This document outlines treatment guidelines for COVID-19 patients based on disease severity and symptoms. It stages COVID-19 infections from mild to severe and describes appropriate treatment, monitoring, and hospital placement for each stage. Red flags that indicate worsening condition or multi-organ dysfunction are also provided. Guidelines cover best practices for oxygen therapy, ventilation, prone positioning, intravenous therapies, and prevention of complications.

2.  Stage I : Mild (Early infection) – Groups A, B and C
 Stage IIa : Moderate (Pulmonary involvement
without hypoxia) – Group D
 Stage IIb : Moderate (Pulmonary involvement with
hypoxia) – Group E
 Stage III : Severe (Systemic hyperinflammation with
cytokine storm) –Group F

3.  Asymtomatic but positive for covid 19
 Isolation ward
 Investigations – CBC, RFT, RBS, LFT, ECG
 Treatment :
Tab HCQ 400 mg BD on day 1
followed by 200 mg BD for 4 days
(Before HCQ – Baseline ECG for QTc)

4.  Symtomatic / URTI without co morbidity
3 out of 4 : Fever
Dry cough
Shortness of breath
Myalgia
 Red flag signs
1.Neutrophil Lymphocyte ratio >3.5
2.Resting tachycardia (HR >100)
 Isolation ward
 Investigations – CBC, RFT, LFT, RBS, ECG, CXR PA, ABG

5. Treatment :
Tab Cefixime 200 mg BD OR
Tab Augmentin 625 mg TDS OR
Tab Azithromycin 500 mg OD
Plus
Tab HCQ 400 mg BD on day 1 followed by 200 mg BD
for 4 days
If patient is symptomatic at day 5 , then continue
therapy for additional 5 days

6.  Symptomatic / URTI with co morbidity
• > 65 years
• Obesity, Diabetes mellitus
• HTN / IHD
• Chronic conditions like CKD, CLD
• Immunosuppresive drugs and other
• Immunocompromised state
 Isloation ward

7.  Red flag signs
1. Neutrophil lymphocyte ratio >3.5
2. PaO2/Fio2 <300
3. 3-4 min exercise induced deoxygenation
4. Resting tachycardia
5. Raised CRP >100 /
serum ferritin >300 ug/L /
D- dimer >1000 ng/dl /
LDH >245 U/L /
raised Triglycerides

8.  Investigations –
CBC, RFT, RBS, LFT, ECG, CXR ABG, ESR, CRP,
LDH, Serum ferritin, D-dimer
( If QTc prolongation on ECG , then daily serum
electrolytes, ionic calcium and magnesium)

9. Treatment :
Tab Cefixime 200 mg BD OR
Tab Augmentin 625 mg TDS OR
Tab Azithromycin 500 mg OD
Plus
Tab HCQ 400 mg BD on day 1 followed by 200 mg BD
for 4 days
 If SPO2 < 88 %,-consider 1.CARP protocol
2.Inj MPS 40 mg iv BD
If patient is symptomatic at day 5 , then continue
therapy for additional 5 days

10.  Pneumonia (LRTI) without respiratory failure
 Red flag signs
1.Neutrophil lymphocyte ratio >3.5
2.PaO2/FiO2 <300
3.Raised CRP/serum ferritin
/Ddimer/LDH/Triglycerides
 Investigations – CBC, RFT, RBS, LFT, ECG, CXR PA, ABG,
ESR, CRP, LDH, Serum ferritin, D-dimer
(If QTc prolongation on ECG , then daily serum electrolytes,
ionic calcium and magnesium)
 Isolation ward / SOS ICU

11. Treatment :
Inj Ceftriaxone 1 gm iv BD for 5 -10 days +
Tab HCQ 400 mg BD on day 1 followed by 200 mg BD for
9 days +
If SPO2 <88 % consider 1.CARP protocol
2.inj.MPS 40 mg iv bd
If CAT C patient goes in ARDS and HCQ contraindicated
like in prolonged Qtc or G6PD,
Tab.Lopinavir/ritonavir 200/50 mg bd for 14 days or 7 days
after asymptomatic.

12.  Pneumonia (LRTI) with respiratory failure
 Red flag signs
1.Neutrophil lymphocyte ratio >3.5
2.PaO2/FiO2 <300
3.Raised CRP / serum ferritin / Ddimer / LDH / Triglycerides / Trop I
CPKMB>twice upper limit of normal
 Investigations – CBC, RFT, RBS, LFT, ECG, CXR PA, ABG, ESR, CRP,
LDH, Serum ferritin, D-dimer,TROP I ,CPKMB
 ( If QTc prolongation on ECG , then daily serum electrolytes, ionic calcium
and magnesium)
 Isolation in ICU

13. Treatment :
 Inj PIPTAZ 4.5 gm iv TDS extended infusion over 4
hours, till symptoms subside +
 Tab HCQ 400 mg BD on day 1 followed by 200 mg
BD for 9 days
 Inj.LMWH 40 mg s/c od +/-
 If SPO2 <88 % consider 1.CARP protocol
2.inj.MPS 40 mg iv bd
( Mechanical Ventilation if not candidate for CARP
protocol )

