Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19

Abstract

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

Critical Care During the Coronavirus Crisis: Challenges and Considerations for the Cardiothoracic and Vascular Anesthesia Community

“…8;13 In the event of cardiac arrest, the conduct of advanced life support in adults, children and neonates can be challenging and requires significant adjustments. [17][18][19] From the trainee perspective, the following issues have been raised in this clinical setting: safety of the institutional protocols; clarification of risk factors for mortality to guide risk-stratification;…”

“…planning and procedures to withhold this resuscitation from patients in accordance with their wishes; and, finally, additional national guidance about these issues. [18][19] As a response to this call for a national conversation, the American Heart Association has recently updated its guidelines for basic and advanced life support in light of COVID-19. 18 This multisociety guideline has recommended multiple adjustments to the protocols for cardiopulmonary resuscitation in 3 major categories as follows: firstly, minimize provider exposure; secondly, emphasize airway and ventilation strategies to minimize aerosolization risk; and, thirdly, consider the appropriateness of resuscitation.…”

“…[18][19] As a response to this call for a national conversation, the American Heart Association has recently updated its guidelines for basic and advanced life support in light of COVID-19. 18 This multisociety guideline has recommended multiple adjustments to the protocols for cardiopulmonary resuscitation in 3 major categories as follows: firstly, minimize provider exposure; secondly, emphasize airway and ventilation strategies to minimize aerosolization risk; and, thirdly, consider the appropriateness of resuscitation. [18][19] In the first group of considerations about exposure control, this guideline has recommended clear and comprehensive communication, protocols for limiting personnel, meticulous utilization of personal protective equipment, and consideration of mechanical devices for chest compressions.…”

“…18 This multisociety guideline has recommended multiple adjustments to the protocols for cardiopulmonary resuscitation in 3 major categories as follows: firstly, minimize provider exposure; secondly, emphasize airway and ventilation strategies to minimize aerosolization risk; and, thirdly, consider the appropriateness of resuscitation. [18][19] In the first group of considerations about exposure control, this guideline has recommended clear and comprehensive communication, protocols for limiting personnel, meticulous utilization of personal protective equipment, and consideration of mechanical devices for chest compressions. 18 In the second group of considerations about control of aerosolization, the guideline has recommended airway filters, lower thresholds for endotracheal intubation, videolaryngoscopy, experienced operators, limiting of bag-and-mask ventilation, and minimizing disconnects of the closed circuit components.…”

“…[18][19] In the first group of considerations about exposure control, this guideline has recommended clear and comprehensive communication, protocols for limiting personnel, meticulous utilization of personal protective equipment, and consideration of mechanical devices for chest compressions. 18 In the second group of considerations about control of aerosolization, the guideline has recommended airway filters, lower thresholds for endotracheal intubation, videolaryngoscopy, experienced operators, limiting of bag-and-mask ventilation, and minimizing disconnects of the closed circuit components. 18 In the third group of considerations about appropriateness of resuscitation, the expert consensus has recommended that the goals of care be addressed wherever possible, including institutional indications for cardiopulmonary resuscitation in COVID-19.…”