COVID-19 infection risk to rescuers from patients in cardiac arrest

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This Review is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final Review will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable.

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: none applicable.

CoSTR Citation

Couper K, Taylor-Phillips S, Grove A, Freeman K., Osokogu O, Court R, Mehrabian A, Morley P, Nolan JP, Soar J, Berg K, Olasveengen T, Wychoff M, Greif, R, Singletary N, Castren M, de Caen A, Wang T, Escalante R, Merchant R, Hazinski M, Kloeck D, Heriot G, Neumar R, Perkins GD on behalf of the International Liaison Committee on Resuscitation.

COVID-19 infection risk to rescuers from patients in cardiac arrest.

Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR), 2020 March 30. Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review (CRD42020175594) conducted by Warwick Evidence at the University of Warwick with involvement of clinical content experts. Evidence for adult and pediatric literature was sought and considered by the ILCOR COVID-19 task and finish group.

Systematic Review

NOT YET PUBLISHED

PICOST

This review encompassed three review questions.

Research question one

The PEOST (Population, Exposure, Outcome, Study Designs and Timeframe)

Population: Individuals in any setting

Exposure: Delivery of:

1) Chest compressions

2) Defibrillation

3) CPR (all CPR-interventions that include chest compressions)

Outcomes: Generation of aerosols (critical outcome).

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies, case reports/series, cadaver studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search completed March 24 2020.

Research question two

The PEOST (Population, Exposure, Outcome, Study Designs and Timeframe)

Population: Individuals in any setting wearing any/ no personal protective equipment

Exposure: Delivery of:

1) Chest compressions

2) Defibrillation

3) CPR (all CPR-interventions that include chest compressions)

Outcomes: Transmission of infection (critical outcome).

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies, case reports/ series) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search completed March 24 2020.

Research question three

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Individuals delivering chest compressions and/or defibrillation and/ or CPR in any setting

Intervention: Wearing of personal protective equipment

Comparison: Wearing any alternative system of personal protective equipment or no personal protective equipment

Outcomes: Infection with the same organism as patient (critical-9); PPE effectiveness (critical- 7); Quality of CPR (important -5)

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies, cadaver studies, simulation studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search completed March 24 2020.

PROSPERO Registration CRD42017080475

In most cases bias was assessed per comparison rather than per outcome, since there were no meaningful differences in bias across outcomes. In cases where differences in risk of bias existed between outcomes this was noted.

Consensus on Science

Across all research questions and outcomes, heterogeneity in study design, exposures and outcomes precluded meta-analysis.

Research question one

For the critical outcome of aerosol generation, we identified evidence from two case reports (Chalumeau 2005 e29-30, Nam 2017 e2017052) involving performance of airway manoeuvres (suctioning/ tracheal intubation), that reported the generation of aerosols based on the transmission of infection. Neither case reported delivery of defibrillation. Overall evidence certainty was rated as very low due to serious risk of bias and serious indirectness.

Research question two

For the critical outcome of transmission of infection, we included two retrospective cohort studies comprising 656 healthcare workers (one with 624 and one with 32 participants),(Loeb 2004 251, Raboud 2010 e10717) one case-control study comprising 477 healthcare workers,(Liu 2009 52-59), and five case-reports(Chalumeau 2005 e29-30, Christian 2004 287-93, Kim 2015 1681-3, Knapp 2016 48-51, Nam 2017 e2017052)

Of the three observational studies, two did not report a statistically significant association between CPR-related activities and infection.(Loeb 2004 251; Raboud 2010 e10717) A case-control study (Liu 2009 52-59) reported an association between chest compression delivery and SARS infection in healthcare workers (adjusted odds ratio 4.52, 95% confidence intervals 1.08-18.81), but the analysis did not adjust for other key potential contacts and there was a significant correlation between chest compressions and tracheal intubation.

Two case reports described transmission of an airborne bacterial infection in cases where CPR was delivered (including ventilation) and PPE was not worn.(Chalumeau 2005 e29-30, Knapp 2016 48-51) In three cases, transmission of an airborne viral infection was described, all of which described healthcare workers wearing PPE.(Christian 2004 287-93, Kim 2015 1681-3, Nam 2017 e2017052) In one case report, a nurse wearing personal protective equipment who delivered only chest compressions developed infective symptoms following a cardiac arrest, although it is unclear whether the nurse was also present in the room during tracheal intubation and bag-mask ventilation. Delivery of defibrillation was not described in any of the three case reports. Overall evidence certainty was rated as very low due to serious risk of bias and serious indirectness.

Research question three

For the critical outcome of Infection with the same organism as the patient, we found no evidence.

