MILD





MODERATE





SEVERE

Clinical Criteria



SPO2



> 94 % in Room Air



90 – 94 % in Room Air

< 90 % in Room Air

RR

< 24 / min

24 – 30

> 30



No Pneumonia



Pneumonia +



Pneumonia ++

CT Chest Criteria





Normal or < 25 %



25 % – 75 %

75 % to 100 %



Grade I



Grade II / III



Grade IV

Laboratory Findings (Expected)



NLR1,2



< 3.2



> 3.2

> 5.5

CRP3

< 40

40 – 125

> 125

Ferritin2

< 500

> 500

> 800

D-Dimer4

< 0.5

> 0.5

> 1.0

LDH

< 300

300 – 400

> 400

IL6

< 4.8

5 – 50

> 80

LFT5



Normal



Slight Derangement



Moderate Derangement

Treatment

Routine

 

T. Paracetamol 500 mg TDS



T. Paracetamol 500 mg TDS

T. Paracetamol 500 mg TDS

Anti-tussives SOS

Anti-tussives SOS

Anti-tussives SOS

T. Vitamin C 500 mg OD

T. Vitamin C 500 mg BD

T. Vitamin C 500 mg BD

T. Zinc 50 mg BD

T. Zinc 50 mg BD

T. Zinc 50 mg BD

C. Omeprazole 20 mg BD

C. Omeprazole 20 mg BD

Inj. Pantoprazole 40 mg IV OD

Fluids

Adequate Hydration – Oral

Adequate Hydration – NS

Conservative Fluids

HCQ

(Not prescribed routinely)

T. HCQ (In high risk patients – DM / HT / CVA / CKD / CLD / Obesity / Age > 60 yrs) Day 1 – 400 mg BD Followed by 400 mg OD x 4 Days

(avoid in cardiac disease or if QTc > 480 ms) – MOHFW Guidelines

T. HCQ (In high risk patients – DM / HT / CVA / CKD / CLD / Obesity / Age > 60 yrs)
Day 1 – 400 mg BD

Followed by 400 mg OD x 4 Days
(avoid in cardiac disease or if QTc > 480 ms) – MOHFW Guidelines

–

Antibiotics

 

T. Azithromycin 500 mg OD x 5 Days (or)
T. AmoxClav 625 BD if T. Azithromycin is



T. Azithromycin 500 mg OD x 5 Days
+



T. Azithromycin 500 mg OD x 5 Days
+
Inj. Piptaz 4.5 mg/ Inj meropenam 500mg IV TDS if



COVID PROTOCOL*

 



Contraindicated and Elderly > 60 yrs.



Inj. Ceftriaxone 1 gm IV BD if secondary bacterial infection suspected



secondary bacterial infection suspected

Anticoagulation

–

Inj. Enoxaparin 40 mg SC OD x 5 Days (can be started as prophylactic without D DIMER)

(Contraindicated in ESRD, active bleeding, emergency surgery, platelets < 20,000/mm3, BP > 200/120) Inj. Dalteparin 2500 IU SC OD ×5 days

In ESRD, UH – 5000U SC BD can be used

Inj. Enoxaparin 40 mg SC BD x 5 Days (can be started as prophylactic without D DIMER) (Contraindicated in ESRD, active bleeding, emergency surgery, platelets < 20,000/mm3, BP > 200/120) Inj. Dalteparin 5000 IU SC OD × 5 day In ESRD, UH – 5000U SC BD can be used

Steroids

–

Inj. Dexamethasone 0.1 – 0.2 mg /kg ≈ 6 mg IV OD x 5 Days
or
inj. Methyl Prednisolone 0.5 -1 mg/kg ≈ 60mg x 5 Days

Inj. Dexamethasone 0.2 – 0.4 mg /kg ≈ 6 mg IV BD x 10 Days
or
inj. Methyl Prednisolone 1.0 -2.0 mg/kg ≈ 80 mg x 10 Days

