COVID-19 CRITICAL CARE CRASH

COURSE FOR UCLA UROLOGY TRAINEES

By Vishnukamal Golla & Rajiv Jayadevan
COVID-19 Critical Care Crash Course for UCLA Urology Trainees
Vishnukamal Golla & Rajiv Jayadevan

Purpose:
This document will serve as a basic guide to critical care for urology trainees who are not
traditionally trained in these areas. It was assembled by reviewing various tutorials, manuals,
and guidelines that are publicly available. We plan for this to be a living document that will be
modified as we gain more knowledge about critical care medicine. While this guide is
preparation for a worst-case scenario, we hope that with some basic knowledge we are able to
provide assistance to our fellow healthcare workers on the frontlines of the COVID-19
pandemic. For quick links to videos on ventilator settings and basic critical care procedures,
please scroll to the bottom.

I. RECOGNITION & ASSESSMENT OF THE SERIOUSLY ILL PATIENT:

Primary Survey:

1) Airway:
a. Observe mouth and chest
b. Tachypnea is the first indicator of critical illness
c. Assure patency of airway (ability to phonate, mental status, stridor, secretions)

2) Breathing:
a. Assess use of accessory muscles (nasal flaring, intercostal retractions, etc.)

b. O2 saturation
3) Circulation:
a. Blood pressure
b. Evidence of decreased perfusion: mental status changes, low urine output,
skin temperature
c. Central and peripheral pulses
d. IV access, IV fluids, hemodynamic support as needed

4) Consciousness
a. Orientation to person, time, or place
b. Confusion
c. Agitation
Hypoxia:
- Normocapneic:
o V/Q mismatch
o ARDS
o Aspiration
o Pulmonary edema
o Pneumonia
o Sepsis
o Pneumothorax
o Pulmonary contusion
- Hypercapneic:
o Hypoventilation
o Obstructive sleep apnea
o Medications (sedatives)
o Neurologic causes
o Flail chest
o Chest wall burns
o Pleural effusion
o Laryngeal obstruction (epiglottitis, croup)
o COPD, asthma
- Diagnostic studies:
o ABG, CBC, BMP, blood cultures (if needed), chest radiograph, CT chest (if
needed).
 II. AIRWAY MANAGEMENT

Patient Assessment:

When evaluating general respiratory function, steps include:

- Observe for level of consciousness and apnea. Can the patient speak?
- Observe chest expansion: suprasternal, supraclavicular, or intercostal retractions;
nasal flaring
- Auscultate over neck and chest

Look, Listen and Feel:

- Look: Assess level of consciousness, evaluate chest expansion, assess whether
patient is spontaneously breathing vs experiencing apnea, assess whether patient
has airway or cervical spine injury
- Listen: Assess for signs of airway obstruction, breath sounds
- Feel: Protective airway reflex (i.e., airway and gag)

*If airway is not open can start with simple chin lift (contraindicated in airway and
cervical spine injury). Can also start non-rebreather mask at 100% O2*

Opening the Airway (No Cervical Spine Injury)

1. Slightly extend neck (when injury not suspected)
2. Elevate mandible
3. Open mouth
4. Consider adjunctive devices such as oral airways

Opening the Airway (Possible Cervical Spine Injury): Jaw Thrust Maneuver
1. Remove the anterior portion of the cervical collar
2. An assistant stabilizes the neck by placing hands or arms along each side of
the neck
3. Using both thumbs, displace the mandible forward by pushing the angle of the
mandible upward
4. This maneuver lifts the tongue forward, prevents obstruction and opens the
airway
Reassessment
- Adequate Spontaneous breathing Great, can also provide O2 supplementation
- If not adequately breathing spontaneously, then manual assisted ventilation will be
needed for patients with:
o Apnea
o Inadequate spontaneous tidal volumes
o Excessive work of breathing
o Hypoxemia with poor ventilation
o Hypoventilation with hypercarbia

MANUAL ASSISTED VENTILATION (Bag/Mask)

*Try to minimize in COVID 19 patients due to virus aerosolization

Manual:
- Open airway
- Apply face mask and obtain seal
- Deliver adequate minute ventilation (see below)
- Monitor cardiac function and pulse oximetry
- Evaluate patient continuously

One-handed:
- Place base of mask over chin and open mouth
- Make sure nose is covered: apex of mask should be over nose
- Pull up on mandible to elevate it, extend neck (if no cervical spine
injury)
- Place downward pressure on mask to help obtain seal

Two-handed (assistant needed):

*Useful in patients with beard, short neck, or short mandible
- Place fingers along mandible on each side
- Extend neck slightly (if no cervical injury)
- Place downward pressure on mask to help obtain seal
Assistant ventilates

Keys in manual mask ventilation

- Bag compression rate: 10-12 breaths/minute (each over 1 second) if patient is apneic
but has a pulse. If pulseless 8-10 breaths/min.
- Tidal Volume: 4–8 ml/kg of predicted body weight for adults
Mask Leak:
- Identify leak, reposition mask or hands, change mask inflation or mask size, change to 2
handed technique, increased downward pressure while lifting face into mask, reposition
orogastric or nasogastric tube.

