key: cord-0772953-gnx7ke41
authors: Hsu, Antony; Sasson, Comilla; Kudenchuk, Peter J.; Atkins, Dianne L.; Aziz, Khalid; Becker, Lance B.; Berg, Robert A.; Bhanji, Farhan; Bradley, Steven M.; Brooks, Steven C.; Chan, Melissa; Chan, Paul S.; Cheng, Adam; Clemency, Brian M.; de Caen, Allan; Duff, Jonathan P.; Edelson, Dana P.; Flores, Gustavo E.; Fuchs, Susan; Girotra, Saket; Hinkson, Carl; Joyner, Benny L.; Kamath-Rayne, Beena D.; Kleinman, Monica; Lasa, Javier J.; Lavonas, Eric J.; Lee, Henry C.; Lehotzky, Rebecca E.; Levy, Arielle; Mancini, Mary E.; McBride, Mary E.; Meckler, Garth; Merchant, Raina M.; Moitra, Vivek K.; Morgan, Ryan W.; Nadkarni, Vinay; Panchal, Ashish R.; Peberdy, Mary Ann; Raymond, Tia; Roberts, Kathryn; Sayre, Michael R.; Schexnayder, Stephen M.; Sutton, Robert M.; Terry, Mark; Walsh, Brian; Wang, David S.; Zelop, Carolyn M.; Topjian, Alexis
title: 2021 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19
date: 2021-10-20
journal: Circ Cardiovasc Qual Outcomes
DOI: 10.1161/circoutcomes.121.008396
sha: 2217b353c2c3a75b90a259b5897e1c320b9aa246
doc_id: 772953
cord_uid: gnx7ke41

nan

October 2021 1105 medical personnel, the updated 2021 interim guidance now aligns with the 2020 AHA guidelines for CPR and ECC with the provision of appropriate PPE usage and aerosol control for suspected and confirmed COVID-19 patients in settings where vaccinations have been readily adopted. International data early during the COVID-19 pandemic described worse survival outcomes for both out-of-hospital and in-hospital cardiac arrests compared with prior years. [3] [4] [5] [6] This worsening of outcomes may have been multifactorial; the severity of SARS-CoV-2-related cardiac arrest, the implementation of termination of resuscitation guidance, local crisis standards of care, or patient hesitancy to seek medical care contributing to delays in care. 7 The provision of prompt chest compressions and defibrillation may also have been delayed due to the additional time required in donning PPE or securing the airway, and the PPE may have accelerated rescuer fatigue resulting in decreased CPR quality. 8, 9 Concerns that resuscitation from cardiac arrest due to COVID-19 may be futile may have led to earlier termination of resuscitative efforts, and overwhelmed Emergency Medical Services systems may have had insufficient resources to respond to increased number of calls for arrests in regions with high rates of COVID-19. 3, 10, 11 Lastly, significant delays in presentation for medical care, such as a tripling of the time from onset of chest pain to presentation to emergency care, may have contributed to an increase in out-of-hospital cardiac arrests rates during the pandemic as compared with before the pandemic. 12 With increased scientific knowledge, a more stable PPE supply chain, and vaccination of frontline health care providers and the general public, application of the best resuscitation science available must be once again assessed and prioritized. The following guidance should be applied to patients with suspected or confirmed COVID-19 infection (Figures 1 through 8) . The standard 2020 CPR algorithms and recommendations for resuscitation should apply to those patients who are known to be COVID-19 negative.

Frontline health care providers are at significant risk for contracting respiratory illnesses due to frequent contact with symptomatic patients. Adequate PPE including N-95 masks or positive air pressure respirators, especially during aerosol generating procedures (AGPs), can reduce the risk of coronavirus transmission. 16 Provider risk may vary based on individual (age/ethnicity/ comorbidities/vaccination status) and system factors.

Health care organizations may need to consider redoubling efforts to maintain a sufficient supply of PPE for AGPs if vaccination of their staff is incomplete as only full vaccination of health care providers ensures an extremely low rate of infection. 15 Even as immunity to SARS-CoV-2 is achieved with health care provider vaccination, it is reasonable for health care providers to continue taking appropriate precautions against COVID-19 and its variants since CPR includes AGPs and vaccination rates of health care providers remain below 100%. 17, 18 On the other hand, the risk to the patient by withholding or delaying the response for cardiac arrest is extremely high compared with the much lower risk that the resuscitation provider will contract COVID-19 and develop serious illness. This risk is particularly low in the vaccinated or unvaccinated provider who provides care while wearing appropriate PPE for AGPs. 19 Although the effectiveness of available vaccines has been demonstrated against the wild-type SARS-CoV-2 and variants of concern, breakthrough infections, which are usually not life threatening, may still occur. Boosters addressing emerging variants of concern may be required. 15, 20 

