“Covid Straight Drives”

*Salient points

*1.* Having symptoms, fever high grade, cold, sore throat, cough, malaise at this time of Pandemic should be taken as suspected covid.

*2.* Day 2 to Day 5 of symptoms to get the Real Time PCR and more likely to come positive. (at present so called gold standard)

No Antigen test.

*3.* HRCT Chest & Xray Chest advisable on Day 4 – 5, acts as a supportive evidence or to pick up early ground glassing

*4.* If test comes negative then though welcome news, watchful for next 7 to 10 days and repeat the test if symptoms worsens.

*5.* If test comes positive then self quarantine, ideally

Separate room

Separate toilet

Self Care

Self hygiene

If separate toilet not possible to flush the toilet thoroughly by disinfectant may be household phenyl after its use by infected person

Monitor SPO2 twice a day daily. Should be more than 95%.

To do six minute test twice a day

Rest SPO2 – > 95%

Walk for 6 minutes in a room itself

SPO2 after walk if equal or less than 93% – likely to have hypoxia

To get hospitalized for further management

Medicines symptomatic

Paracetamol 1gm qds

No need of NSAIDs

Vit C

Zinc

One can take antiviral as

Favipiravir

Lopinavir

Ritonavir

Of late Favipiravir recommended

But then to do basal LFT, ECG

*6.* No role of Prophylactic Antibiotics in home Quarntined positive patients.

*7.* Investigations during quarantine

CBC

CRP

Xray Chest

*8.* Investigations during hospitalization in first 5 days

Besides

CBC

CRP

Xray Chest

D-dimer

LDH

Ferritin

Creatinine

LFT

To watch for N:L ratio

More than 3.5

Warrants Antibiotics

*9.* During hospitalization medicines given

Favipiravir / Lopinavir / Remdesivir

Doxy

Ivermectin

(Doxy & Ivermectin no proven role but can be used on OPD basis treatment)

Vit C high dose 1.5 gm

Zinc 50 mg minimum

*10.* Day 7, Day 8

IL6 test

To detect cytokines storm

*11.* From Day 6

In covid patient with Hypoxia

Antiviral

Remdesivir added

D6 to D10

Five days

200 mg IV First day

100 mg IV for next four days

Availability is issue but available at major hospitals

Cipla & Hetero are manufacturing and hopefully availability will not be issue in next 2 weeks….

Remdesivir only five days

Creatinine clearance should be checked for

The thumb rule in use of antiviral is

Early to start is always better…..

Informed Consent required for use of Remdesivir as well Favipiravir

*12.* Another important drug is use of steroids

Methyl Prednisolone is the drug of choice

1mg/kg/BW BD for 5 days IV

Indications

Rise in inflammatory markers…

CRP high

Ferritin high

But to give under the cover of broad spectrum Antibiotics

To check for that Procalitonin levels are done if high suggests underlying sepsis the Antibiotic cover is important higher ones of course IV

*13.* Use of Dexamethasone instead of MP if issue with cost and availability of MP

Use of Dexamethasone has its value at Hospital

Strictly not to be used on OPD basis for first five days of symptoms

Don’t Start Dexa or any steroids just because one has diagnosed with Covid..It may have detrimental effect if started before time.

Of course as General Practitioners we should not use it

*14.* Low Molecular Weight Heparin is another drug added on Day 5 of symptoms in view of hypoxia / who requires Oxygen

Inj Clexan 40mg / 60 mg once a day continued till discharge and continued at home or replaced by oral anticoagulant for a week and repeated test of D dimer is important. If normal then it is stopped

Sometimes if D dimer is relatively too high then higher therapeutic dose is used of Inj Clexan

Reason of using it – as micro vascular thrombi – pulmonary embolism – is one of the complication

LMWH in all patients irrespective of D dimer

Prophylaxis or Therapeutic doses depend on D dimer levels

*15.* Treatment of Hypoxia

HFNC

High Flow Nasal Canula delivery of Oxygen as high as 40 to 60 lits with closed mouth

in prone position

All the time nursing in Prone Position and CARP protocol has good outcome

Importance of prone position

Heart, anterior mediastinal organs falls forwards….

Better aeration of lungs

Posterior lobe involvement becomes lesser

NIV/CPAP not recommended

NIV has got its limitations including

P SILI (Self Induced Lung Injury) and difficulty in prone nursing

*16.* If on HFNC

Drowsiness……

PCO2 increases…..

ABG not achieved as desired…

PaO2/FiO2 ratio < 150 on HFNC

To shift to ventilator…

*17.* Cosmetic Ventilators are just automated AMBUs and don’t have any role .

*18.* If clinically

Hypoxemic

Fever with chills increases

Tachycardia

indirect evidence of cytokine storm

Recognize cytokine early. Monitor labs frequently

Confirmed by

CRP increase

IL6 increase

Ferritin increase

LDH increase

WBC rise

Tocilizumab (anti IL6) /Eculizumab (anti CD6) injection to be used

Timing is very important

Not early Not late

D8 to D12

3 digit CRP

10 to 12 times rise in IL6

IL6 reports sometime takes two days

But as CRP too high better not to wait for IL6 report otherwise it will be too late

Rule out infection before giving it, send Procalcitonin

Of late cytokine storm is seen in 3rd week too

D16/D17

Only one dose of Tocilizumab

No role for second dose

*19.* Sudden death in Covid causes

Acute Coronary syndrome

Pulmonary embolism

Microthrombi

*20.* Antibody test for surveillance

For plasma donation

High tires 1:1024

Quantitative

*21.* Late complication

Early to say

But may be fibrosis of lung….

*22.* IVIG only if suspecting Infection Induced HLH

LDH/Ferritin in 1000s

*23.* Plasma donation must be encouraged . Committe like ZTCC should be formed for monitoring it’s use..

*24.* All frontline Health Care Provider should take HCQ Prophylaxis weekly till the end of Pandemic .There is no other proven prophylaxis avilable besides HCQ..

*25.* We are nowhere near Herd immunity

*26.* DONT LET YOUR GUARDs DOWN especially in common areas, canteen, chambers when with someone….

*27.* GOOD Basic Supportive Care and Tender Loving Care is the key for favorable outcome.

Received this useful compilation in another group. Quite comprehensive – ofcourse adult medicine.. seniors and colleagues in forefront of covid management please suggest similar protocol for pediatric patients

Tq

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