to identify persons under investigation (PUI) and determine whether or not the patient requires testing.

When managing suspected or confirmed COVID-19 cases, a surgical mask should be placed on the patient’s face, and the patient should be placed in a negative-pressure isolation room with contact and droplet precautions. (Airborne precautions should be taken

Face maskN95 or higherWhen respirators are not available, use the best available alternative, like a face mask.

Isolation gownIsolation gown

Face shield or goggles

Face shield or goggles N95 or higher

respiratorWhen respirators are not available, use the best available alternative, like a face mask.

One pair of clean, nonsterile gloves

One pair of clean, nonsterile gloves

COVID-19 Special Edition n Spring 2020 19

CRITICAL DECISIONWhat safety measures should first responders take when approaching a scene?

EMS personnel, who are an essential part of the emergency medicine continuum, are often the first to respond to reports of chemical and biological exposures. Although most first responders are well versed in PPE, the uncontrolled nature of these high-stakes situations can make it challenging to adhere to proper protocols. The Agency for Toxic Substances and Disease Registry has developed guidelines for EMS personnel on how to deal with HAZMAT scenarios based on specific types of exposures.21

Screening MeasuresScreening questions, which should

be implemented in the prehospital setting just as they would be in the emergency department, can help first responders quickly assess the risk of exposure for both the patient and medical personnel on scene. When there is a risk of COVID-19 or other biological dangers, questions should be posed regarding recent travel to geographical “hot zones,” potential

if performing aerosolized procedures, as previously discussed.) All PPE should be donned prior to entering the patient’s room (Figure 2). Hands should be washed or sanitized with alcohol-based hand sanitizers. Current CDC recommendations for evaluating and treating PUI and confirmed COVID-19 cases are as follows:• Goggles or disposable full-face shield• National Institute for Occupational

Safety and Health-approved N95 FFR or higher

• Gown with level 3 or 4 liquid barrier performance

• One pair of clean, nonsterile glovesShoes or boot covers are not

recommended (Table 2).17-19 Other protective measures to consider include limiting access to the patient’s room as much as possible and avoiding procedures that aerosolize patient secretions.19

There are three key factors necessary for a respirator to be effective. First, it must be donned correctly and worn during the exposure. Second, it must fit snugly against the user’s face without gaps. Third, the respirator must capture 95% of the particles from the air that passes through it, as does an N95 mask

(Figure 3).20 All PPE should be properly disposed of after completing the clinical encounter and exiting the patient’s room.

Unfortunately, national supplies of recommended PPE for COVID-19 are

currently low, and a lack of protection can jeopardize the safety of all clinicians caring for these patients. In such circumstances, recommendations may expand to include contingency PPE. Although these protective measures may not meet the initial standard of care, they still serve an important purpose. Reusable forms of PPE should be considered when conventional equipment is unavailable.

FIGURE 3. Three Key Factors for a Respirator to be Effective16

FIGURE 4. NFPA 704 Labeling System

023

W

HEALTH HAZARD4 – Deadly3 – Extreme danger 2 – Hazardous1 – Slightly hazardous0 – Normal material

FIRE HAZARDFlash points4 – Below 73°F3 – Below 100°F2 – Above 100°F, not exceeding 200°F1 – Above 200°F0 – Will not burn

SPECIFIC HAZARDOxidizer OXAcid ACIDAlkali ALKCorrosive CORUse NO WATER WRadioactive

REACTIVITY4 – May detonate3 – Shock and heat may detonate2 – Violent chemical change1 – Unstable if heated0 – Stable

Critical Decisions in Emergency Medicine20

exposure to the virus, and signs and symptoms associated with the infection.

EMS personnel should be equipped to manage patients in all three risk categories. Low-risk scenarios call for the baseline PPE used when transporting any patient to the hospital (ie, gloves, mask, gown, etc). Moderate- and high-risk patients should trigger enhanced PPE precautions, including the use of respirators with hoods, full coverall suits, and multiple layers of gloves. As always, proper donning and doffing techniques are paramount.

