We have been running training programs/simulations in our Protected Code and Airway Course with UV glow germs…
Some quick thoughts from our experiences…
1. Preparation
1.1. Think about safety first. “There are no emergencies in a pandemic”
1.2. Run training/simulations with ultraviolet tag germs (powder, gel and mist) to identify potential areas of contamination when the blacklights come on.
1.2.1. I know that PPE is in short supply but so are staff members.
1.2.2. Have housekeeping staff clean up after each UV simulations to reinforced good cleaning techniques with visible feedback
1.3. We have identified multiple problem areas. Cover the neck and head… aerosolized virus will find its way there.
1.4. Beware of reaching into bins and drawers. These areas light up with potential glowing virus contamination.
1.5. Minimize room/ambulance/aircraft stock to limited number of items to avoid contamination from contact or aerosolization.
1.6. Due to code cart contamination by opening it in COVID19 room with aerosolizing procedure, most (hopefully all!) facilities are removing cart from room.
1.7. Stock one gallon Ziplock bags with initial code / critical care drugs to start resuscitation – May have individual items in smaller plastic bags to prevent cross contamination.
1.7.1. 2-3 Epinephrine 1 mg in 10 cc (1:10,000)
1.7.2. 1-2 Epinephrine 1 mg in 1 cc (1:1000)
1.7.3. 2 Amps Calcium Gluconate
1.7.4. Amiodarone 300 mg and / or 150 mg units to a total of 450 mg
1.7.5. Assorted 1 cc, 3 cc, 5 cc, 10 cc 60 cc syringes
1.7.6. Assorted needles
1.7.7. Alcohol preps
1.7.8. 3 Way Stopcocks
1.7.9. For additional meds, runner/pharmacy passes to code room.
1.8. Proning is an excellent method to delay or prevent intubation. Practice proning with staff before you have to prone a patient. Management strategies from Wuhan experiences included aggressive proning to promote drainage and increase alveolar recruitment. They were proning patients on 6 LPM NC, not waiting till requiring ventilator.
1.8.1. Practice patient proning with both self and assisted methods. Have staff also practice proning ventilated patient with invasive lines
1.9. Patients who are at risk of acute deterioration or cardiac arrest, should be identified early. Appropriate steps to prevent cardiac arrest and avoid unprotected CPR should be taken. Stage necessary equipment as appropriate
1.10. Keep code room door closed. Consider communications needs in and out of room. (e.g. intercoms, cell phones, baby monitors, cordless phones, etc.)
1.11. Limit staff in the code room.
2. Roles and Responsibilities
2.1. Identify roles and responsibilities. This should be done, ideally prior to the code, but no later than the beginning of the code.
2.2. Roles
2.2.1. Compressor
2.2.2. Airway
2.2.3. 2nd Compressor
2.2.4. IV/IO, Drugs and Defibrillation
2.2.5. Ideally 2 staff members outside the room. e.g. pharmacy, runners, etc. …
3. Hospital – COVID-19 Code Priorities Based on Personal Protective Equipment (PPE) Donned by Staff
3.2. One problem we have found is that staff who are in droplet precautions PPE prior to the code, then the FEEL they are in PPE and forget to leave to get into Airborne PPE when the patient codes.
3.3.1. 0 Staff in PPE – No Basic or Advanced Life Support
3.3.2. 1st Staff in PPE (Ideally RN 1)
3.3.2.1. Check for responsiveness, if not responsive
3.3.2.2. Check carotid pulse and look for breathing at least 5 seconds but no more than 10 seconds. If no breathing or pulse then
