Part 9: Interim Guidance to Healthcare Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates with Suspected or Confirmed COVID-19

The American Heart Association, along with its collaborating organizations American Academy of Pediatrics, American Association for Respiratory Care, American Society of Anesthesiologists, and the Society of Critical Care Anesthesiologists, is committed to providing the most up-to-date evidence-based guidelines on resuscitation and supporting the healthcare providers that provide these interventions. At times, there is a need for an interim statement based on new data or, in the case of this pandemic, a rapidly changing environment. Interim guidance may arise from a scientific review of a single topic, or the need for a best-practice statement because of new or urgent public health initiatives. Based on evolving epidemiologic reports, emergence of new and more transmissible strains of the coronavirus, declining vaccine effectiveness,¹ as well as recent feedback from the healthcare provider community, it became clear that the guidance developed in the spring of 2021 and published in October 2021² needed to be updated to emphasize fully protecting health care providers who perform resuscitation. Our overall guiding principles and goals in providing this interim guidance are to achieve the best possible resuscitation outcomes and simultaneously ensure optimal protection for healthcare providers. Language has been clarified in this updated interim guidance to adhere to this guiding principle. Interim guidance will continue to evolve as the pandemic continues to ensure our guidance reflects the best, most up-to-date science and available evidence to guide best practices.

This guidance is based on available scientific evidence at the time of its development, recommendations from public health organizations, and expert opinion; it should be adapted locally on the basis of current disease burden and resource availability. The interim guidance is not a guidelines statement which is based on a formal evidence review. Thus, the revisions have not undergone a systematic review process and cannot be assigned a Class of Recommendation or Level of Evidence.³ This guidance can be considered similar to a best practice statement. These revisions should always be adapted to changing public health recommendations and local protocols and resources.

The writing group was comprised primarily of authors from the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,³ the Emergency Cardiovascular Care Committee, and the Get With the Guidelines®- Resuscitation Adult and Pediatric Task Forces. Additional writing group members were nominated by the collaborating organizations. Potential conflicts of interest are included in the Disclosures section of this manuscript.

We developed this consensus guidance through conference call of the entire author group, one-to-one and small group conferences, and group/personal email exchanges. The final documents were reviewed by a smaller group of experienced authors who had previously been first authors on AHA statements or guidelines. All authors and organizational liaisons participated in each step of the submission, revision, and final review process. The discussions were centered on healthcare provider protection, reducing provider risk, and appropriate use of personal protective equipment (PPE). The remainder of the 2021 Interim Guidance is included in this document for the convenience of the reader, to have the most current guidance in one document.².

The changes in the interim guidance are focused on these three tenets:

1. Incorporating the most recent Center for Disease Control and Prevention (CDC) and World Health Organization (WHO) guidance: All healthcare providers should wear a respirator (e.g., N95) along with other PPE (gown, gloves, and eye protection) for patients with suspected or confirmed COVID-19 infection, when performing aerosol-generating procedures (AGP)s or in a setting where AGPs are regularly performed.^4,5 The definition of suspected cases should be consistent with the most current definitions from relevant public health officials as well as local standards and protocols. This includes donning appropriate PPE (including respirator) before performing the components of resuscitation that are aerosol generating, which include but are not limited to: chest compressions, defibrillation, bag-mask ventilation, intubation and positive-pressure ventilation. In the event initial responders are not already wearing appropriate PPE, they should immediately don it and then begin CPR. As PPE recommendations change, healthcare providers should continue to follow the most-up-to-date recommendations from the WHO, CDC and regional health authorities and local institutions.
2. Reinforce resuscitation best practices: Cardiac arrest survival rates have decreased dramatically during the COVID-19 pandemic.⁶ OHCA survival in 2020 also declined in regions/time frames that did and did not have significant COVID infection rates. The reasons for this decline are both unclear and complex. Cardiac arrest survival is dependent on early initiation of CPR and we continue to recommend chest compressions as soon as is safely possible. We believe patients with confirmed or suspected COVID-19 should receive the best resuscitative efforts possible⁷ and we are committed to both the training of healthcare providers, and rigorous evaluation of the evidence to ensure our CPR and First Aid guidelines support best practices.
3. Ensure adequate PPE supply: At this time, all healthcare providers should be following appropriate precautions and should have access to PPE in all clinical settings, regardless of the potential of encountering resuscitation events. Effective use of PPE is critical for the safety of healthcare providers performing resuscitations. Healthcare organizations should continue to secure appropriate PPE as available, ensure training regarding appropriate application and use of PPE, reinforce effective use of PPE, and create systems so that health care providers have immediate access to appropriate PPE when emergency care is required.

