What are the current ER management recommendations including treatments, when to admit, when to intubate

Posted on May 21, 2020 by Kristin Walters

Summary

The use of evidence-based approaches to the COVID-19 confirmed and suspected cases will continue to be essential in order to ensure the safety of healthcare workers and provide effective triage of this patient population.  A number of regional, national, and international guidelines have been implemented based on outcome measures.  The latest guidelines support restricting invasive ventilation until specific clinical thresholds have been met, and using HHHF or NIV for immediate oxygen therapy (2). 

I.   Emergency Department Oxygen Therapy and Intubation Threshold Guidelines

Figure 1: Covid-19 Oxygen Therapy and intubation Threshold guidance (BC Centre for Disease Control)

 

Guidelines from the  WHO support  the use of  supplemental oxygen therapy to patients  presenting with respiratory distress, hypoxemia, or shock with a target SPO2 of > 94% (3).  

Brigham and Women’s Hospital has developed Emergency Department Discharge Planning tools which can be found here (4).

II.   Emergency Department Oxygen Support Guidelines (Non-Intubated Patients)

  • AHS clinical guidelines – do not recommend using HHHF or NIV for routine use in patients with suspected or confirmed COVID-19 infection (1).
  • BC EMCrit Project – recommendations for pulmonary care of patients with significant dyspnea or hypoxemia upon admission includes (8):
    • Awake proning +/- HFNC (or standard cannula)
    • CPAP (or BiPAP with high levels of end-expiratory pressure) using a mask, or helmet interface.
    • When in doubt, err on the side of avoiding intubation
    • For patients with severe hypoxemia and bilateral infiltrates: start a steroid (ie. 60 mg methylprednisolone IV or 10 mg dexamethasone IV daily)
  • BC EMCrit Project – recommendations for pulmonary care of non-intubated patients includes:
    •  Starting with low-flow nasal cannula (1-6 L/min)
    • For dyspnea or worsening desaturation, consider early implementation of HFNC (ideally with awake proning) or CPAP/BiPAP.

III.   Criteria and Threshold Levels for Intubation

    • According to several Canadian provincial and guidelines,  evidence of moderate to severe hypoxemic respiratory failure/ARDS will generally require intubation and mechanical ventilation. 
    • Leading practices reiterate the use of preoxygenation as much as possible using NIV (1).
    • Some useful criteria for invasive ventilatory support include the following (2):
      • Refractory hypoxemia (SPO2 < 90% on nonrebreather mask FiO2 >0.85)
      •  Respiratory acidosis (pH <7.2)
      • Clinical evidence of respiratory failure
      • Inability to protect or maintain the airway
    • Additional evidence suggested  using oxygen supplementation if peripheral SPO2 is < 92% and recommend starting supplemental oxygen if SPO2 is < 90%.
    • For adults with COVID-19 and ARDS despite supplemental oxygen, it was suggested utilizing HFNC over NIPPV.
    • In adults with COVID-19 and acute hypoxemic respiratory failure, if HFNC is not available and there is no indication for intubation, it is suggested to use NIPPV with close monitoring over short intervals.
    • Hypotension defined as:
      • SBP < 90mmHg for adults, or relative hypotension with clinical evidence of shock for all ages (altered LOC, oliguria, other end-organ failure) refractory to volume resuscitation requiring vasopressor/inotrope support that cannot be managed on the ward.

IV.   Additional Guidelines and Tools

  • Sunnybrook Health Sciences – Protected Code Blue/Emergent Medical Intervention (ED and ICU’s) (7)
  • BC Emergency Medicine Network – Clinical Management (9)

 

Figure 1: CEEP-CEMU COVID Intake Flowchart (6)

Figure 2: Brigham and Women’s Hospital COVID-19 Clinical Guidelines

 

 

 Figure 3: COVID-19 Adult Emergency Rapid Sequence Intubation Approach (5)

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

    1. AHS. Care of the Adult Critically ILL COVID-19 Patient. Annex D. Provincial Critical Care Communicable Disease Working Group. April 15, 2020. [Online] https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-covid-19-care-adult-critically-ill.pdf Accessed on: May 5, 2020
    2. Ontario Health. Clinical Triage Protocol for Major Surge in COVID Pandemic. March 28, 2020. [Online]https://caep.ca/wp-content/uploads/2020/04/Clinical-Triage-Protocol-for-Major-Surge-in-COVID-Pandemic-March-28-202.pdf Accessed on: May 5, 2020
    3. WHO. Clinical Management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. March 13, 2020. [Online] https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected Accessed on: May 5, 2020
    4. Brigham and Women’s Hospital COVID-19 Clinical Guidelines. ED Discharge Planning. April 27, 2020. [Online] https://covidprotocols.org/protocols/02-ed-inpatient-floor-management-triage-transfers/ Accessed on: May 5, 2020
    5. Kovacs, G., Sowers, N., Campbell, S., et al., Just the Facts: Airway Management During Coronavirus Disease 2019 (COVID-19) pandemic. Canadian Journal of Emergency Medicine. March 30, 2020. [Online] https://www.cambridge.org/core/journals/canadian-journal-of-emergency-medicine/article/just-the-facts-airway-management-during-the-coronavirus-disease-2019-covid19-pandemic/F6386E2DB9FCE5C35EEF313E2210F39E/core-reader Accessed on: May 5, 2020
    6. Centre for Excellence in Emergency Preparedness (CEEP-CEMU). COVID-19 Admission/Ventilation Decision Tree. [Online] https://caep.ca/wp-content/uploads/2020/04/Complete-COVID-AdmissionVentilation-Decision-Tree-Formatted-1.pdf Accessed on: May 5, 2020
    7. Sunnybrook Health Sciences Task Force: AGMP with high consequence pathogens. Protected Code Blue/Emergent Medical Intervention (ED and ICU’s). April 1, 2020. [Online] http://northtorontooht.ca/wp-content/uploads/2020/04/Protected_Code_Blue_ED_ICU_20200401_FV2.0_.pdf Accessed on: May 5, 2020
    8. Farkas, J., COVID-19 EMCrit Project. The Internet Book of Care. March 16, 2020 [Online] https://emcrit.org/ibcc/covid19/#approach_to_ED_patients_getting_admitted_to_the_hospital. Accessed on: May 5, 2020
    9. BC Emergency Medicine Network. Clinical Management Resources. [Online] https://www.bcemergencynetwork.ca/covid-19/#clinical-management Accessed on: May 5, 2020

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.