Care for Critically Ill Patients With COVID-19

x-ray chest of first case of Corona virus pneumonia patient aged 61 years male who died during treatment in WUHAN city of China.

CXR is from a patient with Miliary Tuberculosis. How to proceed with the case?

COVID-19?? 68 year old male with no significant past medical history or surgical history. Presented with shortness of breath, and chest pain. In the emergency department, the patient has a saturation of 79% on room air and is in Moderat respiratory distress. It requires 10 L of nasal oxygen high flow to obtain 93% oxygen saturation. The patient is also febrile to 101°F. Social history: non-smoker, non-drinker. Surgical history: no surgical history. What do you say about the case?

THE COVID-19 SYMPTOMS WE DID NOT KNOW ABOUT As the pandemic spreads around the world, doctors are beginning to scope the coronavirus’s damage. Seen initially as a cause of viral pneumonia during the chaos of an explosion of cases in China, it’s now emerging as an enigmatic pathogen capable of harming the body in a myriad of unexpected, and sometimes lethal, ways. Clinical manifestations range from common cold-like symptoms and bronchitis to more severe disease such as pneumonia, severe acute respiratory distress syndrome, multi-organ failure and even death. The illness may occur as a direct result of viral infection, as well as the body’s response to it. Here’s a snapshot of some of the symptoms Covid-19 causes, including some you might not have heard about. Blood Fever and inflammation may disrupt blood vessels, rendering blood cells more prone to clumping while interfering with the body’s ability to dissolve clots. That may trigger a clotting cascade that can lead to blood-vessel blockages in tissues and organs throughout the body. Life-threatening clots in the arteries of the lung, known as pulmonary emboli, may occur even after symptoms of the infection have resolved. Damaged blood vessels may become leaky and prone to bleeding. In children, inflammation of veins and arteries triggered by excessive immune activation may cause an illness similar to Kawasaki disease, an inflammatory disorder. Brain Dysfunction in the lining of blood vessels and associated bleeding and clotting disorders may cause strokes and bleeding in the brain. Patients may also experience headache, dizziness, confusion, impaired consciousness, poor motor control, delirium and hallucinations. Eyes Red, puffy eyes, sometimes referred to as pink eye, may result from infection in the conjunctiva, the tissue that lines the inside of the eyelids and covers the white part of the eye. Gastrointestinal tract Infection of cells lining the digestive tract may cause diarrhea, nausea, vomiting and abdominal pain. Blood-vessel blockages caused by abnormal clotting have been found to damage the bowel, requiring emergency surgery and resection. Hands Prickling or burning sensation in the hands and limbs may indicate Guillain-Barré syndrome, a rare nervous-system disorder that may be triggered by aberrant immune responses to viral infection. Other symptoms of the syndrome include poor coordination, muscle weakness and temporary paralysis. Heart Cardiac injury, sometimes leading to irregular heartbeat, heart failure, and cardiac arrest, may occur as a result of excess strain, inflammation of the heart muscle and coronary artery, blood clots, and overwhelming multi-organ illness. Infection, fever, and inflammation in people with existing heart-vessel blockages may cause their fatty plaques to break off, blocking or stopping blood flow in organs and tissues. Limbs Obstructions in large blood vessels may cause insufficient flow, or acute ischemia, in the limbs. Severe vascular complications can be lethal. At least one reported cases resulted in lower limb amputation. Liver Liver dysfunction may occur as a direct result of the viral infection, or more likely because of immune-mediated, systemic inflammation and circulatory blockages cutting blood flow to the organ. Lungs The virus targets the epithelial cells that line and protect the respiratory tract as well as the walls of the tiny grape-like air sacs, or alveoli, through which gas exchange occurs to oxygenate the blood. Damage to alveoli and inflammation in the lungs can cause pneumonia, characterized by chest pain and shortness of breath. In severe cases, the lack of oxygen can trigger acute respiratory distress syndrome, leading to multi-organ-system failure. Kidneys Acute kidney injury may result from clots and impaired blood supply, or as a direct result of infection. Nose and tongue While the virus can cause the sneezing and runny nose typical of a common cold, it can also disrupt the olfactory system, causing an abrupt full or partial loss of the sense of smell known as anosmia. Taste may also become distorted in a condition known as dyguesia. Skin Hive-like rashes, small red dots and purplish discolorations on the legs and abdomen are part of a complex category of so-called paraviral dermatoses that may result from the body’s immune response to the virus or from benign, superficial blood-vessel damage beneath the skin. Toes Purple rashes that resemble chickenpox, measles or chilblains may appear on the feet, especially of children and younger adults.

Treatment for severe acute respiratory distress syndrome from COVID-19 In The Lancet Respiratory Medicine, Kollengode Ramanathan and colleagues provide excellent recommendations for the use of extracorporeal membrane oxygenation (ECMO) for patients with respiratory failure from acute respiratory distress syndrome (ARDS) secondary to coronavirus disease 2019 (COVID-19). The authors describe pragmatic approaches to the challenges of delivering ECMO to patients with COVID-19, including training health-care personnel, resolving equipment and facilities issues, implementing systems for infection control and personal protection, providing overall support for health-care staff, and mitigating ethical issues. For patients with COVID-19 who require endotracheal intubation, use of low tidal volume (6 mL/kg per predicted bodyweight) with a plateau airway pressure of less than 30 cm H2O, and increasing the respiratory rate to 35 breaths per min as needed, is the mainstay of lung-protective ventilation. If the hypoxaemia progresses to a PaO2:FiO2 ratio of less than 100–150 mm Hg, there are several therapeutic options. The level of positive end-expiratory pressure can be increased by 2–3 cm H2O every 15–30 min to improve oxygen saturation to 88–90%, with the goal of maintaining a plateau airway pressure of less than 30 cm H2O. Lower driving pressures (plateau airway pressure minus positive end-expiratory pressure) with a target of 13–15 cm H2O can also be used. To read more- https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30127-2/fulltext Source- The Lancet Authors- Michael A Matthay, J Matthew Aldrich, Jeffrey E Gotts