European Resuscitation Council - COVID-19 - 24 April 2020 - ERC
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European
Resuscitation
Council
COVID-19
Guidelines
24 April 2020
European
Resuscitation
Council
COVID-19
Guidelines
Ed i t i o n 1 Photos courtesy of Fotografiepolak
Section 1
Introduction
JP. Nolan
T his guideline was provided on 24 April 2020 and will be subject to evolving
knowledge and experience of COVID-19. As countries are at different stages
of the pandemic, there may be some international variation in practice.
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EUROPEAN RESUSCITATION COUNCIL COVID-19 GUIDELINES
Introduction
The World Health Organization has declared COVID-19 a pandemic. The disease is
caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is
highly contagious. A recent systematic review that included 53,000 patients indicates
that 80% of patients have mild disease, 15% have moderate disease and about 5%
have severe disease requiring intensive care unit (ICU) admission.1 In this review the
fatality rate was 3.1%. Among 136 patients with severe COVID-19 pneumonia and
in-hospital cardiac arrest at a tertiary hospital in Wuhan, China, 119 (87.5%) had a
respiratory cause for their cardiac arrest.2 In this series of patients, the initial cardiac
arrest rhythm was asystole in 122 (89.7%), pulseless electrical activity in 6 (4.4%) and
ventricular fibrillation/ pulseless ventricular tachycardia (VF/pVT) in 8 (5.9%). In a case
series of 138 hospitalised COVID-19 patients, 16.7% of patients developed arrhythmias
and 7.2% had acute cardiac injury.3 Thus, although most cardiac arrests in these
patients are likely to present with a non-shockable rhythm caused by hypoxaemia
(although dehydration, hypotension and sepsis may also contribute), some will have
a shockable rhythm, which may be associated with drugs causing prolonged-QT
syndrome (e.g. chloroquine, azithromycin) or caused by myocardial ischaemia. In the
series of 136 cardiac arrests from Wuhan, four (2.9%) patients survived for at least
30 days but only one of these had a favourable neurological outcome.2
isks associated with cardiopulmonary
R
resuscitation (CPR) in patients with COVID-19
Mechanisms of transmission of SARS-CoV-2
The main mechanism of disease transmission of SARS-CoV-2 is by respiratory
secretions either directly from the patient or by touching contaminated surfaces.
Respiratory secretions are called either droplets (> 5–10 microns in diameter) or
airborne particles (< 5 microns). Droplets fall onto surfaces within 1–2 metres of the
patient’s respiratory tract while airborne particles can remain suspended in the air for
prolonged periods.4
Personal protective equipment (PPE)
The minimum droplet-precaution personal protective equipment (PPE) comprises:
• Gloves
• Short-sleeved apron
• Fluid-resistant surgical mask
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• E ye and face protection (fluid-resistant surgical mask with integrated visor or full-
EUROPEAN RESUSCITATION COUNCIL COVID-19 GUIDELINES
face shield/visor or polycarbonate safety glasses or equivalent).
The minimum airborne-precaution PPE comprises:
• Gloves
• Long-sleeved gown
• F iltering facepiece 3 (FFP3) or N99 mask/respirator (FFP2 or N95 if FFP3 not
available)*
• E ye and face protection (full-face shield/visor or polycarbonate safety glasses or
equivalent). Alternatively, powered air purifying respirators (PAPRs) with hoods
may be used.
* The European Standard (EN 149:2001) classifies FFP respirators into three classes:
FFP1, FFP2, and FFP3 with corresponding minimum filtration efficiencies of 80%,
94%, and 99%. The US National Institute for Occupational Safety and Health (NIOSH)
classifies particulate filtering facepiece respirators into nine categories based on
their resistance to oil and their efficiency in filtering airborne particles. N indicates
not resistant to oil; R is moderately resistant to oil; and P is strongly resistant to oil –
‘oil proof’. The letters N, R or P are followed by numerical designations 95, 99, or 100,
which indicate the filter’s minimum filtration efficiency of 95%, 99%, and 99.97% of
airborne particles (
Some healthcare systems are facing shortages of personnel and equipment, including
ventilators, to treat critically ill patients during the COVID-19 pandemic. Decisions
on triage and allocation of healthcare resources, including the provision of CPR and
other emergency care must be made by individual systems based on their resources,
values and preferences. However, the position of the ERC is that it is never acceptable
to compromise the safety of healthcare professionals.
The International Liaison Committee on Resuscitation (ILCOR) has undertaken a
systematic review addressing 3 questions 7:
1. Is the delivery of chest compressions or defibrillation an aerosol-generating
procedure?