Environmental CluesThe National Fire Academy and

the Emergency Management Institute provide six critical criteria for gauging the risk of hazardous exposure in any given situation: occupancy and location, container shape, markings/colors, placards/labels, shipping papers, and senses.13

EMS personnel should be familiar with areas in their communities that contain high-risk materials (eg, laboratories, construction sites, farms, and factories), and should be able to anticipate the potential number of victims in each. Containers found at a site also can provide valuable clues about the potential for HAZMAT exposure and the amount of chemicals

that may be present.21 The Department of Transportation requires shippers to mark all containers that include reportable quantities of hazardous materials with labels or placards, both before and during transportation. Shipping papers can also provide information about a container’s contents; however, these documents often are kept in close proximity to the material itself and can be difficult to locate.

The National Fire Protection Association employs a standard labeling system (NFPA 704) that warn first responders about the potential dangers present on a given property (Figure 4). The left quadrant (blue) refers to any health risks posed; top (red) indicates flammability; right (yellow) points to reactivity; and bottom (white) contains

specific information and/or warnings about the materials present (ie, radioactive, corrosive). A number in each quadrant (0-4) is used to quantify the related risk, with 0 being minimal.21

It is equally important for EMS personnel to rely on their senses when responding to potentially dangerous situations. Clues like odors, vapor clouds, and skin and eye irritation can indicate the presence of hazardous materials. Immediate exposure can be assumed any time a pungent odor is noticed and should trigger EMS personnel to follow PPE procedures prior to entering the HAZMAT scene. EMS can help the receiving facility properly prepare to manage patients by informing them of potential exposures prior to arrival.23

CASE RESOLUTIONS■ CASE ONE

Prior to entering the room of the febrile patient, the emergency physician prepared by using hand sanitizer and donning an N95 FFR, gloves, gown, and goggles. After the examination, PPE was properly discarded and hand hygiene was repeated. The patient, who tested positive for COVID-19, was treated with an antipyretic and discharged home with quarantine instructions.

■ CASE TWOEMS consulted with medical

control before treating the elderly man with suspected pesticide

poisoning. The paramedics were advised to use PPE before initiating patient contact and medical care; PPE included decontamination suits, PAPRs with chemical-protective cartridges, and gloves. In the emergency department, medical staff prepared the decontamination room by turning on the negative airflow, attaching water-supply hoses, and assembling the portable decontamination tub in anticipation of the patient’s arrival.

■ CASE THREEThe 52-year-old man’s triage

questions and clinical presentation were highly suspicious for COVID-19.

Emergency department staff prepared by donning proper PPE (N95 FFR, surgical gown, gloves, hand hygiene, and face shield), and the patient was placed in a negative-pressure room with airborne precautions. Supplemental oxygen failed to improve his symptoms, so the physician decided to intubate him to avoid aerosolized airway alternatives. His care team was limited to one nurse, one physician, and one respiratory therapist. Additional supportive measures were taken to resuscitate the patient, and he was admitted to the ICU for further management.

n It is critical to follow the proper sequence of donning and doffing PPE to avoid the risk of exposure.

n Respiratory masks should be worn when evaluating patients with flu-like symptoms.

n Proper hand hygiene is paramount and should be performed before and after any patient interaction.

n A minimum of standard precautions should be taken when evaluating and managing any case of suspected or confirmed COVID-19.

COVID-19 Special Edition n Spring 2020 21

CRITICAL DECISIONShould PPE be worn even if its preparation delays patient care?

Emergency physicians are trained to evaluate patients in a timely manner and are understandably concerned when the care of a high-acuity patient becomes delayed to allow the donning of proper PPE. Although the process of putting on any protective equipment can slow treatment by precious seconds, it remains a nonnegotiable part of care in any high-risk situation.23, 24

The decision to properly implement PPE becomes more difficult when dealing with patients that do not fit into a high-risk category. There are no published guidelines pertaining to patients in low- to moderate-risk zones. Although modern medicine will argue against using gestalt over evidence, clinical judgment remains the only available option in such situations. Minimally, physicians should take standard precautions with any patient who may have been subject to an environmental or biological exposure.

SummaryPPE has become an aspect of

emergency medicine practice that cannot be ignored. Its importance is made evident by the numerous microorganisms and chemical agents that patients and caregivers are exposed to every day. Health-care professionals, particularly emergency physicians, must first protect themselves in order to protect their patients.

The evolving COVID-19 pandemic has put infection control in the international spotlight once again,

n Failing to recognize answers to screening questions that put health-care providers at increased risk of COVID-19 exposure.

n Failing to exercise proper hand hygiene when interacting with patients, touching contaminated surfaces, or donning and doffing PPE.

n Assessing a critically ill patient with a biological or chemical exposures prior to applying appropriate PPE.

n Failing to understand the hospital’s protocol for evaluating and managing high-risk infectious exposures.

increasing awareness of PPE and the hazards of handling high-risk patients. It is crucial for clinicians, first responders, and hospitals to comply with national PPE guidelines. The proper sequence of donning and doffing PPE in each scenario must also be emphasized, and clinicians should understand what level of protection is required in any given situation.

