COVID-19 Basic training for doctors Thank YOU for your dedication - - PowerPoint PPT Presentation

WHEN THE SUN RISES

WE WORK HARD TO DELIVER

COVID-19

Basic training for doctors

2

Thank YOU for your dedication to our people

3

Novel Coronavirus

4

SARS

2002

MERS

2012

COVID-19

CIVET CAMEL Potentially PANGOLIN mutates mutates mutates mutates mutates mutates CASE FATALITY RATE 800 8 000 X 100 = 10% 850 2 500 X 100 = 39% 132 922 2 052 508 X 100 = 6.48%

R0 - Reproductive Ratio

Degree of ‘spreadability’ How many people can one person infect

5

1 3 9 27

R0 = 2-3

1

R0

R0 of Influenza

6

1 1 1 1

R0 = 1.3

1

R0

7

1

R0

COVID-19 R0 >1 Influenza R0 = 1 Target: R0 <1

How do we make the R0 drop?

• Quarantining
• Physical distancing
• PREVENTING SPREAD

8

How does COVID-19 spread?

9

Respiratory droplets Fecal-oral Airborne ± 3 hours Mother-to- child

10

Pathophysiology of SARS-CoV-2

11

12

13

14

S-spike protein ACE-2

receptor

+ ss-RNA Ribosome mRNA RNA-dependant RNA polymerase Protease ACE-2

receptor

Translation Type 2 pneumocyte

15

IL-1 IL-6 TNF-α Macrophages

16

IL-1 IL-6 TNF-α

17

Macrophage IL-1 IL-6 TNF-α

18

Neutrophil

Reactive oxygen species Proteases

19

20

Complications of COVID-19

21

ARDS

• Inflammatory response spills
• ver into bloodstream

Systemic inflammatory response

• ↓ blood volume
• ↓ peripheral resistance

Hypotension

• Decreased perfusion of

patients organs

Multi-organ failure

Incubation period

22

2 days

5 days

14 days 27 days

Self-quarantine for 14 days

Signs and Symptoms

23

Some patients can be asymptomatic

24

Person Under Investigation:

• Apply the latest case definition from the NICD : http://www.nicd.ac.za/diseases-a-z-index/covid-19/

25

38˚C

Persons with acute respiratory illness with sudden onset of at least one of the following:

• Cough
• Sore throat
• Shortness of breath,
• Fever [≥ 38°C or subjective history of fever]

HIGH RISK persons:

Patients with any one of the previous symptoms WITH the following are then considered to be HIGH RISK:

26

Worked in, or attended a health care facility where patients

with COVID-19 were being treated without PPE

In the last 14 days:

Close contact with a confirmed or probable case of COVID-19 Live in or travel to areas with local transmission of Coronavirus

(the list of these countries/provinces will change with time – consult the NICD website)

OR OR

Example of a screening tool:

27

Who needs to be tested?

28

Prioritise HIGH RISK All Persons Under Investigations

Differential Diagnoses

29

CAP e.g. coamoxyclav Atypical pneumonia e.g. azithromycin Severe Influenza or with risk factors: oseltamivir TB: RHZE PJP e.g. cotrimoxazole

Rx

Sputum MCS +/- MTB GXP Urine LAM FBC and diff Blood cultures NP or OP swabs for viral /atypical pathogens CXR Urine Legionella Ag

Ix

• Flu

TB Bacterial pneumonia If low immunity: PJP

Diff Dx

LOOK OUT FOR TB

Remember, COVID-19 may have a similar presentation to TB. We must not forget to screen AND test for TB.

30

Choosing the correct PPE:

If you are EDUCATING and SCREENING patients, you only need to wear a medical/surgical mask. You should also try to keep 1-2 metres between you and the patient at all times

31

2 metres

How do I know what PPE to wear?

If you are ASSESSING patients, you need to wear:

32

• Goggles or face shield
• Medical/surgical facemask
• Gown or plastic apron
• Non-sterile gloves

How do I know what PPE to wear?

If you are TESTING patients, you need to wear:

• Goggles or face shield
• N95 respirator
• Gown or plastic apron
• Non-sterile gloves

33

How do I know what PPE to wear?

