COVID-19 Tailored RSI Bulletin

COVID-19 Tailored RSI Bulletin

Protection

  • Safety first!
  • Perform Hand Hygiene.
  • Enhanced PPE is required for Aerosol-generating Medical Procedures (AGMP): N95 respirator or powered air-purifying respirator (PAPR) device, face shield or goggles, gown, and double gloves.
  • Minimize providers in the room to the number necessary to provide safe intubation.
  • Airborne infection isolation rooms, if available.

Preparation

  • Have an intubation plan; use a checklist.
  • Assess for intubation difficulty.
  • Early preparation of drugs and equipment.
  • All necessary equipment is assembled inside the room.
  • Standard monitoring.
  • Connect viral/bacterial filter to circuits and manual ventilators.
  • Use a closed suctioning system.
  • A rescue plan for intubation failure
  • Ensure team dynamics

Pre-oxygenation

Non-bagging approach:

  • Five minutes of pre-oxygenation with oxygen 100% using a non-rebreather mask.
  • Place hydrophobic filter between facemask and breathing circuit.
  • Recommended by experts due to less aerosol generation.
  • Might be non-sufficient.

Avoid the use of high-flow nasal oxygenation and mask CPAP or BiPAP due to a greater risk of aerosol generation.

EMCRIT mentioned the following approaches for Pre-oxygenation

NIPPV (Might be acceptable in a negative pressure room)

  • A 2-tube system (closed circuit) with two viral filters. 
  • Place on CPAP/PSV, leave the PSV at 0, PEEP only if the patient’s saturations do not come up with 100% fiO2.

BVM with Viral Filter

  • Turn BVM flow up to the flush rate.
  • Place a NIPPV mask to allow good seal with you away from the patient or just hold two hands on the mask in a thumbs-forward grip from safer airways.
  • The addition of nasal cannula underneath will allow CPAP with the PEEP valve if needed. 
  • Turn NC up to 4-6 L/m if this used. 

Paralysis and Induction

  • High-dose paralytic to inhibit cough.
  • Appropriate induction agents.

Positioning

  • Head extension, often with flexion of the neck on the body.
  • Full sniffing position with cervical spine extension and head elevation.

Placement of Tube

  • The most experienced physician should perform the intubation.

Use video laryngoscopy rather than regular laryngoscope; to decrease exposure

  •  to patient’s aerosols.
  • Allow the needed time after administration of the NMBA to ensure relaxation.
  • Confirm placement of tube by visualization and EtCO2 rather than auscultation.
  • Apply viral filter prior to bagging or connection to ventilation.

Post-Intubation Management

  • Sedation and analgesia as indicated.
  • ARDS ventilation setting with smaller tidal volumes (6 ml/kg of IBW)

Post Procedure

  • Decontaminate and disinfect all airway equipment.
  • Appropriate doffing of PPE. 
  • Hand hygiene before and after all procedures.
Cite this article as: Israa M Salih, UAE, "COVID-19 Tailored RSI Bulletin," in International Emergency Medicine Education Project, July 3, 2020, https://iem-student.org/2020/07/03/covid-19-tailored-rsi-bulletin/, date accessed: August 9, 2020

References and Further Reading

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