The data regarding which procedures are aerosol generating are conflicting and continue to develop. Some components of CPR are suspected to be aerosol generating. 21 SARS-CoV-2 is transmitted primarily by respiratory droplets and aerosols, with little transmission by fomites. [22] [23] [24] Rapid initiation of chest compressions is critical for successful resuscitation and, in light of the low incidence of documented transmission to health care providers to date, is likely low risk to the compressor. [25] [26] [27] In witnessed sudden arrests of patients with suspected or confirmed COVID-19, chest compressions should not be delayed. Chest compressions can be performed initially by a chest compressor with or without a surgical mask until relieved by responders with appropriate PPE for AGPs. Although data continue to develop, in light of the low incidence of documented transmission to health care providers to date, chest compressions should not be delayed for retrieval and application of a mask or face covering for either the patient or provider. Masks may be considered for providers once compressions have started and before the arrival of responders with appropriate PPE for AGPs. 28 The case definitions of suspected and confirmed COVID-19 have changed over time. 30 For communities and facilities with a higher prevalence of COVID-19 and lower immunization rates, the continuous use of an N-95 respirator and eye protection should be considered when the patient′s COVID-19 status is unknown and resuscitation involves AGP interventions to which compressors and other personnel will be exposed. Provided there is sufficient PPE, additional compressors may be required due to increased fatigue or potential for N-95 respirator slippage resulting from compressions. [31] [32] [33] The application of mechanical compression devices can reduce the number of health care providers required for compressions; however, these devices may not be appropriate or available for morbidly obese adults, infants, children, and small adolescents or for all clinical scenarios. 34 Training and regular practice in the use and rapid application of mechanical compressions devices is required to minimize the early no-flow time and to ensure proper application and utilization of the device. Although the clinical use of mechanical devices has not demonstrated improvement in outcome October 2021 1107 compared with manual CPR, it may reduce the number of additional staff who are needed to participate in the resuscitation event. 35, 36 As not every resuscitation space has negative pressure ventilation, closing the door may help limit contamination of adjacent indoor spaces. In out-of-hospital cardiac arrest, taking measures to better ventilate a confined space such as opening windows or doors may reduce the local concentration of aerosols for health care providers if this does not risk contamination of other spaces in the adjacent vicinity. In addition, some health care organizations may have continued shortages in PPE supply, low vaccination rates among staff, and personnel limitations; this guidance needs to be adapted to local protocols with consideration of current COVID-19 disease burden and resource availability.

Rationale It remains unclear whether defibrillation itself is an AGP; however, preliminary animal data suggest chest compressions following defibrillation may be aerosol generating. 37 On the other hand, case-control and retrospective cohort October 2021 1108 studies of other infectious agents spread by aerosolization indicate that the relative risk of transmission during defibrillation is minimal. 38 A surgical mask on a patient with COVID-19 may help deflect exhaled respiratory particles that can pass through some oxygen-delivering masks. However, mask availability should not delay or prevent time-sensitive lifesaving therapies like chest compressions or defibrillation. When actively ventilating using bag-mask ventilation, a supraglottic airway, or an endotracheal tube, a high-efficiency particulate air (HEPA) filter on the ventilation exhaust port can capture aerosolized particles. Endotracheal intubation should be timed with having sufficient PPE-protected personnel to perform the procedure. disconnections may be a source of aerosolization due to unfiltered exhalation.

Closely monitor for signs and symptoms of clinical deterioration to minimize the need for emergency intubations that put patients and providers at higher risk.

• Address advanced care directives and goals of care with all patients with suspected or confirmed COVID-19 (or proxy) on hospital arrival and with any subsequent significant change in clinical status. • If the patient is at risk for cardiac arrest, consider proactively moving the patient to a negative-pressure room/unit, if available, to minimize risk of exposure to rescuers during a resuscitation. • Close the door when possible to prevent airborne contamination of adjacent indoor space. Conversely, for out-of-hospital cardiac arrests, ventilating confined spaces by opening windows or doors may help disperse aerosolized particles if this does not risk exposure of others in the vicinity and not already in an outdoor setting.

Guidance regarding Emergency Medical Services and lay rescuer is described in detail in other literature. 39, 40 • For the out-of-hospital, public, cardiac arrest chest compressions should be immediately initiated. It is reasonable for the compressor to don a mask immediately, but initiation of chest compressions should not be delayed. Delays due to mask retrieval may increase the risk of death for the patient from delayed CPR while providing little benefit to the provider. • If immediately available, placing a face covering on a known COVID-19 patient may reduce the uncertain risk of aerosol exposure from compressions following defibrillation but should not prevent or delay defibrillation or chest compressions and is unnecessary for providers in appropriate PPE for AGPs. • Before or upon arrival, Emergency Medical Service providers should rapidly don appropriate PPE for AGPs without delay or interruption of chest compressions and excuse unprotected persons from the immediate scene of care as soon as possible.

• Pediatric arrests occur primarily from respiratory causes, and ventilation is a lifesaving priority. Since ventilation of suspected and confirmed COVID-19 pediatric arrests poses a transmission risk, HEPAfiltered ventilation and health care provider masking, when available, can reduce the risk of transmission 

Crowd control for effective direction of resuscitation by the minimum number of people required is advised.

