EXTRA!

SPECIAL REPORT :: COVID-19

FEBRUARY 2020

Novel Coronavirus COVID-19:

An Overview for Emergency Clinicians
AUTHORS
AL Giwa, LLB, MD, MBA, FACEP, FAAEM
Akash Desai, MD
A 42-year-old man presents to your
ED triage area with a high-grade
fever (39.6°C [103.3°F]), cough, and
fatigue for 1 week. He said that the week
KEY POINTS prior he was at a conference in Shanghai
• The mortality rate of COVID-19 appears
and took a city bus tour with some peo-
to be between 2% to 4%. This would
make the COVID-19 the least deadly ple who were coughing excessively, and
of the 3 most pathogenic human not all were wearing masks. The triage
coronaviruses. nurses immediately recognize the risk,
place a mask on the patient, place him
• The relatively lower mortality rate of
COVID-19 may be outweighed by its
in a negative pressure room, and inform
virulence. you that the patient is ready to be seen.
You wonder what to do with the other 10
• 29% of the confirmed NCIP patients patients who were sitting near the pa-
were active health professionals, and
tient while he was waiting to be triaged
12.3% were hospitalized patients,
suggesting an alarming 41% rate of and what you should do next...
nosocomial spread.

Save this supplement as your

trusted reference on COVID-19, with the
relevant links, major studies, authoritative
websites, and useful resources you need.
 Introduction
Coronaviruses earn their name from the characteristic crown-like viral
particles (virions) that dot their surface. This family of viruses infects a wide
range of vertebrates, most notably mammals and birds, and are consid-
ered to be a major cause of viral respiratory infections worldwide.1,2 With
the recent detection of the 2019 novel coronavirus (COVID-19), there are
now a total of 7 coronaviruses known to infect humans:
1. Human coronavirus 229E (HCoV-229E)
2. Human coronavirus OC43 (HCoV-OC43)
3. Human coronavirus NL63 (HCoV-NL63)
4. Human coronavirus HKU1
5. Severe acute respiratory syndrome-related coronavirus (SARS-CoV)
6. Middle East respiratory syndrome-related coronavirus (MERS-CoV)
7. Novel coronavirus (COVID-19, also known informally as Wuhan corona-
virus)3

Prior to the global outbreak of SARS-CoV in 2003, HCoV-229E and

HCoV-OC43 were the only coronaviruses known to infect humans. Follow-
ing the SARS outbreak, 5 additional coronaviruses have been discovered
in humans, most recently the novel coronavirus COVID-19, believed to
have originated in Wuhan, Hubei Province, China. SARS-CoV and MERS-
CoV are particularly pathogenic in humans and are associated with high
mortality. In this review, the epidemiology, pathophysiology, and manage-
ment of the recently discovered COVID-19 are reviewed, with a focus on
best practices and the public health implications.

AUTHORS
AL Giwa LLB, MD, MBA, FACEP, FAAEM
Associate Professor of Emergency Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY

Akash Desai, MD
Icahn School of Medicine at Mount Sinai, New York, NY

PEER REVIEWER
Andy Jagoda, MD, FACEP
Professor and Chair Emeritus, Department of Emergency Medicine; Director,
Center for Emergency Medicine Education and Research, Icahn School of Medicine
at Mount Sinai, New York, NY

Emergency Medicine Practice EXTRA • February 2020 2 Copyright © 2020 EB Medicine. All rights reserved.
 Critical Appraisal of the Literature
PubMed, ISI Web of Knowledge, and the Cochrane Database of Systematic
Reviews resources from 2012 to 2020 were accessed using the keywords
emergency department, epidemic, pandemic, coronavirus, and COVID-19.
The United States Centers for Disease Control and Prevention (CDC) and
the World Health Organization (WHO) websites were also accessed.

Epidemiology
As of February 20, 2020, there have been 78,771 cases of COVID-19
globally, with 76,936 of those in mainland China; there have been 2461
confirmed deaths.4 Confirmed cases span 32 countries across North
America, Europe, Asia, and Australia, prompting the WHO to declare
COVID-19 a global health emergency. Of the 2461 deaths, all but 17
have occurred in China, with the majority occurring in the Hubei prov-
ince of China, the capital of which is Wuhan. This amounts to a current
global mortality rate of 3.12%; however, this number is subject to change
as the number of cases and affected patient populations grow and
change respectively. With the outbreak of COVID-19 coinciding with the
celebration of the Chinese Lunar New Year in late January 2020 and an
associated approximate 15 million visits to Wuhan City, the challenges in
containing the outbreak are and will continue to be difficult to estimate.
Initial reports from affected patient populations in hospitals in China
indicate that the majority of those infected with severe disease and
poor outcomes (as measured by intensive care unit [ICU]-level care and
mortality) tend to be patients with comorbid conditions such as asthma,
chronic obstructive pulmonary disease, or advanced age.5,6

