2. COVID 19 Suspect
• Symptomatic –
1. IT – International travel in last 14 days
2. C – Contacts of laboratory confirmed cases
3. HCP – Health care personnel
4. Hospitalized patients
5. ILI -Influenza like illness(fever, cough, runny nose, sore throat)
from Hotspot regions
• Asymptomatic –
1. Direct and high risk contacts of a confirmed case
2. Pregnant women from Hotspot area likely to deliver in 5 days
3. HCP Risk and Contact Assessment
• Exposure among Colleague in last 14 days and Without PPE-
1. Close Contact – > 15 min and / or < 2 m
2. Casual Contact – < 15 min and / or > 2 m
• Contact with Case in last 14 days-
1. High risk – > 15 min and / or < 2 m, Without PPE(esp. mask)
2. Low risk – Mask worn but some components of PPE missed
4. Asymptomatic HCW
• Casual Contact and Low Risk Exposure –
• Self-monitoring for symptoms
• CONTINUE work – with PPE and Social distancing
• Close contact and High Risk Exposure –
• Home isolation
• COVID 19 test on Day 7 of exposure
• If negative – Return to work with PPE
5. Symptomatic HCW
• Urgent COVID 19 testing
• Admit in Hospital – Major symptoms
• Home isolation – Minor symptoms
• If Positive – Admit and treat as Positive case
• If Negative and symptoms subside – RETURN to
WORK
• If Negative and Symptoms persist : REPEAT test after
48 hours
6. MILD Case Management
• Fever / ILI
• Refer to COVID CARE Centre / Home care
• Contact and Droplet Precaution, Strict Hand Hygiene
• Symptomatic Management
• HCQ in case of –
• Age> 60 years
• CVS disease including HT
• DM and other immunocompromised states
• Chronic lung / CKD / CLD
• Obesity
• Cerebrovascular disease
• Antibiotics and Anti-virals (Against community acquired pneumonia)
• Supplement Vitamin C and Zinc
HCQ = 400 mg BD x 1 DAY f/b 400 mg OD X 4 DAYS
7. MODERATE Disease
• ADMIT in WARD
• Tab HCQ 400 mg BD x 1 Day f/b 400 mg OD x 4 Days,
Chloroquine phosphate 500 mg BD x 10 Days
• Oxygen Support –
• Target SpO2 92-96% (88-92 % in COPD)
• Preferred Device – NON rebreathing FACE mask
• MONITOR for – WOB, Fatigue, Hemodynamics, Change in O2
Requirement
• AWAKE Proning
• 12 Lead ECG Daily
• CBC with DLC, KFT, LFT, Coagulation check DAILY
• CRP, D-Dimer, LDH, Trop I and Ferritin 48-72 hourly
• Inj REMDESIVIR 200 mg I/V on Day 1 f/b 100 mg OD for 5-10
Days
RR >/= 24 / min
SpO2 < 94 % on RA
8. Maximum Exhaled Air Dispersion
Human Simulator at 45 Degrees, Negative Pressure Room
AIIMS, New Delhi
Version 1.2 17th
May, 202
Table showing maximum exhaled air dispersion via different oxygen administration a
ventilatory support strategies: (in a negative pressure room, with human simulator at
inclination of 45’)
Method Maximum exhaled air dispersion
distance (in cm)
Oxygen via NC (5L/min) 100
Oxygen via simple face-mask (4L/min) 40
Oxygen via Venturi mask (FiO2 40%) 33
Oxygen via non rebreathing mask 12 L/min <10
CPAP via oro-nasal mask (20cm of H2O) Negligible
HFNC (60L/min) 17 (62cm sideways leakage if not
tightly fixed)
NIV via full face mask (IPAP 18cm/EPAP 5cm
H2O)
92
NIV via helmet without tight air cushion 27
NIV via helmet with tight air cushion (IPAP
20cm/EPAP 10cm H2O)
Negligible air dispersion
9. Cont …
• Maintain HYDRATION - Euvolemia
• Symptomatic and Supportive Treatment –
• Antipyretics, Anti-biotics (Azithromycin / Doxycycline)
• CONSIDER I/V Methylprednisolone 0.5 – 1 mg / kg X 3 Days Preferably in
48 Hours
• Convalescent PLASMA – ( UNDER TRIAL)
• ANTICOAGULATION – Weigh BENEFIT vs RISK ( if HAS BLED score
>3, Titrate with D-Dimer and SIC Score >/= 4)-
LMWH (Enoxaparin 40 mg SC OD)
• Keep LOW threshold for CTPA
10.
11. SOFA = Sequential Organ Failure Assessment
Total SOFA = CVS + Hepatic + Renal + Respiratory SOFA
SIC SCORE
12. Prone Ventilation
FiO2 ≥ 28% or requiring basic respiratory support to achieve SaO2 92 –96% (88-92% if risk
of hypercapnic respiratory failure) AND suspected/confirmed COVID-19.