If these efforts fail, move to intubation…

INTUBATION

Indicators of need for intubation:

- Airway protection, relief of upper airway obstruction, need for mechanical ventilation to
improve oxygenation, respiratory failure, shock, hypoventilation (need to hyperventilate),
increased work of breathing or need to facilitate suctioning/pulmonary toilet (inability to
clear secretions).

Assess for potential difficulty of intubation:

- Limited neck mobility due to arthritis or injury
- Facial injury or small mouth opening
- Large tongue or short thyromental distance (<6 cm or 3 fingerbreadths). This is the
distance between the anterior prominence of the thyroid cartilage and top of mandible.
- Mallampati classification (higher class higher difficulty)

Preparation for Intubation:

- Optimal ventilation and oxygenation
- Gastric decompression: if OGT/NGT already in place there is high risk for aspiration
during preoxygenation bagging. Place tube to suction to empty gastric contents.
- Preparation of equipment
- Analgesia, sedation, amnesic agents, neuromuscular blockade as needed
- Cricoid pressure to improve visualization of the vocal cords
- Direct or video-assisted laryngoscope
- Laryngeal mask airway
- Use of bag-valve-mask ventilation until help arrives
Steps to Direct Laryngoscopy Intubation (simplified):
*Rapid sequence induction (amnestic and paralytic given simultaneously) is preferred in
COVID patients as it minimizes masked ventilation

1. Gather equipment: Laryngoscope (curved Macintosh type and straight miller type),
10 cc syringe, lubricant, tape, suction equipment. Make sure the light on laryngoscope
works. Check ETT cuff for leaks.
2. Position into “sniffing position” – be mindful of C-spine.

3. Hyper-oxygenate patient with 100% FiO2 for 2-5 minutes

4. Open patient’s mouth with right hand (scissor technique with fingers)
5. Grab laryngoscope with left hand
6. Spread patient’s lips, insert blade between teeth (careful of teeth).
7. Pass the blade to right of tongue and advance blade into hypopharynx, pushing tongue
to left
8. Lift laryngoscope UPWARD and FORWARD without changing angle of blade to
expose vocal cords. Cricoid pressure can be used here (lowers trachea to facilitate
tube passage)
9. Pass the tube with stylet through the vocal cords.
10. Withdraw the stylet.
11. Connect bag-valve mask and begin ventilation with 100% FiO2
12. Verify tube placement (minimize stethoscope use in COVID patients):
a. Auscultate chest (you should hear breath sounds on both sides. If you
only hear on 1 side, pull back a little bit).
b. Auscultate stomach (you shouldn’t hear gurgles with bagging)
13. Inflate the cuff (~7cc).
14. Secure the tube in place with tape.
*If difficulty with intubation, continue to ventilate manually with bag/mask until skilled person
arrives. Request surgical back up early in difficult intubations.

Drugs to Facilitate Intubation

Early Complications of intubation
- Hypertension and tachycardia (if paralyzed but not adequately sedated)
- Hypotension (differential includes positive intrathoracic pressure, hypovolemia,
myocardial ischemia, tension pneumothorax, auto-peep).
EMERGENCY SURGICAL AIRWAY

A Few Comments on Surgical Airways:

- From an ENT chief resident: Even in an emergency always invest 20 seconds to do 3
things:
o Identify someone to assist
o Place a shoulder roll to expose trachea
o Point a light source at the exposed trachea
- Cannula-based (AKA percutaneous) techniques have a far higher failure rate than
surgical techniques, which are successful greater than 90% of the time
- Emergency surgical airway access can be performed in under 60 seconds with just a
#20 scalpel on a handle, a Trousseau dilator or clamp, and an ETT over a Bougie
introducer

Overview of technique:
- Vertical skin incision between thyroid cartilage and cricoid cartilage. Then horizontal
cricothyroid membrane incision followed by dilation and placement of tracheostomy
tube

Video links:
- https://www.youtube.com/watch?v=4gNgiaXDZwI
- https://vimeo.com/132394747
- https://www.youtube.com/watch?v=wVQFJR7qmrQ
III. DIAGNOSIS AND MANAGEMENT OF ACUTE RESPIRATORY FAILURE

