Above Poster: Noninvasive + Invasive Ventilation

Initial Priorities & Principles

These suggestions are being constantly updated.

Remember Principles:

-Filtered & Negative Pressure Room when possible

-Protection on YOU

-Protection on PATIENT. If something changes with patient - Recheck - Mask/Filter on patient??

-Minimize Aerosol

CALL MD if patient UNWELL:

1) Plan and be on the same P A G E

• P PE SLOW & CONTROLLED for workers + Source Control (mask on patient)

• A ssign Team Roles: In(Hot) & Out(Cold) of Room

• G oals should be clear to everyone (ie no Aerosol Gen Procedure)

• E quipment and Meds Organized

2) NO Chest Compressions (unless the patient is intubated first.)(Some places allowing chest compressions with coverage of oropharynx with surgical mask)

Assess for shockable rhythm or bradycardia (shock/intervene if appropriate)

3) DO NOT BAG with BVM unless intubated

O2 at LOW FLOW only - nasal canula with surg mask. Position patient Sit/Prone Progress to NRB as per local guidelines.

Avoid CPAP unless you have a setup to control aerosol

4) Intubation by skilled intubator if needed. Attempt Safe Oxygenation as per MD

Ensure N100 or equialent Viral Filter is placed before ventilating the patient

Cardiac Arrest

Unwitnessed Cardiac Arrest - Take into account the very poor outcomes in such circumstances (0% in one recent McGill study). During the Covid-19 pandemic, the guideline is to NOT attempt resuscitation on an unwitnessed arrest unless the physician judges there is a strong reason to believe the patient could recover. (MUHC 28-03-2020)

Witnessed cardiac arrest: The decision to resuscitate or not should be taken by the attending MD or the CODE BLUE team, based on a consideration that there is a reasonable chance of recovery. (MUHC 28-03-2020)

• A shockable or treatable rhythm (V. Fib or V. Tach, rapid AF, AV block),

• Correctable cause of hemodynamic instability (volume status) or respiratory difficulty (mucous plugging) present the best hope for meaningful recovery.

You must weigh the risk health care providers are put at during Resuscitation and do a Very Complex calculation and Risk Assessment of Your Capacity (Room Filtration, PPE, Ability, Skill in Safe Resusc, Resusc Success). There is no exact recipe for this and it will vary between providers. What is true is that our usual modus operandi is changed. There is now more consideration for the greatest good. Usually resuscitation is fully focussed on the patient and does not pose a risk to health care providers becoming ill and subsequent inability to care for patients. The focus now includes the patient and the potential patients.

• Do not perform BVM ventilation prior to intubation

• Do NOT perform Chest Compressions unless the patient is intubated first (or oropharynx covered in some places)

• Chest compressions should only be performed when wearing appropriate PPE.

The Unwell Patient - See above Diagram: NIV Ventilation & Invasive Ventilation

REHEARSE THIS BEFORE YOU NEED IT!!

Frequent, Short, Focussed practice needs to be part of your daily routine (e.g., PPE, RSI, Team setup).

Scene Safety Plan

Be on the same PAGE

• PPE for workers + Source Control (mask on patient)

• Assign Team Roles (In & Out of Room)

• Goals should be clear to everyone (ie no Aerosols)

• Equipment and Meds

A

• • Avoid Suction if possible

  • Positioning: Sitting up, on side or Prone may help with Recruitment and Secretion Drainage if clinically possible but this is difficult if the patient is not able to do themselves

B

• Positioning - Sitting can help. Prone is an option - easiest if patient can do it

• O2 at max 5-6Lpm

• Nasal prongs vs Non Rebreather Mask with Surgical mask over top

• Avoid Ambu Bagging if not Intubated.

  • If used: do 2 person technique* with a HEPA filter (same as filter for ventilator)

  • See Image Below in PreOxygenation of hand position

• No Nebulization.

  • Use MDI (metered dose inhaler)

• No CPAP/BiPAP (has been used with helmets in Europe. We don’t readily have this in North America). Special CPAP setups may work. You need to know what you are doing.

