Guidance on Resuscitation in COVID-19 Scenarios – 28.03.2020

Updated: 4 hours ago

The Malta Resuscitation Council is issuing guidance to minimise the risks of infection to providers giving resuscitation to patients presenting with complications or comorbidity of COVID-19.

This guidance is subject to change as experience in the care of patients with COVID-19 increases.

Out-of-hospital for laypersons

Safe approach and call for help remain standard practice

If personal protective equipment (PPE) – FFP3 face mask, disposable gloves and eye protection – are available, these should be worn. Inform others who approach the scene to do the same. Limit the rescuers touching the patient to the minimum required for efficient resuscitation.

In the absence of any PPE, each rescuer needs to weigh the risks against the benefits of starting resuscitation in a confirmed case of COVID-19. This difficult decision relies on situational awareness, positive predictive factors and safe ethical considerations in a Disaster/Pandemic situation.

Confirmation of cardiac arrest

DO NOT LISTEN or FEEL FOR BREATHING. LOOK for signs of life such as breathing, movement and colour. Keep away from the head and neck of the victim. Gently shake the patient using the lower part of the body. If there are no signs of life or you are in doubt, assume cardiac arrest and start chest compressions and immediately send for an Automated External Defibrillator (AED).

Dispatch call 112

CLEARLY STATE the risk or confirmed status of COVID-19 of the patient to 112 dispatch.

Chest compressions

BEFORE STARTING chest compressions, quickly fetch a cloth to COVER THE NOSE AND THE MOUTH of the patient.

DO CONTINUOUS chest compressions in the standard position at a rate of at least 100-120 compressions per minute.


Early use of a defibrillator significantly increases the person’s chances of survival and does not increase the risk of infection. Follow the prompts of the AED excluding giving breaths.


After performing CPR on a potential or confirmed COVID-19 patient, WASH YOUR HANDS thoroughly with soap and water. Alcohol-based hand gel is an alternative.

Seek advice from Public Health coronavirus helpline 111 on the need to self-isolate, get swabbed and disposal of your clothes/PPEs.


The paediatric arrest basic life support algorithm is based on five initial rescue breaths.

However, performing rescue breaths, whether mouth-to-mouth or using a pocket mask, increases the risk of the rescuer acquiring the COVID-19 virus.

The importance of taking immediate action in calling an ambulance remains paramount.

In the interim, taking no action will result in certain cardiac arrest and the death of the child. Therefore, although rescue breaths are probably preferable in the event of a paediatric arrest, these need to be weighed against the risk of acquiring COV-19. Rescuers need to decide on the merits/risks of each case but may opt to omit the rescue breaths. Compression-only CPR is still better than no CPR.

Seek public health advice after performing resuscitation on a child at risk of or confirmed COVID-19.

Out-of-hospital for pre-hospital personnel


PPE is MANDATORY. Limit the number of rescuers to the minimum required for efficient resuscitation.


If equipped with an AED, immediately attach it and follow the prompts EXCLUDING giving breaths.

Guidance for laypersons applies here too. Check for a carotid pulse, if trained to do so.


Airway interventions (e.g. supra-glottic airway (SGA) insertion or tracheal intubation) are Aerosol Generating Procedures (AGP) and must be carried out by experienced individuals using the appropriate PPE for such procedures. The Centres for Disease and Control Prevention highlight PPE requirements for AGPs. Individuals should use only the airway skills (e.g. bag-mask ventilation) for which they have received training. In most cases this will mean two-person bag-mask techniques with the use of an oropharyngeal airway, ensuring best seal. Add a bacterial-viral filter to the resuscitation bag if this is available. Arrange for area decontamination before leaving.

Resuscitation of COVID-19 patients in hospital settings

The MRC is in agreement with the guidance issued by the Resuscitation Council UK published 25.03.2020.

Please seek local guidance from your individual departments for Standard Operating Procedures in this regard.

The MRC would like to highlight the need to have a DECISION MAKING PROCESS IN PLACE EARLY ON; based on the fundamentals of doing good and avoiding harm within the ethical considerations in a Disaster/Pandemic situation. Failing to do so might delay the initiation of resuscitation when indicated. On the other hand, futile interventions which can lead to unnecessary contamination of the Resuscitation Team must be avoided.

Further Reading:

Resuscitation Council UK

 RCUK infographic on the resuscitation of COVID-19 patients in hospital

 RCUK Statement on COVID-19 in relation to CPR and resuscitation in healthcare settings

 RCUK Statement on COVID-19 in relation to CPR and resuscitation in first aid and community settings

 RCUK Statement on COVID-19 in relation to CPR and resuscitation in Paediatrics

 Resuscitation Council UK Statement on COVID-19 in relation to CPR and resuscitation for those teaching resuscitation techniques

Mallia P. Towards an ethical theory in disaster situations. Med Health Care Philos. 2015 Feb;18(1):3-11.

Centers for Disease Control and Prevention: Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.


© 2020 Malta Resuscitation Council

Tel: +356 9922 9496

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