Clinical Management of COVID-19 Cases

Clinical Management of COVID-19 Cases

1. Clinical Management of COVID-19 Cases Third wave Covid TOT

2. Introduction Coronaviruses are large group of viruses that cause illness in humans and animals Rarely, animal coronaviruses can evolve and infect people and then spread between people such as has been seen with and SARS outbreak in 2003 which started from China The outbreak of Novel coronavirus disease (COVID-19) was initially noticed in a seafood market in Wuhan city in Hubei Province of China in mid-December, 2019, has now spread to 215 countries worldwide WHO declared COVID-19 a pandemic on 11 th March, 2020

3. Epidemiology Current available evidence for COVID-19 suggests that the causative virus (SARS-CoV-2) has a zoonotic source closely related to bat-origin SARS-like coronavirus

4. Epidemiology The coronaviruses are made up of four structural proteins, namely, the spike (S), membrane (M), envelop (E) and nucleocapsid (N) proteins The S protein is seen to be protruding from the viral surface and is the most important one for attachment on host cell and penetration This protein is composed of two functional subunits (S1 and S2), among which S1 is responsible for binding to the host cell receptor and S2 subunit plays a role in the fusion of viral and host cellular membranes

5. Coronavirus Structure

6. Epidemiology ACE-2 receptor has been identified as a functional receptor for SARS- CoV and is highly expressed on the pulmonary epithelial cells

7. Transmission Major source of infection is Human to Human Transmission via Airborne Droplets generated by Speaking, coughing, sneezing Fomites, from droplets landing on surfaces and virus surviving for variable amount of time

8. Incubation Period Ranges from 1 to 14 days. Median incubation period around 5 days Period of infectivity: From 2 days before symptom onset to around 7 to 10 days after Symptom onset

9. Pathophysiology

10. Case Definitions (Suspect) A A person who meets the clinical AND epidemiological criteria: Clinical Criteria: Acute onset of fever AND cough; OR Acute onset of ANY THREE OR MORE of the following signs or symptoms: Fever, cough, general weakness/ fatigue, headache, myalgia, sore throat, coryza, dyspnoea, anorexia/nausea/vomiting, diarrhoea, altered mental status. AND

11. Case Definitions (Suspect) Epidemiological Criteria: Residing or working in an area with high risk of transmission of virus: closed residential settings, humanitarian settings such as camp and camp-like settings for displaced persons; any time within the 14 days prior to symptom onset or Residing or travel to an area with community transmission any time within the 14 days prior to symptom onset or Working in any healthcare setting, including with in health facilities or within the community; any time within the 14 days prior of symptom onset

12. Case Definitions (Suspect) B A patient with severe acute respiratory illness: SARI: acute respiratory infection with history of fever or measured fever of ≥38 C°; and cough; with onset (within the last 10 days; and requires hospitalization)

13. Case Definitions (Probable) A. A patient who meets clinical criteria above AND is a contact of a probable or confirmed case, or linked to a COVID-19 cluster B. A suspect case with chest imaging showing findings suggestive of COVID-19 disease C. A person with recent onset of anosmia(loss of smell) or ageusia(loss of taste) in the absence of any other identified cause D. Death, not otherwise explained, in an adult with respiratory distress preceding death AND was a contact of a probable or confirmed case or linked to a COVID-19 cluster

14. Case Definitions (Confirmed) A. A person with a positive Nucleic Acid Amplification Test (NAAT) including RT-PCR or any other similar test approved by ICMR B. A person with a positive SARS-CoV-2 Antigen-RDT AND meeting either the probable case definition or suspect criteria OR C. An asymptomatic person with a positive SARS-CoV-2 Antigen-RDT who is a contact of a probable or confirmed case

15. Clinical Presentation History of Fever Malaise Body ache and backache Sore Throat, Rhinitis, Rhinorrhoea, Dry cough Breathlessness on exertion/speaking Diarrhoea Retrosternal Chest Discomfort or frank Chest pain Prostration

16. Clinical Presentation Headache Loss of smell and Taste Severe weakness, fatigue Altered mental Status Fever and severe constitutional symptoms may be absent in Children, Elderly, diabetics Symptoms may be mild in patients who have taken single or both doses of Vaccine History of Contact with a probable or Positive case is Important for suspecting in cases having Mild Symptoms