• Prone Positioning has promise for maintaining Oxygenation, especially in the Happy enough Hypoxics

• LMA Laryngeal Mask Airway as a bridge

Combitube? - clamp the non ventilated tube

Intubation: this will be an option in places with MD's. Typical advice is to go to Intubation rapidly if O₂ is not enough. This is ok in a hospital. It could pose problems in remote environments. See details below.

C

• • AVOID Chest Compressions if airway not controlled.

  • Analyze for Defib and shock if needed (Put a mask on pt first).

  • Avoid aggressive fluid resusc.

Out of hospital arrest - be conservative - do not risk staff for dismal resuscitation rate.

Intubation

This will be an issue for disposition if far from a hospital. Harder to manage a ventilated patient.

If this is the best decision, recommendations:

• Passive oxygenation only - ie No Bagging prior to Tube

• Minimize attempts, Maximize first pass success.

• Most experienced provider, Video Laryngoscopy preferable.

• Apply HEPA viral filter IMMEDIATELY when tube in

• Confirm with EtCO2, No auscultation

• Do Not Extubate or open the circuit by accident. Secure the tube and all connections.

• Clamp the tube if disconnecting circuit.

Vent Settings:

• Lung protective strategy (ARDS ventilatory settings)

• Tidal Volumes à 6 cc/kg of IBW

• RR > 12

• High PEEP à can start at 10

• Plateau pressures à < 30 cmH2O

• (Taken from JGH Approach to the Unstable Patient)

Medication

Up in the air.

Azithromycin, Ceftriaxone, Hydroxychoroquine?

You may not have enough.

If you can rapidly send to a hospital - save your drugs. If you cannot - use them.

Sick patient: O2, Zithro?, Ceftriaxone? and Transfer.

MUHC guidelines being updated q 1-2 days.

Intubation details

Background

In the first few years of practice, intubation is a stressful, uncertain experience due to high acuity & low practice. A choice needs to be made - either get good or get out. Taking a lesson from whitewater kayaking, mountaineering and bjj - if you want to get good - you have to put yourself in the line of fire - accept discomfort (at times extreme) and practice, learn from those more experienced than you, analyze everything critically, and practice more.

In order to incorporate something into my Intubation system it has to pass this test:

Can I do it repeatedly in an active battlefield, with a dying patient, low light, & little support?

If no - then it’s not useful for a rural provider.

Guiding principles

• If you can find an alternative to Invasive ventilation that is safe - do it.

• A difficult airway is a danger for the patient.

• A ‘dangerous’ Airway, i.e., COVID, is a danger to the providers.

• You need to mitigate this risk, not only for yourself but the others in the room.

• The usual situation of providing care to the patient now has the consideration that all those in the room may become patients. The consequence of this could be loss of providers which will hamstring future care, and the fact that you may need to intubate your colleagues at some point. Or you may need to be intubated.

• You need to care for the patient in front of you and the potential patients (you, your colleagues). The calculus is now more complex, and the risk assessment has added features.

Understand that there are Time and Space considerations in your planning. Use the physical setup as a tool to organize your thoughts to reflect your actual work flow. Organize your HR and equipment in relation to it. Practice to troubleshoot.

This is not a complete guide to intubation. Refer to other sources (see below). This document walks through the main points as it is a high risk endeavour. Be informed. Be Safe. There is no good evidence for all of this yet.

A special thank you to Dr. Levitan and Dr. Kovacs.

Safety Ideas - Break it down like an Engineer

Protection Inside the Room

• Source Control, i.e., Decrease amount from patient (Mask on patient)

• Between the Source and Recipient? (Barrier Box?)

  • We will by trying out a plexi box to shield from droplets

  • https://www.nejm.org/doi/full/10.1056/NEJMc2007589?query=RP

• Recipient (Health Care Worker) protection = PPE

The barrier box is experimental for us. We will be practicing with it BEFORE using it to determine if it poses unintended risks - e.g., increased risk of poor mask seal, tube dislodging etc.

Protection Outside the Room

• Using a Negative Pressure Room to protect those outside.

  • Temporary Neg Pressure setup? We are finding out more. Stay tuned.

• PPE of staff outside if no negative pressure is available. Minimize door opening.

