Pre-oxygenation
NC @ 6 L/min
HFNC controversial
Consider facemask or other facial covering to prevent aerosolization
CPAP mask modified with bio-filter
NC @ 6 L/min
HFNC controversial
Consider facemask or other facial covering to prevent aerosolization
CPAP mask modified with bio-filter
Consider facemask or other facial covering to prevent aerosolization
If not available, use BVM with bio-filter
Apneic oxygenation
Personnel in room
Intubating physician (most experienced)
Physician administers meds
Nurse may enter room once circuit is closed to minimize exposure
Respiratory therapist
Personnel outside
Nurse to enter room once circuit closed
Personnel to record/obtain unanticipated supplies
Personnel to enter electronic orders if needed
PPE
CAPR/PAPR preferred
Otherwise
N95 with surgical mask cover recommended
Eye goggles with side shielding
Hair cover
Body suit preferred, otherwise surgical gown
Double gloves recommended
Doffing
All doffing in anteroom preferred
All PPE except facial covering doffed inside room
CAPR/PAPR/mask should be doffed immediately outside
Assign personnel to guide doffing process
Equipment
Video laryngoscopy (only bring into room what’s required)
Direct laryngoscopy NOT recommended
ETT tube with backup unopened from packet
CPAP mask or BVM with bio-filter
Bougie (unopened from packet)
RSI meds pre-drawn (sedation should be pre-ordered)
Have other equipment ready for central & arterial lines outside
Nursing
Set up monitor outside door with extension tubings
Minimize need for mult room entry
Technique
Consider using face hood
If not available, use BVM with bio-filter
Apneic oxygenation
If not available, use BVM with bio-filter
Apneic oxygenation
Intubating physician (most experienced)
Physician administers meds
Nurse may enter room once circuit is closed to minimize exposure
Respiratory therapist
Physician administers meds
Nurse may enter room once circuit is closed to minimize exposure
Nurse to enter room once circuit closed
Personnel to record/obtain unanticipated supplies
Personnel to enter electronic orders if needed
CAPR/PAPR preferred
Otherwise
N95 with surgical mask cover recommended
Eye goggles with side shielding
Hair cover
Body suit preferred, otherwise surgical gown
Double gloves recommended
Doffing
All doffing in anteroom preferred
All PPE except facial covering doffed inside room
CAPR/PAPR/mask should be doffed immediately outside
Assign personnel to guide doffing process
N95 with surgical mask cover recommended
Eye goggles with side shielding
Hair cover
All doffing in anteroom preferred
All PPE except facial covering doffed inside room
CAPR/PAPR/mask should be doffed immediately outside
Assign personnel to guide doffing process
Video laryngoscopy (only bring into room what’s required)
Direct laryngoscopy NOT recommended
ETT tube with backup unopened from packet
CPAP mask or BVM with bio-filter
Bougie (unopened from packet)
RSI meds pre-drawn (sedation should be pre-ordered)
Have other equipment ready for central & arterial lines outside
Direct laryngoscopy NOT recommended
Set up monitor outside door with extension tubings
Minimize need for mult room entry
Consider using face hood
RSI by most experienced personnel
Meds:
Paralytic: succinylcholine/rocuronium
Induction: etomidate/ketamine
Video laryngoscope
Direct laryngoscopy NOT recommended
Minimize suction
Confirm placement with EtCO2 or calorimetric device
Auscultating for BS not recommended
Maintain bio-filter inline with ETT at all times
Ventilation
Set up pre-intubation
Lung protective ventilation
Use ARDSnet
Vt: 8 ml/kg initially - use predicted body weight
Target 6 ml/kg
Goal PaO2 55-80 mm Hg, or SpO2 ≥ 88%
Plateau pressure ≤ 30 cm H2O
PEEP: start at 10; be ready to increase
Use PEEP table to adjust FiO2/PEEP
Sedation: fentanyl/propofol or ketamine/propofol
Albuterol: if needed, administer via inline adapter
HEPA filter as close to patient as possible
Consider establishing an area for incoming crash intubation from EMS
It may be more efficient to bring patient to ED room for RSI
Cover patient's face with mask and/or sheet to minimize aerosolization
Consider apneic oxygenation during transport to room
Have pre-designated route to minimize exposure to staff and ED environment
Receiving team should be transporting patient
RSI by most experienced personnel
Meds:
Paralytic: succinylcholine/rocuronium
Induction: etomidate/ketamine
Video laryngoscope
Direct laryngoscopy NOT recommended
Minimize suction
Confirm placement with EtCO2 or calorimetric device
Auscultating for BS not recommended
Maintain bio-filter inline with ETT at all times
Paralytic: succinylcholine/rocuronium
Induction: etomidate/ketamine
Direct laryngoscopy NOT recommended
Auscultating for BS not recommended
Set up pre-intubation
Lung protective ventilation
Use ARDSnet
Vt: 8 ml/kg initially - use predicted body weight
Target 6 ml/kg
Goal PaO2 55-80 mm Hg, or SpO2 ≥ 88%
Plateau pressure ≤ 30 cm H2O
PEEP: start at 10; be ready to increase
Use PEEP table to adjust FiO2/PEEP
Sedation: fentanyl/propofol or ketamine/propofol
Albuterol: if needed, administer via inline adapter
Use ARDSnet
Vt: 8 ml/kg initially - use predicted body weight
Target 6 ml/kg
Goal PaO2 55-80 mm Hg, or SpO2 ≥ 88%
Plateau pressure ≤ 30 cm H2O
PEEP: start at 10; be ready to increase
Use PEEP table to adjust FiO2/PEEP
It may be more efficient to bring patient to ED room for RSI
Cover patient's face with mask and/or sheet to minimize aerosolization
Consider apneic oxygenation during transport to room
Have pre-designated route to minimize exposure to staff and ED environment
Receiving team should be transporting patient
Cover patient's face with mask and/or sheet to minimize aerosolization
Consider apneic oxygenation during transport to room
Have pre-designated route to minimize exposure to staff and ED environment
Receiving team should be transporting patient
COVID-19: Example hospital protocols
COVID-19: Management of recovered patients
LLSA Readings: 2012
LLSA Readings: 2011
HIV - AIDS 
Maine:Prehospital protocol pediatric wheezing 
Maine:Prehospital protocol pediatric anaphylaxis
Santa Monica:Antibiotics in Sepsis