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Guidelines on clinical management of covid 19

To recognise and sort all patients with COVID -19 at first point of contact with health care system such as the emergency department

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Guidelines on clinical management of covid 19

  1. 1. Guidelines on Clinical Management of COVID - 19
  2. 2. Clinical Management Early recognition of patients with COVID – 19 • To recognise and sort all patients with COVID -19 at first point of contact with health care system such as the emergency department • Consider COVID – 19 as a possible etiology under certain conditions • Triage patients based on disease severity and start treatment accordingly. 08-04-20www.nursingpath.in 2
  3. 3. Definition of Patients with COVID - 19 • SARI ( Severe Acute Respiratory Infection ) - An ARI with history of Fever ( temp. > 38 degree C ) Cough within the last 10 days and Requirinng hospitalisation. • Surviellance case definition of SARI – 1. SARI in a person with history of fever and cough requiring admission to hospitals with no other etiology . And any of the following a) History of international travel in 14 day b) In health care worker working in enviroment where patients with SARI are being cared for without regard to place of residence or history of travels. c) The person develops an unusual or unexplained clinically course, especially sudden deterioration despite appropriate treatment 08-04-20www.nursingpath.in 3
  4. 4. Definition of Patients with COVID -19 2. A person with acute respiratory illness of any degree of severity who within 14 days before onset of illness had any of the following exposures : a) Close physical contact with a confirmed case of COVID -19 infection b) A health care facility in a country where hospital associated COVID- 19 infections have been reported. Close contacts can be defined as • Health care associated exposure Providing direct care for COVID -19 patients Working with health care workers infected with COVID -19 Visiting patients or staying with COVID – 19 patients • Working together or sharing same classroom with a COVID – 19 patients • Travelling together with COVID – 19 patients • Living in the same household as a COVID – 19 patients. 08-04-20www.nursingpath.in 4
  5. 5. Clinical syndromes associated with COVID -19• COVID – 19 may present with mild, moderate , or severe illness Severe illness includes severe pneumonia, ARDS, Sepsis,and septic shock. 1. Uncomplicated illness : Patients with uncomplicated upper respiratory tract viral infection may have non specific symptoms such as fever, cough, sore throat, nasal congestion, malaise, headache. The elderly and immunosuppressed may present with atypical symptoms. These patients do not have any signs of dehydration, sepsis or shortness of breaths. 2. Mild pneumonia : Presents with symptoms of pneumonia and no signs of severe pneumonia . Child presents with cough or difficulty in breathing fast breathing Less than 2 months – 60 or more breaths per minute 2 – 11 months – 50 or more 1 – 5 years – 40 or more and no signs of severe pneumonia 08-04-20www.nursingpath.in 5
  6. 6. Clinical syndromes associated with COVID -19 3. Severe pneumonia  Adult or adolescent : Presents with fever or respiratory infection plus one of the following Respiratory rate > 30 breaths / min Severe respiratory distress SpO2 < 90 on room air  Child presents with cough or difficulty in breathing plus one of the following Central cyanosis or SpO2 <90 % Severe respiratory distress ( grunting, chest in drawing ) Inability to breastfeed or drink Lethargy or unconsciousness or convulsion 08-04-20www.nursingpath.in 6
  7. 7. Clinical syndromes associated with COVID -19 4. Acute Respiratory Distress Syndrome (ARDS ) Onset: New or worsening of respiratory symptoms within one week of known clinical insult Chest imaging : Bilateral opacities Pulmonary oedema Oxygenation : Mild ARDS Moderate ARDS Severe ARDS : PaO2/FiO2 <= 100 mmhgwith PEEP >=5cm H2O When PaO2 is not available SpO2/FiO2 <=315 suggest ARDS 08-04-20www.nursingpath.in 7
  8. 8. Clinical syndromes associated with COVID -19 5.Sepsis : It is a life threatening organ dysfunction caused by a dysregulated host response to infection. Signs of organ dysfunction include • Altered mental status • Difficult or fast breathing • Low oxygen saturation • Reduced urine output • Fast heart rate • Weak pulse • Cold extremities • Skin mottling • Lab evidence : Coagulopathy, Thrombocytopenia, Acidosis, High Lactate or hyperbilirubinemia 08-04-20www.nursingpath.in 8