For the critical outcome of PPE effectiveness, we found evidence from one manikin randomized controlled trial enrolling 30 healthcare providers.(Shin 2017 e8308) The study reported differences in the adequacy of protection provided by different mask types during delivery of chest compressions (cup-type 44.9% ± 42.8 v fold-type 93.2% ± 21.7 v valve-type 59.5% ± 41.7, p<0.001), and evidence of reduced protection from a pre-chest compression baseline assessment. Evidence certainty was rated as low, downgraded for serious risk of bias and serious indirectness.

For the important outcome of CPR quality, we included evidence from three randomized controlled manikin trials enrolling 104 participants.(Schumacher 2013 33-8, Shin 2017 e8308, Watson 2008 333-8) The outcome of treatment time was reported in two studies.(Schumacher 2013 33-8, Watson 2008 333-8) In a study of paediatric cardiac arrest, paramedic time to complete four key tasks, including tracheal intubation and intraosseous access, was longer when paramedics wore personal protective equipment (no PPE 261 ± 12 seconds v full face mask 275 ± 9 v hood 286 ± 13, p=0.001).(Schumacher 2013 33-8) In a study of 58 firefighters that compared the effect of wearing different types of gown along with gloves, eye protection and an N95 mask found that not wearing a gown reduced time to first compression (no gown 39 seconds (95% CI 34–43) v standard gown 71 seconds (95% CI 66–77, p < 0.01); v modified gown 59 seconds (95% CI 54–63), p < 0.001). The outcome of chest compression quality was reported in one study enrolling 30 participants which found no difference in chest compression quality between mask types.(Shin 2017 e8308) Evidence certainty was rated as very low, downgraded for very serious risk of bias and serious indirectness.

Treatment Recommendations

  • We suggest that chest compressions and cardiopulmonary resuscitation have the potential to generate aerosols (weak recommendation, very low certainty evidence).
  • We suggest that in the current COVID-19 pandemic lay rescuers consider compression-only resuscitation and public-access defibrillation (good practice statement).
  • We suggest that in the current COVID-19 pandemic, lay rescuers who are willing, trained and able to do so, may wish to deliver rescue breaths to children in addition to chest compressions (good practice statement).
  • We suggest that in the current COVID-19 pandemic, healthcare professionals should use personal protective equipment for aerosol generating procedures during resuscitation (weak recommendation, very low certainty evidence).
  • We suggest it may be reasonable for healthcare providers to consider defibrillation before donning aerosol generating personal protective equipment in situations where the provider assesses the benefits may exceed the risks (good practice statement)

Justification and Evidence to Decision Framework Highlights

  • This topic was prioritized by ILCOR based on ongoing international clinical uncertainty regarding the optimum approach regarding the initiation of chest compressions and defibrillation in known or suspected COVID-19 patients.
  • In the context of chest compressions, aerosol generation is plausible as chest compressions do generate passive ventilation associated with small tidal volumes.(Deakin 2007 436-443) It also has parallels with chest physiotherapy techniques which are associated with aerosol generation, although in that context the intent is often to induce coughing and aerosol generation.(Simonds 2010 131-172) Furthermore, the person performing chest compressions is in physical contact with the patient and in close proximity to the airway.
  • We did not identify evidence that defibrillation generates aerosols. If it occurs the duration of an aerosol generating process would be brief. Furthermore, the use of adhesive pads means that defibrillation can be delivered without direct contact between the defibrillator operator and patient.
  • We acknowledge the risks of confounding as none of the identified studies were able to separate risks related to individual components of a resuscitation attempt (compressions, ventilations, defibrillation) from the resuscitation attempt as a whole. We further note the indirectness of evidence as no included studies reported data on COVID-19 which may have a different transmissibility risk to other infections.
  • Outside of the COVID-19 pandemic, each year over 1 million people sustain an out of hospital cardiac arrest around the world. CPR and defibrillation provide these people with the only chance of survival. (Iwami 2020 in press)
  • In making recommendations, there is a need to carefully balance the benefit of early treatment with chest compressions and defibrillation (prior to donning personal protective equipment) with the potential harm to the rescuer, their colleagues and the wider community if the rescuer were to be infected with COVID-19.
  • In suggesting that lay rescuers consider compression only CPR and public access defibrillation, the writing group noted that the majority of out of hospital cardiac arrests occur in the home where those providing resuscitation are likely to have been in contact with the person requiring resuscitation; that accessibility to personal protective equipment for aerosol generating procedures is likely to be limited; there may be significant harm from delaying potentially lifesaving treatment if resuscitation is deferred until arrival of personnel with suitable personal protective equipment.
  • In suggesting that lay rescuers who are willing, trained and able to do so, may wish to consider rescue breaths in addition to chest compressions, the writing group considered that bystander rescuers are frequently those who routinely care for the child. In that case, the risk of the rescuer newly acquiring COVID-19 through provision of rescue breaths is greatly outweighed by improved outcome for children in asphyxial arrest who receive ventilations.
  • In suggesting that healthcare professionals should use personal protective equipment for aerosol generating procedures we considered that healthcare professionals would have greater access to PPE, would likely be trained in its use, and may be able to don PPE before arriving at the patient’s side, thus minimizing delays to commencing or continuing resuscitation.
  • Given the potential for defibrillation within the first few minutes of cardiac arrest to achieve a sustained return of spontaneous circulation and the very low likelihood of defibrillation generating an aerosol, we suggest healthcare providers consider the risks versus benefits of attempting defibrillation prior to donning personal protective equipment for aerosol generating procedures.
  • The time taken for a team to don personal protective equipment may be up to 5-minutes, although individuals may don equipment in around one-minute(Abrahamson 2006 R3, Watson 2008 333-8). However, once donned we identified evidence that there is a risk of mask slippage during chest compression delivery rendering the protective equipment less effective.
  • The practical implementation of these recommendations will require healthcare systems to consider availability of PPE, training needs of their workforce and infrastructure / resources to provide on-going care for patients resuscitated from cardiac arrest.

