key: cord-0909401-hp6lf65q
authors: Nolan, J.P.; Monsieurs, K.G.; L.Bossaert; Böttiger, B.W.; Greif, R.; Lott, C.; Madar, J.; Olasveengen, T.M.; Roehr, C.C.; Semeraro, F.; Soar, J.; Van de Voorde, P.; Zideman, D.A.; Perkins, G.D.
title: European Resuscitation Council COVID-19 Guidelines Executive Summary
date: 2020-06-07
journal: Resuscitation
DOI: 10.1016/j.resuscitation.2020.06.001
sha: 4fcd5224194ebf0dd1ad05f126316883132800a9
doc_id: 909401
cord_uid: hp6lf65q

These coronavirus disease 2019 (COVID-19) guidelines focus specifically on patients with suspected or confirmed COVID-19. For resuscitation of those who are low risk or confirmed negative for COVID-19, the reader is directed to the standard resuscitation guidelines for adults and children.1, 2, 3 Where uncertainty exists treatment should be informed by a dynamic risk assessment which may consider current COVID-19 prevalence, the patient's presentation (e.g. history of COVID-19 contact, COVID-19 symptoms), likelihood that treatment will be effective, availability of personal protective equipment (PPE) and personal risks for those providing treatment. These guidelines will be subject to evolving knowledge and experience of COVID-19. As countries are at different stages of the pandemic, there may some international variation in practice.

These coronavirus disease 2019 (COVID- 19) guidelines focus specifically on patients with suspected or confirmed COVID-19. For resuscitation of those who are low risk or confirmed negative for COVID-19, the reader is directed to the standard resuscitation guidelines for adults and children. [1] [2] [3] Where uncertainty exists treatment should be informed by a dynamic risk assessment which may consider current COVID-19 prevalence, the patient's presentation (e.g. history of COVID-19 contact, COVID-19 symptoms), likelihood that treatment will be effective, availability of personal protective equipment (PPE) and personal risks for those providing treatment. These guidelines will be subject to evolving knowledge and experience of COVID-19. As countries are at different stages of the pandemic, there may some international variation in practice.

The World Health Organization has declared COVID-19 a pandemic. The disease is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is highly contagious.

The number of out-of-hospital cardiac arrests in the Lombardy region of Italy increased by 58% during the COVID-19 pandemic in comparison with a similar period in 2019; 77% of the increase in these cardiac arrests were among those with suspected or confirmed COVID-19. 4 In Paris and surrounding suburbs, the incidence of out of hospital cardiac arrest doubled in parallel with an increase in hospital admissions for COVID-19. 5 In the Parisian study only 33% of the increase in the incidence was explained by patients with suspected or confirmed COVID- 19 . This suggests that a significant proportion of the excess cardiac arrests were not directly attributable to Whether this is explained by fear and anxiety delaying presentation for non-COVID-19 related illnesses, deteriorating mental health increasing self-harm or other reasons requires further research. 6 In both studies the proportion of cardiac arrests which occurred at home increased, likely related to the lock-down. Importantly the rate of bystander CPR and public access defibrillation fell as did overall survival. These worrying observations highlight the importance of practical guidance to enable members of the community and healthcare professionals to continue to provide effective resuscitation to the several hundred thousand people who sustain a cardiac arrest each year in Europe. 7 6 Cardiovascular manifestations of COVID-19 include elevation of cardiac biomarkers, cardiac arrhythmia, arterial and venous thromboembolism, cardiogenic shock and cardiac arrest. 9 In a case series of 138 hospitalised COVID-19 patients, 16 .7% of patients developed arrhythmias and 7.2% had acute cardiac injury. 10 Thus, although most cardiac arrests in these patients are likely to present with a non-shockable rhythm caused by hypoxaemia (although dehydration, hypotension, sepsis coagulation activation and pulmonary embolism may also contribute), some will have a shockable rhythm, which may be associated with drugs causing prolonged-QT syndrome (e.g. chloroquine, azithromycin) or caused by myocardial ischaemia. In the series of 136 cardiac arrests from Wuhan, four (2.9%) patients survived for at least 30 days but only one of these had a favourable neurological outcome. 8 [h1] Risks associated with cardiopulmonary resuscitation (CPR) in patients with COVID-19

[h2] Mechanisms of transmission of SARS-CoV-2

The main mechanism of disease transmission of SARS-CoV-2 is by respiratory secretions either directly from the patient or by touching contaminated surfaces. Viable virus is detectable on some surfaces for up to 72 hours. 11 Respiratory secretions are called either droplets (> 5-10 microns in diameter) or airborne particles (< 5 microns). Droplets fall onto surfaces within 1-2 metres of the patient's respiratory tract while airborne particles can remain suspended in the air for prolonged periods. [11] [12] [13] [14] [15] The International Liaison Committee on Resuscitation (ILCOR) has undertaken a systematic review addressing three questions: 16 1. Is the delivery of chest compressions or defibrillation an aerosol-generating procedure?

