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This video aims to provide guidance on the management options for the patient with possible Covid 19 infection. It is the second of two videos detailing clinical assessment of such patients.
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Assessing breathlessness is the key clinical skill. Can the patient complete full sentences when talking? What could they do yesterday, that they can’t do today? What makes them breathless now, that didn’t yesterday? Measure pulse, respiratory rate, oxygen saturation, respiratory effort including use of accessory respiratory muscles, and look for signs of lethargy.
Signs of severe respiratory infection include the following. In an adolescent or adult: Respiratory rate greater than 30, respiratory distress, oxygen saturation less than 93% in room air, or an inability to walk without help. In a child: Central cyanosis, oxygen saturation less than 90%, grunting or severe chest indrawing. Or an inability to breastfeed or drink, increasing lethargy, unconsciousness or convulsions.
Following your assessment ask yourself does this person possibly have Covid 19? Does this person have another condition making them ill also? Are they mildly ill or severely ill? If they are mildly ill, and you suspect Covid 19, discharge the patient home, advise to self-isolate if possible, and take paracetamol for fever. Treat with antibiotics only if the patient meets locally used criteria for antibiotic treatment of pneumonia. Explain the possibility of deterioration, especially during the second week, and instruct the patient to return if this happens. Treat other comorbidities as appropriate.
If the patient is severely ill, consider if admission or transfer to another facility is needed. If considering admission, ask yourself what benefit, if any, might this patient gain? Particularly, what facilities for respiratory support can your institution provide? Patients who may be prioritised for admission for active management, includes those who are severely ill but are younger and without underlying chronic disease.
Patients with severe symptoms that are not easily controlled, may require admission for palliative medications that cannot be given at home. Consider not admitting patients with severe disease if the hospital is not equipped. Sadly, treatment is unlikely to improve their condition. In such cases, avoiding admission is likely to be just as effective, the patient may be more comfortable at home, and it reduces the risk of Covid 19 for staff and other patients.
The principles of active management of patients with severe Covid 19 are as follows. Oxygen to maintain saturation greater than 94% IV antibiotics in case of coexisting bacterial pneumonia Cautious use of IV fluids, noting that fluid overload may worsen oxygenation. Treat the patient’s other conditions as appropriate. Do not routinely use steroids. If the patient has a history of asthma or COPD, steroids may be used for management if appropriate. If severe COVID 19, consider prone positioning as outlined for 12 to 16 hours per day, if tolerated. Further details can be found in links associated with this video.
If the patient is not improving on oxygen therapy, mechanical ventilation may be considered, if the hospital has sufficient trained staff to provide 24-hour care. This may not be feasible in low income countries where the same resources could be better used, providing good supportive care for a larger number of patients. Management of the patient with other co-morbidities and palliative care of Covid 19 are covered in separate videos in the series.
Voice Over: Elias Phiri
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