Chapter 2: History and Assessment: Confronted by COVID
Scroll to the bottom of the blog for a link to the previous chapters
You are starting an evening shift in A and E and pick up the next patient who is a 57-year-old brought in by ambulance and according to the triage card - shock horror - is presenting with shortness of breath...
I know you have played over this scenario time after time in the simulation centre and in OSCEs, and I’m not going to reinvent the wheel by going through an ABC approach to a breathless patient. But this is the real thing - and COVID-19 has brought some unique issues which we are all trying to frantically learn and adapt our practice for, so here are some of the points I think might be useful to you if you find yourself in this situation.
Don’t forget Danger:
Cast your mind back to Basic Life Support teaching - DRSABC. Before anything else, you were searching for live electricity wires, knife-wielding assailants or venomous snakes. Now that danger is much more real and comes in the form of droplets full of SARS-CoV-2.
So before seeing this patient, you need to make sure that you have access to and know how to put on the appropriate Personal Protective Equipment (PPE). These vary from trust to trust but as a bare minimum should include:
There are situations where it is mandatory to be wearing higher levels of PPE due to increased risk of exposure, including being involved in an aerosol generation procedure, where you shouldn’t really be, to be honest (but just in case, a list of these are shown below). A more likely situation, if you have had training, will be taking nasal and throat swabs for COVID.
In either of these situations make sure you are wearing:
In the History:
It is rather surreal how predictable the clinical course of COVID can be. I am almost finding myself copying and pasting histories from patient to patient - they are that similar! The most commonly reported symptoms are, as you would expect from a viral respiratory pathogen:
● Fever (88%)
● Dry cough (68%)
● Fatigue (38%)
● Sputum production (33%
● Dyspnoea (19%)
● Sore throat (14%), headache (14%), arthralgia (15%)
Slightly stranger symptoms to not forget are:
● GI symptoms: A significant number of patients also present with GI symptoms - diarrhoea (29.3%), vomiting (8.1%) and abdominal pain (4%). More worryingly, a small percentage (3%) present only with GI symptoms and studies have shown delays in presentation for these patients. Reference here.
● Anosmia and loss of taste (which i’ve just found is called dysgeusia): In Germany it is reported that more than 2 in 3 confirmed cases have anosmia. In South Korea, where testing has been more widespread, 30% of patients testing positive have had anosmia as their major presenting symptom in otherwise mild cases. Reference here.
In terms of the spectrum of severity, probably the best evidence has come out of a case series of 44,500 patients in China who found that:
● 81% presented with mild symptoms not requiring intervention
● 14% presented with severe disease (dyspnoea, hypoxia or >50% lung involvement radiologically) requiring admission
● 5% presented with a critical disease (respiratory failure, shock or multiorgan dysfunction) requiring intensive care.
Risk Factors for developing the severe disease are important to ascertain in your history. The most important of these are increasing age, cardiovascular disease, diabetes, chronic respiratory conditions, hypertension and cancer (see below).
The Risk of Tunnel Vision - Don’t forget the differentials!
With one diagnosis on everyone's mind, it is incredibly easy to forget that there were still breathless, hypoxic patients before COVID. It is important to keep in mind:
- Other viral pneumonias: Influenza, adenovirus, metapneumoviruses can also present in similar fashions and a generic respiratory viral PCR should be sent
- Bacterial pneumonia: Either as the presenting complaint or a superadded infection to COVID (it is currently unclear the prevalence of this)
- Non-infective causes of hypoxia: Think risk factors and histories suggestive of PE, Pneumothorax and non-infective exacerbations of COPD or Asthma.
How to assess B properly:
One of the good things about this condition is it tends to present with single-organ involvement (initially anyway) - a viral pneumonia affecting the lungs. So, after getting your PPE on and you are happy with the airway, you need to pay particular attention to the breathing in your systematic approach. Here are some tips:
● Take the respiratory rate yourself - you will get used to seeing resps of 16 on obs charts and then finding someone puffing away at 24-30 breaths a minute when you walk in, so just count for yourself - it takes a minute and provides an important picture of early deterioration.
● Look at the work of breathing, not just the numbers - How deep or shallow are the breaths? Are they using accessory muscles? Are they ‘tripoding’ to optimise respiratory mechanics? Are they grunting or breathing through pursed lips?
COVID causes interstitial oedema and affects type 2 pneumocytes which, of course, you remember, produce surfactant.
So picture a premature neonate who is taking rapid, shallow breaths through pursed lips to try and provide positive end-expiratory pressures to keep those alveoli open for gas exchange. Severe COVID patients can resemble these breathing patterns for the same physiological reason.
● Don’t be fooled by normal saturations at rest - Make sure you mobilise the patient if they are saturating > 94% at rest, and are being considered for discharge. Some of them will rapidly drop their oxygen saturations when doing a lap of the emergency department or going to the toilet - which gives a good indication that they are not safe to go home.
Investigations, prognostication and management will be covered in blogs in upcoming weeks. There are also thousands of papers and resources being published every day so bear in mind that protocols and guidelines are changing every day! I'll do my best to summarise these for you.
In the meantime, if you have any burning questions or comments I will be more than happy to answer them so please do get in touch, and subscribe to my blogs below to get an email when the next one comes out.
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