The novel COVID-19 virus pandemic has raised concern about safety of clinicians during cardiopulmonary resuscitation [CPR]. Amongst various aerosol producing procedures performed on patients, CPR is a highly aerosol-generating procedure. Worldwide clinicians are divided on consensus, whether health care workers [HCWs] should perform CPR on COVID-19 patients or not. At present Ppt is scarce on this topic. This disastrous pandemic has changed the risk-benefit balance for CPR. The argument for not attempting CPR on hospital patients with COVID-19 without ensuring personal protection is therefore justifiable, even though it may feel disagreeable.
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To learn AHA guidelines for CPR in Covid 19
To describe causes of cardiac arrest
To discuss risk for health care providers
To explain principles of CPR
To describe situation and setting of CPR
To demonstrate BLS, ACLS in adult and children
LEARNING OBJECTIVES
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• When the COVID pendemic started, we noticed an important
reduction in STEMI and so some of us thought that maybe cardiac
arrest can also be reduced.
• It was out-of-hospital cardiac arrests were increasing day by day,
and they went hand in hand with the COVID-19 trend.”
1st May 2020 (New England Journal of Medicine)
INTRODUCTION
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Figure showing Weekly incidences of OHCA during
the first 17 weeks of years 2012 to 2020.
Out-of-hospital cardiac arrest during the COVID-19 pandemic in
Paris, France: a population-based, observational study
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• Waiting longer to reach out to emergency medical services (EMS)
for help.
• Fear of contracting the illness when cared in a hospital.
• Overwhelmed health care systems lead to longer response times
from ambulances.
• Disease itself the virus causes systemic inflammation and an
enhanced immune 'cytokine' response.
Why the spike?
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• The American Heart Association, in collaboration with in
collaboration with the American Academy of Pediatrics, American
Association for Respiratory Care, American College of Emergency
Physicians, American Society of Anesthesiologists and with the
support of the American Association of Critical Care Nurses
released Interim Guidance for Life Support for COVID-19.
- AHA 9th April 2020
CPR GUIDELINES IN COVID-19
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CAUSES OF CARDIAC ARREST IN COVID-19
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• Acute respiratory distress syndrome
• Myocardial injury
• Ventricular arrhythmias
• Shock
• Some medications such as Hydroxychloroquine and Azithromycin
which can prolong the QT interval prologation.
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1. The administration of CPR involves performing numerous
aerosol-generating procedures, including chest compressions,
positive pressure ventilation, and establishment of an advanced
airway.
2. It require numerous providers to work in close proximity to one
another and the patient. This may result in lapses in infection
control practices.
RISK FOR HEALTH CARE PROVIDERS
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• There should be no discrimination for or against persons who
have or are suspected to have COVID-19 in relation to DNAR
decisions.
• As a general rule, a decision not to attempt CPR applies only to
CPR. A DNAR decision does not mean that other interventions
such as oxygen support or mechanical ventilation will not be
provided.
DNR IN COVID-19
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• If a person with decision-making capacity refuses CPR.
• Those close to the person with knowledge of their previously
expressed goals and preferences consider that he or she would
not want CPR.
• The senior clinical decision maker may judge that the harms of
CPR outweigh the potential benefits.
• Some people may be so unwell that death may be imminent and
unavoidable.
DNR Decision
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1. Reduce provider exposure to COVID-19 :
Before entering the scene, all rescuers should don PPE to guard
against contact with both airborne and droplet particles.
Limit personnel in the room or on the scene to only those essential for
patient care.
PRINCIPLES FOR CPR IN COVID-19
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Replacing manual chest compressions with mechanical CPR
devices to reduce the number of rescuers required for adults.
Clearly communicate COVID-19 status to any new providers
before their arrival on the scene.
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2. Prioritize oxygenation and ventilation strategies with
lower aerosolization risk:
Attach a HEPA filter securely, if available, to any manual or
mechanical ventilation device in the path of exhaled gas.