3 Forms of Acute Respiratory Failure:

1) Hypoxemic:
a. Room air PaO2 ≤ 60 mmHg (8 kPa)
b. Abnormal PaO2/FIO2 ratio
c. VQ Mismatch
d. Differential: ARDS, CHF, interstitial lung disease, pneumonia
e. CXR: Often with alveolar infiltrates
2) Hypercapnic
a. PaCO2 ≥ 50mmHg (6.7kPa) with pH<7.36
b. Decreased minute ventilation
c. Differential: TBI, neuromuscular disease (myasthenia gravis), Guillen
barre syndrome, over sedation, pulmonary embolus
d. CXR: Often with clear, hyperinflated lung fields
3) Mixed
a. COPD, severe CHF

Determinants of gas exchange:

- Oxygenation is affected by FIO2 and mean airway pressure
- Ventilation (CO2 exchange) is affected by: Minute ventilation (RR x
tidal volume)

Pharmacologic Interventions:
- Inhaled B2-agonists (promote bronchial dilation)
o Metered-dose inhaler
o Nebulizer
o Immediate onset
- Inhaled ipratropium (inhibits bronchoconstriction and mucus
secretion)
o Metered-dose inhaler
o Nebulizer
o 15–30 minute onset
- Corticosteroids (decrease inflammation)
- Antibiotics
IV. MECHANICAL VENTILATION (Non-invasive positive pressure ventilation -
NPPV).

*NPPV should generally be avoided in COVID 19 patients due to virus aerosolization that
occurs. At UCLA, NPPV is currently being limited to 2 hours or less. Guidelines are
subject to change.

What is NPPV?
- Respiratory support through some sort of mask device
- Oxygen given with positive pressure
- Types: face mask, nasal mask, oro-nasal masks, mouthpieces

Candidates for NPPV

- Respiratory condition expected to improve in 34-48 hours
- Alert, cooperative
- Hemodynamically stable
- Able to control airway secretions
- Able to coordinate ventilator
- Advantages include decreased need for sedation, decreased LOS,
improved survival, improved patient comfort. Disadvantages (labor
intensive to nurse and RT, gastric distension)

Goals for NPPV:

- Hypoxemic patient treated by increased Expiratory Positive Airway
Pressure (EPAP) and maintain difference between EPAP and IPAP.
- Suggested initial settings IPAP 10 cm H2O and EPAP 5 cm H2O and
these pressures can then be titrated by 2 cm H2O simultaneously until
clinical improvement
- Tidal volume improves with larger gradient between EPAP and IPAP
- Make changes every 15-30 minutes
- Titration should be based on clinical appearance, spO2, occasional
ABG.

IF NPPV FAILS, MOVE TO OROTRACHEAL INTUBATION AND

MECHANICAL VENTILATION
3 Modes of Mechanical Ventilation:

*Typical vent settings:

- Rate: 10-12 breaths per minute
- Tidal Volume: 6-8 ml/kg of predicted body weight
- Initial FiO2: 100%
- PEEP: Start at 5 cm H2O
- *Predicted body weight formula (Kilograms):
o Males: 50 + 2.3(height in inches – 60)
o Females: 45.5 + 2.3(height in inches – 60)

Assist-control (AC)
- Most commonly used vent mode
- Fixed tidal volume (volume AC) or fixed airway pressure (Pressure
AC)
- Minimum # of breaths is programmed
- Additional breaths triggered by patient will be given a full machine
breath

Pressure Support (PSV)

- Flow cycle ventilation
- Inspiratory flow continuous
- No set breath rate.
- Patient triggers every breath and therefore determines respiratory rate
and flow of gas for each breath

Synchronized intermittent mandatory (SIMV)

- Both tidal volume and rate are set
- Patient received specific #of breaths at a certain tidal volume
- Different from (AC) in that additional breaths not supported by
machine. This might require significantly increased work of breathing
by patient. Can add pressure support to this to reduce this work.
- Continuous positive pressure airway pressure (CPAP) - not a mode of
ventilation. Helps hold alveoli and airways open.
Airway Pressure/Flow Tracings:
Monitoring & Assessment of the Patient on Vent After Intubation:
- Chest X-Ray (Confirm ET placement and rule out pneumothorax)
- ABG (15-20 min after intubation)
- Vital signs (assess SpO2)
- Inspiratory pressures (<30-35 cm H2O)
- Inspiratory/Expiratory ratio (1:2, up to 1:4)
- Auto-PEEP (occurs with incomplete exhalation): worsens
oxygenation, hypotension. Reduce auto-PEEP by decreasing
respiratory rate, or decrease tidal volume, or increase gas flow rate

