COVID-Management

1. Dr A P Naveen Kumar

2.  Patients need to be clinically staged which would help
us in admission to an appropriate COVID 19 area and
further management
Proposed clinical staging system
 Stage I: Asymptomatic to mild (early infection)
 Stage II A: moderate (pulmonary involvement without
hypoxia)
 Stage II B: moderate (pulmonary involvement with
hypoxia)
 Stage III: severe (systemic hyperinflammation with
cytokine storm)
2

3.  • ILI is defined as one with acute respiratory infection
– with fever ≥ 380 C (100.40F) and
– cough
– with onset within last 10 days
 • SARI is defined as one with acute respiratory infection
– with fever ≥ 380 C (100.40F),
– cough
– with onset within the last 10 days and requiring
hospitalization
 • Respiratory failure
– Represents the failure of the lung to maintain adequate
gas exchange
– Characterized by ABG abnormalities: PaO2< 60 mmHg
with or without hypercarbia
- PaCO2> 46 mmHg (with drop in pH<7.30)

4.  The median incubation period is 5.1 days (range
2–14 days)
 The precise interval is uncertain.
 The period of infectivity starts 2 days prior to
onset of symptoms and lasts up to 8 days

5.  Trouble breathing
 Persistent pain or pressure in the chest
 New confusion
 Inability to wake or stay awake
 Bluish lips or face

6.  Adults 60 years and older
 Children younger than 2 years old
 Pregnant women and women up to 2 weeks after the
end of pregnancy
 People who live in nursing homes and other long-term
care facilities

7.  COPD ,Moderate to severe Asthma
 CHF ,CAD ,Cardiomyopathies
 T2DM
 CKD CLD
 Obese and BMI > 30
 Sickle cell disease
 Cancer
 Immunocompromised
 Pregnancy
 CVA

8.  A. A patient with acute respiratory illness (fever and at
least one sign/symptom of respiratory disease, e.g.,
cough, shortness of breath), AND a history of travel to or
residence in a location reporting community transmission
of COVID-19 disease during the 14 days prior to symptom
onset;
OR
 B. A patient with any acute respiratory illness AND having
been in contact with a confirmed or probable COVID-19
case in the last 14 days prior to symptom onset;
OR
 C. A patient with severe acute respiratory illness (fever
and at least one sign/symptom of respiratory disease, e.g.,
cough, shortness of breath; AND requiring hospitalization)
AND in the absence of an alternative diagnosis that fully
explains the clinical presentation

9.  A. A suspect case for whom testing for the
COVID-19 virus is inconclusive.
OR
 B. A suspect case for whom testing could not be
performed for any reason.

10.  A person with laboratory confirmation of COVID-
19 infection, irrespective of clinical signs and
symptoms

11.  As per data from Integrated Health Information
Platform (IHIP)/ Integrated Disease Surveillance
Programme (IDSP) portal case investigation forms
for COVID 19 (n=15,366) 11-6-20
 fever (27%)
 cough (21%)
 sore throat (10%)
 breathlessness (8%)
 Weakness (7%)
 running nose (3%)
 and others 24%.

12. Reported symptoms were as follows -USA
 Fever (43.1%)
 Cough (50.3%)
 Shortness of breath (28.5%)
 Myalgia (36.1%)
 Runny nose (6.1%)
 Sore throat (20%)
 Headache (34.4%)
 Nausea/vomiting (11.5%)
 Abdominal pain (7.6%)
 Diarrhea (19.3%)
 Loss of smell or taste (8.3%)

13. Clinical presentation
 Patients with uncomplicated upper respiratory tract
infection, may have mild symptoms such as fever,
cough, sore throat, nasal congestion, malaise,
headache
Clinical parameters
 Without evidence of breathlessness or Hypoxia
(normal saturation).
Remarks
Managed at Covid Care Centre

14. Clinical presentation
 Pneumonia with no signs of severe disease
Clinical parameters
 Adolescent or adult - of dyspnea and or hypoxia, fever,
cough, including SpO2
 <94% (range 90-94%) on room air, Respiratory Rate more
or equal to 24 per minute.
 Child with respiratory distress
 Fast breathing (in breaths/min):
 < 2 months: ≥ 60
 2–11 months: ≥ 50;
 1–5 years: ≥ 40
Remarks
Managed in Dedicated Covid Health Centre
(DCHC)

15. Clinical presentation
 Severe Pneumonia
Clinical parameters
 Adolescent or adult: with clinical signs of
Pneumonia plus one of the following; respiratory
rate >30 breaths/min, severe respiratory distress,
SpO2 <90% on room air.
 The diagnosis is clinical; chest imaging can
exclude complications
Remarks
Managed in Dedicated Covid Hospital

