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Too Long Didn’t Read (tl;dr)

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April 10, 2020

TL;DR Quick Reference

Pre-Hospital Civilian Guidance (not EMS)

  1. Social mitigation works.
    1. Physical distancing of 6 feet or 2 meters.
    2. Don’t share houses.
    3. Family units only.
  2. Wash your hands.
    1. Early.
    2. Often.
    3. Well.
  3. Don’t touch your face.
    1. Fingers to mouth and eyes
  4. Wear home made masks.
    1. train the hands.
    2. free up N95 for staff.
    3. keeps virus in carrier
  5. There is no prophylaxis.
  6. Exercise is okay.
    1. Walking 2m spacing.
    2. Jogging 5m spacing.
  7. Social Media
    1. Do not engage trolls and hoaxers.
    2. Watch Tik Tok
  8. High risk personnel should isolate from family
    1. If not possible review 1 to 4.
    2. Kids 0-14 years are at LOW risk.
    3. Elders are at HIGH risk.
    4. Immunocompromised are at risk.
  9. Use Tele-docs before ER.
  10. Go to hospital if short of breath.

In Hospital – Triage Guidance

  1. Triage rapidly to protect staff and patients.
  2. Clinical Covid is Covid. Full stop.
  3. Droplet PPE for all encounters.
  4. Ignore anti-PPE pencil pushers.

In Hospital – Treatment Guidance

  1. Protect Staff.
    1. Clinical Covid is Covid. Full stop.
    2. Ignore anti-PPE pencil pushers.
    3. PPE Spotters for don and doff.
  2. There are no cures.
  3. Treat early with Supportive care.
  4. Oxygen therapy.
    1. Safe HFNO2.
    2. ROX (SpO2/FiO2)/RR <3.85 Failure.
  5. Empiric Antibiotics.
  6. Restrict Fluids.
  7. Conscious patient self proning.
  8. Watch Closely.
    1. Pts deteriorate fast.
  9. Investigate Early
    1. CXR chest at least.
    2. CT chest even better.
    3. URT and LRT tests.
    4. Repeat URT and LRT tests.

In ICU – Treatment Guidance

  1. Protect Staff
    1. Learn Donning and Doffing.
    2. Always have a spotter.
    3. Protected Intubation is the rule.
    4. Clinical Covid is Covid. Full stop.
    5. Ignore anti-PPE pencil pushers.
  2. Usual Critical Care
  3. Restrict Fluids.
  4. Early vasopressors.
  5. Differentiate Type L from H
    1. Type L compliant, normal weight lung.
    2. Type H non-compliant, edematous heavy lung.
    3. CT scan
  6. HFNC Trial
    1. ROX INDEX (SpO2/FiO2)/RR <3.85 High risk
  7. Conscious patient self proning.
  8. Intubate early
    1. RSI and Indirect visualization
    2. Clamp Tube
    3. Low tidal volumes.
    4. High PEEP
  9. Consider prone ventilation.
  10. Consider ECMO.

Disposition – Decreasing level of care

  1. Standard critical care
    1. Extubate as per standard guidelines.
  2. Know clinical course.
    1. Day 0 = Symptom onset
    2. Day 3-5 Shortness of breath
    3. Day 10 Intubation
    4. Day 20 Death
  3. Consider Age.
  4. Consider co-morbidities.
  5. Consider home supports.

Unknowns

  1. Are pet’s vectors.
    1. Like tigers?
  2. Efficient way to sort types L from H.
  3. Waiting on hydroxy chloroquine evidence.
  4. Will there be enough ventilators?