Introductory Note

This is a collective effort by members of the Council of Cardiopulmonary Resuscitation and the Board of Directors of the Philippine Heart Association guided by current information on the Transmission, Prevention and Management of the COVID- 19 pandemic.^1,2,3,4 All the information and statements from this document are intended to help all healthcare providers in reducing the risk of SARS-COV2 or COVID-19 transmission during the course of resuscitation care.

Please be guided that the information from this document may vary based on different areas of practice which may warrant consultation from our local health department (DOH), government agencies and the scientific community pertaining to concerns on resuscitation.

Please also note that the guidance from this document is only intended specifically for all patients who have known or suspected COVID-19 infection needing resuscitation care. In all other aspects or conditions related to COVID-19 infection, please follow all safety and standard protocols.³

This document contains information on the following:

1. Safety standards for protection and transmission of known or suspected COVID-19
2. Guidelines for out-of-hospital cardiac arrests (OHCA)
3. Guidelines for in-hospital cardiac arrests (IHCA) and Resuscitation Care
4. Special considerations for the pediatric patient
5. Ethical and miscellaneous considerations

A.        Safety Standards for Protection and Transmission of known or suspected COVID-19⁴:

 

1. Use Standard and Transmission-Based Precautions during the care of patients with suspected or confirmed COVID-19 ⁴
   1. Aerosol-generating procedures (e.g., CPR, endotracheal intubation, non-invasive ventilation) expose providers to a greater risk of disease transmission. These procedures should be performed in Airborne Infection Isolation Rooms (AIIRs) and personnel should use respiratory protection. Limit the number of providers present during the procedure to only those essential for patient care and procedural The room should be cleaned and disinfected following the procedure .
   2. Patients with known or suspected COVID-19 should be cared for in a single-person room with the door closed. AIIRs should be reserved for patients undergoing aerosol-generating procedures.
   3. Hand hygiene
   4. Personal Protective Equipment (PPE) Respiratory protection: Put on a respirator or facemask (if a respirator is not available) before entry into the patient room or care area. N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol-generating procedure.
      • Eye protection
      • Gloves

 

•    Gowns: If there are shortages of gowns, they should be prioritized for aerosol- generating procedures, care activities where splashes and sprays are anticipated, and high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of providers.

 

 

2. Additional considerations for aerosol-generating procedures
   1. If intubation is needed, use rapid sequence intubation with appropriate
   2. If possible, avoid procedures which generate aerosols (e.g. bag-valve mask, nebulizers, non- invasive positive pressure ventilation).

3. Consider proceeding directly to endotracheal intubation in patients with acute respiratory failure. The use of high-flow nasal oxygenation and mask CPAP or BiPAP should be avoided due to greater risk of aerosol

B.         Out Of Hospital Cardiac Arrests (OHCA)

 

For Trained and Untrained Lay Rescuers

 

1. For All witnessed and unwitnessed cardiac arrests with known or Suspected COVID infection, it is reasonable for Lay rescuers to do the following :
   1. Check for scene safety and Call EMS
   2. Check for unresponsiveness ONLY if with standard recommended PPE. Otherwise, wait for EMS or call for nearest help for PPE. Strictly NO more feeling for breaths (“Look, Listen and Feel”).
   3. No Rescue
   4. Do Standard Chest compressions ONLY at a rate of 100-120/min until EMS arrives, provided there is available standard recommended Otherwise, wait for EMS or call for nearest help for PPE.
   5. Use AEDs appropriately with the same usual procedures provided rescuer has standard recommended PPE.

2. For All witnessed and unwitnessed cardiac arrests with proven absence or if with doubt of COVID infection, it is reasonable to do Chest compressions only with standard recommended PPE until EMS

For Trained Healthcare Providers and EMS personnel⁵

 

1. Emergency medical dispatchers should question callers and determine the possibility that this call concerns a person who may have signs or symptoms and risk factors for COVID-19. The query process should never supersede the provision of pre-arrival instructions to the caller when immediate lifesaving interventions (e.g., CPR or the Heimlich maneuver) are

2. When COVID-19 is suspected in a patient needing emergency transport, prehospital care providers and healthcare facilities should be notified in advance that they may be caring for, transporting, or receiving a patient who may have COVID-19

