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APRIL 17, 2020 -- The American Heart Association (AHA) and seven other medical societies have issued interim guidance to inform treatment of victims of cardiac arrest with suspected or confirmed COVID-19, focusing on reducing provider exposure, and prioritizing oxygenation and ventilation strategies, goals of care, and appropriateness of resuscitation.
"We were very specific in calling this 'interim guidance' based on expert opinion because things are evolving so quickly and we are learning more and more every day as more and more patients with COVID-19 are taken care of," corresponding author Comilla Sasson, MD, PhD, vice president, Emergency Cardiovascular Care (ECC) Science and Innovation, American Heart Association, told theheart.org | Medscape Cardiology.
"We wanted this to be a starting point for providing the clinical guidance that everyone is looking for and, as we collect more data, the guidance will change, as it has for CDC [Centers for Disease Control and Prevention] and WHO [World Health Organization]," she said
"The guidance sought to balance the provision of timely, high-quality resuscitation to patients while simultaneously protecting rescuers," she added.
The guidance was published online April 9 in Circulation. The AHA produced the guidelines 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 the American Society of Anesthesiologists, with support from the American Association of Critical Care Nurses and National EMS Physicians.
"We think of cardiac arrest in adults, especially as related to cardiac etiologies, but we are now thinking of it in COVID-19 more as hypoxemia or respiratory failure, which can predispose patients to cardiac arrest," Sasson explained.
Healthcare workers are the "highest-risk profession" for contracting the COVID-19, with resuscitations carrying "added risk" for several reasons, the authors note.
Administering CPR involves performing numerous aerosol-generating procedures that can cause viral particles to remain suspended in the air and be inhaled by those nearby, with a half-life of approximately 1 hour, they point out.
Moreover, resuscitation efforts "require numerous providers to work in close proximity to one another and the patient," and the high-stress emergent nature of these events may result in lapses in infection-control procedures.
The guidance is designed "to protect not only the patient but also the provider and involves strategies regarding oxygenation and ventilation that differ from what we've done in the past, since we have a strong feeling that this is a different disease process that may require different approaches than what we've dealt with in the past," Sassoon commented.
Reducing Provider Exposure
Providers should don PPE to protect both themselves and their colleagues from unnecessary exposure, the authors advise, noting that recommendations for PPE standards may "vary considerably," so health or emergency medical services (EMS) standards should be taken into account.
Moreover, it is important to allow only the most essential providers into the room or on the scene. In keeping with reducing the number of rescuers, the authors recommend replacing manual chest compressions with mechanical CPR devices for patients who meet height and weight criteria in settings with "protocols and expertise in place for their use."
Oxygenation and Ventilation Strategies
"Reducing risk of aerosolization during the process of intubation is key," Sasson emphasized.
For this reason, a high-efficiency particulate air HEPA filter (if available) should be attached to any manual or mechanical ventilation device, specifically in the path of exhaled gas, before any breaths are administered.
Moreover, it is important to intubate early with a cuffed tube and connect to a mechanical ventilator, if possible. The intubator should be engaged with the "highest chance of first-pass success" and chest compression should be paused to intubate.
To further increase the chance of a successful first intubation, use of video laryngoscopy (if available) is helpful.
Additional guidance includes:
Using a bag-mask device (or T-piece in neonates) with a HEPA filter and a tight seal prior to intubation
Considering passive oxygenation with non-rebreathing face mask as an alternative to bag-mask device for short duration (in adults)
Considering supraglottic airway if intubation is delayed
Minimizing closed circuit disconnections.
"One big take-home point of the guidance is to consider resuscitation appropriateness, starting with goals of care when the patient comes to us, and continuing or stopping resuscitation when needed, based on the discussion with the family as well as local protocol," Sasson said.
A variety of factors need to be taken into account, including age, comorbidities, and illness severity to determine the appropriateness of resuscitation, and "the likelihood of success" must be balanced "against the risk to rescuers and patients from whom resources are being diverted," the authors state.
An Array of Scenarios
"We divided bystander CPR into adults vs pediatrics and into those who are living with a person who is in cardiac arrest — because they have already been exposed [to COVID-19] — vs those who are not living with the patient," Sasson reported. "We also addressed the role of lay bystanders."
For lay rescuers:
Household members should perform at least hands-only CPR, if willing and able to do so
Use of a face mark or cloth covering of the mouth and nose of the rescuer and/or patient may reduce the risk of transmission to a nonhousehold member
In children, lay rescuers should perform chest compressions and "consider mouth-to-mouth resuscitation," especially if they are household members.
If available, an automated external defibrillator should be used to assess and treat victims of out-of-hospital cardiac arrest (OHCA).
The authors offer additional guidance for in-hospital cardiac arrest (IHCA), including addressing advanced care directives, closing the door when possible to prevent airborne contamination of adjacent space, and considering leaving the patient on a mechanical ventilator with HEPA filter.
They additionally address the special needs of neonates, recommending the presence of a "skilled attendant prepared to resuscitate, irrespective of COVID-19 status," and stressing the importance of PPE, since the mother may be a "potential source of aerosolization for the neonatal team." Additional measures include avoidance of routine airway suctioning and the use of endotracheal medications.
Critically ill pregnant women with COVID-19 are more vulnerable to acute decompensation because of the cardiopulmonary physiological changes associated with pregnancy, the authors note. Preparation for a potential perimortem delivery should take place after 4 minutes of resuscitation and be initiated early in the resuscitation algorithm, so as to allow specialized obstetrical and neonatal teams with PPE to convene.
"We will be continually updating this guidance and we are encouraging people to ask questions," Sasson summarized.
She noted that a hospital-based COVID-19 registry is being formed to collect "clinically relevant data" that will inform and update the current guidance.
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