Protected Code Blue for SARS Patients (revised June 5, 2003)

1. Protected Code Blue for SARS Patients(revised June 5, 2003) Provincial SARS Biohazard Education Team Laurie Mazurik, MD, FRCPC (Emergency Medicine) Randy Wax, MD, FRCPC (Critical Care) Yousouf Peerbaye, MD, FRCPC (Emergency Medicine) Mark Castle, ACP/CRBN Vagia Tsiaousidis Campbell, RRCP Mary Dawson, RRCP John Traill, RRCP For more information or feedback: e-mail: randy.wax@utoronto.ca Note: This material is provided for the education of health care providers caring for patients with SARS. This is a work in progress. Clinicians should review this material and use their own clinical judgment to determine whether the suggestions made apply to their patients. If you have any comments about this material, please let us know!

2. What is a “Protected Code Blue”? • Acute life-saving intervention required (cardiac arrest, intubation) AND • Patient with probable or suspect SARS, or patient under investigation for SARS • Adjunct personal protective equipment (Stryker, PAPR) recommended due to cases of SARS transmission despite N95/gown/gloves/face shield during high-risk procedures

3. What are “high-risk” procedures in SARS patients? • Intubation • Cardiac arrest (includes intubation) • Bronchoscopy Risk unclear but reasonable to consider adjunct protective equipment--examples • Tracheostomy • Chest tube insertion • Major surgical procedures

4. General themes • Avoid high-risk situations • Early ICU transfer when deteriorating, if FiO2 > 0.5 • Consider early intubation when tiring (e.g., respiratory rate > 35-40, signs of respiratory distress even though ABGs and O2 sats not horrible) • Note: Some patients with SARS have required high FiO2 via face mask, had RR in 30s but improved without intubation. Clinical judgment required. Consult SARS Critical Care expert for advice if unsure.

5. General themes • Avoid high-risk situations • No CPAP/BiPAP • Avoid bronchoscopy • Avoid high frequency oscillation • Use high-flow non-humidified O2 face mask with filter on exhalation port (e.g, HiOX)

6. General themes • Minimize number of personnel exposed to high-risk situation • Minimize time exposed to high-risk location • Redundant safety measures • Layers of protection include N95 mask and adjunct equipment (e.g., PAPR hoods or Stryker) • Extensive simulation training in advance so that all members of team prepared

7. General themes • Must develop hospital policy/procedure for Protected Code Blue • Must have protocol in place for activating Protected Code Blue • Overhead announcement • Paging system • NOTE: Usually cannot rely on Code Blue buttons, as locating/communications cannot determine need for “Protected” Code Blue

8. General themes • All members of Protected Code Blue team should have qualitative mask fit testing to ensure good seal with their N95 masks • High-risk procedures should be performed by most experienced person available, must be competent in rapid sequence intubation • Staff anaesthetist • Staff intensivist • Staff emergency physician

9. General themes • PCB Team Members • Airway expert MD • ICU or ED RN • RT • 4th person capable of performing ACLS interventions • Personal protection “coach” • Non-PCB member who is trained to assist with donning and removal of adjunct equipment and room entry/exit procedures • Use checklist to ensure all steps followed

10. General themes • Consider placing a speakerphone or intercom in SARS patient rooms to allow resuscitation team to communicate with personnel outside room (e.g., two-way baby monitor) • Chest auscultation can be performed using an electronic stethoscope with external speaker/amplifier (e.g., Cardionics)

11. Intubation equipment • Have all equipment needed in room • SARS intubation kit • SARS drug kit • Manual bag resuscitator with filter • Filter may be placed between ETT and bag or on exhalation port of bag depending on make/model • Ventilator (if in ICU or ED) • In-line suction unit • Oxygen saturation monitor • Cardiac monitor • BP monitoring (NIBP or manual)

12. Intubation equipment • Have additional equipment on standby outside room • Cardiac arrest cart • Difficult airway cart

