COVID-19 Screening Clinical Pathway — Emergency

Resuscitation During COVID-19 Pandemic

This Guidance is provided for patients who are suspected to be at risk for COVID-19 based on current guidance/epidemiology and who require resuscitation.

Continue to use the resuscitation room for all patients requiring resuscitation

Access to equipment, resources make this the best location for resuscitations
Follow typical guidelines for patient placement in the resuscitation room

Caveat

Patients who are being cared for in a room with respiratory distress that has deteriorated and require intubation, if hemodynamically stable, the team may decide to stay in the room to decrease likelihood of viral transmission associated with patient movement.

PPE Guidance
PPE without Aerosolizing Procedures	Modified Enhanced Precautions: mask + gown + gloves+ eye protection
PPE with Aerosolizing Procedures	Enhanced Precautions: PAPR + gown + single pair of gloves* OR N95 mask + face shield *Consider double gloves only for providers doing hands-on care in resuscitation with high risk of soiling PAPR Donning will take place in room 5.
PPE Monitors	PPE monitors should ideally be used for donning/doffing ED PPE Monitors should respond to room 5 to don staff. Page 77745 for IPC monitor to respond if needed.

Respiratory Support Guidance **AGP**
Routine Oral and Nasopharyngeal Suctioning	NOT aerosolizing procedures
Nebulized Medication	Aerosolizing procedure Avoid nebulized albuterol if it can be delivered via MDI
Deep Suctioning* (Suctioning below the glottis)	Aerosolizing procedure
High Flow Nasal Cannula	NOT an aerosolizing procedure
BVM Ventilation	Aerosolizing procedure Prefer use of self-inflating bag Ensure there is a HEPA filter between — bag and patient
Non-invasive Ventilation	Aerosolizing procedure Full face mask is recommended Aerosolized particle burden is decreased by placing patient on a ventilator circuit that allows filtration of exhaled gases before the gases go into the room (Hamilton, V500) In children with severe distress and significant need for respiratory support, consider endotracheal intubation early in the disease course instead of non-invasive ventilation to minimize aerosolization with increased exposure to caregivers
Endotracheal Intubation	The most experienced provider should perform the procedure to reduce intubation attempts Use Pre-oxygenation and apneic oxygenation via nasal cannula to decrease need for / duration of BVM prior to intubation If possible, avoid BVM ventilation prior to intubation during RSI Use BVM or self-inflating bags with attached HEPA filter Use typical RSI meds, aim for fast time to sedation and paralysis Avoid awake intubation Use a cuffed ETT Place patient on a ventilator that has appropriate HEPA filtration of exhaled gases as quickly as possible after intubation (Hamilton, V500, VDR) ETT suctioning is considered aerosolizing procedure unless inline suction is used; inline suctioning is available and should be put in place as soon as possible Encourage use of CMAC for intubation Video laryngoscopy offers benefit when PAPr used Have LMA available, place immediately if first attempt at intubation is unsuccessful
Patients with Tracheostomy Tubes	Place on ventilator with appropriate HEPA filtration of exhaled gases Replace trach with cuffed trach if patient’s home trach is uncuffed Suction using inline system whenever possible, to decrease aerosolization.

CPR Guidance
Precautions	All staff should use: Enhanced Precautions Consider early intubation to decrease aerosolization
Compressions	Providers performing compressions may require shorter compression duration due to PPE: Switch compression providers as soon as they begin to feel fatigued Initial response should include 2 providers to alternate task Add 3rd provider based on fatigue needs, prioritize staff already in room for this role
e-CPR	Will not be done for out-of-hospital arrests during the COVID pandemic It may be considered for KNOWN COVID-NEGATIVE patients or patients who do not warrant testing if they have a witnessed, in-ED arrest
US Guided IV Placement	Use long probe covers for all US uses May drape non-essential parts of the cart to decreased cleaning burden Change drapes between patients Use Oxivir^® wipes to clean US machine between patients Including screen and probe/cord
IO Drill	Wipe drill with Oxivir wipes after the resuscitation if it was opened in the room, even if it was not used
NOTE: The difficult airway cart, and glidescope will be kept in the BH area and can be pulled into the resuscitation bay if needed. Blood Refrigerator Remains in the bay If blood is needed while a COVID-suspected resuscitation is ongoing or during room downtime after a COVID-patient care event, staff can don Enhanced droplet/contact PPE to obtain blood, or O- blood can be requested from the blood bank to be delivered in a cooler to the room.

Staff Considerations

See pre-round resuscitation script for team preparation, composition and communication

Movement of patients from resuscitation room

See guidance on Movement of Suspected COVID Patients

Decontamination of the Resuscitation Room

For patients who did not require aerosolizing procedures

Normal cleaning process, room can be used again immediately after cleaning

For patients who required aerosolizing procedures

For Resuscitation Bay: A 15 minute downtime is then followed by cleaning of all bed spaces, after which room can be used again

For BH rooms: A 1 hour downtime is then followed by cleaning of all bed spaces, after which room can be used again used again

COVID Disease Course

Significant illness from COVID-19 has been VERY rare in children. Adult data available thus far shows ARDS and cytokine storm as the expected pathophysiology for those with severe illness.
For patients with suspected ARDS, gentle rehydration and protective vent settings is suggested.
Our PICU colleagues are a great resource for treatment strategies for patients remaining in the ED at this stage of care.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.