COVID-19 Critical Care Guidelines

INTUBATION

• NYGH Protected Intubation Checklists (Present in kit)

• NYGH Protected Intubation Pathway (Suggest initial review at home)

• NYGH Protected Intubation Video

• Staff MD Sign up for Protected Intubation SIM

• Staff MD Sign up for Protected Code Blue SIM

• Alternative Protected Intubation Checklist

Suggested Methods for Preoxygenation

• Non-rebreather @ 15L

• NO BAGGING initially

• BVM with 2 hand mask seal @ max 15 L flow and PEEP valve (consider nasal cannula @ max 5 L underneath)

• LMA insertion (also an exit strategy)

General Tips

• The devil is in the details - talk through failed airway, reoxygenation, cardiac arrest, post-intubation hypotension, CICO and other anticipated scenarios prior to entering room and assign personnel to specific tasks. i.e. "RN to start compressions while RT calls for help"

• Consider intubation for any patient requiring FiO2 > 50%

• Prepare all medications and equipment prior to entering room as per checklist

• Have a safety officer and second team outside room

• All staff must use full enhanced PPE (bouffant cap + fluid resistant gown + face shield with bib + long gloves + N95)

• All intubations should be performed by most experienced intubator with minimal staff in room (MD + RT + RN)

• Glidescope is preferred over direct laryngoscopy

• Paralytic to prevent coughing during intubation

• High flow nasal cannula may be used sparingly in non intubating situations with a face mask on top

• Clamp ETT tube before disconnecting BVM/connecting vent

• Inflate cuff prior to ventilation

• Avoid auscultation (confirm with misting and colourimetric CO2 detector)

• Avoid BiPAP / nebulizers

1. Ideal Body Weight Calculator (MDCalc)

2. Endotracheal Tube Depth and Tidal Volume Calculator

PROTECTED CODE BLUE

• Protected Code Blue Simulation Video

• Protected Code Blue Procedure

General Tips

• NRB @ 15L, defibrillation pad application and rhythm analysis may occur with usual droplet/contact precautions

• All personnel MUST don full enhanced PPE (bouffant cap + yellow gown + face shield with bib + long gloves + N95) PRIOR to initiating chest compressions or intubation

• This may result in delays to CPR but MUST be adhered to.

• Consider LMA insertion if unsuccessful intubation on first attempt.

1. Intubation in the ICU for COVID-19

2. Sunnybrook Health Sciences Centre - Protected Intubation

3. BC Emergency Medicine Network - COVID-19: Protected Controlled Intubation & Cardiac Arrest

4. Internet Book of Critical Care - COVID-19

5. Internet Book of Critical Care - Some Additional COVID Airway Management Thoughts

6. AIME Airway COVID Checklist

OTHER CRITICAL CARE TOPICS:

1. Basics of Mechanical Ventilation - Dr Sara Gray

2. Critical Care for Non-Intensivists - EMCrit

3. JAMA COVID 19 - Surviving Sepsis Guidelines

4. Resuscitation 2020 - Cardiac Arrest Outcomes in Patients with COVID-19

5. ICU and Ventilator Mortality in COVID-19 from Georgia hospitals

PROTECTED CODE BLUE GUIDELINES

All personnel should don full enhanced PPE (bouffant cap + fluid resistant gown + neck /face shield + gloves + N95) prior to initiating resuscitative efforts.

This may result in delays to CPR but MUST be adhered to.

Consider LMA insertion if unsuccessful intubation on first attempt.

1. Intubation in the ICU for COVID-19

2. Sunnybrook Health Sciences Centre - Protected Intubation

3. BC Emergency Medicine Network - COVID-19: Protected Controlled Intubation & Cardiac Arrest

4. Internet Book of Critical Care - COVID-19

5. Internet Book of Critical Care - Some Additional COVID Airway Management Thoughts

COVID-19 Guidelines for Staff

Effective Mar 23 2020, all those coming to work, regardless of role, are to wear a procedure mask (droplet mask, ear loop) throughout their day/shift. If staff are to provide care to a patient and/or resident on droplet precautions, the staff member shall remove gown and gloves on exit and perform hand hygiene. If the mask was protected from surface contamination (e.g. visor), then the mask does not need to be change.

For more information, see Mask FAQs.

Protected exposure (with proper PPE and hand hygiene) to COVID+ve patients are not considered high risk.

If you experience URI symptoms (even mild) speak with Occ Health, decisions to be made on a case by case basis regarding eligibility to work.