2. Do the delivery of chest compressions, defibrillation or CPR (all CPR interventions that include chest compressions) increase infection transmission?

3. What type of PPE is required by individuals delivering chest compressions, defibrillation or CPR in order to prevent transmission of infection from the patient to the rescuer?

The evidence addressing these questions is scarce and comprises mainly retrospective cohort studies 17, 18 and case reports. [19] [20] [21] [22] [23] [24] In most cases, delivery of chest compressions and defibrillation are lumped together with all CPR interventions, which means that there is considerable confounding in these studies. Aerosol generation by chest compressions is plausible because they generate small but measurable tidal J o u r n a l P r e -p r o o f volumes. 25, 26 Chest compressions are similar to some chest physiotherapy techniques, which are associated with aerosol generation. 27 Furthermore, the person performing chest compressions is close to the patient's airway.

The ILCOR systematic review did not identify evidence that defibrillation generates aerosols. If it occurs, the duration of an aerosol generating process would be brief. Furthermore, the use of adhesive pads means that defibrillation can be delivered without direct contact between the defibrillator operator and patient. The ILCOR treatment recommendations are listed in Table 1 . The values, preferences and Task Force insights summarise the rationale for recommendations for lay persons and health care professionals.

[h2] Personal protective equipment (PPE)

Recommendations for PPE are summarised in Table 2 . Some healthcare systems are facing shortages of personnel and equipment. The position of the European Resuscitation Council (ERC) is that health systems should prioritise the protection of healthcare personnel and ensure adequate PPE is available to those who are expected to provide treatment for cardiac arrest.

Safety is paramount and the safety priorities are: (1) self; (2) colleagues and bystanders; (3) the patient. The time required to achieve safe care is an acceptable part of the resuscitation process.

Note to typesetter: INSERT TABLE 2 NEAR HERE [28] [29] [30] Please remove the citation numbers from herethey have been added to ensure the correct reference numbering in Table 2 .

[h1]Basic Life Support for Adults with suspected or confirmed COVID-19

For patients with confirmed or suspected COVID-19 the European Resuscitation Council recommends the following changes to basic life support (BLS) based on the recent ILCOR evidence review and commentary: 16, 31 [h2] Basic Life Support in adults by lay persons  Cardiac arrest is identified if a person is unresponsive and not breathing normally. During single-rescuer resuscitation, if possible, use a phone with a hands-free option to   communicate with the emergency medical dispatch centre during CPR.  Lay rescuers should consider placing a facemask or cloth/towel over the person's mouth and nose before performing chest compressions and public-access defibrillation. This may reduce the risk of spreading the virus during chest compressions. 26  Lay rescuers should follow instructions given by the emergency medical dispatch centre.

 After providing CPR, lay rescuers should, as soon as possible, wash their hands thoroughly with soap and water or disinfect their hands with an alcohol-based hand gel and contact the local health authorities to enquire about screening after having been in contact with a person with suspected or confirmed COVID-19.

[h2] Emergency medical dispatch staff  For untrained rescuers, provide compression-only instructions.

 Guide additional rescuers to the nearest automated external defibrillator (AED) when available.  Applying defibrillator pads and delivering a shock from an AED/defibrillator is unlikely to be an aerosol-generating procedure and can be undertaken with the healthcare provider wearing droplet-precaution PPE (fluid-resistant surgical mask, eye protection, short-sleeved apron and gloves.

 Healthcare personnel should always use airborne-precaution PPE for aerosol-generating procedures (chest compressions, airway and ventilation interventions) during resuscitation.  Use a high-efficiency particulate air (HEPA) filter or a heat and moisture exchanger (HME) filter between the self-inflating bag and the mask to minimize the risk of virus spread.

 Apply a defibrillator or an AED and follow any instructions where available.

[h1]Advanced life support for adults with suspected or confirmed COVID-19  If a patient is unresponsive and not breathing normally shout for help/pull emergency bell.

 Check for signs of life/pulse. DO NOT listen for breaths or place your cheek near to the patient's face.

