To say that 2020 has been a challenging year for healthcare workers would be an epic understatement. We went from hearing the rumors of an outbreak of some kind of disease halfway across the world to upwards of 2 million infected and 125,000 dead with little known about the virus that has done all of that damage and threatens to do even more. Approximately 12%-19% of those infected will require hospitalization and 3%-6% become critically ill. These patients are at high risk of cardiac arrest1,2.
Even during a pandemic, the care of patients in our healthcare facilities must continue. Resuscitation is especially challenging in the presence of or the assumption of COVID-19. This article will pull together the recommendations of some of the top experts in resuscitation and infection control in the world. One must keep in mind that recommendations are based upon expert opinion and that their application will differ depending upon the prevalence of disease and the recommendations of localities and State Departments of Health. What is necessary in one place in the country will not necessarily apply to another. COVID-19 is a dynamic situation. Healthcare experts are learning more of this novel virus daily and therefore recommendations will continue to evolve over time. The more data that is available, the better the science that results.
The goal during resuscitation of a patient with COVID-19 or suspected of being positive with COVID-19 is to provide the best possible care without risking contamination of healthcare providers or other patients. This is always a delicate balance.
The priority in any Emergency Medical Service response or in any healthcare facility intervention will always be the safety of the providers. A provider is required to participate in the resuscitation of many patients. This is a difficult priority to maintain with COVID-19 because healthcare workers are the highest risk profession for contracting the virus. This risk is compounded in resuscitation for several reasons.
- Many healthcare workers must work near each other during the resuscitation.
- There are many procedures utilized during resuscitation that cause aerosol respiratory droplets.
- Those droplets can remain in the air for prolonged amounts of time (up to an hour) and contaminate additional personnel that may not have been involved in the original resuscitation.
The risk to providers can be minimized by following some basic guidelines. Before entering the room of a positive or suspected patient, Personal Protective Equipment (PPE) should be donned. The requirements for specific PPE will be governed by hospital or EMS agency policies and procedures, local, state, or even federal Center for Disease Control (CDC) guidelines. Keep in mind that this is a fluid situation and guidelines may change frequently. Make it a priority to stay current with healthcare safety recommendations. The resuscitation should be run by the minimum number of people possible. Care should be taken to limit entrances and exits from the room because of increased exposure to those entering and cross-contamination because of people exiting into the rest of the department. If possible, members of the healthcare team who would be at the highest risk of complications from COVID-19 should be eliminated from resuscitation.
In EMS, the number of crew members at a scene should be limited to those necessary for resuscitation. In States with Cease Resuscitation Protocols, whenever possible, the arrest should be worked to return spontaneous circulation (ROSC) or to termination at the scene. This eliminates the need to transport the patient to the Emergency Department unnecessarily and prevents further contamination of the ambulance and the Emergency Department (ED).
There are a couple of things that may help in minimizing personnel. One is to utilize a mechanical compression device such as the Lucas device. This eliminates the need for a healthcare provider to perform compressions. Although it is customary to perform manual compressions for 10 minutes prior to placing these devices (AHA Recommendations 2015, 2019), in the case of COVID-19 it should be placed as early as possible in the resuscitation.
All participants in the patient’s care should be notified clearly that the patient is either COVID-19 positive or suspected of being COVID-19 positive. Be sure to communicate this information when care passes to new providers such as from EMS to the ED or from the ED to the intensive care unit (ICU).
There are many ethical considerations when speaking of resuscitation in this setting. CPR utilizes many resources and increases the risk to providers. In a pandemic, situation resources are severely limited and must be utilized in the most efficient way possible. Working a resuscitation removes multiple resources from the care of multiple other patients. Decisions in this regard will differ depending upon the stress on the healthcare system or the EMS agency based upon the number of cases within their region. We know that the mortality among critically ill COVID-19 patients is high and increases with age, cardiovascular disease, and other comorbidities. It is reasonable to consider all this data when making a disease to begin or to continue resuscitation. One must always balance the benefit to patients with risk to providers as well as if the resources can have a larger impact if utilized on other patients. Many of the difficulties of these decisions can be minimized if they are dealt with by addressing them with the patient or his/her proxy prior to the need for resuscitation. 3.
