Covid

Virus: Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV-2)

The disease: Coronavirus Disease 2019 (COVID-19)
Coronaviruses, named after their spikey projections on their surface (proteins), resembling prongs of a
crown, or “corona” in Latin, are enveloped, nonsegmented, single-stranded, positive-sense RNA viruses
The important structural proteins include spike (S), envelope (E), membrane (M), and nucleocapsid (N).
They have a tendency for recombination and inherently high mutation rates compared with DNA viruses,
which allows them to adapt to new hosts.
There are four main subgroupings of coronaviruses—alpha, beta, delta, and gamma—that are broadly
distributed in mammals and birds, and only alpha and beta are known to cause disease in humans. These
viruses cause respiratory, enteric, cardiovascular, and neurological illnesses.
Mode of transmission primarily between people through direct, indirect, or close contact with infected
people through infected secretions such as saliva and respiratory secretions, or through their respiratory
droplets, which are expelled when an infected person coughs, sneezes, talks or sings.
Incubation period: 3–6 days (5 days)
Pathogenesis: of SARI

Entry of virus into respiratory tract

Attacks type 2 pneumocyte in alveoli

Virus adheres to and mimics ACE2 receptor in alveoli, gaining access into cell

Viral replication (new progeny of viral cells)

damage to the alveoli

Release of inflammatory cytokines: Interferons, Interleukin 6IL-1, IL-8, TNF

Interleukin 6, IL-1, IL-8, TNF

(Called Cytokine storm) Very high level of IL-6 Increase the vascular permeability

Increased VEGF& coagulation factors Leakage of fluid in interstitium, alveoli, and lung parenchyma

Systemic effect Interstitial and Alveolar edema

predispose to microthrombi and thrombi formation damaging alveolar cells

Increased vascular permeability in Lungs +/- Other organs

Interstitial edema & pulmonary edema and multiorgan damage

damaging alveolar cells ARDS/Acute Lung injury

Prevention of transmission …..(Short Note)

 Testing and Isolating positive cases
 Contact tracing & quarantine measures
1. Close contact- within 1 m (3 ft) of a COVID-19 infected person for more than 15 min while not
wearing a mask. In such instances, the recommendation is to quarantine for 14 days,regularly take
temperature and monitor symptoms, and to keep a safe distance for other members of the household

 Nonpharmaceutical interventions include and are not limited to the following

1. Universal masking mandate in public areas
2. Maintaining safe distances between people in public spaces-keeping a distance of 6 ft apart
3. Preventative measures: handwashing, coughing into the elbows
4. Banning public events and large gatherings that generate crowds
5. Closing schools and universities
6. Closing nonessential businesses
7. Stay at home orders (“Lock down”)
Clinical features: Depends on spectrum of Presentation

1. Asymptomatic!!!!!!!! (here as well!!)

2. Mild disease: Uncomplicated URTI without evidence of breathlessness and/or hypoxia

Constitutional and/or Focal:

Very commonly
Acute febrile illness Naso-Pharyngeal: ANY ≥ 1 of
+/- ANY ≥ 1 of Anosmia
Bodyache (Malaise) Ageusia
Chill (+/- Rigor) Blocked Nose/Rhinorrhoea
Decreased appetite Cough: mostly dry
Energy loss Less commonly:
Early warning signs: In a Mild case GI: Diarrhoea
≥1 of these indicate/predict possible lung/other organ involvement Neuro: Covid Encephalopathy
Room Air SpO2 <94% “ABCD” of encephalopathy
Breathing Difficulty
Cough: Severe
Deoxygenation: during ‘6 minutes walk test’
Elevated heart rate (Resting tachycardia)
Laboratory Markers/ parameters:
• Abnormal Chest X-Ray
• ST-T changes in ECG or high cardiac markers suggestive of Myocarditis (Trop-T/I)
• Exacerbation of Co-morbid laboratory parameters
• Neutrophil: Lymphocyte Ratio ≥3.13

2. Moderate Disease: Clinico- radiological signs/evidence of Pneumonia without signs of severe disease
• Dyspnea and /or hypoxia: Respiratory Rate ≥ 24 /minute and/or Oxygen Saturation ≤ 94 % in room air

