COVID-19 INFECTION - MANAGEMENT PROTOCOL

I.WHEN TO SUSPECT COVID 19 INFECTION?

SUSPECT COVID-19 IN ANY PATIENT WITH FOLLOWING COMPLAINTS

1. History of Fever of any grade and any duration (during this pandemic)
2. Myalgia
3. Cough
4. Breathlessness - SUSPECT SEVERE FORM OF COVID DISEASE
5. Loss of smell & taste.
6. Malaise, Feeling of extreme weakness
7. Vomiting, Diarrhoea - SUSPECT SEVERE FORM OF COVID DISEASE
8. Headache
9. Runny nose
10. Abdominal Pain
11. Altered sensorium

II. WHO ARE AT HIGH RISK FOR SEVERE COVID DISEASE?

• People of more than 60 years age

• People of any age with following comorbidities
1. Cardio vascular Disease
2. Chronic Lung Disease (COPD / Bronchial Asthma / Post TB sequelae)
3. Chronic Kidney diseases
4. Obesity (BMI ≥ 25)
5. Uncontrolled Diabetes & Uncontrolled Hypertension
6. People with Cancer undergoing active Chemotherapy or
Radiotherapy
7. Post transplantation patients on Immunosuppressive therapy
8. Chronic Neurological conditions
9. Problems with Spleen such as sickle cell disease/ splenectomy
III. DIAGNOSTIC TESTS FOR COVID 19 INFECTION
o RT PCR testing for all cases
o Trunat
o CBNAAT
o Antigen detection tests are done in seriously ill patients with severe
symptoms for rapid diagnosis.
→Persons with Positive Rapid Antigen test are treated as per treatment
protocol depending on the severity
→ Persons with Negative Antigen tests should be re-tested by
RTPCR.
→ In persons with high suspicion and worsening clinical condition,
CT chest is done and treated accordingly.
• Antibody tests are not useful for confirmation of active infection & for
guiding treatment

IV. CATEGORISATION OF COVID-19 RT- PCR POSITIVE

PATIENTS (Depending on severity of symptoms at presentation)

Group A: Asymptomatic patients & patients with mild symptoms

Group B: Symptomatic patients with mild to moderate pneumonia
with no signs of severe disease
Respiratory rate: ≥ 24 /minute
SPO2 : 90 - 94% of Room Air
Group C: Symptomatic patients with severe pneumonia
Respiratory rate: > 30 /minute
SPO2: <90% at Room Air / <94% with oxygen
ARDS
Septic Shock
Multi organ Dysfunction
Categorisation of mild / moderate / severe should be reassessed regularly.

Management of any covid-19 patient mandates all the healthcare

personnel (HCP) to be in full personal protection equipment(PPE)
V. INVESTIGATIONS
All covid-19 Positive patients should be subjected for the following
investigations at presentation and may be repeated whenever
necessary
BASIC INVESTIGATIONS: to be done for all COVID positive patients

Complete Blood Counts with Neutrophil Lymphocyte Ratio(NLR)

RBS
RFT
LFT
ECG
X ray chest PA view

ADDITIONAL INVESTIGATIONS: to be done depending on the severity of the

disease
• Serum Electrolytes
• C-Reactive Protein(CRP)
• LDH
• Serum Ferritin
• D-Dimer
• Troponin T
• PT, APTT /INR
• Procalcitonin
• Arterial Blood Gas analysis
• CT Scan of chest
• IL-6 in Severe Cases
• Nasopharyngeal swab for qualitative PCR for SARS COV2 –
if initial RTPCR is negative
• S. Uric Acid – before starting Favipiravir
• HbA1C in Diabetics
• 2D Echo in Heart Disease Patients
VI. ADMISSION CRITERIA
Group A: Home isolation/ Covid Care Centre
Group B: Admission in Dedicated Covid Health Centre(DCHC)
Group C: Admission in Dedicated Covid Hospital for Critical Care

VII. INDICATIONS FOR ICU ADMISSIONS

Age > 60 years / Comorbidities –DM/HTN/COPD/Br. Asthma/CKD
H/O Respiratory distress with
SPO2 < 90% or RR > 30 / minute
PR >100 /minute or SBP < 90 mm
H/O Altered Sensorium
Lymphopenia with Neutrophil/Lymphocyte ratio > 3.5
CRP >100 mg/l
Serum Ferritin >300 µg/L
LDH >245
D-Dimer> 1.0

