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COVID-19: Emergency Medicine Perspectives
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Introduction
The challenges posed by the COVID-19 pandemic have affected all of humanity, as well as the full range of medical specialties, yet one of the single most affected specialties has been emergency medicine. Emergency medicine specialists have been at the forefront for decades confronting all human crises related to physical and mental health and are trained in a variety of life-, limb- and vision-saving interventions. However, the COVID-19 pandemic added additional burden to already strained emergency medicine departments. The pandemic adversely affected the care of non–COVID-19 patients, just as it affected the patients seeking service from other fields of medical specialties, including definitive and often elective treatments and procedures in oncology, cardiology, and orthopedics, to name a few.
COVID-19 can affect multiple organ systems and often manifests with confusing clinical scenarios and diverse ramifications.
The following sections of this chapter attempt to capture the various manifestations of COVID-19 infection as emergency situations for the patients; the challenges in arriving at a proper diagnosis; appropriate workup, including laboratory and imaging studies; and the rather uncharted territory of interventions and management protocols, including supportive care, medications, and invasive procedures. As more experience is gained in dealing with this pandemic, many aspects of clinical management will evolve and change, for the better, just as in the past 2 years.
Clinical Manifestations
The clinical manifestation of COVID-19 is highly variable and includes a wide range of reported symptoms, making early clinical differentiation of this disease process challenging within the emergency department (ED). In one review that included over 40,000 patients, at least 26 different clinical manifestations were reported. Symptomatic manifestations can also range in severity from mild to critical. Additionally, time to recovery is also highly variable, with some individuals experiencing only a few days of symptoms and others having persistent symptoms and long-term sequalae. Of those individuals who develop symptoms, approximately 97.6% will do so within 11.5 days of the infection.
The most common symptom of all patients diagnosed with COVID-19 is fever. After fever, in the general population, the following symptoms were most common: cough, dyspnea, fatigue, malaise, myalgias, nausea and/or vomiting or diarrhea, headache, and anosmia or ageusia. Less frequent symptoms reported include sore throat, chest pain, and abdominal pain. ,
History
Patient-provided history is a crucial piece for any potential or confirmed COVID-19 patient. Initial history questions regarding travel, sick contacts, or known COVID-19–positive exposure can be collected during the triage process and can help guide appropriate clinical care, diagnostics, and subsequent isolation needs. Next, signs and symptoms provided by the patient, such as fevers, cough, shortness of breath, body aches, nausea and/or vomiting, and loss of taste or smell, will help further guide diagnostic workup and testing. A detailed investigation into immunocompromised status and additional comorbidities is also needed to help stratify risk as well as guide potential treatment modalities. Finally, general demographics questions such as occupation, age, race, surrounding population statistics, travel history, and socioeconomic status can all be helpful at this stage in an ED evaluation. In the advent of widespread vaccine availability, ascertaining a patient’s previous positive or negative testing status along with their current vaccine status can additionally provide key details for the clinician.
Physical Examination
Physical examination findings are very diverse and can be nonspecific, and similar to those of other viral illnesses and common infections such as influenza, pneumonia, bronchitis, or gastroenteritis. Special attention to vital signs is an important first step of any ED evaluation as abnormalities in any of the vital signs can be seen with COVID-19. The most common, however, is fever (>38°C).
Pulmonary
COVID-19 predominately affects the respiratory system, making dyspnea (53%–80%) and cough (60%–86%) the most common symptoms and contributors to clinical presentation. , Special consideration to respiratory rate and pulse oximetry is critical in the ED because these play a critical role in disposition and potential inpatient and outpatient treatment strategies. Despite predominately affecting the respiratory system, auscultatory findings can be either normal or abnormal. Coarse breath sounds are the most common finding identified during auscultation. Fine and coarse crackles were the next most common. Hypoxia with or without associated symptoms was frequently reported. When hypoxia was observed without additional clinical manifestations, it was often referred to as “silent hypoxemia,” which came to be an initial hallmark of SARS-CoV-2–infected individuals.
Ear, Nose, and Throat
Ear, nose, and throat (ENT) symptoms and clinical findings are less common. A unique and distinctive feature of COVID-19 was sensory alterations to smell and/or taste. Although a loss of taste and smell has a wide variation in prevalence, ranging from 4.23% to 98.33%, it is a clear pointer to COVID-19 when elicited during a history or examination. Other ENT symptoms that have been documented are more nonspecific, making them less useful in isolation. These include sneezing, rhinitis, sore throat, rhinorrhea, and nasal congestion. Objective ENT physical examination findings are more uncommon with tonsillar swelling, throat congestion, and lymphadenopathy seen in less than 2% of patients.
Neurological
Several neurological manifestations have been associated with COVID-19 infection. Reported symptoms include myalgias, headaches, and dizziness. Encephalopathy also can occur and is more frequent in the elderly. Cerebrovascular occlusions have been documented and attributed as a complication to COVID-19 manifesting with associated neurological deficits. , ,
Gastrointestinal
The most common gastrointestinal (GI) symptoms include anorexia, diarrhea, and nausea and/or vomiting. Abdominal pain and vomiting are recorded in approximately 5% of patients. In one study, patients with GI symptoms had a longer time from onset to admission, which was thought to be related to delayed diagnosis given nonspecific symptoms. These nonspecific symptoms made diagnosis more challenging because 7% of the COVID-19 patients with GI symptoms had no other respiratory or ENT complaints. ,
Diagnostic Workup and Investigation
The diagnostic evaluation of suspected patients with COVID-19 in the ED is discussed in the following section. These diagnostic tools serve as adjuncts to the clinical evaluation and treatment of life-threatening situations by the ED provider. A sample diagnostic and treatment pathway is shown in Fig. 15.1 .
