Basic Life Support & Advanced Life Support - Communique during the COVID-19 Pandemic

Basic Life Support &
            Advanced Life Support
Communique during the COVID-19 Pandemic

Basic Life Support and Advanced Life Support;
Communique during the COVID-19 Pandemic
Introduction
The current COVID-19 pandemic has caused a high level of concern to health care workers and the wider
community, with ongoing uncertainty and variation in practice around the world concerning the optimal
clinical approach to resuscitative procedures in known or suspected COVID-19 patients.
In the context of Primary Health Care (PHC) clinics, be they metropolitan, rural or remote based, there is
another dimension outside of hospital settings that adds further or amended considerations.
The danger to the first responders and Health Care team is the risk of potential transmission of the virus
during resuscitative procedures, hence the critical importance of the use of Personal Protective Equipment
(PPE) and an awareness of the potential of generating aerosols in using supportive treatments.
The Key aim is to provide basic resuscitation as per recommended guidelines, with adaptions to mitigate
risks.

Key Points
The Australian Resuscitation Council, 2020, has issued a communique from ANZCOR (Australian and New
Zealand Committee on Resuscitation) in regard to CPR in present pandemic situation; https://resus.org.au/
Their key message is that underlying principles for CPR remain the same:
       Any Attempt at Resuscitation is better than No Attempt.
       What has changed with this COVID-19 pandemic is the risk to rescuers.
       Healthcare workers should be provided with appropriate PPE to perform their roles.
       Note, many sudden cardiac arrests occur in the presence of family members, and many will be
        unrelated to COVID-19. For lay rescuers who are unable or unwilling to do rescue breathing,
        compression only CPR is acceptable.
       After any attempts at resuscitation, please adhere to current advice about hand washing, cleaning
        and decontamination

Key Considerations for both Basic Life Support (BLS) & Advanced Life Support (ALS)
       The question posed in many approaches is to ascertain if resuscitation is appropriate.
        The considerations for such action will vary greatly from situation to situation and is a decision
        made by the health care team with full knowledge of each situation.
       Aerosol generation: Chest compressions, assisted ventilation, and advanced airway manoeuvres
        are all considered potentially aerosol-generating procedures, and should only be performed by
        responders in airborne PPE (P2/N95 mask, gown, gloves, eye protection, hair covering)

        Defibrillation is not considered an aerosol-generating procedure and can be performed by
        responders wearing droplet precautions (surgical mask, gloves, gown, eye protection) as long as the
        patient’s mouth and nose are covered and no chest compressions

       As cardiac arrest is a time-sensitive condition, where delays to treatment reduce the likelihood of a
        good patient outcome, an alternative approach is to perform defibrillation prior to donning
        personal protective equipment if the arrest is witnessed and a defibrillator is immediately available,
        and the patients mouth, and nose are covered
       Thorough preparation in being prepared in responding to cardiac arrest situations, should include
        access to full PPE gear in responder packs and on Emergency trolleys, including hand wash.
       Consider permitting time for donning before you get to an out of clinic response. The opportunity
        to don appropriate PPE prior to arrival at the scene will minimise delays to response.

AHCSA | BLS & ALS Communique during the COVID-19 Pandemic                                                    1

Basic Life Support
Defined: The preservation of life by the initial establishment of, and/or maintenance of, airway, breathing,
circulation and related emergency care, including use of an AED (ARC, 2020).

DANGER: the key danger is to the first responder and the need to protect themselves from potential cross
contamination in performing BLS. The main risk in transmission is in aerosol generating procedures which is
likely to be limited in the initial response.

         Use of PPE as available. First responders should be wearing at least a surgical mask, eye protection
          and gloves.
         Consider placing a mask (or cloth) over the face of the person being attended to

RESPONSE: check for Response from a distance

SEND FOR HELP: Minimise the number of responders/persons in the room/close vicinity. Any available
bystanders should support maintaining necessary infection control measures where possible.

BREATHS: no rescue breaths with the exception for children, the Advanced Paediatric Life Support (APLS)
recommendation is that due to the most common scenario that hypoxia precipitates a cardiac arrest,
effective ventilation is a priority.

In contrast to the advice in adults in the out-of-hospital setting, APLS recommends that in the current
COVID-19 pandemic, health care professionals and lay rescuers who are willing, trained and able to do so,
should continue to deliver rescue breaths to children in addition to chest compressions. If rescuers are
untrained or unwilling to perform rescue breaths, chest compression only CPR is preferable to no CPR
(APLS, 2020)

COMPRESSIONS: only, exception for children to include breaths as above

DEFIBRILLATION: attach and follow instructions (see table) or insert flowchart reference

POST RESUS CARE: including adhering to all cleaning and disinfecting recommendations

                                              BASIC LIFE SUPPORT
                                   Protection of responder is priority
        DANGER
                                   Don PPE
        RESPONSE                   Look for response
                                   Send for Help
        SEND for Help              Limit the number of persons
                                   Provide infection control support measures
        AIRWAY                     Check and observe
        BREATHING                  No rescue breaths (except for children)
                                   START CPR 30 compressions
        COMPRESSIONS
                                   Continue until responsive or other decision as directed
        DEFIBRILLATION             Attach Defibrillatorand follow instructions
        POST RESUS CARE

Equipment requirements: If using pocket masks ensure availability of disposable filters

AHCSA | BLS & ALS Communique during the COVID-19 Pandemic                                                   2

Advanced Life Support
Defined: The provision of effective airway management, ventilation of the lungs and production of a
circulation by means of techniques additional to those of BASIC LIFE SUPPORT. These techniques may
include, but not be limited to, advanced airway management, vascular access/drug therapy and
defibrillation (ARC, 2020).