Closing the door to the resuscitation area, when possible, may minimize airborne contamination of adjacent indoor space. Health care personnel should continue to wear appropriate PPE for clinical care including masks, eye protection, and gloves as recommended by the Centers for Disease Control and Prevention. 41 The standard 2020 AHA guidelines for CPR and ECC should apply to those patients who are known to be COVID-19 negative. 1

Consider leaving the patient on a mechanical ventilator with a HEPA filter to maintain a closed circuit and to reduce aerosolization and adjust the ventilator settings to allow asynchronous ventilation with the following suggestions:

• Increase the FiO2 to 1.0. • Use either pressure or volume control ventilation and limit pressure or tidal volume to generate adequate chest rise (4-6 mL/kg ideal body weight is often targeted for adults and neonates, 5-8 mL/ kg for children). • Adjust the trigger settings to prevent the ventilator from auto-triggering with chest compressions and possibly prevent hyperventilation and air trapping.

• Adjust respiratory rate to 10 breaths/min for adults, 20 to 30 breaths/min for infants and children, and 30 breaths/min for neonates. • Assess the need to adjust the positive end-expiratory pressure level to balance lung volumes and venous return. • Adjust ventilator settings to deliver full breaths with asynchronous chest compressions. • Ensure endotracheal tube/tracheostomy and ventilator circuit continuity to prevent unplanned airway dislodgement or tubing disconnections. If return of spontaneous circulation is achieved, set ventilator settings as appropriate to the patients′ clinical condition and treat the underlying cause of cardiac arrest.

Anticipation and preparation are important in rotating patients to a supine position. The limited evidence for providing CPR in the prone position suggests it may be better than not providing CPR. For patients in the prone position with an advanced airway, it may be reasonable to provide manual compressions in the prone position until a patient can be safely transitioned to a supine position with a trained team. If deemed necessary for optimal clinical care, such as assessing endotracheal tube patency and positioning, the following steps for transitioning a patient to a supine position are suggested:

• Provide compressions with hands centered over the T7/T10 vertebral bodies. • Arrange for sufficient, trained, PPE-protected personnel to achieve safe supination on the first attempt. • If already intubated, ensure ventilation and vascular tubing continuity and apply the posterior defibrillator pad to the patient′s back before rotating. • Immediately resume CPR supine once the patient has been rotated. Confirm tubing and access lines have not been dislodged and are in working order.

Health care providers wearing appropriate PPE should continue to provide postcardiac arrest care per the 2020 AHA guidelines for CPR and ECC. 42,43

Address and follow the patient′s goals of care and commit to ethical and evidence-based organizational policies to guide the determination of initiation and continuing resuscitative efforts. Follow the 2020 AHA guidelines for CPR and ECC for termination of resuscitation. 42

Inquire with the infection control officer or medical examiner if further postmortem testing is required for epidemiological or contact tracing purposes. 44

Neonatal Resuscitation Every newborn baby should have a skilled attendant prepared to resuscitate regardless of the COVID-19 status. The newborn baby is unlikely to be a source of COVID-19 transmission even when mothers have confirmed COVID-19, but maternal respiratory secretions and fluids may be a potential source of SARS-COV-2 transmission for the neonatal team and newborn. 45 When appropriate, mothers can be encouraged to wear a surgical mask during the delivery. For suspected or confirmed COVID-19-infected mothers, health care providers should don appropriate PPE for AGPs to decrease the risk of transmission to themselves and the baby.

• Initial steps: routine neonatal care and the initial steps of neonatal resuscitation are unlikely to be aerosol generating; they include drying, tactile stimulation, placement into a plastic bag or wrap, assessment of heart rate, and placement of pulse oximetry and electrocardiographic leads. • Suction: suction of the airway after delivery should not be performed routinely for clear or meconium-stained amniotic fluid. Suctioning is a suspected AGP and is not indicated for uncomplicated deliveries, regardless of the COVID-19 status. • Endotracheal medications: endotracheal instillation of medications such as surfactant or epinephrine is suspected to be an aerosol generating procedure, especially via an uncuffed tube. Intravenous delivery of epinephrine via a low-lying umbilical venous catheter is the preferred route of administration during neonatal resuscitation, regardless of the COVID-19 status. • Positive pressure ventilation remains the main resuscitation strategy for newborns for apnea, ineffective breathing (gasping), and bradycardia. Chest compressions occur later in the resuscitation algorithm. • Delayed cord clamping and skin-to-skin contact may be practiced in the setting of a suspected or confirmed COVID-19-positive mother in stable neonates provided the mother is appropriately masked. • Until confirmed to be COVID-19 negative, suspected or confirmed COVID-19-positive mothers should practice hand and breast hygiene and wear a mask during care and feeding. • Closed incubators: closed incubator transfer and care (with appropriate distancing) should be used for neonatal intensive care patients when possible, but incubators do not protect against aerosolized particles. 

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