Timely detection of hypoxia can prevent death
The first trigger is silent hypoxia or “happy hypoxia”. It appears more when fever subsides (between Day 7 to 9). It may occur in patients who have no comorbid conditions.
Normally, in hypoxia, carbon dioxide levels are raised and the person is irritable. In hypoxia in COVID patients, the carbon dioxide level is normal, lung elasticity is normal. In these patients, microvasculitis occurs in lungs, microclots are formed due to vascular endothelial dysfunction with resultant intussusception of the artery, i.e., the artery is partially thrombosed and partially patent, so perfusion is maintained.
If SpO2 level falls more than 4 on talking or walking, this is the first sign of hypoxia.
Once the trigger is known, it is time to act. Before beginning the search for a hospital bed, give: One dose of antiviral (remdesivir if available), one dose of LMWH, water-soluble aspirin stat and start home oxygen therapy before shifting to a hospital.
Do a hemogram, CRP, LDH, D-dimer along with RT PCR
If at the time of diagnosis, lymphocyte count, CRP (<10) and ESR are normal, the disease is most likely to be self-limiting.
Raised ESR, CRP levels are indicative of inflammation in the body. Patients with high ESR, CRP (>26), ferritin and D-dimer levels are at high risk for severe illness.
At the time of diagnosis:
If lymphocyte count is <1000: Admit the patient *If progressive lymphopenia (<800) with rising LDH:* Admit the patient in ICU *If lymphocyte count is >1000:* non-severe illness Give first dose of LMWH if there is progressive rise in D-dimer levels.
Loss of smell and taste: Around 20% of patients develop loss of smell and taste. Sweet and salt taste are lost, sour and bitter are retained. They are indicative of less severe illness with less chance of complications.
If a patient has diarrhea, he/she is more contagious and may have higher viral load. May be the super spreader.
Assurance and relief of anxiety is important. Cellular stress can lead to inflammatory reaction in the body, which can precipitate microthrombi.
If baseline X-ray chest shows two opacities- admit; 3 opacities - likely to go for high flow oxygen.
On the 9th day, the person is recovered, not cured. The virus becomes non-infectious. After 10th day, self-quarantine for one week.
If fever >103oFpersists for more than 2 weeks look for precipitation of underlying immunological disease.
Give LMW heparin prophylactically to all elderly and high risk individuals with comorbidity.