Objectives
To guide the management of adults presenting to medical facilities with suspected COVID-19 infection.
Scope
This guideline describes the assessment and management of patients presenting with suspected or confirmed COVID-19 infection. Treating clinicians should consider the reporting and isolation requirements that are out with the scope of this guideline.
Audience
This guideline is intended for the use of registered healthcare professionals fulfilling a general role in a forward medical location or in an Emergency Department on deployed operations.
Initial Assessment & Management
Assessment
COVID-19 is clinically indistinguishable from many common upper respiratory viral syndromes. For the purposes of this guideline, diagnosis is reliant upon laboratory PCR testing.
In the context of an outbreak, deployed public health authorities may recommend a clinical case definition that includes the use of point of care (POC) tests.
The performance and interpretation of POC tests in COVID-19 is complex and influenced by a range of factors outside the scope of this CGO. POC tests should not be employed without prior guidance from the relevant deployed public health authorities.
COVID-19 infection can cause a spectrum of illness including asymptomatic infection, mild upper respiratory tract infection (URTI), severe pneumonia and other complications. Suspect a diagnosis of COVID-19 if a person presents with:
- Fever
- New continuous cough
- Loss or change to sense of smell or taste
- Shortness of breath
- Malaise
- Myalgia
- Headache
- Sore throat
- Coryza
- Loss of appetite
- Diarrhoea
- Nausea and/or vomiting
In most cases COVID-19 remains a mild and self-limiting disease. Use the following signs and symptoms to help identify people with COVID‑19 with the most severe illness:
- Severe shortness of breath at rest
- Oxygen saturation levels <94%
- Cyanosis
- Haemoptysis
- Feeling cold and clammy with pale or mottled skin
- Syncope
- New confusion
- Drowsiness
- Reduced urine output
Treatment
Most cases improve with supportive care alone.
Encourage self-care with antipyretics and oral fluids.
Breathlessness symptoms may benefit from patient positioning, a cool environment and reassurance.
If saturations <94% on room air, oxygen therapy should be initiated (target saturations 92-96%). Patients requiring oxygen therapy at Role 1 to maintain saturations >94% require immediate evacuation to Role 2.
Patients who require >40% FiO2 to maintain oxygen saturations >94% are high risk for escalation to invasive respiratory support.
Give corticosteroids to all patients with COVID‑19 who require supplemental oxygen:
First line: Dexamethasone [LT1] - 6mg PO OD for 10 days or
Prednisolone (40mg PO OD for 10 days) or Hydrocortisone (50mg IV 8 hourly for 10 days)
Do not use antibiotics for preventing or treating COVID-19 unless there is clinical suspicion of bacterial co-infection.
Advanced Assessment & Management
InvestigationThis section focuses on COVID-19 findings and tests that may indicate disease severity or complications, but is not intended to provide a comprehensive list of investigations for suspected or confirmed COVID-19.
SARS-CoV-2 RNA RT-PCR – Gold standard test for diagnosis of COVID-19
Chest X-ray (CXR) – typical appearance is bilateral patchy infiltrates; lower zone predominant. This may progress to diffuse bilateral airspace consolidation.
In early disease (0-4 days) CXR may appear normal despite clinical evidence of significant disease.
Computerised Tomogram (CT) chest – Do not routinely use CT to diagnose COVID-19. CT may be of use if there is diagnostic uncertainty.
Arrange CT (with contrast angiography) in patients with clinical suspicion for pulmonary embolism including those with sudden deterioration or hypoxia that appears disproportionate to radiographic changes.
Consider CT in patients with severe disease and concerns for progression to ARDS.
Common or useful laboratory findings
Full blood count (FBC) - Low lymphocyte count (<1.1 x 10⁹/L) is a non-specific but early prognostic marker that correlates with moderate to severe disease.
Procalcitonin (PCT) – if significantly elevated may indicate bacterial co-infection.
Creatinine Kinase (CK) – commonly elevated, and usually of skeletal muscle origin, but may indicate myositis/myocardial involvement.
Troponin (TnT) - elevation may indicate myocardial injury (interpret with caution when renal function abnormal).
Elevated serum levels of the following markers are associated with increased risk of severe disease and mortality in COVID-19:
-
-
- D-dimer
- Ferritin
- C-Reactive Protein (CRP)
- PCT
- Troponin/Brain Natriuretic Peptide (BNP)
Respiratory support
Conscious proning should be considered for patients with FiO2 ≥ 28% or requiring basic respiratory support to achieve SaO2 92 – 96%. This strategy may reduce overall FiO2 requirements and may reduce likelihood of mechanical ventilation.
Consider continuous positive airway pressure (CPAP) for people with COVID-19 and hypoxaemia that is not responding to supplemental oxygen at an FiO2 0.4 (40%) or more and for whom escalation to invasive mechanical ventilation is not immediately needed.
High-flow nasal oxygen (HFNO) may be available in the deployed environment but should only be used as the main form of respiratory support for people with COVID-19 and respiratory failure if maximal conventional oxygen is not maintaining target oxygen saturations and neither invasive mechanical ventilation nor CPAP are suitable.
If escalating to invasive mechanical ventilation, standard protective lung ventilation guidelines used for ARDS should be deployed. Aim for tidal volumes of 6 mL/kg and driving pressures <15cm H2O.
Therapeutics
Corticosteroids have the strongest evidence base for mortality reduction in severely unwell patients with COVID-19 (see initial management section for dosing guidance).
NICE also recommend selected use of anti-viral agents (prevention of severe illness in vulnerable patients) and Tocilizumab (IL-6 receptor blockers), however it is unlikely that these therapeutic agents will be available in the deployed environment. See accordion content for further detail.
Acute complications
Acute Kidney injury (AKI) is associated with increased mortality. AKI may be due to hypovolaemia, haemodynamic changes, direct viral renal tubular injury, thrombotic vascular processes, glomerular pathology or rhabdomyolysis. Maintain optimal fluid status, taking account of insensible losses and consider the relative risk of AKI when selecting therapeutic agents.
Acute myocardial injury may occur due to cardiac inflammatory response may occur in COVID-19 infections. This may be clinically challenging to distinguish from acute coronary syndrome. In patients with symptoms of myocardial injury consider serial ECGs monitoring for dynamic changes, serial high sensitivity troponin I measurement and continuous monitoring (due to the risk of rapid cardio-respiratory deterioration).
Venothromboembolism (VTE) - A prothrombotic phenotype (high fibrinogen and D-dimer) is common with COVID-19. Use a combination of mechanical and pharmacological measures to reduce the risk of VTE.
At least 30% of ICU patients with COVID-19 develop a thromboembolic event.
Offer standard prophylactic dose of low molecular weight heparin (LMWH) to all patients that require oxygen therapy (provided they do not have significant bleeding risk). Continue prophylaxis for a minimum of 7 days.
Seek expert advice in severe disease as it may be appropriate to escalate to prophylactic LMWH to doses normally used for treatment.
Prolonged Casualty Care
No specific considerations.
Paediatric Considerations
No specific paediatric considerations.
