Managing COVID-19 infection risks during cardiac arrest treatment
What the ILCOR recommendations for managing infection risks during CPR and intubation of patients who may be infected with SARS-CoV-2 mean for EMS
By Kenneth W. Navarro
A Task Force for the International Liaison Committee on Resuscitation (ILCOR) recently began a continuous evidence evaluation process related to the global uncertainty of infection risks posed to healthcare professionals by patients suffering cardiac arrest who may be infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
The Task Force addressed three specific research questions and reviewed all relevant research published before Mar. 24, 2020. The main purpose of the ILCOR evaluation was to generate evidence-based treatment recommendations for healthcare teams who participate in the resuscitation attempt . A draft of those recommendations is available for public comment
ILCOR draft recommendations for healthcare providers
Based on the evidence review – examined below – ILCOR drafted the following recommendations :
- Weak recommendation: Chest compressions create passive ventilation with small tidal volumes . It is plausible this air movement has the potential to generate aerosols. Further, EMS personnel performing chest compressions are in physical contact with the patient in close proximity to the patient’s airway. Based on very low certainty evidence, EMS professionals participating in a resuscitation attempt should use PPE that protects against aerosol transmission.
- Good Practice Statement: The evidence reviewed did not suggest aerosol production from defibrillation. However, if the muscle contractions brought about during the shock were to generate an aerosol, the process would be brief. Further, the widespread use of adhesive pads increases the distance between the patient and the defibrillator operator. Therefore, it is reasonable for EMS personnel to consider providing a defibrillation attempt prior to donning PPE that protects against aerosol transmission if the situation assessment suggests the benefits exceed the risks.
Initiating or terminating resuscitation in the field
Although the Task Force did not specifically address whether confirmation or suspicions of COVID-19 should factor into the decision to begin resuscitation or terminate a resuscitation in progress, they did make some relevant comments . Individual EMS systems must carefully balance the benefits of CPR and early defibrillation with the potential harm.
In the context of COVID-19, potential harm could come in transmission of the SARS-CoV-2 virus to members of the prehospital resuscitation team, emergency department personnel if the patient is transported, and to members of the civilian population who interact with the healthcare team both on- and off-duty. The same risk versus benefit analysis should be a factor in the decision to field terminate resuscitations already in progress.
Previous American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommended that trained emergency medical dispatchers provide CPR instructions to bystanders who call to report a possible cardiac arrest . For simplicity, those same guidelines recommended dispatchers give hands-only CPR instructions to untrained bystanders for adult victims of cardiac arrest with the flexibility to give conventional CPR instructions if the adult or pediatric patient suffered an asphyxial cardiac arrest.
The Task Force acknowledged the majority of out-of-hospital cardiac arrests occur in the home, where the individual who suffers the arrest will likely have already had close contact with those available to provide initial care. Additionally, those lay rescuers will not likely have access to PPE capable of protecting against aerosol transmission. Finally, not providing CPR instructions creates considerable risk to the individual who suffered the cardiac arrest. Although the ILCOR Task Force did not specifically address dispatcher-assisted CPR during the current COVID-19 pandemic, they did make two recommendations specifically targeting the lay rescuer population that have some relevancy to dispatcher-assisted CPR :
- Good Practice Statement: Despite the plausibility of aerosol generation from chest compressions, lay rescuers should consider providing compression-only resuscitation and public-access defibrillation (when available).
- Good Practice Statement: Lay rescuers who are trained and willing to provide rescue breaths to children should do so.
These two Good Practice Statements are consistent with current AHA recommendations and do not change any previous recommendations for dispatcher-assisted CPR instructions.
Research Question 1
Although current evidence suggests airborne transmission is not a major contributor to SARS-CoV-2 transmission, the World Health Organization believes airborne transmission may be possible when performing interventions that generate aerosols, such as manual ventilation with a bag-mask device, endotracheal intubation, or CPR [2,3]. The first question reviewed by the ILCOR Task Force concerned whether resuscitation procedures such as chest compressions, defibrillation or any CPR-interventions that included chest compressions delivered in any setting were capable of generating aerosols.
Up to the time of the literature search, only two published case reports addressed this question. The earlier case involved the resuscitation of a 4-month-old being treated for right lobar pneumonia secondary to infection with methicillin-susceptible S. aureus . The child developed cardiac arrest outside of a critical care area and no one on the resuscitation team wore personal protective equipment (PPE). Five days after the resuscitation attempt, the physician member of the team developed furuncles on his face and hands. Subsequent testing of the 15-member resuscitation team found five tested positive for S. aureus. However, genetic analysis of all bacterial samples found the organism infecting the physician was the only match with the organism that killed the child. Although the physician did not perform chest compressions, he did perform endotracheal intubation. The case report indicates the physician had direct contact with blood from the patient’s airway, however, one cannot rule out the possibility of aerosol transmission during the procedure.