 Send someone to place a COVID cardiac arrest call (2222 or equivalent local number), and to bring a defibrillator.  Ensure there is a viral filter (HME filter or HEPA filter) between the self-inflating bag and airway (mask, supraglottic airway, tracheal tube) to filter exhaled breaths.

 Experienced airway staff should insert a supraglottic airway or intubate the trachea early so that the period of bag-mask ventilation is minimised. Consider videolaryngoscopy for tracheal intubation by providers familiar with its use -this will enable the intubator to remain further from the patient's mouth.

 If a supraglottic airway has been inserted, use a 30:2 chest compression ventilation ratio, pausing the chest compressions to enable ventilation. This will minimise the risk of aerosol generation caused by gas leaking from the seal between the supraglottic airway and larynx.

 Consider stopping CPR early if treatable reversible causes of cardiac arrest have been addressed.

 If there is a need for prolonged CPR, consider the use of a mechanical chest compression device in those settings that are familiar with its use.

 Ensure the safe removal ('doffing') of PPE to prevent self-contamination.

 Undertake a team debrief.

[h2]Resuscitation in intubated patients at the time of cardiac arrest  Resuscitation team members should wear airborne-precaution PPE.

 In the event of cardiac arrest in an intubated and mechanically ventilated patient, do not disconnect the ventilator circuit when starting CPR to avoid aerosol generation.

 Increase the FiO 2 to 1.0 and set the ventilator to deliver 10 breaths a minute. It may be necessary to use a volume control mode and to increase the pressure limits.

 Quickly check the ventilator and circuit to ensure that they have not contributed to the cardiac arrest, e.g. blocked filter, breath-stacking with high auto-PEEP, or mechanical failure. Follow local guidance regarding ventilator disconnection to minimise aerosol generation e.g. clamping the tube prior to disconnection, use of viral filters etc. Most of these patients will be intubated, but in some cases awake unintubated COVID-19 patients may also be nursed in the prone position. In the event of cardiac arrest in the unintubated, prone patient, whilst wearing the correct PPE, immediately turn the patient supine before starting chest compressions. In the event of cardiac arrest in an intubated patient who is prone, it is possible to deliver chest compressions by pressing the patient's back. This can provide some perfusion of vital organs while a team prepares to turn the patient supine, as follows:

1. Resuscitation team members should wear airborne-precaution PPE.

2. Compress between the scapulae (shoulder blades) at the usual depth and rate (5 to 6 cm at 2 compressions per second). [h2]Out-of-hospital cardiac arrest Most of the principles described for the management of in-hospital cardiac arrest in adults with confirmed or suspected COVID-19 also apply to ALS for such patients in cardiac arrest out-ofhospital. In the context of COVID-19, early recognition of cardiac arrest by the dispatcher will enable emergency medical services (EMS) staff to put on airborne-precaution PPE as soon as possible.

[h1]Paediatric basic and advanced life support with suspected or confirmed COVID-19

Children are susceptible to COVID-19 but often seem to have only mild disease. [33] [34] [35] [36] [37] [38] [39] Very young children and children with co-morbid diseases may be more prone to severe illness. 40, 41 J o u r n a l P r e -p r o o f

In approximately 70% of paediatric out-of-hospital cardiac arrests, rescuers are likely to be family members and therefore, if the child is infected with SARS-CoV-2, they are likely to have had previous exposure to the virus. They might also consider their personal risk far less important than the potential benefit for the child. This is unlikely to be true for random bystanders. Healthcare providers may also value the benefit for the child higher than their personal risk, but they should be aware of their responsibility towards their relatives, colleagues and the wider community as well. 42 [h2] Basic life support for children [h1]Newborn life support

Case series suggest the risk of vertical transmission of SARS-CoV-2 at birth is unlikely and that there is a low risk of babies being infected at birth even if born to a confirmed COVID-19 positive mother. 43, 44 J o u r n a l P r e -p r o o f

Maternal infection with COVID-19 does not appear to increase the risk of spontaneous preterm labour (35a) but may increase the risk of premature delivery. 45 There is a tendency for more deliveries to be via caesarean section with foetal compromise cited as an indication. 46 Concerns about maternal health may also prompt a decision to deliver. 47  Local recommendations may take into account the regional prevalence of COVID-19.

 Where maternal COVID-19 is not clinically suspected, staff should follow local or national guidelines for PPE, which may include the routine use of droplet-precaution PPE for any attendance.