16.  Acute life-threatening organ dysfunction caused
by a dys-regulated host response to suspected or
proven infection.
 Signs of organ dysfunction include: altered
mental status, difficult or fast breathing, low
oxygen saturation, reduced urine output, fast
heart rate, weak pulse, cold extremities or low
blood pressure, skin mottling, or laboratory
evidence of coagulopathy, thrombocytopenia,
acidosis, high lactate or hyperbilirubinemia

17.  Persisting hypotension despite volume
resuscitation, requiring vasopressors to
maintain MAP ≥65 mmHg and serum
lactate level > 2 mmol/L

18. 18
 Counsel the patients to self record their temperature, pulse and
saturation twice daily.
 All the patients should be advised to do 6 min walk test and
record their saturation and pulse rate.
 The patient should be counselled to inform immediately in case of
worsening clinical status.
 After completion, history, vitals to be entered in the case sheet .
 Calculate BMI and note down the GRBS for diabetics at the time of
admission.
 Now let us discuss how to substage the patient given the clinical
details.

20. a) Asymptomatic patients without comorbidities and age<60 yrs
Saturations more than 95%, no fever, no tachycardia.
Investigations required
a) Baseline ECG (Calculate Qtc)
b) Chest radiograph (Look for chest infiltrates)
c) Haemogram (Look for leucopenia, lymphopenia,
thrombocytopenia)
d) RFT
e) LFT
f) RBS
g) CRP
h) Sr Uric acid
 These patients can be advised for home quarantine if it is feasible
and above reports are normal.
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21. 21
Treatment for Stage 1a
a) Tab. Vitamin C 500mg BD for period of isolation
b) Tab. Zincovit B.D for period of isolation
c) Vit D 60k U once weekly for 8 weeks if not taken recently

22.  This stage includes
 Symptomatic / URTI without comorbidities. These include
a) Fever or chills
b) Cough
c) Fatigue
d) Muscle or body aches
e) Headache
f) New loss of taste or smell
g) Sore throat
h)Congestion or runny nose
i) Nausea or Vomiting
j) Diarrhoea.
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23. 23
 Investigations required for Stage 1b
 Haemogram(Look for leucopenia, lymphopenia, thrombocytopenia)
 RFT
 LFT
 RBS
 CXR (Look for chest infiltrates)
 ECG (Baseline Qtc)
 CRP
In case of persistent fever
 Any other investigation deemed to be necessary like blood
cultures, CUE and Urine c/s, USG Abdomen and Procalcitonin,
tropical fever work up ( Dengue antigen and serology, Smear
for MP, Strip for Pf)
 If persistent fever spikes present beyond Day 5 , send inflammatory
markers, (CRP, Ferritin, LDH, D-dimers, LDH, CT if needed)

24. 24
Treatment of Stage 1B
a) Tab. Vitamin C 500mg BD continue until period of isolation.
b) Tab. Zincovit BD until isolation period.
c) Vit D3 60k U once weekly for 8 weeks.
d) Tab. Dolo (paracetamol) 650 mg can be given upto qid dosage.
Addition of antibiotics or HCQS is at the discretion of treating
physician
OR
Doxycycline + Ivermectin 12 mgs
OR
Fabipiravir

25. • 1. Neutrophil lymphocyte ratio > 3.5 -- monitor CBP with
differentials
(consider only if leucopenia present)
 2. Resting tachycardia– closely monitor Pulse, BP, Saturation
 3. 6 min walk deoxygenation,--(Refer to Level 2 care)
4. Persistent fever spikes beyond day 5 and raised
inflammatory markers( alert level 2 care team)
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26.  To Oxygen ward
 1. Respiratory rate > 24/min (or)
 2. SpO2 < 94% on room air. (or)
 3. PaO2/FiO2 level <300 (Mild ARDS)
 To COVID ICU
• 1. Moderate/Severe ARDS
 2. Multi-organ dysfunction
 3. Shock
 4. Transfer from ward to ICU if needs mechanical
ventilation/closer monitoring.
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27. • Asymptomatic or Symptomatic / URTI with comorbidities
a) obesity
b) Age>60 years-
c) DM
d ) HTN/IHD
e) COPD or any chronic lung disease
f) CLD
g) Immuno-compromised state
h) CKD
i) CVA
j) Malignancy
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28. 28
Investigations required for Stage 1c
a) Haemogram with ESR (Look for leucopenia, lymphopenia,
thrombocytopenia)
b) LFT
c) RFT
d) RBS
e) CXR (Look for chest infiltrates)
f) Spo2 at rest and post 6 min walk.
g) ECG (Calculate baseline Qtc)
h) CRP(100mg/L)
i) LDH (>245 U/L), CPK (2*ULN)
j) S.ferritin (>500ug/L)
k) D-Dimer, PT, aPTT, INR (D-dimer>1000ng/mL)
l) S. Triglycerides
m) Trop I levels (>2*ULN)
n) Do procalcitonin if persistent fever spikes present along with
blood cultures, Complete urine exam and urine culture and
tropical fever work up)