In late January 2020, the first data detailing the clinical features, course,
and prognosis from infection with COVID-19 relative to the previous 2
deadly coronavirus outbreaks (MERS-CoV and SARS-CoV) were published
in The Lancet.7,8 (See Table 1, page 4.) In the time since the publication
of these data, the global disease burden of COVID-19 has come to drasti-
cally outpace that of the previous 2 novel coronavirus outbreaks. With the
aforementioned 78,771 cases and 2461 deaths as of February 23, 2020,
COVID-19 is the deadliest of the novel coronaviruses in absolute magni-
tude while approximating the mortality rate found in this early study.4,7,8

Emergency Medicine Practice EXTRA • February 2020 3 Copyright © 2020 EB Medicine. All rights reserved.
 Table 1. Early Demographic and Clinical Characteristics of COVID-19 Relative to
Outbreaks of Previously Novel Coronaviruses, MERS-CoV and SARS-CoV4,8
Clinical Characteristics COVID-19 MERS-CoV SARS-CoV
Epidemiologic Statisticsa
Cases 78,771 2494 8096
Deaths 2461 858 744
Mortality 3.12% 37% 10%
Demographic Statisticsb
Date December 2019 June 2012 November 2002
Location of first detection Wuhan, China Jeddah, Saudi Arabia Guangdong, China
Age, years (range) 49 (21-76) 56 (14-94) 40 (1-91)
Male:female ratio 2.7:1 3.3:1 1:1.25
b
Symptoms (%)
Fever 98 98 99-100
Dry cough 76 47 29-75
Dyspnea 55 72 40-42
Diarrhea 3 26 20-25
Sore throat 0 21 13-25
Ventilatory support 9.8 80 14-20

a
Epidemiologic statistics on COVID-19 as of February 23, 2020.4
b
Demographic and symptom statistics for COVID-19 are based on early epidemiologic data from
the first 41 patients reported by Chaolin Huang, et al (admitted before January 2, 2020).8 Further
data will be needed to detail clinical symptomatology and demographics in the > 70,000 cases
now confirmed. Data are n, or n% unless otherwise stated.

Of note, though findings are quite early and the actual prevalence of the
virus is far greater than the numbers listed in Table 1, the mortality rate
appears to be relatively consistent with current trends, between 2.5% and
3.5%. This would make the COVID-19 the least deadly of the 3 most patho-
genic human coronaviruses. Nonetheless, this relatively lower mortality rate
may be outweighed by the virulence of COVID-19. With more than 75,000
cases and 2400 deaths, the total death toll from COVID-19 has exceeded
that of both the MERS-CoV and SARS-CoV combined.4

In epidemiology, the R0 value (pronounced “R-naught”) is known as

the basic reproduction number and can be thought of as the expected
number of cases generated directly by 1 case in a population, where
all individuals are susceptible to infection. Early epidemiologic studies
in the case of COVID-19 estimate an R0 value of 2.2 (90% high density
interval: 1.4-3.8), a value similar to SARS-CoV and pandemic influenza,
suggesting the potential for sustained human-to-human transmission
and a global pandemic.9

Given the early timeframe of these calculations, the recent spate of

case clusters outside of China with untraceable origins, and the first
confirmed case in Africa (Egypt), where the primary and public health-

Emergency Medicine Practice EXTRA • February 2020 4 Copyright © 2020 EB Medicine. All rights reserved.
 care systems are less equipped to contain viral spread, fears of
COVID-19 becoming a pandemic are mounting.10,11

Virology
Coronaviruses are in the order Nidovirales, in the family Coronaviridae, and
subfamily Orthocoronavirinae. Coronaviruses are enveloped with positive-
sense single-stranded RNA, and possess the largest genome of all RNA viruses.
Two-thirds of the coronavirus genome at the 5’ terminus encodes viral proteins
involved in transcribing viral RNA and replication, while one-third at the 3’ termi-
nus encodes viral structural and group-specific accessory proteins.2 The major
proteins in coronaviruses are named S (spike), E (envelope), M (membrane), and
N (nucleocapsid) proteins. These biomarkers play a central role not just in how
we diagnose the disease, but how we will come to understand its pathogenicity
profile, and ultimately any options for a vaccine and/or direct antiviral treatment
targeted to dismantle the viral life cycle. (See Figure 1.)