VIII. GENERAL MANAGEMENT GUIDELINES FOR COVID 19

• Isolation of the patient
• Monitor Heart Rate and oxygen saturation with Finger pulse oximeter.
• Check oxygen saturation after walking for 6 minutes →
If <95% inform hospital authority
• Check temperature with Digital thermometer
• Check BP with Automatic BP apparatus
• Steam inhalation
• Wear mask
• Frequent hand washing
• Follow Social distancing norms
• Maintain good Hydration - Frequent drinking of Hot water
• Normal Diet supplemented with Immune boosters
• Breathing Exercises / Follow yoga & meditation / Relaxation techniques
• Keep moving in the room
• Diabetic patients - self-monitoring of blood glucose with glucometer 🡪
Maintain blood glucose levels within normal range and adjusted with
insulin if needed
• Continue regular Inhalers as advised by chest physician –
AVOID NEBULIZATION
• Avoid NSAIDS other than paracetamol unless absolutely indicated
 • Psychological counselling if needed
• Antibiotics – for secondary bacterial infections according to institutional
protocols.

IX. MANAGEMENT OF MILD COVID INFECTION

• Fever and/ or uncomplicated upper respiratory tract infection
without breathlessness
• SPO2 > 94% in Room air
• CT Chest normal (if done)

Laboratory tests:- Neutrophil lymphocyte ratio < 3.2

CRP < 40
LFT Normal

Treatment: - To follow all general guidelines.

SUPPORTIVE Rx
• Tab paracetamol 500mg tid
• Tab Vit-C 500mg tid for 7 days
• Tab Zinc 50mg OD for 7 days
• Cap Vit-D 60000 IU weekly once for 4 weeks
• Tab. Hydroxy Chloroquine (HCQS): ( after checking baseline ECG)
400 mg bid on day 1 followed by 200 mg bid from day 2 to day 5
• Tab Azithromycin 500 mg od for 5 days
• Tab Omeprazole / Rabeprazole 20 mg once a day for 5 days
• Antibiotics – when secondary bacterial infection is suspected.

ANTIVIRAL DRUGS

• FAVIPIRAVIR: 200mg x 9 tabs. bid on D1 and then 4 tab. bid for 13

days - for high risk group – as decided by treating physician
Discharge criteria for mild covid-19 positive patients
✓ Afebrile for three days without antipyretic and no breathlessness
✓ 10 days from symptom onset
✓ Repeat RT PCR not required
Discharge advice: Isolation and self-monitoring for 7 days
X. MANAGEMENT OF MODERATE COVID INFECTION

Symptoms of breathlessness can be present

SPO2 - 90- 94% in Room air
RR: ≥ 24 / Min
CT chest – CORAD Features present >40% of lung involvement
Laboratory Findings:
Neutrophil-to-Lymphocyte ratio > 3.2
CRP: >100
LFT : Slight Derangement
LDH: 300 to 400
Ferritin: > 500
D-dimer > 0.5
IL -6 : 5 - 50

Treatment: Vitals monitoring every 4th hourly

(more frequently as the clinical condition warrants)
SUPPORTIVE Rx: as recommended for Mild COVID infection +
o Tab N-Acetyl Cysteine 600mg tid in patients with cough
o When secondary infection is suspected & increase in leucocyte
count with Neutrophilia - IV or Oral antibiotics according to the
clinical picture & local antibiogram
ANTIVIRAL DRUGS:
• FAVIPIRAVIR: for stable Moderate COVID infections -
as decided by treating physician
200mg x 9 tabs. bid on Day 1 and then 4 tab. bid for 13 days

• REMDESIVIR: Indicated in worsening clinical condition

Day 1- Loading dose of 200 mg given as IV infusion over 30 – 120 minutes
Followed by 100 mg IV daily from Day 2 – Day 10
Remdesivir may not be effective if started one week after symptom onset.
Stop Favipiravir when Remdesivir is started.
ANTICOAGULATION THERAPY: Low Molecular Weight Heparin (LMWH)
Start if X Ray/CT chest showing ground glass opacities even without
D-Dimer test.
• Enoxaparin 40 mg S/C od for 7 days – Increase to bid if D-dimer > 1

