Managing critically ill COVID19 patients in the ED

Managing critically ill COVID19 patients in the ED As the numbers of COVID 19 patients 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. 2. 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. 3. 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. 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. Source- SSCM guidelines


A very Lucid presentation of emergency treatment of critically ill COVID-,19 patients in ED .Thanks ARDS needs to be differentiated into degree of severity . Mild ARDS - 200 mm Hg 5 cm H2O or non - ventilated . Moderate ARDS - 100 mm Hg 5 cm H20 or non - ventilated Severe ARDS - PaO2 /FIO2 <100 mm Hg with PEEP > 5 cm H20 or non ventilated.
Excellent communication but I request all the readers to magnify their knowledge regarding ARDS and fool proof preventive and precautionary measures because of lose of our fraternity colleagues in various parts of india and world.
Thanks Dr Dinesh Gupta
Very informative post sir thanks for sharing
Useful information...thanks
Impressive in great detail
Excellent write up .
Nice cme thanks sir

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