3. Severe Disease: 1 OR 2
1. Clinico- radiological signs/evidence of Pneumonia PLUS one of the following: -
Dyspnea and /or hypoxia: RR ≥ 30 /minute and/or Oxygen Saturation ≤ 90 % in room air
OR
2. Case with Moderate Disease PLUS
ARDS (Radiologically) with Acute Respiratory Failure (in ABG)
AND/OR
Sepsis with Multi-Organ Dysfunction Syndrome
AND/OR
Septic Shock
Risk Factors for Severe Disease
1. Age > 50 years 7. Cardiovascular disease
2. BP: Hypertension 8. Cerebrovascular disease
3. BMI ≥40 9. Cancer (any)
4. Chronic Lung disease 10. Diabetes
5. Chronic Kidney disease 11. Deficient immunity:
6. Chronic Liver disease HIV/ those on Immunosuppressive Drugs
Investigations:

Microbiological confirmation (“Organism finding test”)

Sample: Nasopharyngeal swab (”local sample/material)

Test modalities: (“detects imprint of the organism”)
• RT-PCR RT PCR for SARS CoV-2: detects Viral RNA has a high specificity and moderate sensitivity.
• Rapid Antigen Test: Rapid detection of Viral specific antigen: ‘spike protein’
• Nucleic acid amplification test(NAAT): True NAAT/ CBNAAT: BOTH detect SARS-CoV-2 E-gene
 For both: If negative the patient is considered to be negative
 If Positive:
CBNAAT- considered to be +VE
True NAAT- to be confirmed by RT-PCR
Supportive investigations: To assess severity/complication/Organ involvement
Mild cases: Preferable Investigations:
CBC+ CRP C/F…Investigation….Management….Long Q
LFT Part of them…Short Note
Creatinine
ECG

Moderate & severe cases Imaging

Blood
CBC+ CRP 1.Chest XRay
ABG
LFT 2.HRCT Chest: MOST important Invn.
KFT shows Pneumoia with an unique appearance
Coagulation Profile (appearance different from conventional Pneumonia)
D-dimer
Ferritin These 4 have been used as predictors of disease severity and complications
IL6 level ● OFTEN (therefore NOT ALWAYS) high in Mod-Severe disease
Trop T ● High in some cases of Mild disease as well
ECG
Echo
Treatment:
Where to treat ?
Types of Cases Treatment at
Suspected Mild Case Home isolation
Test Confirmed Mild Case Home isolation/ Safe Home
Suspected Moderate / Severe Case (SARI) SARI ICU/ HDU
Test Confirmed Moderate/ Severe Case Designated COVID ICU/ HDU
Test Confirmed Mild Case with High Risk Designated COVID ward/ ICU/ HDU

Mild Case- Management: Eligibility For Home Isolation….(Short Note)

