If a patient has known risk for or exposure to COVID-19, manage as a PUI regardless of the differential diagnosis.
Examination should include, but not limited to, full vital signs including pulse oximetry, work of breathing assessment, pulmonary auscultation, skin temperature, and capillary refill.
COVID-19 RT-PCR assay not usually available in austere environments.
Co-infections along with alternative and/or comorbid diagnoses are possible.
Life threatening alternative diagnoses (e.g. pulmonary embolism, pneumothorax, acute myocardial infarction, etc.) should be considered and managed according to standard practices.
False negative rates for COVID-19 RT-PCR assay tests are significant. Isolate & treat (or quarantine) those with typical symptoms, recent travel and/or exposure to another sick individual.
Testing priority should be guided by CDC recommendations balanced with operational priorities. Mild symptoms and no high-risk factors may not warrant immediate testing, while mission critical is determined by the combat command, and testing may be considered a higher priority.
If testing is negative, release from strict isolation while following strict social distancing practices, wearing a face covering, and thoroughly cleaning their workplace.
Ancillary Tests
Minimum:
If febrile and in malaria endemic area: Binax Now rapid malaria testing
Better (Above +):
Ultrasound (pulmonary + cardiac)
If dyspnea/hypoxia - iStat ABG or VBG
12-Lead ECG
Rapid Flu Testing
Rapid Dengue Testing
Best (Above +):
Chest X-Ray
Respiratory Pathogen Film Array (i.e. Biofire)
COVID-19 PCR Testing
Other laboratory testing listed DoD COVID19 PRACTICE MANAGEMENT GUIDE
Identifying Risk for Deterioration
Among patients with mild symptoms & normal resting SpO2, risk of deterioration is increased in those presenting with dyspnea (even if mild), desaturation on exercise testing, & those with comorbidity (age over 45, cardiovascular disease, pulmonary disease). These patients should be monitored closer & considered for evacuation sooner.
Exercise Test: Patient should jog or walk in place for 3 minutes. Inability to complete the test or desaturation below SpO2 <94% confers a higher risk for clinical deterioration. This is an un-validated triage test used by hospitals to help gauge the need for closer inpatient monitoring.
Consider Alternative Diagnoses
If a patient has known risk for or exposure to COVID-19, the patient should be managed as a PUI regardless of the differential diagnosis. COVID-19 patients can be co-infected with other pathogens or possess other underlying conditions.
Life threatening alternative diagnoses (e.g. pulmonary embolism, pneumothorax, acute myocardial infarction, etc.) should always be considered and managed according to standard practices for diagnosis and treatment.
Laboratory abnormalities
Coagulopathy with mild thrombocytopenia, increased D-dimer levels (strongly associated with greater risk of death), increased fibrin degradation products, and prolonged prothrombin time