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Learn more about Clinical Skills today! Standardize education and management competency among nurses, therapists and other health professionals to ensure knowledge and skills are current and reflect best practices and the latest clinical guidelines.
Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.
Refer to the American Heart Association (AHA) interim guidelines for resuscitation of the patient with coronavirus 2019 (COVID-19) or a person under investigation (PUI) (Box 1).10
Because neuromuscular blocking agents (NMBAs) can cause respiratory arrest, health care team members skilled in intubation must be present and ready at the bedside before the medication is administered. Ensure that an alternative airway is immediately available in case intubation fails.
A personal or family history of malignant hyperthermia is an absolute contraindication to succinylcholine.7 Relative contraindications include conditions that increase the risk of succinylcholine-induced hyperkalemia (e.g., hyperkalemia; myopathies or neuromuscular disorders; or burns, crush injuries, or severe infections that are more than 5 days old).7
Take steps to eliminate interruptions and distractions during medication preparation.
This skill is performed by health care professionals with additional knowledge, skills, and demonstrated competence, and in accordance with the professional’s regulatory scope of practice and the organization’s practice.
NMBAs (also called paralytics) are the foundation of emergency airway management. They allow placement of the oral endotracheal (ET) tube while minimizing potential complications, such as aspiration. There are two classes of NMBAs.
Drug Assisted Intubation (DAI) is performed for these purposes:
If the patient expresses concern regarding the accuracy of a medication, the medication should not be given. The concern should be explored, the intubator notified, and the order verified.
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Noninvasive positive pressure ventilation (NIPPV) such as bag-mask ventilation or bilevel positive pressure ventilation (BiPAP) should be avoided as much as possible to prevent aerosolization in patients with a known or suspected airborne transmitted infectious illness.
For patients with a known or suspected airborne transmitted infectious illness, preoxygenation should be initiated using nonaerosol generating approaches such as: elevating the head of the bed, airway maneuvers, and positive end expiratory pressure (PEEP) valves.
Oxygen delivery devices providing 6 L or more of oxygen per minute (e.g., high-flow nasal cannula) are considered high flow and should be avoided as much as possible to prevent aerosolization in patients with a known or suspected airborne transmitted infectious illness. If a high-flow nasal cannula must be used for preoxygenation, a surgical mask can be placed on the patient over the device.
Do not use any medication that is cloudy or precipitated unless such is indicated by its manufacturer as being safe; this may lead to harmful reactions.
The induction agent should always be administered before the NMBA.
Rationale: This maneuver can allow a better view of the glottis.
The routine use of cricoid pressure (Sellick maneuver) for DAI or during cardiac arrest is not recommended.
3,5 Cricoid pressure (Sellick maneuver) can worsen the laryngoscopic view.
For patients with a known or suspected airborne transmitted infectious illness, video laryngoscopy is preferred over direct laryngoscopy to increase the distance between the patient and the intubator.
For patients with a known or suspected airborne transmitted infectious illness, the cuff should be inflated right after the ET tube is placed. The ET tube should then be connected to the ventilator via high-efficiency particulate air (HEPA) filter and capnography waveform device. Ventilations should start upon confirmation of ET tube cuff inflation. ET tube placement should be initially verified by capnography waveform, followed by five-point auscultation.
For patients with a known or suspected airborne transmitted infectious illness, gentle ventilations with a supraglottic airway (e.g., laryngeal mask airway) has been recommended as an option for preoxygenation in place of bag-mask ventilation to decrease the need for additional manpower and to reduce exposure. Currently, there is no concrete evidence to support this practice.
Rationale: The AHA recommends continuous waveform capnography in addition to clinical assessment to monitor tube placement.
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