Title: Advanced Cardiac Life Support Recommendations for Patients During the COVID-19 Pandemic with Suspected or Confirmed COVID-19

Target Audience

Alfred Health medical and nursing workforce

Purpose

To provide guidance to the target audience on the management of a patient who has had a cardio-respiratory arrest with suspected or confirmed COVID-19.

Authors

Dr Luke Phillips - Emergency Physician (Key Contact)

A/Prof Chris Nickson - Intensive Care Specialist
Dr Judit Orosz - Intensive Care Specialist (MET/CODE BLUE Key Contact)

Dr Simon Hendel  - Anaesthetist and Trauma Physician.

Natalie Kondos - Resuscitation  Nurse Educator (Coordinator)

Dr Neil Campbell - Senior Registrar ICU

Fiona Tweedley - Safer Patient Care Officer

Approval

Dr Tony Kambourakis - Director Medical Services

A/Prof de Villiers Smit - Director, Emergency & Trauma Centre & Emergency Services Alfred Health, Deputy Program; Director, Emergency and Acute Medicine

A/Prof Steve McGloughlin - Director, Intensive Care Unit

Prof Paul Myles - Director, Department of Anaesthesiology and Perioperative Medicine

Updates:
2/4/20:

• Updated airway management section and the ANZCOR modified flowchart (appendix 2) to give option of either keeping hudson mask in place awaiting intubation or BVM with 2 handed seal (no bagging) - LP
• ED in-situ Sim to key documents.  - LP

17/4/20:

• Clarification of our position for contact/droplet PPE for chest compressions component of CPR - LP, CN, JO, SH.  
• Suctioning can be considered airway contaminated if the whole team in AGP PPE - LP
• Stacked shocks can be considered in event of witnessed and monitored cardiac arrest - CN
• New references added - LP, CN

18/6/20:

• Modified document to include only patients with suspected or confirmed COVID-19 rather than all patients in line with hospital CODE BLUE/MET call policy. Standard ACLS pathway should be followed for non-COVID-19 patients - LP, CN, JO

4/11/20 (LP, NK, JO)

• Review of PPE requirements
• Updated references ARC/ACEM
• Changed MET/Code Blue Number to 22 22

1/9/21 (CN, JO, LP)

• Adjusted IP guidance for current level of PPE
• Deleted risk rating table
• Added turning on O2 to 6L/min after application of Hudson mask
• Added Suctioning airway is ok if required to manage airway obstruction such as blood or vomitus/pooled secretions if team is in Tier 3 PPE.
• Updated Figure 1
• Updated MET Call/Code Blue response guidelines.

Table of Contents

Guideline        4

Personal Protective Equipment (PPE)        4

Modifications to ANZCOR 2016 Guidelines        6

Initial Assessment and Basic Life Support (See Figure 1 and Appendix 1)        6

Early Defibrillation        7

CPR        7

Reversible Causes        8

Airway Management        8

Decision Making        8

MET/Code Blue Team Response Modifications        10

Out of Hospital Cardiac Arrests (OOHCA) with Ongoing CPR Presenting to the Emergency  Department        12

Notification and Call-out:        12

Preparation:        12

Patient Arrival:        12

Termination of resuscitation early if minimal likelihood of recovery based on:        13

Return of  Spontaneous Circulation        13

Key related documents        14

References        14

Appendix 1 - COVID-19 Cardiac Arrest Infogram        15

Appendix 2 - Advanced Life Support Modification to ANZCOR 2016 Guidelines        16

Appendix 3 - Bag-Valve-Mask with in-line Viral Filter.        17

Guideline

It is essential to assess whether a deteriorating patient may meet the case definition for COVID-19 as part of the MET call/Code Blue/Internal emergency (ED/ICU/Theatre) response, and apply appropriate precautions.

In the event of a cardiac arrest of patients during the COVID-19 pandemic and if the patient is suspected or confirmed to have e COVID-19:

STAFF SAFETY NEEDS TO BE PRIORITISED OVER RESUSCITATIVE EVENTS        

It is important to ensure early identification of any patients with a COVID-19 like illness, who are at risk of acute deterioration or cardiac arrest. The early recognition of deterioration; and either escalation of care, or a decision for limitations of treatment is essential to reduce the probability of unexpected cardiac arrest.

Personal Protective Equipment (PPE)

Prior to entering the room adequate PPE needs to be applied.

If COVID-19 is suspected / confirmed, or cannot be safely excluded we recommend the following approach.

The current COVID19 Infection Prevention Guideline for Clinical Staffoutlines clear mandatory PPE for patients with COVID or Suspected COVID and is adjusted according to the current COVID risk rating. Please refer to the minimum current PPE requirements in your area of work/local guidelines.