Knowledge Gaps

No identified study assessed the potential for aerosol generation through delivery of chest compressions and/or defibrillation without associated airway manoeuvres.

Attachments

Evidence-to-Decision Table: COVID-19 infection risk to rescuers from patients in cardiac arrest

GRADE Table: COVID-19 infection risk to rescuers from patients in cardiac arrest

References

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Chalumeau M, Bidet P, Lina G, Mokhtari M, Andre MC, Gendrel D, Bingen E and Raymond J. Transmission of Panton-Valentine leukocidin-producing Staphylococcus aureus to a physician during resuscitation of a child. Clinical Infectious Diseases. 2005;41:e29-30.

Chan PS, Krumholz HM, Nichol G and Nallamothu BK. Delayed Time to Defibrillation after In-Hospital Cardiac Arrest. New England Journal of Medicine. 2008;358:9-17.

Christian MD, Loutfy M, McDonald LC, Martinez KF, Ofner M, Wong T, Wallington T, Gold WL, Mederski B, Green K, Low DE and Team SI. Possible SARS coronavirus transmission during cardiopulmonary resuscitation. Emerg Infect Dis. 2004;10:287-93.

Deakin CD, Cheung S, Petley GW and Clewlow F. Assessment of the quality of cardiopulmonary resuscitation following modification of a standard telephone-directed protocol. Resuscitation. 2007;72:436-443.

Gräsner J-T, Wnent J, Herlitz J, Perkins GD, Lefering R, Tjelmeland I, Koster RW, Masterson S, Rossell-Ortiz F, Maurer H, Böttiger BW, Moertl M, Mols P, Alihodžić H, Hadžibegović I, Ioannides M, Truhlář A, Wissenberg M, Salo A, Escutnaire J, Nikolaou N, Nagy E, Jonsson BS, Wright P, Semeraro F, Clarens C, Beesems S, Cebula G, Correia VH, Cimpoesu D, Raffay V, Trenkler S, Markota A, Strömsöe A, Burkart R, Booth S and Bossaert L. Survival after out-of-hospital cardiac arrest in Europe - Results of the EuReCa TWO study. Resuscitation. 2020;148:218-226.

Hawkes C, Booth S, Ji C, Brace-McDonnell SJ, Whittington A, Mapstone J, Cooke MW, Deakin CD, Gale CP, Fothergill R, Nolan JP, Rees N, Soar J, Siriwardena AN, Brown TP and Perkins GD. Epidemiology and outcomes from out-of-hospital cardiac arrests in England. Resuscitation. 2017;110:133-140.

Kim WY, Choi W, Park SW, Wang EB, Lee WJ, Jee Y, Lim KS, Lee HJ, Kim SM, Lee SO, Choi SH, Kim YS, Woo JH and Kim SH. Nosocomial transmission of severe fever with thrombocytopenia syndrome in Korea. Clinical Infectious Diseases. 2015;60:1681-3.

Knapp J, Weigand MA and Popp E. Transmission of tuberculosis during cardiopulmonary resuscitation. Focus on breathing system filters. [German]. Notfall und Rettungsmedizin. 2016;19:48-51.

