Cardiopulmonary Resuscitation during COVID-19

A lot of heat hassurrounded cardiopulmonary Resuscitation (CPR) since coronavirus hit the world with health institutions moving to protect healthcare workers at the expense of patient lives.

Cardiopulmonary resuscitation (CPR), is an emergency treatment that aims at restarting a human heart. It helps one to start breathing and reduces the risk of death.

The CPR process involves activities such as chest compressions that aid in pumping blood around the body, and the famous ‘kiss of life’, also known as rescue breaths, that are done to supply the patient’s lungs with oxygen.

Since the beginning of the Covid-19 pandemic, health officials have advised all medical personnel not to get close to their patients to avoid contracting the virus. This led to the abolishment of many CPR procedures (like mouth-to-mouth) due to the risks of contracting a disease when attempting to save a life.

Nations in Disagreements over CPR amid Coronavirus

The UK Resuscitation Council, for instance, has stated that chest compressions are still allowed for use by the members of the public, provided they follow the correct guidelines given by the health officials.

In the UK, over 30,000 cardiac arrests take place outside the hospitals each year, with over 80% of them taking place at homes. We, therefore, the need to ensure that the members of the public are aware of what to do, and what to avoid in such situations. Proper education can help ensure people take more care when administering CPR or dealing with SCA patients.

When someone is in need of CPR, passersby should call for an ambulance, then use a towel or a piece of clothing and lay it over the mouth and the nose of the patient, Resuscitation Council UK. After that you should start the chest compressions to the “Stayin’ Alive” by the Bee Gees tempo, using a defibrillator in case it is available.

“Placing a towel over the victims face, providesadditional protection ensuring the Good Samaritan saves the life of a loved one without placing themselves at increased risk.” the Resuscitation Council UK Vice President Dr. Andrew Lockey told Drivetime.

Dr. Lockey argued that the risk to health care staff in hospitals is far greater than any other person.

“We are seeing far too many healthcare personnel who are dying from Covid-19, and they need to be adequately protected in this high-risk environments.”

“The difference with the home setting is that the cardiac arrest may not be related to Covid-19 and household members who witness it will already have been exposed to the same risks for infection.” Said Dr. Andrew Lockey, the Resuscitation Council UK Vice President.

In the meantime, St Andrew’s First Aid charity put training on hold in all programs related to CPR, because of the shutting down of institutions and the ban of social gatherings.

There has been a conflict in the opinions of different people about what personal protective (PPE) the doctors and nurses should have when carrying out Cardiopulmonary resuscitation (CPR) amid the COVID-19 pandemic.

The Resuscitation Council UK described that cardiopulmonary resuscitation (CPR) during this time is an aerosol-generating procedure (AGP), stating that it is invasive. This means that the procedure is the potential of exposing both the doctors and nurses to a high risk of contracting an infection and in this case COVID-19.

The World Health Organization (WHO) directs that the PPE with the highest level of protection should be used when contacting an Aerosol Generating Procedure (AGP). This entails wearing the so-called FFP3 mask, both eye and face protection, a fluid-resistant gown that should be sleeved and gloves.

Most Resuscitation Councils across the world, including the UK Resuscitation Council, support the guideline given by WHO about AGPs and PPE. In other places, the governments have decided that chest compressions and defibrillation amid COVID-19 are not AGPs. This is evident in the English, Scottish, Welsh, and Northern Irish.

This has caused a lot of questions among health professionals, about whether or authorities are make suchmoves to cover the possible lack of the PPE required to perform AGPs.

“We are effectively asking those who work in primary care and community settings (and indeed bystanders) to risk their lives on a futile exercise. We simply cannot be adequately protected.” One GP told BBC Scotland’s Drivetime program.

The Resuscitation Council UK (RCUK) spokesman agreed “significant confusion” is evident in the NHS on the matter.

“Our concern remains that not providing Level 3 PPE to health care professionals performing chest compressions on Covod-19 patients is a clear risk to their safety,” said the Resuscitation Council UK (RCUK) spokesman.

“In a pandemic where healthcare professionals are tragically dying, we challenge the rationale for advocating a lesser form of PPE where expert consensus states that it is indeed risky to human health.” He added.

The Scottish government spokesman said: “It is incorrect to say there is in Scotland a lack of facemasks or any other part of PPE. We currently have adequate supplies and we are working all the time to build still further on the substantial enhancements we have made to the distribution of PPE to ensure the right equipment reaches the right staff with the highest degree of urgency.”

“Cardiac arrest is a rare event and paramedics and other healthcare workers are highly trained at delivering appropriate resuscitation at the scene of the arrest. These interventions are always risk assessed – including on the use of PPE – and these assessments exist to save lives while protecting staff. The current four nation’s guidance is that chest compressions are not considered as aerosol-generating procedures and we will keep this under review.” The spokesman added.

Scotland’s National Clinical Director Jason Leitch, while responding to a question about chest compressions on Drivetime, said: “People should only do it if they feel safe to do so”.