29. 29
 Treatment for Stage 1c
a) Tab. HCQ 400mg stat f/by 200mg BD for 4 days or Doxycycline BID for 5
days plus Ivermectin 12 mgs for 3 days
b) Tab. Vitamin C 500mg BD till the period of isolation.
c) Tab. Zincovit B.D. till the period of isolation.
d) Vit D 60k U once weekly for 8 weeks.
e) Tab. DOLO( paracetamol) 650 mg upto QID
f) Inj. Clexane 0.6 cc s/c OD (to all patients) and BD if high D-dimer or an
increasing d-dimer levels (HASBLED score less than 3 for therapeutic dose)
g) Consider steroids if HRCT is showing moderate involvement
h) Antibiotics as per treating physician discretion

30. • Pneumonia/ Lower respiratory tract infections without
hypoxia/breathlessness
• Consolidation/ground glass opacities on imaging (Cxray or
HRCT)
 Investigations required
Haemogram (Look for leucopenia, lymphopenia,
thrombocytopenia)
LFT
RFT
RBS
ECG (Baseline Qtc)
Chest radiograph (monitoring progression of pneumonia)
CRP
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31.  CRP (>100 mg/L)
 D-dimers ,PT, aPTT, INR (D-dimer>1000ng/mL)
 Trop I(>2*ULN)
 LDH (245 U/L), CPK (2*ULN)
 Ferritin(>500ug/L)
 Procalcitonin (if suspecting infection)
 Blood cultures 2 sets mandatory before starting IV antibiotics,
CUE, Urine c/s
 Other tropical fever ( Dengue antigen and Serology, Smear for
MP, Pf strip test, )work up if necessary
 Any other investigation required at the discretion of treating
physician.
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32. Treatment
a) Tab. HCQ 400mg stat f/by 200mg BD for 4 days or Doxycycline BID for 5
days plus Ivermectin 12 mgs for 3 days
b) Tab. Vitamin C 500mg BD till the period of isolation.
c) Tab. Zincovit B.D till the period of isolation.
d) Vit D 60k U once weekly for 8 weeks.
e) Tab. DOLO (paracetamol) 650 mg upto QID
f) Inj. Clexane 60mg s/c OD (to all patient) and BD if high D-dimer or an
increasing d-dimer levels (HASBLED score<3)
g) Consider steroids if HRCT is showing moderate involvement
g) Antibiotics as per treating physician discretion.
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33. • 1. Neutrophil lymphocyte ratio > 3.5,--monitor daily CBP with
differentials
 2. Resting tachycardia-- monitor pulse, BP, saturation.
3. 6 min walk test desaturation
 4. Raised inflammatory markers
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34. How do we recognise?
Tachypnea and Hypoxia at rest
 Investigations of stage 2b :
Haemogram (Look for leucopenia, lymphopenia,
thrombocytopenia)
Repeat CBC,DC daily
RFT (Repeat daily)
RBS CRP
LFT (Repeat daily)
ECG (Baseline Qtc)
Chest radiograph (monitoring for progression of pneumonia),
HRCT chest
ABG (Repeat daily)
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35. Treatment of Stage 2b
a) Tab. HCQ 400mg stat f/by 200mg BD for 4 days
b) Tab. Vitamin C 500mg BD till the period of isolation.
c) Tab. Zincovit B.D till the period of isolation
d) Vit D , 60k U once weekly for 8 weeks.
e) Tab. DOLO(paracetamol) 650 mg upto QID
f) Inj. Clexane 60mg s/c OD and BD if high D-dimer or an increasing d-
dimer levels.(HASBLED score<3)
g) Antibiotics as per treating physician discretion.
h)
i) Inj. Methyl Prednisolone 40mg IV BD-0.5-1 mg/kg body weight for 3 to
5 days. If stable can switch to oral form
Or
Inj. Decadron 6- 8mg IV -0.1-0.2 mg/kg body weight
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36. • 1. Neutrophil lymphocyte ratio > 3.5,--monitor daily CBP with
(consider leucopenia) differentials
 2. Resting tachycardia-- monitor pulse, BP, saturation
 3. Raised inflammatory markers-
 If HCQs cannot be given for any reason like prolong Qtc or
G6PD deficiency,
Ivermectin 12mg dose for 3 days with Doxycycline 100 mg BD
for 5 days may be considered.
36

