Managing critically ill COVID19 patients in the ED A brief overview based on current SCCM guidelines
As the numbers keep rising, more critically ill patients present to the ED, and lag time in getting isolation beds upstairs increases, we anticipate the need to manage these critically ill patients on our own downstairs. Below are a few tips.
#1
Before you intubate
Resuscitate a patient with shock like you normally would: Fluids as first-line resuscitation, buffered crystalloids (e.g., LR, plasma-lyte)>unbuffered crystalloids (e.g., NS)> colloids>albumin> starches. Conservative fluid strategy (dry lungs are happy lungs) 500cc at a time. Add pressors when fluids are not enough. First-line agent preference: norepinephrine > vasopressin = epinephrine > dopamine Titrate vasoactive agents to target a MAP of 60-65 mmHg, rather than higher MAP targets. Respiratory Failure Guideline: 1. Start patients out on nasal cannula up to 6L/min. Goal SpO2 of 88-92%. 2. Next, if the patient continues to have issues with hypoxia, use High Flow Nasal Cannula. (HFNC) oxygen. Results vary substantially between patients. Begin with an FiO2 of 50% (0.5) with a flow rate of 50 L/min (LPM). Many experts recommend a maximum 25 LPM to reduce the risk of aerosolizing. Goal oxygen saturation remains 88-92%. Increase FiO2 to optimize oxygenation. Intubate IF:
Take away:
#2
Minimize IVF, lactated ringers, norepinephrine, MAP 60-65
While you intubate
Wear ALL the PPE, minimize people in the room to minimize exposure risk. Avoid using the BVM. Use a HEPA filter if you have to use BVM. Video-guided laryngoscopy > direct laryngoscopy.
Take away:
#3
PPE, minimize staff in the room, video-guided laryngoscopy
So, you just intubated a PUI. Now what?
Take a deep breath! These patients have an ARDS-like picture, and with the little evidence we have, ARDS protocols seem to be helping. VENT SETTINGS: Which vent setting to pick? Assist control is ideal for the majority of newly intubated patients.
Low tidal volume* 4-8mL/kg of predicted body weight. *Start around 6mL/kg and adjust from there). High PEEP strategy Start around 10cm H2O, adjust as needed from. ARDSnet can be useful to help adjust PEEP/RR/Volume. If you find that the patient is exhibiting ventilator dyssynchrony or high plateau pressure (>30 cm H2O), consider DEEPER SEDATION. You can add another agent (e.g., fentanyl or ketamine). Consider paralysis if you are maxed out on sedation and the patient is still fighting the vent. Ensure that the endotracheal tube has a HEPA filter attached to it. Avoid BVM during transport because of aerosolizing.
Take away:
High PEEP, low tidal volume, HEPA filter
More Resources Lung Ultrasound for COVID: http://www.thepocusatlas.com/covid19 Isolated Intubation: https://m.youtube.com/watch? feature=youtu.be&v=pdJPkiY_oQ0&fbclid=IwAR1AyZ00BdbZ_Hn1VCSm6TH5R3T2S7yE0eN8s1psLBey6kCFcxnOljjLRk https://emcrit.org/ibcc/covid19/ ARDSNET Protocol: https://www.grepmed.com/images/2577/management-protocol-mechanical-ardsnetventilator-criticalcare-ventilation
If you are still having difficulty, call your local critical care colleagues, anytime! Source: https://sccm.org/getattachment/Disaster/SSC-COVID19-Critical-Care-Guidelines.pdf?lang=en-US&_zs=awIjd1&_zl=k1cc6