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clexane

24 May, 28 tweets, 6 min read

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COVID management
-------- RULE OF 3--------
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#Covid_19
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**3 must remember warning signs**

- High grade fever even after 5 days
- Increasing dry cough while sleeping,talking
- Exhaustion,exertional dyspnea (worsening from before)

*3 reasons for late presentation*
- Attributing fever to post vaccination and waiting( post vaccination fever is never more than 48 hrs)
- Using DOLO/PCM 6 hrly x 1week as a drug, masking fever
- Wrong timeline, reporting testing day as day 1, not onset of symptom.

*3 minor symptoms- can be ignored*

- Anosmia, altered taste
- Cold,stuffy nose
- Body aches, throat pain

*3 must have things with home treated patients*

- Thermometer
- Pulse oximeter
- Emg doctor/hosp contact details

**3 points not to forget on first OP/ tele visit**
- 6 to 12 days is the dangerous period.
-Report ASAP if danger signs present (give a written printed format)
-Avoid long prescriptions with 10 + drugs, patient misses what’s important.

**3 things to be monitored daily and inform**

- Spo2 with 6 min walk <94
- Temperature>101( after 4th day)
- Heart rate (resting >100)

**3 lab parameters indicating storm**

- CBP - high N/L ratio>3.5, high monocyte>8%
- CRP,Ferritin,LDH , IL-6 (inflammatory markers)
- D Dimer (coagulation risk)

*3 lab values in resource poor settings*

- CBP- --TLC above 10000
- N/L ratio >3.5 High monocytes
- CRP,ESR,CXR

*3 Things to see on CT*

-Day of illness (early CT misleads)
-Severity Score (not CORAD 1-5, CORAD 5 doesn’t mean severe covid) -Progressive/ resolving changes

**3 mistakes to avoid**

- Starting steroids in first 5 days( prolongs viral clearance and duration of illness,
- late and severe storm)
- Early CT and lab work up (before 5th day unless sick)

- Missing on prophylactic anticoagulation in high risk (as dimer normal despite other signs of storm)

**3 indicators of cytokine storm **

-Re spiking/continued high fevers +/- chills, past 5 th day
-Loose stools after 5 th day - Increasing dry cough /
-breathless/exhaustion on routine work

**3 causes of exhaustion in COVID**

- Viral myalgias severe (improves over 1 st week)
- Cytokine Storm,happy hypoxia (worsening towards end of 1st week)
- Hyperglycemia (weakness plus polyuria)

*3 clues to catch in early happy hypoxia*
- - Mandatory 6 min walk spo2 test daily
-- afebrile resting heart rate (>110)
- - Cough on lying down, deep inspiration, interrupting speech

**3 most important medications to counter storm**

- -Steroids (oral/IV)
- - Anticoagulant(oral/SC)
- -Oxygen (rebreather mask very useful)

**3 supportive care measures usually neglected**
- -Prone positioning
- - Glycemic control
-- Fluid intake (dehydration increases thrombosis risk)

**3 mistakes with steroids**

- -Early use from day 1 or 2 (irrespective of dose)
- - Using very high doses(iv 40-80 mg methylpred or equivalent is sufficient in most)
- -Not tapering at the earliest improvement

**3 complications with steroids**

- -Poor glycemic control (most need insulin)
- - Bacterial sepsis (respiking fevers/ worsening lung)
- -Opportunistic infections
- -( oral,esophageal candidiasis, pulm aspergillosis, rhinoocular mucormycosis)

**3 misinterpreted lab values**

- -Increasing WBC,neutrophil count after steroids as sepsis(NLR in CBP is not
- -reliable after starting steroid)
- - High CRP as sepsis in early 2 nd week
- -Normal dimer value as no need for anticoagulant even in sick

- (False positive widal due to cross antibodies as typhoid)

*3 extended tests useful in ICU*

- IL6 (more than 10 times, >50
- indicates severe cytokine storm)
- Procalcitonin ( as CRP can’t differentiate inflammation vs sepsis,to rule out severe
bacterial infection if >2. Useful only in ICU sick cases)
-Bacterial and fungal cultures

**3 unnecessary tests**

- -CT chest to see for improvement /resolution ( despite clinical improvement) - PCR /Rapid @ day 14( false positive even if dead virus present)
- - Lab markers despite clinical improvement,off oxygen (except dimer to be done if high)

***3 must do things if hypoxic and waiting for a bed(HOME or ambulance)***
- -Inj. Dexa 2 ml bd / Tab predmet 32mg Bd
- - Inj Clexane 0.6 ml SC bd/ Tab apixaban 5 mg bd
- -Dont panic if remdesvir not available,above 2 drugs make all the difference

***3 Points on Remdesvir***

- -Mild disease : Dont give

- - Moderate:
=Affordable, available - Dont delay
=Affordable, not available -Dont panic
=Not affordable,unavailable-Dont bother

- -Severe/late
=Role questionable.