The diagnosis of myocardial infarction (heart attack) in Scotland, according to the National Records for Scotland, has increased from 375 people per 100,000 of the population in the year 2006-2007 to 518 in the year 2015-2016 which is a 37.9% increase.

This digit is expected to have increased in the recent years, and this year due to the present COVID-19 global pandemic.

Cardiopulmonary Resuscitationamidst Corona in the UK.

The Resuscitation Council UK (RCUK) stated that all healthcare workers (HCWs) performing CPR in non-acute hospital settings must be protected. These include people working in community hospitals, mental health, autism inpatient settings, learning disability, among others.

Staff guidance should be given in each hospital, according to the level of care they provide. This will ensure that the HCWs do not risking exposure to COVID-19 while performing any of their duties.

COVID-19, just like seasonal influenza, spreads for one person to another via contact and droplets. This, therefore, means that in each situation, the standard principles of infection control and droplet precautions are the main control strategy.

Hand hygiene should be given total attention, and the processes of containing respiratory secretions produced through coughs and sneezes are pillars of effective infection control.

All healthcare workers (HCWs) managing patients suspected or confirmed to be infected with the COVID-19 disease must follow both national and worldwide guidance on controlling COVID-19 and the use of PPE.

There has always been a risk of both doctors and nurses getting exposed to the body fluids of the patients they are saving during a CPR.

This is because the procedures used for CPR, such as tracheal intubation, ventilation, and/ or chest compressions, often generate infectious droplets.

Each health care organization should, therefore, must carry out risk assessment according to its level and services offered. The assessments should be done relative to the latest guidance from institutions such as RCUK, DHSC, PHE regarding PPE for HCWs to develop local guidance.

The resuscitation team members must be well trained to safely put on and remove the PPE, including the respirator fit testing, to dwindle possibility of self-contamination.

It is also important to carefully consider the benefits and the burdens of resuscitation before to the victim because it is a highly invasive procedure. The discussion should be done relative to the mental capacity act and may require the involvement of the Power of Attorney.

Whenever a patient requires an individual emergency care treatment plan which involves recommendations for the suitability of cardiopulmonary resuscitation, both communication and treatment escalation plans must be done. It is good to ensure that “do not attempt cardiopulmonary resuscitation” (DNACPR) decisions are well documented and communicated.

The staff members should follow PPE guidance for HCWs when delivering health care services within 2 meters. A minimum fluid-resistant surgical mask, gloves, apron, and eye protection should be used. This will protect the doctors and nurses from droplet transmissions and avoid contamination from surfaces.

If a cardiac arrest is likely to occur, the non-acute hospital setting should ensure that a lasting stock of the level 3 PPE equipment is always in place. This will enable the healthcare givers to safely offer the service whenever it is required.

Proper storage of the equipment is mandatory and should be easily accessible when the emergency arises. Regular training should be done on the doctors, nurses, and any other healthcare officer dealing with the equipment or taking part in the emergency response.

Proper measures should be put in place, to identify any patient at the risk of acute deterioration or cardiac arrest as early as possible. The most appropriate steps to prevent cardiac arrest and avoid unprotected CPR should always be taken.

To ensure that the acutely ill patients are identified as early as possible, it is advisable to use the physiological track-and-trigger systems such as NEWS2.  This will help in making the decisions whether resuscitation will be appropriate for the patient or not in good time, and hence communicating early.

This will also help in taking the most appropriate steps, such as transferring the patient to an advanced acute medical care unit or institution.

There are however other assessment procedures to follow when the patient becomes unresponsive, which helps in reducing the risk of droplet transmission. To begin with, you should look for the absence of signs of life and normal breathing.

Do not look for breathing by listening or feeling through placing your ear or cheek on the patient’s mouth. Instead, feel the victim’s carotid pulse, or an expert to do it.

Call for helpers as early as possible, and put on the PPE immediately, if you’ll need it.

If you find out that the patient is still unresponsive and isn’t breathing normally, call the resuscitation team. If the team isn’t present in your hospital, call for an ambulance service stating the risk of COVID-19, following the directives given by your employer and through the right channel.

While waiting for the response of the helpers, attach a defibrillator to assess the initial rhythm and administer up to 3 shocks.

Administer shocks as guided by the instructions in the AED you are using. The earlier the defibrillation for a shockable cardiac arrest, the higher the chance of survival.

If you are not wearing the level 3 PPE, which includes an FFP3 mask, eye /face protection, fluid-resistant long-sleeved gown, and gloves, do not deliver ventilation or chest compressions. These are AGPs that need a level 3 Protection equipment for everyone in the area or room.

In some hospitals, HCWs will have additional airway management skills and will be able to take over CPR as soon as their PPE Level 3 is donned.

In other trusts, this ALS response will be provided via the ambulance service or resuscitation team. Every non-acute hospital as defined above with HCWs that have additional respiratory response training or any form of on-site resuscitation team must ensure, via risk assessment, that the appropriate amount of Level 3 PPE is available and accessible on-site.

