COVID 19 - Diagnosis and Treatment ECMO EXPERTS

1. Critically ill Mild or Moderate
PCR must be
repeated
in 48 hours
Referral to
designated
Hospital
If Positive
Diagnosis and Treatment
Protocol for COVID-19 COVID-19
≥ILI, Fever 38 , cough , sore throat , shortness of breath
or meet the updated suspected case definition (Page 3)
Assessment for:
Isolation , Chest X ray
CBC, Samples, CT
Chest if available
Home Isolation
14 days
Hospital
Isolation
Rest
IPC measures
Oseltamivir if needed
Antibiotic if needed
Anti-pyretic (Paracetamol)
Restricted IPC measures
Supportive measures
Antipyretic
Close monitoring
Fluid (conservative)
Oseltamivir(75mg/12 hours for 5 days)
Hydroxy Chloroquine (400mg twice in
first day, 200mg twice for 4 days) or
Chloroquine phosphate 500 mg twice
serum ferritin, D- Dimer
Restricted infection control (IPC) measures
Supportive measures
Antipyretic
Close monitoring
Oxygen therapy keep saturation above 93%
Fluid (conservative)
Oseltamivir ( 150mg/ 12 hours for 5 days)
Hydroxy Chloroquine (400mg twice in first
day, 200mg twice for 4 days) or Chloroquine
phosphate 500 mg twice, if contraindicated
use combination of Lopinavir/Ritonavir
2 tabs /12 hours ( Max 10 days)
serum ferritin, D- Dimer
Oxygen , fluids (according to assessment)
Empiric antibiotic (Cephalosporins)
Oseltamivir ( 75mg/ 12 hours for 5 days)
Waiting for result
Dyspnea, Tachypnea,
Tachycardia Co morbidities,
Immunosuppressant
Above 65 years
Social isolation
No
improvement
after 3 days
Negative PCR for COVID-19 Positive PCR for COVID-19
Severe
Asymptomatic
Mild symptoms
Social applicable
Yes
Improved with 2 samples
negative (48 hours apart)
ICU
Admission
Assess for home
discharge
ILI
Influenza Like Illness
N.B.
1-Healthcare providers exposed to suspected or confirmed COVID-19 case would follow the algorithm shown in MOHP guide booklet.
2- Dose and drug modifications are required for children below 12 years.
3- Check Chloroquine contraindications.
IPC
Infection Prevention
and Control
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2. ICU Management Protocol
for COVID-19
Failed or
not applicable
Medications:
Restrict IV fluids
Antibiotics according to the guidelines
Oseltamivir (150mg Twice daily)
Hydroxy Chloroquine (or Chloroquine
phosphate)
Azithromycin (500mg daily )
Hydrocortisone (50 mg every 6 hours
if hypotensive patient )
Consider Theraputic anticoagulants if
D-Dimer > 2
Tocilizumab 4-8 mg/Kg maximum 400 mg
once only /Or if not available
methylprednisolone 2 mg/kg/24
hours for 5 days if HScore >169
Laboratory investigations:
1-PCR swab for COVID 19 every
72 hours.
2- CBC with differential daily.
3- AST, creatinine, D-dimer, Ferritin,
Triglycerides, Fibrinogen, ESR,
CRP daily.
4-Cultures on admission and whenever
needed.
Imaging:
1-Daily chest X-Ray.
2-Echocardiography with starting
hemodynamic instability or inappropriate
tachycardia.
3- Abdominal ultrasound if needed.
Invasive Mechanical ventilation Protocol:
Sedation (Midazolam or Propofol or
Dexmedetomidine).
Muscle paralysis (Atracurium).
Consider Prone Positioning.
Volume cycled control mode (VCV) start
FiO2: 1
Tidal volume 4-8 ml/kg PBW.
PEEP ≥ 10 cm H2
O.
Respiratory rate < 30 BPM.
Target Plateau Pressure < 30 cm
H2
O.Switch to pressure controlled
ventilation (PCV) with PIP of 30 if plateau
pressure is high on VCV.
Target Driving Pressure < 15 cm H2
O).
Invasive Mechanical Ventilation (IMV)if:
PaO2
<60mmHg or O2
saturation
< 90% despite oxygen or NIV
Progressive hypercapnia
Respiratory acidosis (PH <7.3)
Progressive or refractory Septic shock
Non Invasive Ventilation trial (NIV)
Conscious patient with minimal
secretions
Shall be short (30min).
If Sp02
< 93% or hypercapnia
≥ 40 cmH2
0, PH <7.3 shift to IMV
Improving
Yes
No Yes
Improved with 2 samples negative (48 hours apart)
Deteriorating or
severe myocarditis
Not
deteriorating
Keep
IMV
Consider
ECMO
Assess for
weaning
Weaning criteria
PaO2
≥ 60 mmHg on FiO2
< 40–50 %
and PEEP ≤ 5 – 8 cm H2
O
PaO2
normal or baseline
Patient is able to initiate an
inspiratory effort
Assess for
home discharge
ECMO
Extracorporeal Membrane Oxygenation
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COVID-19
Assessment for Mechanical Ventilation
N.B.
Dose and drug modifications are required for children below 12 years.

3. Definition of Suspected
Cases
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A.
Any one of the epidemiological history with any of the clinical features.
Epidemiological history:
1. History of travel to or residence in communities where cases reported within
14 days prior to the onset of the disease.
2. In contact with viral RNA positive people within 14 days prior to disease onset.
3. In contact with patients who have fever or respiratory symptoms from
communities confirmed cases reported within 14 days before disease onset.
B.
All three clinical features. Clinical features:
1.Fever and/or respiratory symptoms.
2.Imaging characteristics.
3.The white blood cells was normal or decreased, with lymphocyte decreased.
C.
Severe Acute Respiratory Infection (SARI) with no other obvious cause.
COVID-19
OR
OR
N.B.
Healthcare providers exposed to suspected or confirmed COVID-19 case would follow the algorithm shown in MOHP guide booklet.

4. Treatment Protocol
Revised By:
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NAME
Dr.Hossam Hosny Masoud
Dr.Gehan Elassal
Dr.Samy Zaki
Dr.Amin Abdel Baky
Dr.Hamdy Ibrahim
Dr.Wagdy Amin
Dr.Akram Abdelbary
Dr.Ahmad Said Abdel Mohsen
Dr.Mohamed Hassany
Dr.Alaa Eid
Dr.Noha Asem Mohamed
Dr.Ehab Kamal
Professor of Chest Diseases. Head of Pulmonary
Hypertension Unit, Faculty of Medicine,
Cairo University
Professor of Pulmonary Medicine
Ain Shams University
Professor of Hepatogastroenterology and
Infectious Diseases,
Al Azhar University
Consultant of Hepatoogy, Gastroenterology and
Infectious Diseases. National Hepatology and
Tropical Medicine Research Institute (NHTMRI),
Cairo, Egypt
General Director of Directorate of Fever Hospitals,
MOHP
Director General for Chest Diseases,MOHP
Professor of critical care medicine,
Cairo University
Chairman elect of ELSO SWAAC chapter
Lecturer of critical care medicine,
Faculty of Medicine, Cairo University
Fellow of Infectious Diseases and
Endemic Hepatogastroentrology,
National Hepatology and
Tropical Medicine Research Institute
Head of Preventive Medical Sector MOHP
Minister's Advisor for Research and
Health Development.
Chairman of Research Ethics Committee MOHP.
Lecturer of Public Health, Cairo University.
Consultant Tropical Medicine Researcher of
Tropical Medicine.
Medical Division National Research Center.
AFFILIATION
COVID-19