As we continue to navigate the active COVID-19 pandemic with an inadequate stock of PPE, it is more important than ever to continue to follow guidelines, monitor inventories, and maintain control over existing materials until the supply chain is restored or an alternative method can be implemented to decontaminate disposable PPE.

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multidrug-resistant bacteria to healthcare workers’ gloves and gowns after patient contact increases with environmental contamination. Crit Care Med. 2012 Apr;40(4):1045-1051.

2. Cheung GK. PPE from the beginning. Health and Safety Middle East. HSME website. Published March 11, 2013. Accessed January 20, 2015. http://www. hsmemagazine.com/article.php?article_id=786.

3. Occupational Safety & Health Administration. Personal protective equipment. OSHA website. Accessed January 19, 2015. https://www.osha.gov/Publications/osha3151.pdf.

4. Fischer WA 2nd, Hynes NA, Perl TM. Protecting health care workers from Ebola: personal protective equipment is critical but is not enough. Ann Intern Med. 2014 Nov;161(10):753-754.

5. Agboola F, McCarthy T, Biddinger PD. Impact of emergency preparedness exercise on performance. J Public Health Manag Pract. 2013 Sep-Oct;19(2):S77-S83.

6. Centers for Disease Control and Prevention and National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Personal protective equipment: questions and answers. CDC website. Updated March 14, 2020. Accessed March 28, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use-faq.html.

7. Center for Disease Control and Prevention and The National Personal Protective Technology Laboratory. Considerations for selecting protective clothing used healthcare for protection against microorganisms in blood and body fluids. CDC website. Accessed March 28, 2020. https://www.cdc.gov/niosh/npptl/topics/protectiveclothing/default.html.

8. Center for Disease Control and Prevention and National Center for Emergency and Zoonotic Infectious Disease (NCEZID), Division of Healthcare Quality Promotion (DHQP). 2007 guidelines for isolation precautions: preventing transmission of infectious agents in healthcare settings. CDC website. Updated July 2019. Accessed March 28, 2020. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf.

9. Centers for Disease Control and Prevention and National Institute for Occupational Safety and Health (NIOSH). Emergency response resources: personal protective equipment. CDC website. Updated 2018. Accessed March 28, 2020. http://www.cdc. gov/niosh/topics/emres/ppe.html.

10. Centers for Disease Control and Prevention and National Institute for Occupational Safety and Health (NIOSH). Eye safety: emergency response and disaster recovery. Accessed March 28, 2020. https://www.cdc.gov/niosh/topics/eye/eyesafe.html.

11. Centers for Disease Control and Prevention. Sequence for putting on personal protective equipment (PPE). How to safely remove personal protective equipment (PPE). CDC website. Accessed March 28, 2020. https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf.

12. Ceballos DM, Reeb-Whitaker C, Sasakura M, et al. Protection efficacy of gloves against components of the solvent in a sprayed isocyanate coating utilizing a reciprocating permeation panel. Ann Occup Hyg. 2015 Apr;59(3):358-372.

13. Centers for Disease Control and Prevention and National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP). Guide to infection prevention for outpatient settings: minimum expectations for safe care. CDC website. Accessed March 28, 2020. https://www.cdc.gov/hai/settings/outpatient/outpatient-care-guidelines.html.

14. Occupational Safety & Health Administration (OSHA). Healthcare wide hazards (lack of) universal precautions. OSHA website. Accessed March 28, 2020. https://www.osha.gov/SLTC/etools/hospital/hazards/univprec/univ.html.

15. Centers for Disease Control and Prevention. CDC statement for healthcare personnel on hand hygiene during the response to the international emergence of COVID-19. CDC website. Accessed March 28, 2020. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/hcp-hand-sanitizer.html.

16. Centers for Disease Control and Prevention. Guidance for Selection and use of PPE in healthcare settings. CDC website. Accessed March 28, 2020. https://www.cdc.gov/hai/pdfs/ppe/ppeslides6-29-04.pdf.

17. Centers for Disease Control and Prevention. Symptoms of Coronavirus. CDC website. Accessed March 28, 2020. http://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html.