17. Categorization of Severity (Mild) Symptoms such as dry cough, sore throat, mild fever, body ache etc suggestive of Upper respiratory infection only Normal saturation, No Dyspnoea, Tachypnea, Tachycardia

18. Categorization of Severity (Moderate) Patients with Pneumonia but without signs of severe disease Saturation between 90 to 93 % on room air Respiratory Rate > 24/ min in adults

19. Categorization of Severity (Severe) Patient with severe pneumonia with Severe Respiratory Distress Saturation < 90% on room air Hypotension Unconsciousness or altered sensorium Cyanosis

20. Clinical Assessment at OPD/Triage/Indoor facility. History taking with special emphasis on Age Comorbidities Duration of current illness (Onset of 1 st Symptom) In case of Female: LMP and in case of pregnancy, duration of Pregnancy Medication History VACCINATION STATUS. (patients who have completed 2 weeks after 2 nd Dose of Vaccination are less likely to progress to severe disease) History of steroid use, immune suppressants use, addictions

21. Clinical Assessment at OPD/Triage/Indoor facility. Examination should focus on Overall General examination: Cyanosis, Shock, sense of distress, air hunger Temperature Pulse rate (can be seen on Pulse Oximeter finger probe) Respiratory Rate Brachial Blood Pressure Evaluation of Sensorium Quick examination to see for Use of Accessory muscles, distress, Cyanosis, Pallor Screening RBS by Glucometer in all suspected/probable/confirmed cases BMI may be calculated Oxygen saturation (can be seen on Pulse Oximeter finger probe)

22. Testing for COVID-19 All suspected case should be tested by RAT/RTPCR RAT negative cases should be confirmed by RTPCR RTPCR test must not be repeated in any individual who has tested positive once either by RAT or RTPCR No testing is required for COVID-19 recovered individuals at the time of hospital discharge in accordance with the discharge policy of Mo H& FW The need for RTPCR test in healthy individuals undertaking inter-state domestic travel may be completely removed to reduce the load on laboratories

23. PLACE OF TREATMENT MILD CASES : AT HOME ISOLATION/PHC/CHC/CCCs. MODERATE CASES: Dedicated COVID health Centre(DCHC) SEVERE CASES: Dedicated Covid Hospital (DCH)

24. Indications for Admission to Hospital facility Persistent High Fever Respiratory Rate >24/min Patient in Respiratory Distress ( Increased rate, Use of accessory muscles, Nasal Flaring, inability to walk, breathlessness while speaking etc) Tachycardia Saturation < 94% on room air Severe weakness, fatigue Uncontrolled diabetes, Morbid Obesity, Heart Failure, underlying COPD Patients having above findings should be monitored closely for complications and disease progression and should be admitted at a facility having availability of Oxygen

25. Medical management of COVID-19 cases as per severity

26. Medical management of COVID-19 cases as per severity

27. Medical management of COVID-19 cases as per severity

28. Investigations to be done in Moderate to severe cases of COVID-19 Investigations suggested in Mild Cases Plus RBS, FBS/PP2BS and HbA1C if patient is diabetic or RBS is high Serum Electrolytes Serum Ferritin Inflammatory markers like CRP, Serum Ferritin, should be done at discretion of treating doctor Markers suggesting Cytokine storm should be done based on clinical suspicion by treating doctor IL 6 levels not to be repeated after administration of Tocilizumab

29. Investigations to be done in Moderate to severe cases of COVID-19 In moderate and severe cases repeat investigations should be done as follows: CRP and D-dimer every 24-48 hours CBC, RFT, LFT daily Repeat investigations should be done at discretion of treating doctor

30. Investigations to be done in Moderate to severe cases of COVID-19 ABG should be done for all patients on BiPAP/Invasive ventilator as required or on clinical worsening of patient In case of suspected Bacterial Infection, Pro-Calcitonin can be done at discretion of treating doctor In suspected Bacterial infection Culture of Sputum/ET aspirate, Blood, Body Fluids may be done based on clinical scenario and discretion of treating doctor Pro-Calcitonin may be done before administration of Tocilizumab