 

3. EMS clinician practices should be based on the most up to date COVID-19 clinical recommendations and information from appropriate public health authorities and EMS medical direction. Modifications may include:
   19. If dispatchers advise that the patient is suspected of having COVID-19, EMS clinicians should follow Standard Precautions, including the use of eye protection, and should put on appropriate PPE before entering the scene. Appropriate PPE includes: • Respiratory protection: N95 or higher-level respirator or facemask (if a respirator is not available). N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol-generating When the supply chain is restored, fit-tested EMS clinicians should return to use of respirators for patients with known or suspected COVID-19.
       • Eye protection (i.e., goggles or disposable face shield that fully covers the front and

sides of the face)

• A single pair of disposable patient examination gloves

•  Gowns: If there are shortages of gowns, they should be prioritized for aerosol- generating procedures, care activities where splashes and sprays are anticipated, and high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of EMS clinicians (e.g., moving patient onto a stretcher).

1. If information about potential for COVID-19 has not been provided by the dispatcher, EMS clinicians should exercise appropriate precautions when responding to any patient with signs or symptoms of a respiratory infection. Initial assessment should begin from a distance of at least 6 feet from the patient, if possible. Patient contact should be minimized to the extent possible until a facemask is on the
2. If COVID-19 is not suspected, EMS clinicians should follow standard procedures and use appropriate PPE for evaluating a patient with a potential respiratory
3. A facemask should be worn by the patient for source control. If a nasal cannula is in place, a facemask should be worn over the nasal Alternatively, an oxygen mask can be used if clinically indicated.
4. During transport, limit the number of providers in the patient compartment to essential personnel to minimize possible

4. Aerosol-generating procedures (e.g., CPR, endotracheal intubation, non-invasive ventilation) expose providers to a greater risk of disease transmission and require additional

1. BVMs, and other ventilatory equipment, should be equipped with HEPA filtration for expired air.
2. EMS organizations should consult their ventilator equipment manufacturer to confirm appropriate filtration capability and the effect of filtration on positive-pressure
3. If possible, the rear doors of the transport vehicle should be opened and the HVAC system should be activated during aerosol-generating procedures. This should be done away from pedestrian

5. Special considerations for transport of patients who may have COVID-19
   1. EMS clinicians should notify the receiving healthcare facility if the patient has an exposure history and signs and symptoms suggestive of COVID-19 so that appropriate infection control precautions may be taken prior to patient
   2. Keep the patient separated from other people as much as

 

1. Family members and other contacts of patients with possible COVID-19 should not ride in the transport vehicle, if possible. If riding in the transport vehicle, they should wear a facemask.
2. Isolate the ambulance driver from the patient compartment and keep pass-through doors and windows tightly
   1. If a vehicle without an isolated driver compartment and ventilation must be used, open the outside air vents in the driver area and turn on the rear exhaust ventilation fans to the highest setting. This will create a negative pressure gradient in the patient

C.         In – Hospital Cardiac Arrests (IHCA) and Resuscitation care (Adapted with permission from AUF Cardiovascular Institute)⁶

 

1. Prior to CPR
   1. Team All members of the resuscitation team must be properly oriented regarding roles, equipment, procedures, and protocols. They should particularly be well-versed in donning and doffing of personal protective equipment as recommended by the Centers for Disease Control.³ All personnel called to perform CPR must first be alerted of a potential COVID- 19 diagnosis.
   2. Protective equipment. Only properly-equipped personnel are recommended to enter the room and participate in resuscitative efforts. The necessary personal protective equipment (PPE) must be readily available and replenished at the code/crash cart area for easy access for resuscitative efforts. If there are any doubts regarding the certainty of protection provided by available standard or improvised PPE, best clinical judgment of the team will prevail. This will include: 1) respirator (N95 or masks with higher protection), 2) eye protection (goggles and face shield), 3) multiple layer hand protection (gloves), 4) impermeable gown, 5) foot cover (shoe cover), 6)
   3. Team composition. Only the bare minimum number of personnel is recommended, to minimize risk of transmission while ensuring performance of high-quality CPR. This number should allow for the following: 1) rotation to minimize fatigue and maintain high-quality chest compressions, 2) rapid airway management (intubation) and/or provision of tight airway seal and proper ventilation, 3) administration of medications, and 4) provision of electrical therapies. The recommendations from the Safe Airway Society may be adopted for this purpose.⁷ The elderly (> 60 years), immunocompromised, pregnant., or those with serious or unstable co-morbid medical conditions are preferably excluded from doing CPR, as they comprise the vulnerable ⁷ However, provisions must be in place to provide back-up staff in case needed.
   4. Environment for resuscitation. Patients who need CPR must preferably be inside an airborne infection isolation room⁵ (ideally a negative pressure room with antechamber), or promptly transferred to one by properly-equipped personnel, if time permits. Otherwise, the CPR can be performed inside the patient’s room at bedside with normal pressure but closed The decision to move a patient prior to airway management will rest on the physician’s assessment of clinical stability as well as the risks and benefits of transferring to a more controlled and more-equipped environment.⁷