Preparation: Equipment, Human Resources, Physical Space

Outside the room:

• Pre-made PreOx & Intubation Equipment bags outside to minimize in and out. See lists in videos.

• Set up PPE stations outside the room

• Set up a table for a Runner nurse to be able to transfer you equipment you may need in the room.

• Plan your teams - How many people in and out of the room. It will be hard to be less than 3 inside the intubation room. Outside, 2-3?

• You may not have an RT. As an MD you will be the Intubator and RT. Call in a colleague(s) to help you. You need them to do this more securely.

• Doffing instructions in and out of Antechamber (if you have) and room

  • Setup garbage inside the room and reusable material bin outside the room

The Room:

• • • • Which room?

      • Negative Pressure?

      • Location in relation to other rooms?

Inside the Room:

• Do practice runs in the room with equipment and people. Identify what does or does not work. Setup all the equipment with people and debug your system and physical layout.

Time:

• Practice before you need it.

• Debrief when it happens.

• Practice sometime after.

• Short, focussed, frequent with progressive increases in difficulty.

PPE

See the PPE section.

Have clear instructions posted where don and doff will happen.

Develop a system to have an official observer always - especially for doffing.

Practice this often.

Shrouds?

Pre-oxygenation

Your approach should be based on reality with a hierarchy of efficacity but also rapidity. (and safety) Ie in general fastest, simplest, effective safe thing first, then the more complicated definitive things next. (Some of the definitive things take more time to set up - you don't want your patient expiring while you are getting set up. Eg - in a normal time - you do CPR before Defib because it CPR is fast and immediate. CAUTION - NO CPR without Intubation in COVID)

Eg - If I have a head injury and ICP is increasing - the first and rapid steps are to raise the head of the bed, then mannitol or hypertonic NS and then surgery. We don't jump to surgery first for a couple of reasons!

Similarly - if the sat is low - prior to intubation an apneic O2 attempt with a new or unfamiliar setups will be slower. Before that - Sit the patient up. Next step - If you are not familiar with setting up a BVM system with CPAP with MDI adapter - at least get nasal prongs and a BVM with 2 person seal on. We all likely know how to that smoothly and safely.

Someone can then work on optimizing a CPAP BVM with MDI adapter. Once you have done set this up several time under pressure - Then it may become a rapid go too.

Many different setups that are evolving rapidly. At the moment I like George Kovacs’ setup. It doesn’t require special equipment, you will already be familiar with everything. Watch his AIME videos - links below

An explanation of the issue of apneic oxygenatio here from liftl. You will require Two O2 sources for this - check your room!

https://litfl.com/apnoeic-cpap-for-oxygenation-of-covid-19-patients/

• No Bagging

• Have a good face seal using the VE technique. Pull up on the jaw to open the airway and down on the mask. Leaks will occur from poor mask application and also pressure differential - if the airway is not open the pressure inside the mouth will overcome the pressure you are applying.

• Make sure you are in a strong, solid, comfortable position to be able to maintain this (Keep things close and tight to your body).

• Not sure the Plexi Box will work with a BVM setup with a viral filter as it creates a bit of a tower. Will examine and update this.

• You need 2 people - one to hold the mask and one to support the bag.

• You may need drugs to help with being able to pre-oxygenate. Ketamine can be a good choice.

Image left: Safer Airways via emCrit

Intubation

Is ther any way to avoid this? Can you maintain the patient without Invasive ventilation?

If not:

Whoa! Hold On!! Check Everything Before you proceed. You would be a fool to not have someone using a checklist for making sure all equipment and people are organized for Intubation.

You can also use a checklist for the intubation procedure and your backup plans. This is a double edged sword. Complicated checklists in stressful situations can make things worse. Demand Simplicity and Robustness in your systems and memory aids. Practice with them.

Whatever you do - Make sure you and your team are all aware and on the same page and know Plan A, B, C, D

RSI rules here. Have your drugs sorted out. Double check all doses. Do Not trust anything written here.

Induction:

Ketamine 1.5mg/kg for induction. Some patients who are habituated with alcohol require much larger doses. Have enough ready to go and a second agent ready. E.g., Etomidate or Propofol.