31. Investigations to be done in Moderate to severe cases of COVID-19 ECG should be done in all patients, repeated if required Bedside X Ray Chest, if patient is on Oxygen and facility available X Ray may be repeated in case of sudden worsening, to rule out complications like Pneumothorax, Pneumo-mediastinum Routine use of HRCT is not required. (in case HRCT is planned Oxygenation during transportation and Procedure and Risk benefit ratio should be considered) In radiological investigations look for extent of disease, Pneumothorax Echocardiography if available in suspected PTE or Heart Failure Venous Doppler in case of suspected DVT Arterial Doppler in case of suspected occlusion

32. Radiological features COVID-19 Typical Chest Imaging findings in COVID -19 Include Chest Radiography : Hazy opacities often rounded in morphology with peripheral and lower lung distribution Chest CT : Multiple bilateral ground glass opacities, often rounded in morphology with peripheral and lower lung distribution Lung Ultrasound : Thickened pleural lines, B Lines (multifocal discrete or confluent) consolidative patterns with or without air bronchograms

33. Radiological features COVID-19 Summary of potential chest radiograph findings in covid-19 pneumonia The chest radiograph may be normal in up to 63% of people with covid-19 pneumonia, particularly in the early stages Changes include ground glass (68.5%),  coarse horizontal linear opacities, and consolidation. These are more likely to be peripheral and in the lower zones , but the whole lung can be involved Ground glass appearance is common in earlier presentations and may precede the appearance of consolidation Bilateral lung involvement is most common (72.9%) Signs suggestive of potential comorbidities on chest radiography might be obscured by signs of covid-19 pneumonia

34. Radiological features COVID-19 Ground glass (GGO) pattern is the most common finding in COVID-19 infections. They are usually multifocal, bilateral and peripheral, but in the early phase of the disease the GGO may present as a unifocal lesion

35. Radiological features COVID-19

36. Patient selection for Home isolation Saturation Normal Respiratory rate, Pulse rate normal No exertional dyspnoea, tachypnoea No co-morbidities/ comorbidities under control Patient and relatives capable of monitoring health Able to and willing to follow home isolation protocol Within reach of medical facility in case condition worsens

37. Guidelines for patients kept at home isolation Self Isolation should be done even before testing if symptoms appear Patients should be explained regarding need for Isolation at home and wearing mask throughout stay at home Not to come in close contact with elderly and young children Perform frequent hand Hygiene Take adequate fluids and diet Take medicines prescribed as per doctors’ advice Patients not having facilities for Home isolation, persons staying in institutions should be preferably admitted for facility quarantine to prevent transmission. Patients should be encouraged for awake proning. Monitoring of Oxygen saturation should be done for 3 to 4 times a day

38. Guidelines for patients kept at home isolation Symptoms to monitor and seek medical help: Persistent Fever Severe weakness and Prostration Persistent vomiting Palpitations Breathlessness on activities or at rest Severe coughing Saturation below 95% In case of elderly, drowsiness or altered behaviour Closer monitoring for patients with Co-morbidities should be done

39. Drug Treatment for patients with mild disease Cold sponging for fever Tablet paracetamol 500mg one or one and half tablet Give Tab Paracetamol for symptomatic treatment of fever. If fever is not controlled with a maximum dose of Tab. Paracetamol four times a day, consult the treating doctor who may consider advising other drugs like non-steroidal anti-inflammatory drug (NSAID) (ex: Tab. Naproxen 250 mg twice a day). Antibiotics if indicated (Azithromycin/Doxycycline or as per treating doctor) Supportive treatment Bed Rest Vitamin supplements Electrolyte solutions Proton Pump Inhibitors

40. Drug Treatment for patients with mild disease Inhalational Budesonide (given via inhalers with spacer at a dose of 800 mcg twice daily for 5 to 7 days) to be given if symptoms (fever and/or cough) are persistent beyond 5 days of disease onset Systemic oral steroids not indicated in mild disease If symptoms persist beyond 7 days (persistent fever, worsening cough etc.) consult the treating doctor for treatment with low dose oral steroids Continue the medications for other co-morbid illness after consulting the treating physician