Clinical Template for Machine ventilation options:

- Mode (i.e assist control, volume)
- FIO2 (i.e 1.0)
- Tidal Volume
- Respiratory Rate
- PEEP (can start at 5 cm H2O)

Clinical Data available after starting mechanical ventilation:

- SpO2
- Blood gas (pH, PaO2, PCO2), usually 20 min after intubation
- PPeak (peak inspiratory pressure)
- PPlat (inspiratory plateau pressure). Maintain ≤30 cmH2O
- Auto-PEEP (preferred at 0 cm H2O). If elevated can decrease
ventilator rate
- Respiratory Rate

Clinical Pearl: I just intubated, now what?!

Remember your A’s:
- Adjust (vent settings)
- A temp probe/Air (Bair hugger)
- Antibiotics
- Another IV/A line?
- Acid (OG Tube)?

Acute Lung Injury/ARDS Management (Used for COVID Respiratory Failure):

- Hypoxemic respiratory failure
- Decreased lung compliance high airways pressures
- Lower tidal volume needed (4-8 mL/kg of ideal body weight)
- Maintain Pplat ≤ 30 cm H2O
- PEEP to improve oxygenation
- Permissive hypercapnia (pH as low as 7.2 acceptable)
- Prone positioning for >12 hours per day in patients with severe ARDS
recommended as well. Only can be performed with sufficient human
resources and expertise present
V. DIAGNOSIS AND MANAGEMENT OF SHOCK

Shock: any state during which tissues do not receive sufficient oxygen or perfusion
- Cardiogenic
- Hypovolemic (Hemorrhagic, non-hemorrhagic)
- Distributive (septic, adrenal crisis, anaphylactic, neurogenic)
- Obstructive (PE, cardiac tamponade, tension pneumothorax,
constrictive pericarditis)

Interventions for Managing Shock

*Initial therapy for all types of shock is IV fluids, EXCEPT for CARDIOGENIC
SHOCK. Mechanical ventilation might be needed. Vasodilators only used if blood
pressure is adequate or elevated in cardiogenic shock. Cannot use vasodilators if
patient is hypotensive in cardiogenic shock because BP will drop further.
Fluid Management pearls1:

- Typically start with normo-osmol fluid (NS or LR)

- Consider switch from NS to LR, except in neuro cases (because of
decreased osmolality) and hyperkalemic patients
- Be wary of using too much NS in hyperkalemic patients as the
hyperchloremic metabolic acidosis can increase serum potassium as
well
- Type and cross for pRBC and other blood products prior to surgery if
anticipation significant blood loss (i.e, trauma, coagulopathy)
- Consider that rapid volume resuscitation with only pRBC may still
create dilutional coagulopathy (if receiving >2 units pRBC, consider
FFP use)
- Septic shock:
o Start with 4L NS (careful about pulmonary edema) in first 6 hrs
o If BP remains low, use vasopressor (norepinephrine preferred in
septic shock. Dopamine can also be used, but causes tachycardia.
o Can add vasopressin as second agent
o Dobutamine/milrinone (used in septic shock with concerns for
cardiac output), but cannot be used in hypotensive patients
o Don’t forget antibiotics

“Classical” Fluid Management:

Maintenance fluids:
- 4-2-1 rule: 4 mg/kg/hr for first 10 kg. 2 ml/kg/hr for next 10-20 kg,
and 1 ml/kg/hr for each additional kg above 20 kg
o To simplify this rule, maintenance = 40 ml/hr + patient’s weight in
kilograms (100 kg patient = 140 ml/hr)

Preexisting Fluid deficits:

- Multiply maintenance requirement by # of hours NPO
- Give ½ over 1st hour, ¼ over 2nd hour, and ¼ over 3rd hour

Ongoing Losses:
- Evaporative and Interstitial Losses (capillary leak):
o Minimal tissue trauma (eg: hernia repair): 0-2 ml/kg/hr
o Moderate tissue trauma (eg: cholecystectomy): 2-4 ml/kg/hr
o Severe tissue trauma (eg: bowel resection): 4-8 ml/kg/hr
- Blood Loss:
o EBL = (suction cannister – irrigation) + laps (100-150 mL each) +
4x4 sponges (10 mL each) + field estimate (very approximate est)
o Replace with pRBC, colloid, or crystalloid
VI. COVID-19 SPECIFIC ICU AND MEDICAL CARE

