Posted on 04/09/2020

DALLAS, TX -- With COVID-19 incidence currently increasing exponentially worldwide, the percentage of cardiac arrests with COVID-19 are also likely to increase. The evolving and expanding outbreak of COVID-19 cases creates challenges around resuscitation efforts and requires potential modifications of established processes and practices.

The American Heart Association has compiled interim CPR guidelines to help rescuers treat victims of cardiac arrest with suspected or confirmed COVID-19.

The Association, in collaboration with the American Academy of Pediatrics, American Society of Anesthesiologists, American Association of Respiratory Care, The Society of Critical Care Anesthesiologists and American College of Emergency Physicians, published “Interim Guidance for Basic and Advanced Life Support in Adults, Children and Neonates with Suspected or Confirmed COVID-19,” in its flagship journal, Circulation today.

The goal is to ensure that patients with or without COVID-19 who experience cardiac arrest have the best possible chance of survival without compromising the safety of rescuers.

“CPR remains a critical component of care for many of our patients, particularly during this pandemic, but it does place rescuers at increased risk of COVID-19 exposure,” said Dana P. Edelson, MD, MS, executive medical director of Rescue Care at the University of Chicago and corresponding author of the volunteer writing group. “This guidance draws on evolving science and expert opinion to help health systems and providers mitigate that risk with the hopes of maintaining the survival gains for cardiac arrest achieved over the past two decades.”

Principles for resuscitation in suspected and confirmed COVID-19 patients provided in the statement include:

  • Reducing provider exposure to COVID-19. Limit personnel in the room or on the scene to only those essential for patient care.
  • Prioritizing oxygenation and ventilation strategies with lower aerosolization risk. Emphasis has been placed on the use of HEPA filters for all ventilation and early and successful intubation with mechanical intubation to minimize the airborne spread of the virus.
  • Considering the appropriateness of starting and continuing resuscitation. Health care systems and EMS agencies should institute policies to guide front-line providers in determining the appropriateness of starting and terminating CPR for patients with COVID-19, taking into account patient risk factors to estimate the likelihood of survival.
  • Continuing to encourage bystander CPR and defibrillation, for those willing and able, especially if they are household members who have already been exposed to the victim at home. For out-of-home cardiac arrests, a face mask or cloth covering the mouth and nose of the rescuer and/or victim may reduce the risk of transmission to a bystander during Hands-Only CPR.

Supporting organizations for the statement include the American Association of Critical-Care Nurses and the National Association of EMS Physicians.

Out-of-Hospital Cardiac Arrest

Below are specific considerations for cardiac arrest in victims with suspected or confirmed COVID-19 occurring outside of the hospital. Depending on local prevalence of disease and evidence of community spread, it may be reasonable to suspect COVID-19 in all out-of-hospital cardiac arrests (OHCA), by default.

Lay rescuers

Bystander CPR has consistently been shown to improve the likelihood of survival from OHCA, which decreases with every minute that CPR and defibrillation are delayed. Rescuers in the community are unlikely to have access to adequate PPE and, therefore, are at increased risk of exposure to COVID-19 during CPR, compared to healthcare providers with adequate PPE. Rescuers with increasing age and the presence of comorbid conditions, such as heart disease, diabetes, hypertension, and chronic lung disease, are at increased risk of becoming critically ill if infected with SARS-CoV2.

However, when the cardiac arrest occurs at home (as has been reported in 70% of OHCAs before the recent wide-spread shelter-at-home ordinances) lay rescuers are likely to already have been exposed to COVID-19.

Chest compressions

  • For adults: Lay rescuers should perform at least hands-only CPR after recognition of a cardiac arrest event, if willing and able, especially if they are household members who have been exposed to the victim at home. A face mask or cloth covering the mouth and nose of the rescuer and/or victim may reduce the risk of transmission to a non-household bystander.
  • For children: Lay rescuers should perform chest compressions and consider mouth-to-mouth ventilation, if willing and able, given the higher incidence of respiratory arrest in children, especially if they are household members who have been exposed to the victim at home. A face mask or cloth covering the mouth and nose of the rescuer and/or victim may reduce the risk of transmission to a non-household bystander if unable or unwilling to perform mouth-to-mouth ventilation.

Public access defibrillation

Because defibrillation is not expected to be a highly aerosolizing procedure, lay rescuers should use an automated external defibrillator, if available, to assess and treat victims of OHCA.

EMS

Telecommunications (Dispatch)

Telecommunicators, consistent with local protocols, should screen all calls for COVID-19 symptoms (e.g., fever, cough, shortness of breath) or known COVID-19 infection in the victim or any recent contacts, including any household members.

For lay rescuers, telecommunicators should provide guidance about risk of exposure to COVID-19 for rescuers and instructions for compression-only CPR, as above. For EMS, telecommunicators should alert dispatched EMS teams to don PPE if there is any suspicion for COVID-19 infection.

Transport

  • Family members and other contacts of patients with suspected or confirmed COVID-19 should not ride in the transport vehicle.
  • If return of spontaneous circulation (ROSC) has not been achieved after appropriate resuscitation efforts in the field, consider not transferring to hospital given the low likelihood of survival for the patient, balanced against the added risk of additional exposure to prehospital and hospital providers.

Excerpt downloaded from http://ahajournals.org on April 9, 2020

SOURCE: American Heart Association