BANKSTOWN EMERGENCY DEPARTMENT



BANKSTOWN EMERGENCY DEPARTMENTINTUBATION GUIDELINE FOR COVID-19Adapted from: ‘Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 patient group’BACKGROUNDThe COVID-19 pandemic is likely to result in a significant number of presentations to the emergency department (ED) with respiratory illness. Data from Wuhan, the initial outbreak site, indicated 4% of patients required intubation and mechanical ventilation. While exact numbers will differ in the Australian healthcare setting, it can be expected that a significant number of patients will require intubation.There is an increased risk of infection to healthcare workers performing airway management procedures. COVID-19 is transmitted primarily through droplet spread. Airway management procedures may generate aerosols composed of smaller virus containing particles suspended in air. These particles may be inhaled within a radius of up to 2m, increasing the risk of transmission. Aerosolization may also expose clinicians to a higher viral load and potentially more severe illness.This guideline outlines an approach to safe intubation of these patients and should be followed for all patients with respiratory failure requiring intubation in the ED who are suspected or confirmed to have COVID-19. Preparation for IntubationENVIRONMENTPatients requiring intubation should be placed in isolation in the negative pressure room (Acute Beds 3 and 4)Ensure that negative pressure ventilation is turned ONIntubation should be performed in this locationWhen the negative pressure room cannot be used, the patient should be intubated in a normal pressure room with closed doors (Acute Beds 1 and 2 or the Paediatric Procedure Room)PERSONNELThe number of healthcare workers in the room should be strictly limited to those directly involved in the process of airway managementThe most senior operator should perform intubation to minimise risk to the team and because COVID-19 patients can desaturate very rapidlyIf difficulty is anticipated, the anaesthetic consultant should be present BEFORE intubationConsider excluding staff who are vulnerable to infection from the airway teamOlder (>50 years)Significant co-morbidities or immunosuppressedPregnantThe roles of the intubating team should consist of:Airway operator: Critical care consultant or senior registrar (ED, ICU or Anaesthetic)Airway assistant: Senior nurse with experience as airway assistantTeam leader: Senior clinician with airway experience to coordinate team, manage drugs, observe monitoring and provide airway help (including surgical airway) if requiredRunner inside room: Request and receive required equipment from outside runnerRunner outside room: Obtain and pass equipment into room as required by team, act as a spotter for breaches of PPE when team members are task focusedPPE FOR INTUBATING TEAMPPE for Airway Operator and Airway Assistant:Surgical gownTheatre hatN95 maskFace shield (or goggles if not available)Double glovesShoe coversPPE for other team membersPlastic gownN95 maskEye protectionGlovesThe outside runner must check that team members entering the room are donning and doffing PPE correctly EQUIPMENT TO BE TAKEN INTO THE ROOM FOR INTUBATIONWhere an equivalent disposable item of equipment is available, this is always preferred over reusable equipmentThe main airway trolley should be kept outside the room to avoid contaminationEquipment required for intubation should be prepared BEFORE entering the room, and placed in a sterilisable tray or dedicated trolley that can be disinfectedEquipment to be brought into the room is listed in Appendix A EQUIPMENT TO BE IMMEDIATELY AVAILABLE OUTSIDE THE ROOM FOR EMERGENCY USEMain airway trolleyCardiac arrest trolley, containing:Adrenaline 1mg 1:10,000Amiodarone 300mgMetaraminol 10mg vialAtropine 600mcgDefibrillatorDefibrillator pads0.9% saline and pump setPLANNING AND COMMUNICATIONAs much as possible, the equipment and intubation checklists should be completed BEFORE entering the roomIt is critical that there is communication between the whole team prior to intubation to share a mental model which includes:Role allocationsAnticipated challengesAirway management strategyPost-intubation plan for ventilation and sedationPPE donning and doffing processesAs in all emergencies, closed-loop communication is vital and team members should be empowered to verbalise their thoughts and speak uppROCESS FOR