2.  During CPR

1. Chest compressions. Standard recommendations and criteria for High quality chest compressions All standard Advanced Cardiac Life Support management

 

recommendations  apply.         In situations where there is doubt regarding cardiac arrest (presumed hypoxic arrest), avoid rescue breaths and proceed with chest compressions.⁸ Critical patients with Severe Respiratory disease with Mechanical Ventilator support managed in prone position who goes into cardiac arrest,

Standard CPR techniques on supine position will be done provided a minimum 3 team nursing group will do rapid coordinated turning from prone to supine position. Once revived, may revert back to prone position once stable. Also in such cases, if constrained by time and technical difficulties regarding rapid turning from prone to supine, Prone CPR may be reasonably done with caution provided if with experience and technical expertise of the procedure.⁷

1. Pulse When doing pulse check, do it promptly and skip the part on listening and feeling for breathing.
2. Electrical therapies. Do prompt defibrillation of shockable rhythms. Restoration of circulation may obviate need for airway and ventilatory support.⁸ If a ventilator is already connected to the patient, this would not need to be removed, and defibrillation can safely be done as long as exhaled gases and other sources of oxygen are vented away from the ⁹
3. Airway management. Various procedures during CPR carry a high risk for aerosol-generation, such as positive pressure ventilation with inadequate seal, provision of high-flow nasal oxygen, tracheal suction without a closed system, and tracheal extubation. Meanwhile, the following procedures carry a much lower risk but are still vulnerable to aerosol generation: laryngoscopy, tracheal intubation, or front-of-neck airway procedures (e.g. tracheostomy, cricothyroidotomy).^5,7
4. Airway interventions. All airway interventions (supraglottic airway insertion or tracheal intubation, videoscopic laryngospcopy) must be performed by the most experienced and competent personnel, preferably the anesthesiologist, to ensure immediate airway access and minimize prolonged exposure.⁹ Consider early and rapid-sequence intubation. ensuring that the injected paralytic takes effect to avoid provoking cough.⁷ Attach a viral filter to the endotracheal tube, if available. Ensure adequate cuff inflation prior to providing positive pressure breaths. Use of protective devices during endotracheal intubation such as Acrylic Intubation Hood boxes may be reasonably used for ensured protection. For intubated patients, care must be taken ensure adequate coverage of the patient’s mouth or oral airway to seal any exposed areas outside the tube. A nasogastric tube is also best inserted as soon as possible. Equipment used for airway interventions, such as the laryngoscope, face masks, or airway devices must not be placed on the patient’s bed or pillow, but rather on a separate tray.⁸

a. Ventilation. Avoid mouth-to-mouth or pocket mask ventilation. If a face mask is already in place prior to CPR, it is recommended to switch off the oxygen supply prior to removing the cannula to prevent aerosolization. Bag mask ventilation during cardiac arrest should be avoided to minimize aerosolization. Immediate Rapid Sequence intubation should be done and subsequently patient be hooked to Mechanical Ventilator in Assist mode and CPR continued. Mechanical Ventilator settings are tailored to meet adequate oxygenation especially during cardiac arrest setting Fio2 at 100% until with return of spontaneous circulation then adjusted accordingly to maintain O2 saturation > 95%.⁷

3.  After CPR

1. Staff Post-resuscitation debriefing must be implemented. This will include: 1) staff check to ensure absence of direct contamination, 2) advice regarding subsequent active

 

monitoring for development of symptoms. Any doubts regarding the need for quarantine will be left to the best judgment of the group.