DANGER: As described in BLS regarding use of PPE, considerations must made in regards to aerosol
generating treatments.

Health care workers are encouraged to become familiar with and adhere to local guidleines which describe
the PPE that should be worn for aerosol generating procedures as per expert recommendations . The ideal
appropriate PPE for all resuscitaions that involve chest compressions , is a P2/N95 mask, gown, goggles,
gloves and hair covering

CPR: Compressions only with exception of children, as per APLS recommendations

ATTACH MONITOR DEFIBRILLATOR:Proceed as per recommnded Guidleines (ARC guidleines)

AIRWAY: The risk associated with aerosol-generating procedures (AGPs) should, where practical be
minimised and the following recommendations considered:
       Preferentially allocating the most experienced clinician to manage the airway
       Do not attempt to clear the airway using any methods other than head tilt or chin lift
       Suctioning of the airway should not occur through an open suction device (i.e. Yankauer sucker)
        until in an appropriate room with airborne PPE.
       A supraglottic airway (i.e. LMA) is preferred to a face mask, as it is thought to reduce the risk of
        aerosols
       Pause compressions before inserting a supraglottic airway or attempting to intubate
       Recognising that a cuffed Endotracheal tube (ETT) is preferable to a supraglottic airway (LMA),
        which is preferable to Bag Valve Mask Ventilation (BVM)

VENTILATION:
       If using BVM, a two person technique with an oropharyngeal airway, is recommended as an option
        to increase the seal and minimise aerosol production
       Addition of appropriate viral filters on all airway devices inclusive of Bag Valve Mask, Supraglottic
        airway or ETT where available and as close to the patient as possible. Take care to ensure that all
        connections are secure and consider the use of reinforcing tape.

  ADVANCED LIFE SUPPORT           COVID-19 considerations for COVID-19 suspected or confirmed case
  CPR                             Compressions only (exception for children)
  MONITOR/DEFIBRILLATOR           Attach and follow algorithim
  AIRWAY                          Minimising aerosol generation as practical and contextual
  VENTILATION                     Minimising aerosol generation as practical and contextual
  Continue CPR                    Follow ALS algorithim
  POST RESUS

Equipment requirements: HME filters as a minimum

AHCSA | BLS & ALS Communique during the COVID-19 Pandemic                                                      3

References
Advanced Paediatric Life Support, 2020. APLS Statement on Paediatric Ewesuscitaion during the COVID-19
Pandemic. Accessed https://apls.org.au/

Australian College of Emergency Medicine. Adult Cardiac Arrest Managemen. Accessed.
https://acem.org.au/Content-Sources/Advancing-Emergency-Medicine/COVID-19/Resources/Clinical-
Guidelines/Adult-Cardiac-Arrest-Management

Australian Resuscitation Council, April 2020. Resuscitation during the COVID-19 Pandemic, accessed
https://resus.org.au/World Health Organisation. 2020 Modes of transmission of virus causing COVID-
19:implications for IPC precaution recommendations.

Couper K, Taylor-Phillips S, Grove A, Freeman K, Osokogu O, Court R, Mehrabian A, Morley P, Nolan JP, Soar
J, Berg K, Olasveengen T, Wychoff M, Greif, R, Singletary N, Castren M, de Caen A, Wang T, Escalante R,
Merchant R, Hazinski M, Kloeck D, Heriot G, Neumar R, Perkins GD on behalf of the International Liaison
Committee on Resuscitation.

COVID-19 infection risk to rescuers from patients in cardiac arrest.

Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison
Committee on Resuscitation (ILCOR), 2020 March 30. Available from: http://ilcor.org

WHO reference number: WHO/2019-nCoV/Sci_Brief/Transmission_modes/2020.2 Accessed
https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-
implications-for-ipc-precaution-recommendations

AHCSA | BLS & ALS Communique during the COVID-19 Pandemic                                              4

BASIC LIFE SUPPORT
COVID-19 considerations for COVID-19 suspected or confirmed cases

                                   Dangers?
                        Protection of responder is priority

                                 Responsive?
                                Look for response

                                Send for help
                           Limit the number of persons
                             Provide infection control

                                 Open Airway
                                Check and observe

                             Normal Breathing?
                      No rescue breaths (except for children)

                                  Start CPR
                  30 compressions and continue until responsive
                          or other decision as directed

                         Attach Defibrillator (AED)
                                Follow instructions

      Continue CPR until responsiveness or normal breathing
               occurs and provide post-resus care

ADVANCED LIFE SUPPORT
      COVID-19 considerations for COVID-19 suspected or confirmed cases

                                            Start CPR
                            Compressions only (exception for children)
                                       Appropriate PPE

                                              Attach
                           Defibrillator / Monitor and follow algorithm

                                         Assess Rhythm

       Shockable                                                  Non-Shockable

                                       Return of Spontaneous
           Shock
                                            circulation?

             CPR                                                              CPR
      for 2 minutes                                                    for 2 minutes

 AIRWAY: Use interventions                                               VENTILATION:
that minimise aerosol generation.                                  Use interventions that minimise
 A supraglottic airway (i.e. LMA) is                              aerosol generation. If using BVM,
preferred to a face mask; a cuffed                                   a 2 person technique with
    Endotracheal Tube (ETT) is         Post Resuscitation             oropharyngeal airway, is
preferable to a supraglottic airway                               recommended with the addition
(LMA), which is preferable to BVM             Care                          of viral filters