Covid-19

RespED – flow chart

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
  • 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 guidanceHERE 
    • 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
Treatment

Avoid NSAIDS

Tamiflu – Only if confirmed influenza

CPR

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

 

Arrhythmia Clinic (COVID-19 escalation)

March 26, 2020

Due to the limited capacity when referring patients to the “New Arrhythmia Clinic” we MUST Send a BNP We don’t need to wait for the result in ED prior to referral and discharge BNP Result (clinic will review) >400, we will arrange an urgent echo and face-to-face clinic. <400, we will book a remote… Read more

COVID-19 (CPAP)

March 19, 2020

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  Read more

COVID-19 (CPR)

March 19, 2020

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 Procedure)

Read more

COVID-19 (Death Certification)

April 4, 2020

The rules have changed since 25th march 2020 on death certification, below is a brief summary of how this might affect us. We are aiming to keep a death certification box in both ED’s so that these can be completed in a timely fashion.
MCCD
Any doctor can complete a death certificate (MCCD) even if they haven’t seen the patient providing

The doctor that saw the patient is unable to sign the MCCD (impractical for them due to the extensive pressures or due to being in isolation) AND
The doctor who is going to sign the MCCD to the best of their knowledge can determine the cause of death AND
A doctor has attended to the deceased within 28 days of death (this can be by video consultation but not audio)

Read more

COVID-19 (Doning/Doffing Video)

March 10, 2020

2 video links to PHE how to Don and Doff your PPE Read more

COVID-19 (Donning/Doffing-LOCAL)

March 25, 2020

Local instructional videos for donning/doffing Non-Aerosol Generating Procedures Aerosol Generating Procedures Disponible FFP3 (Leeds) Read more