COVID-19 Intubation Simulation

This video is a simulation of our COVID-19 Emergency Intubation Checklist. We’ve developed our guideline based on the international guidelines and local expertise. Please note that this checklist will be subject to change over time. So please refer to the most recent available guidelines. The guideline consists of a number of steps. Outside the room, these include assemble team, prepare equipment, team brief and airway plan, prepare yourselves, prepare to enter the room. After entry to the room, the steps are pre-intubation checklist and post-intubation. Just to recap the scenario, this is a 59 year old gentleman who’s come in with suspected COVID-19. So increasing oxygen requirements his set to now 88%.

And I think there’s a consensus in our team that we’re going to intubate him, which we will need to do with all PPE in place. I think Max has got our box. Excellent. So let’s start working through our checklist. One. Assemble team and allocate roles. Can we just all introduce ourselves? Hi, I’m Anita. I’m Consultant anaesthetist assist. I’m intubator number one. OK. I’m Carolina, runner. I’m Max. I’m an anaesthetic registrar. And I’m Ellie, ODP. And you’re going to be first intubator. I am. Yeah. OK. I’m going to be team leader. I’m going to give drugs. And I’m going to be second intubator. And you’re going to be our skilled assistant in the room. And you’re helping with the airway. Yes.

You’re going to be our runner. Two. Prepare equipment. Consider allocating two team members to check airway equipment, whilst the other two members start donning PPE. Assemble airway equipment using a call and response method with closed loop communication. Get a face mask.

Face mask. OK. Please refer to the full airway equipment list from the guideline. We need to also get our video laryngoscope. Video laryngoscope. Now we’re going to get our drugs ready.

Next, draw up RSI and emergency drugs. For the purpose of this checklist, we recommend higher dose fentanyl with ketamine for a cardiostable RSI with rocuronium. In addition to normal emergency drugs, consider drawing up dilute adrenaline. Propofol infusion. We’ve got the propofol there. And we’ve got for maintenance as well. 20 mL, and we’ve got a 50 mL. And you just check what’s inside. Just looking through the window, without opening the door. Check equipment list and clarify whether anything else needs to be brought into the room. Extra kit should not be handed directly from the runner to the team in the room. It should be placed unopened on the floor or on a trolley that can be slid into the room.

Ensure the following are available inside the room or prepared to take in– monitor, cables, ECG dots, blood pressure cuff and tubing, end-tidal CO2 modules, water trap and sampling line, sats probe, water circuit, oxygen outlet, suction and tubing, oxylog ventilator and tubing, infusion pump, clinical waste bin, and alcohol gel. Also consider taking a nasogastric tube, central line, arterial lines, and accompanying equipment, as needed. So now we’re going to stage 3, discuss airway plan. Three. Team brief, airway plan. We’ve got to pre-oxygenate for 3 minutes. Would you like us to do cricoid? Yes. We’ll have some cricoid to start with, but if there’s any difficulty, I’ll ask you to take that off. OK. Quickly.

So plan A will be our best attempt– video laryngoscopy with a stylet. We’re going to do three attempts for intubator number 1. And I’ll do one attempt as intubator number 2. Plan B will be supraglottic airway, which we have here. Plan C will be 2-person face mask ventilation with adjuncts, which we have laid out. Plan D will be emergency front-of-neck access for difficult intubation. I will be doing the front-of-neck access, if we need to. And other important point is we’re going to inflate the cuff before we do any sort of ventilation. If at all possible, we’re going to immediately connect the HME filter. And for any sort of circuit disconnection, we’re going to clamp the tube.

And we’re going to check that there’s equal bilateral chest rise. We’re going to check that with end-tidal CO2 and with chest expansion. We’re not going to auscultate. And we’re going to connect them to the oxylog. We have to make sure that we always have an HME filter connected. Yes. Excellent. So the next step is to get donned up in our PPE. Four. Prepare yourselves. Please refer to current guidelines for donning for aerosolizing procedures. Important points are as follows. Don with the help of a buddy. Consider a third set of gloves for intubator, as these can be removed after the tube is secured. Make sure you buddy check each other’s kit.

Ensure that you project your voice once FFP3 mask is on. Mask on first. Take care with straps. Consider names on stickers for visors.

Five, enter room.

Any questions? Nope. No. OK. Let’s go in. Six. In room, pre-intubation. All right. Can we quickly assess his airway. He’s Mallampati 1 and he’s got good thyromental distance. Good mouth opening. And you’ve identified the cricothyroid membrane. Yes, we’ve done that. OK. Prepare to check the Water’s circuit. And suction.

We’ve got CO2 line connected, 100% oxygen Check.

Good. And I’ve got suction.

All right. There’s suction. I’m all set and ready. Brilliant. Let’s check and preprogram ventilator settings. I’ve done that already. OK. Optimise patient position. I’m happy with this position. Perform and check monitor including end-tidal CO2. All the monitoring is on. You can see it on the screen there. And it gives the final end-tidal CO2. OK. OK. Great, and we’ve got inco pads under the airway equipment. Make sure adequate I.V. access with fluids attached to it . Got two cannulae left and right. OK. Right. So we’re going to start with pre- oxygenating now. Water circuit with HME filter. Check.

OK, Ellie, can you tell me when he stops breathing– can you tell me when breathing starts? has started. OK. So what we’re going to do is we’re going to give the drugs. We’re going to have 60 seconds of apnea. Then we’re going to perform intubation. Our first plan is video laryngoscope. We’ve got everything set up for that. And plan B will be supraglottic airway. Plan C will be two-person face mask ventilation. Plan D will be front of neck access. Good. You let us know when the three minutes are over. I’m going to get the medications ready.

Three minutes is up. Excellent. Are you ready? I’m ready. Are you ready? I’m ready. Brilliant. Give some fentanyl. Going to give some ketamine. And rocuronium is in. Time? I’ve got cricoid on. Let me know when 60 seconds are up, please.

60 seconds are up.

Stop.

We just need to inflate the cuff. That’s that. Cuff up.

And he’s got good chest wall movement bilaterally. Got misting in the tube. I can see that we’ve got some CO2 in our metre. I’m happy that it’s in the right place so cricoid can come off, please. My ventilator’s set and ready to go. So I’ll clamp the tube before I disconnect him properly from the monitor. And I’ll tie the tube in. Seven. Post-intubation. Ensure immediate HME filter application. Confirm correct ET tube position. Do not auscultate. Use end-tidal CO2 and chest expansion. Place dirty airway kit onto inco pads, which can then be wrapped around the GlideScope blade. Remember to remove your third pair of gloves. Ensure equipment is cleaned thoroughly before leaving the room. Doff PPE with extreme caution.

Make sure you go one at a time and use a buddy system. It’s important to be aware of space in the room and make sure that you do not contaminate yourself or others.