Pre-hospital critical care management of severe hypoxemia in victims of Covid-19: a case series

Mæhlen, Jens Otto; Mikalsen, Roger; Heimdal, Hans Julius; Rehn, Marius; Hagemo, Jostein S.; Ottestad, William

OBJECTIVE: Despite critical hypoxemia, Covid-19 patients may present without proportional signs of respiratory distress. We report three patients with critical respiratory failure due to Covid-19, in which all presented with severe hypoxemia refractory to supplemental oxygen therapy. We discuss possible strategies for ventilatory support in the emergency pre-hospital setting, and point out some pitfalls regarding the management of these patients. Guidelines for pre-hospital care of critically ill Covid-19 patients cannot be established based on the current evidence base, and we have to apply our understanding of respiratory physiology and mechanics in order to optimize respiratory support. METHODS: Three cases with similar clinical presentation were identified within the Norwegian national helicopter emergency medical service (HEMS) system. The HEMS units are manned by a consultant anaesthesiologist. Patient’s next of kin and the Regional committee for medical and health research ethics approved the publication of this report. CONCLUSION: Patients with Covid-19 and severe hypoxemia may pose a considerable challenge for the pre-hospital emergency medical services. Intubation may be associated with a high risk of complications in these patients and should be carried out with diligence when considered necessary. The following interventions are worth considering in Covid-19 patients with refractory hypoxemia before proceeding to intubation. First, administering oxygen via a tight fitting BVM with an oxygen flow rate that exceeds the patient’s ventilatory minute volume. Second, applying continuous positive airway pressure, while simultaneously maintaining a high FiO(2). Finally, assuming the patient is cooperative, repositioning to prone position.