Ep 140 COVID-19 Part 4 – Protected Intubation

There are many complicated guides on airway management and protected intubation since the COVID-19 pandemic broke. This can be confusing in our rush to develop protocols and guides in our own EDs. In this podcast, part of the COVID-19 EM Cases 5-part series, we aim to simplify protected intubation so that you can adapt it to your ED rapidly. Canada's leading airway expert, George Kovacs guides us through the general principles and important details of the protected RSI... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Anton Helman March, 2020 Cite this podcast as: Helman, A. Kovacs, G. Episode 140 COVID-19 Part 4 - Protected Intubation. Emergency Medicine Cases. March, 2020. https://emergencymedicinecases.com/covid-19-protected-intubation. Accessed [date] This podcast and blog post are based on Level C evidence - consensus and expert opinion. Examples of protocols, checklists and algorithms are for educational purposes and require modification for your particular needs as well as approval by your hospital before use in clinical practice. This podcast was recorded on March 19th, 2020 and the information within is accurate up to this date only, as the COVID pandemic evolves and new data emerges. The blog post will be updated regularly and we are working on a weekly update via the EM Cases Newsletter which will be replicated on the EM Cases website under 'COVID-19' in the navigation bar. COVID-19 oxygenation algorithm and indications for intubation Update April 2nd, 2020 Oxygenation Strategies on REBELEM Update April 2nd, 2020 COVID Respiratory Severity Scale on MDCalc What is different about the protected RSI compared to the standard RSI? Guiding general principles of protected intubation * The emphasis is on provider safety: rapidly securing the airway but slowing down to prepare yourself, your team and your patient with strict adherence to PPE donning/doffing * With these safety measures we may not be able to optimize the patient prior to intubation as we normally would, and have to accept this. * We need to pay particular attention to the details of how to prepare for, how to pre-oxygenate, and the sequencing of RSI * There is no high level evidence for these modifications - at best the evidence is Level C - consensus/expert opinion * Slow down so that you and your team’s safety is preserved - take the time to prepare yourself, your team and your gear before you enter the room * We need to think about how PPE might effect our performance and come up with solutions or modifications * Training properly is paramount to ensure the safety of ED providers and patients Do’s and Don'ts of protected intubation Do's * Do ensure viral filters on all masks (e.g. Tavish, HiOx NRB) * Do accept lower oxygenation goals at lower flows * Do have all necessary equipment at arm’s reach * Do paralyze the patient before intubation to avoid coughing and subsequent aerosilization of particles and wait 45-90 seconds after pushing the paralytic * Do understand that all patients will be apnea intolerant * Do slow down to ensure you and your team are safe * Do employ the most experienced available airway provider * Do limit personnel in room to 3 if possible * Do employ positive pressure ventilation and sustained waveform CO2 only after the cuff is inflated.