key: cord-0687871-byp1cnuw
authors: Latsios, George; Synetos, Andreas; Mastrokostopoulos, Antonios; Georgia Vogiatzi; Bounas, Pavlos; Nikitas, Georgios; Papanikolaou, Aggelos; Parisis, Charalampos; Kanakakis, Ioannis; Goudevenos, John
title: Cardiopulmonary Resuscitation in patients with suspected or confirmed Covid-19. A Consensus of the Working group of the Cardiopulmonary Resuscitation of the Hellenic Society of Cardiology
date: 2020-09-17
journal: Hellenic J Cardiol
DOI: 10.1016/j.hjc.2020.09.010
sha: 5bf1c7318137b547a2fe66c112b78efcf6a32d38
doc_id: 687871
cord_uid: byp1cnuw

The unprecedented for modern medicine pandemic caused by the SARS-COV-2 virus ("coronavirus", Covid-19) creates in turn new data on the survival of cardiac arrest victims, but mainly on the safety of Cardiopulmonary Resuscitation (CPR) providers. The covid19 pandemic resulted in losses in thousands of lives, and many more people were hospitalized in simple beds or in intensive care units both globally and in Greece. More specifically, in victims of cardiac arrest, both in and out of hospital, the increased mortality and high contagiousness of the SARS-CoV-2 virus put the CPR rescuers in front of new questions of both medical and moral nature. What we all know in Resuscitation, is that we cannot harm the victim and therefore do the most/best we can, it is no longer the full reality. What we need to know and incorporate into decision-making in the resuscitation process is the distribution of limited human and material resources, the potentially very poor outcome of patients with covid-19 and cardiac arrest, and especially that a potential infection of health professionals can lead in the absence of health professionals in the near future. This review tries to incorporate the added skills and precautions for CPR providers in terms of both in hospital and out hospital CPR.

Coronaviruses are a group of viruses that usually cause respiratory infections of varying severity in humans and animals. Initially in Wuhan (China), at the end of 2019 and in the beginning of 2020 there was a series of pneumonia cases for which, on January 9 2020, the Chinese health authorities announced that it was due to a new coronavirus strain (2019-nCoV, later SARS-CoV-2). During the following months, the transmission of the virus around the world led to a pandemic, with main characteristics being its high contagiousness, even in pre-or asymptomatic stages, and a high mortality, especially between the elderly or patients with comorbidities.

The unprecedented for modern medicine pandemic caused by the SARS-COV-2 virus ("coronavirus", Covid-19) creates in turn new data on the survival of cardiac arrest victims, but mainly on the safety of Cardiopulmonary Resuscitation (CPR) providers. It is of particular importance, especially during CPR, the mode of virus transmission, aerogenously, with droplets exhaled through the patient's mouth and nose to the rescuer's mucosa, from the resulting aerosol that suspends for a long time in closed spaces or even from surfaces. Health professionals during Advanced Life Support (ALS), as well as non-health professionals that provide Basic Life Support (BLS) can be exposed during CPR to this new virus characterized by high contagiousness. As a result, they need to take protective measures and adjust their actions based on the new data, especially as long as there is a lack of effective weapons for its prevention and treatment (vaccines, anti-viral drugs, immunotherapy) 1-3 .

During the pandemic, there was a dramatic increase in deaths around the world in the affected countries. In countries with a proven increase in deaths, this was accompanied by a simultaneous increase in out-of-hospital cardiac arrests (OHCA), both in time and in geographical coincidence. For example, in Italy, this increase in J o u r n a l P r e -p r o o f OHCA was 58% compared to corresponding period last year while in New York district (USA) calls to Emergency Medical Services (EMS) quadrupled (ie increased by 400% www.nbcnewyork.com/news/..../2368678/) 1, 2 .

The above show the increased need for extensive CPR performance in the community by health professionals and by educated citizens. In addition, there is need for early and clear adjustment of the guidelines for the CPR performance both in national (Hellenic Society of Cardiology, National Public Health Organization) and in global level (European Resuscitation Council, American Heart Association) in order to reassure the efficacy and safety of rescuers. With reservation for the scientific data available so far and in line with global recommendations, we need to re-examine the safe way to perform CPR in victims of both out-of-hospital and in-hospital arrest 3, 4 .

Recommendations for performing CPR and/or defibrillation in an out-of-

Every time CPR is performed, especially to an unknown victim, there is a risk of cross-infection, which is particularly related to rescue breathings. Normally, this risk is very low and is considered negligible compared to the fact that the victim of cardiac arrest will die if no effective help is given. In any case, based on the existing guidelines, the first thing to do is call for help and call the Emergency Medical Services immediately at 112/166, informing that there is a victim of sudden cardiac arrest (SCA) ("he is dead", "he is not breathing", etc). The bystanders and the first ones to respond to a SCA (eg specialized staff at the workplace, trainers, etc), who are required to provide initial care, which may include CPR, should have already specific orders from their employers, special for each workplace. It is already foreseen The level of PPE to be used in order to evaluate a patient, to initiate chest compressions and to assess heart rhythm in the regular intervals of two minutes is determined by the National Guidelines. In any case, as few as possible, absolutely necessary, healthcare professionals should participate in the ALS while ideally; it should take place in a special, negative pressure isolation room.

The need for PPE may delay CPR initiation with Covid-19. Reviewing the relevant procedures (including PPE availability in resuscitation carts), along with theoretical training and practice, will minimize these delays. Staff safety is of paramount importance. In cardiac arrest that is likely to be of hypoxemic cause, early ventilation J o u r n a l P r e -p r o o f with oxygen is usually recommended. Passive oxygenation should be provided by a non-rebreathing mask covered by a surgical mask 6 .

However, any action or invasive procedure on the airway that is performed without proper protection with PPE will put the rescuer at significant risk of infection.

Therefore What we all teach in Resuscitation, is that we cannot harm the victim and therefore do the most/best we can, it is no longer the full reality. While until recently CPR, with simple precautions -skills, was completely harmless to the members of the group, it is no longer valid. What they need to think about now and incorporate into decisionmaking in the resuscitation process is the distribution of limited human and material resources, the potentially very poor outcome of patients with Covid-19 and cardiac arrest, and especially that a potential infection of health professionals can lead in the absence of health professionals in the near future. This absence can lead to multiple deaths from the one they initially tried to prevent.

Although in Greece, due to successful restriction of the Covid-19 pandemic (sick and hospitalized patients, dead people), this was not perceived, globally, the moral compass in Resuscitation is shifted considerably. The Hippocratic balance of "benefit or do no harm" of the acceptable risks for patients and healthcare professionals (physicians, nurses) has clearly shifted and modern medicine has moved with it.

J o u r n a l P r e -p r o o f Kalogridaki.

Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy

Cardiopulmonary resuscitation after hospital admission with covid-19

CPR in the Covid-19 Era -An Ethical Framework

Successful primary PCI during prolonged continuous cardiopulmonary resuscitation with an automated chest compression device (AutoPulse)

European Resuscitation Council COVID-19 guidelines executive summary

Cardiopulmonary resuscitation in COVID-19 patients

Cardiac arrest during emergency intubation in an elderly patient with confirmed coronavirus disease 2019

Role of anaesthesiologists during the COVID-19 outbreak in China

In-hospital cardiac arrest outcomes among patients