Script Writer: Anna McLean and Laura Glenn
Editor: Laura Glenn
Interviewer: Anna McLean
Interviewee: Laura Glenn
Anna McLean chats to Laura Glenn about how to recognise and manage a deteriorating COVID-19 positive patient.
Dr. Anna McLean is a Respiratory and Sleep Advanced Trainee at Royal Prince Alfred Hospital, Australia. She is a Clinical Lecturer with the University of Sydney and has had a long-standing interest in the medical education and pastoral care of both medical students and junior medical officers.
Dr. Laura Glenn is a final year Advanced Trainee in Respiratory Medicine and is also undertaking a PhD with The University of Sydney in the field of interstitial lung disease. She has a strong interest in education and clinical leadership, and is an Associate Clinical Lecturer with The University of Sydney Medical School.
With Dr. Anna McLean and Dr. Laura Glenn, Respiratory Registrars at the Royal Prince Alfred Hospital, New South Wales, Australia.
COVID-19 is a respiratory tract infection caused by the newly emergent coronavirus. This was first recognised in Wuhan, China in December 2019. While most people with COVID-19 develop mild or uncomplicated illness, approximately 14% will develop severe disease and that requires hospitalisation and oxygen support; and 5% will require ICU admission. Identifying those with severe or worsening symptoms early allows us to optimise supportive care and enables safe, rapid referral to appropriate management areas such as ICU.
This podcast goes through a real COVID-19 case (with some dramatic licence) with a particular focus on recognising signs of deterioration as well as appropriate investigations and management steps.
A 44-year-old male presented to ED with a 1-week history of fevers and rigors associated with dyspnoea, lethargy, and anorexia. He had no significant past medical history and was on no regular medications. On initial examination, he was saturating at 99% on room air with a respiratory rate of 18/minute. His blood pressure was 120/80mmHg and his heart rate was 87bpm. A chest x-ray, bloods, and COVID-19 swab were performed, and he was admitted to the ward. You are called by the nursing staff to see him as on routine observations he was noted to be saturating at 87% on room air and had a respiratory rate of 23/minute.
You assess the patient: his respiratory rate is 23/minute, he is saturating at 92% on 4L/minute nasal prong oxygen, his blood pressure is 130/80mmHg, his heart rate is 94bpm and his temperature is 37.6oC. The patient is alert and orientated, but he is using his accessory muscles of respiration. On auscultation of the chest, you hear bi-basal crackles but there are no other clinical signs of heart failure.
You review the results of initial investigations: the white cell count is normal with a mild lymphopenia, the CRP is elevated at 89mg/L, liver function tests are mildly deranged with a transaminitis and the ABG reveals pH 7.44, PaO2 63mmHg and PaCO2 35mmHg. The chest x-ray shows bibasal interstitial opacities.
The patient continues to feel more breathless and you are no longer able to maintain the patient’s oxygen saturations >90% despite administering 8L/minute oxygen via a Hudson mask.