1. Risk assessment. After resuscitative efforts, all involved personnel must be immediately assessed for the integrity of their PPE equipment. This will guide the team on deciding which personnel will require immediate
2. Equipment disposal. All disposable equipment used during resuscitation must be disposed properly according to manufacturer’s recommendations. All other devices and equipment used must be disinfected adequately. All rubbish and contaminated material must be double- bagged and deposited into a designated COVID bin or disposal ⁸
3. Personal precautions. Standard and intensified health precautions such as hand hygiene and full body bath after resuscitation are recommended, prior to resuming patient and staff contact.
4. Post-resuscitation care. Appropriate post-resuscitation or post-mortem care (if applicable) must be implemented in accordance with strict infection control protocols, as well as debriefing of the patient and/or next of

D.        Special considerations for the pediatric patient

1. Pediatric patients who have arrested generally have a higher likelihood of a respiratory rather than a cardiac etiology. As such, prompt airway management and early ventilation is ¹⁰
2. Therefore, any properly-equipped and trained personnel must be promptly deployed to assess the patient and prioritize airway

 

1. Ethical and miscellaneous considerations
   1. If there are uncertainties regarding the need for initiation, continuation or withdrawal of CPR in selected scenarios, pre-specified guidelines and protocols must be in place, with proper consultation done with the institution’s Ethics
   2. Advanced directives regarding withholding of resuscitation, intubation or extraordinary measures must be properly documented and cascaded early on to the staff to avoid inadvertent and unnecessary exposure to the CPR
   3. The decision to withhold CPR for carefully-selected scenarios is ideally taken up in culturally- sensitive and medically-rational discussion with the family along with ample guidance from a medical ethics

References

1. Novel Coronavirus 2019, World Health Organization. Available at http://www.int/emergencies/diseases/novel-coronavirus-2019/
2. Handbook of Covid-19 Prevention and Treatment, The First Affiliated Hospital, Zhiehiang University School of Medicine, February https://covid- 19.alibabacloud.com/
3. Sequencing for Personal Protective Equipment (PPE). Centers for Disease Control and Prevention; CS250672-E. Available at http://www.cdc.gov/hai/pdfs/ppe/ppesequence.Pdf
4. Up to Date, Covid 2019, March 13 2020. Available at https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19
5. Interim Guidance for Healthcare Providers during COVID-19 Outbreak. American Heart Association. (https://cpr.heart.org/-/media/cpr-files/resources/covid- 19-resources-for-cpr-training/interim-guidance-during-covid19-healthcare-providers.pdf?la=en&hash=613D491E7C9A6F5868D269F60892CCAB5EDCFD53). March
6. Tailored Guidelines for In-hospital Resuscitation of Patients in the Setting of COVID-19 Infection (A Supplementary Document from the Guidelines for Heightened Infection Control and Cardiovascular Staff Safety Amidst Emerging Task Force for Cardiovascular Quality and Safety of the Angeles University Foundation Cardiovascular Institute, March 25, 2020
7. Brewster DJ, Chrimes NC, Do TB, et al. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID- 19 adult patient group. The Medical Journal of Australia.
8. Resuscitation Council UK Statement on COVID-19 in relation to CPR and resuscitation in healthcare settings. (https://resus.org.uk/media/statements/resuscitationcouncil-uk-statements-on-covid-19-coronavirus-cpr-and-resuscitation/covid-healthcare/). March 20, 2020.
9. Reducing the risk of ventilation fires. The Official Journal of the Anesthesia Patient Safety Foundation. Volume 24, No. 3, 33-44. 2009 (https://www.apsf.org/article/reducingthe-risk-of-defibrillation-fires/)
10. Resuscitation Council UK Statement on COVID-19 in relation to CPR and resuscitation in (https://www.resus.org.uk/media/statements/resuscitation- council-uk-statements-on-covid-19-coronavirus-cpr-and-resuscitation/covid-paediatrics/). March 4, 2020.