International data early during the COVID-19 pandemic described worse survival outcomes for both out-of-hospital and in-hospital cardiac arrests compared to prior years.^{6, 7, 8, 9, 10} This worsening of outcomes may have been multifactorial; the severity of SARS-CoV-2 related cardiac arrest, the implementation of termination of resuscitation guidance, local crisis standards of care or patient hesitancy to seek medical care contributing to delays in care.¹¹ The provision of prompt chest compressions and defibrillation may also have been delayed due to the additional time required in donning PPE or securing the airway and the PPE may have accelerated rescuer fatigue resulting in decreased CPR quality.^12,13 Concerns that resuscitation from cardiac arrest due to COVID-19 may be futile may have led to earlier termination of resuscitative efforts and overwhelmed Emergency Medical Services (EMS) systems may have had insufficient resources to respond to increased number of calls for arrests in regions with high rates of COVID-19.^{6, 14} Lastly, significant delays in presentation for medical care, such as a tripling of the time from onset of chest pain to presentation to emergency care, may have contributed to an increase in out-of-hospital cardiac arrests rates during the pandemic as compared to before the pandemic.¹⁵.

With increased scientific knowledge, a more stable PPE supply chain and increasing availability of vaccines for healthcare providers and the general public, application of the best resuscitation science available must be once again assessed and prioritized. The following guidance should be applied to patients with suspected or confirmed COVID-19 infection (Figures 1 through 2) (Figures 3 through 8).

Effective use of PPE is critical for the safety of healthcare providers performing resuscitations. Healthcare organizations should continue to secure appropriate PPE as available, ensure training regarding appropriate application and use of PPE, reinforce effective use of PPE, and create systems so that health care providers have immediate access to appropriate PPE when emergency care is required. Frontline healthcare providers are at significant risk for contracting respiratory illnesses due to frequent contact with symptomatic patients. Adequate PPE including N-95 masks or positive air pressure respirators, especially during AGPs, can reduce the risk of coronavirus transmission.²⁴ Provider risk may vary based on individual (age/ethnicity/comorbidities/vaccination status) and system factors. Healthcare providers can significantly reduce their risk of infection, especially severe illness or death, by receiving the vaccine and booster against the SARS-CoV-2 virus.^{16, 17,18} The American Heart Association strongly encourages all health care providers to receive the vaccines and comply with updated recommendations for boosters.

The data regarding which procedures are aerosol generating are conflicting and continue to develop. CPR is considered to be aerosol-generating.²⁵ SARS-CoV-2 is transmitted primarily by respiratory droplets and aerosols, with little transmission by fomites.^{5, 26, 27} Rapid initiation of chest compressions is critical for successful resuscitation. Healthcare providers should wear a respirator (e.g., N95) along with other PPE (gown, gloves, and eye protection) for patients with suspected or confirmed COVID-19 infection, when performing AGPs or in a setting where AGPs are regularly performed. This includes donning appropriate PPE (including respirator) before performing the components of resuscitation that are aerosol generating, which include but are not limited to: chest compressions, defibrillation, bag-mask ventilation, intubation and positive pressure ventilation. In the event initial responders are not already wearing appropriate PPE, they should immediately don it and then begin CPR. As PPE recommendations change, healthcare providers should continue to follow the most-up-to-date recommendations from the WHO, CDC and regional health authorities and local institutions.

The case definitions of suspected and confirmed COVID-19 have changed over time.²⁸ The incidence of COVID-19 disease has shifted rapidly over time with uneven geographic distribution.²⁹ The definition of suspected cases should be consistent with the most current definitions from relevant public health officials as well as local standards and protocols. Continuous use of an N-95 respirator and eye protection should be considered when the patient’s COVID-19 status is unknown and resuscitation involves AGPs to which compressors and other personnel will be exposed.⁴ This may apply to patients who initially tested negative for COVID19 on admission to the hospital and suffer a cardiac arrest during the hospitalization. Initiate chest compressions without delay or interruption while wearing appropriate PPE. All persons not wearing appropriate PPE should be immediately excused from the room or area. Provided there is sufficient PPE, additional compressors may be required due to increased fatigue or potential for N-95 respirator slippage resulting from compressions.^{30, 31, 32} The application of mechanical compression devices can reduce the number of healthcare providers required for compressions; however, these devices may not be appropriate or available for morbidly obese adults, infants, children and small adolescents or for all clinical scenarios.³³ Training and regular practice in the use and rapid application of mechanical compressions devices is required to minimize the early no-flow time and to ensure proper application and utilization of the device.²³ Although the clinical use of mechanical devices has not demonstrated improvement in outcome compared to manual CPR, it may reduce the number of additional staff who are needed to participate in the resuscitation event.^{21, 22}