Consider prone position if ability to;
- Communicate and co-operate with procedure.
- Rotate to front and adjust position independently
- No anticipated airway issues
Continue
supine
Continue
supine
Absolute contraindications
- Respiratory distress (RR ≥ 35, PaCO2 ≥ 6.5, accessory muscle use)
- Immediate need for intubation
- Haemodynamic instability (SBP < 90mmHg) or arrhythmia
- Agitation or altered mental status
- Unstable spine/thoracic injury/recent abdominal surgery
Relative Contraindications:
- Facial injury
- Neurological issues (e.g. frequent seizures)
- Morbid obesity
- Pregnancy (2/3rd trimesters)
Continue
Supine or
consider
escalation
to medical
team
YES
YES
YES
NO
NO
Considerpronepositionifabilityto;
- Communicateandco-operatewithprocedure.
- Rotatetofrontandadjustpositionindependently
- Noanticipatedairwayissues
Continue
supine
Continue
supine
Absolutecontraindications
- Respiratorydistress(RR≥35,PaCO2≥6.5,accessorymuscleuse)
- Immediateneedforintubation
- Haemodynamicinstability(SBP<90mmHg)orarrhythmia
- Agitationoralteredmentalstatus
- Unstablespine/thoracicinjury/recentabdominalsurgery
RelativeContraindications:
Continue
Supineor
consider
escalation
YES
YES
NO
Absolutecontraindications
- Respiratorydistress(RR ≥ 35,PaCO2≥ 6.5,acc
- Immediateneedforintubation
- Haemodynamicinstability (SBP<90mmHg)o
- Agitationoralteredmentalstatus
- Unstablespine/thoracicinjury/recentabdomi
RelativeContraindications:
- Facialinjury
- Neurologicalissues(e.g.frequentseizures)
- Morbidobesity
- Pregnancy(2/3rd trimesters)
- Pressuresores/ulcers
YES
13. All Positions for 30 min to 2 hours
• Fully prone (bed flat)
• Right (bed flat)
• Sitting up (30-60 degrees)
• Left (bed flat)
• Prone AGAIN
• Continue to repeat the cycle.......
Discontinue –
No Improvement
Unable to tolerate
• RR >/= 35
• Looks tired
• Accessory muscles use
14. SEVERE CASES
• Cautious trial of CPAP with Oro-nasal mask / NIV with helmet
interface / HFNC if WOB is LOW
• Intubation – WOB is HIGH, Not tolerating NIV, Keep LOW Threshold
• ARDS protocol Ventilation (Low Tidal volume, High frequency)
• Euvolemia
• I/V Methylprednisolone 1-2 mg/kg/day for 5-7 Days (as 2 divided
doses)
• Manage Sepsis / Septic shock
• Sedation and Nutrition as per Institutional Protocol
• Respiratory distress requiring Mechanical Ventilation
(Invasive or NIV)
• Hemodynamic instability
15. Cont…
• Symptomatic and Supportive treatment –
• Antipyretics, Anti-biotics (Azithromycin / Doxycycline)
• Inj REMDESIVIR 200 mg I/V on Day 1 f/b 100 mg OD for 5-10
Days
• Tocilizumab – Progressive worsening, IL-6 Elevated
Dose : 8 mg/kg (Maximum 800 mg as single dose) in 100 ml NS
over 1 hour
• Therapeutic Plasma Exchange - As part of TRIAL
16. EXTUBATED PATIENTS
INTUBATED PATIENTS
• One person for attaching monitors and any drugs, if required.
Receive extubated patients on nasal prongs with N95 facemask.
Switch off the oxygen source at shifting trolley before
disconnecting the prong.
Clamp the tubing of prong temporarily.
Disconnect it from shifting oxygen source.
Attach with ICU source of oxygen.
Remove the clamp.
Start oxygenation
Transfer Of Patients
17. How to Transfer a Patient On Ventilator?
Ensure patient is well sedated/ paralyzed.
Recheck quickly the ventilator settings.
Switch off the oxygen flow to the transport ventilator/
Bain's circuit.
Turn down the Transport ventilator.
Always clamp the ETT.
Disconnect the ETT with viral filter from transport circuit.
Connect ETT with filter with the ventilator.
Unclamp ETT and start Ventilation.
Confirm with etCO2.
Start sedation
INTUBATED PATIENTS
Start oxygenation
Receive a well sedated / paralyzed patients.
Check for cuff inflation and viral filter.
Follow the protocol for transferring patients to ventilator.
Start ventilation.
How to Transfer a Patient On Ventilator?
Ensure patient is well sedated/ paralyzed.
Recheck quickly the ventilator settings.
Switch off the oxygen flow to the transport ventilator/
Bain's circuit.
