There is increasing evidence that Awake Self-Proning of our Covid-19 patients can improve oxygenation. Proning the patient can has several effects which can dramatically improve their SaO2
Improves Ventilation to back of the lung (the back of the lung contains more alveoli than the anterior lung)
Improves Perfusion – as blood supply to the back of the lung is always better than the front
Improves Clearance of secretions
NIV/CPAP
NIV/CPAP is an Aerosol Generating Proceedure (AGP)
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
If Treating Moderate/Severe Pneumonia with antibiotic please ensure – Sputum/Urine/Blood samples ordered
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)
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.
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.
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.
Defibrillate shockable rhythms rapidly
LMA/ETT insertion – must be carried out by experienced individuals.
Identify and treat any reversible causes
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.
During the COVID-19 Pandemic the pathways to stream patients out of ED are changing to allow for better flow through the ED’s and prevent congestion at the front door.
ENT
If the patient is suitable for outpatient treatment – M-F call ENT clinic 01422 222336, Out of hours: If COVID is not suspected book a clinic appointment directly via ED reception, if COVID is suspected ask the patient to phone the clinic the next working day.
If the patient is stable and no suspicison of COVID contact the Gynae SPR bleep no. 2409 and then send the patient to 1D, if unstable or COVID is suspected contact the Gynae SPR and they will attend ED at CRH. IF at HRI the patient must be seen by ED and stablised for transfer.
If at HRI 9.00-17.00 contact the Gynae SPR on bleep 565 for review in the ED
If the Gynae SPR is not available please contact the Gyane consultant via switchboard out of hours.
Maxillofacial
Monday-Friday 9.00-17.00 for facial trauma and injuries contact the HRI Max fac team on 01484 342336, out of hours contact the on-call maxillofacial team at BRI. For acute dental problems (toothache/ mild swelling/ borken teeth) patient to contact their own dentist if registered or 111 if not registered with a dentist.
Phone the helpline 01422 222999 and they will advice where to send the patient for assessment – wither Ward 12 or Ward 14 at HRI depending on capacity.
Opthalmology
8.30-17.30 M-F and 8.30-12.00 Sat. contact Eye clinic on 01422 222539 out of hours contact the on-call opthalmologist via switchboard who will advise where to send the patient and when.
At HRI M-F 9-5 any fracture that does not normally get discharged immediately from ED or required an intervention in ED should be referred to the Ortho SPR bleep 062.
Out of hours and at CRH follow the normal ED pathways.
Patients requiring admission e.g. #NOF still require ECG/bloods/CXR/FNB prior to sending to the ward.
Paediatrics
There is a Paediatric Consultant based in ED at CRH 13.00-17.00 Monday – Thursday to review children and aid decision making. Any child under 3 months old with a fever and a PAWS <10 and no clinical concern can go to PAU directly for assessment.
Contact the 2nd on call Surgical Consultant on 07741363257 who will either come and review the patient or advise where to send them. Urology and Vascular patients need to be referred to the on-call middle grade or consultant for the speciality.