GUIDELINES FOR THE CLINICAL MANAGEMENT OF COVID 19

Edited by:-
Dr. Ragunanthanan MD
Dr. C. Rajendiran MD
Dr. N.Babu MD

This clinical guidelines was prepared by the TN COVID Expert Committee Constituted by the
Government of Tamil Nadu to standardise treatment across the state. This document is intended for
clinicians taking care of hospitalised adult patient of COVID - 19. It is to strengthen clinical
management of these patients and provide to up-to-date guidance for the treating physicians. Best
practices for COVID - 19 including IPC and optimized supportive care for severely ill patients are
essential. This document aims to provide clinicians with updated interim guidance to treat the
patients
This especially
Clinical Guidelinepatients with severe
was prepared acuteCOVID-19
by the “TN respiratory illness
Expert and critically
Committee” ill. by the
Constituted
Government of Tamil Nadu to standardise treatment across the state under Clinical Establishment
(Regulations) Rules, 2018. This document is intended for clinicians taking care of adult patients of COVID -
19.Best practices for COVID - 19 including IPC and optimized supportive care for severely ill patients are
essential.
Version 2 - 13th April 2020
 TAMIL NADU COVID -19 EXPERT COMMITTEE
Sl.no Name Designation Institution
1 Dr. Ragunanthanan Director, Institute of Internal Medicine Madras Medical College

2 Dr. C. Rajendiran Former Director, Institute of internal Madras Medical College.

Medicine.

3 Dr. A. Mahilmaran Director Institute of Thoracic Medicine.

4 Dr Ranganathan Former Director Institute of Thoracic Medicine

5 Dr N. Babu Medical superintendent & Director, Vijaya Hospital, Chennai
Critical Care Medicine.

6 Dr. Sridhar Professor of Medicine. Stanley Medical College.

7 Dr. Paranthaman. Professor of Medicine Kilpauk Medical College

Government Royapettah Hospital

8 Dr.Chandrasekaran Professor of Medicine Kilpauk Medical College

9 Dr. O. R. Krishna Professor of Respiratory Medicine. Balaji Medical College

Rajasekhar.

10 Dr.C.Ramasubramanian Infectious Diseases patrol Apollo,Chennai.

11 Dr. T. V Ramakrishnan HOD of Emergency Medicine Sri Ramachandra university

12 Dr. Hariharan HOD in Medicine Stanley Medical College

13 Dr. Sivakumar HOD in Medicine Villupuram Medical College

14 Dr. Narmatha HOD in Medicine. Chengalpattu Medical College

15 Dr. Rama Rajagopal Consultant Physician. Apollo, Chennai

16 Dr. Ram Consultant, Infectious Diseases Apollo Hospitals

Gopalakrishnan

17 Dr. Babu K. Senior Consultant Apollo Hospitals

 FEVER OPD-FLOW CHART

Fever surveillance area

Hand washing area All Medical and Paramedical personnel
Give face mask to all
All patients and attenders patients and maintain should wear 3-layer face mask. After
should wash their hands social distance examining each patient use Hand
with soap and water Sanitizer/Hand Wash
Keep at least one metre
distance

Check vitals and system examination Thermal screening, detailed history taking including
personal details (Verified Contact Number & Residential
Legible Single Breath Count* and SpO2**
address). Travel history, Contact history. Comorbid
conditions, etc.

Do CBC and X-ray Chest**** in an exclusive facility

If normal, manage as outpatient and follow up on
daily basis for 14 days

If x-ray is abnormal, plan CT Chest and admit the patient Based on History

Symptoms &Signs

Fever, cough and

shortness of breath with Symptomatic
Patients with Severe Acute health care
travel history/contact
Respiratory Infection (SARI) provider
with high risk group

Symptomatic 1. Fever > 38C ͦ

persons in contact 2. RR > 24/min
with COVID positive
patient patient 3. Cough onset within 10 days

On admission, take swab for COVID and do other basic investigations

If positive, treat as per If negative, treat as per

protocol Standard guidelines

*Single Breath Count <30,

**SpO2 <94% at room air.

***CBC- Lymphopenia and Neutrophil Lymphocyte Ratio > 3.1

****Bilateral lower lobe subpleural Ground Glass Opacities (GOO) with crazy paving pattern/ consolidation
 TREATMENT PROTOCOL FOR COVID POSITIVE PATIENT

Admit in isolated room /ward with toilet facilities.

Close monitoring of vitals (Temp, PR, RR, SpO2 with finger probe pulse oximetry, BP, intake
output Chart).
Investigations;
• CBC, LFT, RFT Urine routine, ABG, Chest X-ray, CT chest*, ECG**
• Other investigations at the discretion of treating Physician (eg CRP, CPK, LDH, D-
dimer, Troponin and ferritin)
• Blood culture if necessary.
Supplemental Oxygen Therapy (if SpO2 < 94% in room air)
• For hypoxemia initiate 02 through venturi device to achieve target SpO2 > 94%
If venturi device not available,
• Initiate 02 at 3 - 5 L /min using face mask with reservoir bag
• Can increase up to 10-15 L/min
• Target SpO2 > 94%.
Backrest at 30 -45 degrees.
Appropriate fluid therapy and maintain l/O chart
DRUG THERAPY:

1.Tab. Azithromycin 500mg Once Daily for 5 days in combination with

2.Tab. Hydroxy-Chloroquine 400mg Twice Daily on day one, followed by 200mg Twice

Daily for next 4 days

(These drugs should be administered under close medical supervision with monitoring for

side effects including QTc interval).

