NewYork-Presbyterian Emergency Medicine



NYP ED Medication Use Guidelines in the COVID-19 PandemicAdult Emergency DepartmentLast updated April 15, 2020This medication use guideline only applies in the ED and is an effort to standardize across all campuses and put information from our NYP pharmacy colleagues in one easy place to find. It incorporates information from some of the ED pathways, including the asthma pathway. This medication use guideline does not take the place of clinical judgment. Antibiotics: Most patients with diagnosed COVID-19 do not have bacterial co-infection. It is reasonable to not administer antibiotics in patients admitted with minimal O2 requirements and without signs of septic shock when COVID-19 is considered the top cause on the differential diagnosis (i.e. when viral sepsis is likely).It is reasonable to use clinical judgment in the decision to administer antibiotics in patients admitted with significant O2 requirements or signs of septic shock.Findings that may suggest bacterial infection:Elevated procalcitoninElevated WBCLobar infiltrateFor patients admitted from the ED with pneumonia:Continue to order vancomycin with piperacillin-tazobactam for healthcare-associated pneumonia (HCAP) coverage and Ceftriaxone for community acquired pneumonia (CAP) coverageDosing adjustments may be needed for weight or renal function.PLUS: Continue to order one dose of Azithromycin 500mg (PO preferred) if treating for bacterial pneumonia for atypical coverage. Further doses require ID approval.* For patients discharged from the ED:Doxycycline should be the preferred antibiotic for bacterial respiratory infection (considering drug shortages)Anticoagulation:Venothromboembolism (VTE) Prophylaxis for deep vein thrombosis or pulmonary embolus: After considering contraindications to anticoagulation, ED Admissions should have VTE prophylaxis initiated in the ED at time of admission, as there is a high incidence of VTE in COVID-19 patients. Low molecular weight heparin (LMWH) preferred, even in AKI/CKD/CRRT, if there are no other contraindications.Adjust dose as needed for aboveRefer to campus specific regimens for dosing preferencesProvide this information in the hand-off to the inpatient team.VTE Treatment: Empiric initiation of “therapeutic” dose anticoagulation for patients with COVID and elevated D-Dimer is currently under review.Current recommendation: Initiate when DVT or PE is discovered.While in the ED, clinical judgment will guide the further evaluation and diagnosis of VTE. You can consider the following tests to further evaluate for VTE:Bedside ultrasound for right heart strainPortable DVT studies by sonographerCT Chest for r/o PEPlease indicate in comments that patient is also r/o COVIDCT scanner/room require terminal clean after study, so can delay further imagingAntipyretics: Acetaminophen: Continues to be the first line antipyretic for most patients.Concern if taking every 4 hours for overdose (upwards of 6 grams per day). NSAIDs:There is no compelling clinical evidence suggesting avoidance of NSAIDs in patients with COVID.Recommended standard precautions around relative contraindications to NSAID useExperimental therapies: Hydroxychloroquine:Not currently recommended for any patient discharged from the EDFollow current local ID guidelines for admitted patients.Other therapies, such as Ivermectin, Remdesivir, Tocilizumab, corticosteroids for COVID-19 without history of asthma or COPD, etc. ID input is needed for any other therapiesManagement of Asthma/COPD exacerbation: Taken directly from COVID-19 ED Asthma/COPD pathwayNebulizer treatments should be in a negative pressure room (air-borne infection isolation room). Albuterol MDI 8 puffs q20 minutes prn (8 puffs = 1 neb treatment)Ipratropium MDI 8 puffs q6 hours Prednisone 40-60mg po or other equivalent steroids, if neededCampus specific preferences may exist on steroid usage and dosingMagnesium Sulfate 2 grams IV, if neededSecond line: Epinephrine 0.3mg SQ q20min prn (up to 3 doses)Terbutaline 0.25mg SQ q20min prn (up to 2 doses)*Pharmacy Service Bulletin. New York-Presbyterian Enterprise Formulary and Therapeutics Committee. Azithromycin Restricted to Infectious Diseases Approval. Vol.41, No.6, March 2020. References:1. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Interim Clinical Guidance for the Management of Patients with Confirmed Coronavirus Disease (COVID-19). Last accessed 13Apr20. 2. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with Covid-19. Last accessed 13Apr20. 3. World Heatlh Organization. Clinical Care of Severe Acute Respiratory Infections-Tool Kit. 11-Apr-2020. Last Accessed 13Apr2020. ................
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