Liu W, Tang F, Fang LQ, De Vlas SJ, Ma HJ, Zhou JP, Looman CWN, Richardus JH and Cao WC. Risk factors for SARS infection among hospital healthcare workers in Beijing: A case control study. Tropical Medicine and International Health. 2009;14:52-59.

Loeb M, McGeer A, Henry B, Ofner M, Rose D, Hlywka T, Levie J, McQueen J, Smith S, Moss L, Smith A, Green K and Walter SD. SARS among critical care nurses, Toronto. Emerging infectious diseases. 2004;10:251-5.

Nam HS, Yeon MY, Park JW, Hong JY and Son JW. Healthcare worker infected with Middle East Respiratory Syndrome during cardiopulmonary resuscitation in Korea, 2015. Epidemiol Health. 2017;39:e2017052.

Nikolaou N, Dainty KN, Couper K, Morley P, Tijssen J, Vaillancourt C, Olasveegen T, Mancini MB, Travers A, Løfgren B, Nishiyama C, Stanton D, Ristagno G, Considine J, Castren M, Smyth M, Kudenchuk P, Escalante R, Gazmuri R, Brooks S, Chung SP, Hatanaka T, Perkins G, Maconachie I, Aickin R, Caen AD, Atkins D, Bingham R, Couto TB, Guerguerian A-M, Meaney P, Nadkarni V, Ng K-C, Nuthall G, Ong Y-KG, Reis A, Schexnayder S, Shimizu N and Voorde PVd. A systematic review and meta-analysis of the effect of dispatcher-assisted CPR on outcomes from sudden cardiac arrest in adults and children. Resuscitation. 2019;138:82-105.