34

If you are conducting an AUTOPSY, you need to wear:

• Scrub suit
• Long-sleeved, fluid

resistant gown

• Gloves
• Goggles or face shield
• N95 respirator

Conducting an autopsy with aerosol-generating procedures

(long sleeved, fluid resistant)

scrub suit

N95 respirator

35

Write your name on it Reusable for 1 week Hang up after each use

36

N95 respirator

Re-usable for up to 1 week

• UNLESS IT GETS:
• Wet
• Soiled
• Damaged
• Elastics become

loose

How to keep it between use

• Hang it up on a

hook

• OR
• Keep in a brown

bag

• Use gloves to

insert and remove

Putting on and taking off mask

• Never touch the

front of the mask

• Use the elastics

to put on and take off

N95 respirator

37

How to test COVID-19 suspects

38

Don PPE Assess patient Clinically triage Conduct testing

PPE: patient assessment

39

Patient assessment:

40

Assess the patient: Symptoms Ability to self-quarantine Risk of deterioration

Triage patient:

41

Triage the patient according to assessment:

Mild disease Severe disease

Mild disease

• SpO2 ≥95%
• Respiratory rate <25
• Heart rate <120
• Temperature 36 – 39˚C
• Normal mental status

Mild disease

• Separate bedroom available for patient to home-quarantine in
• Patient able to contact, and return to, healthcare facility in case of deterioration

Able to safely self-quarantine

• Age <65 years
• No cardiac or pulmonary comorbidities
• No other debilitating comorbidities (e.g. cancer)

Not at high risk of deterioration

Underlying comorbidities:

43

UNDE

NDERL RLYING YING MEDIC DICAL AL CON ONDIT DITION IONS OF OF COVID-19

19 IN

IN CHIN HINA

20 40 60

Hypertension Other Diabetes Cardiovascular disease Lung disease Chronic liver disease Chronic kidney disease Immunodeficiency diseases

Proportion of cases (%) Mild Severe Critical

19230 Confirmed cases with detailed epidemiological investigation information

China CDC/NHC 2020

Immuno- deficiency disease Hypertension Diabetes Heart disease Lung disease Liver disease Kidney disease

HIV TB malnutrition

44

• SpO2 ≥95%
• Respiratory rate <25
• Heart rate <120
• Temperature 36 – 39˚C
• Normal mental status

Mild disease

• Separate bedroom available for patient to home-quarantine in
• Patient able to contact, and return to, healthcare facility in case of deterioration

Able to safely self-quarantine

• Age <65 years
• No cardiac or pulmonary comorbidities
• No other debilitating comorbidities (e.g. cancer)

Not at high risk of deterioration

Mild disease AND Able to self-quarantine AND Low risk

Home-quarantine

Mild disease AND Low risk BUT Unable to self-quarantine

Refer to quarantine site

Severe disease OR High risk

Require hospitalisation

Testing:

45

Specimen forms Documentation completion Patient Notification Register

Nasopharyngeal swab Oropharyngeal swab Sputum

Don PPE:

46

2 types of swabs can be used:

Swab with Universal Transport Medium

47

3 types of swabs can be used:

Dry swab

48

Anatomy of the naso- and oropharynx

49

Anatomy of the oropharynx and tonsils

50

Oropharynx

How to take a nasopharyngeal swab:

51

1.

• Measure the distance from the nose to the ear
• This is how far you need to insert the swab into the nose

2.

• Gently insert swab into one nostril, aiming backwards, along the floor of the nasal cavity, until the

nasopharynx is reached

3.

• If resistance is encountered during insertion of the swab, remove it and try the other nostril

฀Gently rotate the swab and hold in place for a few seconds, then slowly withdraw the swab

4.

฀If you have the universal transport medium, unscrew the cap and insert the swab directly into the vial ฀Break plastic shaft at the break point so that it can fit in the tube

5.

฀If you are using a dry swab, insert the swab into the plastic swab container

52

Nasopharynx

How to take a oropharyngeal swab:

53

1.