41. Drug Treatment for patients with mild disease

42. Management of Moderate Disease Management of moderate cases should be preferably done at a DCHC. Patient may be Admitted from OPD Referred from CCC/PHC/CHC/Field Worker May progress from Mild case in Indoor facility AT THE CENTRE DETAILED HISTORY ESPECIALLY ONSET AND DURATION OF SYMPTOMS SHOULD BE NOTED FOR APPROPRIATE TREATMENT PROTOCOLS

43. Management of Moderate Disease Symptomatic treatment such as antipyretic (Paracetamol) for fever and pain, anti- tussive for cough Adequate hydration to be ensured Treatment of co-morbid conditions Oxygen Support: Target SpO2: 92-96% (88-92% in patients with COPD). The initial device chosen for administering oxygen (nasal prongs, simple face mask, or masks non-rebreathing reservoir bag) depends upon the severity of hypoxia and work of breathing In general simple nasal cannula is used, triple layered medical mask should be applied over it Injectable antibiotics like Inj Ceftriaxone

44. Management of Moderate Disease Anticoagulation Prophylactic dose of Un-Fractionated Heparin (UFH) or Low Molecular Weight Heparin (LMWH) (e.g., enoxaparin 0.5 mg / Kg body wt per day SC) There should be no contraindication or high risk of bleeding [Contraindications: End Stage Renal Disease (ESRD), active bleeding, emergency surgery] Consider unfractionated heparin in ESRD Anti-inflammatory or immunomodulatory therapy Consider IV methylprednisolone 0.5 to 1 mg/kg OR IV Dexamethasone 0.1 to 0.2 mg/kg usually for a duration of 5 to 10 days Review the duration of administration as per clinical response. Patients may be initiated or switched to oral route if stable and/or improving

45. Management of Moderate Disease Elevated Total leucocyte count may occur due to Steroids, inflammation, COVID itself apart from Bacterial super infection. Hence investigations like Pro-Calcitonin may be done if feasible and decided by treating doctor before use of Higher Antibiotics Steroids should be preferably avoided in first week of illness when active Viral Replication is on-going Awake proning : Should be encouraged in all patients who require supplemental oxygen therapy Any COVID-19 patient with respiratory embarrassment severe enough to be admitted to the hospital may be considered for rotation and early self-proning

46. Proning

47. Proning positions

48. Management of Moderate Disease Care must be taken to not disrupt the flow of oxygen during patient rotation Typical protocols include 30–120 minutes in prone position, followed by 30–120 minutes in left lateral decubitus, right lateral decubitus, and upright sitting position Control of Co-morbid conditions like Diabetes, Hypertension, Heart Failure should be done in consultation if needed with Physician

49. Red Flag signs Close monitoring should be done for Falling Saturation (monitored by continuous monitor) Increasing Respiratory Rate and Distress Tachycardia Fall Blood Pressure High Fever Reduced Urine Output Poor Oral Intake Alteration in sensorium

50. Management of Severe Cases Symptomatic treatment with Paracetamol and antitussives to continue Maintain euvolemia , use conservative fluid management in patients with Severe Covid when there is no evidence of shock Respiratory support : Give supplemental oxygen therapy immediately to patients with Severe Covid and respiratory distress, hypoxemia, or shock Initiate oxygen therapy at 5 L/min and titrate flow rates to reach target SpO2 ≥ 90% in non-pregnant adults and SpO2 ≥ 92- 96% in pregnant patients Consider use of NIV/HFNC (Helmet or face mask interface depending on availability) in patients with increasing oxygen requirement, if work of breathing is increasing

51. Management of Severe Cases Use conventional ARDS protocol for ventilatory management. Anti-inflammatory or immunomodulatory therapy: Inj Methylprednisolone 1 to 2mg/kg IV in 2 divided doses (or 0.2-0.4mg/kg of dexamethasone) usually for a duration 5 to 10 days Anticoagulation: Weight based intermediate dose of prophylactic unfractionated heparin or Low Molecular Weight Heparin (e.g., Enoxaparin 0.5mg/kg per dose SC BD). There should be no contraindication or high risk of bleeding

52. Oxygenation Devices Nasal Prongs Suitable for flow rates up to 1 to 5 Litres/minute Ensure probes are clean and no reused Check for leaks at Humidifier level Patient does not need to remove for eating

