Covid 19 Management Protocol from East Virginia posted at FB of Dr. Sharif Sultan

Live healthy and long

                                      The new protocol does not support intubation.*

*Results in 100% fatality


It is an oxygenation failure, not a respiratory failure

The paper admonishes vs use of ventilators to prevent mechanical injury.  Let nature  heal the patient, according to their literature

Covid 19 Management Protocol

URGENT! Please circulate as widely as possible. It is crucial that every pulmonologist, every critical care doctor and nurse, every hospital administrator, every public health official receive this information immediately. This is our recommended approach to COVID-19 based on the best (and most recent) available literature including the Shanghai Management Guideline for COVID and recent information from Italy. We should not re-invent the wheel, but learn from the experience of others around the world. It is important to recognize that COVID-19 does not cause “typical ARDS”… this disease must be treated differently and it is likely that mechanical ventilation may be exacerbating this situation by causing ventilator induced lung injury (i.e. the ventilator may cause the disease we think we are treating). Patients suffer from oxygenation failure and not lung failure. Furthermore, this is predominantly an immune and clotting disorder and not a lung disease. This is a very dynamic situation; therefore, we will be updating the guideline as new information emerges. Please check on the EVMS website for updated versions of this protocol. EVMS COVID website: https://www.evms.edu/covid-19/medical_information_resources/ Short url: evms.edu/covidcare



https://www.evms.edu/media/evms_public/departments/internal_medicine/EVMS_Critical_Care_COVID-19_Protocol.pdf?fbclid=IwAR0Ra7gzMrBhtVk7W2GMZjNrdeCGajDByxkw6hSAg5OJo6wTXJpp-qBVw5Y


Intubation is not recommended


Prophylaxis While there is very limited data (and none specific for COVID-19), the following “cocktail” may have a role in the prevention/mitigation of COVID-19 disease. While there is no high level evidence that this cocktail is effective; it is cheap, safe and widely available. • Vitamin C 500 mg BID and Quercetin 250-500 mg BID • Zinc 75-100 mg/day (acetate, gluconate or picolinate). Zinc lozenges are preferred.


 After 1-2 months, reduce the dose to 30-50 mg/day. • Melatonin (slow release): Begin with 0.3mg and increase as tolerated to 1-2 mg at night • Vitamin D3 1000-4000 u/day (optimal dose unknown). Mildly Symptomatic patients (at home): • Vitamin C 500mg BID and Quercetin 250-500 mg BID (if available) • Zinc 75-100 mg/day • Melatonin 6-12 mg at night (the optimal dose is unknown) • Vitamin D3 1000-4000 u/day • Optional: Hydroxychloroquine 400mg BID day 1 followed by 200mg BID for 4 days


Mildly Symptomatic patients (on floor): • Vitamin C 500mg BID and Quercetin 250-500 mg BID (if available) • Zinc 75-100 mg/day • Melatonin 6-12 mg at night (the optimal dose is unknown) • Vitamin D3 1000-4000 u/day • Methylprednisolone 40 mg daily • Enoxaparin 40-60 mg daily • Optional: Hydroxychloroquine 400mg BID day 1 followed by 200mg BID for 4 days • N/C 2L /min if required (max 4 L/min; consider early t/f to ICU for escalation of care). • Avoid Nebulization and Respiratory treatments. Use “Spinhaler” or MDI and spacer if required. • Avoid non-invasive ventilation • T/f EARLY to the ICU for increasing respiratory signs/symptoms



Respiratory symptoms (SOB; hypoxia- requiring N/C ≥ 4 L min: admit to ICU): Essential Treatment (dampening the STORM) 1. Methylprednisolone 80 mg loading dose then 40mg q 12 hourly for at least 7 days and until transferred out of ICU. Alterative approach: Hydrocortisone 50 mg q 6 hourly. 2. Ascorbic acid (Vitamin C) 3g IV q 6 hourly for at least 7 days and/or until transferred out of ICU. Note caution with POC glucose testing (see below). 3. Full anticoagulation: Unless contraindicated we suggest FULL anticoagulation (on admission to the ICU) with enoxaparin, i.e 1 mg kg s/c q 12 hourly (dose adjust with Cr Cl < 30mls/min). Heparin is suggested with CrCl < 15 ml/min. Alternative approach: Half-dose rTPA: 25mg of tPA over 2 hours followed by a 25mg tPA infusion administered over the subsequent 22 hours, with a dose not to exceed 0.9 mg/kg followed by full anticoagulation. On transfer to floor, consider reducing enoxaparin to 40-60 mg /day. Note: Early termination of ascorbic acid and corticosteroids will likely result in a rebound effect (see graphic below).


Additional Treatment Components (the Full Monty) 4. Melatonin 6-12 mg at night (the optimal dose is unknown). 5. Magnesium: 2 g stat IV. Keep Mg between 2.0 and 2.4 mmol/l. Prevent hypomagnesemia (which increases the cytokine storm and prolongs Qtc). 6. Optional: Azithromycin 500 mg day 1 then 250 mg for 4 days (has immunomodulating properties including downregulating IL-6; in addition Rx of concomitant bacterial pneumonia). 7. Optional: Atorvastatin 40-80 mg/day. Of theoretical but unproven benefit. Statins have been demonstrated to reduce mortality in the hyper-inflammatory ARDS phenotype. Statins have pleotropic anti-inflammatory, immunomodulatory, antibacterial and antiviral effects. In addition, statins decrease expression of PAI-1 8. Broad-spectrum antibiotics if superadded bacterial pneumonia is suspected based on procalcitonin levels and resp. culture (no bronchoscopy). Co-infection with other viruses appears to be uncommon, however a full respiratory viral panel is still recommended. Superadded bacterial infection is reported to be uncommon (however, this may not be correct). 9. Maintain EUVOLEMIA (this is not non-cardiogenic pulmonary edema). Due to the prolonged “symptomatic phase” with flu-like symptoms (6-8 days) patients may be volume depleted. Cautious rehydration with 500 ml boluses of Lactate Ringers may be warranted, ideally guided by noninvasive hemodynamic monitoring. Diuretics should be avoided unless the patient has obvious intravascular volume overload. 10. Early norepinephrine for hypotension. While the angiotenin II agonist Giapreza ™ has a limited role in septic shock, this drug may uniquely be beneficial in patients with COVID-19 (