intubationThe overriding principle is to use familiar, reliable techniques that will maximise 1st pass success while minimising aerosol generating procedures. The aim is to secure the airway rapidly in order to minimize apnoea time and the duration of staff exposure to this high-risk procedure.PRE-OXYGENATIONPreoxygenation is particularly important as these patients will often desaturate quickly, and face mask ventilation should be avoided wherever possible.In the period before the team enters the room to perform intubation, the patient’s oxygen delivery should be maximised by:Placing patient in 45° head up position Using a non-rebreather mask at 15L/min O2Non-invasive ventilation should be avoidedWhile there is evidence that high flow nasal oxygen is effective in COVID-19 patients and may decrease the number of patients requiring intubation, it may cause increased aerosolization of virus (particularly if cannulae are poorly sized or secured) and should be avoidedAfter the team enters the room:The patient should remain in a 45° head up position and pre-oxygenation should be commenced using the BVM with a viral HME filter and ETCO2 in the circuitManual ventilation should be minimised unless required for rescue oxygenation as the BVM is a non-rebreathing circuit and expels expired gas into the roomUse of a PEEP valve may reduce this and should be connected if availableA two-handed vice-grip technique should be used to maximise the face-mask seal and prevent leaksA triangular rather than square ETCO2 trace during preoxygenation suggests a leak around the face mask and should prompt interventions to improve the seal.INDUCTIONNeuromuscular blockade can be achieved with rocuronium (1.5mg/kg IBW) OR suxamethonium (1.5mg/kg TBW)Generous dosing promotes rapid onset of deep neuromuscular blockade and minimises the risk of the patient coughing during airway instrumentationCare should be taken to minimise apnoea time by closely monitoring the time between administration of the neuromuscular blocking agent and intubation, while ensuring adequate time is given for the agent to take effect prior to airway instrumentation to avoid precipitating coughingINTUBATIONApnoeic oxygenation (via high flow nasal prongs or standard nasal prongs at 15L/min) should NOT routinely be used during intubation attempts due to proximity of intubator to patient’s airwayThe video laryngoscope should be used for intubationThe airway operator should remain standing upright with a straight elbow, and utilise the screen to visualise the larynx as this will maximise the distance between the airway operator’s face and the patientCare should be taken to place tube to correct depth first time, to minimise disconnections and cuff deflationsOnce tube placed, cuff should be inflated before positive pressure ventilation is attemptedIf a bougie or stylet is used, care must be taken not to cause contamination when removing it from the patient’s airway -it should be laid down carefully on a ‘bluey’ on the patient’s bed, and wrapped and disposed of carefully after intubationpost intubationDisposable items should be placed in a bag inside the room and then placed in a second bag held open by the outside runnerPPE should be carefully removed, and hand hygiene performed as per guidelinesThe ventilation plan should be discussed prior to intubationCircuit disconnections should be avoided if possibleIf a circuit disconnection is required, the ventilator must be placed into standby beforehandAPPENDIX A: CHECKLIST FOR IN-ROOM INTUBATING EQUIPMENTEQUIPMENTPRESENT?Disposable Macintosh video laryngoscope blade – appropriate size for patientDisposable hyperangulated video laryngoscope blade (‘D-blade’)Macintosh direct laryngoscope – appropriate size for patientBougie10ml syringeEndotracheal tubes – appropriate size and extras with range of sizesETT tube tie Satchet lubricantOropharyngeal airwayNasopharyngeal airwaysLaryngeal mask airway – appropriately sized for patientAppropriately sized nasogastric tube, collection bag and syringePre-packed CICO kitAssembled circuit (in-line suction, ETCO2 and viral HME filter)Self-inflating bag-valve-mask (BVM) with PEEP valveCMAC towerIntubating drugs (sedative, relaxant, metaraminol)Post-intubation sedationSyringe drivers/infusion pumps as required1000ml bag 0.9% saline and pump setAPPENDIX B: COVID INTUBATION CHECKLIST ................
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