Dr. Ravikanth Moka (Internal Medicine) needs a second opinion on this medical case.
Salient points from webinar organised by Navi Mumbai IAP on 29.06.2020 "Covid Straight Drives from Masters Dr Rahul Pandit and Dr Anita Mathew" the Moderators being Dr. Jeetendra Gavahane, Navi Mumbai IAP President & Dr. Upendra Kinjawdekar. 1. Having symptoms, fever high grade, cold, sore throat, cough, malaise at this time of Pandemic should be taken as suspected covid. 2. Day 2 to Day 5 of symptoms to get the Real Time PCR and more likely to come positive. (at present so called gold standard) No Antigen test. 3. HRCT Chest & Xray Chest advisable on Day 4 - 5, acts as a supportive evidence or to pick up early ground glassing 4. If test comes negative then though welcome news, watchful for next 7 to 10 days and repeat the test if symptoms worsens. 5. If test comes positive then self quarantine, ideally Separate room Separate toilet Self Care Self hygiene If separate toilet not possible to flush the toilet thoroughly by disinfectant may be household phenyl after its use by infected person Monitor SPO2 twice a day daily. Should be more than 95%. To do six minute test twice a day Rest SPO2 - > 95% Walk for 6 minutes in a room itself SPO2 after walk if equal or less than 93% - likely to have happy hypoxia To get hospitalized for further management Medicines symptomatic Paracetamol 1gm qds No need of NSAIDs Vit C Zinc One can take antiviral as Favipiravir Lopinavir Ritonavir Of late Favipiravir recommended But then to do basal LFT, ECG 6. No role of Prophylactic Antibiotics in home Quarntined positive patients. 7. Investigations during quarantine CBC CRP Xray Chest 8. Investigations during hospitalization in first 5 days Besides CBC CRP Xray Chest D-dimer LDH Ferritin Creatinine LFT To watch for N:L ratio More than 3.5 Warrants Antibiotics 9. During hospitalization medicines given Favipiravir / Lopinavir / Remdesivir Doxy Ivermectin (Doxy & Ivermectin no proven role but can be used on OPD basis treatment) Vit C high dose 1.5 gm Zinc 50 mg minimum 10. Day 7, Day 8 IL6 test To detect cytokines storm 11. From Day 6 In covid patient with Hypoxia Antiviral Remdesivir added D6 to D10 Five days 200 mg IV First day 100 mg IV for next four days Availability is issue but available at major hospitals Cipla & Hetero are manufacturing and hopefully availability will not be issue in next 2 weeks.... Remdesivir only five days Creatinine clearance should be checked for The thumb rule in use of antiviral is Early to start is always better..... Informed Consent required for use of Remdesivir as well Favipiravir 12. Another important drug is use of steroids Methyl Prednisolone is the drug of choice 1mg/kg/BW BD for 5 days IV Indications Rise in inflammatory markers... CRP high Ferritin high But to give under the cover of broad spectrum Antibiotics To check for that Procalitonin levels are done if high suggests underlying sepsis the Antibiotic cover is important higher ones of course IV 13. Use of Dexamethasone instead of MP if issue with cost and availability of MP Use of Dexamethasone has its value at Hospital Strictly not to be used on OPD basis for first five days of symptoms Don't Start Dexa or any steroids just because one has diagnosed with Covid..It may have detrimental effect if started before time. Of course as General Practitioners we should not use it 14. Low Molecular Weight Heparin is another drug added on Day 5 of symptoms in view of hypoxia / who requires Oxygen Inj Clexan 40mg / 60 mg once a day continued till discharge and continued at home or replaced by oral anticoagulant for a week and repeated test of D dimer is important. If normal then it is stopped Sometimes if D dimer is relatively too high then higher therapeutic dose is used of Inj Clexan Reason of using it - as micro vascular thrombi - pulmonary embolism - is one of the complication LMWH in all patients irrespective of D dimer Prophylaxis or Therapeutic doses depend on D dimer levels 15. Treatment of Hypoxia HFNC High Flow Nasal Canula delivery of Oxygen as high as 40 to 60 lits with closed mouth in prone position All the time nursing in Prone Position and CARP protocol has good outcome Importance of prone position Heart, anterior mediastinal organs falls forwards.... Better aeration of lungs Posterior lobe involvement becomes lesser NIV/CPAP not recommended NIV has got its limitations including P SILI (Self Induced Ling Injury) and difficulty in prone nursing 16. If on HFNC Drowsiness...... PCO2 increases..... ABG not achieved as desired... PaO2/FiO2 ratio < 150 on HFNC To shift to ventilator... 17. Cosmetic Ventilators are just automated AMBUs and don't have any role . 18. If clinically Hypoxemic Fever with chills increases Tachycardia indirect evidence of cytokine storm Recognize cytokine early. Monitor labs frequently Confirmed by CRP increase IL6 increase Ferritin increase LDH increase WBC rise Tocilizumab (anti IL6) /Eculizumab (anti CD6) injection to be used Timing is very important Not early Not late D8 to D12 3 digit CRP 10 to 12 times rise in IL6 IL6 reports sometime takes two days But as CRP too high better not to wait for IL6 report otherwise it will be too late Rule out infection before giving it, send Procalcitonin Of late cytokine storm is seen in 3rd week too D16/D17 Only one dose of Tocilizumab No role for second dose 19. Sudden death in Covid causes Acute Coronary syndrome Pulmonary embolism Microthrombi 20. Antibody test for surveillance For plasma donation High tires 1:1024 Quantitative 21.Late complication Early to say But may be fibrosis of lung.... 22.IVIG only if suspecting Infection Induced HLH LDH/Ferritin in 1000s 23. Plasma donation must be encouraged . Committe like ZTCC should be formed for monitoring it's use.. 24. All frontline Health Care Provider should take HCQ Prophylaxis weekly till the end of Pandemic .There is no other proven prophylaxis avilable besides HCQ.. 25. We are nowhere near Herd immunity 26. DONT LET YOUR GUARDs DOWN especially in common areas, canteen, chambers when with someone.... 27. GOOD Basic Supportive Care and Tender Loving Care is the key for favorable outcome.........✨✨✨ ......
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