Airways, Safety and Strategy for SARS-CoV2
This is a special podcast episode with Dr Tim Leeuwenburg – who is one of the co-authors of the hot-of-the-press Safe Airways Society paper on managing the Coronavirus in your hospital.
We discuss PPE, minimisation of aerosolization events and how we can optimise the human factors in this new world of SARS.
There is a lot in here about rural and remote strategy too.
Have a listen to the podcast and there are a number of resources we mention that are below.
The original MJA Safe Airways Society paper is here.
Dr Justin Morgenstern’s review of the statement is here at First10EM.
The St Emlyn’s podcast with Dr Cosentini is here
The Covid PPE Simulation paper out of Vancouver is here .
This paper contains a great illustration ond checklist for the set up for proper PPE and the contents of an airway kit and drug lists that should be ready and available in your isolation / negative pressure room for airway intubation.
Podcast: Play in new window | Download
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Hope: from Home Birth to Hospice
Relative Absolute Risk – the discussion
Lactate PK by Dr Laura Castle
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
Hi Casey, thanks so much for this very helpful podcast and resources. As a rural go with very limited intubation experience I was thinking if I had to manage this in my rural community I would go for the SGA first….do you think paralysing the patient would be safest in the covid context or could we give good doses of induction agents without paralysing agents …., I work in a small rural town in NZ we cover all services and have low volumes of patients but lots of copd as ex coal miners ++
Tough question
Generally I think doing the safest for the patient is priority but CoVid changes the equation with real risk to the team
So I would do everything to stave off intubation eg. Awake proning and call for backup… you have hours usually in this disease
But plan to do a normal RSI
Sod you cannot pass a tube then LMA is plan B (as it is on any protocol regardless of skill level)
Hi Nina
That really goes to heart of the issue for many of the smaller rural centres without anaesthetic or airway operator cover.
I must admit that placement of a SGA makes me nervous – risk of cough, aerosolisaztion etc etc. Generally we’d want to obtund airway reflexes to the point of no risk – decent dose of induction agent (counter this with risk of haemodyanmic compromise – not uncommon in the critically ill) and of course adding in a neuromuscular blocker makes sense to me with anaesthetic hat on….for an ETT….but nervous re the patient in remote location with a non-experienced airway operator.
My approach if isolated and not confident with ETT
– early recognition of COVIDITY and potential to go bad, with rapid transport of all O2 dependent patients to a tertiary centre or location where can be ventilated if goes bad
– if a choice between use of HFNO or NIPPV as a bridge to this, discuss with your retrieval service as a risk/benefit vs obtunding airway reflexes with drugs and placement of an LMA
– if patient is in respiratory arrest, make a decision – place second gen SGA and ventilate w viral filter and full PPE….or if you think the arrest is due to COVId alone you may decide to palliate and not attempt resus
Hard to give a one size fits all without being more familiar with your equipment, team, set up and of course own comfort with airway management.
In short, I’d be trying too temporise them for as long as possible – with a view to ETT – rather than move earlier to obtund them and ventilate on a SGA
There are of course many ways to skin a catnap the final decision will depend on a mix of patient, location and operational factors
Great question and interested to hear of other options….especially from ambulance who may already have SGA-based protocols?
Thanks, very helpful, cheers nina
Thanks Casey & Tim. Am in sunny Katherine & came across a CPAP Venturi device https://otwo.com/products/immediate-care/emergency-cpap/o_two-single-use-cpap/ which one of our remote-ish primary care clinics will use for transfer with addition of a viral filter.
It wouldn’t really deliver proper CPAP. I was thinking that it might be a good temporising measure to avoid intubation, or a pre-ox/ap-ox bit of kit that minimises aerosolisation? Your thoughts?