Suspected COVID-19 Cases

Management in Triage Hospitals

Patient enters Triage Hospitals

(referred from another hospital, referred by 105, walk in)

PCR

Home Isolation if
possible until
PCR result
- Start management
* Rest
* Infection control
(IPC measures)
* Antibiotic if needed
* Anti-pyretic
(Paracetamol)

Admitted to COVID-19
area in triage hospital
and manage
according to protocol

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PCR Positive Cases

Mild Case
Symptomatic case
With Lymphopenia or Leucopenia
With no radiological signs for pneumonia

Check for

1. Age
2. Temperature > 38
3. SaO2 ≤ 92%
4. Heart Rate ≥ 110
5. Respiratory Rate ≥ 25 /min.
6. Neutrophil / lymphocyte ratio on CBC ≥ 3.1
7. Comorbidities
All No Any YES
8. Immunosuppressive Drug
9. Pregnancy
10. Active Malignancy
and OR
11. On Chemotherapy
12. Obesity (BMI>40)

Age < 60 Age > 60

• Home Isolation (Symptomatic Treatment) Isolation in a

• Strict isolation healthcare facility
• Follow and use personal protective guide
equipment
• If any deterioration occurs, back to hospital
NB: Paracetamol is the preferred agent

Treatment

 Hydroxychloroquine (400 mg twice in first day then 200 mg twice for 6 days)
 Vitamin C (1gm daily)  Zinc 50mg daily
 Acelylcysteine 200 mg t.d.s.  lactoferrin one sachet twice daily

Moderate Case
Patient has pneumonia manifestations on radiology associated with symptoms &/Or leucopenia or lymphopenia

Hospitalization

• Lopinavir/Ritonavir (2 tab 200/50) • Hydroxychloroquine

every 12 hrs (if NO contraindication) 400mg /12
• Ribavirin 400 mg every 12 hrs For hrs for 1 day then 200 mg every 12
hours for 9 days
14 Days
(Not recommended if symptoms OR +
started for more than 7 days)
• Anticoagulation: Prophylactic OR
+
Therapeutic if D-dimer > 1000
• Anticoagulation: Prophylactic OR
Therapeutic if D-dimer > 1000

Steroids if patients is dyspneic or CT SCAN showed significant deterioration

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PCR Positive Cases

Severe and Critically Ill Case

If any of the following criteria is present

1. RR > 30 2. Sa02 < 92 at room air 3. PaO2/FiO2 ratio < 300

4. Chest radiology showing more than 50% lesion or progressive lesion within 24 to 48 hrs
5. Critically ill if SaO2 <92, or RR>30, or PaO2/FiO2 ratio < 200 despite Oxygen Therapy.

Admit to Intermediate Care Or Intensive care

Early Block Tocilizumab

the storm if 4-8mg/kg/dose
Max 2 doses
steroids failed

Anti- Avoid
Antiviral Steroids Prone
Coagulation Hypoxia
Drugs As is In Methylprednisolone Awake or
Enoxaparine O2/
Severe case 1-2 mg/kg/d ventilated
1 mg/kg BID NIV/HFNC/IMV

Add Antibiotics 1 mg for non Consider Improves V/Q Don’t wait too
As per protocol ventilated and 2 D-dimer level as a matching and much for any
mg for ventilated guide survival type of support
Keep plateau<30

COVID 19 Critical Care Chain of Survival

Antiviral drugs

• Lopinavir/Ritonavir (2 tab 200/50) • Hydroxychloroquine (if NO

every 12 hrs. contraindication) 400mg /12
+ Ribavirin 400 mg /12 hrs hrs for 1 day then 200 mg every 12
+ Interferon beta 1b + hours for 9 days +
Azithromycin (500mg daily) or
doxycycline (200 mg first day then
OR • Lopinavir/Ritonavir (2tab 200/50)
every 12 hrs.+
100mg daily OR
• Doxycycline 200 mg first day and 100
NB: Remdesivir if available: 200 mg day
mg daily or Azithromycin 500 mg daily
1 then 100 mg daily for 9 days

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 PCR Positive Cases

Non Invasive Ventilation or High flow nasal cannula (HFNC):

• Conscious patients with minimal secretions.