 Where maternal COVID-19 is suspected or confirmed, staff must attend in full airborneprecaution PPE.

[h2]Delivery area  Significant numbers of asymptomatic mothers may be infected with COVID-19 at the time of childbirth. 50 Whilst it is recommended that mothers with suspected or confirmed COVID-19

should deliver their babies in a designated area, it may not be feasible to segregate all such mothers. Therefore, take appropriate precautions and wear PPE when attending all deliveries.

 Ideally, delivery of a baby from a mother with suspected or confirmed COVID-19 should take place in a negative-pressure room, but these facilities may not be available in all delivery or operating rooms.

J o u r n a l P r e -p r o o f  As a minimum precaution, resuscitation of the baby should ideally take place at least 2m from the mother in order to minimise the risk of droplet spread (the risk from airborne spread still exists). 29 Provision of a mask for the mother may reduce droplet spread.

 Consider a partition or locating the resuscitation area separate from the delivery area. 48  Operating rooms are associated with a higher risk of droplet or airborne spread because of aerosol-generating procedures carried out on the mother (airway management, diathermy etc.).

[h2]Pre-delivery discussions with suspected or confirmed COVID-19 positive parents  Droplet-precaution PPE is required for face-to-face consultation.

 Video consultation may be an alternative to reduce contact.

 If the neonatal team is unable to counsel the family then the obstetric/midwifery team may need to undertake such discussions.

[h2]Neonatal team attending in advance (for suspected or COVID-19 positive mother)

 Check and prepare the resuscitation area before the mother is in the room.

 Where a neonatal team is called in advance, careful planning is required to minimise the number who enter the room. The team should include someone experienced in newborn resuscitation and interventional procedures. Additional team members may be required to help with PPE.

 Ensure that there are facilities for safely putting on and taking off PPE. Handling PPE may incur delays.

 Full airborne-precaution PPE is required for anyone entering the room. Team members should put on PPE in advance although they may choose to leave off their masks/visors until it is clear they are required to attend the baby.

[h2]Delivery  There are no changes to the immediate management of the baby following delivery in the presence of suspected or confirmed COVID-19 infection. Delayed cord clamping should still be considered. Initial assessment of the newborn may take place on the perineum provided extra care is taken. 48, 51, 52  The baby should only be passed to the neonatal team if intervention is needed; babies doing well stay with mother and the neonatal team may be able to avoid exposure.

[h2]Neonatal team called after delivery (of a suspected or confirmed COVID-19 positive mother) J o u r n a l P r e -p r o o f  Staff attending any delivery need to be able to initiate the resuscitation of a compromised baby before the neonatal team arrives. Call for help early because there may be a delay as the neonatal team puts on full airborne-precaution PPE.

[h2]Approach to resuscitation and stabilisation  The approach to resuscitation and stabilisation follows standard NLS recommendations. 49  Take measures to minimise potential COVID-19 exposure.

 A wet towel must be considered contaminated and removed with care.

 A viral filter (HME filter or HEPA filter) between the T-piece/self-inflating bag and mask might be considered. If a filter is used ensure that it is appropriate for the size of the baby and that ventilation is not compromised.

 Two-person airway support reduces mask leakage and is preferred where enough staff with appropriate PPE are available.

 Minimise potential aerosol-generating procedures (AGPs) such as suction and ensure that the most experienced team member carries out any advanced airway manoeuvres. 48 [h2]Neonatal post resuscitation care  Decisions to separate a COVID-19 positive mother and her baby should follow local guidance.

Generally, a baby should stay with their mother if she is well enough. Skin-to-skin care and breast feeding may be possible if adequate precautions are taken including strict hand hygiene and a fluid-resistant surgical mask for the mother to reduce the risk of droplet spread. 53,54

 Should the baby require admission to a neonatal intensive care unit we recommend that transfer takes place in a closed incubator. Minimise exposure of the incubator to the contaminated area; it may be kept out of the delivery area/operating room if the resuscitation area is in the same room and the baby carried to it.

 Staff escorting the baby to the neonatal unit should consider wearing full airborne-precaution PPE where they might need to intervene during the transfer.

 If possible, avoid AGPs outside controlled areas such as the neonatal unit.

 Following resuscitation, isolate the baby until its COVID-19 status is known.

 A team debrief will support staff and improve future performance.  Any resuscitation should take place in a designated area to minimise the risk of cross-infection.