Paralysis

Will not be getting into the Succ Roc debate. Where I work we have to be Anesthesia, RT and ED doc. We are far from a hospital. I prefer succinylcholine for initial paralysis 1.5mg/kg. It will wear off if something goes very wrong and possibly avoid a cric. However, I have Rocuronium high dose 1.5mg/kg ready to go to maintain paralysis once I confirm tube placement. You can also go straight to high dose Rocuronium which may have a faster onset than usual dose, but it is a one way street unless you have a reversal agent. Be ready for whatever you decide. Whatever you use - Ensure Paralysis to avoid Vomitus.

VL technique - keeps your face further away

• Video Laryngoscopy is great especially if you can use a Mac Blade. This is the Best of both worlds - i.e., Direct and Indirect Views.

• Not all of us have Mac blades on our VL. You need to understand the technical differences of using a hyperangulated VL blade: Watch the video (link below).

  • Load the tube with a stylet. If glidescope stylet - don't lock it really hard into place. Leave a bit of loose so you don’t dislodge the tube later.

  • You have already ensured optimal positioning and paralysis before introducing the VL.

  • Look into the mouth and place the VL. Windshield wipe the handle to point to 3 o’clock to avoid the chest if needed.

  • Look at the screen and advance down until you get a perfect amazing view.

  • Once you have this view - DO NOT take your eyes off the screen and pull the VL out a tiny bit to degrade your view. If you try to put a tube in with a perfect view with VL - you will have trouble!! Your view will not be aligned with the way the tube is going in. The lens will be pointing up - your tube cannot do this curve.

  • Place the cuff of the tube at level of cords or just past. THEN STOP!! Do not advance the tube.

  • Have someone pull the stylet out 2”. Then advance the tube.

  • CLAMP, VIRAL FILTER, inflate cuff, EtCO2.

  • SECURE THE TUBE.

  • No auscultation. CXR? - No rush

With Direct Laryngoscopy, I always use a Bougie for the free practice and it’s good.

A Bougie with a Regular Hyperangulated VL Blade is NOT something that is your go to. It can be done but it is more complicated because of the angles. You need to be an advanced airway expert.

With a Mac blade - Yes 100% - go Bougie.

Vent vs BVM

Depends on your ventilator, whether you have to travel in an ambulance road vs plane, length of time to transfer, length of transfer.

Whatever you decide - make sure you know what you are doing. I and several senior ED colleagues are careful before using a portable vent in shorter road ambulance transfers because of the vents being finicky. The back of a moving ambulance is not the best place to be doing ventilator troubleshooting diagnostics. You will have to clammp the tube, disconnect, BVM, sort out ventilator or not and retry. With a Dangerous airway - I suggest caution.

If you have spent a lot of time in the ICU and know your vent - go for it.

BVM is always an option.

DO NOT DISLODGE the TUBE or BREAK CONNECTIONS IN YOUR SYSTEM!

Move the patient slowly with Everyone aware of what is happening. Get eye contact with Everyone and ensure they understand. Do Not use Left or Right in your directions. Point to where in the room you want movement. Ensure everybody understands. YOU DO NOT WANT EXTUBATION or DISCONNECTIONS.

I see the cords, I see the tube, I can't pass the tube!! #@%#$

This is not an uncommon scenario.

Troubleshooting tips:

1. Follow the directions above to get a perfect view, then degrade the view specifically as described in the video.

2. Info to come on how to troubleshoot in 3 dimensions. Well actually 4 dimensions cuz time is a factor.

That’s all for now. Watch the videos below. Talk to colleagues. Ask for help. This is not the time to be experimenting alone.

Source: AIME - George Kovacs and his team

Prep: https://vimeo.com/403083851

Preox: https://vimeo.com/user83266459

Hyperangulated VL: https://vimeo.com/404091445

Apneic CPAP: https://vimeo.com/400368564

Protected Code Blue Scenario

Info to follow...

• Unwitnessed cardiac arrest - dismal survival.

  • In context of COVID - consider NOT initiating maneuvers.

• Protected Code Blue - to be elaborated. Very hard rurally. ++ staff required. Sunnybrook protocol is very people heavy - difficult feasibility in rural areas.

• You may not be able to do full resusc safely.

• Examine this carefully. Colleagues are working on it.