Due to shortage of PPE in this covid 19 crisis we have to priortize our use of PPEs. also precautions to be taken while handling covid 19 suspect/patient.

1. RATIONAL USE OF PPE
DURING COVID 19 OUTBREAK
DR. BHAGWATI PRASAD DEWANGAN
CONSULTANT ANAESTHESIOLOGIST
FOPJHRC, RAIGARH

2. What are PPEs ?
Personal Protective Equipments
(PPEs) are protective gears
designed to safeguard the health
of workers by minimizing the
exposure to a biological agent.

3. COMPONENTS OF PPE
Goggles
Face-shield
Mask
Gloves
Coverall/Gowns (With Or Without Aprons)
Head Cover And
Shoe Cover.

4. HAZMAT SUITS

7. GLOVES
Nitrile > latex
Sterile > Non-sterile
Powder free > powdered
Outer gloves preferably reach mid-forearm (minimum 280 mm total length)
Different sizes (6.5 &7)
Quality compliant with the below standards, or equivalent:
EU standard directive 93/42/EEC Class I, EN 455
EU standard directive 89/686/EEC Category Ill, EN 374 ANSI/SEA 105-2011
ASTM D6319-10

8. Change gloves when
• Heavily soiled
• Breach in continuity/ tear/ rupture
• After each patient

9. COVERALL > GOWNS
• Impermeable to blood and body fluids
• Single use
• Avoid culturally unacceptable colors e.g. black
• Light colors are preferable to better detect possible contamination
• Thumb/finger loops to anchor sleeves in place
• Quality compliant with following standard
a. Meets or exceeds ISO 16603 class 3 exposure pressure, or equivalent

10. GOGGLES
• With transparent glasses, zero power, well fitting, covered from all sides with elastic
band/or adjustable holder.
• Good seal with the skin of the face
• Flexible frame to easily fit all face contours without too much pressure
• Covers the eyes and the surrounding areas and accommodates for prescription glasses
• Fog and scratch resistant
• Adjustable band to secure firmly so as not to become loose during clinical activity

11. Cont.
• Indirect venting to reduce fogging
• May be re-usable (provided appropriate arrangements for decontamination are in
place) or disposable
• Quality compliant with the below standards, or equivalent:
a. EU standard directive 86/686/EEC, EN 166/2002
b. ANSI/SEA Z87.1-2010

12. MASKS
1. TRIPLE LAYERED MASKS
Three layered medical mask of non-woven material with nose piece, having filter efficiency of
99% for 3 micron particle size.
ISI specifications orequivalent
2. N 95 MASKS
• Shape that will not collapse easily
• High filtration efficiency
• Good breathability, with expiratory valve

13. Cont.
• Quality compliant with standards for medical N95 respirator:
a. NIOSHN95,EN149FFP2,orequivalent
• Fluid resistance: minimum 80 mmHg pressure based on
ASTM F1862, ISO 22609, or equivalent
• Quality compliant with standards for particulate respirator
that can be worn with full- face shield

14. FACE SHIELDS
Made of clear plastic and provides good visibility to both the wearer and the patient
Adjustable band to attach firmly around the head and fit snuggly against the forehead
Fog resistant (preferable)
Completely covers the sides and length of the face
May be re-usable (made of material which can be cleaned and disinfected) or disposable
Quality compliant with the below standards, or equivalent:
a. EU standard directive 86/686/EEC, EN 166/2002 b. ANSI/SEA Z87.1-2010

15. SHOE COVER AND HEAD COVER
1. SHOE COVERS
Shoe covers should be made up of impermeable fabric to be used over shoes to
facilitate personal protection and decontamination.
2. HEAD COVERS
Coveralls usually cover the head.
Those using gowns, should use a head cover that covers the head and neck while
providing clinical care for patients.
Hair and hair extensions should fit inside the head cover.