18. Centers for Disease Control and Prevention and National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings. CDC website. Updated March 20, 2020. Accessed March 28, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html.

19. Green C, Pigott DC. COVID-19 for the emergency provider: what you need to know. ACEP Now. 2020 Marc;39(3):1, 21-23.

20. Centers for Disease Control and Prevention. Three key factors required for a respirator to be effective. CDC website. Accessed March 28, 2020. https://www.cdc.gov/niosh/npptl/pdfs/KeyFactorsRequiedResp01042018-508.pdf.

21. Centers for Disease Control and Prevention, Agency for Toxic Substances & Disease Registry. Managing hazardous materials incidents (MHMIs). Accessed March 28, 2020. http://www.atsdr.cdc.gov/MHMI/index.html.

22. Department of Transportation and Federal Motor Carrier Safety Administration. How to comply with federal hazardous materials regulations. FMCSA website. Accessed March 28, 2020. https://www.fmcsa.dot.gov/regulations/hazardous-materials/how-comply-federal-hazardous-materials-regulations.

23. Centers for Disease Control and Prevention. Interim guidance for emergency medical services (EMS) systems and 9-1-1 public safety answering points (PSAPs) for management of patients under investigation (PUIs) for Ebola virus disease (EVD) in the United States. CDC website. Accessed March 28, 2020. https://www.cdc.gov/vhf/ebola/clinicians/emergency-services/ems-systems.html.

24. Watson L, Sault W, Gwyn R, Verbeek PR. The “delay effect” of donning a gown during cardiopulmonary resuscitation in a simulation model. CJEM. 2008 Jul;10(4):333-338.

Critical Decisions in Emergency Medicine22

On arrival, his vital signs are blood pressure 108/77, heart rate 75, respiratory rate 22, temperature 36.1°C (97°F), and oxygen saturation 94% on 4 L oxygen via nasal cannula. He is alert and speaking in full sentences. He appears tachypneic, with faint bilateral rhonchi. His heart sounds are regular with no murmurs, and his abdomen is slightly tender in the epigastric region. A physical examination reveals 1+ bilateral leg edema.

He has a WBC count of 1.7, with a neutrophil count of 1.0 and lymphocyte count of 0.5. His BMP and BNP are normal. His D-dimer level is 1141 ng/mL (normal <500), and his C-reactive protein level is 2.51 mg/dL (normal 70.60 mg/dL). Influenza testing is negative.

He is placed on airborne and contact isolation, and a portable chest x-ray is obtained, followed by a CT scan of his chest.

The Critical ImageA 60-year-old man with lymphoma presents with a cough, hemo-ptysis, a sore throat, and mild abdominal pain for the past 5 days. Overnight, he became acutely short of breath and presented to the infirmary at his group living facility, where he was found to be febrile (38.6°C [101.5°F]) and hypoxic (oxygen saturation 85% on room air). The patient was transported to the emergency department; EMS reports that multiple residents at the facility have similar symptoms.

By Joshua S. Broder, MD, FACEPDr. Broder is an associate professor and the residency program director in the Division of Emergency Medicine at Duke University Medical Center in Durham, North Carolina.

1. ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection. American College of Radiology. (Accessed 4/24/2020, at https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection.)

2. Jacobi A, Chung M, Bernheim A, Eber C. Portable chest x-ray in corona virus disease-19 (COVID-19): A pictorial review.

Clin Imaging. Apr 2020;64:35-42.3. Zhao W, Zhong Z, Xie X, Yu Q, Liu J. Relation

between chest CT findings and clinical conditions of coronavirus disease (COVID-19) pneumonia: a multicenter study. Am J Roentgenol. May 2020;214:1072-1077.

4. Klok FA, Kruip M, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. Apr 2020; S0049-3848(20)30120-121.

A. Chest radiograph. Bibasilar opacities and a nodular opacity are noted in the left thorax.

Case contributor: Shawna Foley, MD

Peripheral nodular opacity

Bilateral basilar opacities

A

BGround-

glass opacities

Nodular opacity

B. Axial chest CT with IV contrast, lung window. CT demonstrates multifocal ground-glass opacities and a more nodular opacity. Given the patient’s history of lymphoma, the mass-like opacity likely represents malignancy, while the ground-glass appearance suggests superimposed infection.