The most difficult procedures to perform with safety are those that involve the airway of the patient. Many airway procedures produce aerosolization. These include, but are not limited to, nebulized bronchodilators, CPAP, endotracheal intubation, and CPR. When the patient is stable and aerosol-generating treatments can safely be deferred until the patient is in a protected and stable environment, they should be deferred. However, if the patient is unstable or is facing a life-threatening condition, these treatments should not be deferred.
There are changes that can be made in patient care that can help minimize exposure. In lace of nebulized bronchodilators, an albuterol multidose inhaler (MDI) can be used with a spacer. Giving puffs of albuterol from an MDI is equivalent to a nebulizer treatment. Once used, MDI should be discarded and not utilized on another patient.
If a patient must be ventilated, an inline HEPA filter should be utilized with the BVM or on the ventilator circuit.
The filter should be placed in the path of exhaled gas BEFORE administering any breaths. Although intubation increases the risk of aerosolization during the procedure, it reduces the risk during ventilation once the endotracheal cuff has been inflated and the patient is connected to a ventilator with an inline HEPA filter. For this reason, the patient should be intubated as early as possible with the provider wearing full PPE. In order to limit the number of required attempts at intubation, the most skilled provider should be utilized for the procedure. In the patient without COVID-19, chest compressions should never be paused to secure an endotracheal tube. However, to decrease the likelihood of failed attempts, compressions should be paused during intubation 4,5.
The ventilator should be set to Pressure or Volume control so that it will permit asynchronous ventilation. FIO2 should be increased to 1.0. Pressure or volume control should be used to ensure adequate chest rise during ventilation. Set the trigger to “off” to be certain that the ventilator will not auto-trigger with chest compressions and prevent hyperventilation6.
If the patient is prone at the time of arrest and cannot be easily turned, it is acceptable to deliver CPR in this position. Defibrillation pads should be placed in the anterior/posterior position. Compressions are done in the standard position over the T7 – T10 vertebral bodies7.
In the absence of a bag valve mask or the possibility of intubation, the rescuer should use either continuous chest compressions without ventilation or compressions with passive ventilation. A face mask is placed on the patient with high flow oxygen and compressions are performed. As always when the Automated External Defibrillator arrives it should be utilized immediately.
Resuscitation in this pandemic environment presents a challenging proposition at best. The healthcare provider must remain the highest priority in patient care environments. Remember to stay healthy, stay happy, and take care of yourself first.References:
- Centers for Disease Control and Prevention. Severe outcomes among patients with coronavirus disease 2019 (COVID-29)-United States, February 12-March 16, 2020 MMW R Morb Mortal Wkly Rep. 2020; 69:343-346. Doi: 10.15585/mmwr.mm6912e2
- Wu Z, McGoogan JM. Characteristics of an important lesson from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72,314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020: 323;1239-1242. Doi: 10.1001/jama.2020.2648
- Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, Zhang C. Boyle C, Smith M. Phillips JP. Fair allocation of scare medical resources in the time of COVID-19. N Engl J Med. 2020; 382:2049-2055. Doi: 10.1056/NEJMsb2005114
- Centers for Disease Control and Prevention. Information for clinicians on therapeutic options for COVID-19 patients. April 7, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/therapeutic-options.html/ Accessed June 26, 2020
- vanDoremalen N, Bushmaker T, Morris DH, Holbrook, MG, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N. Eng J Med. 2020; 382:1564-1567. Doi: 10.1056/NEJMc2004973
- ECRI. Mechanical ventilation of SARS patients: lessons from the 2003 SARS outbreak. February 18, 2020. https://www.ecri.org/components/HDJournal/Pages/Mechanical-Ventiliation-of-SARS-Patients-2003-SARS-Outbreak.aspx#. Accessed June 22, 2020
- Mazer SP, Weisfeldt M, Bai D, Cardinale C. Arora R, et al. Reverse CPR: a pilot study of CPR in the prone position. Resuscitation. 2003;57:279-285. Doi: 10.1016/s0300-9572(03)00037-6