confirmed the importance of high‐quality CPR commencing as soon as cardiac arrest has been recognized. It referenced multiple studies that found no differences in neurologic outcomes or mortality between compression‐only and conventional high‐quality CPR but recommended that first‐responders should perform ventilations if trained and willing. It similarly re‐emphasized the importance of components such as compression rate between 100 and 120/min, noting lower survival when rates were faster. It emphasized a depth of 5 cm or 2 inches, the need for adequate chest recoil, and the need for a high as possible chest compression fraction [78].
As with many other facets of resuscitation, the COVID‐19 pandemic has significantly altered some of these recommendations, as the risk of coronavirus infection has increased the risk of some interventions (Figure 12.5). In Seattle, COVID‐19 was diagnosed in fewer than 10% of patients with OHCA and investigators estimated that, with an approximate 1% mortality rate for COVID‐19, approximately 1 rescuer in 10,000 bystander CPR events might die from the disease, compared with over 300 lives/10,000 events saved by the CPR [79].
Although older lay rescuers are more vulnerable to infection with SARS‐CoV‐2 and are unlikely to have access to adequate personal protective equipment (PPE), new guidelines state that if the cardiac arrest occurs at home, as the majority do, lay rescuers are likely to have already been exposed to COVID‐19 [80]. It is recommended that compression‐only CPR be delivered by lay rescuers, with a facemask or cloth covering the mouth and nose of the rescuer and the patient. Rescue breaths are still recommended for pediatric cardiac arrests, if the lay rescuers are household members who have been exposed to the patient at home. Lay rescuers should follow instructions given by the 9‐1‐1 telecommunicator [81].
The June 2020 consensus statement from the Emergency Cardiovascular Care Committee and Get With The Guidelines‐Resuscitation Adult and Pediatric Task Forces of the AHA stated that, “Before entering the scene, all rescuers should don PPE to guard against contact with both airborne and droplet particles,” and that personnel in the room or on the scene should be limited to those “essential for patient care” [80]. Hand hygiene should be performed before and after all patient contact, putting on and after removing PPE (including gloves), and contact with potentially infectious material [82].
The diagnosis of cardiac arrest still relies on the combination of unresponsiveness and an absence of normal breathing. Instead of opening the airway, and looking, listening, and feeling for breathing with the rescuer’s face close to the patient’s mouth and nose, it is recommended that rescuers place a hand on patient’s chest to feel for chest rise and fall while assessing for normal breathing [83]. The AHA statement continues to suggest that health care personnel check for a pulse while assessing respiratory effort.
ILCOR concluded that chest compressions and cardiopulmonary resuscitation have the potential to generate aerosols [84]. However, the risk of aerosol generation with defibrillation is very low. Therefore, ILCOR recommended that first‐responders move rapidly to defibrillation, using AEDs when possible. AHA guidelines state that efforts should be made to cover the face of the cardiac arrest victim with a cloth or face mask, with similar protection for the rescuer [80, 85]. Professional rescuers may consider defibrillation before donning PPE if they perceive that the benefit is greater than the risk [86].
Advanced Life Support
Biphasic defibrillation energies should be at least 150 J and monophasic energies should be 360 J. Following initial defibrillation, high‐quality CPR should follow. The highest possible inspired oxygen concentration should be used during CPR, although consideration should be given to titrating this downward if return of spontaneous circulation is obtained, as there is evidence of harm from both hypoxia and hyperoxia [85, 87]. An advanced airway such as a supraglottic airway, an endotracheal tube, or a bag‐mask device is acceptable for ventilation during CPR, with waveform capnography used to confirm and monitor endotracheal tube position.
Figure 12.5 ACLS cardiac arrest algorithm for patients with suspected or confirmed COVID‐19, reflecting a June 2020 consensus statement from the Emergency Cardiovascular Care Committee and Get With The Guidelines‐Resuscitation Adult and Pediatric Task Forces of the American Heart Association.
Source: Available at https://cpr.heart.org/‐/media/cpr‐files/resources/covid‐19‐resources‐for‐cpr‐training/english/algorithmacls_cacovid_200406.pdf?la=en. Reprinted with permission from: Circulation. 2020;141:e922–43, © 2020 American Heart Association, Inc.
Communicable Disease Considerations
The COVID‐19 pandemic has brought some additional communicable disease considerations to the forefront in ways that have changed systems’ approaches. There are clear risks to health care practitioners during care for potentially or actually infected patients. Health care workers are already the highest‐risk profession for contracting the disease due to proximity to patients and exposure, with paramedics being among the most vulnerable [88]. The World Health Organization, the AHA, and the Centers for Disease Control and Prevention defined several aerosol‐generating procedures for which clinicians need to wear aerosol level PPE, comprising face shield or goggles, N95 mask, gown and gloves [89, 90]. These were defined as:
open suctioning of airways
sputum induction
cardiopulmonary resuscitation
endotracheal intubation and extubation
non‐invasive ventilation (e.g., bi‐level positive or continuous positive airway pressure)
bronchoscopy
manual ventilation.
Procedures in which there was uncertainty about the potential for spread of infection included nebulization and high‐flow oxygen delivery. Although a systematic review was unable to find enough evidence to estimate the risk of chest compressions or defibrillation in relation to aerosol generation, guidelines have incorporated aerosol PPE for cardiac arrest resuscitation once a first attempt at defibrillation has been made [91].
Changes in advanced cardiac life support processes are primarily based on the risk associated with aerosol‐generating procedures. The first is early decision making about the need and appropriateness for continuing resuscitation, which is now recommended before transfer of a patient with OHCA into the emergency department. Factors may include age, comorbidities, and severity of illness [90]. Futile resuscitation attempts should be terminated in the field to limit the exposure of health personnel as much as possible, although this may be challenging. Some EMS guidelines have mandated that field termination of resuscitation should be considered immediately for patients with an initial rhythm of asystole or pulseless electrical activity, or after four rounds of CPR [92]. Similarly, they have indicated that return of spontaneous circulation should be sustained for at least 5 minutes, with a palpable pulse present and systolic blood pressure greater than 60 mmHg, before transporting the patient.
Airway management is a key consideration in controlling
