Pre-hospital/emergency department
1. During cardiac arrest, first responders should don an N95 (or best available) mask.
2. One rescuer should confirm pulselessness and non-responsiveness of the victim and start compression only CPR (rescue breaths may be needed in children).
3. He (or a second rescuer) must inquire about the possibility of COVID-19 infection of the patient, and the hospital emergency department (ED) should be notified in advance that they may be receiving a patient with possible COVID-19 infection. The query process should never delay any immediate lifesaving intervention.
4. If automated external defibrillation (AED) is available, it should be used early as indicated.
5. If the dispatcher did not provide information about the possible COVID-19 status of the patient, emergency medical services (EMS) clinicians should take appropriate precautions when responding to any patient especially with manifestations of a respiratory infection.
In-hospital
1. CPR should (when possible) be done in a single-person room with the door closed.
2. Negative pressure rooms are an advantage, but rarely present in the ED.
3. The room should be disinfected following the procedure.
Personnel
1. The number of providers present during the procedure should be limited to only those necessary for resuscitation.
Personal protective equipment
1. Respiratory protection: put on a respirator or surgical facemask (if a respirator is not available) before dealing with the patient. N95 respirators or others that offer a higher level of protection should be used instead of a facemask when performing an aerosol-generating procedure (e.g., CPR, endotracheal intubation, non-invasive ventilation).
2. Eye protection
3. Gloves
4. Gowns
Procedures
Cardiopulmonary resuscitation is done in the standard manner, with the following precautions to minimize spread of infection to the staff and accompanying people:
1. When assessing breathing, look for normal breathing but do not place your face next to the victims’ mouth and nose.
2. It is preferable to pause chest compressions during ventilations to minimize the risk of spread of infection.
3. Lay rescuers are to consider compression-only CPR, but may accept to deliver rescue breaths to children in addition to chest compressions.
4. If available, it is advisable to use adhesive pads for defibrillation, hence delivering shock without direct contact between the defibrillator operator and the patient.
5. Intubation and mechanical ventilation:
• If intubation is needed, rapid sequence intubation, with appropriate personal protective equipment (PPE), may be used.
• Proceeding directly to endotracheal intubation in patients with acute respiratory failure may be considered.
• Avoid, as possible, procedures which generate aerosols (e.g., non-invasive positive pressure ventilation, nebulizers).
• Ventilatory equipment should be provided with HEPA filtration for expired air.
6. As COVID-19 patients are occasionally managed in the prone position to improve oxygenation, it is advisable that:
• In the event of cardiac arrest in the un-intubated, prone patient, while wearing the correct PPE, the rescuer should 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 (between the scapulae at the usual depth and rate of 5 to 6 cm at a rate of 2 compressions per second) while a team prepares to turn the patient supine.
• Defibrillator pads may be placed with patient in the prone position either anterior-posterior or bi-axillary.
7. Family members and other contacts of patients with possible COVID-19 should not be in the vicinity of CPR site while CPR is ongoing.
Intra-hospital transport
1. EMS personnel should notify the receiving intensive care unit (ICU) if the patient has an exposure history and/or manifestations suggestive of COVID-19.
2. The hospital path (including elevators) should be cleared of visitors before transfer.
3. Transporting personnel should be donning full PPE.
4. Avoid crowded areas and crowded times as possible.
5. Keep the patient with suspected COVID-19 separated from other people as much as possible.
Figures 1 and 2 illustrate the modified basic and advanced adult cardiac life support algorithm during the COVID-19 pandemic.