COVID-19 Special Edition n Spring 2020 23

KEY POINTSn The evaluation and treatment of

COVID-19 infections are rapidly evolving. At the time of this publication, the CDC and the American College of Radiology (ACR) do not recommend using chest x-rays or CT for diagnosing COVID-19. Viral testing that is specific for COVID-19 is necessary for disease confirmation, even when imaging findings are suggestive of the pathology.1 Chest x-ray and CT findings that are consistent with COVID-19 overlap a number of other pulmonary processes.

n COVID-19 infections have a range of radiographic appearances; although the x-ray may be normal, bilateral, peripheral, or basilar pulmonary opacities may be present. A diffusely hazy chest x-ray appearance may also be seen.2

n The CT appearance of COVID-19 commonly includes ground-glass opacities (GGOs) (86%), aptly named for their resemblance to glass that has been roughened to a matte finish. GGOs in patients with the disease are usually peripheral (87%), bilateral (82%), predominant in lung bases (55%), and multifocal (55%).3 However, GGOs are not specific to COVID-19.

n The ACR recommends using por table chest x-rays to reduce the contamination and cleaning requirements of other imaging equipment, such as fixed radiography machines and CT scanners. CT is not recommended as a screening tool or first-line testing modality.1

n While chest CT does not appear to be routinely indicated for COVID-19 infections, it may be helpful for identifying competing or coexisting conditions, such as malignancies or pulmonary emboli. Some studies have demonstrated an increased thrombotic risk associated with COVID-19 infections, with rates of thrombosis as high as 31% in critically ill patients.4

n Ultrasound is also being explored for diagnosing COVID-19, but it is beyond the scope of this article.

CASE RESOLUTIONThe patient was treated with cefepime and azithromycin for possible bacterial pneumonia in the setting of neutropenia and fever. He was not anticoagulated for his portal vein thrombus. His COVID-19 SARS-CoV-2 polymerase chain reaction test was positive. The patient’s oxygen requirement decreased over several days, and he was discharged from the hospital.

D. Abdominal CT with IV contrast, soft-tissue window. A thrombus is visible in the portal vein.

C. Coronal chest CT with IV contrast, lung window. Like Figure B, this image demonstrates multifocal ground-glass opacities. Vascular windows (not shown) did not demonstrate pulmonary emboli.

E. Ground-glass bottle stopper

D

C

E

Celiac artery

Aorta

Portal vein

Inferior vena cava

Thrombus

Ground- glass

opacities

Ground glass

Critical Decisions in Emergency Medicine24

1 Based on data from China, what is the average age of hospitalized patients infected with COVID-19?

A. <30 years oldB. 30 to 40 years oldC. 45 to 55 years oldD. >65 years old

2 What is the median time between the onset of first COVID-19 symptoms and the development of ARDS?A. 3 daysB. 8 daysC. 14 daysD. 21 days

3 A 52-year-old man presents with a cough, a fever, and hypoxia. Bilateral infiltrates are seen on his chest x-ray, and his procalcitonin level is elevated. What can be concluded from the patient’s procalcitonin abnormality? A. COVID-19 can be ruled outB. He has a higher likelihood of having severe

disease, whether viral or bacterial C. He is confirmed to have COVID-19D. He is suffering from a definite bacterial infection

4 What early CT finding(s) can be expected in a patient with COVID-19?A. Lung cavitation and ground-glass opacitiesB. Lymphadenopathy C. Pleural effusionsD. Small, patchy shadows and interstitial changes

5 A 60-year-old man with no medical history presents with a cough, a fever, and shortness of breath. The patient has tachypnea but no accessory muscle use. He can speak in full sentences, and his lungs are clear. He is on a 6-L nasal cannula with an oxygen saturation of 88% at rest. What is a reasonable choice for oxygen delivery?A. Decrease the nasal cannula to 2 L B. Initiate BiPAPC. Intubate the patient immediatelyD. Provide a high-flow nasal cannula

6 What is the most common symptom in admitted patients with COVID-19?

A. Altered mental statusB. AnosmiaC. Fever D. Hypoxia

7 Besides supplemental oxygen and ventilation support, what maneuver can help improve oxygenation?

A. Position the patient close to the door so they can be easily monitored

B. Position the patient under an intubation tent for the duration of their time in the emergency department

C. Prolonged supine positioningD. Prone positioning

8 A 54-year-old man tests positive for COVID-19. He takes lisinopril to treat his hypertension. What pharmacologic recommendations should be made?

