June 23/30, 2020 e933 Existing American Heart Association cardiopulmonary resuscitation (CPR) guidelines do not address the challenges of providing resuscitation in the setting of the coronavirus disease 2019 (COVID-19) global pandemic, wherein rescuers must continuously balance the immediate needs of the patients with their own safety. To address this gap, the American Heart Association, in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists, and with the support of the American Association of Critical Care Nurses and National Association of EMS Physicians, has compiled interim guidance to help rescuers treat individuals with cardiac arrest with suspected or confirmed COVID-19.Over the past 2 decades, there has been a steady improvement in survival after cardiac arrest occurring both inside and outside the hospital. 1 That success has relied on initiating proven resuscitation interventions such as high-quality chest compressions and defibrillation within seconds to minutes. The evolving and expanding outbreak of severe acute respiratory syndrome coronavirus 2 infections has created important challenges to such resuscitation efforts and requires potential modifications of established processes and practices. The challenge is to ensure that patients with or without COVID-19 who experience cardiac arrest get the best possible chance of survival without compromising the safety of rescuers, who will be needed to care for future patients. Complicating the emergency response to both out-of-hospital and in-hospital cardiac arrest is that COVID-19 is highly transmissible, particularly during resuscitation, and carries a high morbidity and mortality.Approximately 12% to 19% of COVID-positive patients require hospital admission, and 3% to 6% become critically ill. [2][3][4] Hypoxemic respiratory failure secondary to acute respiratory distress syndrome, myocardial injury, ventricular arrhythmias, and shock are common among critically ill patients and predispose them to cardiac arrest, [5][6][7][8] as do some of the proposed treatments such as hydroxychloroquine and azithromycin, which can prolong the QT. 9 With infections currently growing exponentially in the United States and internationally, the percentage of patients with cardiac arrests and COVID-19 is likely to increase.Healthcare workers are already the highest-risk profession for contracting the disease. 10 This risk is compounded by worldwide shortages of personal protective equipment (PPE). Resuscitations carry added risk to healthcare workers for many reasons. First, the administration of CPR involves performing numerous aerosol-generating procedures, including chest compressions, positive-pressure ventilation, and establishment of an advanced airway. During those procedures, viral particles can remain suspended in the air with a half-life of ≈1 hour and

More than 20 000 infants and children have a cardiac arrest per year in the United States. 1-4 In 2015, emergency medical service-documented out-of-hospital cardiac arrest (OHCA) occurred in more than 7000 infants and children. 4

Successful resuscitation from cardiac arrest results in a post–cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The components of post–cardiac arrest syndrome are brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathophysiology. Pediatric post–cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes. This scientific statement on post–cardiac arrest care is the result of a consensus process that included pediatric and adult emergency medicine, critical care, cardiac critical care, cardiology, neurology, and nursing specialists who analyzed the past 20 years of pediatric cardiac arrest, adult cardiac arrest, and pediatric critical illness peer-reviewed published literature. The statement summarizes the epidemiology, pathophysiology, management, and prognostication after return of sustained circulation after cardiac arrest, and it provides consensus on the current evidence supporting elements of pediatric post–cardiac arrest care.

Background Although extracorporeal CPR (E-CPR) can result in survival after failed conventional CPR (C-CPR), no large, systematic comparison of pediatric E-CPR versus continued C-CPR has been reported. Methods and Results Consecutive patients <18 years old with CPR events ≥ 10 minutes duration reported to GWTG-R between January 2000 and December 2011 were identified. Hospitals were grouped by teaching status and location. Primary outcome was survival to discharge. Regression modeling was performed conditioning on hospital groups. A secondary analysis was performed using propensity-score matching. Of 3,756 evaluable patients, 591 (16%) received E-CPR and 3,165 (84%) received C-CPR only. Survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category score of 1–3 or unchanged from admission) were greater for E-CPR [40% (237/591) and 27% (133/496)] versus C-CPR patients [27% (862/3,165) and 18% (512/2,840)]. Odds ratios for survival to hospital discharge and survival with favorable neurologic outcome were greater for E-CPR versus C-CPR. After adjusting for covariates, patients receiving E-CPR had higher odds of survival to discharge [OR 2.80, 95% CI 2.13–3.69, p <0.001] and survival with favorable neurologic outcome [OR 2.64, 95% CI 1.91–3.64, p < 0.001] than patient who received C-CPR. This association persisted when analyzed by propensity-score matched cohorts [OR 1.70, 95% CI 1.33–2.18, p < 0.001 and OR 1.78, 95% CI 1.31–2.41, p < 0.001 respectively]. Conclusions For children with in-hospital CPR ≥ 10 minutes duration, E-CPR was associated with improved survival to hospital discharge and survival with favorable neurologic outcome when compared to C-CPR.

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