ACEP COVID-19 Field Guide

Table of Contents

ICU Care in the Emergency Department


Authors: Jamie Allen, DO, Chief Resident, Emergency Medicine Residency, Lehigh Valley Health Network; Susan R. Wilcox, MD, FACEP, Division Chief, Critical Care, Department of Emergency Medicine, Associate Professor of Emergency Medicine, Harvard Medical School, Associate Chief Medical Officer, Boston MedFlight; and Nicholas Johnson, MD, FACEP, Assistant Professor Emergency Medicine, Adjunct Assistant Professor Division of Pulmonary, Critical Care, & Sleep Medicine, Associate Program Director, Critical Care Medicine Fellowship.

  • Admission or transfer to the ICU should be based on your facility’s criteria for patients meeting “ICU-level care.”
  • The average number of days of symptoms for patients requiring hospitalization is 3 to 11 days.
  • The average number of days of ICU admission is 9 to 10 days of illness.
  • The primary causes of ICU admission include hypoxic respiratory failure and ARDS.

Additional resources

Treatment of hypoxemia

  1. NIPPV: Use of BiPAP/CPAP is not routinely recommended due to the risk of aerosolization and an increased 90-day mortality rate, as compared to patients receiving high-flow oxygen.
    1. FLORALI study: There was no significant difference in the overall intubation rates between NIPPV, a nonrebreather mask, and high-flow oxygen, but there was a decreased 90-day mortality rate for patients receiving high-flow nasal cannula (HFNC).
    2. In absence of indication for endotracheal intubation, a closely monitored trial of NIPPV for adults can be used when HFNC is unavailable.
    3. NIPPV should be used in a negative-pressure room, as able. The expiratory limb should be fitted with a viral filter and a tight mask seal should be ensured. Providers caring for patients receiving NIPPV should use airborne precautions.
  2. HFNC: HFNC is the preferred noninvasive method of oxygenation in the ICU-level patient.
  3. Mechanical ventilation: Low tidal volume ventilation (≤6 ml/kg of predicted body weight) should be used. Plateau pressure should be <30 cmH20. PEEP should be titrated using PEEP ladder or to minimize driving pressure (Plateau-PEEP). Respiratory rate should be set to maintain pH >7.15, if possible. FiO2 and PEEP should be titrated to maintain SpO2 88%-92% or PaO2 >55 mmHg. Additional information can be found in the ARDSnet protocol.

Rapid sequence intubation recommendations

  • Perform intubation in a negative-pressure room whenever possible.
  • Perform preoxygenation with nasal cannula, a nonrebreather mask, or high-flow nasal cannula, as indicated by the degree of hypoxia.
  • Avoid bag-valve-mask (BVM) ventilation whenever possible.
  • Rapid sequence intubation is the preferred method.
    • Ketamine or etomidate is a reasonable induction agent.
    • Succinylcholine or rocuronium 1.5 mg/kg should be used to minimize the time to onset.
    • Wait until the neuromuscular block (NMB) has taken full effect to start laryngoscopy to reduce the risk of coughing.
  • Propofol may be used for induction, but caution should be taken with dose-dependent hypotension and QTc prolongation if the patient is also receiving azithromycin/hydroxychloroquine.
  • Post-induction vasopressor support may be required.
  • Use of video laryngoscopy is preferred. Maximize first-pass success, and maintain clinician distance from the airway.
  • Intubation should be performed by the most experienced airway manager.
  • If BVM is required post intubation, fully inflate the cuff, and use a viral filter prior to bagging or connecting the ventilator.
  • Use of a viral filter on BVM and in the ventilatory circuit is strongly recommended.
  • Use of EtCO2 monitoring and visualization of the tube passing the cords are preferred for tube placement confirmation. (Avoid excess exposure to x-ray technicians; avoid close-contact auscultation.) 

