To improve management and maintain protection for staff and patients we have created a RespED at both sites, much of the flow chart is based on information from the Italian society of emergency medicine

As time more information becomes avalible this will inevitably change

RespED – flow chart

• NIV/CPAP  is an Aerosol Generating Proceedure (AGP)
  • Staff must wear full APG PPE
  • In Side room with a door
  • Door Marked with APG sign – HERE
• CPAP/EPAP levels of 8-15cmH₂O is suggested to work well by the Italian society of Emergency medicine
• BTS has released the guidance – HERE 
  • Masks
    • Well-fitting oronasal facemasks, masks over the total face, or helmets should produce least droplet dissemination.
    • Vented masks could worsen contamination of the environment
    • Any patient on acute NIV should be managed with a non-vented mask and an exhalation port in the circuit.
    • Ensure that the ventilator mode employed supports the use of non-vented masks and exhalation ports.
    • Sequence of actions: NIV mask on >ventilator on; ventilator off > NIV mask off.
  • Filters
    • A viral/bacterial filter should be placed in the circuit between the mask and the exhalation port (Figure below).
    • This viral/bacterial filter can replace any filter at the machine end of the circuit.
    • Viral/bacterial filters should ideally be changed every 24 hours or sooner. (There is a risk that they will become wet due to exhaled gas and that this may increase resistance to flow.)
    • An external humidifier must not be used.
    • Blocked filters can be mistaken for clinical deterioration; this issue is remedied by changing filters.
  • Oxygen – entrained at patients end (on mask

Destinations

• • • Failing on NIV/CPAP – Consider either escalation to intubation OR palliation
    • Maintaining Oxygenation – At CRH negative pressure room, at HRI side room acute floor

Avoid NSAIDS

Tamiflu – Only if confirmed influenza

Deteriorating Patients

• Early senior decision making around DNACPR, is vital for both staff, patients, and families.
• Document decsion making and communications clearly
• There will be regular updates in “handover” about ICU admission criteria – as these may change over time

CPR (Aerosol Generation Proceedure)

1. Recognise cardiac arrest.
   • Look for the absence of signs of life and normal breathing.
   • Feel for a carotid pulse if trained to do so.
   • Do not listen or feel for breathing
   • If there are any doubts – start chest compressions until help arrives.
   • When calling for help/2222, state the risk of COVID 19.
2. Minimum PPE; gown, eye protection, gloves and FFP3 mask/Hood before starting chest compressions
   • No chest compressions or airway procedures such as those detailed below should be undertaken without full AGP PPE.
3. Start compression-only CPR and monitor the patient’s cardiac arrest rhythm as soon as possible.
   • Avoid mouth-to-mouth ventilation and the use of a pocket mask.
   • Place oxygen face mask on the patient’s face during chest compressions (may limit aerosol spread).
   • Restrict the number of staff in the room (if a single room). Allocate a gatekeeper to do this.
4. Defibrillate shockable rhythms rapidly 
5. LMA/ETT insertion –  must be carried out by experienced individuals.
6. Identify and treat any reversible causes 
7. Post-CPR
   • Dispose of, or clean, all equipment used during CPR
   • Remove PPE safely to avoid self-contamination
   • Hand hygiene has an important role in decreasing transmission.
   • Post resuscitation debrief is important and should be planned.

FULL Resus Council – GUIDE HERE