For the purpose of this document:

• Tier 1 PPE includes a surgical mask and eye protection (Goggles/Face Shield)

• Tier 2 PPE includes disposable gloves and gown, surgical mask and eye protection (Goggle/Face Shield)

• Tier 3 PPE includes disposable gloves and fluid-repellent gown, P2/N95 respirator mask and eye protection (Goggles/Face Shield).

There are discrepancies between some recently published guidelines regarding the PPE requirements for CPR. We have sought advice on this from local infection prevention experts and, in accordance with DHHS Victoria COVID19 Healthcare worker PPE Guidance, ACEM guidelines, Australian Resuscitation Council and the UK Government Infection Prevention and Control guidance on COVID19 Personal Protective Equipment, Chest compressions only and defibrillation are not considered AGPs. This can be considered for all low risk sCOVID or covid at risk patients prior to the arrival of the resuscitation team depending on current hospital risk rating and would be superseded by the above PPE requirements outlined by infection prevention.

All sCOVID and at risk patients should be managed in Tier 3 PPE whilst in the ED (until cleared or further risk assessed) or the ICU (until cleared) or if the patient unable to give a reliable history of risk factors or recent symptoms

Using a bag-valve-mask and performing airway maneuvers during CPR is a high risk AGP. Given this it would be reasonable to start compressions only CPR and defibrillate the patient in Tier 2 PPE if this was what the provider was currently wearing. The resuscitation team should prioritise swapping out team members in Tier  2 (droplet/contact) PPE at the earliest opportunity with team members in Tier 3 (contact/airborne) PPE to mitigate this risk.

It is important to limit the number of people entering the room and if able, close the door.  A record of staff entering and leaving should be kept for potential contact tracing. A door monitor should also be employed to check PPE and avoid unnecessary entry of staff.

Safe PPE doffing principles and hand hygiene moments should be followed to avoid self-contamination. 

Equipment should be disposed of (or cleaned) as per current practice guidelines.

Modifications to ANZCOR 2016 Guidelines

The following modifications to the ANZCOR 2016 Protocols for Advanced Life Support will be necessary for patients with suspected or confirmed COVID-19 infection and include:

Initial Assessment and Basic Life Support (See Figure 1 and Appendix 1)

• Danger: Ensure Adequate PPE and Staff Safety is priority. No AGP procedures should be performed until the whole team is in Tier 3 (airborne and contact) PPE.
• Response: Recognise cardiac arrest by assessing for an absence of signs of life and normal breathing.  This is best done by LOOKING from the end of the bed.
• Send for Help: Activate internal emergency buzzer and if on the wards activate CODE BLUE (22 22)
• Airway: Open airway, apply oxygen mask. If possible, do not suction the patient although it may be acceptable to suction the patient to clear airway obstruction or vomitius if the team are in Tier 3 PPE. Avoid use of oropharyngeal airways.
• Breathing:  Do not listen or feel for breathing by placing your ear and cheek close to the patient’s mouth. Do not provide mouth-to-mouth ventilations or squeeze the bag on a BVM. Feel for a carotid pulse if trained to do so.
• COMPRESSION ONLY CPR: Commence if safe to do so and continue until help arrives

• Ensure that all other staff stand away from the patient’s head (e.g. at foot of bed).
• Leave the oxygen face-mask on the patient whilst chest compression continues if already in-situ. Apply a hudson mask at 6L/min O2 if absent to help protect from droplets produced during CPR and to provide apnoeic oxygenation

• DEFIBRILLATE: Prioritise this early if shockable rhythm.        

Figure 1 - Summary table of key modifications to standard approach to cardiac arrest management in suspected/ confirmed COVID-19 patients using a DRSABCD approach.

Early Defibrillation

• Defibrillate shockable rhythms rapidly - the early restoration of circulation may prevent the need for airway and ventilatory support
• Position defibrillator

• At foot of bed
• >2m from patient’s head

• Do not remove the oxygen mask during defibrillation. Turn off oxygen flow at the flowmeter.

• Restart oxygen flow at 6L/min when compressions restart.

• In the event of a witnessed & monitored arrest with shockable rhythm - 3 stacked shocks can be considered.

CPR

• The need to put on PPE will delay the commencement of CPR. This is acceptable because staff safety must be prioritised.
• Consider early use of a mechanical chest compression device if available to decrease the number of staff required in the room.

Reversible Causes

• In a cardiac arrest of presumed hypoxic aetiology (especially paediatric events), early ventilation with oxygen is usually advised but not without adequate PPE suitable for higher risk AGP. Therefore even in a presumed hypoxic arrest, start with chest compressions in suspected COVID-19 patients.
• Early airway management on CODE BLUE team arrival will be critical.