Sedation of the ventilated Covid-19 patient

  1. Propofol
    1. A national shortage of available propofol may be looming.
    2. QTc prolongation: Caution should be used in patients also receiving azithromycin/hydroxychloroquine.
    3. Hypertriglyceridemia has been noted in critically ill COVID-19 patients.
    4. Caution should be used with prolonged propofol infusions to avoid propofol infusion syndrome.
    1. Acts on GABA receptors; sedative/hypnotic
    2. Considerations:
  2. Benzodiazepines
    1. Benzodiazepines may be preferred over propofol due to a lack of QTc prolongation.
    2. There is less dose-dependent hypotension at therapeutic levels (see “Hemodynamic Characteristics of Midazolam, Propofol, and Dexmedetomidine in Healthy Volunteers”).
    3. Caution should be used with lorazepam and diazepam infusions for propylene-glycol toxicity (eg, unexplained metabolic acidosis, elevated anion gap, hyperosmolality, and then clinical deterioration). 
    1. Act on GABA receptors
    2. Considerations:
  3. Dexmedetomidine
    1. Central acting alpha-2 agonist
    2. Dexmedetomidine is not recommended as the initial sedative of choice, or at all (preferred in vent weaning, sedation <24 hours).
    3. May be suitable for patients undergoing ventilator weaning and breathing trials.

Analgesia of the ventilated COVID-19 patient

  • Multiple options include fentanyl, morphine, and dilaudid.
  • Considerations: National fentanyl shortages may occur; consider other opioid infusions. 
  • NSAIDs: According to the WHO on March 19, there is no scientific evidence to suggest NSAIDs worsen COVID; use NSAIDs cautiously in all critically ill patients.

Vasopressor therapy in the COVID-19 patient

  • Agents:
    • Norepinephrine
    • Vasopressin
    • Epinephrine
    • Phenylephrine
  • Considerations:
    • Choice of agents and goals of therapy should still be consistent with the Surviving Sepsis Campaign guidelines.
    • Norepinephrine remains the first-line agent of choice for shock.
    • Second-line therapy: vasopressin (to raise MAP or decrease norepinephrine dose) or epinephrine added to norepinephrine to maintain MAP >65 mm Hg
    • Epinephrine is recommended as the first-line agent for decreased cardiac output or a bradycardic patient.
    • Inotropic agents (dobutamine, milrinone) can be considered in patients who demonstrate myocardial dysfunction.
      • Bhatraju PK, Ghassemieh BJ, Nichols M, et al. COVID-19 in critically ill patients in the Seattle region - case series [published online ahead of print, 2020 Mar 30]. N Engl J Med. 2020;10.1056/NEJMoa2004500. doi:10.1056/NEJMoa2004500 
      • This case series of patients from Seattle describes no new myocardial dysfunction on echocardiogram, although it is a small sample size (N = 9).

Use of paralytics in the mechanically ventilated COVID-19 ARDS patient

  • Agents: 
    • Rocuronium
      • Nondepolarizing agent
      • Onset 1 minute
      • Recovery time 30 to 40 minutes
    • Vecuronium
      • Nondepolarizing agent
      • Onset 2 to 3 minutes
      • Recovery time 30 to 45 minutes
    • Cisatracurium
      • Onset 5 to 7 minutes
      • Recovery 40 seconds to 5 minutes
      • Metabolized via Hofmann degradation
        • Use in the setting of liver or renal dysfunction.
  • Considerations:
    • The original ACURASYS study by Papazian et al in 2010 showed 9.1% absolute difference in the 90-day mortality rate in the paralyzed group, although this is not statistically significant.
    • Results met significance after being controlled for baseline PaO2:FiO2, SAPS II, and plateau pressure.
    • The ROSE trial from 2019 showed no difference in the primary outcome or 90-day mortality rate.
    • For patients who are sedated but remain dyssynchronous with a ventilator, a NMB is appropriate to facilitate lung-protective ventilation.
    • Adequate deep sedation must be given to all paralyzed patients.