14.  Pneumonia (LRTI) with respiratory failure with MODS
 Red flag signs
1.Neutrophil lymphocyte ratio >3.5
2.Raised CRP/serum ferritin
/Ddimer/LDH/Triglycerides/TROP I/CPKMB
 Investigations – CBC, RFT, RBS, LFT, ECG, CXR PA, ABG,
ESR, CRP, LDH, Serum ferritin, D-dimer,Trop I, CPKMB,
blood culture and sensitivity
 ( If QTc prolongation on ECG , then daily serum electrolytes,
ionic calcium and magnesium)
 Isolation in ICU

15. Treatment :
 Inj MEROPENEM 1 gm iv TDS extended
infusion over 3 hours, till symptoms subside +
 Tab HCQ 400 mg BD on day 1 followed by 200
mg BD for 9 days
 Inj.LMWH 40 mg s/c bd
 If SPO2 <88 % consider 1.CARP protocol
2.inj.MPS 40 mg iv bd

16.  Mechanical ventilation as per Covid ARDS protocol
 Can consider use of convalescent plasma.
 If evidence of cytokine storm- Inj.MPS 500 mg iv OD
for 5 days and review.

17. Cytokine Storm Syndrome
 Overreaction of the immune system in response to
viral infection.
 Driven by IL-2, IL-6, IL-7, GCSF, TNF alpha.
 Harmful to the host causing multiorgan dysfunction
and carries a poor prognosis.
 2nd week of hospital stay based on the Wuhan and
Italian experience.

18.  Zinc supplementation 50 mg BD
 Vit C 100 mg BD
 Vit A 25000 IU single dose
 Vit D 4000 IU daily
 Mgso4 2 gm iv SOS
 Use of Toclizumab ,Colchicine , Ivermectin
and convalescent serum is not part of protocol,decision to
use of these depends on treating physician.

19.  All suspected symptomatic patients to be
given
 Tab Oseltamivir 75 mg bd for URTI and
 Tab Oseltamivir 150 mg bd for LRTI
 Irrespective of COVID status but once pt
report comes covid positive oseltamivir is to
be discontinued .

20.  Prone positioning improves oxygenation in spontaneously breathing
non-intubated patients with hypoxemic acute respiratory failure
 Indications for Awake Proning:
(1) Isolated hypoxemic respiratory failure without substantial dyspnea
 Not in multi-organ failure
 Expectation that patient has a fairly reversible lung injury
 Normal mental status, able to communicate distress
 No anticipation of difficult airway
(2) Patients who do not give consent for intubation.
The main risk -excessive delays in intubation . .

21.  Patients should prone, as tolerated for 2-4 hours/session for 2-4
days.
 Patients may need light sedation in order to tolerate pronation.
 Timed Position Changes
 Every 2 hrs, ask patient to switch between the following
positions.
 1. Left Lateral Recumbent
 2. Right Lateral Recumbent
 3. Sitting Upright 60-90 degrees
 4. Lying Prone in bed

22.  If these 4 positions are not raising the Oxygen
Saturation, a 5th position can be tried:
 5. Trendelenburg position (Supine, Bed 30 degrees
Head Down)
 10-15 Minutes after each position change, check to
make sure that Oxygen Saturation has not
decreased. If it has, try another position.

24.  • Need for mechanical ventilation.
 • Need for vasopressors.
 • Respiratory rate >25 breaths per minute.
 • PaO2 <60 mm Hg on room air or SpO2 <85% on
supplemental oxygen of 6 L/M.
 • Confusion.

25.  N/L ratio > 3.5
 • Thrombocytopenia.
 • Uremia
 • Multilobar infiltrates.
 • Hypotension requiring fluid resuscitation.
 • Hypothermia.

26.  Semi-recumbent position if not contraindicated.
 Avoid NSAIDs
 Inhaled medicines (bronchodilators) to be given by MDIs to
reduce the chances of aerosolization. Avoid nebulised drugs
 Use PPI to prevent gastrointestinal bleeding. Sucralfate can
be added
 Consider discontinuation of inhaled steroids as they may
reduce local immunity and promote viral replication .
.

27.  Conservative or de-resuscitative fluid strategy after
initial resuscitation with early detection of myocardial
involvement through the measurement of troponin
 .Pharmacologic thromboprophylaxis, if not
contraindicated, should be given. Mechanical
thromboprophylaxis using intermittent pneumatic
compression stockings can be used in cases where
pharmacologic thromboprophylaxis is
contraindicated.
 Judicious use of sedation

28.  Daily sedation-free intervals, and assessment for
weaning .
 Use of disposable ventilator circuits for each
patient.
 Standardized slower weaning protocols.
 Closed suctions and HME filters should be preferred
to prevent aerosol spread.
 Optimal care to reduce the incidence of catheter-
related blood stream infections

29.  Early enteral nutrition (within 24 to 48 hours of
admission) if not contraindicated.
 Frequent position change to prevent pressure
sores.
 Early mobilization including passive and active
rehabilitation exercises to prevent critical illness-
related neuromuscular weakness.
 Tracheostomy in patients with prolonged
mechanical ventilation.

30.  A ray of hope
1. Vaccine for Covid 19

31. Thank you