Airway Management

• A consultant anaesthesiologist or anaesthesiology fellow has been rostered to attend all in-hospital cardiac arrests, 7 days/week, 24 hours/day. ED and ICU will manage their own arrests in-house.
• Advanced airway management should be prioritised after early defibrillation to decrease risk of aerosolisation and correct hypoxia. All staff should be in Tier 3 (airborne and contact)  PPE prior to this occurring.
• This should be performed by the most experienced operator, ideally being delayed until the anaesthesiologist or senior and experienced ICU/ED clinician attends.
• A severely contaminated airway can be carefully suctioned if all staff are in appropriate Tier 3 PPE.  
• Prior to intubation Airway operators can either keep the hudson mask in-situ or trained staff in Tier 3 PPE may commence bag-valve-mask ventilation with viral filter and ETCO2 fitted, using a two operator technique to ensure a good seal to minimise aerosolisation. Consider the safe use of airway adjuncts or preferably a supraglottic airway device (SAD).
• If a skilled operator is present then perform tracheal intubation early.  

• Ensure the BVM has a viral filter (appendix  3) and ETCO2 attached.
• In-line closed suctioning should also be added.
• Consider use of high dose paralytic agents (e.g. rocuronium 1.6 mg/kg IV IBW) prior to intubation to prevent coughing in the event of ROSC or if pseudo PEA.
• Video-laryngoscopy and bougie is the recommended method for intubation due to the increased distance between the patient’s airway and the intubator’s face.

• If the patient requires ventilation, or intubation is delayed or difficult, then insertion of a supraglottic airway device  with a viral filter (appendix 3) is recommended rather than attempting bag-valve-mask ventilation.  

Decision Making

• In many cases, cardiac arrest in patients with COVID-19 will be an irreversible deterioration of cardiopulmonary function (e.g. hypoxaemic cardiac arrest) that cannot be reversed by standard ALS procedures. However, arrhythmia may occur from myocarditis in COVID-19 patients and may respond to defibrillation. Patients with COVID-19 disease may also suffer cardiac arrest due to reversible causes related to other disease processes such as myocardial infarction or pulmonary embolism.
• The conversations and decision-making processes around ceasing resuscitation must continue and should be individualised unless directives state otherwise.
• Ensure decisions and conversations around goals of care and treatment limitations are well documented in the EMR and communicated.
• Early referral to ICU for consideration of ECMO CPR (Ext 62622)

MET/Code Blue Team Response Modifications

• Appropriate PPE should be stored on all emergency trolleys and MET bags should contain PPE suitable for AGP. MET Call or CODE (22 22) blue notification through switch as per normal processes.
• Ward team to notify MET team on arrival of patient COVID-19 status.
• The MET team should put on appropriate PPE prior to taking over from initial  responders.

• MET Call /Code Blue Response for inpatients considered COVID-19 negative.PPE as outlined by current infection prevention guidelines and risk rating.

• It is important to assess whether a deteriorating patient initially considered COVID-19 negative may meet the case definition for COVID-19 as a cause of the MET/Code Blue.

• MET Call /Code Blue Response for Confirmed COVID-19 patients, Suspected COVID-19 (sCOVID) patients, COVID-19 at risk patients and all Code Blue Visitors (irrespective of COVID status):

• Staff are to adopt Tier 3 PPE (airborne precautions) for all management.
• Trained staff in Tier 3 PPE may commence bag-valve-mask ventilation with viral filter fitted, using a two operator technique, to ensure a good seal to minimise aerosolisation.
• Only trained staff (anaesthetics, ED, ICU) should perform advanced airway management.

• Resuscitation Trolleys must remain outside the room and only necessary equipment brought into the room.
• Modifications to the ANZCOR guidelines as outlined above should be implemented by the MET/CODE Blue Team.
• Early recognition of deterioration and activation of a MET call or escalation through normal internal processes in ICU/ED/Theatre may prevent cardiac arrests. ICU notification is mandatory on MET calls where:

• O2 ≥ 8L/min and patient’s goals of care-resuscitation status (GOC) is A or B
• FIO2 ≥ 0.5 (50%)  on high-flow nasal prongs (HFNP)
• Notify ICU Registrar (ext. 62622) early if any concerns, as deteriorating patients should be considered for early ICU admission and intubation
• Notify the ICU registrar of all patients on HFNP where the GOC is A or B.

• Goals of care-resuscitation status (GOC) should be completed for all patients on admission and checked at first available opportunity by the MET team responding to the patient.  

Out of Hospital Cardiac Arrests (OOHCA) with Ongoing CPR Presenting to the Emergency  Department

These guidelines should apply to all patients presenting to the Emergency Department during the COVID-19 Pandemic with an OOHCA with Suspected  or Confirmed COVID-19 or whom COVID-19 cannot be ruled out from Ambulance Victoria screening question/NOK.