Use of prone positioning in ARDS

  • A benefit was demonstrated in the PROSEVA trial by Guérin et al in mechanically ventilated patients with severe ARDS (inclusion: ARDS <36 hours; PaO2:FIO2  <150; FIO2 of at least 60%; PEEP >5; Tv: ≤6 ml/kg)
    • Benefits: improved oxygenation via improved V/Q matching; keeps alveoli open and evenly distributed at end-expiration to avoid ventilator-induced lung injury 
    • Prone positioning for mechanically ventilated patients is recommended for 12 to 16 hours per day.
  • Prone positioning can be considered in patients on nasal cannula and high-flow oxygen (ie, non-mechanically ventilated patients). It appears safe and may improve oxygenation, but its impact on mortality, ventilator-free days, or longer-term outcomes is unclear.
    • Prone positioning for non-intubated patients can be done in cycles of 2-4 hours (as tolerated) with brief periods in the supine position for comfort.
  • Beneficial in patients with moderate-to-severe ARDS PaO2:FIO2  <150
  • The decision to prone a patient should generally be made in conjunction with and after discussion with a critical care attending.
  • Multiple complications (eg, device dislodgement, , difficult to perform procedures, facial edema, skin breakdown,; labor intensive)
  • Patients should be transitioned back to the supine position at least every 16 hours per the PROSEVA protocol. If patients meet the following criteria >4 hours after returning to the supine position, proning cycles should be stopped. If they do not meet the criteria below, proning cycles should continue.
    • PROSEVA criteria for stopping proning improvement in oxygenation: Supine; PaO2:FIO2  ≥150 with PEEP <10 and  FiO2 ≤60%, a decrease in the PaO2:FIO2  of more than 20%  relative to the ratio in the supine position, before two consecutive prone sessions; or complications occurring during a prone session and leading to its immediate interruption


  • Untrained staff
  • Increased intracranial pressure; increased abdominal pressure
  • Abdominal and/or chest wounds
  • Cervical spine injury
  • Extreme obesity
  • Hemodynamic instability

Use of ECMO for COVID-19 patients

  • Veno-venous ECMO is most commonly used.
  • 551 suspected or confirmed cases of COVID-19 are on ECMO (worldwide) (as of April 24, 2020).
    • 52/122 (42%) of patients taken off ECMO thus far have been discharged alive.
  • Current indications (as of April 1, 2020):
    • pH <7.25 with PaCO2 >60 for more than 6 hours and no contraindications → use ECMO
    • Try adjunctive measures first:
      • Prone positioning (unless contraindicated), NMB, high PEEP ventilation, inhaled pulmonary vasodilators, or recruitment maneuvers
    • If adjunctive measures fail and any of the following are present and no contraindication to ECMO → use ECMO:
      • P/f <80 for more than 6 hours
      • P/f <50 for more than 3 hours
      • pH <7.25 with PaCO2 >60 for more than 6 hours
    • If P/f ratio >150:
    • If P/f ratio <150: 
  • Contraindications:
    • Terminal disease, severe CNS damage, DNR status, and advanced directives refusing such therapy 
  • More information is available via the Extracorporeal Life Support Organization (ELSO):
    • This PDF is available in other languages.

Additional references

  1. Gattinoni L, Caironi P, Cressoni M, et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med. 2006;354(17):1775-1786. doi:10.1056/NEJMoa052052
  2. Bhatraju PK, Ghassemieh BJ, Nichols M, et al. Covid-19 in Critically ill patients in the Seattle region - case series [published online ahead of print, 2020 Mar 30]. N Engl J Med. 2020;10.1056/NEJMoa2004500. doi:10.1056/NEJMoa2004500
  3. Ware LB, Matthay MA. The acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1334-1349. doi:10.1056/NEJM200005043421806
  4. Barrot L, Asfar P, Mauny F, et al. Liberal or conservative oxygen therapy for acute respiratory distress syndrome. N Engl J Med. 2020;382(11):999-1008. doi:10.1056/NEJMoa1916431
  5. Caputo ND, Strayer RJ, Levitan R. Early self-proning in awake, non-intubated patients in the emergency department: a single ED's experience during the COVID-19 pandemic [published online ahead of print, 2020 Apr 22]. Acad Emerg Med. 2020;10.1111/acem.13994. doi:10.1111/acem.13994
  6. Guérin C, Reignier J, Richard JC, et al. PROSEVA Study Group. Prone Positioning in Severe Acute Respiratory Distress Syndrome. N Engl J Med (2013);368: 2159–2168. 
  7. Sud S, Friedrich J, Adhikari N, et al. Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: a systematic review and meta-analysis. CMAJ (2014);186 (10): 381-390. 

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