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CPR
COVID-19

Discussion

GUEST
Ken Spearpoint (303 posts)
Thank you for the rapid publication of this review. I have conducted an extensive search of the literature independent of this important work. I could only one paper that mentions defibrillation in the context of being a potential AGP, and it indicated as you have done that there is no reliable evidence that defibrillation is an AGP’s, but it is important to safety to note that there is no evidence that defibrillation is NOT an AGP. In the absence of evidence we have to rely on professional opinion. When we defibrillate people, arms can flail and air is usually expelled very rapidly from the patient’s mouth and nose as a result of the widespread muscular contraction that occurs in the chest, lungs and heart as a result of electrical energy passing through the person’s chest wall. It isn’t difficult to work out, that if a person infected with the Covid-19 virus, receives an electric shock from a defibrillator, at that moment, millions of viral particles will be forcefully expelled into the air from the mouth and the nose. There is very strong evidence specific to corona virus particles, that theses particles may remain present in the air for up to three hours. (https://www.nejm.org/doi/10.1056/NEJMc2004973) This places any HCP without adequate mask protection (not wearing a respirator type mask) in the vicinity of the patient in a position of risk. I would not put myself in that position, nor would I expect any other HCP to do so. I would be grateful if you would consider this as a significant safety risk to hospital-based healthcare workers
Reply
GUEST
Kate Field (303 posts)
Ken, I completely concur with your statement that there is no evidence that defibrillation is NOT an AGP, and agree with your opinion. I think it is imperative that HCW's safety is prioritised over defibrillation, failure to recommend PPE for HCWs in the setting of defibrillation of COVID-19 positive patients (or presumed positive) unnecessarily puts them at risk, and may have future legal repercussions.
GUEST
Mike Gale (303 posts)
Ken, I completely agree. The evidence is poor in relation to defibrillation being an AGP. Rapid muscular contraction from the immediate delivery of energy from defibrillation may produce little expiratory aerosol, however the ROSC will. The benefit of rapid and early defibrillation is to the patient with the risks the HCP's not fully accounted for. What are the benefits and risks associated with delayed defibrillation and appropriate PPE. Defibrillation of shockable rhythm may produce ROSC in a timeframe not permitting the donning of PPE even if it is available. Defibrillation prior to donning of PPE would risk HCP's to an unnecessary risk.
GUEST
Jonathan Wyllie (303 posts)
This is an excellent and timely review. It is helpful to all who are trying to deal with COVID-19 and should inform regional and national guidelines. There is a lack of evidence identified which hopefully this pandemic will rectify if countries keep appropriate data. For the present if Health Care Professional Health is prioritised the recommendations aren’t entirely appropriate in the balance of probabilities and risks. Thank you for this work at this time.
Reply
GUEST
Vinay Nadkarni (303 posts)
This statement needs to be qualified for ADULTS: "We suggest that in the current COVID-19 pandemic lay rescuers consider compression-only resuscitation and public-access defibrillation (good practice statement)." also the review did not seem to pick up the manuscript showing that CPR can be done effectively in full PPE for children: Pediatr Emerg Care. 2020 Feb 24. doi: 10.1097/PEC.0000000000002028. [Epub ahead of print] Impact of Personal Protective Equipment on the Performance of Emergency Pediatric Tasks. Adler MD1,2, Krug S1, Eiger C3, Good GL4, Kou M5, Nash M6, Henretig FM7, Hornik CP8, Gosnell L8, Chen JY9, Debski J9, Sharma G9, Siegel D10, Donoghue AJ7,11; Best Pharmaceuticals for Children Act–Pediatric Trials Network¶¶. Author information Abstract OBJECTIVES: Personal protective equipment (PPE) is worn by health care providers (HCPs) to protect against hazardous exposures. Studies of HCPs performing critical resuscitation tasks in PPE have yielded mixed results and have not evaluated performance in care of children. We evaluated the impacts of PPE on timeliness or success of emergency procedures performed by pediatric HCPs. METHODS: This prospective study was conducted at 2 tertiary children's hospitals. For session 1, HCPs (medical doctors and registered nurses) wore normal attire; for session 2, they wore full-shroud PPE garb with 2 glove types: Ebola level or chemical. During each session, they performed clinical tasks on a patient simulator: intubation, bag-valve mask ventilation, venous catheter (IV) placement, push-pull fluid bolus, and defibrillation. Differences in completion time per task were compared. RESULTS: There were no significant differences in medical doctor completion time across sessions. For registered nurses, there was a significant difference between baseline and PPE sessions for both defibrillation and IV placement tasks. Registered nurses were faster to defibrillate in Ebola PPE and slower when wearing chemical PPE (median difference, -3.5 vs 2 seconds, respectively; P < 0.01). Registered nurse IV placement took longer in Ebola and chemical PPE (5.5 vs 42 seconds, respectively; P < 0.01). After the PPE session, participants were significantly less likely to indicate that full-body PPE interfered with procedures, was claustrophobic, or slowed them down. CONCLUSIONS: Personal protective equipment did not affect procedure timeliness or success on a simulated child, with the exception of IV placement. Further study is needed to investigate PPE's impact on procedures performed in a clinical care context.
Reply
GUEST
Annette Rickard (303 posts)
We need evidence from the current pandemic. This literature looks at historic smaller outbreaks and not specifically at the important areas of compression only or ventilation or defibrillation. Please, please start gathering data from the regions of the international community who have experienced this first and let us do some learning.
Reply
GUEST
Carl Gwinnutt (303 posts)
