Management Protocol for COVID-19 Patients Version 1.4/30th May 2020 Ministry of health and population (MOHP), Egypt.

Abstract

Ministry of Health and Population
Coronavirus Disease 2019 (COVID-19), SARS COV2
Management Guide

Full text

Version 1.4 / 30th May 2020 1
Management Protocol
in Hospitals
C VID-19
Ministry of Health and Population, Egypt
Management protocol for COVID-19
Patients
Version 1.4 / 30th May 2020
Management Protocol for
Patients

Version 1.4 / 30th May 2020
2

Version 1.4 / 30th May 2020 3
Table of contents
Item Page
Number
Management in Triage Hospitals 4
Management of Mild Cases 6
Management of Moderate Cases 7
Management of Severe and
Critically Ill Cases 8

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4
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
the last 14 days.
2. In contact with viral RNA
positive people
within the last 14 days.
3. In contact with a patient who
has fever or respiratory
symptoms or from a
community
with conrmed cases reported
within the last 14 days.
B
Asessing the presence of at
least two of the following
clinical features:
1.Fever and/or respiratory
symptoms.
2.Imaging characteristics.
CT scan is preferred, if not
appicable do CXR
3.Dierential CBC ndings:
white blood cells is normal
or decreased, with decreased
lymphocytic count.
C
Severe Acute Respiratory
Infection
(SARI) with no other
obvious cause.
Patient enters Triage Hospital
(referred from another hospital, referred by 105, walkin)
Assess to identify suspected cases
OR OR
N.B.
- Asymptomatic contact to +ve case should undergo home isolation and should seek medical
advice whenever symptoms develop.
- Healthcare providers exposed to suspected or conrmed COVID-19 cases should follow the
algorithim shown in MoHP guide booklet.
Management in Triage Hospitals

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Suspected COVID-19
Assess patient
Yes No
Non Covid-19 Cases
Management in Triage Hospitals
Impossible home isolation
or
sever symptoms (dyspnea,
tachypnea, tachycardia,
uncontrolled comorbidities,
Immunosuppressant, above
60 years)
Mild symptoms
(CT or CXR not
showing pneumonia)
Home Isolation if
possible until
PCR result
- start managment:
* Rest
* Infection control
(IPC measures)
* Antibiotic if needed
* Anti-pyretic
(Paracetamol)
Obtain PCR
sample
Continue treatment
until the 7th day
Home isolation for
14 days and close
follow up
Symptoms
resolved
Yes
-ve
Manage accordingly
-ve
PCR results
Repeat PCR
after 48
No
Manage
accordingly
Transfer to
COVID-19 hospitals
Repeat PCR
after 48
-ve
-ve
+ve
PCR result
Admied to COVID-19 area
in triage hospital
and manage according
to protocol
Obtain PCR sample
If deteriorated to
severe symptoms
Is it an
emergency
case?
Refer to
general
hospital
Stabilize
patient
Admit to non
COVID area
Yes No
Unstable
Stable
Stable

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6
PCR Positive Cases
Mild Case
Symptomatic case
with lymphopenia or leucopenia
with no radiological signs for pneumonia
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. Uncontrolled Comorbidities
8. Immunosuppressive Drug
9. Pregnancy
10. Active Malignancy
11. On Chemotherapy
12. Obesity (BMI>40)
Check for
Any YES
All No
Age ≥ 60
OR
Age < 60
AND
• Strict Home Isolation (Symptomatic
Treatment)
• Follow and use personal protective guide
equipment
• If any deterioration occurs, back to
hospital
NB: Paracetamol is the preferred antipyretic
Isolation in
a healthcare facility
Treatment
- Hydroxychloroquine (400 mg twice in
rst 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

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Moderate Case
Patient has pneumonia manifestations on radiology associated with
symptoms &/Or leucopenia or lymphopenia
Hospitalization
• Lopinavir/Ritonavir (2 tab
200/50) every 12 hrs
• Ribavirin 400 mg every 12 hrs
for 14 days
(Not recommended if symptoms
started for more than 7 days)
+
• Anticoagulation: prophylactic
or Therapeutic if D-dimer > 1000
• Hydroxychloroquine (if NO
contraindication) 400mg /12 hrs
for 1 day then 200 mg every 12
hours for 9 days
+
• Anticoagulation: prophylactic
or Therapeutic if D-dimer > 1000
OR
Steroids if patients is dyspneic or CT SCAN showed signicant deterioration
PCR Positive Cases

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Severe and Critically Ill Case
PCR Positive Cases
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
Tocilizumab
4-8mg/kg/dose
Max 2 doses
Early Block
the storm
if steroids
failed
Antiviral
Drugs As is In
Severe case
Steroids
Methylpred-
nisolone
1-2 mg/kg/d
Anti-
Coagulation
Enoxaparine
1 mg/kg BID
Prone
Awake or
ventilated
Avoid
Hypoxia
O2/ NIV/
HFNC/IMV
Add
Antibiotics
As per
protocol
1 mg for non
ventilated
and 2 mg for
ventilated
Consider
D-dimer level
as a guide
Improves
V/Q matching
and survival
Don’t wait
too much for
any type of
support Keep
plateau<30

Version 1.4 / 30th May 2020 9
Antiviral drugs
• Lopinavir/Ritonavir (2 tab
200/50) every 12 hrs.
+ Ribavirin 400 mg /12 hrs
+ Interferon beta 1b +
Azithromycin (500mg daily) or
doxycycline (200 mg rst day
then 100mg daily OR
NB: Remdesivir if available: 200
mg day 1 then 100 mg daily for 9
days
Hydroxychloroquine (if NO con-
traindication) 400mg /12 hrs for 1
day then 200 mg every 12 hours
for 9 days +
• Lopinavir/Ritonavir (2tab
200/50) every 12 hrs.+
• Doxycycline 200 mg rst day
and 100 mg daily or Azithromy-
cin 500 mg
OR
COVID 19 Critical Care Chain of Survival
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.

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Plateau
P<30 cmH2O
Incremental
PEEP
PCR Positive Cases
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.
Initiation of Invasive Mechanical Ventilation
Step 1:
VCV
TV 8 ml/kg
PEEP 5 cmH2O
Plateau
Pressure
Less than 30
cmH2O
Sat >93
Keep and Watch
Less than 30
Sat<93
Increase PEEP
to 10
More than 30
ARDSnet
protocol
Inspiratory Pause for 1 second
Shift to ARDSNet protocol if needed
Step 2:
IF PLATEAU ABOVE 30 CMH2O
- ARDSNet protocol:
LOW TV
6-4 ml/kg Driving
P<15 cmH2O

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PCR Positive Cases
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.
Assessment of respiratory support outcome
Step 3:
ImprovedImproved
Weaning of
respiratory
support
AssessAssess
ABGs, Clinical
Radiological
StationaryStationary
Continue
respiratory
support as
needed
DeterioratingDeteriorating
Criteria for
ECMO*
*Criteria for VV ECMO: Age below 55, mechanical ventilation duration
less than 7 days, no comorbidities, preserved conscious level, PaO2/FiO2
<100 despite prone RESPscore >0.
Expert opinion is needed and depends on availability.

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

Version 1.4 / 30th May 2020 13
Ministry of Health and Population
Management protocol for COVID-19
Patients
Egypt / May 2020

Version 1.4 / 30th May 2020
14
Ministry of Health and Population
Egypt / May 2020