16. BODY BAGS
1) Impermeable
2) Leak proof
3) Air sealed
4) Double sealed
5) Disposable
6) Opaque
7) White
8) U shape with Zip
9) 4/6 grips
10) Size: 2.2 x 1.2 Mts
11) Standards:
a) ISO 16602:2007
b) ISO 16603:2004
c) IS016604:2004
d) ISO/DIS 22611:2003

17. All items to be supplied need to be accompanied with certificate of analysis from national/ international
organizations/labs indicating conformity to standards
All items: Expiry 5 years
* Due to scarcity of coveralls, and risk versus benefit, that as an emergency temporary measure in larger public
interest, in present given circumstances, the fabric that cleared/passed ‘Synthetic Blood Penetration
Resistance Test’ (ISO 16603) and the garment that passed ‘Resistance to penetration by biologically
contaminated solid particles (ISO 22612:2005) may be considered as the benchmark specification to
manufacture Coveralls.” The Coveralls should be taped at the seams to prevent fluid/droplets/aerosol entry.
The test for these two standards (ISO 16603 and ISO 22612:2005), which can be performed in Indian
laboratories are as per WHO Disease Commodity Package (Version 4.0)

18. RATIONAL USE OF PPE

26. KEY POINTS ABOUT
PPE• Don before contact with the patient, generally before entering the room
** drink water or go to toilet before donning PPE
• Use carefully – don’t spread contamination
• Remove and discard carefully, either at the doorway or immediately outside
patient room; remove respirator outside room
• Immediately perform hand hygiene

27. SEQUENCE FOR DONNING PPE
First pair of gloves*
Shoe cover
Gown
Mask or respirator
Face hood
Goggles or face shield *
Second pair of Gloves *
*Combination of PPE will affect sequence – be practical

28. HOW TO DON A GOWN
• Select appropriate type and size
• Opening is in the back
• Secure at neck and waist
• If gown is too small, use two gowns – Gown #1 ties in front –
Gown #2 ties in back

29. HOW TO DON A MASK
• Place over nose, mouth and chin
• Fit flexible nose piece over nose bridge
• Secure on head with ties or elastic
• Adjust to fit

30. HOW TO DON A PARTICULATE RESPIRATOR
• Select a fit tested respirator
• Place over nose, mouth and chin
• Fit flexible nose piece over nose bridge
• Secure on head with elastic
• Adjust to fit
• Perform a fit check –
– Inhale – respirator should collapse
– Exhale – check for leakage around face

31. HOW TO DON EYE AND FACE PROTECTION
• Position goggles over eyes and secure to the head using the ear pieces
or headband.
- Should fit snuggly over and around eyes.
• Position face shield over face and secure on brow with headband.
-Should cover forehead, extend below chin and wrap around side of face
• Adjust to fit comfortably

32. HOW TO DON GLOVES
• Don gloves last
• Select correct type and size
• Insert hands into gloves
• Extend gloves over isolation gown cuffs

33. HOW TO SAFELY REMOVE PPE

34. ‘CONTAMINATED’ AND ‘CLEAN’ AREAS OF PPE
• Contaminated – outside front
• Areas of PPE that have or are likely to have been in contact with body sites,
materials, or environmental surfaces where the infectious organism may reside
• Clean – inside, outside back, ties on head and back
• Areas of PPE that are not likely to have been in contact with the infectious
organism

35. WHERE TO REMOVE PPE
• At doorway, before leaving patient room or in anteroom*
• Remove respirator outside room, after door has been closed*
* Ensure that hand hygiene facilities are available at the point
needed, e.g., sink or alcohol-based hand rub
* If removal is in the anteroom, ask your assistant to open the
door of ward or icu or isolation room.

36. SEQUENCE FOR REMOVING PPE
Shoe cover
Outer Gloves
Face shield or goggles
hood
Gown
Inner gloves
Mask or respirator
*Its better to maintain hand hygiene during each step of removing PPE

37. HOW TO REMOVE GLOVES
How to Remove Gloves (1)
• Grasp outside edge near wrist
• Peel away from hand, turning glove inside-out
• Hold in opposite gloved hand
How to Remove Gloves (2)
• Slide ungloved finger under the wrist of the remaining glove
• Peel off from inside, creating a bag for both gloves •

38. HOW TO REMOVE GOGGLES AND FACE SHIELD
• Grasp ear or head pieces with ungloved hands
• Lift away from face
• Place in designated receptacle for reprocessing or disposal

39. HOW TO REMOVE ISOLATION GOWN / COVERALL
• Unfasten ties
• Peel gown away from neck and shoulder
• Turn contaminated outside toward the inside
• Fold or roll into a bundle
• Discard

40. HOW TO REMOVE MASK
1. REMOVING A MASK
• Untie the bottom, then top, tie
• Remove from face
• Discard
2. REMOVING A PARTICULATE RESPIRATOR
• Lift the bottom elastic over your head first
• Then lift off the top elastic
• Discard

