Jeff Clawson, M.D.

Jeff Clawson, M.D.

Brett Patterson

Brett Patterson

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Dr. Jeff Clawson and Brett Patterson

Recently, three related documents were released that contain some basic recommendations regarding resuscitation guidelines during the COVID-19 pandemic. The first is entitled “Resuscitation Council UK Statement on COVID-19 in relation to CPR and resuscitation in first aid and community settings” (released on March 4 and updated on March 24). The second is the American Heart Association’s (AHA) release of “Interim Guidance for Healthcare Providers during COVID-19 Outbreak,” which was based on the March 11 recommendations from the Centers for Disease Control (CDC). The third was released more recently on April 9 and is more comprehensive. Published in Circulation, it is entitled “Interim Guidance for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19.”

https://www.gov.uk/government/publications/novel-coronavirus-2019-ncov-interim-guidance-for-first- responders/interim-guidance-for-first-responders-and-others-in-close-contact-with-symptomatic-people- with-potential-2019-ncov

https://professional.heart.org/idc/groups/ahamah- public/@wcm/@sop/@smd/documents/downloadable/ucm_505872.pdf

Critical to this discussion is the fact that this guidance is specific to patients suspected of, symptomatic of, or diagnosed with COVID-19, and not the general population at large. This is clearly stated in all of these documents. Specifically, the more recent AHA document states: “This statement applies to all adult, pediatric, and neonatal resuscitations with suspected or confirmed COVID-19 ...” And the previous AHA guidance asserts: “Please note that the following guidance is intended specifically for when patients have known or suspected COVID-19.” In all other cases, follow your standard protocol.

The Rules Group of the Academy’s Council of Standards recently approved a temporary change to PAI Panel C/YC-3 that removes the instruction to “Put your ear next to her/his mouth” and modifies the operant question accordingly. While this change is not exclusive to patients suspected or symptomatic of COVID-19, it is aimed at reducing unnecessary face-to-face contact with all unconscious patients. There will be no immediate changes regarding the head-tilt airway maneuver or Mouth-to-Mouth (M-T-M) instructions for the limited subset of patients where M-T-M ventilations are recommended, i.e., children and arrest with suspected respiratory etiology. The risk-benefit ratio is heavily weighted in favor of these lifesaving instructions for this cohort of patients that are not suspected of COVID-19 infection and have a clear and primary respiratory component that needs to be addressed. Additionally, COVID-19 deaths follow a well-documented pattern that does not appear to commonly include sudden cardiac arrest but rather a disease progression that results in hospitalization prior to death.

In the vast majority of cardiac arrest cases, respirations are not advised in the MPDS®. They are provided for cases with a known respiratory cause—think suffocation, asthma attack, or overdose—but not pneumonia. They are also provided after 600 compressions in the Compressions 1st pathway, which responder arrival usually precedes. So, simply choosing the Compressions Only Pathway for suspected cardiac arrest avoids M-T-M with all but the relatively rare, primary respiratory etiology patients and children.

Note that a Refused M-T-M Pathway is available in the event the caller doesn’t want to provide M-T-M respirations. Should your agency’s medical control dictate the cessation of M-T-M instructions, a written procedure authorizing the alternative use of this pathway will facilitate such an order. However, note that this is not advised or supported, in any way, by the IAED. Airway control and maintenance, and rescue breaths when indicated by protocol, are potentially lifesaving interventions that should not be withheld without clear and obvious scene safety concerns—think infant drowning or teenage hanging. It is the Academy’s current position that patients not suspected of COVID-19 that qualify for M-T- M (children and suspected asphyxial arrest) do not present a substantial threat to lay rescuers, while withholding such instruction does present a substantial threat to patients in need of such therapy.