37. GENERAL GUIDELINES
 Continue the same antihypertensives which the patient has been
using unless there is contraindication regarding prolonged Qtc
like beta blockers.
 GRBS to be monitored TID (premeal) by the patients.
 Continue the same medications for DM, if well controlled . If
GRBS more than 200mg/dL consider use of Basal or short acting
insulin as is necessary.
 Carefully adjust drug doses and monitor patients in case of CKD,
and CLD.
 Always take speciality consultations as and when required.
 Those patients who have been started on steroids,
monitor GRBS TID, electrolytes every alternate day.
Add folic acid 5mg and calcium 500mg BD to the treatment
protocol.
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38. Finger Pulse Oximeter for continuous monitoring of Heart rate and Oxygen
saturation
 • Start oxygen with Mask at saturation of 94% or lower
 • HFNC to be used if there is failed oxygen therapy and Non-invasive
ventilation (NIV) to be used appropriately with two limb circuit expiratory
filters
 • Counselling of COVID19 patients ( By Counsellor/psychologist/psychiatrist)
 • Normal feeding, no dietary restrictions, good oral hydration
 • Maintenance IV fluids (If indicated)
 • Maintain blood glucose levels <180 mg/dl.
 • If Patient is on ACE inhibitors/ARBs, should be continued
 • Avoid using NSAIDs other than Paracetamol Unless Absolutely Necessary
 • Avoid using Nebulized drugs to avoid aerosolization of virus. PREFER MDI
with SPACER
 • Antibiotic selection in case of superadded bacterial pneumonia should be
according to institution antibiogram.
Supportive Care

43. Dose:
 Tab HCQ 400MG BD FOR 1 DAY Followed by 200MG
1-0-1 X 4 Days
CONTRAINDICATION FOR HCQS
 QT INTERVAL > 480ms
 • Pre-existing cardiomyopathy and cardiac rhythm disorders
 • History of Unexplained Syncope
 • Retinopathy,
 • Hypersensitivity to HCQ or 4-aminoquinoline compounds
 • G6PD deficiency
 • Epilepsy
 • Hypokalemia (K+ < 3 Meq)
Hydroxychloroquine (HCQS)

44.  Pro Coagulant factors are increased in COVID-19 infection and associated
with increased risk of thrombosis
 The most marked abnormality is an elevation of D-Dimer (if D-dimer is more
than 1000ng/ml) but without a parallel fall in platelet or prolongation of
clotting time
 Dose:
 Inj ENOXAPARIN 40MG S/C Once daily for mild and moderate. Twice daily in
severe cases
 Other options:
 • Inj Fondaparinux 2.5mg OD SC
 • Unfractioned Heparin 5000 Units BD SC
 Contraindications:
 ESRD, active bleeding, emergency surgery, platelets < 20,000/mm, BP
>200/120 mmHg)

45.  may be considered in patients with moderate
disease (those on oxygen) with none of the
following
Contraindications:
 AST/ALT > 5 times Upper limit of normal (ULN)
 Severe renal impairment (i.e., eGFR < 30ml/min/m2 or need for hemodialysis)
 Pregnancy or lactating females
 Children (< 12 years of age)
 Dose: 200 mg IV on day 1 followed by 100 mg IV daily for 4 days (total 5 days)
 100mgs-To be given in 100ml Normal Saline over 1-2 hours

46.  may be considered in patients with severe disease with
progressively increasing oxygen requirements and in
mechanically ventilated patients not improving despite use of
steroids. Long term safety data in COVID 19 remains largely
unknown.
Special considerations before its use include:
 IL-6 levels 50-100 fold higher than normal (Normal range 0 -
9.5pg/ml
 Worsening trend of the inflammatory markers (Ferritin, LDH, CRP)
 Deteriorating clinical condition with worsening of PaO2/Fio2 ratio
(more than 25% deterioration from the immediate previous value)