13. Laryngoscope handle Macintosh and Miller 3 and 4 blades Magill forceps Stylette Oral airways #8, #9, #10 Endotracheal tubes 6.0, 7.5, 8.0, 8.5 Scalpel Bougie Lubricating gel Scissors Yankeur suction tip Pink tape Disposable CO2 detector Esophageal detection device In-line suction catheter 10 cc syringe SARS Intubation Kit—Airway equipment (an example)

14. Midazolam 5mg/ml x 2 vials Succinylcholine 1 vial (expires after 14 days at room temperature) Rocuronium 2 vials (expires after 60 days at room temperature) Atropine 1 mg prefilled amps x 2 Epinephrine 1 mg prefilled amps x 2 Phenylephrine 1 amp + 100 mL bag of D5W for mixing 20 ml syringe 10 ml syringe x 3 5 ml syringe x 3 Needles and labels SARS Drug Kit(an example)

15. Protective equipment • All personnel in immediate area of procedure outside room must wear: • New N95 or N100 mask • Double gown • Full face visor/shield • Double gloves • Cap/bouffant • Consider disposable Tyvek hood • All personnel entering room must wear additional adjunct protective equipment—examples: • 3M AirMate PAPR hood • Stryker Personal Protection System

16. Role of “First responder” • First person to realize that patient needs immediate intervention to prevent death • Will be wearing standard SARS personal protection equipment but usually no adjunct equipment • Should not perform high-risk procedures or be present in room when high-risk procedures take place • Must leave room as soon as first person in adjunct protection equipment arrives

17. Role of “First responder” • First responder should not start bag ventilation, mouth-to-mask ventilation or mouth-to-mouth ventilation • HiOx high-flow O2 mask with exhalation filter to be placed on patient (if no respiratory effort/no pulse and HiOx unavailable, can put N95 mask on patient) • First responder can perform chest compressions if no pulse

18. Protected Code Blue in SARS Patients—First Responder First Responder calls Protected Code Blue Apply HiOx mask with exhalation filter Check pulse If no pulse, start chest compressions If pulse present, wait at doorway for first PCB team member to arrive Give report Leave room

19. Is it safe to perform chest compressions wearing standard SARS protection gear? • Has not been tested BUT • Unlikely that chest compressions would generate more droplets or aerosolization than spontaneously breathing/coughing patient • Double filter barrier between patient and health care worker before starting chest compressions • HiOx exhalation filter or N95 mask on patient • N95 mask on health care worker

20. Protected Code Blue algorithms • Two typical scenarios: • Patient has rapid respiratory deterioration and requires immediate intubation • Patient develops cardiac arrest due to respiratory or non-respiratory cause • Other scenarios where use of adjunct protective gear may be considered…example: • Cardioversion for rapid atrial fibrillation • Might become apneic due to sedation • Potential scenarios that might not require adjunct protective gear • Isolated hemodynamic instability requiring placement of central line, starting vasoactive agents

21. Patients with SARS in Respiratory Failure—PCB Team PCB#1 arrives Bring cardiac monitor and pulse oximeter into room Take report, send First Responder out Verify HiOx mask with exhalation filter in place, confirm pulse present PCB#2 arrives Bring SARS intubation/drug kits into room Attach cardiac monitor/pulse oximeter Prepare BVM with exhalation filter and intubation equipment If respiratory arrest occurs before designated intubator arrives initiate 2-person bagging PCB#3 arrives If designated intubator is now present, proceed with rapid sequence intubation Otherwise, PCB#3 to prepare drugs for intubation, initiate 2-person bagging if respiratory arrest occurs PCB#4 arrives Enter if PCB#4 is designated intubator Otherwise wait outside for direction from Team Leader

22. Patients with SARS in Respiratory Failure—PCB Team Notes FIRST RESPONDER should call for Protected Code Blue, and while waiting, place HiOx mask with exhalation filter on patient and check pulse; once complete, wait at doorway. • PCB TEAM • Non-team staff assist PCB team in donning equipment. • Controlled intubation requires at least 3 people. Skilled intubator may not arrive first, so team may have to wait. Even if intubator arrives, must wait for at least 3 team members. • Avoid manual bag ventilation unless apneic or impending respiratory collapse. Pre-oxygenation of spontaneously breathing patient followed by rapid sequence intubation preferred. • Roles: • Skilled intubator (experienced with rapid-sequence intubation) • Intubation assistant • Drug Administration • 4th person to assist as directed or wait outside room with additional equipment (e.g., cardiac arrest cart)