 Assessment and resuscitation follow standard NLS principles regardless of circumstances  Those undertaking initial assessment and support should as a minimum use droplet-precaution PPE. Any staff attending subsequently should wear full airborne-precaution PPE as it may be necessary to undertake AGPs. If intubation is necessary, consider videolaryngoscopy.

 Ideally respiratory support should not be delayed. Mask ventilation and cardiac compressions are considered AGPs in all age groups outside the immediate newborn period. 16, 29, 31 There is no [

This educational guidance considers the infection risk for instructors and candidates during a pandemic. Minimising the risk of infection during courses is paramount -distance learning, selfdirected learning, augmented and virtual learning will become much more important in CPR teaching.

[h2]General guidance for education in CPR during the pandemic  Life support teaching programmes must include specific interventions for COVID-19 patients focusing on infection prevention whilst being adaptable for local needs and requirements.

 Self-protection against infection (equipment and procedures) must be part of CPR education.

 Modify on-site teaching facilities to avoid virus transmission:

o Individuals who should be isolating or have symptoms must not take part in the course.

o Everyone must wear a surgical mask, wash/alcohol-gel their hands frequently, and maintain a 2-m spatial distance.

o During hands-on sessions when practising on a manikin, for training purposes candidates and instructors should wear PPE which should be kept throughout the course. and doffing (taking off) and in a buddy system.

 Course organisers should provide enough PPE to run courses.

 Plenary sessions will initially be replaced by small group workshops; in the long-term, e-learning content and webinars should be developed.

 Do not exceed 6 candidates per group for hands-on training and maintain the same groups throughout the course. During the pandemic, suspend social programmes, get togethers, formal and informal break meetings.

 Ensure availability of enough disinfectant and hand-washing facilities.

 The validity of all ERC certificates has been extended for one year to reduce pressure on candidates and instructors.

 In case of limited resources for teaching CPR during this COVID-19 pandemic, those with close contact with COVID-19 patients and the risk of having to treat a person in cardiac arrest should be trained first, followed by those with the longest gap in CPR teaching.

[h2]Basic courses during the COVID-19 pandemic  During the pandemic, for BLS education for laypeople the ERC recommends individual selfdirected learning, apps and virtual reality resources for BLS -they are readily available and are effective for teaching chest compressions and the use of an AED.

 Self-directed learning or distance learning will reduce the infection risk for both candidates and instructors. to the victim's mouth/nose. No mouth-to-mouth ventilation will be taught.

[h3] BLS education for professionals  For professionals, self-directed learning or distance learning is feasible and effective and has the potential to reduce the infection risk for both candidates and instructors.

 The ERC suggests self-directed learning for those professionals who have a duty to respond but who rarely treat cardiac arrest patients. For this group of rescuers, the educational focus is on chest compressions, use of an AED, and the donning (putting on) and doffing (taking off) of PPE.  Continuous assessment may be preferred over summative assessment to avoid pooling of candidates and to ensure adherence to social distancing.

 Minimise faculty meetings during ALS courses, keeping sufficient personal distance to minimise the risk of infection. Before and after courses, internet-based faculty meetings are encouraged.

[h2]Instructor education during the COVID-19 pandemic [h1] Ethics and end-of-life decisions during the COVID-19 pandemic

During a pandemic many concomitant risks might put further pressure on the already strained healthcare system and potentially lead to excess mortality: 42  If the casualty is a household contact of the care provider and infected with COVID-19, that provider has likely already been exposed and may be willing to provide direct first aid.

 If the casualty is not a household contact:

o Follow national advice on social distancing and the use of PPE wherever possible. o wash all your clothing as soon as practicable;

o be prepared to self-isolate and follow national guidance if you develop COVID-19

symptoms after providing direct first aid. 

 We suggest that chest compressions and cardiopulmonary resuscitation have the potential to generate aerosols (weak recommendation, very low certainty evidence).

 We suggest that in the current COVID-19 pandemic lay rescuers consider compression-only resuscitation and public-access defibrillation (good practice statement).

 We suggest that in the current COVID-19 pandemic, lay rescuers who are willing, trained and able to do so, may wish to deliver rescue breaths to children in addition to chest compressions (good practice statement).

 We suggest that in the current COVID-19 pandemic, healthcare professionals should use personal protective equipment for aerosol-generating procedures during resuscitation (weak recommendation, very low certainty evidence).

 We suggest that it may be reasonable for healthcare providers to consider defibrillation before donning aerosol generating personal protective equipment in situations where the provider assesses the benefits may exceed the risks (good practice statement). 

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