Editors’ Note: This article was accepted on April 6, 2020, and was accurate at that time. Because information about SARS-CoV-2 and COVID-19 is evolving rapidly, please verify these recommendations and information.

Here, we will itemize the process that was implemented in our emergency department for high-risk intubations of patients suspected of having SARS-CoV-2, the virus that causes COVID-19. The principal factors in establishing a formal protocol focused on limiting exposure of health care workers and minimizing unnecessary personal protective equipment (PPE) utilization. The major adaptation is the construction and implementation of a protective intubation box in an attempt to reduce circulated viral aerosolized particles during the intubation process.

PPE

Once it is established that the patient will be intubated, the most experienced physician, registered nurse, and respiratory therapist proceed to don PPE. They proceed in this order: small shoe covers, white coverall zip-up suit if available, boot covers, one set of gloves, Tyvek gown, second set of gloves, N95, bouffant cap, neck cover, and face shield (this may be substituted for a hood). Once PPE is in place, they proceed into a negative pressure room with all necessary medications and equipment for the procedure. This should include post-intubation sedation and pain medications.

Setup

Figure 1 (LEFT): Simulated COVID-19 patient covered by protective intubation box.

Ideally, each individual involved with the intubation should have a counterpart of their discipline outside the room as backup. Place the intubation box over the patient prior to the patient moving to a negative pressure room if they are not already there to decrease viral spread (see Figure 1). Intubation tools may be placed next to the patient’s head prior to placing the protective intubation box or placed through the access hole at the cephalad portion of the box. Necessary tools include: large forceps with protective cover over teeth to clamp the endotracheal tube after confirmed placement, endotracheal tube and stylet with 10-cc syringe attached, and video laryngoscope.