Covid 19

Detailed presentation for Covid 19

1. Sars-Cov-2 Covid-19 Dr. Rajesh Shrivastava Consultant Bariatric & Laparoscopic Surgeon Asst. Professor – Vedanta Institute of Medical Sciences Director - Shreeji Hospital Bhilad Director Hernia Surgery – DHI Mumbai

2. Int r oduction Coronavirus disease 2019 (COVID-19) is an infectious disease caused by SARS- CoV-2, a virus closely related to the SARS (Severe Acute Respiratory Syndrome) The disease is the cause of the 2019–20 coronavirus outbreak. Started from “Wuhan City” of Mainland China It is primarily spread between people via respiratory droplets from infected individuals when they cough or sneeze. Time from exposure to onset of symptoms is generally between 2 and 14 days. The mortality rate is around 2%. The WHO has declared the 2019–20 coronavirus outbreak to be a Public Health Emergency of International Concern (PHEIC).

3. The new coronavirus, first called 2019–nCoV and officially renamed as SARS- CoV2 (the virus) and COVID-19 (the disease) , belongs to the family of coronavirus , the name to crown-like spikes on their surface. Most described coronavirus are found in birds or mammals, particularly bats. The new coronavirus is called SARS-CoV2 because its genetic sequence is very similar to that of SARS , another coronavirus that appeared for first (and only) time in 2002 and caused a pandemic with more than 8,000 infected people and 800 deaths.

4. About structure They look like a tennis ball with all these spikes sticking out of it. Depending on the type of spikes, it allows that virus to attach to certain places. So some viruses, hey have this spike that attaches to your nose. So basically you just get a common cold. But the SARS virus and this new virus that has the spike that allows it to attach to the cells in your lung and when it attaches there, it puts in information to make photocopies of itself 4

5. A person can contract COVID-19 if: They come in contact with another person infected with the virus Someone infected coughs or sneezes directly to them They touch any surface with little droplets from infected people’s cough or sneezes and then touch their eyes, nose or mouth Sometimes contact of body fluids HOW do YOU get C OVI D - 19?

6. Clinical Featu res The incubation period of COVID-19 is 1-14 days (mean duration of 5-7 days), with peak viraemia occurring before the onset of symptoms. T he most common presenting features of COVID-19 infection are listed below: Symptoms (frequency in %) Fever (80-90) Cough (60-80) Breathlessness (18-46) Fatigue (38) Body ache/joint pain (15) Sore throat (11-14) Headache (6-14) Chills (12) Running nose (5) Nausea/vomiting (5) Diarrhea (2-10) Loss of smell & taste

7. Warning signs or red flag signs that can assist in triage, indicating the need for urgent care/hospitalization, are listed below: Wa r n i n g s i g n s Fever and upper respiratory symptoms lasting for >5 days and any of the following: Breathlessness/respiratory rate >24/min Oxygen saturation (SpO2 ) less than 94% or fall by 4mm after 6 min walk test 110/bpm heart rate or less than 90 mm of Systolic blood pressure E M E R G E N C Y

8. C OVI D nucleic acid te st positive. Without a ny cli n ical symp toms but the person can infect others. HRCT imaging might shows GROUND GLASS APPEARANCE A symptomic condition

9. Categorization of probable coronavirus disease 2019 (COVID-19) severity, testing and admission strategy Clinical category of COVID-19 Features Testing strategy Level of care MILD Fever with upper respiratory symptoms Mild sore throat and GI symptoms Testing may be considered in select individuals individuals in the high-risk group low priority HOME CARE MODERATE Breathlessness/respiratory rate >24/min Oxygen saturation (SpO2) <95% in room air Fatigue with heart rate of >110/bpm Systolic blood pressure <90 mmHg HIGH PRIORITY INPATIENT CARE SEVERE SpO2 <90% in room air Hypotension requiring ionotropic support ARDS/myocarditis HIGH PRIORITY INTENSIVE CARE

10. The life cycle of SARS-CoV-2 in the host cells

11. Travel history to endemic countries CBC (leukopenia, seen in 30% to 45% of patients, and lymphocytopenia, seen in 85% of the patients) Chest X-Ray (cheaper & easier with 60% sensitivity) RT PCR ( 65% sensitivity) Chest CT Scan (95% sensitivity, low specificity) Antigen Test IgM/IgG combo test for COVID-19 DIAGNOSIS

12. Supportive Blood Tests CBC CRP LDH FERRITIN D DIMER IL6 TROPONIN I LIVER ENZYMES

13. clinical management

14. CASE DEFINITION

15. Mild COVID-19 - Management Symptomatic treatment such as antipyretic (Paracetamol) for fever and pain, antitussives for cough Adequate nutrition and appropriate hydration to ensured. Tab Hydroxychloroquine (HCQ) may be considered for any of those having high risk features for severe disease (such as age> 60 years; Hypertension, diabetes, chronic lung/kidney/ liver disease, Cerebrovascular disease and obesity) under strict medical supervision, preferably after shifting to DCHC/DCH. Avoid HCQ in patients with underlying cardiac disease, history of unexplained syncope or QT prolongation

16. Management of Moderate cases Symptomatic treatment such as antipyretic (Paracetamol) for fever and pain, antitussives for cough Adequate hydration to be ensured Oxygen Support : Target SpO2: 92-96% (88-92% in patients with COPD) The device for administering oxygen (nasal prongs, mask, or masks with breathing / non-rebreathing reservoir bag) depends upon the increasing requirement of oxygen therapy. If HFNC or simple nasal cannula is used, N95 mask should be applied over it. Awake proning may be used as a rescue therapy.