• Ask the patient to tilt their head back and open mouth wide
• Hold the tongue down with a tongue depressor, and ask the patient to say “AHHHH”

2.

• Using a new swab (separate to the nasopharyngeal swab), swab each tonsil first, then the

posterior pharynx in a “figure 8” movement

3.

฀ Avoid swabbing the soft palate ฀ Do not touch the tongue with the swab tip as this procedure can induce the gag reflex

4.

฀ If you have the universal transport medium, insert the swab directly into the same vial containing the nasopharyngeal swab

5.

฀ If you are using a dry swab, insert the swab into its own plastic swab container

54

Posterior pharynx

Sputum

• If the patient has a productive cough, it is useful to also collect a

sputum sample for COVID-19 testing

• DO NOT induce sputum

55

Storage and Transport

56

1.

• Close the lid of the tube or plastic container

2.

• Label the tube/plastic container with patient’s details

3.

• Place an NHLS barcode sticker on the specimen

4.

฀Place the specimen into the plastic bag and seal it

Other testing modalities:

• Broncho-alveolar lavage
• Fibro-bronchoscope brush biopsy
• Blood
• Coming soon: RAPID TESTS

57

Review of testing modalities:

58

Complete forms

You need to complete the following forms to send with the specimen to NHLS:

59

1. 2.

• NHLS requisition form
• Specimen submission

form

NHLS Requisition form

60

COVID-19

Fill in ALL of the patients details, including address, ID number, etc. Where the form says ‘Other tests’ write:

COVID-19

Place a sticker on:

• Specimen
• Specimen Submission Form
• Testing Register

Specimen key: indicate that you have taken 2 swabs You can also indicate sputum if you took a sample.

Specimen Submission form

61

Patients details YOUR

• wn

details Specimen details

Complete forms:

You need to complete the following forms and send electronically to NICD via email (ncov@nicd.ac.za), online (https://cci.nicd.ac.za/) or on the NICD app:

62

1. 2.

• PUI form
• Contact Line List

These are now combined into 1 form

Submit forms online:

63

Submit forms online:

64

Person Under Investigation (PUI) form:

65

66

67

68

But who is a contact?

69

Today: Testing day Close Contacts

Day symptoms started 14 days before

Who is a close contact?

A person having had face-to-face contact (≤1 metres) or was in a closed environment for more than 15minutes with a COVID-19 case. This includes, amongst others:

All persons living in the same household as a COVID-19 case People working closely in the same environment as a case Sat in the same classroom or attended the same gathering as a case A healthcare worker or other person providing direct care for a COVID-19 case, while not wearing recommended PPE A contact in an aircraft, taxi, or bus sitting within 1 metre of a COVID-19 case

How to transport the specimen:

71

The specimen needs to be taken to the nearest NHLS laboratory Place the specimen, with the 2 forms into the plastic specimen sleeve Take the specimen directly to the lab immediately, otherwise place into a cooler box with one block of ice, and seal the cooler box Write “COVID-19” and the hospital laboratory address on the top of the box, if you do not have an onsite lab and need to courier the specimen

NHLS Requisition form Specimen Submission form

Patient Notification Register

72

Every facility should have a COVID-19 Patient Notification Register, where every COVID-19 test conducted is recorded:

Additional work-up for COVID-19:

73

BLOODWORK RADIOLOGY

Bloodwork:

74

FBC

• Lymphopenia

General markers of infection

• CRP
• ESR
• IL-6
• LDH
• D-Dimer
• Ferritin
• (raised infective

markers may indicate a worse prognosis)

PCT

• Should be

NORMAL unless patient has a superimposed bacterial infection

Signs of multi-organ failure

• ALT/AST/Bili

(liver failure)

• Creatinine (renal

failure)

• Troponins and

CK-MB (heart failure)

• (higher mortality

rate in people presenting with multi-organ failure)

Radiology:

75

Chest x-ray

• Bilateral areas
• f ground-

glass opacities

• Pleural

effusions

• Consolidations

CT scan

• Ground glass
• pacities

peripherally

• Consolidations
• “Crazy paving

pattern”