3.Cap. Omeprazole 20mg Once Daily for 5 days

4.Tab. Ondansetron 4mg as and when required

5.Tab. Zinc 150mg Once Daily for 5 days

6.Tab. Vit C 500mg Once Daily for 5 days

7. Tab. Paracetamol 500mg as and when required

Oseltamivir:

Patients presenting as Severe Acute Respiratory Illness (SARI) , can be initiated on Empirical
Oseltamivir therapy. If Covid-19 test becomes Positive Oseltamivir shall be stopped.

Dosage:

Tab. Oseltamivir 75 mg twice daily for 5 days

Methylprednisolone:

Indication:
Persistent Severe Hypoxemia /ARDS.
Persistent Hypotension despite fluid resuscitation and vasopressors.
Radiological Deterioration in spite of conventional treatment in 48 hours
Dose:
Methylprednisolone 1mg/kg IV once daily for 5 days.

Tocilizumab:
The Committee recommends Tocilizumab on Clinical Trial basis.
Convalescent Plasma:
The Committee recommends Convalescent Plasma as one of the therapeutic interventions for
severe cases as a part of the Clinical Trial.

LMWH:
The Committee recommends prophylactic LMWH for severely ill patients unless there is
active bleeding or platelet count < 25000/dl
Enoxaparin 40 mg OD SC

Supportive and Complimentary Therapy:

• Patients are encouraged to take foods rich in Vitamin A, Zinc, Magnesium, Vitamin C
and anti-oxidants like nuts, fresh fruits, greens and vegetables.
• Counselling and Stress relaxation therapy
• Avoid NSAID, SEDATIVES and COUGH SUPPRESSANTS.
• Avoid Nebulization ( to prevent aerosol generation) and use
Metered Dose Inhalers, if necessary
• Recognize and treat septic shock
• Hemodynamic monitoring including ECHO
 INDICATIONS FOR MECHANICAL VENTILATION
• Persistent Hypoxia (SpO2 less than 90%) on 60% venturi mask
• Persistent tachypnoea (RR >30/min) or respiratory distress
• Systolic BP < 90 mmHg in spite of IV fluids and vasopressors.
• GCS less than 8.

Management of Hypoxemic Respiratory Failure

• Avoid NIV (Non-Invasive Ventilation) as far as possible (to prevent aerosol generation).
• Intubation and aerosol precautions by trained and experienced provider.
• Ventilator management as per ARDS protocol
• Closed suction and HME filters – if available.
• Prone ventilation, ECMO for refractory hypoxemia.

Prevention of Complications:

• DVT prophylaxis
• Stress ulcer prophylaxis
• Early mobilization

*CT chest -Bilateral lower lobe sub-pleural Ground Glass Opacities(GGO) with crazy paving
pattern/consolidation.

**ECG – at admission & daily if required for QTc monitoring. QTc prolongation >450ms is
significant.

#Kindly keep updated on the new guidelines (www.mohfw gov.in)

DISCHARGE CRITERIA

• Based on clinical criteria - Asymptomatic and clinically stable for72 hours.

• Based on Radiological criteria -Radiological clearance of Chest X-ray.
• Repeat 2 Swab tests (atleast24 hrs apart) if above criteria have been fulfilled and
both tests should be negative.
• Once patient is discharged, he/she shall be kept under quarantine for a minimum of 14
days.
THREE LEVEL OF QUARANTINE FACILITIES

1)Hospital isolation

• All those with travel history, contact history, exposure history, epidemiological linkage
and symptoms of COVID-19 (fever, cough, sore throat, running nose) should be
isolated in hospital isolation rooms.
• All the patient with severe acute respiratory illness should be admitted in separate
isolation rooms
• All positive cases should be admitted in isolation rooms/exclusive COVID-19 positive
wards with 3 meters distance between the beds.

2)Government facility quarantine

All those with definite history of exposure to positive cases like attending a mass gathering
event

If any under this category is tested negative

• They should be continued in the facility quarantine in individual rooms if feasible

• If facilities are not available, district official may examine on case to case basis the
availability of adequate facility at home. If they are satisfied that the person tested
negative has a separate room at home and comply with home quarantine protocol
standards, it may be permitted and monitored properly.
• Exit test should be conducted on the 14th day

3) Home quarantine

• All asymptomatic household contact, close contact.

• Low risk contacts like those living in close vicinity with possibility of exposure, co
passengers and co workers in the close environment of the positive case, living in the
same apartment complex and sharing living spaces such as elevator, parks, swimming
pools etc, people who were visited by the individuals such as friends, shops, saloons,
bank, ration shop etc.

For this group of individuals home quarantine guidelines should be followed strictly.

REFERENCES

1- WHO guidelines.
2- MoHFW and ICMR guidelines.
3- State guidelines from Kerala, AllMS.
4- Journals - Lancet, NEJM, JAMA
5- Journal of Thrombosis and Haemostasis.

For queries related to this document please contact.

Dr. Ragunanthanan - hemaragu@yahoo.com

Dr. C. Rajendiran –dr.crajendiran@gmail.com

Dr. N. Babu- drbabunarayan@gmail.com