1. Symptoms – Mild / Very Mild / Asymptomatic
2. Facility – One separate room to stay in isolation with own toilet. Room for others with separate toilet.
3. Doctor – Must be under a Doctor who is available for Teleconsultation, Medical Care and Guidance 24x7
4. Care Giver –
 To provide care 24x7
 Communication with Health Set up for the entire duration of home isolation
 Care giver and all close contacts of such cases should take Ivermectin prophylaxis as per protocol
5.Consent – To monitor own health, obey the Doctor and to inform Health Team
6. Undertaking – “Having home isolation on own choice and will follow Home isolation Guidelines”
Criteria for admission to Safe Home (= Isolation/ Quarantine centres)
• Home isolation not suitable/feasible
• No caregiver at home
• Higher age group (>50 yrs) plus one Risk Factor for severe disease
• Two risk factors for severe disease irrespective of age.
Drugs: All oral drugs
Ivermectin; Doxycycline; Hydroxychloroquin
1. Ivermectin (12 mg once daily for 5 days)
these 3 MIGHT have some “antiviral” property
AND
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2. Doxycycline (100 mg twice daily for 7 days) OR ● Hydroxychloroquine (HCQs) 400 mg BD on day 1
3. Vitamin C 500 mg twice daily then 400 daily for 4 days
4. Zinc 50 mg per day
5. Vitamin D3 60000 IU weekly No strong evidence that ANY of 1-5 change the course/outcome/ mortality
6. Paracetamol for fever So, there are “Doctors” who DON’T prescribe any of these!!!
Completion of Isolation
• After 17 days from onset of Symptoms (10+7) where afebrile for 10 days
• After 17 days from Testing Date, if the patient is asymptomatic
• No need of Repeat Testing (to prove Negative) after the home isolation period is over
Moderate- Severe
Supportive: Many of these depending on the condition Definitive: Drugs
Admit: ALL mod-severe cases- SARI/Covid ICU/HDU 1. Antivirals
Airway protection: Intubation- who needs to be ventilated ● HCQ 400 mg BD on day 1 then
Absolute bed rest: till vital parameters are stable 400 mg OD for next 4 days
Breathing: OR
Proning improves oxygenation with ventilation in the prone ● Remdesivir 200 mg IV on day 1 then
100 mg IV daily for 4 days
position in those with moderate-severe ARDS
OR
 Conscious proning in whom despite use of high flow
● Ivermectin 12 mg OD for 5 Days
oxygen hypoxia persists
++
 Prone ventilation when refractory Hypoxemia
Doxycycline 100 mg BD for 7 days
Breathing support: ≥ 1 of these depending on the situation.
 Oxygen support via: Nasal cannula/ face mask 2. Antibiotics- ONLY if secondary
 Oxygen support via High Flow Nasal Cannula (HFNC) infection is suspected
 Ventilatory support Support may need to be escalated 3.Anticoagulation: to prevent/treat PTE
 NIV CPAP/BiPAP or deescalated with deterioration Unfractionated Heparin (UFH) OR
 ECMO & improvement respectively Low Molecular Weight Heparin(LMWH)
Bed sore prevention: for bedbound patients  High-dose prophylactic
Basic investigations: Blood: On admission + post admission:  Therapeutic dose if confirmed PE
monitoring of CBC, CRP, ABG, LFT, KFT, D-dimer, IL6 4.Biologics: Tocilizumab(IL6 inhibitor)
Imaging: HRCT chest In selected SEVERE cases with IL6 level
Circulation: IV fluid if volume depleted- Septic/septic shock >6 times of Normal
Catheter: to monitor urine output: volume depleted
5.Corticosteroids
patients- Septic/septic shock
IV Methylprednisolone 0.5-1 mg/kg for 3-
CBG monitoring 5 days
Drugs used in Corona…short note
Diet: Nutritious diet OR
 Oral IV Dexamethasone 0.1 to 0.2 mg/kg for 3-5
 NG tube feeding- for ventilated patients days
6.Convalescent Plasma therapy: Results
DVT prophylaxis
are not very encouraging
Exercise: Chest Physiotherapy
Complications:…(Short Note)
VERY COMMON:
 Pulmonary
Pneumonia
ARDS
Pulmonary Embolism
Pulmonary Fibrosis
Happy Hypoxics: Among the many surprises of the novel coronavirus, some patients
seem to defy the basic physiology of hypoxia as they can be well & comfortable
with no signs of distress even with significantly LOW SpO2 and PaO2. Clinicians
call them “happy hypoxics”.

 Psychological: Stress/Anxiety/depression/ Post traumatic Stess disorder

COMMON
 Cardiac
Myo-pericarditis
Heart Failure
Arrhythymia
 Nervous system:
CNS
Headache
cerebrovascular disease
Rarely Encephalitis and Meningitis
PNS: Rarely Guillain–Barré syndrome

Severe Acute Respiratory Infection(SARI) ….short Note

All of the following criteria must be present to be considered a SARI case:

 Respiratory symptoms: fever* (over 100.4 F) AND new onset of (or exacerbation of chronic) cough or
breathing difficulty
*Note: fever may not be prominent in patients under 5 or over 65 years of age, or as well as
immunosuppressed individuals. Self-reported symptoms of elevated body temperature should be
considered as evidence of fever.
AND
 Evidence of illness progression, defined by the following:
Radiographic evidence of infiltrates consistent with pneumonia OR diagnosis of ARDS
or
Severe influenza like illness (ILI) which may also include complications such as encephalitis, myocarditis or
other severe and life-threatening complications
AND
Admission to the ICU/other area of the hospital where critically ill patients are cared for OR mechanical
ventilation
AND
No alternate diagnosis within the first 72 hours of hospitalization: o Results of preliminary clinical and/or
laboratory investigations, within first 72 hours of hospitalization cannot ascertain a diagnosis reasonably
explaining the illness
AND
Exposure to one or more of the “high risk” areas/persons/laboratory/animal