Oxygen Support

Not Required

Maintain Target SPo2 of 92 to 96 %

Nasal Prongs (4 lit / min) ↓
Face Mask (5-10 lit / min) ↓

NRM (10 -15 lit / min) ↓
HFNC (10 – 40 lit / min) ↓

CPAP (TV 6ml/kg; PEEP 5-15 cm H20; Target PP 30 cm H20)

Maintain Target SPo2 > 90 %

NRM (10 -15 lit / min) ↓
HFNC (10 – 60 lit / min) ↓

CPAP (TV 6ml/kg; PEEP 5-15 cm H20; Target PP 30 cm H20)
↓
MV (ARDS Protocol)

Proning

–

Awake Proning (if > 4 L / min)
– 30 to 120 mins prone
– 30 to 120 mins left lateral
– 30 to 120 mins right lateral – 30 to 120 mins upright

– Contraindicated in altered mental status and hemodynamic instability, pregnancy

Prone Ventilation 16 to 18 hrs / Day

Cytokine Storm

–

Inj. Toculizumab 400 mg (max 800 mg) slow IV in 100 ml NS over 1 Hour
Repeat Dose after 12 hours if needed

–

COVID PROTOCOL*

  

 



Contra Indications – Active Infections, TB, Hepatitis, Platelets < 1L/mm3, ANC < 2000/mm3





COMORBIDITY AND COMPLICATIONS



Comorbidity

CAD, HT, DM, Hypothyroid, Epilepsy



Treat Appropriately



Treat Appropriately

Treat Appropriately

Complications

Septic Shock
AKI, MODS Delirium Electrolytes
ECG- abnormalities Stress Ulcers Liver Dysfunction

Treat Appropriately

Treat Appropriately

Treat Appropriately

  

Trial Therapies

1

–

Inj. Remdesivir
200mg IV OD on Day 1 and 100 mg IV OD x 4 Days Contraindication – Liver Dysfunction/ CKD / Pregnancy / Lactation / Children
DI – avoid HCQ, Dexa use Methyl Prednisolone

–

2

–

Convalescent Plasma 200 ml slow IV
Single Dose

–

3

–

(Lopinavir 400 mg + Ritonavir 100 mg) Twice Daily x 14 Days Suspended by WHO wef 4.7.20.

–

4



–



(Lopinavir 400 mg + Ritonavir 100 mg) Twice Daily x 14 Days
+

Interferon Beta 8 Million IU on Alternate Days x 3 Doses

–



MONITORING



BP / HR



Daily



6th Hourly

4th Hourly

RR / WOB /spO2

 

6th Hourly



2nd Hourly



Continuously



* based on clinical management protocol, Covid 19 – MOHFW GOI dt 03.07.20

Bibiliography

1. Minping et al., doi:

2. Chuan Qin et al., doi:

3. Ruan Q et al.,

4. Zhou et al.,

5.

https://doi.org/10.1093/cid/ciaa248

COVID PROTOCOL*

 

CBC / NLR / RFT / LFT



Baseline



Every 2 Days



Daily

COVID Profile

Baseline

Once every 4 days

Once every 2 days

D Dimer

Repeated 4th day

Once every 4 days

Once every 2 days

ECG

Baseline

Once every 2 days

Daily

ABG

–

–

Daily

X Ray



–



If Clinical Deterioration



DISCHARGE CRITERIA





Afebrile > 3 Days without antipyretics +
No Breathlessnes



Afebrile > 3 Days without antipyretics
+
No Breathlessnes

Afebrile > 3 Days without antipyretics
+
No Breathlessnes

10 Days from Symptom Onset

10 Days from Symptom Onset

Clinical Recovery

–

No O2 Requirement for 3 Days

RT-PCR not Required

RT-PCR not Required

Repeat RT-PCR if Swab Negative Transfer to Non Covid Care Ward – if clinical recovery is delayed

POST DISCHARGE ADVICE

 

Isolation + Self Monitoring for 7 Days



Isolation + Self Monitoring for 7 Days



Isolation + Self Monitoring for 7 Days





10.21203/rs.3.rs-28850/v1

 

doi: 10.1007/s00134-020-05991-x



doi: 10.1016/S0140-6736(20)30566-3



Zhang et al., doi.org/10.1016/S2468-1253(20)30057-1