Marking a shift from its earlier stance, the American Heart Association (AHA) now recommends that cardiopulmonary resuscitation (CPR) on known or suspected Covid-19 patients with cardiac arrest should not be delayed for want of donning personal protective equipment (PPE) or putting a face covering on the patient.

In its latest interim guidance, the AHA says that health care providers should perform rapid chest compressions “without delay or interruption” and defibrillate “as soon as possible when indicated” without first waiting to wear masks and/or other PPE.

Even for witnessed out-of-hospital cardiac arrests, chest compressions should be initiated right away. The provider should wear their own masks, but without delaying or interrupting compressions. Similarly, a mask or face covering can be put on the patient, but again compressions should not be interrupted or delayed because of it.

Last year, at the beginning of the pandemic, the AHA had recommended that all healthcare workers must wear appropriate PPE before carrying out any aerosol-generating procedure (AGP) such as CPR in Covid patients.

Addressing the concerns of risk of infection to the rescuers, the guidelines say that the risk of infection can be reduced by taking the authorised Covid-19 vaccines along with the booster dose (if approved). The next team wearing appropriate PPE - N95 masks with eye protection or positive airway pressure respirators, gloves, gowns - should take over the resuscitation as soon as possible. The Covid-19 status of the patient should be communicated to the relieving team. Consider using mechanical CPR devices if available and personnel are already trained. For newborns, it is safe to use a bag mask or T-piece/mask ventilation. Appropriate PPE must be worn as the maternal respiratory secretions and fluids may be potential sources of SARS-CoV-2 transmission for the newborn and the neonatal team.

Other key recommendations for pediatric and adult cardiac arrest include

• “For agonal breathing, consider passive oxygenation until HEPA filtered ventilation can be provided.
• Securely attach a HEPA filter to any ventilation drive.
• Ventilate with a bag mask HEPA filter with tight seal until a supraglottic or endotracheal airway is placed.
• Engage the intubator with the highest chance of first pass success.
• Consider the use of video laryngoscopy, if available and personnel are already trained.
• Maximise chest compression fraction, pausing to intubate only if needed.
• Minimise endotracheal administration of medications to avoid aerosol generation.
• Minimise closed ventilation circuit disconnections.
• Commit to ethical and evidence-based termination of resuscitation policies.”

The authors write in the journal Circulation. Cardiovascular quality and outcomes, “the risk to the patient by withholding or delaying the response for cardiac arrest is extremely high compared with the much lower risk that the resuscitation provider will contract COVID-19 and develop serious illness. This risk is particularly low in the vaccinated or unvaccinated provider who provides care while wearing appropriate PPE for AGPs.”

Dr KK Aggarwal had devised the Formula of 10, hands-only compression to emphasise the need for immediate resuscitation in victims of sudden cardiac arrest and also remember the technique of CPR “To revive after sudden cardiac arrest, within 10 minutes of death (earlier the better), at least for the next 10 minutes (longer the better), compress the centre of the chest of the victim with a speed of 10×10 i.e., 100 per minutes.” He had further said, “Numerologically also, the CPR equates to number 10. In English alphabets, ‘C’ comes at number ‘3’, ‘P’ comes at number ‘16’ and ‘R’ comes at number ‘18’. If we add the three i.e., C=3, P=16, R=18 (3 + 16 + 18 = 37) and, if we further add the two digits in ‘3 + 7’, the total we get is ‘10’. So, numerologically ‘CPR 10’ should be an effective way to remember.”

Reference

1. Hsu A, et al. 2021 interim guidance to health care providers for basic and advanced cardiac life support in adults, children, and neonates with suspected or confirmed COVID-19. Circ Cardiovasc Qual Outcomes. 2021 Oct 13;CIRCOUTCOMES121008396. doi: 10.1161/CIRCOUTCOMES.121.008396.