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.
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 .
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.
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.
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.
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.
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.