Resuscitation Council UK – Update
Healthcare professionals performing CPR
Resuscitation Council UK has provided this specific guidance for healthcare workers (HCWs) on CPR for patients with suspected or confirmed COVID-19. This guidance may change based on increasing experience in the care of patients with COVID-19, as well as the effect of the outbreak on health services.
COVID-19 is thought to spread in a way similar to seasonal influenza; from person-to-person through close contact and droplets. Standard principles of infection control and droplet precautions are the main control strategies and should be followed rigorously. Aerosol transmission can also occur. Attention to hand hygiene and containment of respiratory secretions produced by coughing and sneezing are the cornerstones of effective infection control.
During CPR, there is always the potential for rescuers to be exposed to bodily fluids, and for procedures (e.g. chest compressions, tracheal intubation or ventilation) to generate an infectious aerosol. Resuscitation team members must be trained to put on/remove PPE safely (including respirator-fit testing) and to avoid self-contamination.
CPR in patients with a COVID-19 like illness or confirmed case of COVID-19
Patients with a COVID-19 like illness, who are at risk of acute deterioration or cardiac arrest, should be identified early. Appropriate steps to prevent cardiac arrest and to avoid unprotected CPR should be taken. Use of physiological track-and-trigger systems (e.g. NEWS2) will enable early detection of acutely ill patients. Patients for whom a ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) and/or other similar decision is appropriate should also be identified early.
The locally/nationally agreed minimum level of PPE must be used to assess a patient, start chest compressions and establish monitoring of the cardiac arrest rhythm. The need to don PPE may delay CPR in patients with COVID-19. Review of the processes involved along with training and practice, will minimise these delays. Staff safety is paramount.
In a cardiac arrest of presumed hypoxic aetiology (including paediatric events), early ventilation with oxygen is usually advised. ANY airway intervention performed WITHOUT the correct PPE protection will subject the rescuer to a significant risk of infection. Consequently, we recommend even in presumed hypoxic arrest starting with chest compressions. Recognise cardiac arrest. Look for the absence of signs of life and normal breathing. Feel for a carotid pulse if trained to do so. Do not listen or feel for breathing by placing your ear and cheek close to the patient’s mouth. If a defibrillator is readily available, defibrillate shockable rhythms rapidly prior to starting chest compressions. The early restoration of circulation may prevent the need for further resuscitation measures.
Sets of AGP PPE must be readily available and Full Aerosol Generating Procedure (AGP) Personal Protective Equipment (PPE) must be worn by all members of the team beforeentering the room / area. No chest compressions or airway procedures such as those detailed below should be undertaken without full AGP PPE.
Once suitably clothed, start compression-only CPR and monitor the patient’s cardiac arrest rhythm as soon as possible. Do not do mouth-to-mouth ventilation or use a pocket mask. If the patient is already receiving supplemental oxygen therapy using a face mask, leave the mask on the patient’s face during chest compressions as this may limit aerosol spread.If not in situ, but one is readily available, put a simple oxygen mask on the patient’s face. Restrict the number of staff in the area room.
Airway interventions (e.g. supraglottic airway (SGA) insertion or tracheal intubation) must be carried out by experienced individuals. Clinicians should only employ the airway skills(e.g. bag-mask ventilation) for which they have received training. For many HCWs this will mean two-person bag-mask techniques with the use of an oropharyngeal airway. Tracheal intubation or SGA insertion must only be attempted by individuals who are experienced and competent in this procedure.
Identify and treat any reversible causes (e.g. severe hypoxaemia) before considering stopping CPR. Discussion should be maintained throughout the resuscitation event and early planning of the post resuscitation phase undertaken. Contact senior help and gain advice from critical care partners as part of the planning.
Bag-up and secure all equipment used during CPR following local guidelines. Any work surfaces used for airway/resuscitation equipment must be cleaned according to local guidelines. Specifically, ensure equipment used is not left lying laying around as a further hazard to others.
Once you have completed your tasks and left the “infected area” Remove PPE safely to avoid self-contamination and dispose of clinical waste bags as per local guidelines. Do NOT re-enter the “infected area” unless you have donned appropriate PPE. Hand hygiene has an important role, thoroughly wash hands with soap and water; alternatively, alcohol hand rub is also effective.
30 March 2020
East of England Ambulance Service
Unison Health and Safety Officer
Single Point of Contact (SPOC) Covid-19