Figure 1. Coronavirus With Major Proteins Labeled

S-protein

HE-protein

3'-poly A

5'-cap A
RNA
Nucleocapsid
N-protein

M-protein

Envelope

Reprinted from Virology. Stephen N.J. Korsman, Gert U. van Zyl, Louise Nutt, et al. Human
coronaviruses. Pages 94-95. Copyright 2012, with permission from Elsevier.

The SARS-CoV and MERS-CoV viruses were both believed to have resulted
from zoonotic spread from the bat population.12 While coronaviruses likely
evolved over thousands of years remaining confined to bat populations,
intermediate mammalian hosts, such as civet cats in the case of SARS-CoV,
and dromedary camels in the case of MERS-CoV, have been implicated and
likely play a role in the ultimate transmission of these novel coronaviruses

Emergency Medicine Practice EXTRA • February 2020 5 Copyright © 2020 EB Medicine. All rights reserved.
 to humans.13,14 The outbreak of COVID-19 is suspected to have originated
in the Huanan Seafood Wholesale Market in Wuhan City; however, other
researchers have suggested that this market may not be the original source
of viral transmission to humans.7,15 Bats are rare in markets in China, but they
are hunted and sold directly to restaurants for food.16

Pathophysiology
Coronaviruses primarily infect the upper respiratory and gastrointestinal
tracts of birds and mammals. The surface spike glycoprotein (S-protein)
is a key factor in the virulence of coronaviruses, as it is believed to en-
able it to attach to host cells. In SARS-CoV, human angiotensin-converting
enzyme 2 (ACE2) is the primary cellular receptor, and is believed to have
played a role in the ability of SARS-CoV to produce infections of both the
upper and lower respiratory tracts, contributing to its lethality.17 Similarly,
MERS-CoV has been shown to bind to dipeptidyl-peptidase 4 (DPP4), a
protein that has been conserved across species known to harbor this strain
of coronavirus. While most respiratory viruses infect ciliated cells, DPP4 is
expressed in nonciliated cells in human airways, which is believed to be an
important factor in its zoonotic transmission and high mortality rate.18

Prevention
Based on the transmission specifications of coronaviruses as a class and
documented transmission patterns of the SARS-CoV and MERS-CoV out-
breaks, the transmission of COVID-19 is presumed to be primarily through
droplets and fomites. The WHO and the CDC recommendations for infec-
tion control and transmission prevention differ slightly from each other.

• WHO recommendations: Standard, contact, and droplet precautions

with eye or face protection. Airborne precautions are recommended in
cases where the patient is undergoing aerosol-generating procedures,
such as tracheal intubation, noninvasive ventilation, tracheotomy, car-
diopulmonary resuscitation, manual ventilation (eg, prior to intubation),
and bronchoscopy.19 This is especially important in the context of pre-
liminary data from an initial cohort of 138 COVID-19-infected patients,
which showed a rate of nosocomial infection as high as 41%.6

• CDC recommendations: Standard, contact, and airborne precautions,

with eye protection. If an airborne infection isolation room is unavail-
able, the patient should wear a mask and be placed in a private room
with the door closed. All personnel interacting with the patient should
wear the appropriate personal protective equipment in accordance
with the precautions delineated above.20

Emergency Medicine Practice EXTRA • February 2020 6 Copyright © 2020 EB Medicine. All rights reserved.
 Both the WHO and CDC guidelines similarly emphasize the importance of
strict hand hygiene in curtailing COVID-19 transmission. This stems from
the uncertainty surrounding the transmission vectors aboard the quaran-
tined Diamond Princess cruise ship off the coastal waters of Japan, as well
as increasing reports from around the world of COVID-19 appearing in
people who have not had direct contact with a known or suspected carrier
or a traveler to China.21,22 Given the recent reports from the Chinese CDC of
COVID-19 virus being found in the feces of seropositive patients, the likeli-
hood of fecal-oral and, hence, hand transmission is very high.23 Healthcare
professionals and patients should follow standard hand-washing techniques:
wash hands with soap and water for at least 20 seconds, especially after go-
ing to the bathroom; before and after eating; and after blowing the nose,
coughing, or sneezing. If soap and water are not available, one should use
an alcohol-based sanitizer with at least 60% alcohol.3 While in vitro survival
rates of COVID-19 on surfaces remains to be studied, past data on HCoV-
229E suggest the capability for strains of coronavirus to survive outside of
the host for multiple days, under the right conditions.24,25

Additional guidelines for those with close contacts and suspicious expo-
sures include “strong recommendations” (based on high-quality evidence)
for immediate medical attention, an observation period of 14 days, wear-
ing N95 masks, prioritizing private transportation over public, prenotifica-
tion of the hospital prior to patient arrival, and cleansing of the transport
vehicle with 500 mg/L chlorine-containing disinfectant, with open ven-
tilation.26 Note that the recommended observation period may soon be
modified, given recent case reports and studies suggesting incubation
periods of 0 to 24 days.27,28