A. Advise him to continue his medication as prescribed and follow up with his primary care physician for continued management of his hypertension

B. Advise him to stop taking all blood pressure medications until the COVID-19 pandemic has passed

C. Advise him to stop the lisinopril and consult his primary care physician regarding alternative ways to manage his hypertension

D. Advise him to stop the lisinopril, and provide him with a prescription for amlodipine instead

9 A 68-year-old man presents with a cough and fever; he underwent a renal transplant several years ago. He says he has been taking 800 mg of ibuprofen every 6 hours for his fever. What counseling should be given regarding this patient’s ibuprofen use?

A. Continue NSAID use as needed for fever and myalgias

B. Decrease the NSAID dose to 400 mg every 6 hours, as there is no known benefit to increasing the quantity of ibuprofen

C. Stop all NSAID use, as it can worsen COVID-19 infections

D. Use caution when taking NSAIDs, as they can worsen renal function in the presence of a renal pathology

CME QUESTIONS

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may

receive CME certificates for up to 2.5 ACEP Category I credits, 2.5 AMA PRA

Category 1 Credits™, and 2.5 AOA Category 2-B credits for completing this

activity in its entirety. Submit your answers online at acep.org/cdem; a score of

75% or better is required. You may receive credit for completing the CME activity

any time within 3 years of its publication date.

Reviewed by Lynn Roppolo, MD, FACEP

COVID-19 Special Edition n Spring 2020 25

Who should be present during the intubation of a patient with COVID-19?

A. A full resuscitation team to prepare for the possibility of cardiac arrest after intubation

B. As few clinicians as possibleC. Hospital administrators to ensure that the

clinicians are compliant with PPE protocols D. Only the provider performing the intubation

According to the CDC, what should be a clinician’s first and last steps when taking “standard” precautions?

A. Determining and recording airborne or droplet precautions

B. Gown application and disposalC. Hand hygieneD. Placement and removal of isolation signs

outside the patient’s room

Which statement applies when treating a patient who requires expanded isolation?

A. Caregivers should don an N95 FFR or PAPR before entering the room of any patient requiring airborne isolation

B. Contact isolation is only required for patients with confirmed infectious disease

C. Droplet isolation alone is required for any patient with suspected Ebola exposure

D. Patients who require droplet isolation should be confined to a filtrated isolation room

  In general, which item should be donned first when preparing to see a patient?

A. GlovesB. Goggles or face shield C. GownD. Mask or respirator

  You are caring for a 60-year-old woman who is +COVID-19. Her initial complaints are a fever and shortness of breath. She was stable upon arrival, but she has worsened significantly over the course of her stay and now requires endotracheal intubation. The PPE you are currently wearing consists of goggles, a surgical mask, a surgical gown, and gloves. What, if any, change(s) should you make to your PPE prior to intubating this patient?

A. Add a surgical capB. Add coveralls and shoe coversC. No changes are requiredD. Switch from a surgical mask to an N95 FFR

What is the most common error hospital personnel make when using PPE?

A. Delaying patient care to don PPEB. Failing to don and doff in the proper orderC. Failing to don and doff PPE between patientsD. Improperly discarding contaminated equipment

Which property is indicated in the blue quadrant of a standard NFPA 704 hazard system label?

A. FlammabilityB. HealthC. ReactivityD. Weight of materials

Which environmental clue most reliably indicates the presence of hazardous materials?

A. Patient account of preceding eventsB. Pungent odorsC. Skin irritationD. Visible vapors

A 40-year-old man presents with fever, cough, and shortness of breath. He says he has had direct contact with a family member who has tested positive for COVID-19. Which PPE should be used when evaluating this patient?

A. Gloves, coveralls, and N95 FFRB. Gloves, goggles, surgical gown, and coverallsC. Gloves, goggles, surgical gown, and N95 FFRD. Gloves, surgical gown, and surgical mask

Which guideline should be considered when preparing to evaluate a patient for a high-risk biological exposure?

A. Care should always be delayed in favor of properly donning PPE

B. Care should never be delayedC. Care should only be delayed for a maximum of

15 minutes to properly don PPED. Care should only be delayed for adult patients

to allow time to don PPE; do not delay when managing children

What key factors are required for a respirator to be effective?

