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
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.
19.
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.
20
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.
22
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)
25
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.
26
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
27
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
30
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.
31
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.
32
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
33
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)
34
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
35
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.
37
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
39.
40.
41.
42.
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.
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