Evaluation and Diagnosis in the Emergency Department

Although we are approaching the end of the winter season, with its abun-
dance of influenza and influenza-like illnesses, reports from the CDC and
WHO suggest COVID-19 may persist well past the winter season. Emer-
gency department (ED) staff need to maintain a high index of suspicion
when evaluating a patient with fever, cough, dyspnea, or signs of a lower
respiratory tract illness who have had recent travel or contact with a recent
traveler to endemic areas. The CDC had initially focused their travel warn-
ings and epidemiological risks on those with recent travel or contact with a
traveler to Wuhan City, Hubei province, China; however, with people in the
United States, Egypt, Iran, Italy, Canada, and other non-Asian countries
contracting COVID-19 and potentially spreading it to others, the connec-
tion to China will increasingly diminish. See Table 2, page 8 for the CDC’s
clinical features and epidemiological risks for the evaluations of persons
suspected of having COVID-19.

Emergency Medicine Practice EXTRA • February 2020 7 Copyright © 2020 EB Medicine. All rights reserved.
 Table 2. Clinical Features and Epidemiological Risks of COVID-19
Clinical Features AND Epidemiologic Risk
Fever* or signs/symptoms of lower AND Any person, including healthcare workers,
respiratory illness (eg, cough or shortness who has had close contact* with a
of breath) laboratory-confirmed* 2019-nCoV patient*
within 14 days of symptom onset
Fever* and signs/symptoms of a lower AND A history of travel from Hubei Province,
respiratory illness (eg, cough or shortness China* within 14 days of symptom onset
of breath)
Fever* and signs/symptoms of a lower AND A history of travel from mainland China*
respiratory illness (eg, cough or shortness within 14 days of symptom onset
of breath) requiring hospitalization

*For explanation of use of the terms, fever, close contact, laboratory-confirmed, 2019-nCoV patient,
and China, view the source at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.
html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fclinical-
criteria.html#foot1

An early, retrospective, single-center case series of 138 consecutively

hospitalized patients with confirmed novel coronavirus-infected pneu-
monia (NCIP) provides valuable information on the clinical presentation
and laboratory trends for patients infected with this virus. The findings
from this study are summarized in the article published in JAMA, which
can be accessed in full at: https://jamanetwork.com/journals/jama/fullar-
ticle/2761044. According to Table 1 in the JAMA article, notable demo-
graphics include a median age of 56 years, with interquartile range of 42
to 68 years, with ICU patients strongly favoring those more advanced in
age. Of note, 40 (29%) of the confirmed NCIP patients were active health
professionals, and 17 (12.3%) were hospitalized patients, suggesting an
alarming 41% rate of nosocomial spread. Infected patients requiring ICU-
level care were more likely to have underlying comorbidities.6

According to Table 2 in the JAMA article, notable laboratory findings in

this population include lymphopenia in 97 patients (70.3%), prolonged
prothrombin time (13.0 seconds [interquartile range,12.3-13.7 seconds]) in
80 patients (58%), and elevated lactate dehydrogenase (261 U/L [interquar-
tile range, 182-403 U/L]) in 55 patients (39.9%). Patients requiring ICU-level
care tended to have higher white blood cell counts, with a P = .03, and
higher lactate dehydrogenase levels (P < .001).

Findings on chest imaging in COVID-19 have been similar to findings seen

in previous years from the SARS-CoV and MERS-CoV outbreaks. A recent
cohort analysis of 41 patients infected with COVID-19 found all but 1 with
bilateral lung involvement.8 A study of computed tomography (CT) scans
of 21 patients with COVID-19 infection showed 3 (21%) with normal CT
scans; 12 (57%) with ground-glass opacity only; 6 (29%) with ground-glass
opacity and consolidation at presentation; and interestingly, 3 (14%) with

Emergency Medicine Practice EXTRA • February 2020 8 Copyright © 2020 EB Medicine. All rights reserved.
 normal scans at diagnosis. Fifteen patients (71%) had 2 or more lobes
involved, and 16 (76%) had bilateral disease.29 Of the 18 patients with posi-
tive findings on chest CT, all had the presence of ground glass opacities,
with 12 of the 18 having concomitant lobar consolidations.29

The article, “A Rapid Advice Guideline for the Diagnosis and Treatment of
2019 Novel Coronavirus (2019-nCoV)-Infected Pneumonia (standard ver-
sion),” published in the journal, Military Medical Research, provided rapid
advice guidelines and diagnostic imaging of several cases. Figure 2 pres-
ents a typical x-ray and CT images of a patient with COVID-19.

