Guidelines
General Information

General Information

Background

  • Coronaviruses are a large family of viruses, some of which cause illness in humans.

  • COVID-19 (COVID-19 = Coronavirus Disease 2019) is the name of the disease caused by this virus, known as the SARS-CoV-2 virus.

  • Some coronaviruses cause only minor respiratory symptoms like those of a cold (NL63/OC43/229E/HKU1), whereas other coronaviruses, such as severe acute respiratory syndrome (SARS CoV) and Middle East respiratory syndrome (MERS CoV), have been associated with more serious and life-threatening diseases.

  • Incubation period is 5 days (median), but ranges from 2-14 days.

Transmission occurs via droplet and contact. Most commonly spread from an infected person through:

  • Coughing and sneezing

  • Close personal contact, touching, or shaking hands

  • Touching something with the virus on it, then touching your mouth, nose, or eyes before washing your hands.

Airborne spread is NOT known to occur outside of aerosol-generating medical procedures (AGMP).

Reported illnesses have ranged from people being mildly sick to people being severely ill and dying. Asymptomatic infections have also been well documented.

More frequent (>50%) Less frequent (<50%) Rare (<10%)
Fever (44-91%) Sputum production (28–33%) Confusion
Cough (57-74%) Muscle aches (11–44%) Runny nose
Shortness of breath (31–63%) Chest pain (16-36%) Fainting
Fatigue (31–70%) Diarrhea (5-24%) Skin manifestations
Loss of appetite (39-84%) Nausea/vomiting (5-19%)
Loss of smell and/or taste (54-88%) Headache (6-70%)
Dizziness (9-17%)
Sore throat (11-13%)

Note: Symptoms among older adults (65 years of age and older) and those with underlying medical conditions may be atypical or subtle; for instance they may be more likely to present without fever or respiratory symptoms.

Symptoms may appear in as few as 2 days or as long as 14 days after exposure. This is the longest known incubation period for this disease.

(adapted from the Public Health Agency of Canada)

In children, the reported signs and symptoms have been similar to those observed in adults, though they may often be less severe or altogether absent. See this link for general advice on how to care for a child with COVID-19.

Reports have found fever (children 56% vs. adults 71%), cough (children 46% vs. adults 80%), and shortness of breath (children 13% vs. adults 43%) at a lower frequency in children. Gastrointestinal symptoms are often predominant in clinical presentation, including abdominal pain, diarrhea, nausea, and vomiting.

Clinicians should be aware of very rare complications that have been associated with COVID-19 infection. A severe multisystem inflammatory syndrome in children (MIS-C) has been reported to share features of typical or atypical Kawasaki disease or toxic shock syndrome.

The WHO preliminary case definition for MIS-C states that cases should be suspected in children and adolescents 0-19 years of age with fever for ≥ 3 days and two of the following signs or symptoms:

  • rash or bilateral non-purulent conjunctivitis or muco-cutaneous inflammation signs (oral, hands or feet)
  • hypotension or shock
  • features of myocardial dysfunction, or pericarditis, or valvulitis, or coronary abnormalities (ECHO findings or elevated Troponin/NT-proBNP)
  • evidence of coagulopathy (abnormal PT, PTT, elevated D-Dimers)
  • acute gastrointestinal problems (diarrhea, vomiting or abdominal pain)

AND

  • elevated markers of inflammation such as ESR, C-reactive protein or procalcitonin

AND

  • no other obvious microbial cause of inflammation, including bacterial sepsis, staphylococcal or streptococcal shock syndromes

AND

  • evidence of COVID-19 (RT-PCR, antigen test or serology positive) or likely contact with patients with COVID-19

Clinicians should have a high index of suspicion to obtain bloodwork for children and adolescents who present with the symptoms mentioned above.

Adapted from the Public Health Agency of Canada.

Disease Progression & Risk Groups

Progression to severe or critical illness occurs late in the disease course at a median of 8 days after symptom onset.

  • Associated with severe illness and mortality
  • Higher risk of deterioration and should be monitored closely
  • Risk factors include:
    • Age more than 60 years (increasing with age)
    • Diabetes mellitus
    • Neurodevelopmental disorders
    • Cardiovascular disease including heart failure/hypertension
    • Chronic lung disease
    • Cerebrovascular disease
    • Chronic kidney disease
    • Chronic liver disease
    • Immunosuppression
    • Cancer
    • Obesity
    • Pregnancy
    • Schizophrenia/mood disorders
    • Smoking

Syndrome Definitions & Disease Severity

Asymptomatic infections have been well documented but it is unclear what proportion of infected individuals remain asymptomatic. Some studies have estimated the frequency of pauci-symptomatic or asymptomatic individuals to be as high as 50%.

Outpatient, not requiring hospitalization

Patients NOT requiring supplementary oxygen.

  • Clinical signs of pneumonia (fever, cough, dyspnea, tachypnea) may or may not be present.
  • No signs of severe pneumonia.

Hospitalized, non-ICU-based care

Patients requiring supplementary oxygen therapy.

  • Fever or suspected respiratory infection plus one of the following:
    • Respiratory rate > 30 breaths/min
    • Severe respiratory distress
    • SpO2 ≤ 92% on room air

Hospitalized, ICU-based care

Patients requiring respiratory support (high-flow oxygen, noninvasive ventilation, or mechanical ventilation) and/or vasopressor or inotropic support

  • May be characterized by ARDS, Sepsis or Septic Shock
  • acute pulmonary embolism,

  • acute coronary syndrome,

  • acute stroke

  • delirium.

Clinical suspicion for these complications should be heightened when caring for COVID-19 patients, and appropriate diagnostic and treatment protocols available.