Guidance on Resuscitation in COVID-19 Scenarios – 10.04.2020

Updated: Apr 25

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) – FFP2 / 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’s lower part of the body and assess for response. If there are no signs of life or you are in doubt, assume cardiac arrest; call 112, start chest compressions and send for an Automated External Defibrillator (AED). If you are alone and an AED is in the vicinity, go and fetch the AED first.



Dispatch call 112


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



Ventilate the room


If you are indoors, OPEN DOOR and WINDOW wide open before you start resuscitation.



Chest compressions


BEFORE STARTING chest compressions, quickly fetch a cloth to COVER THE NOSE AND THE MOUTH of the patient, based on ILCOR recommendation that chest compressions and CPR have the potential to generate aerosols.

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



AED


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.



Stopping CPR


Keep doing chest compressions only CPR, changing provider doing chest compressions every two minutes, till the emergency team arrives on site. If in the meantime the victim shows signs of life, stop chest compressions, turn in the recovery position and continue assessing at a distance of two metres, if the space allows, till the emergency team arrives. If the victim stops showing signs of life, reposition face up, covering nose and mouth, and restart chest compressions. AT NO TIME should breathing be reassessed using THE LISTEN OR FEEL APPROACH.



AFTER HAND-OVER TO EMERGENCY SERVICES


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.



CPR on CHILDREN


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.


Bystander rescuers who routinely care for the child and are willing, trained and able to do so, may wish to consider rescue breaths in addition to chest compressions. In these cases, the benefit to the child outweighs the risk to the rescuer who is already in contact with that child.


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


SAFE APPROACH


Try to establish risk of COVID-19 prior to arrival at the scene. In the event of widespread community spread, have a low threshold. If so, ask other household members to ventilate the site by opening windows prior to arrival of the prehospital team.


PPE is MANDATORY. PPE advised are: FFP2 or FFP3 mask, an impermeable disposable gown, eye protection or face shield, double latex gloves and head cover/cap. The delay in commencing resuscitation caused by donning of PPE is an accepted delay and should not be compromised. Communicate with members of the same household from a two metre distance. Limit the number of rescuers to the minimum required for efficient resuscitation.



CONFIRMATION OF CARDIAC ARREST


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.



CHEST COMPRESSIONS


BEFORE STARTING chest compressions, COVER THE NOSE AND THE MOUTH of the patient, based on ILCOR recommendation that chest compressions and CPR have the potential to generate aerosols. (weak recommendation, very low certainty evidence).

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

Consider changing the person doing chest compressions EVERY MINUTE. Doing chest compressions using PPE is more tiring, decreasing compressions’ efficacy.

USE A MECHANICAL CHEST COMPRESSION DEVICE if available.



AIRWAY MANAGEMENT


All airway opening manoeuvres and adjunct use, including suctioning are to be avoided in COViD-19 scenarios until further direction.

Emphasis of pre-hospital resuscitation management will remain on early AED use and chest-compressions only CPR.



VASCULAR ACCESS


Attempts at vascular access remains important and unchanged.

The PROXIMAL TIBIA should be the preferred site if intraosseous access is used.



DURATION OF RESUSCITATION

TWENTY MINUTES of a sustained NON-SHOCKABLE rhythm should be considered as an indication to cease the resuscitation effort.



DECONTAMINATION

Arrange for area decontamination before leaving. Ensure Public Health Care contact with other household members.

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



CPR on CHILDREN

Rescuers who are coming in contact with the child for the first time, need to decide on the merits/risks of each case but may opt to omit the rescue breaths. Compression-only CPR is accepted in this scenario and all risk-abating advises for adult management hold true.




Resuscitation of COVID-19 patients in hospital settings


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.


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




Further Reading:


International Liaison Committee on Resuscitation (ILCOR). COVID-19 infection risk to rescuers from patients in cardiac arrest. Draft document. 30 Mar 2020. Updated 10 Apr 2020.

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

https://www.resus.org.uk/media/statements/resuscitation-council-uk-statements-on-covid-19-coronavirus-cpr-andresuscitation/

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

World Health Organisation. Getting your workplace ready for COVID-19. 03 Mar 2020. https://www.who.int/docs/default-source/coronaviruse/getting-workplace-ready-for-covid-19.pdf

World Health Organisation. Rational use of personal protective equipment for coronavirus disease (COVID-19). 19 MAR 2020.

https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdf?sequence=1&isAllowed=y

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.

https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html

Italian Resuscitation Council. Rianimazione Cardiopolmonare (RCP) durante l’epidemia da SARS-COV-2 e in caso di sospetta o confermata infezione COVID-19.

https://www.ircouncil.it/PER-IL-PUBBLICO/CORONAVIRUS-2/

© 2020 Malta Resuscitation Council