LABORATORY CONFIRMED COVID 19 PATIENT



MILD DISEASE

Uncomplicated URTI (&/or Fever) WITHOUT breathlessness/ Hypoxia

SEVERE DISEASE

Respiratory rate ≥ 30/min AND/ OR SpO2< 90% on Room Air

MODERATE DISEASE

Respiratory rate ≥24/min AND/ OR SpO2< 94% on Room Air

  

ADMIT in COVID WARD

ANTIVIRALS

  HCQ 400 mg BD for 1-day f/b 400 mg OD for next
4 days
Or
Inj REMDESIVIR 200 mg Iv on day 1 f/b 100 mg IV daily for 5 days (Not to use both together)
Or
IVERMECTIN 12 mg OD for 5 Days with DOXYCYCLINE 100 mg BD for 7 days

  CONVALESCENT PLASMA
OXYGEN SUPPORT

  Target SpO2 ≥ 95 % (88-92% in patients with COPD)

  Preferred Devices for oxygenation: non-re- breathing face mask,

  Conscious proning may be used in whom despite use of high flow oxygen hypoxia persist. (sequential position changes every 1-2 hours)
STEROIDS (Indications: Increasing Oxygen requirement, increasing inflammatory markers, within 48 hours of admission)

  IV methylprednisolone 0.5-1 mg/kg for 3-5 days OR

  Dexamethasone 0.1 to 0.2 mg/kg for 3-5 days
ANTICOAGULATION (Prophylaxis for all high-risk patients, Therapeutic for suspected or documented Pulmonary Thrombo-embolism, increased PT, aPTT, raised D-dimer, prolonged immobilization, cancer, etc) Prophylactic dose of UFH or LMWH (Enoxaparin 40 mg day SC)
Therapeutic dose (Enoxaparin 40 mg SC BD)

ANTIBIOTICS (Antibiotics should be used judiciously as per Antibiotic protocol)

Monitor

  CBC, LFT, KFT, D-dimer, Ferritin, Trop T, CRP, ECG Coagulation Profile.

  Change in oxygen requirement

  Work of breathing

  Hemodynamic instability

HOME ISOLATION / SAFE HOME

  Supportive Management

  Mask, Hand Hygiene, Physical
distancing, droplet precaution

  Hydroxychloroquine (400 mg BD on Day 1, followed by 400 mg OD for 4 Days) considering high risk groups with prior
ECG
OR
IVERMECTIN 12 mg OD for 5 Days with DOXYCYCLINE 100 mg BD for 7 days

  MONITOR: SpO2, BP, Temp, Pulse, Sensorium

  Preferable Investigations: CXR PA, CBC, CRP, LFT, ECG, CBG, Serum Creatinine



Warning Signs

  Difficulty in breathing

  Chest pain/ tightness

  Severe Cough

  Resting tachycardia

  SpO2 <94% ( Room Air)

  6 minutes walking induce
deoxygenation (3 min for >60
years/ having co- morbidities)

  As advised by physician

ADMIT in COVID ICU

RESPIRATORY SUPPORT

  HFNC if work of breathing is LOW

  A cautious trial of NIV with helmet interface (if available otherwise face mask interface)/
CPAP with oronasal mask

  Consider Intubation if work of breathing is
high/ NIV is not tolerated

  Lung protective ventilation strategy by ARDS
net protocol

  Prone ventilation when refractory
Hypoxemia
ANTIVIRAL
 Antiviral agents are less likely to be beneficial at this stage; use of Remdesivir to be decided on case to case basis
CORTICOSTEROIDS

  IV Methylprednisolone 1- 2mg/kg in 2 divided doses for 5-7 days OR

  Dexamethasone 0.2 to 0.4 mg/kg for 5-7 days
TOCILIZUMAB may be considered on a case to case basis after shared decision making
ANTICOAGULATION
 High-dose prophylactic UFH or LMWH (e.g. Enoxaparin 40 mg or 0.5 mg/kg BD SC), if not at high risk of bleeding
ANTIBIOTICS should be used judiciously as per Antibiotic protocol
INVESTIGATIONS
Essential investigations along with Cultures (Blood / Urine), FBS, PPBS, Ferritin, Trop-T/ Quantitative Troponins, Procalcitonin, CRP, LDH, D-Dimer, Coagulation Profile, NCCT Chest, USG Chest
SUPPORTIVE MEASURES
• Maintain euvolemia
• Sepsis/septic shock: manage as per protocol and antibiotic policy
• Sedation and nutrition therapy as per existing guidelines

 

REFER TO COVID HOSPITAL (WARD/ICU)

  

After clinical Improvement discharge as per revised discharge criteria



EUA/ Off label therapies (use based on limited available evidence):

• Remdesivir (EUA) to be considered in Moderate to severe disease (requiring oxygen): Rule out renal or hepatic dysfunction (eGFR <30 ml/min/m2; AST/ALT >5 times ULN), Not to be combined with HCQ

• Tocilizumab (Off-label) may be considered in when all the below criteria are met: Moderate to Severe disease, significantly raised inflammatory markers (CRP &/or IL-6), Not improving despite use of steroids, Rule out active bacterial infections. The recommended dose is 4 to 8mg/kg (with a maximum dose of 800 mg at one time) in 100 ml NS over 1 hour (dose can be repeated once after 12 to 24 hours, if needed)

• Convalescent plasma (Off-label) may be considered when following are met: Early moderate disease, Increasing oxygen requirement

• Ivermectin Clinical trial is going on. Physicians should share clinical records and data regarding use of Ivermectin with state. Ivermectin and



doxycycline combination can be used in mild-moderate diseases.