There is no single strategy recommended for management of severe ARDS. Many interventions are due to resource constraints within austere environments. If unfamiliar with these techniques, obtain teleconsultation guidance.
Consider systemic corticosteroids in the treatment of COVID-19 related moderate to severe Acute Respiratory Distress Syndrome (ARDS). Discuss with advanced provider via telehealth prior to initiating treatment.
IV acetaminophen 1000mg every 6 hours (or PO/PR 975mg every 6 hours) as needed for temperature over 38degC (100.4 degF)
Fixed rate vasopressin infusion (0.04 units/min) is useful as an early adjunct in non-cardiogenic shock; may start vasopressin when norepinephrine reaches doses above 12mcg/min. Epinephrine is the second line titratable pressor.
Better (Above +):
Best (Above +):
Coagulopathy with mild thrombocytopenia, increased D-dimer levels (strongly associated with greater risk of death), increased fibrin degradation products, and prolonged prothrombin time
Note: Hypotension out of proportion to sedation and PEEP indicates further need of evaluation into causes of shock. Development of jugular venous distension and cool mottled extremities may indicate cardiogenic shock. Limited transthoracic echocardiography may be useful in discriminating between hypovolemic, cardiogenic, & distributive shock (in personnel trained to perform the assessment).
Contact: Spreads via direct contact with an infected patient or contaminated surface. Contact precautions reduce method of transmission.
Note: Covid-19 may survive on surfaces for 96 hours or longer. Decontaminate surfaces frequently using a diluted bleach solution by mixing 5 tablespoons (1/3 cup) bleach per gallon of water. Clean and disinfect high-touch surfaces frequently medical such as equipment, floors, tables, hard-backed chairs, doorknobs, light switches, phones, tablets, touch screens, keyboards, handles, desks, toilets, sinks. If a separate, designated bathroom is not available, bathrooms should be cleaned and disinfected after each use by personnel wearing best possible PPE, and waste considered hazardous, disposed according to theater hazardous waste policy.
Droplet: Spreads via relatively large liquid particles that settle from the air quickly (within a few feet). Droplet precautions reduce transmission.
Airborne: Spreads of via small liquid particles (aerosols) that remain suspended in the air for prolonged periods of time, traveling longer distances. Airborne precautions reduce transmission.
Note: Upon evacuation team arrival to receive the patient, handoff report should be repeated with key elements above, including any recent patient changes.
Warning: Transition to the evacuation team equipment presents risk of exposure to healthcare team. To reduce risk: Personnel should be limited to those directly involved in the care of the patient. Best available PPE should be worn by everyone involved in the care transition.
Use COVID-19 H&P and associated forms. Document COVID-19 status (PUI vs confirmed), vital signs, exam findings, and monitoring trends or changes, medication regimen including antibiotics, anticoagulants, sedation, analgesia, paralysis, and vasopressors), PPE status, oxygen requirements, and ventilator settings
Equipment must be decontaminated before sharing between patients & according to manufacturer recommendations.