47. Contraindications
 PLHIV, those with active infections (systemic bacterial/fungal)
 High Serum. Procalcitonin, Tuberculosis, active hepatitis,
Absolute Neutrophil Count < 2000/mm3 and Platelet count <
1,00,000/mm3
 hepatic and renal impairment; patients on chronic steroid
therapy
 Paediatric patients <18 years old; Pregnancy and, Nursing
mothers
 Dose: 8mg/kg (maximum 800 mg at one time)
given slowly in 100 ml NS over 1 hour; dose can be
repeated once after 12 to 24 hours if needed

48.  may be considered in patients with moderate disease who are not
improving (oxygen requirement is progressively increasing) despite use
of steroids.
Special prerequisites while considering convalescent plasma include:
 ABO compatibility and cross matching of the donor plasma
 Neutralizing titer of donor plasma should be above the specific threshold
(if the latter is
 not available, plasma IgG titer (against S-protein RBD) above 1:640 should
be used)
 Recipient should be closely monitored for several hours post transfusion
for any transfusion related adverse events
 Use should be avoided in patients with IgA deficiency or immunoglobulin
allergy
 Dose: Dose is variable ranging from 4 to 13 ml/kg (usually 200 ml single
dose given slowly over not less than 2 hours

49.  Favipiravir RTP selectively inhibits RNA polymerase
 Indications: mild to moderate cases of COVID19 in adults >18yrs old
 Dose: 1800mg bid followed by 800mg bid upto maximum of 14days
 Contraindications: Hyperuricaemia, severe hepatic & renal impairment,
Pregnant women and lactating mothers
 Side Effects: increased Uric Acid levels, diarrhea, decreased neutrophil
counts, increase in AST/ALT levels
 Drug Interactions: metabolised partly by Aldehyde Oxidase(AO) and partly by
Xanthine Oxidase(XO). Precauitons for co-administration with Pyrazinamide,
Repaglinide, Theophyline, Famciclovir

50.  CT chest is not recommended routinely
 If patient progressively deteriorates clinically with worsening
of hypoxia , HRCT can be considered at the discretion of
physician
 If PTE is suspected, ECG, 2 D Echo and CT chest
50

51. •CO-RADS is a categorical assessment scheme used for
reporting of chest CT patients, suspected of COVID-19.
•It represents the level of suspicion for pulmonary involvemen
•For example, if CO-RADS is level 5 then there is very high
surety for Typical COVID-19 findings.

52. CO-RADS
LEVEL OF SUSPICION FOR COVID-19 INFECTION
CT Findings
CO-RADS 1 No Normal or non-infections abnormalities
CO-RADS 2 Low Abnormalities consistent with infections
other than COVID-19
CO-RADS 3 Intermediate Equivocal findings for COVID-19 infections
CO-RADS 4 High Abnormalities suspicious for COVID-19
infection
CO-RADS 5 Very high Typical COVID-19 findings
CO-RADS 6 PCR +

53. HRCT REPORT TEMPLATE
LOW DOSE H.R.C.T. CHEST
SCREENING (L.D.C.T.S.):
IMPRESSION:
Findings are suggestive of atypical
viral pneumonia, possibility of
COVID-19 infection. (CO-RADS V).
CT severity score 9 / 25 (Moderate)
CO-RADS 5 means there is
very high suspicion of COVID
19 infection in this particular
patient with typical COVID-19
infection

54. 5 % INFECTED
5-25 % INFECTED
25-50 % INFECTED
50-75 % INFECTED
 75 % INFECTED
: SCORE 1
: SCORE 2
: SCORE 3
: SCORE 4
: SCORE 5
Score calculation is done based on each lobe involvement. Each lobe
has maximum score 5.
And so 5 lobes has maximum score of 25.
For example, score 5 means that lobe is > 75% involved or affected by
COVID- 19.

55. SCORE CT SEVERITY
< 8 MILD
9 - 15 MODERATE
> 15 SEVERE

56. HRCT REPORT TEMPLATE
LOW DOSE H.R.C.T. CHEST
SCREENING
(L.D.C.T.S.):
IMPRESSION:
Findings are suggestive of atypical viral
pneumonia, possibility of COVID-19
infection. (CO-RADS V).
CT severity score 9 / 25
(Moderate)
CT SEVERITY SCORE 9 OUT OF 25
means lungs are moderately
infected with COVID-19 in this
particular patient.
CT
Severity
%Invol
ve
ment
Sco
re
Right upper lobe 5 to 25% 2
Rt middle lobe 5% 1
Right lower lobe 25% 2
Left upper lobe 5 to 25% 2
Left lower lobe 5 to 25% 2
Total 9 /25

57. 
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58. THANK YOU