*Covid Update-130*

COVID SECOND WAVE *Guiding Principles*

1. RT-PCR may be negative-(read ORF/Rdrp and N/E gene as S gene may not be detectable).

2. Diagnosis (If RT-PCR negative) Clinical symptoms, Serum Markers CT Chest.

3. Loss of smell is equal to RT-PCR

4. Virus stops replicating after 9 days.

5. Around15 minutes of exposure is required to get the infection.

*Features of Pneumonia*

Temp> 101

CRP> Rapid rise of CRP

Persistant Cough

5% fall in SPO2 after 6 min.walk.

*Investigation at Home in mild cases on day 3 and repeat at day 7-8*

1. CBC with NLR ( Neutrophil/Lymphocyte Ratio)

2. CRP,

3. D-DIMER (Very important- Repeat after 3 days)

5. Blood Sugar

*Add Investigations in Moderate/Severe cases*

6.CT Chest

7. IL-6

8. Ferritin

9. LDH (A sign of cell death)

10. LFT

11. KFT

*Interpretation of Investigations*:

1. CRP a good marker to start Steroid

2 NLR a good prognostic factor.

4. Increasing Lymphopenia indicates severity

5. D-Dimer-Monitor every 2-3 days

6. LDH – Useful follow-up parameter only

7. IL-6 is very unreliable.(Timely collection and rapid transportation required. Choose the same LAB)

8. Thrombocytopenia can be seen in about 20%cases

*IMPORTANT Principles*:

1. Antivirals are most helpful, given in (replication phase 1 to 7days of symptoms)

2. Anti inflammatory (steroids) should be started in early Pulmonary phase i.e. after 7 days (replication phase)to prevent Covid Cytokine storm.This phase may set in early in Severe cases

3. LMWH (ENOXAPERIN) 40mg or 1mg/Kg S/C OD dose should be given in all admitted patients/all patients of Pneumonia

*CRITICAL SIGNS*

1. Temp> 103 without PCM or 101 after PCM

2. Persistent cough

3. Sudden onset of shortness of Breath(SOB)

4. Rapid increase in CRP

5. CT Chest score >13/25

*GENERAL Home TREATMENT*

1. REST is a big help (light walking, sitting allowed)

1. SPO2 monitoring

2. Plenty of fluids

3. Paracetamol. Don’t hesitate to add Nimuselide/Mefenamic acid in case of high fever and bodyache

4. Good diet

5. Vit-C, Vit-D, Zinc

6. Ivermectin/ Favipiravir may/maynot help ( doubtful weak antivirals). Don’t be anxious as Fevipiravir is not available these days

7. Azithromycin, Doxycycline are used to counter secondary infection or undiagnosed sore throat.

8. Cetrizine/Allegra/Lorfast/cough syrups may help

9. Steam kadha help as throat soothing agents

10. Isolation to protect others in family

*SPECIFIC TREATMENT*

1. *STEROIDS*- Start Early to all patients with SPO2 <94 (persistent) on any day of Disease.

*Which steroid to use*:

Inj Dexamethasone (2ml= 8mg dexamethasone sodium phosphate contains 6mg Dexamethasone) to be given IV

Or

Tab/inj Methyl Prednisolone 32 mg

Or

Tab Wysolone/Tab Omnacortil 40 may be especially useful for patients in Home isolation waiting to get a bed

Or

Dexona tablets are available in 0.5 mg tab ..So 16 tab may be required if taken orally.

*All steroids Dexa/Solumedrol/Prednisone/methylprednisolone likely to have same effect*

In Hospital steroids doses are higher

*When to avoid Steroids*

Better to avoid steroids in early replication phase, in asymptomatic cases, in mild symptoms but less than 7 days, in Viremia phase with normal CRP and CT Chest.

Controversial: in cases with CT score <8 with Disease <7 days,

2. ENOXAPERIN40mg (1mg/Kg)

a. To all moderate to severe symptomatic patients

(If SPO2 <94,PR >110, RR is>24)

b. If Pneumonia suspected clinically, by Xray or CT Chest start LMWH.

(Oral Anticoagulant like Rivoraxaban15mg per day

or Apixaban may be options for patients on Home isolation with no injection facility)

3. REMDESIVIR- In hospitalized patients (should be started in less than 10 days of onset).

*How to Suspect CYTOKINE STORM* 🏹

1. Unremitting fever extreme with extreme weakness and Fatigue

2. Shortness of Breath in second week.sudden

3. High Fever onset in second week

4. increase Cytopenia

6. Hyperferritinemia

7. Pulmonary involvement

8. Rising CRP >50

9. Worsening CT Chest

*Above Guidelines are primarily for Home Use but under medical supervision*..

.

1) Plasma therapy is not at all recommended in the 2nd wave by WHO or any other Organisations around the World. It is waste of time & money.

2) If needed, CT scan of lungs to be done between 5th to 7th day, otherwise report may be misguiding.

3) No need of any Medication in the 1st week of infection, except Paracetamol (if fever persists) along with Multivitamins & Zinc. In case of Fever Paracetamol should not be taken SOS but regularly in 6 hourly interval.

4) If symptoms continue, Condition worsens in 2nd week between 7th & 10th day, so pl. keep close monitoring on Oxygen level, Coughing frequency, Pulse & Temperature.

5) If Condition worsens in 2nd week, without wasting time start treatment with Steroids in consultation with Doctor. Steroid treatment is the most effective way of treating Lungs infection.

6) Oxygen concentrator of 5L is not suitable, as they probably cannot bring back Oxygen saturation above 94 continuously.

7) Proning is now officially approved method for improving Oxygen level.

8) Positive persons after becoming negative are safe from infection for next 90-180 days.

9) Positive persons should take their 1st or 2nd Jab after 90 days of becoming negative, as they have sufficient antibody for next 90 days at least.

10) Condition of young people in the age group of 30-45 yrs. worsens suddenly as they have strong capacity to hold back till a point and thereafter collapses suddenly. Close monitoring is essential and each passing day is crucial.

*Good points to be taken care by everyone*

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