17. Management of Moderate cases… 6. Anticoagulation – LMWH or UFH ( eg - enoxaparin). 7. Corticosteroids – iv methylprednisolone / Dexamethasone preferably within 48 hrs of admission. 8. Tab HCQ 400 mg BD on day one followed by 200 mg BD for 4 days 9 . Antivirals – Remdesivir 10. Treatment of Co-morbid conditions 11 . Follow up Blood Tests & Monitoring

18. Hydroxychloroquine: The 4-aminoquinolone, commonly used as an antimalarial and anti-inflammatory agent, possesses broad antiviral activity. While the exact mechanisms are unknown, it is considered to gain its antiviral effects through alkalinization of the phagolysosome as well as inhibition of viral entry by blocking receptor binding and membrane fusion. Remdesivir: It is an adenosine analogue and RNA polymerase blocker, is a novel drug developed for the treatment of Ebola virus infection. Oseltamivir: Lopinavir……. The following drugs have shown some promise for the management of COVID-19

19. Interleukin-6 (IL-6) inhibitors A subgroup of patients with COVID-19 develop severe cytokine activation and secondary haemophagocytic lymphohistiocytosis (HLH), leading to rapid-onset hypoxemia, shock and multiorgan dysfunction. A higher neutrophil count and elevated C-reactive protein may predict this subgroup of patients. Interleukin-6 (IL-6) is a key cytokine in the cytokine storm, and tocilizumb, a humanized anti- IL-6 receptor antibody, is proposed as a therapeutic agent in severe SARS-CoV-2 disease. Convalescent plasma from COVID-19 survivors Convalescent plasma plasma therapy was attempted with some benefit in MERS, Ebola and H1N1 pandemic influenza49-51. A small case series of patients with critically ill COVID-19 on mechanical mechanical ventilation improving after receiving therapy on the third week of illness is encouraging M a n a g e m e n t

20. Management of Severe Cases Continue the treatment as in moderate cases Management of hypoxemic respiratory failure Management of ARDS Management of Septic Shock Management of Multiorgan Failure

21. Return to Work Criteria for HCP HCP with mild to moderate illness who are not severely immunocompromised : At least 10 days have passed since symptoms first appeared and At least 24 hours have passed since -last fever without the use of fever-reducing medications -Symptoms (e.g., cough, shortness of breath) have improved Note:  HCP with severe to critical illness or who are severely immunocompromised : At least 20 days have passed since symptoms rst appeared At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved

22. Cover your mouth and your nose with your bent elbow or a tissue when coughing Seek medical attention if you have difficulty breathing and a high fever Follow the directions of your national or local health authorities Wash your hands with an alcohol-based sanitizer or with soap and water Keep a distance of at least 1 meter between yourself and anyone who coughs or sneezes Try your best not to touch your eyes, your nose and your mouth PROTECTING YOURSELF AND PREVENTING THE SPREAD OF THE DISEASE

23. COVID-19 IN DIFFERENT SURFACES SURFACE TIME Sprayers 3 hours Copper 4 hours Plastic 2-3 days SURFACE TIME Cardboard 24 hours Steel 2-3 days Wood 4 days

24. Before wearing a mask, wash your hands with an alcohol-based disinfectant or with soap and water. Cover your mouth and nose with the mask and make sure the mask is firmly pressed against your face. Replace the mask as soon as it gets wet and do not reuse disposable masks. Remove the mask from behind (do not touch its front side); throw it away in a closed container and then wash your hands with an alcohol-based disinfectant or with soap and water. HOW TO USE A MASK

25. Mask Rotation Acquire a set number of N95 masks (at least 5 per the CDC), and rotate their use each day, allowing them to dry for long enough that the virus is no longer viable (> 72 hours). Proper storage for this technique requires either hanging the respirators to dry, or keeping them in a clean, breathable container like a paper bag between uses. Make sure the masks do not touch each other, and that you do not share your respirator with other people. A  user seal check  should be performed before each use.

26. Personal protective equipment's

27. FACE SHEILD

28. 8 ways to protect doctors caring for patients with COVID-19 Minimize chance for exposure Adhere to precautions Manage visitor access and movement Implement engineering controls Monitor and manage health personnel Train and educate health professionals Implement environmental infection control Establish reporting to public health authorities