COVID-19 Management Summary
The table below shows a summary and notes of a COVID-19 treatment protocol devised at Charlotte Maxeke Johannesburg Academic Hospital by Prof Guy Richards. It is accessible on EMGuidance. I have modified the information to make it easier for me to revisit/revise (my notes). However, I would advise anyone who is reading this for the first time to access their wonderful protocol directly using EMGuidance. There is more information discussed on their protocol. I will also be adding information from other resources.
| Asymptomatic COVID-19 | |
| Clinical | Asymptomatic |
| Supportive Treatment | Counsel and Advice the patient. Can they self-isolate? If symptomatic, do they have access to healthcare? |
| Antiviral Treatment | None |
| Anti-Inflammatory Treatment | None |
| URTI Symptoms | |
| Clinical | The patient may present with fever, headaches, sore throat, and coughing. However, no symptoms of a lower respiratory tract infection (shortness of breath). Saturations are normal. |
| Supportive Treatment | Supplements Vitamin D2 (Calciferol) 50 000 units PO stat Zinc 20 – 50mg PO daily for 5 daysNicotinic acid (Vit B3) 25mg – 50mg PO daily Vitamin C 500mg PO TDSThiamine 100mg PO daily |
| Antiviral Treatment | None |
| Anti-Inflammatory Treatment | Paracetamol 1g PO QID |
| URTI Symptoms + Comorbidies/Age>65 OR LRTI Symptoms and evidence on CXR | |
| Clinical | Same as above, but with co-morbidities May also have shortness of breath, tachypnea, crackles, oxygen saturation < 90%, P/F ratio < 300, electrolyte imbalances |
| Supportive Treatment | Supplements as above, OXYGEN therapy should be included. |
| Antiviral Treatment | None |
| Anti-inflammatory Treatment | Paracetamol 1g PO QID Corticosteroids as well: Hydrocortisone 100mg IV stat then 50mg 6 hourly OR Dexamethasone 8mg IV BD x 1, then 8mg daily OR Methylprednisolone 40mg BD x 1, then 40mg daily OR Prednisone 40mg BD x 1 then 40mg daily Colchicine 1.5mg PO stat then 0.5mg PO BD |
| Severe Symptoms | |
| Clinical | Tachypnea, cyanosis, saturation< 90%, P/F ratio < 200; Mechanical ventilation Hypotension, Hypokalaemia, organ dysfunction, CRP >150 and rising; D-Dimer rising, Il-6 > 80 if available IL-6 (pg/ml) / lymphocyte (106/ml) ratio> 50 APACHE II >17 |
| Supportive Treatment | Supportive Treatment as above ICU: High Nasal Nasal Cannula Self Proning Mechanical Ventilation ECMO if available/resources allow. |
| Antiviral Treatment | Remdesivir, when available. |
| Anti-inflammatory Treatment | Therapy as above If deteriorating: CRP rising; sats worsening or requires intubation on admission consider in addition to above: Tocilizumab 400mg IVI over 60 mins x one dose Or if unavailable Polygam 24g x 1-2 days Review with an expert group |
Notes:
- Difference between Vitamin D2 and Vitamin D3 usage/doses
- Blood Gas Analysis: P/F Ratio
- Steroids: 8mg dexamethasone = 30mg methylpred= 40mg mg prednisone = Hydrocortisone 200mg daily
- Immunotherapy: Tocilizumab or polygam, for those patients not improving on standard care. Tocilizumab use is off label and it requires patient or family consent.
- If on High Flow Nasal Cannula and RR >26 or sat <90% consider mechanical ventilation
- Initiate corticosteroids early in all with pneumonic changes and hypoxaemia to avoid mechanical ventilation if possible
- If mechanical ventilation required: distress, acidosis, cognitive deterioration, progressive decline in sats, etc. do not withhold it on the assumption that it may do harm. Settings: PEEP:10; Peak Pressures 26; FiO2 to maintain Sat > 90%.
- If patient still hypoxaemic or FiO2 > 0.6 then prone the patient and increase the mean airway pressures. Max Peak Pressures 30 or 34 if obese;
- Limit fluid intake but maintain nutrition – avoid oedema (sacral)
- The protocol considers the usage of heparin nebs 5000U BD (monitor Xa and aPTT) in certain clinical scenarios
- Remember, these patients may present with with non-pulmonary pathology such as strokes, seizures, encephalitis, myocardial infarction, acute kidney injury
References
- Richards, G., 2020. COVID-19 Protocol Version 10 – Charlotte Maxeke Johannesburg Academic Hospital / Gauteng ICU Group. [online] EMGuidance. Available at: <https://emguidance.com/content/18990?t=suggestions&context=search&position=0&s=COVID-19%20Protocol%20Version%2010%20-%20Charlotte%20Maxeke%20Johannesburg%20Academic%20Hospital%20%2F%20Gauteng%20ICU%20Group> [Accessed 18 May 2022].