​​​​​​​​​Quick reference guide​

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Presentation

Intended for adult patients presenting to NSW emergency departments with high probability COVID-19 infection.

Initial assessment

Severity of illness

​Observations​ ​Mild​ ​Moderate ​Severe
​Saturations on ro​om air
​≥93% (or at baseline in chronic lung disease)​​
90–92% (or less than baseline in chronic lung disease)​​
​≤89% (or less than baseline in chronic lung disease)​
Respiratory rate​ ​10-25 ​8-10 or 26-30​ <8 or >30
Heart rate​ ​50-120 ​40-50 or 120-140 <40 or >140​
GCS​ ​15 ​15 ​≤14​

 
Risk stratification is based on vital signs in conjunction with high risk factors and response to treatment.

High ri​sk factors

  • age ≥65
  • chronic respiratory disease
  • chronic kidney disease
  • chronic cardiovascular disease
  • immunosuppression
  • diabetes
  • cancer.​

High probability COVID-19 signs and symptoms

  • fever
  • dyspnoea
  • fatigue
  • change in smell or taste
  • high epidemiological risk.

​​Investigations

​​Mild​​ ​Moderate ​Severe
​COVID-19 nucleic acid detection swab +/- influenza PCR (use local protocol).
  • nil
  • FBC, EUC, INR, D-dimer, troponin
  • VBG (including lactate and glucose)
  • LFT, APTT, CRP (if available)
  • Blood culture if febrile ≥38.5°C
  • ECG, chest X-ray
  • POCUS (if available)​

​​​​​​Severe disease has been correlated with

  • Lymphopenia (<1.1 × 10⁹ cells/L)​
  • Thrombocytopenia (<50 x109 cells/L)
  • D-dimer >1.0mg/L
  • new acute kidney injury
  • raised ALT/AST
  • raised inflammatory markers (CRP, WCC)
  • r​aised troponin (late)
  • Lactate (VBG) >3.0mmol/L.​

Management and treatment

​​Mild​​ ​Moderate ​Severe
  • nil

​​Respiratory support
  • ​aim for SpO2 ≥93% (or at baseline for chronic lung disease 88–92%)
  • NIV as indicated in single room with contact, droplet and airborne precautions. See NSW Health guidance
  • HDU/ICU referral when more than 10L O2/min required.

  • nil

​​Restrictive fluid strategy
  • 250mL boluses up to 3 times if SBP <100mmHg
  • if not responsive then commence vasopressors
  • no maintenance fluids unless specific indication​.​

Additional therapy

For some patients, it may be most appropriate to offer palliative care.

Disposition

​​Mild​​​ ​Moderate ​Severe
  • discharge
  • arrange follow-up five days post symptom onset (e.g. COVID-19 service, GP, community care)​
  • discharge if SpO2 ≥93% on room air (or at baseline in chronic lung disease)​
  • refer for daily follow-up via local COVID-19 service (e.g. Hospital in the Home (HITH), community care)​

HDU/ICU referral if:
  • ​​10L/min required to maintain SpO2 ≥93%
  • intubated
  • vasopressor support
  • meets normal referral criteria.​​

On discharge, provide patient or carer with information on management at home and follow up

Including:
  • factsheets​
  • signs and symptoms for seeking further medical advice.
For more information, contact your public health unit.

This summary was written to reflect current understanding of best practice in assessment and management of COVID-19 in adults.

 

Document information

Developed by

Dr Louisa Ng, Natalie Wright, Dr Michael Golding (ECI), ACI and ECI in collaboration with the COVID-19 Emergency Department COP and multiple ED Clinicians.

Consultation

Endorsed by

Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning, NSW Ministry of Health.

Reviewed by

ECI, Emergency Department COP, Virtual care COP and other COPs involved in development.​

For use by

This document is a quick reference guide for ED clinicians treating adults presenting to ED with symptoms consistent with suspected or confirmed COVID-19. This advice should be considered in conjunction with local guidelines.​​​​

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Current as at: Thursday 8 October 2020
Contact page owner: Health Protection NSW