COVID management pearls thread...
Some collective wisdom from our EM attending group @SinaiEM - the epicenter of the epicenter #COVID19
This is anecdotal experience based on what is working for us after trial and error (so take it with a grain of salt)
1/x

Awake postural changes - patients should move around and change posture (sitting straight upright, left side up, right side up, prone) every 1-2 hours at least. These postural changes should also be initiated for Sp02 <90% and can stave off escalation of NRB, CPAP, ETT, etc
2/x

HiFlow oxygen is a very reasonable alternative to CPAP or could potentially be used before CPAP
3/x

Comfortable, interactive patients can frequently be managed conservatively despite awful appearing numbers – Sp02 much lower than 90% and/or substantial tachypnea
4/x

Patients most likely to fail conservative management seem to have the following characteristics:
Older/frail
Less interactive (ie. not texting or FaceTiming family)
Comorbidity (esp: esrd, copd, asthma, chf)
Very high d. dimer, very low lymphocyte count, awful CXR
High WOB
5/x

If possible, consider having the patient call or video-chat with their family prior to intubation
6/x

Closed loop CPAP (CPAP tubing that has 2 limbs) is significantly safer than open loop (single limb, frequently with a small tube that senses), because the open loop vents into to the room
7/x

Sedation of the un-intubated patient on CPAP:
(difficulty following mask directions and decompensate without the mask):
Low dose ketamine (0.1-0.3mg/kg) bolus or low dose ketamine infusions (0.05-0.1mg/kg/hr).
Low dose fentanyl drip (0.1 mcg/kg/hr)
8/x

Caution with Droperidol or Haloperidol
- both increase the QTc and many COVID patients are receiving hydroxychloroquine/azithromycin
9/x

BVM will spray virions into the environment. When it does need to be used, a PEEP valve is a must
10/x

Video laryngoscopy should be considered when possible to keep the provider farther away from the patient’s mouth
11/x

Rocuronium vs Sux
- Sux is significantly faster onset
- Sux allows patients to return to spontaneous breathing on the vent within a few minutes so prefer Sux if you are planning a spontaneous breathing vent plan (APRV)
12/x

For the intubated patients who are difficult to turn and prone, consider Chest PT
13/x

It will frequently take patients 15-30 minutes to figure out how to breath comfortably on APRV, and after that they really settle in. Very light sedation is indicated as the whole point is that patients are breathing spontaneously
14/x

Hypotension - septic shock like presentations are uncommon and should prompt a search for an alternative diagnosis (e.g. PE, high pressures with poor venous return)
15/x

Decompensation on vent - Patients who rapidly decompensate both 02 Sat and BP may be suffering from PE and it would be reasonable to treat them with lytics (consider pushing TNK)
16/x

Hospital pumps:
- We have run out of pumps several times
- If you have to shift from using a pump to a drip count in order to dose infusions, consider shifting to meds that have high therapeutic index like ketamine, using intermittent bolus dosing of opioids and benzos
17/x

Fin 18/x