Interesting and useful review. Can this be made clear that this it only refers to adult victims of cardiac arrest. Emergency Service response times can be in excess of 20-30 minutes, even for a cardiac arrest, especially in isolated rural settings such as the southwest of the UK where I live. Chest compressions only CPR is unlikely to be effective. Furthermore not all cardiac arrests in these circumstances will be due to COVID-19. Where there is good evidence that it is in someone with known cardiac disease, and no evidence of infection with COVID-19, CPR should be performed with use of an AED at the earliest opportunity. Finally, the reference to work by Deakin is incorrect. The correct reference is Deakin CD, O'Neill JF, Tabor T. Resuscitation 2007;75:53-59. This was a study in intubated patients, receiving chest compression only CPR, where the mean tidal volume was only 41.4 ml (range 33-62ml). No investigation was carried out into aerosol generation.
Reply
GUEST
Christian Vaillancourt (303 posts)
Unfortunately, experience from Italy, NY, New Orleans, Copenhagen reveals that Covid-19 was found often in unsuspected cases. On CT-abd for patients admitted for appendicitis (lower lung cuts), on shoulder Xray of dislocated shoulder, and on autopsy...all unsuspected Covid+ cases. Once reaching a pandemic and significant community transmission, especially given the possible contagiousness starting 24-48hrs prior to any symptom, it is probably dangerous to play a guessing game when it come to who has and who doesn't have Covid. Agree many will fall victim of these precautions...but we cannot afford to lose any more healthcare workers.
GUEST
David Cooper (303 posts)
Experience in China, Italy and elsewhere demonstrates that the most critical shortfall in the healthcare system is not a shortage of ventilators, nor of PPE, but of trained personnel to use them, especially as the pandemic drags on for weeks or months. Preservation of skilled staff is essential for the long-term sustainability of the healthcare system. Acknowledging the dearth of high-level evidence at this time, I believe that a stronger stance on the use of personal protective equipment in the face of the unknown would be appropriate. ILCOR should take this opportunity to provide leadership in a time of crisis and not be hamstrung by academic conventions that were never meant for this type of situation. If little level 1 evidence exists then an opinion based on first-principles may reasonably be offered to minimise harm.
Reply
GUEST
Christian Vaillancourt (303 posts)
Timely and important review. Many thanks to all the authors. I have some concerns with regard to the treatment recommendation on potential for production of aerosol particles during chest compressions. The treatment recommendation currently reads as follow: We suggest that chest compressions and cardiopulmonary resuscitation have the potential to generate aerosols (weak recommendation, very low certainty evidence). Reading the review content, it appears there was no direct evidence evaluating this question specifically. On the other hand, some suggestions have been made that the tidal volume generated during chest compressions is barely above the patient's respiratory dead space. Would be far less significant than a patient's own cough, which is considered a "droplet" producing event. I have no doubt that chest compressions DO generate some levels of particle production. A key element to determine is if these are "droplets" or "aerosolized" particles. Most health care workers are now wearing surgical masks on clinical units. We have recently completed a cardiac arrest simulation at our institution where we are asking these health care workers to doff their surgical masks and put on aerosol N95 masks BEFORE initiation of chest compressions. At best, this resulted in a 2-3 min no flow delay before compressions were initiated. I am completely in support of staff wearing PPE during chest compressions. I can't help but wonder if aerosol N95 masks are necessary during chest compressions. This, before we start manipulating the airway for LMA/ETT intubation during which N95s SHOULD be worn. We should of course always be on the side of safety...but in the absence of any direct evidence, how many cardiac arrest victims may be harmed using this abundance of caution? Person discovering the cardiac arrest victim could possibly initiate CPR (and apply AED/defib) while wearing their "droplet" surgical mask, and leave the room as soon as someone else enters wearing "aerosol" protection with N95 and BEFORE airway manipulation occur.
Reply
GUEST
Nat Kondos (303 posts)
I completely agree with the above statement from Christian Vaillancourt- at our organisation most staff (outside of high risk areas ED,ICU, theatre or recovery) for covid positive patients for routine care- not aerosol generating will be wearing droplet precautions so we have put in place that the first responder can start compressions only CPR once Hudson mask applied to patient's face but this responder needs to replaced as soon as possible and if the second responder who would be wearing airborne precautions enters the room and defib can be attempted but with the first responder in droplet precautions is to stand at the foot of the bed- at least two meters away from the patient. Then they get swapped out at the earliest possible time with a responder in airborne precautions- once all staff in the room are in airborne precautions then we can attempt airway-ventilation with intubation/LMA bag vent with viral filter and lots of muscle relaxant etc. as per the ideal process- then recommence CPR once airway secured. If staff are caring for a patient in a non-covid area and non-covid positive patient then they leave the room as soon as cardiac arrest is confirmed and don aerosol precautions PPE. It does increase delay to compressions but staff safety is imminent. Happy for your thoughts on this.
GUEST
AbdulMajeed Khan (303 posts)
Thanks for your quick response to the situation of COVID19. It very extensive review and up to the points needed by most of the councils particularly in our area.
Reply
GUEST
Resy van Beek (303 posts)