As not every resuscitation space has negative pressure ventilation, closing the door may help limit contamination of adjacent indoor spaces. In out-of-hospital cardiac arrest, taking measures to better ventilate a confined space such as opening windows or doors may reduce the local concentration of aerosols for healthcare providers if this does not risk contamination of other spaces in the adjacent vicinity. In addition, some healthcare organizations may have continued shortages in PPE supply, low vaccination rates amongst staff, and personnel limitations; this guidance needs to be adapted to local protocols with consideration of current COVID-19 disease burden and resource availability.

Below we describe several specific scenarios related to resuscitation care and their application to the COVID-19 pandemic. We provide these comments covering topics such as prone position, starting/stopping CPR, pregnancy, compression devices, and post-arrest care to give readers insight in to the complex discussion that occurred among committee members during each of the interim guidance documents of 2020 and 2021.^2,38 A comprehensive and evidenced-based review on each of these distinct scenarios is beyond the scope of this interim guidance, but additional discussion on these topics can be found in the AHA 2020 Guidelines.²³

Crowd control for effective direction of resuscitation by the minimum number of persons required is advised. Closing the door to the resuscitation area, when possible, may minimize airborne contamination of adjacent indoor space. Healthcare personnel should continue to wear appropriate PPE for clinical care including masks, eye protection and gloves as recommended by the CDC and WHO. ^{4, 41} All persons not wearing appropriate PPE should be immediately excused from the room or area.

Patients who are intubated prior to arrest

Consider leaving the patient on a mechanical ventilator with a HEPA filter to maintain a closed circuit and to reduce aerosolization and adjust the ventilator settings to allow asynchronous ventilation with the following suggestions:

• Increase the FiO2 to 1.0
• Use either pressure or volume control ventilation and limit pressure or tidal volume to generate adequate chest rise (4-6 mL/kg ideal body weight is often targeted for adults and neonates, 5-8 mL/kg for children).
• Adjust the trigger settings to prevent the ventilator from auto triggering with chest compressions and possibly prevent hyperventilation and air trapping.
• Adjust respiratory rate to 10 breaths/min for adults, 20 to 30 breaths/min for infants and children and 30 breaths/min for neonates.
• Assess the need to adjust the positive end-expiratory pressure level to balance lung volumes and venous return.
• Adjust ventilator settings to deliver full breaths with asynchronous chest compressions.
• Ensure endotracheal tube/tracheostomy and ventilator circuit continuity to prevent unplanned airway dislodgement or tubing disconnections.

If return of spontaneous circulation is achieved, set ventilator settings as appropriate to the patients’ clinical condition and treat the underlying cause of cardiac arrest.

Patients who are in prone position at the time of arrest

Anticipation and preparation are important in rotating patients to a supine position. The very limited evidence for providing CPR in the prone position suggests it may be better than not providing CPR.^23,42 For patients in the prone position with an advanced airway, it may be reasonable to provide manual compressions in the prone position until a patient can be safely transitioned to a supine position with a trained team. If deemed necessary for optimal clinical care, such as assessing endotracheal tube patency and positioning, the following steps for transitioning a patient to a supine position are suggested:

• Provide compressions with hands centered over the T7-T10 vertebral bodies.
• Arrange for sufficient, trained, PPE-protected personnel to achieve safe supination on the first attempt.
• If already intubated, ensure ventilation and vascular tubing continuity and apply the posterior defibrillator pad to the patient’s back prior to rotating.
• Immediately resume CPR supine once the patient has been rotated. Confirm tubing and access lines have not been dislodged and are in working order

Additional discussion of CPR in the prone position is available in the AHA 2020 Guidelines.²³

Post-arrest patients

Healthcare providers wearing appropriate PPE should continue to provide post cardiac arrest care per the 2020 AHA guidelines for CPR and ECC.^{23, 43}

Guidance regarding EMS and lay rescuer is described in detail in other literature.^{39, 40}