53. Oxygenation Devices NRBM Ensure that thin flap valve is present Should not be reused See that mask is clean and devoid of food particles etc Ensure that Bag is inflated NRBM should not be used if needed flow is less than 6 Litres/min While taking rounds see that Bag is inflated If not inflated see, for: Leak at humidifier causing low delivery to patient Missing flap valve inside mask Inadequate flow rate(< 6 litres/min)

54. Oxygenation Devices NRBM (non rebreathing mask) Ensure that thin plastic flap Valve is present.

55. Oxygen Devices Use distilled water/RO water for filling in Humidifier Tap water not to be used Look for Algae in Bottle Water change should be done at least once a day. Ensure that rubber gasket is available while tightening the bottle Bottle should not be loose or without Gasket as it leads to major leak and Waste of Oxygen

56. Suggestions for use of EUA drugs Latest Guidelines published by MOHFW and ICMR should be followed before use of Remdesivir/Tocilizumab and other drugs approved under Emergency Use Authorization Remdesivir (EUA) may be considered ONLY in patients with: Moderate to severe disease (requiring SUPPLEMENTAL OXYGEN), AND No renal or hepatic dysfunction AND Who are within 10 days of onset of symptom/s Recommended dose: 200 mg IV on day 1 followed by 100 mg IV OD for next 4 days Not to be used in: Mild cases patients who are NOT on oxygen support home settings

57. Suggestions for use of EUA drugs Tocilizumab (Off-label) may be considered when ALL OF THE BELOW CRITERIA ARE MET Presence of severe disease (preferably within 24 to 48 hours of onset of severe disease/ICU admission) Significantly raised inflammatory markers (CRP &/or IL-6) Not improving despite use of steroids No active bacterial/fungal/tubercular infection Recommended single dose: 4 to 6 mg/kg (400 mg in 60kg adult) in 100 ml NS over 1 hour

58. Duration of treatment Remdesivir should be given in selected cases for 5 days Duration of steroid therapy should be 7 to 10 days with rapid tapering However duration of therapy should be decided in individual cases by treating doctor according to clinical situation Anticoagulants should be given during the period of Hospital admission After discharge continuation of Oral anticoagulant to be decided by treating doctor after considering risk-benefit ratio in individual cases Immune modulators like Tocilizumab should not be repeated

59. Complications Acute: ARDS Respiratory Failure Thromboembolic complications Stroke AKI Sepsis Myocarditis Shock Sudden death Mucormycosis MIS (A)

60. Complications Chronic: Lung Fibrosis Pulmonary Hypertension Heart Failure Psychological complications Mucormycosis

61. Mucormycosis One-sided facial swelling Headache Nasal or sinus congestion Black lesions on nasal bridge or upper inside of mouth that quickly become more severe Fever R hino orbito cerebral mucormycosis  

62. Management of Mucormycosis Surgical (ENT, Ophthalmology, Dentistry, Neurosurgery) Medical Antifungals Amphotericin B Posaconazole Isuvaconazole Diabetic Control

63. Discharge Patient should be clinically stable at time of discharge Should be afebrile without anti- pyretics Saturation should be >94% at room air without distress/tachypnoea In case of patients with prolonged admission(more than 2 to 3 weeks) saturation above 92% may be considered for discharge if patient is comfortable and able to do routine personal care without distress or desaturation Patients being discharged should be explained regarding symptoms/Physical rest, saturation monitoring with Pulse Oxymeter and need to consult doctor if required.

64. Discharge Patients on steroids for more than 10 days can be rapidly tapered by switching to oral tablets Anticoagulants should be continued for variable duration as per discretion of treating doctor and D Dimer levels Proper diet, adequate hydration should be advised To approach doctor is symptoms like nasal pain, facial pain, swelling of eyes with eye pain appear Diabetics should monitor Sugar status and contact if uncontrolled hyper/hypoglycaemia Advise regarding physiotherapy and pranayama to be given

65. DISCHARGE SOP

66. Vaccine Available COVISHIELD 2 doses 12 weeks apart COVAXIN 2 doses 4 weeks apart SPUTNIK 2 doses 3 weeks apart

67. THANK YOU