• Hypoxia SpO2 < 90% on oxygen. Or PaCO2 >40 mmHg provided pH 7.3 and above.
• NIV trial shall be short with ABG 30 minutes apart.
• Any deterioration in blood gases from baseline or oxygen saturation or consciousness level
shift to IMV.
• CPAP gradually increased from 5-10 cmH2O.
• Pressure support from 10-15 cm H2O.
• HFNC can be alternative to NIV.

Invasive Mechanical ventilation:

• Use PPE specially goggles during intubation and avoid bagging.

• Indications:
• Failed NIV or not available or not practical.
• PaO2  60 mmhg despite oxygen supplementation.
• Progressive Hypercapnia.
• Respiratory acidosis (PH  7.30).
• Progressive or refractory septic shock.
• Disturbed consciousness level (GCS ≤ 8) or deterioration in consciousness level from
baseline.

Step 1: Initiation of Invasive Mechanical ventilation

VCV
TV 8 ml/kg
PEEP 5 cmH2O

Plateau
Inspiratory Pause for 1 second
Pressure

Less than 30 cmH2O Less than 30

More than 30
Sat >93 Sat<93
ARDSnet protocol
Keep and Watch Increase PEEP to 10

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PCR Positive Cases

IF PLATEAU ABOVE 30 CMH2O

Step 2: Shift to ARDSNet protocol if needed

▪ ARDSNet protocol:

Start with tidal volume of 6 ml/Kg to keep plateau pressure on volume controlled ventilation (VCV) below
30 cmH2O, decrease to 4 ml/kg if the plateau remain higher than 30 allow permissive hypercapnia so long
the pH is above 7.3 compensate by increasing respiratory rate up to 30 breath/minute. Consider heavy
sedation and paralysis. If pressures are high or any evidence of barotrauma shift to pressure controlled
ventilation and be cautious about low tidal volume alarms for fear of unnoticed endotracheal tube
obstruction. Consider ECMO early if eligible. Increase PEEP gradually if the patient remains hypoxic
according to FIO2 level to keep driving pressure < 15cmH2O. NEVER FORGET PRONE POSITION.

Step 3: Assessment of Respiratory support Outcome

Assess
ABGs, Clinical
Radiologic

Improved Stationary
Deteriorating
Weaning of Respiratory Continue Respiratory
Criteria for ECMO*
support support as needed

*Criteria for VV ECMO: Age below 55, Mechanical ventilation duration less than 7 days, No
comorbidities, Preserved consciousness level, PaO2/FiO2 <100 despite prone RESPscore >0.
Expert opinion is needed and depends on availability.

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Prepared By

NAME AFFILIATION

Professor of Chest Diseases.

Dr. Hossam Hosny Masoud Head of Pulmonary Hypertension Unit, Faculty of Medicine,

Cairo University

Professor of Pulmonary Medicine

Dr. Gehan Elassal
Ain Shams University

Professor of Hepatogastroenterology and Infectious

Dr. Samy Zaky Diseases,

Al Azhar University

Consultant of Hepatoogy, Gastroenterology and Infectious

Dr. Amin Abdel Baki Diseases. National Hepatology and Tropical Medicine
Research Institute (NHTMRI), Cairo, Egypt

Consultant of infectious diseases and director of ICU,Imbaba

Dr. Hamdy Ibrahim
Fever and infectious diseases hospital MOHP.

Dr. Wagdy Amin Director General for Chest Diseases, MOHP

Professor of critical care medicine, Cairo University,

Dr. Akram Abdelbary
Chairman elect of ELSO SWAAC chapter

Lecturer of critical care medicine, Faculty of Medicine,

Dr. Ahmad Said Abdel Mohsen
Cairo University

Fellow of Infectious Diseases and Endemic

Hepatogastroentrology,
Dr. Mohamed Hassany
National Hepatology and Tropical Medicine Research
Institute

Dr. Alaa Eid Head of Preventive Medical Sector MOHP

Minister's Advisor for Research and Health Development.

Dr. Noha Asem Mohamed Chairman of Research Ethics Committee MOHP.

Lecturer of Public Health, Cairo University.

Researcher of Tropical Medicine. Medical Division National

Dr. Ehab Kamal Research Center. General Director of Directorate of Fever
Hospitals, MOHP

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