  9. 9. Clinical syndromes associated with COVID -19 6.Septic shock : Adult : Persisting hypotension requiring vasopressor to maintain MAP>=65 mmhg and serum lactate level< 2mmol/L Children : Any hypotension with 2 – 3 of the following Altered mental state Bradycardia or Tachycardia ( HR < 90bpm or >160bpm in infants and HR <70bpm or > 150bpm in children) Prolonged capillary refill ( > 2 sec ) mottled skin or petechial or purpuric rash Increased Lactate Oliguria Hyperthermia or hypothermia 08-04-20www.nursingpath.in 9
  10. 10. Implementation of appropriate IPC measure • At triage :  Give patient a tripple layer surgical mask  Direct patient to separate area  Keep at least 1 metre distance between patients  Instruct all patients to cover nose and mouth during coughing or sneezing with tissue or flex elbow  Perform hand hygiene after contact with respiratory secretions. • Droplet Precaution :  Use tripple layer surgical mask  Place patients with similar clinical diagnosis at separate place  Use eye protection ( face mask or goggles ) while providing care in close contact with a patients with respiratory symptoms )  Limit patients movement within the institution 08-04-20www.nursingpath.in 10
  11. 11. Implementation of appropriate IPC measure • Contact precaution :  Use PPE ( tripple layer surgical mask, eye protection, gloves and gown) when entering room and remove PPE when leaving  Use disposable equipment ( stethoscope, blood pressure cuffs and thermometer) if possible.  If equipment needs to be shared among patients clean and disinfect between each patient use.  Health care workers refrain from touching their eyes, nose, and mouth with contaminated gloved or ungloved hands.  Avoid contaminating environmental surfaces e.g door handles and light switches etc.  Ensure adequate room ventilation  Avoid movement of patients  Perform hand hygiene 08-04-20www.nursingpath.in 11
  12. 12. Implementation of appropriate IPC measure • Airborne precaution :  Use PPE including gloves, long sleeved gown, eye protection and N95 mask while performing aerosol generating procedures like open suctioning of respiratory tract, intubation, bronchoscopy, cardiopulmonary resuscitation  Use adequately ventilated single rooms when performing aerosol generating procedures  Use negative pressure rooms with minimum of 12 air changes per hour or atleast 160 litres /second/patients in facilities with natural ventilation.  Avoid the presence of unnecessary individuals in the room. 08-04-20www.nursingpath.in 12
  13. 13. Early Supportive therapy and monitoring a) Oxygen therapy : Give oxygen therapy immediately to patients with SARI and respiratory distress, hypoxemia or shock Initiate oxygen therapy at 5L/min and titrate flow rate to reach target of SpO2 >=90% but in pregnant adult SpO2 > =92 – 95 % Places where patients of SARI are cared should be equiped with • Pulse oxymeter • Functioning oxygen system • Disposable oxygen delivering interfaces such as nasal canula ,simple face mask and mask with reservoir bag. b)Fluid management : Conservative fluid management in SARI if no evidence of shock present. Because aggressive fluid resuscitation may worsen oxygenation. 08-04-20www.nursingpath.in 13
  14. 14. Early Supportive therapy and monitoring C ) Antimicrobial therapy : Give empiric antimicrobials within one hour of initial patient assesment to treat all likely pathogens causing SARI. Empirical therapy includes a neuraminidase inhibitor for treatment of influenza when there is local circulation or travel history. D) Corticosteroids : Do not routinely give systemic corticosteroids for treatment of viral pneumonia or ARDS. E) Closely monitor patients with SARI for signs of clinical deterioration such as respiratory failure and sepsis and apply supportive care interventions immediately. F) Co-morbid condition : Treat co morbid condition if any. 08-04-20www.nursingpath.in 14
  15. 15. Collection of specimens for laboratory diagnosis • Blood culture : collect blood for culture of causative organism that causes pneumonia and sepsis ideally before antimicrobial therapy. BUT DO NOT delay antimicrobial therapy to collect blood sample. • RT – PCR : collect nasopharyngial and oro pharyngial swab • Use appropriate PPE for specimen collection . When collecting URT samples, use viral swabs and viral transport media. • In hospitalised patients with confirmed COVID – 19 infection repeat samples should be collected to demonstrate viral clearance at least every 2 – 4 days untill there are two consecutive negative results of URT samples at least 24 hours apart 08-04-20www.nursingpath.in 15
  16. 16. . Thank You 08-04-20www.nursingpath.in 16