Patients with severe COVID-19 commonly develop acute respiratory distress syndrome, myocardial injury, ventricular arrhythmias, and shock, all of which, increase their risk of cardiac arrest. Moreover, some medications, such as hydroxychloroquine and azithromycin, used to treat COVID-19 can prolong the QT interval, which also predisposes them to cardiac arrest (Edelson, 2020). It’s well known that survival after cardiac arrest depends on providing immediate high-quality chest compressions and defibrillation (Panchal, 2019).
Cardiac arrest in patients with COVID-19: Reducing resuscitation risks
But with the pandemic, how do health care workers give the best possible care to patients with known or suspected COVID-19, yet protect themselves during resuscitation? It isn’t easy considering the shortages of personal protective equipment and the aerosol-generating procedures required during cardiopulmonary resuscitation (CPR).
Interim guidance for life support
The American Heart Association, in collaboration with other professional organizations, released Interim Guidance for Life Support for COVID-19. This guidance aims to protect rescuers delivering CPR, while at the same time providing timely, high-quality resuscitation to patients.
Three key principles for CPR in patients with confirmed or suspected COVID-19
The interim guidance, based on expert opinion, contains three key principles that apply to adult, pediatric, and neonatal resuscitations in patients with confirmed or suspected COVID-19.
1. Reduce health care worker exposure to COVID-19.
- Put on personal protective equipment before entering the patient’s room.
- Limit clinicians in the room to only those essential for patient care.
- Consider replacing manual chest compressions with mechanical CPR devices in adults and adolescents who meet the manufacturer’s height and weight requirements to reduce number of clinicians required.
- Communicate the patient’s COVID-19 status to any new clinicians who arrive on the scene or upon receipt of the patient when transferring to another setting (Edelson, 2020).
2. Prioritize those ventilation and oxygenation interventions that have a lower risk of generating aerosols.
- Fasten a high-efficiency particulate air (HEPA) filter, if available, to the exhalation path of any manual or mechanical ventilation device before administering any breaths to the patient.
- Assess the patient’s rhythm, defibrillate any ventricular arrhythmias, and then intubate the patient with a cuffed endotracheal (ET) tube, as soon as possible. Connect the ET tube to a ventilator with a HEPA filter, if available.
- Reduce the risk for failed intubation attempts by assigning the clinician and approach that has the best chance of first-pass intubation success and pausing chest compressions for intubation.
- Consider video laryngoscopy, if available.
- Use a bag-mask device (or T-piece in neonates) with a HEPA filter and tight seal before intubation. For adults, consider passive oxygenation using a nonrebreather mask, covered with a surgical mask.
- Consider manual ventilation with a supraglottic airway or bag-mask device with a HEPA filter, for delayed intubation.
- Minimize disconnections after connection to a closed circuit to reduce aerosolization (Edelson, 2020).
3. Consider whether it’s appropriate to begin and continue CPR.
- Discuss care goals with patients (or their proxies) who have confirmed or suspected COVID-19 in anticipation of the need for higher levels of care.
- Implement policies to help clinicians determine whether it’s appropriate to start or terminate CPR for patients with COVID-19, using risk factors to assess the prospect of recovery.
- Keep in mind when making care decisions that there’s insufficient data to support extracorporeal CPR for COVID-19 patients (Edelson, 2020).
In addition to these principles, the AHA made revisions to their algorithms for Basic Life Support and Advanced Cardiac Life Support, which can be found in the AHA’s Interim Guidance for Life Support for COVID-19.
Lippincott Solutions note: for the latest coverage on COVID-19 by the Lippincott Nursing team, please visit nursingcenter.com/coronavirus.
Edelson, D.P. (2020). Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates with Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines® – Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and Nation EMS physicians.
Panchal, A.R., et al. (2019). 2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal Cardiopulmonary Resuscitation During Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
About the author
Collette Bishop Hendler, RN, MS, MA, CIC, Editor-in-Chief, Lippincott Solutions, Point-of-Care, is certified by the Certification Board of Infection Control and Epidemiology, Inc. as an Infection Preventionist. She has more than 15 years’ experience in critical care nursing and maintains Alumnus Status as a Critical-Care Registered Nurse.