• Unfractionated Heparin 5000 SC BID can be used in End Stage Renal

Disease

STEROIDS IN MODERATE COVID 19 DISEASE

Inj. Methylprednisolone - 0.5 to 1 mg /kg BW for 3 days
Inj. Dexamethasone- 0.1 to 0.2 mg /kg BW for 3 days
preferably Start within 48 Hours of admission or
if Oxygen requirement is increasing and
if inflammatory markers are increasing
Inj. Hydrocortisone 80 mg bid for 5 days – pregnant & lactating women
Review the duration of steroid treatment as per the clinical response

OXYGEN THERAPY IN MODERATE COVID DISEASE

Target SpO2 92 to 96% (88 to 92% in COPD Patients)
The device for administering oxygen depends on the O2 requirement -
Nasal prongs
Mask
Mask with breathing / Non - Rebreathing reservoir bag
If SPO2 ≤ 94%: start O2 with face mask – 5 L/min or Nasal prongs -2.5 L/min
If High Flow Nasal Cannula(HFNC) or simple cannula is used , N95 mask to
be applied over it.
Awake proning may be used as rescue therapy
Monitor oxygen requirement
Monitor for work of breathing
 All patients should have 12 lead ECG
Watch for Haemodynamic dynamic instability

SELF PRONING PROCEDURE

• Continuous SPO2 monitoring required
• Cardiac leads monitoring if needed
• Prior to proning
o Ask patient to empty bladder
o Make sure that mobile phone and calling Bell reachable
o If possible place bed in reverse Trendelenburg position (head 10
degrees above feet) to reduce intraocular pressure
o Arrange tubing so that it comes on top of bed and not across the
chest (to avoid tangling)
Contraindications for proning
• Hemodynamic instability
• Elevated intracranial or intra-abdominal pressure
• Fractures, wounds in face and chest
• Cervical neck problems that may be exacerbated.
• Extreme obesity, second & third trimester of pregnancy.
• GCS < 8

Care must be taken to not disturb the flow of oxygen during patient rotation

Typical protocols for proning include 30 - 120 minutes in prone position,

followed by 30-120 minutes left lateral decubitus, right lateral decubitus and
upright sitting position

Follow up of Moderate disease patient in the admission

Repeat CBC with NLR / RFT /LFT -- Every 2 days
D-Dimer / Ferritin / Coagulation parameters - Q 48-72hr
ECG / X-ray Chest / CT chest - Depending on the clinical condition
Discharge criteria for moderate Covid Disease
Afebrile > 3 days without antipyretics
No breathlessness
10 days from symptom onset
No oxygen requirement for 3 days
RT-PCR not advised at the time of discharge

Discharge advice: Isolation + self-monitoring first for seven days

Warning signs in moderate Covid disease:
Patient should be reassessed regularly for
Increasing Respiratory rate
Fever 104o F
PR > 100/ min
SPO2 < 95% in Air
Systolic BP < 90 mm
Altered sensorium
Decreasing Urine output
Severe Headache or vomiting
Worsening chest X-ray /CT Chest

PASS management:
P- Proning
A-Anticoagulation (Early - based on clinical, radiological & blood investigations)
S- Steroids (Early - based on clinical, radiological& blood investigations)
S- Supportive therapy (Oxygen /NIV/Ventilation/
nursing care for close monitoring)

XI: MANAGEMENT OF SEVERE COVID INFECTION

Admit in ICU
Patients with H/O fever > 39 ◦C & SOB with SPO < 90% in Room air
2

Infiltrates on CT chest (CORADS > 5)

Respiratory distress requiring mechanical ventilation
(Non-invasive and invasive)
Hemodynamic instability
 Laboratory findings: inflammatory markers to be repeated daily
Neutrophil-to-lymphocyte ratio > 5.5
CRP > 125
LFT- moderate derangement
LDH > 400
Ferritin > 800 - prognostic sign of cytokine Storm & risk of Stroke
D-dimer > 1.0
IL-6 > 80
Troponin T > 2 times the Upper normal limit
CPK >2 times Upper normal

