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

1. Guidelines on Clinical
Management of
COVID - 19

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. .
Thank You
08-04-20www.nursingpath.in 16