The second case report involved the resuscitation attempt of an 82-year-old male inpatient being treated for bacterial pneumonia secondary to Middle East Respiratory Syndrome, a condition caused by a virus similar to SARS-CoV-2 . The intubation attempt released a considerable amount of blood from the patient’s lower airways, which splashed onto the bedsheets and the PPE of the healthcare team. A nurse who was splashed with the body fluids stayed behind after termination of the resuscitation attempt to clean the room. The nurse remembered touching her goggles with her contaminated gloves during an adjustment, as the goggles did not fit properly. Although it is more likely the nurse became infected by direct contact with the patient’s body fluids or through doffing of PPE, one cannot rule out the possibility of aerosol transmission during airway control and hygiene procedures.
Research Question 2
The subject of the second question was whether resuscitation procedures delivered in any setting were capable of transmitting infections to individuals with or without personal protective equipment. As one may imagine, all publications that addressed this question were observational in nature. Thus, one cannot assume causation from any of the results.
A retrospective study of nurses from two critical care units in Toronto during the SARS outbreak in 2003 (n=624) did not find a significantly increased risk of becoming infected when performing CPR or defibrillating . However, for all patients, not just those in cardiac arrest, nurses who participated in pre-intubation suctioning or the actual intubation procedure itself were four times more likely to become infected than by not participating in those activities . Similarly, in a retrospective analysis involving patients infected with SARS who required endotracheal intubation (n=45), neither defibrillation nor providing chest compressions increased the risk of patient-to-healthcare worker infection . However, the number of intubated patients who actually developed cardiac arrest may have been too small (n=9) to detect a significant difference. As in the previously mentioned retrospective study, being in the room during fiberoptic intubation resulted in a 300% increase in the chances of viral transmission from patient to healthcare provider. Finally, a retrospective case-controlled study of healthcare workers exposed to patients with SARS at a hospital in China (n=477) found both endotracheal intubation and chest compressions were associated with an increased risk of contracting the virus . However, because of the significant correlation between contact through chest compressions and contact during endotracheal intubation, it was difficult to determine whether the increased risk was the result of one intervention or the other.
Five case reports also addressed this question. All five reports describe pathogen transmission from patient to healthcare personnel performing resuscitative procedures. In two of the cases, the infected healthcare workers were not wearing PPE [4,9]. The healthcare workers in the remaining three case reports were wearing PPE, although in one report, the staff did not wear all required PPE [5,10,11]. In one case, nine healthcare workers participated in the resuscitation effort, and within three days of the resuscitation event, three ICU nurses began experiencing symptoms consistent with SARS infection . Ultimately, only one tested positive for SARS. That nurse did not perform chest compressions but was present in the room when the patient was intubated.
Research Question 3
The final research question addressed whether wearing PPE compared to an alternative system of PPE or no PPE (a) protected resuscitation team members from infection with the same organism as the patient, (b) affected PPE effectiveness, or (c) affected the quality of CPR.
There were no studies addressing whether wearing PPE protected against infection with the same organism as the patient compared to alternative systems of PPE or no PPE at all.
Only one laboratory study involving 30 healthcare providers compared the effectiveness of three type of N95 masks while performing chest compressions on an instrumented manikin . The researchers compared effectiveness between a cup-type, fold-type, and a valve-type N95 mask. Performing chest compressions significantly reduced the effectiveness of all three masks compared to baseline pre-compression measurements, likely as the result of the movements associated with performing compressions. While performing chest compressions, the fold-type masks had the highest mean effectiveness score (93.2%) compared to the cup-type (44.9%) and the valve-type (59.5%) masks.
Three randomized controlled trials (RCTs) addressed the impact of PPE, alternative forms of PPE, or no PPE on CPR quality. In the previously mentioned study involving 30 healthcare workers from an emergency department, use of any of the various types of N95 masks did not result in significant decreases in the quality of CPR compared to baseline measurements . During simulated pediatric cardiac arrest involving 16 paramedics, the mean time for completion of four resuscitation tasks such as assisted ventilation, endotracheal intubation and establishing intraosseous access was significantly longer when paramedics wore PPE that protected against droplet and aerosol transmission compared to no PPE at all . A study involving 58 firefighters found that adding gowns to PPE already consisting of gloves, eye protection and N95 masks significantly increased the time to first ventilation and the time to first compression during a simulated cardiac arrest scenario using an adult manikin .
It is important to note the data found in the publications reviewed by the Task Force only indirectly applies to SARS-CoV-2, which may have different transmission risks than those offered by the pathogens described in the publications.
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