Figure 2. X-Ray and Computed Tomography Imaging

of COVID-19 Pneumonia

Typical CT /X-ray imaging manifestation (case 2). A 51-year-old male with general muscle ache
and fatigue for 1 week, fever for 1 day (39.1°C), anemia. Laboratory tests: normal white blood cells
(9.24 × 109/L), lymphocytes percentage (5.1%), decreased lymphocytes (0.47 × 109/ L), decreased
eosinophil count (0 × 109/L), increased C-reaction protein (170.91 mg/L), increased procalcitonin
(0.45 ng/mL), increased erythrocyte sedimentation rate (48 mm/hr). Imaging examination: (a) shows
patchy shadows in the outer region of the left lower lobe; (b) shows large ground-glass opacity in
the left lower lobe; (c) shows subpleural patchy ground-glass opacity in posterior part of right up-
per lobe and lower tongue of left upper lobe; and (d) shows large ground-glass opacity in the basal
segment of the left lower lobe.
Available at: https://doi.org/10.1186/s40779-020-0233-6
Published under the terms of Creative Commons CC BY license, Springer Nature.

The article, “Evolution of CT Manifestations in a Patient Recovered from

2019 Novel Coronavirus (2019-nCoV) Pneumonia in Wuhan, China,” pub-
lished in the journal Radiology, published 6 images of the evolution of
chest imaging of a 42-year-old male patient infected with COVID-19 who
recovered over 31 days.30 These images can be viewed at: https://doi.
org/10.1148/radiol.2020200269

Within a month of initial reports detailing the COVID-19 outbreak, the

CDC developed a real-time reverse transcription-polymerase chain reac-
tion (rRT-PCR) test that diagnoses COVID-19. While diagnostic testing in
the United States was available initially only through the CDC, this assay
is now being made available at the state level with the use of the Inter-
national Reagent Resource (IRR). The IRR was initially established by the
CDC for the study and detection of influenza, but it has been expanded
to include newly discovered influenza and coronaviruses.31 International,

Emergency Medicine Practice EXTRA • February 2020 9 Copyright © 2020 EB Medicine. All rights reserved.
 state, and local public health departments utilize this standard reagent in
order to monitor and ensure quality control and standardized results. The
reagent is expected to be available at the state and local levels by the
end of the first quarter of 2020.32 It should be noted that widely available
respiratory viral panels test only for the earlier forms of human coronavirus,
namely human coronaviruses 229E, NL63, OC43, and HKU1.33 The SARS-
CoV, MERS-CoV, and COVID-19 strains require more specialized assays
that are not as widely available.

Management
In the case of infection with any of the coronavirus strains, there is no
known directed treatment specific to the virus. Many patients with con-
firmed NCIP in the JAMA study received broad-spectrum antibacterial
therapy (moxifloxacin, 89 [64.4%]; ceftriaxone, 34 [24.6%]; azithromycin, 25
[18.1%]) and most received antiviral therapy (oseltamivir, 124 [89.9%]), with
some additionally receiving steroids (glucocorticoid therapy, 62 [44.9%]).6

Considering the lack of direct evidence with regard to treatment of

COVID-19, recently proposed guidelines have been built largely on treat-
ment guidelines for SARS-CoV, MERS-CoV, and influenza. Currently, there
are weak recommendations for alpha-interferon atomization inhalation
twice/day, and lopinavir/ritonavir orally twice/day; however, evidence sup-
porting these in reducing the incidence and mortality of acute respiratory
distress syndrome (ARDS) in patients infected with SARS-CoV and MERS-
CoV are limited to case series and case reports.26 A recent systematic
review showed that lopinavir/ritonavir’s anticoronavirus effect was seen
mainly in its early application, and no significant effect was seen in late
application of therapy.34 At this time, the use of combined antivirals in the
treatment of COVID-19 is controversial, as there are currently no random-
ized controlled trials in humans to support their use.35,36

In a systematic review in the Chinese literature of treatments for SARS-

CoV, 14 studies were identified in which steroids were used. Twelve stud-
ies were inconclusive and 2 showed potential harm. One study reported
diabetes onset associated with methylprednisolone treatment.37 Another
uncontrolled, retrospective study of 40 SARS patients reported avascular
necrosis and osteoporosis among corticosteroid-treated SARS patients.38
A randomized, double-blind, placebo-controlled trial measured SARS-CoV
plasma viral load across time after fever onset and found corticosteroid
use within the first week of illness was associated with delayed viral clear-
ance.39 Yet another case-controlled study found that patients who devel-
oped psychosis while on steroids received higher cumulative doses of ste-
roids than patients without psychosis (10,975 mg vs 6780 mg; P = .017).40