Patients in cardiac arrest should be intubated with a cuffed
endotracheal tube.
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Video laryngoscopy may reduce intubator exposure to
aerosolized particles and should be considered. If available.
If intubation is delayed and before intubation, consider manual
ventilation with a supraglottic airway or bag-mask device with a
HEPA filter.
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3. Consider the appropriateness of starting and continuing
resuscitation:
Healthcare systems should institute policies to guide front-line
providers in determining the appropriateness of starting and
terminating CPR for patients with COVID-19.
Risk stratification and policies should be communicated to
patients.
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1. Out-of-Hospital Cardiac Arrest (OHCA) :
Lay rescuers:
Rescuers in the community are unlikely to have access to
adequate PPE and therefore are at increased risk of exposure to
COVID-19 during CPR, compared to healthcare providers with
adequate PPE.
SITUATION & SETTING FOR CPR
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Chest compressions :
Lay rescuers should perform at least hands-only CPR after
recognition of a cardiac arrest event.
If willing and able, especially if they are household members who
have been exposed to the victim at home.
A face mask or cloth covering the mouth and nose of the rescuer
and victim may reduce the risk of transmission to a non-
household bystander.
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Public access defibrillation:
Because defibrillation is not expected to be a highly aerosolizing
procedure.
Lay rescuers should use an automated external defibrillator, if
available, to assess and treat victims of OHCA.
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2. In-Hospital Cardiac Arrest (IHCA) :
For those for whom resuscitation would be inappropriate,
decisions must be made and communicated.
For such patients, a do not attempt CPR (DNAR) decision is likely
to be appropriate.
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If the patient is at risk for cardiac arrest, consider proactively
moving the patient to Airborne Infection Isolation Rooms (AIIRs)
are where aerosol-generating procedures such as CPR should be
performed in the hospital.
Restrict the number of staff in the room or at the bedside.
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Adjust the ventilator settings :
Increase the FIO2 to 1.0.
Change mode to Pressure Control Ventilation to Assist Control and
limit pressure as needed to generate adequate chest rise (6 mL/kg
ideal body weight is often targeted, 4-6 mL/kg for neonates).
Adjust the trigger to Off.
Adjust respiratory rate to 10/min for adults and pediatrics and
30/min for neonates.
Adjust positive end-expiratory pressure level to balance lung
volumes and venous return.
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Proned patients at the time of arrest:
COVID-19 patients are often managed in the prone position
because this can improve oxygenation. Most of these patients will
be intubated.
In the event of cardiac arrest in the unintubated, prone patient,
whilst wearing the correct PPE,immediately turn the patient
supine before starting chest compressions.
In the event of cardiac arrest in an intubated patient who is prone,
it is possible to deliver chest compressions by pressing the
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STEPS :
Rescuers should wear airborne-precaution PPE.
Compress between the scapulae over the T7/10 vertebral bodies
at the usual depth and rate (5 to 6 cm at 2 compressions per
second).
Turn patient supine if:
a. Ineffective compressions – look at arterial line and aim for
diastolic pressure greater than 25 mmhg
b. Unable to restore a circulation rapidly.
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Defibrillator pad placement options in the prone position include:
a. Anterior-posterior (front and back) or
b. Bi-axillary (both armpits).
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Personal protective equipment (PPE) :
Gloves
Long-sleeved gown
Filtering facepiece 3 (FFP3) or N99 mask/respirator (FFP2 or
N95 if FFP3 not available)
Eye and face protection (full-face shield or polycarbonate
safety glasses or equivalent).
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The researchers conducted a Retrospective, cohort analysis in
Wuhan, China.
119 (87.5%) patients had a respiratory cause for their cardiac arrest
and 113 (83.1%) were resuscitated.
The patients receiving CPR, ROSC was achieved in 18 (13.2%)
patients, 4 (2.9%) patients survived for at least 30 days.
The researchers concluded that the survival of patients with severe
COVID-19 pneumonia who had an in-hospital cardiac arrest was
poor in Wuhan.
