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