Emergency Medicine Practice EXTRA • February 2020 10 Copyright © 2020 EB Medicine. All rights reserved.
 In patients who deteriorate and require ICU-level care, treatment should
consider noninvasive ventilation, mechanical ventilation, or extracorporeal
life support if necessary.26 In patients with poor outcomes, development
of ARDS and respiratory decompensation plays a central role in pathogen-
esis. In this sense, the following treatment principles are key in managing
COVID-19 patients:
• Hemodynamic management, with vasopressor support if necessary
• Nutritional support
• Blood glucose control
• Expeditious evaluation and treatment of nosocomial or superinfective
pneumonia
• Prophylaxis against deep vein thrombosis and gastrointestinal bleeding
• Proper patient positioning to aid oxygenation and ventilation

Looking to the Future

The future is unpredictable regarding the outbreak of COVID-19. Given
case reports of transmission of COVID-19 from asymptomatic carri-
ers,27 its spread and containment will face unprecedented challenges.
Daily information (and misinformation) have added to the challenges to
the general public as well as the medical community. The Lancet pub-
lished an online editorial (https://www.thelancet.com/action/showPdf?pii
=S0140-6736%2820%2930379-2), which appeals to the medical community
to seek verified information through the CDC or WHO and avoid social
media and other unverified sources for information. Many worried well
patients will show up in the ED, taxing our already overburdened systems.
This is an opportunity for hospital leadership to develop and/or expand
their telehealth options to be used during such an outbreak, to minimize
the numbers of worried well or low-risk patients with mild symptoms bom-
barding local EDs.

There has been funding directed at producing a vaccine for MERS-CoV,

which is notorious for its high mortality, and the effort has met with signifi-
cant advances as well as continued challenges. There is currently a DNA
vaccine candidate that has entered into human clinical trials, while 2 vector-
based candidates will soon begin human trials; protein-based vaccines are
still at the preclinical stage.41 Challenges to successful vaccine development
include incomplete understanding of viral transmission, pathogenesis, and
immune response; lack of optimal animal challenge models and standard-
ized immunological assays; as well as insufficient sustainable funding.

Remdesivir has recently been recognized as a promising antiviral drug

against a wide array of RNA viruses, including SARS-CoV and MERS-CoV
infection in vitro and in nonhuman primate models.42 Furthermore, recent

Emergency Medicine Practice EXTRA • February 2020 11 Copyright © 2020 EB Medicine. All rights reserved.
 in vitro studies conducted on COVID-19 have found that remdesivir and
chloroquine inhibit viral infection of cells with low micromolar concentra-
tion with a high selectivity index.41

Hospital Management
With several media and public health agencies warning of a continued
global outbreak and possible pandemic, there is a high probability United
States hospitals will see a large influx of cases of COVID-19, which will
overwhelm many health systems. The CDC has issued guidance to all
healthcare institutions, stating:

All United States hospitals should be prepared for the possible arrival of
patients with COVID-19. All hospitals should ensure their staff are trained,
equipped, and capable of practices needed to:

• Prevent the spread of respiratory diseases, including COVID-19, within

the facility
• Promptly identify and isolate patients with possible COVID-19 and
inform the correct facility staff and public health authorities
• Care for a limited number of patients with confirmed or suspected
COVID-19 as part of routine operations
• Potentially care for a larger number of patients in the context of an
escalating outbreak
• Monitor and manage any healthcare personnel that might be exposed
to COVID-19
• Communicate effectively within the facility and plan for appropriate
external communication related to COVID-1943

Additionally, the CDC has released a checklist for hospital preparedness,

which can be found at: https://www.cdc.gov/coronavirus/2019-ncov/
downloads/hospital-preparedness-checklist.pdf

In the event of a mass influx of patients with exposure to or symptoms

concerning for COVID-19, immediate isolation is required. If 1 infected
person presents to a busy ED triage area without a mask and touches
objects, there is a high likelihood of spreading the virus and potentially
contaminating others. The CDC recommends placing ample supplies of
touchless hand sanitizer stations and easy-dispense boxes of face masks
at entrances to the ED and hospital. They also recommend placing signs
that advise anyone entering the facility to “immediately put on a mask and
keep it on during their assessment; cover their mouth/nose when cough-
ing or sneezing; use and dispose of tissues; and perform hand hygiene
after contact with respiratory secretions.”43 The CDC also advises patients
with fever or symptoms of respiratory infection and recent travel outside
the United States, specifically to China, to immediately notify triage per-

Emergency Medicine Practice EXTRA • February 2020 12 Copyright © 2020 EB Medicine. All rights reserved.
 sonnel, so appropriate precautions can be put in place.43 However, travel
history is becoming increasingly vague as more cases outside of China,
and without a connection to China, become prevalent.