General information:
- Patient requiring critical care usually older (60 years) with comorbid
conditions (diabetes & cardiac disease)
- Data from Wuhan showed that median duration between onset of
symptoms and ICU admission 9–10 days.
- Most documented reason for ICU care is that 2/3 of patients have
met criteria for acute respiratory distress syndrome (ARDS).2
- Majority of patient with COVID-19 present with fever as first
symptom.
- Most common laboratory abnormalities are leukopenia and
lymphopenia (2/2 to possible bone marrow suppression, lymphocyte
sequestration, or apoptosis).3,4
- Characteristic radiographic findings are ground glass opacities
(bilateral and peripheral), coexisting with consolidations or cord-like
opacities.3,5 Radiologic features rare with COVID-19 include
lymphadenopathy, nodules, pleural effusions, or cavitation.

Clinical Management of COVID Patients:

- Management of severe COVID-19 is largely similar to management
of viral pneumonia causing respiratory failure/ARDS. Diagram
below publish in JAMA 2020 by Murthy et al. highlights major
differences2.
Acute Lung Injury/ARDS Management
- Hypoxemic respiratory failure
- Decreased lung compliance high airways pressures
- Lower tidal volume needed (4-8 mL/kg of ideal body weight)
- Maintain Pplat ≤ 30 cm H2O
- PEEP to improve oxygenation
- Permissive hypercapnia (pH as low as 7.2 acceptable)
- Prone positioning for >12 hours per day in patients with severe ARDS
recommended as well. Only can be performed with sufficient human
resources and expertise present

Additional COVID-19 management points:

- Initial trial of high-flow nasal cannula appears reasonable
- Limit NPPV of high-flow nasal cannula to less than 2 hours if no
clinical improvement based on WHO guidelines6,7
- High-flow nasal cannula or NPPV is contraindicated in patients with
hemodynamic instability, multiorgan failure, or altered mental status
- Use any modality for preoxygenation for 5 min (non-rebreather mask,
bag valve mask, high flow nasal cannula, NPPV)
- Rapid sequence induction when possible to avoid coughing or need for
positive pressure breaths7,8
VII. CRITICAL CARE PROCEDURES

1) Central Line Placement: https://wish.washington.edu/cvc-emodules-uw

2) 9A-line Placement: https://www.youtube.com/watch?v=8hK04ai17-k

3) 10Femoral Line Placement: https://www.youtube.com/watch?v=ZUnIHbahP5I

4) Peripheral IV Placement: https://www.youtube.com/watch?v=qRWb9CJU0Yk

VIII. VENT SETTINGS AND CRITICAL CARE MODULES

1) https://sccm.org/covid19
2) https://www.youtube.com/watch?v=RHx-p5RFoaA
REFERENCES:

1. Adriano A, Skanchy J. 2018 CA-1 TUTORIAL TEXTBOOK 12th Edition. 2018.

2. Murthy S, Gomersall CD, Fowler RA. Care for Critically Ill Patients With COVID-19.
Jama. 2020:1-2. doi:10.1001/jama.2020.3633
3. Wang L, Ph D, London MJ. Special section: covid-19.
doi:10.1097/ALN.0000000000003303
4. Arentz M, Yim E, Klaff L, et al. Characteristics and Outcomes of 21 Critically Ill Patients
With COVID-19 in Washington State. Jama. 2020;4720:2019-2021.
doi:10.1001/jama.2020.4326
5. Zhu W, Wang Y, Xiao K, et al. Establishing and Managing a Temporary Coronavirus
Disease 2019 Specialty Hospital in Wuhan, China. Anesthesiology. 2020.
doi:10.1097/ALN.0000000000003299
6. Clinical WHO, Who W. World Health Organization. Clinical management of severe acute
respiratory infection when novel coronavirus (2019-nCoV) infection is suspected: interim
guidance. 2020:1-11.
7. Meng L, Qiu H, Wan L, et al. Intubation and Ventilation amid the COVID-19 Outbreak:
Wuhan’s Experience. Anesthesiology. 2020. doi:10.1097/ALN.0000000000003296
8. Zhang H-F, Bo L-L, Lin Y, et al. Response of Chinese Anesthesiologists to the COVID-
19 Outbreak. Anesthesiology. 2020. doi:10.1097/ALN.0000000000003300
9. Berrizbeitia LD. Placement of an arterial line [13]. N Engl J Med. 2006;355(3):324.
doi:10.1056/NEJMc061124
10. Tsui JY, Collins AB, White DW, Lai J, Tabas JA. Placement of a femoral venous catheter.
N Engl J Med. 2008;358(26). doi:10.1056/NEJMvcm0801006