As soon as helpers in level 3 protection equipment arrive, the first rescuer must withdraw to a safe distance of over 2 meters.

If the cardiac arrest caused by ligature, it is authoritative that the ligature is removed as soon as possible, and as much safe as possible. If the hospital must provide the staff to issue emergency ventilation.

 This will entail the delivery of assisted ventilation with a bag-valve-mask, an adequate provision of level 3 protection equipment to safely facilitate this response. Because of the potential hypoxic nature of the cardiac arrest, it is chiefly significant that the advanced life-supporting team is on stand-by.

It is advisable to always follow the PHE guidance on hygiene when removing the PPE and disposing clinical waste bags. This is because you can self-contaminate yourself while removing the PPE, or disposing of the clinical bags.

Hand hygiene is vital in decreasing the transmission of COVID-19, and almost all the other airborne diseases. Always wash your hands thoroughly with soap and water, or use an alcohol hand rub which will also be effective.

The equipment used in the CPR process and should be well cleaned, according to the manufacturer’s guidelines and recommendations. The work surfaces used in the processes in whichever way should also be cleaned according to the guidelines in your hospital.

All equipment used in airway interventions such as face masks and laryngoscopes must be disposed of in a tray or a clinical bag, and not left on the patient’s bed. The contaminated end of the Yankauer sucker should be put in a disposable glove. This will reduce the chances of contamination during and after CPR.

In case you need more information you can check the Department of Health and Social Care (DHSC), the Health Protection Scotland (HPS), the Public Health of Wales, and the Department of Health Northern Ireland (DHNI). This information may change due to increased experience in CPR and the general health care on COVID-19 patients.

It is therefore very important to always check the latest updates on the guidelines in the following websites: DHSC, PHE, PHW, HPS, and DHNI.

Cardiopulmonary Resuscitationamid Corona in the US.

MD (University of Chicago, IL), and colleagues say. “The challenge is to ensure that patients with or without COVID-19 who experience cardiac arrest get the best possible chance of survival without compromising the safety of rescuers, who will be needed to care for future patients.”

The practical advice on how to resuscitate a COVID-19 patient arises from a team effort by the American Heart Association (AHA) in collaboration with the other seven organizations.

These organizations are the American Academy of Pediatrics, the American Association for Respiratory Care, theAmerican College of Emergency Physicians, Society of Critical Care Anesthesiologists, and the American Society of Anesthesiologists, with the support of both the American Association of Critical Care Nurses and National EMS Physicians.

“There’s a reason why we had eight organizations be a part of this. Part of that is because there’s a very small knowledge base right now for how to treat COVID patients and a lot of the knowledge is based on things that are being published hourly, coming out of China, Italy, France, and other countries,” said ComillaSasson, MD, Ph.D. (University of Colorado Hospital, Denver).

 “What we tried to do was to take the best available evidence, for which there is very limited data, combined with what we know from prior infectious disease outbreaks like SARS and MERS, and then really try to figure out [the] delicate balance of making sure that we are trying to optimize patient survival but at the same time being very mindful of exposure risks to providers as well,” she explained.

“Healthcare providers are a limited, scarce resource, and we have to make sure that their safety is paramount, especially in an infectious disease like this.”Sasson stated.

This is the first time for CPR recommendations to call for clinicians to take some time and ensure their safety is guaranteed before getting into the exercise.

Because COVID-19 is a concern to everyone, healthcare workers are advised to don PPE before starting CPR and reduce the number of health care professionals taking part in the exercise. The use of mechanical CPR devices also can reduce exposure.

The decisions whether to go for CPR or not should be carefully done according to the guidelines, considering the age of the patient, comorbidities, and severity of illness.

 “Cardiopulmonary resuscitation is a high-intensity team effort that diverts rescuer attention away from other patients. In the context of COVID-19, the risk to the clinical team is increased and resources can be profoundly more limited, particularly in regions that experiencing many infections.While the outcomes for cardiac arrest in COVID- 19 are as of yet unknown, the mortality for critically ill COVID-19 patients is high and rises with increasing age and comorbidities, particularly cardiovascular diseases” she adds

However, cardiac arrest resuscitations should continue normally according to the standard algorithms in COVID-19 negative patients.

One good thing to come out as a result of COVID-19 is creative thinking when it comes to healthcare, according to ComillaSasson, MD, Ph.D. (University of Colorado Hospital, Denver).

“What used to work is not going to work going forward. I think all of us know that. We can be fluid and dynamic, which doesn’t mean chaos and disorganization. It just means things are changing,” added ComillaSasson.

A change in approach!

The primary lesson, from the COVID-19 pandemic, to the world of medicine is that nothing is written in stone.

Instead of creating chaos out of the cardiopulmonary resuscitation issue, we should adapt to the changes and think creatively to rise above the challenges we face.

Curing the sick is part of the fight against corona, which is why we should avoid them when they need us most. Still, health care officials must be protected.

We are not in the habit of sacrificing any life for the other. Let’s all worry about the safety and wellbeing of everyone.

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