Clearly, each hospital will have differing capabilities to put appropriate

precautions in place, as this could require dedicated isolation areas for
perhaps a handful of patients to potentially several dozen (or more). The
mere potential magnitude of cases presenting to EDs across the United
States is staggering and should raise a heightened sense of urgency to
emergency management and infectious disease prevention specialists
to ensure their hospitals have enough isolation areas and supplies for
patients and staff. It is unlikely that the United States has the capability
to build several-thousand-square-foot dedicated isolation (quarantine)
hospitals in the span of days to cope with the potential outbreaks in each
metropolitan area, as was done in China. However, with the assistance of
the federal government, agencies such as the Federal Emergency Man-
agement Agency (FEMA) and the Department of Defense (DoD) could be
mobilized to bring portable emergency hospitals to areas that may have
local hospitals that are overwhelmed. Hospital leadership should be coor-
dinating with FEMA and the DoD pre-emptively, and not during an out-
break. Lastly, emergency medical services (EMS) medical directors should
develop or establish protocols for paramedics or emergency medical tech-
nicians (EMTs) to render aid to those at home who are not sick enough to
require hospital services.

Case Conclusion
You recalled your recent training on recognizing infectious diseases and
the need for immediate and proper donning of personal protective equip-
ment. You and a nurse put on your complete PPE and obtained the pa-
tient's vital signs, which confirmed a temperature of 39.6°C [103.3°F], pulse
of 106 beats/min, respirations of 22 breaths/min, blood pressure 102/68
mm Hg, and pulse oximetry 89% on room air. His exam was notable mostly
for rhonchi bilaterally to all lung fields. You started him immediately on
supplemental oxygen and confirmed his travel history and possible con-
tacts with people who may have been exposed to COVID-19. You con-
tacted your hospital infectious disease and infection prevention team, who
directed you to also contact your local department of public health, who
sent a representative to find out all of his possible contacts. The patient was
eventually admitted to an isolation room after bilateral patchy infiltrates
were noted on his chest x-ray. You started empirical coverage for bacterial
pneumonia, consulted the CDC and WHO for up-to-date guidance on ad-
ditional treatment recommendations, and remembered to avoid steroids.

Emergency Medicine Practice EXTRA • February 2020 13 Copyright © 2020 EB Medicine. All rights reserved.
 Table 3. Helpful Resources for COVID-19
Organization Link
United States Centers for Disease https://www.cdc.gov/coronavirus/2019-ncov/index.html
Control and Prevention
World Health Organization https://www.who.int/emergencies/diseases/novel-
coronavirus-2019
Johns Hopkins University https://gisanddata.maps.arcgis.com/apps/opsdashboard/
COVID-19 Global Case Tracker index.html#/bda7594740fd40299423467b48e9ecf6
United States Department of https://www.cdc.gov/coronavirus/2019-ncov/index.html
Labor, Occupational Safety and
Health Administration
American College of Emergency https://www.acep.org/by-medical-focus/infectious-
Physicians COVID-19 Clinical diseases/coronavirus/
Alert
The Lancet COVID-19 Resource https://www.thelancet.com/coronavirus?dgcid=kr_pop-
Centre up_tlcoronavirus20

References
Evidence-based medicine requires a critical appraisal of the literature
based upon study methodology and number of subjects. Not all refer-
ences are equally robust. The findings of a large, prospective, randomized,
and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent in-
formation about the study, such as the type of study and the number of
patients in the study will be included in bold type following the references,
where available.

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Emergency Medicine Practice EXTRA • February 2020 14 Copyright © 2020 EB Medicine. All rights reserved.
 5. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical charac-
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2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506.
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lance and simulation study)
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idUSKBN20D284. Accessed February 20, 2020. (News article)
11. No author listed. “COVID-19: Fighting Panic with Information.” The Lan-
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Accessed February 22, 2020. (Editorial article)
12. Wang N, Li SY, Yang XL, et al. Serological evidence of bat SARS-related
coronavirus infection in humans, China. Virol Sin. 2018;33(1):104-107.
(Epidemiologic surveillance study [serologic])
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cal, epidemiologic, and clinical features. Infect Dis Clin North Am.
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Available at: https://publons.com/publon/878949/#review-2686681.
Accessed February 15, 2020. (Epidemiologic history)