Notification and Call-out:

• Pre-alert call from Ambulance Victoria (AV).

• COVID-19 status should be clarified with the AV team or ambulance clinician by the resource nurse or ED admitting officer.

• Notification to Cardiology/ICU/ECMO team as appropriate.

Preparation:

• Role Allocation:

• ED team leader to assemble team and allocate roles.
• Minimise staff numbers in the room as much as possible.
• Assign a door keeper and PPE safety person.

• Prepare resus bay and equipment

• Resus 3 in the E&TC or alternatively a room with ability to close the door.
• Remove all unnecessary equipment from the room.
• BVM should have a viral filter (Appendix 3) and ETCO2 pre-setup in line.  
• Airway trolley set up if patient not intubated.
• Defibrillator should be placed at the foot end of the bed.
• Use the specified COVID-19 Ultrasound probe cover and single use gel.

• The team should don Tier 3 (airborne and contact) PPE suitable to protect from AGP prior to taking over from AV. 

Patient Arrival:

• Transfer to resus bay.
• Modifications to the ANZCOR guidelines as outlined above should be implemented to ensure staff safety.
• Leave the ambulance BVM connected to their SAD/ETT but do NOT ventilate during the transfer. Be careful not to disconnect the circuit.
• Transfer directly to the LUCAS device and commence compression-only CPR.
• Ensure viral filter and ETCO2 is connected in-line with the SAD/ETT. Only ventilate if this is in place. Ensure the ETT tube is clamped prior to any disconnection from BVM. In-line suction should also be connected to the ETT.
• If there is audible leak from the SAD, stop ventilations and reposition SAD. Avoid BVM ventilation.
• Team leader to take handover from AV team.
• Obtain IV/IO access if  IV access is not present.
• Early discussions with the ICU ECMO team
• Rapidly assess for reversible cause of the cardiac arrest and correct.

Termination of resuscitation early if minimal likelihood of recovery based on:

• Time since arrest (long no-flow/low flow time)
• Asystole
• No cardiac activity on ECHO
• ETCO2 < 10mmHg
• Age, comorbidities/ frailty
• Advanced care plan

Return of  Spontaneous Circulation

• If SAD in situ, provide post ROSC sedation / analgesia. Do not immediately intubate the patient.
• Further assess the patient to determine clinical priorities.
• ED specialist, intensivist, and admitting specialist to establish goals of care, and availability of necessary interventions such as PCI.
• If suitable for ongoing active management, then proceed with intubation as per current guidelines.

Key related documents

• COVID19 Infection Prevention Guideline for Clinical Staff
• Alfred Health Novel Respiratory Illness guideline
• Alfred Health PPE guideline
• Alfred Health Standard and Transmission Based Precautions guideline
• ANZCOR guideline- Protocols for Advanced Adult Life Support
• Medical Emergency Response Guideline (See Appendix 7 For COVID-19 MET/CODE Blue Response)  
• ED In-Situ Simulation

References

• ACEM COVID-19 Guidelines - Adult Cardiac Arrest Management
• Australian Resuscitation Council - Flow Chart 6: CPR in Hospital
• Christian, M. D., Loutfy, M., McDonald, L. C., Martinez, K. F., Ofner, M., Wong, T., Wallington, T., Gold, W. L., Mederski, B., Green, K., Low, D. E., & SARS Investigation Team (2004). Possible SARS coronavirus transmission during cardiopulmonary resuscitation. Emerging infectious diseases, 10(2), 287–293. https://doi.org/10.3201/eid1002.030700
• DHHS - COVID19 Healthcare worker PPE Guidance
• UK Government Infection Prevention and Control: COVID19 Personal Protective Equipment
• ILCOR: COVID-19 infection risk to rescuers from patients in cardiac arrest
• ILCOR: COVID-19 Practical Guidance for Implementation
• NHS Scotland: Aerosol Generating Procedures
• Resuscitation Council UK: Guidance for the resuscitation of COVID-19 patients in hospital
• Resuscitation Council UK: Resuscitation Council UK Statement on COVID-19 in relation to CPR and resuscitation in healthcare settings
• Tran, K., Cimon, K., Severn, M., Pessoa-Silva, C. L., & Conly, J. (2012). Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PloS one, 7(4), e35797. https://doi.org/10.1371/journal.pone.0035797

Appendix 1 - COVID-19 Cardiac Arrest Infogram

Appendix 2 - Advanced Life Support Modification to ANZCOR 2016 Guidelines

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Appendix 3 - Bag-Valve-Mask with in-line Viral Filter.