Thank you for this extensive review as well as for the responses. I am in agreement with some of the comments already made. I will mainly comment on BLS in the health care setting as that is where my area of expertise is. As mentioned by some already, the evidence for the risk for AGP of defibrillation is unclear and the risk for transmission during CPR is not deemed high, I do agree with comments made by others that health care staff safety is most important. I think providing defibrillation prior to donning PPE should NOT be recommended. I think all health care staff should done PPE prior to attempt any part of the BLS (and ALS) algorithm for COVID positive/suspected patients. I am in strong favour of compression-only CPR until a definitive airway (LMA) has been established. ANd airway management should only be attempted by experienced operators. We all know that maintaining a good seal with bag mask ventilation can be very challenging during a cardiac arrest and the airway operator is the person closest to the 'fire line' of COVID droplets so we should not put more people at risk than required. I would like ILCOR (and the national resuscitation councils following ILCOR guidelines) to be strong in their advice for recommendations for BLS/ALS during the COVID-pandemic. Recommendations that state that "providers can consider" might not provide enough guidance and can create more confusion. I would prefer strong recommendations. Individual health care organisations and first aid provides can still decide what they do with these recommendations. People are looking at experts to get advice - I think in times like these the panels of experts need to step up and provide strong guidance.
Reply
GUEST
Nilmini Wijesuriya (303 posts)
We still have a very limited access to defib pads. As the rescuer has to get quite close to deliver shocks with paddles ,isn’t it better to approach only with proper PPE?
Reply
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Mitragee Premaratne (303 posts)
Timely and important review. Many thanks to all the authors In most developing countries we use manual hand held paddles instead of self adhesive pads . Is this considered a AGP ? When we talk about defibrillation it is better to reflect on above as well. Bringing both paddles to the chest and switching off oxygen before the shock needs 2 persons unless single rescuer switch off oxygen , select energy charge the paddles on the machine and then bring the paddles to the chest .
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Chamila Jayasekera (303 posts)
There are countries like ours which still use paddles in some centres, for defibrillation, instead of adhesive pads and would be interesting to know what recommendations can be given. Thanks.
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James Fenwick (303 posts)
Could we not just ask resuscitation professionals who has, during resuscitation experienced splashing from the patients mouth / airway while performing chest compressions, especially with so much emphasis on compressions we are often starting when the patient is not breathing normally, so encounter agonal breaths against our compressions. I know several people I have spoken with have experienced it. Is that an aerosol? For me, it is.
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Paul Snobelen (303 posts)
Such an important and relevant review considering the times we are in. Thank you to all involved on the timeliness of this work. A couple of comments: 1) I would also note that dispatcher provided CPR should remove instruction to “ventilate” or provide “rescue breaths” if that is part of their current instruction. Also advise that dispatch directed CPR modifing breathing assessment from “place your ear close to the patient’s mouth” to “Can you see the chest moving up and down” 2) In the absence of having a cloth or towel to place over the mouth and nose of someone suffering an OHCA for lay rescuers, could it also be recommended that the lay rescuer turn the patients head to the side to allow any froth, blood or fluids to drain. Our work with lay rescuers has shown that fluids can cause a distraction for lay rescuers as they will physically roll a person to clear the mouth. Turning the head will help minimize the potential movement and promote uninterrupted compressions. However, I support the notion of a cloth being placed over the mouth and nose as this will hide some of the visuals associated with agonal breathing. A potential problem is if they hear audible noises as a result of agonal breathing and experience has shown a lay rescuer will most likely remove the cloth and discontinue compressions. We will watch for this our OHCA’s. Our work has shown that the distraction of agonal breathing interrupting compressions was only present in a quarter of the cases we followed-up with. So in addition to the cloth as a barrier, an alternative I would suggest would be to turn the patients head to the side. I do not foresee a cognitive barrier or concern from a lay rescuer’s perspective discontinuing ventilations and switching to compression only CPR. Compression only CPR is very common now.
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Johannes Heymer (303 posts)
We conducted a study on aerosol spread during cpr. A preprint short report can be found here: https://zenodo.org/record/3739498 Recent research revealed, that a supraglottic airway is at least non inferior to other methods of airway management and ventilation in the context of cardiac arrest. We conclude that, especially in the prehospital environment and in the context of limited PPE, the immediate insertion of a laryngeal tube with an airway filter may reduce aerosol spread during chest compressions.
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Johannes Heymer (303 posts)
We conducted a study on aerosol spread during cpr. A preprint short report can be found here: https://zenodo.org/record/3739498 Recent research revealed, that a supraglottic airway is at least non inferior to other methods of airway management and ventilation in the context of cardiac arrest. We conclude that, especially in the prehospital environment and in the context of limited PPE, the immediate insertion of a laryngeal tube with an airway filter may reduce aerosol spread during chest compressions.
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Justin Morgenstern (303 posts)
I think the conclusion around CPR and transmission made here is entirely inappropriate based on the data. You cite 2 studies that were not statistically significant, but one of those studies had a total of 3 people who gave CPR. (Loeb2004) That is clearly not enough to conclude the practice is safe. The problem is that you have framed the question wrong. The question should not and cannot be "is there evidence that CPR increases transmission?" The question needs to be, "Is there evidence that CPR can be done safely without full airborne precautions?" In other words, if you were designed this as a trial right now, you must be designing it as a non-inferiority trial. Common sense tells us that CPR is incredibly high risk. Basic science tells us it is incredibly high risk. The number of healthcare workers who have become ill (with SARS and COVID19) tells us that it is high risk. We would need strong proof to move away from that position. When you combine the data from the 3 available studies, the point estimate for for the odds ratio is on the side of CPR being dangerous (OR 2.3) and the 95% confidence interval goes all the way to an odds ratio of 22. You absolutely cannot use that data to make the statement that CPR is safe. It is not accurate, and will lead to significant harm in the healthcare community.