Point of care ultrasound

• Pleural line

thickening

• Increasing B-

lines within specific zones

• Consolidations

with air bronchograms

If a patient does not need admission:

76

If the patient cannot do Home-Quarantine, refer them to a Quarantine Site Fill in any gaps in their knowledge Ensure the patient understands Home-Quarantine Counsel patients on Home-Quarantine and provide the patient, and their family, with an information pamphlet

• n how to do so

If they don’t have their own bedroom or cannot call or get to a clinic if needed

77

78

Medical Management:

Currently, SUPPORTIVE MANAGEMENT

79

Conservative fluid administration

• Fever →

dehydration

• BUT ARDS leads to

fluid overloading of lung tissue

• Thus, SPARING

fluid administration with RL or 0.9% NS Management of fever

• Use of antipyretics
• ie. Paracetamol

Management of hypoxemia

• Supplemental
• xygen
• Should be

administered early via appropriate device

Supplemental oxygen management:

80 80

• SpO2 ≥ 90%

Adults and children

EXCEPT

• SpO2 ≥ 92-95%

Pregnant ladies

• SpO2 ≥ 94%

Children with emergency signs

SOLIDARITY clinical trial for COVID-19 treatments

81

Remdesivir

• Previously tested as

an Ebola treatment. It has generated promising results in animal studies for MERS-CoV and SARS, which are also caused by coronaviruses, suggesting it may have some effect in patients with COVID- 19.

Lopinavir/Ritonavir

• Licensed treatment

for HIV. Evidence for COVID-19, MERS and SARS is yet to show it can improve clinical

• utcomes or prevent
• infection. This trial

aims to identify and confirm any benefit for COVID-19

• patients. While there

are indications from laboratory experiments that this combination may be effective against COVID-19, studies done so far in COVID-19 patients have been inconclusive.

Chloroquine and hydroxychloroquine

• Closely related and

used to treat malaria and rheumatology conditions

• respectively. In China

and France, small studies provided some indications of possible benefit of chloroquine against pneumonia caused by COVID-19 but need confirmation through randomized trials

Interferon beta-1

• Immunomodulator

used to treat multiple sclerosis.

82

S-spike protein ACE-2

receptor

+ ss-RNA Ribosome mRNA RNA-dependant RNA polymerase Protease ACE-2

receptor

Translation Type 2 pneumocyte

COVID-19 and NSAID use:

• Some clinicians have suggested the use of NSAIDs early in the

course of disease may have a negative impact on disease

• utcome
• The European Medicines Agency (EMA) and the WHO do not

recommend that NSAIDs be avoided when clinically indicated

83

COVID-19 and Glucocorticosteroid use:

• Associated with an increased risk for mortality in patients with

influenza and delayed viral clearance in patients with MERS-CoV infection

• The WHO and CDC recommend glucocorticoids not be used in

patients with COVID-19 pneumonia unless there are other indications(ie. Acute exacerbation of COPD)

84

COVID-19 and ACE inhibitors:

• Patients on ACE-I or ARBs upregulate ACE-2 receptors, the binding

site for SARS-CoV-2, within tissues including the lung and heart, prompting concern that this might place patients at risk of worse

• utcomes with COVID-19
• Currently no evidence of a linkage to poor clinical outcomes
• Switching patients off ACE-I or ARBs is not recommended

currently unless there are other medical reasons to do so

85

Refractory hypoxaemia

Management: MECHANICAL VENITLATION To note:

• Preferable avoid high flow nasal

cannula and NIPPV as these aerosolise the virus

86

Mechanical ventilation:

87

AC Volume control

• Low tidal volume (4-

6mL/kg)

• Increase respiratory

rate (±20bpm)

• High PEEP (>5cmH2O)

Pressure control

• More commonly

utilised in ICU setting

Take home points:

• Always don the appropriate PPE prior to seeing or managing patients
• Min required lab specimens: NP and OP swabs
• Ensure all forms are completed accurately, in full
• Provide EARLY oxygen therapy as required

88

WHEN THE SUN RISES

WE WORK HARD TO DELIVER

Thank you