Treatment: Supportive Rx as advised for Moderate COVID infection +

➢ Prone ventilation for 16 to 18 hours per day
➢ Maintain SPO2 > 90% with High flow Nasal oxygen -
Cautious trial of CPAP oro- nasal mask/ NIV with helmet interface.
If patient deteriorates, early intubation should be considered.
➢ Maintain Euvolemia/ Monitor for Electrolyte abnormalities /
Correct acidosis
➢ Inj. Methylprednisolone Intravenous: 1- 2 mg/Kg /day for 5 - 7 days
(OR)
Inj. Dexamethasone Intravenous - 0.2 -0.4 mg/Kg/day for 5 -7 days
➢ LMWH – Enoxaparin 40 mg bid, SC (if not at high risk of bleeding)
➢ Inj. Remdesivir - IV 200 mg on Day 1 & then 100 MG IV for 4 Days
➢ Treat comorbidities - HTN/DM

Cytokine storm:
• Check IL-6 levels
• Check fibrinogen levels
• LDH > 500
• Ferritin > 800
• Absolute lymphocyte count < 800 / Platelets < 25000
• PaO /Fio ratio < 300
2 2

• Rapid worsening of respiratory gas exchange with or without

availability of non-invasive or invasive ventilation.
Treatment of Cytokine storm: Tocilizumab –
Recombinant humanized monoclonal antibody against IL-6 receptor
8 mg/ kg (to a maximum dose of 800mg) given as infusion over 1 hour
Second dose should be administered after 8 to 12 hours

Contraindications for drugs used in COVID Infections

Contraindications for HCQs : Avoid combination with Azithromycin -

• QT interval ≥ to 500 m sec Porphyria

• Myasthenia gravis Retinal pathology
• Epilepsy Hypokalemia

Contraindications for Favipiravir

▪ Hyperuricemia
▪ Severe hepatic and renal impairment
▪ Pregnant and lactating women
➢ Side effects of Favipiravir:
Increase in Uric acid levels / Increase in AST/ALT
Diarrhoea
Decrease in Neutrophil Count

Contraindications for Remdesivir

• Liver dysfunction ( ALT > 5 times normal limit )
• CKD – GFR < 50 ml / minute
• Pregnancy & Lactation
• Children < 12 years
Drug interactions of Remdesivir
• HCQs (Chloroquine)
• Dexamethasone - (use only methylprednisolone with Remdesivir )
Avoid using Remdesivir with
Phenytoin Carbamazepine
Efavirenz Nevirapine
 Common side effects of Remdesivir
• Increase in transaminases elevation
• Infusion reactions Diaphoresis /Hypotension/ Nausea /shivering
/vomiting

Contra indications for LMWH

End-stage renal disease Active bleeding
Emergency surgery Platelets < 20000 / mm 3

BP > 200 /120 mm HG

Contraindications for Toclilzumab

• In severe hepatic impairment
• contraindicated in active TB infection
The above protocols are prepared with available references till 25-7-2020 and
updated versions will be given accordingly.

REFERENCES:

1. CLINICAL MANAGEMENT PROTOCOL: COVID 19 by MOHFW OF GOI

(VERSION 5 dt. 03.07.2020)

2. GOVT. OF AP PROTOCOLS FOR COVID 19

3. HANDBOOK FOR THE CLINICAL MANAGEMENT OF COVID 19

COMPILED BY

Dr. P. Krishna Prasanthi, MD, FICP, FRSSDI,

Senior Consultant Physician, Vice Chairperson API - AP State, IMA WDW
9985309595, [email protected]

With Lead Team IMA, Tirupati Branch

Dr. D. Sreehari Rao, Chittor District IMA COVID Coordinator

Dr. P. Ravi Raju, President IMA, Tirupati

Dr. I. Yugandhar, Secretary IMA, Tirupati

Dr. K. Madhusudan Rao, Treasurer IMA, Tirupati

EXPERT PANEL OF DOCTORS:

Dr. C. Aruna Sulochana Devi MBBS;DDVL, Addl. DMHO & DLO, Chittoor

Dr. S. Subba Rao MD, Chittoor District Nodal Officer for COVID

Dr. C. Hithaishi, DM, DNB, (Nephro)

Dr. S. Madan Mohan Reddy, MD, (Anae)

Dr. C. Venkataramana, DM, (Cardio)

Dr. P. Bhaskar Reddy, MCh, DNB, (Uro)

Dr. D. GopiKrishna Reddy, MS (Gen)

Dr. V. Sunanda Kumar Reddy, MS (Ortho)

Dr. K. Kishore Kumar, DPM

Dr. R. Nirupama, DGO