In Search of Rationality: Prehospital Care of COVID 19 Patients

This is a personal summary of the COVID situation (without going into nuances or details) with some references meant for non-specialists and some recommendations for various situations. They are based on ballpark figures, approximations and estimates and are therefore not written in stone and will change with time. Ordinarily these discussions are meant to be face to face with a specialist and tailored to specific situations in each patient, but these are extraordinary times.

If 100 patients get COVID-19 : 85 will settle with no treatment at all. 15 of these 100 will develop SpO₂ (oxygen saturation) levels of 93 and below¹ (usually between days 8 to 12²) and should be hospitalized.

10 of these 15 will settle with nasal oxygen up to 6 litres /minute, steroids, prophylactic anticoagulants and occasionally Tocilizumab. Remdesivir may be given at this stage but it does not decrease deaths. Convalescent plasma has not been found to be beneficial^3–7.

The other 5 will require critical care and escalation of respiratory support with non-invasive ventilation /CPAP or HFNC (High flow nasal cannula) oxygen. 3 out of 5 will settle down and be discharged. 2 will need to be intubated and invasively ventilated. 1 of these 2 will survive.

Even under ideal conditions 1 of 100 symptomatic covid patients may die⁸. If hospital beds are not available all 5 who get critically ill and perhaps half of those who become hypoxic will die – increasing deaths to about 10 in 100.

Asymptomatic patients in general do not get hypoxic or die. The infection fatality rate (including both symptomatic and asymptomatic patients) is estimated at 0.3% retrospectively looking at positive serology^9,10.

PREHOSPITAL CARE

There is no proven treatment for non-hospitalized patients and in particular HCQS^11–13, Azithromycin¹⁴, Doxycycline¹⁵, Vitamin C¹⁶, Vitamin D¹⁷, Zinc¹⁶ and Favipiravir^18,19 do not work and is not recommended. Ivermectin is not recommended because of poor quality data^3,6 and trials showing lack of efficacy²⁰ .

Colchicine²¹ and inhaled Budesonide^22,23 have some data as prehospital treatment, but their efficacy is still debated. If used Colchicine is given 0.5mg twice daily for 3 days ,then once daily up to 14 days (Colchicine cannot be used in kidney or liver disease and pregnancy). Budesonide has been used via inhaler 800mcg twice daily. There is a signal of reduced hospital admissions with these medications which need to be confirmed by more robust trials.

PREHOSPITAL CARE IN PATIENTS WHO SHOULD BE HOSPITALIZED

With the onset of hypoxia (defined as SpO₂ <94) the patient should be in hospital but may not find a bed. In these extenuating circumstances it is reasonable to start treatment with Dexamethasone 6 mg (OR Methylprednisolone 32 mg OR Prednisolone 40 mg) once daily after breakfast for 10 days along with prophylactic anticoagulation (Either Rivaroxaban 10 mg once daily OR Apixaban 2.5 mg twice daily orally). The patient and their carers must be warned that a substantial proportion of such patients will deteriorate and likely die if not treated in hospital. Please note that starting steroids before the patient becomes hypoxic is likely to HARM the patient.

Dr Sumit Sengupta MD, MRCP (UK), CCST (UK) in Respiratory Medicine, FRCP(London)

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3. WHO. Therapeutics and COVID-19: living guideline. Published 2021. Accessed April 14, 2021. https://www.who.int/publications/i/item/WHO-2019-nCoV-therapeutics-2021.1
4. NIH. Therapeutic Management. COVID-19 Treatment Guidelines. Published 2021. Accessed April 25, 2021. https://www.covid19treatmentguidelines.nih.gov/therapeutic-management/
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14. Butler CC, Dorward J, Yu L-M, et al. Azithromycin for community treatment of suspected COVID-19 in people at increased risk of an adverse clinical course in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial. The Lancet. 2021;397(10279):1063-1074. doi:10.1016/S0140-6736(21)00461-X
15. Study finds azithromycin and doxycycline ineffective for Covid-19. Accessed April 25, 2021. https://www.clinicaltrialsarena.com/news/uk-study-azithromycin-doxycycline/
16. Thomas S, Patel D, Bittel B, et al. Effect of High-Dose Zinc and Ascorbic Acid Supplementation vs Usual Care on Symptom Length and Reduction Among Ambulatory Patients With SARS-CoV-2 Infection: The COVID A to Z Randomized Clinical Trial. JAMA Netw Open. 2021;4(2):e210369. doi:10.1001/jamanetworkopen.2021.0369
17. Murai IH, Fernandes AL, Sales LP, et al. Effect of a Single High Dose of Vitamin D3 on Hospital Length of Stay in Patients With Moderate to Severe COVID-19: A Randomized Clinical Trial. JAMA. 2021;325(11):1053-1060. doi:10.1001/jama.2020.26848
18. Dabbous HM, El-Sayed MH, El Assal G, et al. Safety and efficacy of favipiravir versus hydroxychloroquine in management of COVID-19: A randomised controlled trial. Sci Rep. 2021;11(1):7282. doi:10.1038/s41598-021-85227-0
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20. López-Medina E, López P, Hurtado IC, et al. Effect of Ivermectin on Time to Resolution of Symptoms Among Adults With Mild COVID-19: A Randomized Clinical Trial. JAMA. 2021;325(14):1426-1435. doi:10.1001/jama.2021.3071
21. Tardif J-C, Bouabdallaoui N, L’Allier PL, et al. Efficacy of Colchicine in Non-Hospitalized Patients with COVID-19. medRxiv. Published online January 27, 2021:2021.01.26.21250494. doi:10.1101/2021.01.26.21250494
22. Group PC, Yu L-M, Bafadhel M, et al. Inhaled budesonide for COVID-19 in people at higher risk of adverse outcomes in the community: interim analyses from the PRINCIPLE trial. medRxiv. Published online April 12, 2021:2021.04.10.21254672. doi:10.1101/2021.04.10.21254672
23. Ramakrishnan S, Nicolau DV, Langford B, et al. Inhaled budesonide in the treatment of early COVID-19 (STOIC): a phase 2, open-label, randomised controlled trial. Lancet Respir Med. 2021;0(0). doi:10.1016/S2213-2600(21)00160-0