3.3.2.3. Place defibrillation pads on patient, rhythm check / defib as indicated
3.3.2.3.1. Ideally use AED or Defibrillator with AED Function
3.3.2.4. Defibrillate as indicated, then
3.3.2.5. Place nasal cannula (6 LPM) on patient. Then place surgical mask over patient’s face and nasal cannula.
3.3.2.6. If patient is in bed, place bed in CPR Mode or CPR board/ headboard under chest
3.3.2.7. Begin hands only CPR
3.3.3. 2nd Staff in PPE (Ideally RN 2)
3.3.3.1. Depending on skills and time, may need to rotate with compressor initially and/or every 2 minutes
3.3.3.2. Start IV/IO
3.3.3.3. Administer fluids and drugs as indicate by appropriate ACLS algorithm
3.3.4. 3rd Staff in PPE – Manages Airway, Depending on skills (Ideally EM or Anesthesia)
3.3.4.1. Initially 2nd generation LMA or King Airway with viral filter and BVM
3.3.4.2. Option – With addition of 4th Staff in PPE, 2 person BVM or Endotracheal Intubation
3.3.5. 4th Staff in PPE – Team Leader and / or rotate out with other team members. (Ideally EM or CCM)
4. Donning and Doffing
4.1. If resources allow, have a safety officer observe donning and doffing, passing equipment, supplies and drugs from clean to dirty.
4.2. If a safety officer is not available, utilize a buddy system with checklist to observe donning and doffing.
4.3. Get used to wearing 2 pair of gloves as it gives you the ability to quickly strip off contamination. You can also clean gloves with alcohol sanitizer between activities on the same patient.
4.4. Resources
5. Resuscitation
5.1. Prioritize your resources by getting the right people/skills into the room as safely and quickly as possible. See above “X” Staff in PPE
5.2. Ventilation
5.2.1. Bag Valve Mask (BVM) should be 2 person, using the 2 Thumbs Up, Jaw Thrust Method and maintain constant mask seal
5.2.2. Where a supraglottic airway is required, use of a second-generation device (wedge shaped heel of mask for seating at base of tongue) is recommended. It has a higher seal pressure during positive pressure ventilation decreasing the risk of aerosolization of the virus.
5.2.3. Endotracheal Intubation
5.2.3.1. Intubators have one of the highest risks of becoming infected.
5.2.3.1.1. Operator should be wearing a PAPR due to being in the direct air stream.
5.2.3.1.2. Ideally VL should be used with a separate video monitor to keep intubator out of this direct airflow.
5.2.3.1.3. Another method of intubation is to cover the patient’s upper torso with a clear drape/bag drape and have intubator reach under the drape to intubate.
5.2.3.1.4. Once the patient is intubated, closed suction systems should be used to minimize aerosolization of the virus.
5.2.3.1.5. Cuff manometer should be available to measure tracheal tube cuff pressure in order to minimize leaks and the risk of aerosolization of the virus.
5.2.3.1.6. A naso / orogastric tube should be placed at the time of intubation to avoid further close contact with the airway.
5.3. Circulation
5.3.1. Ensure that patient has a total of 2 IVs/IOs for access
5.3.2. What about patients in the prone position?
5.3.2.1. The Efficacy of Cardiopulmonary Resuscitation in the Prone Position
6. Return of Spontaneous Circulation (ROSC)
6.1. Plan on hypotension. Have fluids, push dose pressors (Epinephrine, Neosynephrine or Ephedrine) and a bag of Norepinephrine mixed up and ready to go.
6.2. Now is the time to change out or upgrade your airway. In a controlled and safe manner, endotracheal intubation (ETI) or change out existing SGA or RGA airways should now be a priority.
6.3. Get patient on ventilator as soon as possible. This will free up resources as well as provide more options and consistency of ventilation.
6.4. Consider doing other procedures that the patient my require after intubation. e.g. central lines, art lines, etc.
6.4.1. Have Central Venous Line (CVL) and Arterial Line (AL) Kits available nearby
6.4.1.1. Avoid subclavian CVL – These patients do not tolerate pneumothorax
6.4.1.2. Consider femoral CVL and AL, this is preferred location
6.4.1.3. COVID19 patients seem to be extremely hypercoagulable, consider anticoagulation
7. See our post on the Protected Airway for information on intubation and airway management.
Videos:
Setting up BVM w Peep and Viral Filter
How to use ventilator for multiple patients
Intubation of the COVID patient:
How to modify a BiPap to ventilate patients