41. HAND HYGIENE
• Perform hand hygiene immediately after removing PPE.
– If hands become visibly contaminated during PPE removal,
wash hands before continuing to remove PPE
• Wash hands with soap and water or use an alcohol-based
hand rub
* Ensure that hand hygiene facilities are available at the point
needed, e.g., sink or alcohol-based hand rub

42. WHEN TO SUSPECT ??
All symptomatic individuals who have undertaken international travel in the last 14 days or
All symptomatic contacts of laboratory confirmed cases or
All symptomatic healthcare personnel (HCP) or
All hospitalized patients with severe acute respiratory illness ( SARI) (fever AND cough and/or
shortness of breath)or
Asymptomatic direct and high risk contacts of a confirmed case (should be tested once between
day 5 and day 14 after contact)
***Symptomatic refers to fever/cough/shortness of breath.
***Direct and high-risk contacts include those who live in the same household with a confirmed
case and HCP who examined a confirmed case.

43. AT TRIAGE AREA
Give suspect patient a triple layer surgical mask and direct
patient to separate area, an isolation room if available.
Keep at least 1meter distance between suspected patients and
other patients.
Instruct all patients to cover nose and mouth during coughing or
sneezing with tissue or flexed elbow for others.
Perform hand hygiene after contact with respiratory secretions

44. DROPLET PRECAUTIONS
Droplet precautions prevent large droplet transmission of respiratory viruses.
Use a triple layer surgical mask if working within 1-2 metres of the patient.
Place patients in single rooms, or group together those with the same etiological diagnosis.
If an etiological diagnosis is not possible, group patients with similar clinical diagnosis and based on
epidemiological risk factors, with a spatial separation.
When providing care in close contact with a patient with respiratory symptoms (e.g. coughing or
sneezing), use eye protection (face-mask or goggles), because sprays of secretions may occur.
Limit patient movement within the institution and ensure that patients wear triple layer surgical masks
when outside their rooms

45. CONTACT PRECAUTIONS
Droplet and contact precautions prevent direct or indirect transmission from contact with
contaminated surfaces or equipment (i.e. contact with contaminated oxygen
tubing/interfaces).
Use PPE (triple layer surgical mask, eye protection, gloves and gown) when entering
room and remove PPE when leaving.
If possible, use either disposable or dedicated equipment (e.g. stethoscopes, blood
pressure cuffs and thermometers).
If equipment needs to be shared among patients, clean and disinfect between each
patient use.
Ensure that health care workers refrain from touching their eyes, nose, and mouth with
potentially contaminated gloved or ungloved hands.

46. Cont.
Avoid contaminating environmental surfaces that are not directly
related to patient care (e.g. door handles and light switches).
Ensure adequate room ventilation. Avoid movement of patients or
transport. Perform hand hygiene.
While auscultation, ask the patient to turn around and auscultate
in between scapula.
Don’t keep patient in emergency room for long time. Fast track to
isolation ward or ICU as required.

47. AEROSOL/ AIRBORNE PRECAUTIONS
Ensure that healthcare workers performing aerosol-generating procedures (i.e. open
suctioning of respiratory tract, intubation, bronchoscopy, cardiopulmonary resuscitation)
use PPE, including gloves, long-sleeved gowns, eye protection, and fit-tested particulate
respirators (N95). (The scheduled fit test should not be confused with user seal check
before each use.)
Whenever possible, use adequately ventilated single rooms when performing aerosol-
generating procedures, meaning negative pressure rooms with minimum of 12 air changes
per hour or at least 160 litres/second/patient in facilities with natural ventilation.
Avoid the presence of unnecessary individuals in the room.
Care for the patient in the same type of room after mechanical ventilation commences

48. INTUBATING A PATIENT
WITH COVID 19

49. WE ARE THIS CLOSE WHILE
INTUBATION

51. USE OF
VIDEOLARYNGOSCOPE

60. SAMPLE TAKING AND
TRANSPORTATION

68. TAKE HOME MESSAGES
Stay away from social media for a while- things that u should know u
already know.
Take good sleep – it helps boost your immunity.
Take Vit. C supplements- it is a natural immunity booster.
Take stairs instead of lift.
Don’t panic …… stay calm and take precautions.

69. THANK YOU