ACEP COVID-19 Field Guide

Author: Angela Cornelius, MD, MA, FACEP, Associate System Medical Director Metropolitan Area EMS Authority, Core Faculty at John Peter Smith Hospital Fort Worth Emergency Medicine Residency, Associate Professor at Louisiana State University Shreveport Health, Associate Professor at Texas Christian University Medical School; AMC Physician Advisor Board

The objective of these guidelines is to balance optimal care of critically ill patients with suspected or confirmed COVID-19 with the safety of air medical crews. This balancing act requires an in-depth understanding of the transmission risks and potential benefits of various treatment modalities.

General considerations

• Staff should don appropriate personal protective equipment (PPE) when around any patient with a respiratory or infectious chief complaint. At a minimum, PPE should include a tight-fitting surgical mask and gloves at the first encounter with the patient. PPE should be escalated to full respiratory and droplet precautions (ie, gown, N95 mask, goggles, and gloves) when COVID-19 is suspected or high-risk therapies (ie, nebulizer therapy, continuous positive airway pressure [CPAP]/bilevel positive airway pressure [BiPAP], bag-valve-mask [BVM] ventilation, placement of an advanced airway) are used.
• The maximum level of PPE used for a patient should be maintained until decontamination of the cabin and equipment is performed.
• Flight crews are encouraged to involve online medical control prior to transport of a suspected or confirmed COVID-19 patient with ongoing bronchodilator therapy or noninvasive positive-pressure ventilation (NIPPV), or with any concerns about optimal therapy expressed by the sending or receiving facilities or the air medical crews.
• Any potential exposure should be reported to the area manager, who will notify the clinical director.
• High-risk exposures with suspected or confirmed COVID-19 patients include either: (1) absence of at least a surgical mask and gloves; or (2) failure to don full respiratory and droplet precautions with implementation of high-risk therapies.
• For a nonintubated patient with a respiratory illness, consider leaving jump bags outside the patient’s examination room while one clinician remains with the bags and the other clinician completes an assessment to determine what items are necessary for patient care. After completing the assessment, the clinician in the examination room should communicate with the clinician outside about which necessary items to provide for patient care. (This process reduces the exposure of jump bags to possible contaminants in the examination room.)
• Place a surgical mask on patients who are receiving oxygen by nasal cannula because of a respiratory illness.
• Clinicians are required to contact online medical control when they encounter any ventilated patient in a prone position to determine how best to proceed. If the patient is transported in a prone position, clinicians are required to carefully secure the patient on the transport stretcher in a way they can closely monitor the endotracheal tube for possible displacement. Clinicians must be prepared to immediately manage a displaced endotracheal tube. The receiving facility must be notified that the patient has suspected or confirmed COVID-19, and the receiving unit must be prepared to receive the patient.

Bronchodilator therapy

• The pulmonary syndrome associated with COVID-19 is an inflammatory condition that is unlikely to respond to bronchodilators in the absence of a reactive airway disease (eg, asthma, COPD).
• Bronchodilators, such as albuterol, and other nebulized medications increase the efficiency of COVID-19 transmission, which should be considered in the risk-benefit analysis when treating suspected or confirmed COVID-19 patients.
• The use of bronchodilators increases exposure risk and should prompt the use of full droplet precautions.
• Suspected or confirmed COVID-19 patients with a reactive airway disease may require bronchodilators as part of their therapy. It is reasonable to first try alternative routes for β-agonist administration, such as the use of terbutaline or subcutaneous epinephrine, in the absence of cardiovascular risk factors.
• The administration of β-agonists via metered-dose inhalers, ideally administered with a spacer chamber, is preferable to the use of nebulizers in these patients. Whenever possible, these devices should be requested from the sending facility as an alternative to nebulizers.
• Albuterol four to eight puffs every 20 minutes can be administered for bronchospasm.
• If a spacer chamber is available, spray one puff at a time into the spacer chamber and have the patient take three to four slow, deep breaths; repeat for four to eight total puffs.
• If a spacer chamber is unavailable, have the patient exhale completely; then, spray one puff at a time simultaneous to the inhale of a maximum tidal volume breath. Repeat for four to eight total puffs.

NIPPV

• The use of positive pressure via BVM ventilation, high-flow oxygen devices, or CPAP or BiPAP ventilation in a suspected or confirmed COVID-19 patient may be reasonable to avoid intubation — particularly with a scarcity of mechanical ventilators — but should be considered high risk. Full respiratory and droplet precautions should be donned prior to initiating these forms of NIPPV.
• Whenever available, an in-line filter should be placed immediately over the mask, with the end-tidal CO₂ (EtCO₂) sensor placed above the mask (ie, farther from the patient) when performing BVM ventilation.
• The risk of transmission decreases after intubation. Thus, if progression of disease is anticipated in a suspected or confirmed COVID-19 patient, the potential benefit of providing intubation and mechanical ventilation prior to transport to reduce the virus’ transmission risk should be considered in the risk-benefit analysis.

Advanced airways

• Insertion of an advanced airway is considered a high-risk procedure. Full respiratory and droplet precautions should be donned prior to initiating the procedure. A full-face shield (separate from the mask) with a forehead seal should be used, if available.
• The use of passive oxygenation can be deferred in a suspected or confirmed COVID-19 patient to avoid facilitating transmission to the advanced airway practitioner. If passive oxygenation is provided by a nonrebreather mask, place a full-face shield (separate from the mask) with a forehead seal, if available, on the patient to direct passive airflow in a caudal direction. Leave the full-face shield in place during the oral suction procedure. Remove the full-face shield once the patient is fully sedated or chemically paralyzed and the clinician is prepared to initiate an oral intubation.
• Assisted ventilation and NIPPV using BVM ventilation should be performed, as needed, for preoxygenation in suspected or confirmed COVID-19 patients who have a high likelihood of hypoxemia. When providing mask seal ventilations, use a two-person technique to ensure a tight seal and include an in-line filter immediately above the mask, which will substantially decrease the transmission risk.
• An in-line filter should be placed immediately proximal to the advanced airway, with the EtCO₂ adapter placed proximal to the filter. Additionally, sidestream capnography has a filter mechanism within the sampling line, and mainstream capnography has a closed circuit.
• In-line suction systems should be used when available for pulmonary hygiene (or pulmonary toilet) in suspected or confirmed COVID-19 patients with an advanced airway.
• The endotracheal tube should be clamped during transfer from one ventilator to another to minimize the transmission risk.

Resuscitation

• Patients with COVID-19 may have increased sensitivity to crystalloid intravenous fluid boluses.
• Elevated serum lactic acid is often a result of hypoxia or cytokine storm and does not require a 30-mL/kg crystalloid intravenous fluid bolus.
• Vasopressors are used early for MAP <65 mm Hg, rather than crystalloid intravenous fluid resuscitation.

Cardiac arrest

• Chest compressions are a high-risk procedure that aerosolizes the virus.
• At no point should the safety of the clinician be compromised during CPR.
• Secure the airway with tracheal intubation prior to any virus-aerosolizing procedure, including chest compressions.
• Contact medical control early for any COVID-19 patient in cardiac arrest.

Additional readings

• Martin T. Fixed wing patient air transport during the COVID-19 pandemic. Air Med J. 2020 May;39(3):149-153. doi: 10.1016/j.amj.2020.04.001
• Air Medical Physician Association Board of Trustees. AMPA position statement on COVID-19. Air Med J. 2020 May;39(3):221. doi: 10.1016/j.amj.2020.03.006