A. Must fit snugly without gaps and capture 90% of the air particles that pass through it

B. Must fit snugly without gaps and capture 95% of the air particles that pass through it

C. Must fit with minor gaps and capture 90% of the air particles that pass through it

D. Must fit with minor gaps and capture 95% of the air particles that pass through it

10

11

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20

12

17

15

16

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19

Tox Box

Mechanism• Contact with mucous membranes can be corrosive due

to the production of hypochlorous acid.• Bleach can liberate toxic gas if mixed with acid (chlorine

gas) or ammonia (chloramine gas).

Clinical Effects• Dermal: irritation• Ocular: irritation, corrosive corneal injury• GI: mucosal burns, vomiting, esophageal/stomach

necrosis or perforation, mediastinitis• Metabolic: acidosis, hypernatremia, hyperchloremia• Pulmonary: inhalational irritation if mixed with acid or

ammonia

Evaluation• Electrolytes in cases of large ingestions• Chest x-ray if pulmonary symptoms• Endoscopy if significant symptoms are present (eg, pain,

dysphagia, hematemesis), especially after a large, intentional ingestion (>40 mL; >5 mL/kg)

Decontamination• Activated charcoal is not recommended.• The patient’s mouth and eyes can be rinsed if irritated.

Disposition• Pediatric

− No assessment needed unless symptomatic− Mild esophageal burns in rare cases

• Adults (Observe for 4-6 hours) − Discharge if asymptomatic and can eat and drink

normally− Symptomatic: supportive care, attend to airway, and

consider early endoscopy

SODIUM HYPOCHLORITE POISONINGBy Christian A. Tomaszewski, MD, MBA, FACEP University of California, San DiegoHousehold bleach, a solution of 3% to 6% sodium hypo-chlorite, is one of the few disinfectants to meet EPA criteria for use against SARS-CoV-2. A strong oxidizing agent, bleach also contains sodium hydroxide (0.1%-1%). The alkaline pH (~12.6) prevents degradation to chlorine gas. Most pediatric exposures can be managed at home. Significant caustic injury has only been reported from large, deliberate ingestions.

Drug BoxHYDROXYCHLOROQUINE FOR COVID-19By Frank LoVecchio, DO, MPH, FACEP Abrazo Health, Goodyear, ArizonaTo date, there is no proof that any drug, including hydro xychloro quine, can cure or prevent COVID-19 infections. Although the agent can inhibit SARS-CoV-2 in vitro, hydroxychloroquine appears to have more potent antiviral activity. However, clinical data are limited, and the efficacy of hydroxychloroquine against SARS-CoV-2 is poor.

Emergency Indications The FDA issued an emergency authorization to allow the use of the drug in adolescents and adults hospitalized for COVID-19. However, if hydroxychloroquine is used outside of a clinical trial, the possibility of drug interactions and toxicity (eg, QTc prolongation, in particular; cardiomyopathy; and retinal toxicity) should be considered, especially when managing those who may be more susceptible to these effects. All patients should be monitored closely for complications.

DosingAlthough optimal dosing is uncertain, the FDA suggests administering 800 mg of hydroxycholoroquine on day 1 followed by 400 mg daily and 1 g of chloroquine on day 1 followed by 500 mg daily, each for 4 to 7 days total depending on the clinical response. Other hydro xy chlor o-quine regimens include 400 mg twice daily on day 1, then 400 mg daily for 5 days; 400 mg twice daily on day 1, then 200 mg twice daily for 4 days; and 600 mg twice daily on day 1, then 400 mg daily for 4 days. Evidence Adding hydroxychloroquine to standard care improved fever, cough, and chest imaging findings in a trial of 61 patients with mild COVID-19 pneumonia and no hypoxia; however, the research has not been published in a peer-reviewed journal. In an open-label study of 36 patients with COVID-19, hydroxychloroquine (200 mg 3x/day for 10 days) was associated with a higher rate of undetectable SARS-CoV-2 RNA compared with no specific treatment (70% versus 12.5%). In this study, the use of azithromycin in combination with hydroxychloroquine was associated with a more rapid decline in viral RNA; however, the study has methodologic flaws and ill-defined end points.

Precautions Although the safety of hydroxycholoroquine has not been established in humans with COVID-19, phase III trials focused on the use of remdesivir for Ebola virus revealed serum creatinine and serum AST elevations. The medication was associated with hypotension and one cardiac arrest in a patient with Recent data suggests that combined treatment with hydroxycholoroquine and azithromycin is harmful and has no proven benefit.