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Timothy Ellender (303 posts)
Our simulation team did a small study with residents 6 months prior to COVID where we looked at resident exposure risk in multi-task procedures. We use fluorescent tracer and looked at room/personnel spread. Wow! Spread was reduced by 1/2 when we used a simple cotton cover sheet-separating patient and personnel.
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Justin Morgenstern (303 posts)
I made a previous comment after completely misreading the recommendations being made here. I think the key point in my comment that we need to be asking whether there is evidence that it is safe to do procedures, rather than asking whether there is evidence that such procedures are clearly dangerous, is correct. However, the criticism of the guideline was entirely unfounded and based entirely on my misinterpretation. I apologize for any confusion. I think this is tremendous work and appreciate everything your group does trying to make this complex literature usable for all of us. (I don't see the comment yet, so maybe it never even made it through, and I will be saved the embarrassment.)
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Andy Davies Resuscitation Coordinator (303 posts)
New , current New Zealand guidelines are as follows If you have access to personal protective equipment (PPE) (e.g. appropriate face mask, disposable gloves, eye protection), these should be worn. Lay a piece of clothing or a towel over the person’s mouth. The cloth is not PPE but may prevent some droplets/cough spray. Check for Response Check to see if the person is responding. Call for Help Call for an Ambulance. Advise operators if the person is in isolation because of possible COVID- 19. Remember, the Ambulance personnel responding will be wearing PPE. Recognise Cardiac Arrest Open the person’s airway with a head tilt, chin lift. Look for the absence of normal breathing. Do not listen or feel for breathing by placing your face next to theirs. If in doubt, commence compressions. Commence Chest Compressions Push in the centre of the chest, hard and fast Adults and Children Mouth-to-Mouth In many cases the person in cardiac arrest is a loved one or known to you. In that situation you may be willing to do mouth-to-mouth. This gives the best chance of survival, particularly for children. Without treatment, people in cardiac arrest will die. Defibrillators Get a defibrillator as quickly as possible. Follow the instructions to defibrillate shockable rhythms rapidly. The early restoration of circulation may prevent the need for airway and ventilatory support. We know that MOST people who have COVID , under the age of 60, don't die, but everyone in cardiac arrest- without intervention, does. The risk of contracting COVID from a CA victim without symptoms would be low, and the risk of a rescuer under 60 dying, also low. We should try to avoid mixing layperson CPR with guidelines for Health professionals. There needs to be 3 clear parthways 1- Chart for CPR on the street (Non-symptomatic ) 2- COVID 19 +ve or suspected at home. 3-COVID 19 +ve or suspected in hospital . Most COVID19 deaths we assume are PEA and end of life events .
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Daniel Jost (303 posts)
I can contribute by bringing our experience as professional first responders (firefighters) to our homes. When they arrive at the bedside of an unconscious patient, to validate the absence of ventilation and, therefore the cardiac arrest, they use of the "Hands-on belly" method (Derkenne et al. 2020) that we use systematically since several years for OHCA detections by telephone by lay rescuers. The Firefighters put their hands on the chest or stomach to detect any movement. If this movement (eventually gasp) is more than 7 seconds apart, they start chest compressions and put the defibrillator on. They do not need to approach the victim's face to recognize the cardiac arrest formally.
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Emily Oliver (303 posts)
Thank you for this rapid and important review. The British Red Cross is providing this response in the context of eventually using the recommendations to shape its own communications, clinically and educationally, to lay responders and first aid volunteers. The paper addresses questions asked on the assumption that cardiac arrest is already confirmed. It does not refer to earlier aspects of the BLS algorithm of safety, checking for response, opening the airway and checking breathing which we understand could present the greatest risk to the lay rescuer given the proximity to the patient's nose and mouth. These aspects also have COVID-19 related considerations. Whilst recognising that this was not the focus of the paper, acknowledgement of considerations regarding infection risk at the assessment stage of the process from the lay rescuer perspective would be helpful, particularly with regard to moving the patient to their back, exposing their chest etc. It is also important to note that considerations regarding both touching the patient and use of PPE are necessarily different for lay responders living with the patient requiring CPR (and therefore already exposed to coronavirus if it is present amongst inhabitants), versus professional responders, particularly regarding the skill set involved in recognising the need for CPR and having adequate PPE available. The writing group has done a laudable job in acknowledging the circumstances of likely need for lay responder CPR (i.e. in the home, with members of a household who are necessarily occupying the same space already during this pandemic). However, it would be helpful if advice which is more specific for lay versus professional responders could be explicit. Messaging which implies a similar level of danger to both lay responders living with the patient and incoming professional responders could be misconstrued. Re-enforcement of the role that compression-only CPR can play in reducing infection risk during adult CPR to the lay responder is helpful. Acknowledgement that retention of ventilations for child CPR appears justified based on the stated consideration of the writing group
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