The American Heart Association (AHA) and seven other medical societies have issued interim guidance to inform treatment of victims of cardiac arrest with suspected or confirmed COVID-19, focusing on reducing provider exposure, and prioritizing oxygenation and ventilation strategies, goals of care, and appropriateness of resuscitation.
The guidance is designed “to protect not only the patient but also the provider and involves strategies regarding oxygenation and ventilation that differ from what we’ve done in the past, since we have a strong feeling that this is a different disease process that may require different approaches than what we’ve dealt with in the past,” corresponding author Comilla Sasson, MD, PhD, vice president, Emergency Cardiovascular Care (ECC) Science and Innovation, American Heart Association, commented.
COVID-19 status should be communicated to any new providers prior to their arrival on the scene, the authors stress.
“Reducing risk of aerosolization during the process of intubation is key,” Sasson emphasized.
For this reason, a high-efficiency particulate air HEPA filter (if available) should be attached to any manual or mechanical ventilation device, specifically in the path of exhaled gas, before any breaths are administered.
Moreover, it is important to intubate early with a cuffed tube and connect to a mechanical ventilator, if possible. The intubator should be engaged with the “highest chance of first-pass success” and chest compression should be paused to intubate.
To further increase the chance of a successful first intubation, use of video laryngoscopy (if available) is helpful.
Additional guidance includes:
· Using a bag-mask device (or T-piece in neonates) with a HEPA filter and a tight seal prior to intubation
· Considering passive oxygenation with non-rebreathing face mask as an alternative to bag-mask device for short duration (in adults)
· Considering supraglottic airway if intubation is delayed
· Minimizing closed circuit disconnections.
“One big take-home point of the guidance is to consider resuscitation appropriateness, starting with goals of care when the patient comes to us, and continuing or stopping resuscitation when needed, based on the discussion with the family as well as local protocol,” Sasson said.
A variety of factors need to be taken into account, including age, comorbidities, and illness severity to determine the appropriateness of resuscitation, and “the likelihood of success” must be balanced “against the risk to rescuers and patients from whom resources are being diverted,” the authors state.
REFERENCE: Edelson et al: Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19; https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.047463