*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
deemagclinic
deemagclinic 