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 15. Cohen J. “Wuhan Seafood Market May Not Be Source of Novel Virus
Spreading Globally.” Science. 2020. Available at: https://www.sci-
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source-novel-virus-spreading-globally. Accessed February 15, 2020.
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16. Li H, Mendelsohn E, Zong C, et al. Human-animal interactions and
bat coronavirus spillover potential among rural residents in Southern
China. Biosafety and Health. 2019;1(2):84-90. (Prospective epidemio-
logic surveillance study; 1597 patients)
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vere acute respiratory syndrome coronavirus (SARS-COV) spike protein
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19. World Health Organization. Infection prevention and control during
health care when novel coronavirus (nCoV) infection is suspected.
Published January 25, 2020. Available at: https://www.who.int/publi-
cations-detail/infection-prevention-and-control-during-health-care-
when-novel-coronavirus-(ncov)-infection-is-suspected-20200125.
Accessed February 15, 2020. (Guidelines)
20. United States Centers for Disease Control and Prevention. “What
Healthcare Personnel Should Know About Caring for Patients With
Confirmed or Possible 2019-nCoV Infection.” Available at: https://
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21. Lesney MS. “WHO Urges That 'Window of Opportunity' on Containing
Novel Coronavirus Not Be Missed.” Medscape Medical News. Available
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23. Zhang Y, Chen C, Zhu S, et al. Isolation of 2019-nCoV from a stool speci-
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chinacdc.cn/en/article/id/ffa97a96-db2a-4715-9dfb-ef662660e89d.
Accessed February 20, 2020. (China CDC website; translated)

Emergency Medicine Practice EXTRA • February 2020 16 Copyright © 2020 EB Medicine. All rights reserved.
 24. Ijaz MK, Brunner AH, Sattar SA, et al. Survival characteristics of airborne
human coronavirus 229E. J Gen Virol. 1985;Dec; 66 (Pt 12):2743-2748.
(Basic science research)
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25. Geller C, Varbanov M, Duval RE. Human coronaviruses: insights into
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view) DOI: https://doi.org/10.3390/v4113044
26. Jin Y-H, Cai L, Cheng Z-S, et al. A rapid advice guideline for the diag-
nosis and treatment of 2019 novel coronavirus (2019-nCoV) infected
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tice guidelines – United States)
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Litonawe (LPV/r) as treatment for novel coronavirus COVID-19 pneu-
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 studies. Zhonghua Jizhen Yixue Zazhi. 220;29(2):182-186. (Systematic
review of Chinese literature on antivirals in SARS-CoV and MERS-
CoV) DOI: https://tinyurl.com/tkbefz3
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42. Sims A. The small molecule nucleoside prodrug GS-5734 exhibits
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hospital-checklist.html. Accessed February 20, 2020. (CDC website)

Emergency Medicine Practice EXTRA • February 2020 18 Copyright © 2020 EB Medicine. All rights reserved.
 Practice Questions

1. Which of the following is most accurate regarding the epidemiol-

ogy of COVID-19?
a. It affects mostly children under the age of 12
b. Early data suggests COVID-19 is much more clinically severe than
MERS-CoV or SARS-CoV
c. Early data suggests a mortality rate of approximately 3%
d. It predominantly causes a severe viral pneumonia in a single lung

2. What is the most common clinical symptom in patients found to be

infected with COVID-19?
a. Cough
b. Diarrhea
c. Fever
d. Vomiting

3. Which animal is thought to have harbored coronaviruses during its

evolution, prior to zoonotic transmission to humans?
a. Cats
b. Bats
c. Gnats
d. Camels

Answer Key is on page 20.

Emergency Medicine Practice EXTRA • February 2020 19 Copyright © 2020 EB Medicine. All rights reserved.
 Answer Key

1. Which of the following is most accurate regarding the epidemiol-

ogy of COVID-19?

Answer: C, Early data suggest a mortality rate of approximately 3% from

COVID-19. See Table 1, page 4. According to the early findings, the mor-
tality of COVID-19 is 3.12%. The age range is 21 years to 76 years. In the
“Evaluation and Diagnosis in the Emergency Department” section on
pages 8 and 9, the early findings on chest imaging in COVID-19 have
shown typically bilateral lung involvement.

2. What is the most common clinical symptom in patients found to be

infected with COVID-19?

Answer: C, Fever. See Table 1, page 4. Early findings show that fever is
present in 98% of patients with COVID-19. Also see Table 2, page 8 for the
CDC’s recent findings that fever is the most common clinical symptom in
patients with COVID-19.

3. Which animal is thought to have harbored coronaviruses during its

evolution prior, to zoonotic transmission to humans?

Answer: B, Bats. See the “Virology” section, page 5. Although the origin
has not been confirmed, serologic evidence has shown that those corona-
viruses are believed to have resulted from zoonotic spread from the bat
population, with an intermediate mammalian host (civet cats for SARS-
CoV and dromedary camels in the case of MERS-CoV).

Emergency Medicine Practice EXTRA • February 2020 20 Copyright © 2020 EB Medicine. All rights reserved.
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