COVID management – RULE OF three

COVID management – RULE OF 3

**3 must remember warning signs

–  High grade fever even after 5 days

–  Increasing dry cough while sleeping,talking

–  Exhaustion,exertional dyspnea (worsening from before)
*3 reasons for late presentation

–  Attributing fever to post vaccination and waiting( post vaccination fever is never
more than 48 hrs)

–  Using DOLO/PCM 6 hrly x 1week as a drug, masking fever

–  Wrong timeline, reporting testing day as day 1, not onset of symptom.
3 minor symptoms- can be ignored

–  Anosmia, altered taste

–  Cold,stuffy nose

–  Body aches, throat pain
3 must have things with home treated patients

–  Thermometer

–  Pulse oximeter

–  Emg doctor/hosp contact details
**3 points not to forget on first OP/ tele visit

– – –

6 to 12 days is the dangerous period.
Report ASAP if danger signs present (give a written printed format)
Avoid long prescriptions with 10 + drugs, patient misses what’s important.

**3 things to be monitored daily and inform

–  Spo2 with 6 min walk <94

–  Temperature>101( after 4th day)

–  Heart rate (resting >100)
**3 lab parameters indicating storm

–  CBP – high N/L ratio>3.5, high monocyte>8%

–  CRP,Ferritin,LDH (inflammatory markers)

–  D Dimer (coagulation risk)

3 lab values in resource poor settings – CBP- TLC above 10000

N/L ratio >3.5 High monocytes

– CRP,ESR – CXR

3 Things to see on CT
-Day of illness (early CT misleads)
-Severity Score (not CORAD 1-5, CORAD 5 doesn’t mean severe covid) -Progressive/ resolving changes

**3 mistakes to avoid

–  Starting steroids in first 5 days( prolongs viral clearance and duration of illness,
late and severe storm)

–  Early CT and lab work up (before 5th day unless sick)

–  Missing on prophylactic anticoagulation in high risk (as dimer normal despite
other signs of storm)
**3 indicators of cytokine storm -Respiking/continued high fevers +/- chills, past 5 th day
-Loosestools after 5 th day – Increasing dry cough /
breathless/exhaustion on routine work
3 causes of exhaustion in COVID

–  Viral myalgias severe (improves over 1 st week)

–  Cytokine Storm,happy hypoxia (worsening towards end of 1st week)

–  Hyperglycemia (weakness plus polyuria)
3 clues to catch in early happy hypoxia

–  Mandatory 6 min walk spo2 test daily

–  afebrile resting heart rate (>110)

–  Cough on lying down, deep inspiration, interrupting speech
**3 most important medications to counter storm

–  Steroids (oral/IV)

–  Anticoagulant(oral/SC)

–  Oxygen (rebreather mask very useful)
**3 supportive care measures usually neglected

–  Prone positioning

–  Glycemic control

–  Fluid intake (dehydration increases thrombosis risk)
**3 mistakes with steroids

–  Early use from day 1 or 2 (irrespective of dose)

–  Using very high doses(iv 40-80 mg methylpred or equivalent is sufficient in most)

–  Not tapering at the earliest improvement
3 complications with steroids

–  Poor glycemic control (most need insulin)

–  Bacterial sepsis (respiking fevers/ worsening lung)

–  Opportunistic infections
( oral,esophageal candidiasis, pulm aspergillosis, rhinoocular mucormycosis)
3 misinterpreted lab values

–  Increasing WBC,neutrophil count after steroids as sepsis(NLR in CBP is not
reliable after starting steroid)

–  High CRP as sepsis in early 2 nd week

–  Normal dimer value as no need for anticoagulant even in sick
(False positive widal due to cross antibodies as typhoid)
3 extended tests useful in ICU
– IL6 (more than 10 times, >50
indicates severe cytokine storm)
– Procalcitonin ( as CRP can’t differentiate inflammation vs sepsis,to rule out severe
bacterial infection if >2. Useful only in ICU sick cases) – Bacterial and fungal cultures
3 unnecessary tests
– CT chest to see for improvement /resolution ( despite clinical improvement

) – PCR /Rapid @ day 14( false positive even if dead virus present)
– Lab markers despite clinical improvement,off oxygen (except

dimer to be done if high)

**3 points on anticoagulants

–  Aspirin /clopidogrel have no proven role..dont use the

–  Oral apixaban or SC Enoxaparin/heparin only indicated

–  Use for minimum of 2-3 weeks post discharge in moderate to severely sick.
*3 must do things if hypoxic and waiting for a bed(HOME or ambulance)

–  Inj. Dexa 8 mg bd / Tab predmet 32mg Bd

–  Inj Clexane 60mg SC bd/ Tab apixaban 5 mg bd

–  Dont panic if remdesvir not available,above 2 drugs make all the difference
3 Points on Remdesvir

–  Mild disease : Dont give

–  Moderate
Affordable, available – Dont delay Affordable, not available -Dont panic Not affordable,unavailable-Dont bother

–  Severe/late
Role questionable.
3 things to avoid while on treatment

–  Whatsapp

–  Google updates

–  NEWS
3 things which are making the difference

–  Will power

–  Immunity

–  Faith in treatment (fake remdesvir also worked 🙂

Dr.Deepthi (MD,PGIMER) Varma Hospitals Bhimavaram. AP

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