Turn down the Transport ventilator.
Always clamp the ETT.
INTUBATED PATIENTS
Receive a well sedated / paralyzed patients.
Check for cuff inflation and viral filter.
Follow the protocol for transferring patients to ventilator.
Start ventilation.
18. Discharge Protocol
CLINICAL Category Definition When to Discharge ??? RTPCR
MILD Fever / ILI After 10 days of Onset
NO fever X 3 days
NO
MODERATE Pneumonia with –
RR =16-30 / min
SpO2 = 90-94% RA
• Fever resolved in 3 days
• O2 saturation without support
Discharge after 10 days of onset
• Symptoms NOT resolved
• Demand of oxygen increased
Discharge –
• Resolution of symptoms
• SpO2> 95% on RA for > 3 days
NO
NO
Severe
Includes –
Immunocompromised
• HIV patients
• Transplant
• Malignancy
RR ≥ 30 / min
SpO2 < 90% on RA
Discharge after Clinical Recovery YES
7 Days of Home Isolation
If Symptoms re-develop -> Call COVID Care Centre OR State Helpline 1075
If no symptoms – Follow up with Telephone on Day 14
19. Eligibility for HOME isolation
• Clinically Mild
• Available Facility for self and Family contacts IF
required
• 24 X 7 Care giver
• HCQ prophylaxis for Care giver and other contacts
• Arogya Setu App DOWNLOADED and ACTIVE all times
• Undertaking filled by PATIENT
20. UNDERTAKING
Annexure I
Undertaking on self-isolation
I ………………………… S/W of ……………………, resident of ……………………………………
being diagnosed as a confirmed/suspect case of COVID-19, do hereby voluntarily undertake to
maintain strict self-isolation at all times for the prescribed period. During this period I shall monitor
my health and those around me and interact with the assigned surveillance team/with the call center
(1075), in case I suffer from any deteriorating symptoms or any of my close family contacts develops
any symptoms consistent with COVID-19.
I have been explained in detail about the precautions that I need to follow while I am under self-
isolation.
I am liable to be acted on under the prescribed law for any non-adherence to self-isolation protocol.
Signature____________________
Date________________________
Contact Number ______________
21. Instructions for PATIENT
• SEPARATE, WELL-VENTILATED room
• Preferably attached / separate TOILET
• RESTRICT movements
• TAKE rest, Keep HYDRATED
• EAT in room
• Distance of 2 metres in shared spaces, Use
Mask (Triple layer)
• DISCARD mask after 8 hours, EARLIER if wet or
soiled
• STAY AWAY from Elderly, pregnant, children and co-
morbid persons
• Say NO TO public gatherings
• Proper Hand washing (All Steps)- Thoroughly
• Soap and water (atleast 40 seconds)
• Alcohol-based hand sanitizer (atleast 20 seconds)
• Don’t SHARE
• DON’T use USED mask
• SELF MONITOR - If symptoms worsen, inform nearest
health centre OR call 011-23978046
22. Instructions for the family members
• STAY in separate room
• Only one assigned member – TAKES responsibility
• KEEP AWAY pets
• Use Disposable gloves when cleaning surfaces or soiled linen handling
• TRIPLE layer mask – when in patient’s room
• DON’T TOUCH face, nose or mouth
• USE Gloves and CLEAN Utensils soap/detergent, MAY RE-USE
• Wash hands after removing gloves, Thoroughly –
• Soap and water (at least 40 seconds)
• Alcohol-based hand sanitizer (at least 20 seconds)
• PROHIBIT non-essential visitors
23. Environmental Sanitation
• Immediately Remove and Wash – Soiled Clothes and Bedding
• Clean and Disinfect – Touched surfaces DAILY with
• 1% Sodium Hypochlorite OR
• 5% ordinary Bleach
• Clean and Disinfect – Toilet surfaces DAILY with phenolic disinfectants
• WASH laundry SEPARATELY, WARMEST temperature (clothing label)
• LINED Container for DISPOSAL of Gloves, mask and other soiled waste
with Household waste, WASH Hands POST disposal
• TOILET SEAT – PATIENT Post use
24.
25. Types of PPE Kits
LEVEL PPE KIT Components
Level I Gown based PPE Kit Gown + N-95 + Goggles +
Gloves
Level II Coverall (same material as
Gown) based PPE Kit
Gown + N-95 + Goggles +
Gloves + Long Shoe Cover
Level III Coverall
(Tyvec/Tychem/Kimberly Clark)
based PPE Kit
Gown + N-95 + Goggles +
Gloves + Long Shoe Cover
Face Shields for Aerosol Generating Procedures (AGP) and Sampling
26. TAKE HOME MESSAGES
• Need for DYNAMIC Guidelines
• Should be an entity for Medical Personnel Discretion