Laboratory Evaluation
COVID-19 Testing
COVID-19 testing should be performed in the emergency department (ED) to assist in the diagnosis of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). While Although testing continues to evolve, there are two basic types of testing: viral testing (nucleic acid amplification tests ([NAATs)] and antigen tests) and antibody tests (serological tests). Antibody testing is mostly limited to identifying past infections and is less beneficial for ED testing of suspected patients; current literature suggests that they should not be used as a definitive test in a point-of-care hospital setting. Included in NAATs is the reverse transcriptase polymerase chain reaction (RT-PCR) test. RT-PCR and other NAATs are generally considered the preferred testing method for the ED as long as the hospital’s laboratory has the appropriate equipment; laboratory-based NAATs are generally considered the most sensitive form of testing. Sensitivity and specificity are affected by several factors that include the analytical testing instrument used and the quality of acquisition of the sample. Nasopharyngeal samples are considered superior to throat samples. , Turnaround times (TATs) affect the utility of the test for the ED provider as because they can range from minutes to days. Ideally, an ED must perform rapid NAAT testing to confirm a diagnosis of COVID-19. Depending on capacity, an ED may choose to prioritize cohorts of patients into more rapid testing depending on disposition, severity, or other factors.
Supplemental Testing
A complete blood count is a commonly ordered study on many patients. A study with both outpatient- and inpatient-confirmed COVID-19 cases found a median white blood cell (WBC) count of 4700 mm 3 , and another retrospective study of hospitalized patients found the median to be 7000 mm 3 . A lymphopenia has been seen associated with COVID-19 in up to 83% of cases. The basic metabolic panel, another commonly ordered test, does not seem to show any pathognomonic findings. Other laboratory tests that are often ordered, some to determine severity of disease, include d -dimer, C-reactive protein (CRP), lactate dehydrogenase (LDH), and procalcitonin. d -Dimer has been found to be elevated (≥0.5 mg/L) in 46.4% of all patients and 59.6% of those with severe disease. CRP of 10 mg/L or greater has been seen in 60.7% of patients, with a higher percentage of those with elevation with severe disease to 81.5%. LDH is found to be elevated in 41% of patients with a threshold of 250 U/L. Procalcitonin is often not found to be elevated; only 5.5% of all patients and 13.7% with severe disease had procalcitonin levels 0.5 ng/mL or greater. Testing for other respiratory infections, such as influenza, also may be performed concurrently based on prevalence of other infections at the time.
Imaging
Chest x-ray is a common test ordered on patients with respiratory complaints and abnormalities, which are commonly noted in patients with COVID-19. A majority (59.1%) of patients who had a chest x-ray examination demonstrated an abnormality; among patients with increased disease severity, a higher proportion (76.7%) showed evidence of radiographical abnormalities. The most frequently found abnormalities in descending order of prevalence are bilateral patchy shadowing, local patchy shadowing, ground-glass opacity, and interstitial abnormalities. As expected, these findings increase with disease severity. Chest computed tomography (CT) is another imaging modality used to better evaluate lung pathological conditions in COVID-19 patients. Given the increased sensitivity of this imaging modality, a higher percentage of patients (86.2%) had a noted abnormality. In severely ill patients, this increased to almost 95%. Similar abnormalities to the chest radiographs were noted on chest CT. It should be noted, however, that one study found that 56% of patients who presented within 2 days of diagnosis had normal a CT image. Pulmonary embolus is a known sequela of COVID-19 infection, and CT pulmonary angiograms should be considered in patients for whom there is a high clinical suspicion or who have not shown improvement along the expected recovery pattern.
Consultation
Consultation practices should follow the locally determined pathways for engagement with critical care services, infectious disease, and other specialists. Extracorporeal membrane oxygenation (ECMO) may be considered in the severely ill patient, and the appropriate teams should be considered based on the specific hospital’s guidelines. Telemedicine consultation with specialists or other providers may be used in the appropriate circumstances to limit in-person contact and provide additional recommendations.
Management
Treatment of SARS-CoV-2 (COVID-19) in the ED ranges from symptomatic and supportive care to identifying and treating associated end-organ dysfunction and invasive life-sustaining care for severe and critically ill patients. A sample diagnostic and treatment algorithm is shown in Fig. 15.1 . Several medications are currently under investigation and may be appropriate for select patients (see medications section). The National Institutes of Health (NIH) has published information on caring for patients with COVID-19, and detailed information can be found at online at the NIH Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. ,
Symptomatic Support
Patients meeting criteria for mild to moderate disease without oxygen requirement or progressive dyspnea can be managed at home. Treatment consists of supportive care, education on preventing the spread of COVID-19 to others, and guidance on when to seek input from a health care provider or in-person evaluation. Patients with dyspnea may find prone positioning helpful while sleeping or resting. Supportive care includes antipyretics, analgesics, antitussives, and antiemetics. Rest and hydration should be emphasized, as well as signs and symptoms of dehydration that would prompt a need for return visit to the ED. Regarding antipyretics, there is current controversy over the use of nonsteroidal antiinflammatory drugs (NSAIDs), including ibuprofen; therefore it is reasonable to suggest acetaminophen as first-line therapy and using NSAIDs sparingly or for breakthrough fever and pain. Patients who are currently taking NSAIDs for comorbid conditions may continue using as directed. Opioids for pain are usually not indicated and may cause respiratory depression.
Home Oxygen
Depending on hospital capacity and the availability of alternative care facilities, some patients with mild to moderate dyspnea and limited supplemental oxygen requirement may be discharged from the ED with supplemental oxygen with planned virtual reassessment within 24 to 48 hours.
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