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  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

The 4C mortality score has been developed by ISARIC, based on 35.463 UK Covid-19 patients.

If cases climb prognostication may become more important and this appears to be a good tool developed on our population.

4C Mortality Score tool – Click HERE

Factors:

• Age: <50(0), 50-59(2), 60-69(4), 70-79(6), ≥80(7)
• Sex: Female(0), Male(1)
• Comorbidities*: None(0), 1(1), ≥2(2)
• Respiratory Rate: <20(0), 20-29(1), ≥30(2)
• Oxygen Saturations (Air): ≥92(0), <92(2)
• GCS: 15(0), <15(2)
• Urea: ≤7(0), 7-14(1), >14(3)
• CRP: <50(0), 50-99(1), ≥100(2)

*Comorbidities inc: Obesity, CardioVasc(MI,CHF,PVD,Stoke/TIA), Dementia, Hemipelgia, COPD, Mod-Severe CKD, Liver disease, Diabetes, Peptic Ulcer disease, Connective tissue disease, Haem/Onc Malignancies, AIDS

Risk Score (sum of the factor scores)

• Low 0-3: 1.2% mortality
• Intermediate 4-8: 9.9% mortality
• High 9-14: 31.4% mortality
• Very High ≥15: 61.5% mortality

4C Mortality Score tool – Click HERE

Pathways out of ED

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.

Full Pathway – ENT pathway.docx

Gynae

If the patient is stable and no suspicison of COVID contact the Gynae SPR bleep no. 2409 and then send the patient to 4c 7.00-19.00 or 8c OOH, 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 on 01422 22 5330 8.30-20.30 or via switchboard out of hours.

Full Pathway –Gynae pathway

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.

Maxillofacial Pathway

Oncology

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.

Opthalmology pathway

Orthopaedics

Orthopaedic Consultants are available in the Minor Injuries Unit at HRI 10.00-22.00  – direct as many patients to them as possible. If unable to sit e.g. # NOF call the on-call Orthopaedic Registrar bleep no. 062 at HRI.

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.

Febrile under 3mth

Surgical Patients

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.