EMRAP LIVE COVID-19 Update | October 27th 2020

As we approach a new surge in the global pandemic, many regions that were previously spared are seeing a rise in cases and a strain on resources. The team is back this month with updates on therapeutics, critical care and the latest on the multisystem inflammatory disorder associated with Covid-19.

Tracy G. -

Question from Dr. Bob:

Here in our part of Canada, we didn't get many critically ill Covid-19 patients during the first wave and those who did need intubation were managed by anesthesiology (their elective cases were all cancelled).

Now it's up to us in the ED for the second wave and many of us don't have enough experience with Covid airway management. Some EPs feel hemmed in by guidelines that constrain our actions from what we might reasonably have done in the times before the pandemic.

So, may I ask how your ICU-emergency physicians would handle the following case (thinking here of Scott Weingart and/or Dr Sara Crager):

A 72-year-old female, obese, diabetic with known Covid-19 for one week calls 911 because of dyspnea.

Her vital signs are: RR 42bpm HR 145bpm, BP 155/?
The patient is diaphoretic, fatigued and speaking in short sentences. She is transported to hospital by ambulance using a non-rebreather at 15L/min and nasal prongs at 6L/min.

In the ED: SpO2 in 40s. In an effort to increase her oxygenation, she has a BVM with added PEEP sealed on her face, effectively functioning as CPAP. To be clear, there is no active insufflation of the bag. Her O2 saturation really doesn't improve much.

Now what?

Anand S. -

Dr. Bob:
CPAP would be my go to but it sounds like you're working with a "MacGyver CPAP" here. This set up can function as a CPAP but has to be carefully constructed. Weingart's set up is here: https://emcrit.org/emcrit/covid-airway-management/
but this really depends on the exact equipment in your shop. I had to tweak this a bit based on what we had. Big difference for me: our CPAP masks have a one way valve and exhalation port allowing venting of exhaled air into the room. We removed the one way valve and placed a tegaderm over the exhalation port so as not to completely contaminate the room.

If CPAP isn't working, you're pretty much left with intubation. This patient sounds very sick and is likely to need mechanical vent due to her tiring out.

I've treated a couple hundred critically ill COVID patients and my hand was forced to intubation for a couple of dozen at least as they failed CPAP.

Hope this helps - swami

Tracy G. -

From Dr. Bob:

Thank you Swami! This information is greatly appreciated!

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