23. Intubation protocol: an example • Pre-oxygenate with HiOx mask • Have manual bag resuscitator with filter of exhaled gas available • Cricoid pressure by assistant • Atropine 0.6 mg IV push • Midazolam (Versed) 5 mg IV push • Succinylcholine 1.5 mg/kg IV push • Intubate once respiratory effort stops • Verify placement of tube with “end-of-bed” observation, disposable CO2 detector, esophageal detector device, electronic stethoscope with external speaker

24. Non-intubated Patients with SARS: Vital Signs AbsentPCB Team PCB#1 arrives Bring cardiac monitor and pulse oximeter into room Verify HiOx mask with exhalation filter in place Attach cardiac monitor/defibrillator Take over chest compressions, Get report, Send First Responder out of room Deliver up to 3 shocks for VF/ pulseless VT Consider immediate discontinuation of resuscitation if unwitnessed asystolic arrest PCB#2 arrives Bring SARS intubation/drug kits into room IV access, epinephrine, look for cause Consider needle decompression if signs of pneumothorax (PEA rhythm, subcut emphysema) PCB#3 arrives If designated intubator is now present, prepare intubation equipment and proceed with intubation If designated intubator not present, prepare BVM/filter and initiate 2-person bagging Provide other ACLS support as appropriate Observe for signs of pneumothorax (difficult to bag, asymmetric breath sounds) and decompress if suspected PCB#4 arrives Enter if PCB#4 is designated intubator Otherwise wait outside for direction from Team Leader

25. Non-intubated Patients with SARS in VSA Arrest Notes FIRST RESPONDERshould call for Protected Code Blue, and while waiting, place HiOx mask on patient, and initiate chest compressions if pulse absent • PCB TEAM • Non-team staff assist PCB team in donning equipment. • Safe initiation of bag ventilation and/or intubation requires at least 3 people. The patient should be intubated immediately once skilled intubator arrives. Only provide manual bag ventilation if skilled intubator not available. Literature supports adequacy of chest compressions without ventilation until full ACLS team available (N Engl J Med 2000;342:1546-1553). • Given low likelihood of survival from unwitnessed asystolic arrest, risk to PCB team likely outweighs miniscule chance for successful resuscitation (CMAJ 2002 Aug 20;167(4):343-8). Must verify asystole in multiple leads and confirm no monitor equipment failure. Resuscitation terminated by order of physician or by standing order approved by hospital policy. • Roles: • Skilled intubator (experienced with rapid-sequence intubation) • Intubation assistant • Drug Administration • 4th person to assist (e.g, bringing in cardiac arrest cart) or wait outside room as directed

26. Always consider pneumothorax! • Pneumothorax is a common complication of SARS • Suspect pneumothorax if: • Asymmetric breath sounds • Difficult to bag • Pulseless electrical activity • Consider bilateral needle thoracostomies if pulseless electrical activity arrest and no other explanation

27. Post-resuscitation issues • NOTE: Any room where a high-risk procedure takes place should be considered a “hot zone” for 2 hours post-procedure…all personnel entering the room should wear adjunct protective equipment • Personnel transporting patient to another location do not require adjunct gear but do require usual SARS personal protection (N95 mask/double gown/double glove/face visor or shield) • Adjunct gear used in the room should be removed prior to transport to avoid contamination of other locations

28. Preparation for transport • Tape connections between ETT and manual bag resuscitator or transport ventilator to prevent accidental disconnect • Exhaled gas must be filtered • If not intubated, place on HiOx mask with exhalation filter • Consider placing clear plastic sheet or tarp over patient to reduce any droplet spread during transport • Heavy sedation +/- paralysis for transport

29. Transport of patients • Security should clear corridors of staff and visitors • Consider using dedicated SARS elevator for patient transport • Any staff in vicinity must be wearing usual SARS personal protective gear • Patient room and elevator must be decontaminated