Today we’re going to forego trauma Tuesday to talk about everyone’s favorite topics nowadays: coronavirus and intubating!
Your patient has suspected or known COVID-19 and is starting to desaturate on room air. Now what?
Just like any other patient, the first thing to try is oxygen, either via nasal cannula or NRB
You can crank up the nasal cannula as high as 6 in order to help maintain oxygenation
Great, but my patient is continuing to desaturate even with oxygen.
This is where things change from any other patient:
DO NOT USE BIPAP OR HIGH FLOW NC
When these patients get very ill, these modalities have a high likelihood of failing them
These 2 modalities also will result in significant aerosolized spread of covid-19
Even if you put them in a negative pressure isolation room with the bipap, you will have no way of transporting them
SO JUST DON’T DO IT
OK, so I can’t use bipap or HFNC but my patient is still desaturating…
It’s time to intubate!
You should intubate early with these patients, and avoid crash intubations whenever possible
Step 1: gown up
This means gown, gloves, N95, and a mask with face shield over your N95
Step 2: pre-oxygenate
Pre-oxygenate using NRB
You do not want to use apneic oxygenation via nasal cannula, as this will further aerosolize the virus and has marginal evidence supporting it even in the best conditions
Do not bag the patient if it can at all be avoided; again, this will aerosolize the virus and result in increased risk of exposure for everyone in the area
Step 3: intubate
Use VL instead of DL
VL allows you to stay farther away from the patients mouth and secretions, helping protect you against the virus
The most experienced person should be performing the intubation – you want to maximize the chances for first pass success
Step 4: set the vent (or have someone else do it if you’re gowned up)
Treat these patients as ARDS patients and use the ARDSnet protocol with low tidal volumes
Unlike ARDS, however, steroids do not play a role in management
Step 5: de-gown
Ideally, have a spotter present so they can help make sure you don’t accidentally contaminate yourself during this process
In particular, be careful not to contaminate any mucous membranes, meaning be particularly careful around your eyes, nose, and mouth
Wash your hands!
Congratulations! You have successfully intubated this patient without unnecessarily exposing yourself or your colleagues to coronavirus!