CPR on a COVID Patient: Not a Moment to Waste Looking for PPE

Timely CPR on cardiac arrest patients with known or suspected COVID-19 should take precedence over resuscitators donning personal protective equipment (PPE), the American Heart Association (AHA) outlined in a guidance update.

In resuscitation of adults and children, the healthcare provider is now instructed to give rapid chest compressions and to defibrillate as soon as possible without delay for application of masks or other PPE. “Delays due to mask retrieval may increase the risk of death for the patient from delayed CPR while providing little benefit to the provider,” according to the latest interim guidance.

This is a departure from the initial COVID-specific guidance the AHA put out in March 2020, when the pandemic first took hold in the U.S. The older recommendation was that caregivers wear PPE before beginning any procedures on people with known or suspected COVID-19 and performing aerosol-generating procedures, such as CPR, in isolation rooms.

“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 aerosol-generating procedures,” according to Comilla Sasson, MD, PhD, of the AHA, and collaborators of the latest guidance, published in Circulation: Cardiovascular Quality and Outcomes.

“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,” they wrote.

Their new interim guidance elaborates on general CPR guidelines, which the AHA updated in October 2020, and introduces specific recommendations for the resuscitation of SARS-CoV-2-infected mothers and babies in cardiac arrest.

Given that newborns are unlikely to be a source of COVID-19 transmission even when mothers are confirmed to have COVID-19, rescue breathing and CPR should be performed with HEPA-filtered bag-mask ventilation and, if available, surgical masks and other PPE.

Pregnant women with symptomatic COVID-19 are at an increased risk of severe illness, so oxygenation with intubation should be prioritized earlier for these women.

The AHA group also recommends that rescuers:

• Consider passive oxygenation until HEPA filtered ventilation can be provided in cases of agonal breathing
• Securely attach a HEPA filter to any ventilation device
• Ventilate with a bag-mask-HEPA filter with tight seal until a supraglottic or endotracheal airway is placed
• Engage the intubator with the highest chance of first pass success
• Consider use of video laryngoscopy, if available and personnel are already trained
• Maximize chest compression fraction, pausing to intubate only if needed
• Minimize endotracheal administration of medication to avoid aerosol generation
• Minimize closed ventilation circuit disconnections
• Commit to ethical and evidence-based termination of resuscitation policies

Sasson and colleagues said that in out-of-hospital settings, providers should consider two additional factors: ventilation and contamination.

In cases where there may be contamination to other rooms, providers should minimize contamination by closing doors at the expense of ventilation. If there is no risk of contamination to others, providers should maximize air ventilation to reduce the risk of COVID-19 spread, the AHA committee said.

The group noted that during the pandemic, survival outcomes for both in- and out-of-hospital cardiac arrest patients have been worse in the U.S., perhaps due to factors such as delays in donning PPE, overwhelmed EMS services, and reluctance from patients to seek care.