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
– 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

deemagclinic