CME INDIA Presentation by Dr Anand Malani, MD, Sangli (Maharashtra). Interest – Critical care/ Infectious diseases/ Rheumatology.

HOME CARE FOR COVID-19

An article about self-treatment guidance and care for Medicos getting treated at home.

Young frontline and health care workers are doing amazing work at this most desperate time. Many of the health care workers are getting ill and paucity of beds and Medicare is frightening. At this time, slight intelligent use of simple scientific facts can be extremely game changer in proper care. Dr Anand Malani’s article is an attempt to deliver the best advices to the needy.

The purpose of this article is to standardise home care, alleviate anxiety and fears and make the reader aware of warning symptoms of need of hospitalization.

All medicos can also use information in this article to treat their near and dear ones at home, in addition to self-treatment. A physician will not be required always for the same, nor will be available on phone or WhatsApp 24×7 for time constraints, they being very busy in covid care and away, in addition to their routines. Many are attending more than 25-50 mobile calls per day and equal number of messages for COVID home treatment issues-minor to major. Becoming impossible to attend all of them!

[Disclaimer: This is just a guidance article intended for easing home care. No responsibility in any regard rests with the writer regarding any treatment taken as per medical advice given below.]

Once you are symptomatic or diagnosed, it is surely going to cause intense anxiety and fear. Thoughts of getting critical, needing ICU and further things will come to your mind. Be assured that 85% patients come out of this with the least of intervention. Another 10% recover well with timely treatment. Instead of panicking let us accept the situation and focus on the next course of action. Alleviating anxiety of family members is most important step to avoid panic and depressing environment.

THINGS YOU ARE GOING TO NEED

• Pulse oximeter.
• Hygiene related things – Gloves, masks, sanitizers.
• Isolation room in your home.
• Basic medicines.
• Things for record keeping.
• Things for entertainment.
• Contact numbers at hand – Physician, Ambulance, Hospitals, Friends and relatives.

 WHAT TO DO AND WHAT NOT TO DO?

• Mentor a Physician. Have faith in him. No multiple opinions please.
• Fix a time and mode of communication with him on daily basis initially and then as and when required. This will be comfortable for everyone.
• Don’t Google or binge read. The treatment is as per Guidelines with some minor modifications and quite simple.
• Don’t try experimental drugs.
• Follow strict isolation and mask etiquettes. You should not be out of your room throughout the course except for medical care.
• No exercise or Pranayama during disease. Already diseased lungs are more prone for self-inflicted lung injury or volutrauma.

BASIC INVESTIGATIONS AT ONSET OF SYMPTOMS OR AFTER GETTING DIAGNOSED

• A throat swab confirmation by RT PCR is preferred.
• CBC-PS-ESR.
• BSL R / PP BSL-HBA1C IF diabetic.
• LFT.
• RFT.
• Urinogram.
• CRP.
• LDH.
• D-dimer.
• Ferritin.
• Chest Xray.
• ECG –optional or if easily possible.
• CT Chest preferred. Although not mentioned in guidelines, and not recommended for all, it is of great diagnostic value and prognostic value. It will also pick up those with false negative swabs. [Note – Asymptomatic can skip the inflammatory marker panel]

TREATMENT PART

I. ASYMPTOMATIC

• Adequate hydration and proper diet. Nothing specific.
• Asymptomatic don’t need any treatment as such. Vitamin C / Zinc / Betadine gargles should suffice.

II. MILD TO MODERATELY SYMPTOMATIC

A. Mildly symptomatic means– Fever / cough / aches and pains / GI upsets etc. No hypoxia, no respiratory distress, CT severity score less than or equal to 9/25. Spo2 always above 94%.

B. Moderate symptoms –Above symptoms bit more in intensity, or with comorbid conditions, or CT score 10-18/25. No respiratory distress or hypoxia. Spo2 above 94%.

• PPI with Domperidone
• Ondansetron sos.
• Paracetamol sos.
• Antibiotic to prevent secondary infection for 5 days Azithromycin 250 mg bid x 5 days, Or Cefepodoxime/ Cefixime/ Amoxy clav – as per your preference. No much advantage of one over other.
• Favipiravir to be preferred over HCQS.
  • Tablets available in 200 and 400 mg strengths.
  • Baseline LFT/ RFT has to be normal.
  • Avoid in age above 75 Y.
  • Drink at least 3-4 litres of water a day, otherwise chance of crystallization in renal tubules.
  • Dose is 1800 mg for first 2 doses, then 800 mg for next 6 days.
• Vitamin C / Zinc
• Antihistaminic cough syrup for dry cough or any cough without wheezing.
• Bronchodilator cough syrup if wheezing. Wheezing is uncommon.
• Pre-probiotics if Diarrhoea.
• Consider Enoxaparin 40 mg s/c daily if d dimer and or Ferritin are significantly high – 3-4 times above normal, despite mildly to moderately symptomatic. Hypercoagulable state can be seen even with modest disease.
• Alternative to Enoxaparin will be Tab Orokinase / Nattokinase – Efficacy yet to be proven!
• Continue treatment of comorbid conditions including Aspirin/ Statins/ACEI or ARBs.

MONITORING – MOST IMPORTANT ASPECT OF HOME CARE

• PULSE / BP/ SPO2 AT REST – 2 times a day and SOS.
• 6 MIN WALK TEST twice a day – Walk in your room for 6 minutes at normal speed and check Heart rate and Spo2. Drop of saturation below 93% or an absolute drop of saturation by 3% from baseline is a positive walk test. It indicates masked hypoxia and potential for worsening. Be prepared for admission in case positive.
• Maintain a chart of above. Can share with your physician once a day.
• Intake Output – Arbitrary of approximate.
• Repeat basic lab and inflammatory markers after 5 days or earlier if toxaemia develops.
• IL6 levels if persistent fever/ toxaemia/ raised other markers.
• No need to repeat CT scan or RT PCR.

DIRECT ADMISSION/ NO HOME TREATMENT IF

• Oxygen saturation below 94% at rest.
• Breathlessness on minimal activity like going to washroom.
• Extreme tachycardia – resting pulse 125 and above.
• CT index > 18/25.

RED FLAG SIGNS – PROBABLY

TIME TO ADMIT – Rather better to ADMIT

• SPO2 at any time below 94%
• Positive walk test.
• Breathless at rest.
• Resting tachycardia in absence of fever.
• Raised or rising inflammatory markers.
• Severe Lymphopenia.
• Persistent and high fever.
• 7th to 10th day of disease [from symptom onset] are important – ARDS and Cytokine storm usually occur in this period.
• Uncontrolled comorbid conditions/ Age factor should receive due consideration even in the absence of red flag signs.

HOW LONG?

• Infectivity goes down after 10th day of illness.
• Another 7 days of home isolation to be added. Can mix with other members after completing minimum of 10 days or if totally asymptomatic for at least 3 days, whichever later.

Hope this helps! Queries welcome!

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