2. Do the delivery of chest compressions, defibrillation or CPR (all CPR interventions
that include chest compressions) increase infection transmission?
3. What type of PPE is required by individuals delivering chest compressions,
defibrillation or CPR in order to prevent transmission of infection from the
patient to the rescuer?
The evidence addressing these questions is scarce and comprises mainly retrospective
cohort studies 8,9 and case reports.10-15 3
EUROPEAN RESUSCITATION COUNCIL COVID-19 GUIDELINES
In most cases, delivery of chest compressions and defibrillation are lumped together
with all CPR interventions, which means that there is considerable confounding in
these studies. Aerosol generation by chest compressions is plausible because they
generate small but measurable tidal volumes.16 Chest compressions are similar to
some chest physiotherapy techniques, which are associated with aerosol generation.17
Furthermore, the person performing chest compressions is close to the patient’s
airway.
The ILCOR systematic review did not identify evidence that defibrillation generates
aerosols. If it occurs, the duration of an aerosol generating process would be brief.
Furthermore, the use of adhesive pads means that defibrillation can be delivered
without direct contact between the defibrillator operator and patient.
The ILCOR treatment recommendations are:
• e suggest that chest compressions and cardiopulmonary resuscitation have
W
the potential to generate aerosols (weak recommendation, very low certainty
evidence).
• e suggest that in the current COVID-19 pandemic lay rescuers* consider
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compression-only resuscitation and public-access defibrillation (good practice
statement).
• e suggest that in the current COVID-19 pandemic, lay rescuers who are willing,
W
trained and able to do so, may wish to deliver rescue breaths to children in addition
to chest compressions (good practice statement).
• e suggest that in the current COVID-19 pandemic, healthcare professionals
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should use personal protective equipment for aerosol-generating procedures
during resuscitation (weak recommendation, very low certainty evidence).
• e suggest that it may be reasonable for healthcare providers to consider
W
defibrillation before donning aerosol generating personal protective equipment
in situations where the provider assesses the benefits may exceed the risks (good
practice statement)
*Comment - it is the view of the ERC that this applies to first responders as well as lay
rescuers.
REFERENCES
1. Ma C, Gu J, Hou P, et al. Incidence, clinical characteristics and prognostic factor of patients
with COVID-19: a systematic review and meta-analysis. medRxiv 2020.
2. Shao F, Xu S, Ma X, et al. In-hospital cardiac arrest outcomes among patients with COVID-19
pneumonia in Wuhan, China. Resuscitation 2020;151:18-23.
3. Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel
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Coronavirus-Infected Pneumonia in Wuhan, China. JAMA 2020.
EUROPEAN RESUSCITATION COUNCIL COVID-19 GUIDELINES
4. Gralton J, Tovey E, McLaws ML, Rawlinson WD. The role of particle size in aerosolised
pathogen transmission: a review. J Infect 2011;62:1-13.
5. Lee SA, Hwang DC, Li HY, Tsai CF, Chen CW, Chen JK. Particle Size-Selective Assessment of
Protection of European Standard FFP Respirators and Surgical Masks against Particles-Tested
with Human Subjects. J Healthc Eng 2016;2016.
6. Cook TM. Personal protective equipment during the COVID-19 pandemic - a narrative review.
Anaesthesia 2020.
7. Couper K, Taylor-Phillips S, Grove A, et al. COVID-19 in cardiac arrest and infection
risk to rescuers: a systematic review. Resuscitation 2020. https://doi.org/10.1016/j.
resuscitation.2020.04.022
8. Loeb M, McGeer A, Henry B, et al. SARS among critical care nurses, Toronto. Emerg Infect Dis
2004;10:251-5.
9. Raboud J, Shigayeva A, McGeer A, et al. Risk factors for SARS transmission from patients
requiring intubation: a multicentre investigation in Toronto, Canada. PLoS One 2010;5:e10717.
10. Liu B, Tang F, Fang LQ, et al. Risk factors for SARS infection among hospital healthcare workers
in Beijing: A case control study. Tropical Medicine and International Health 2009;14:52-9.
11. Chalumeau M, Bidet P, Lina G, et al. Transmission of Panton-Valentine leukocidin-producing
Staphylococcus aureus to a physician during resuscitation of a child. Clinical Infectious
Diseases 2005;41:e29-30.
12. Christian MD, Loutfy M, McDonald LC, et al. Possible SARS coronavirus transmission during
cardiopulmonary resuscitation. Emerg Infect Dis 2004;10:287-93.
13. Kim WY, Choi W, Park SW, et al. Nosocomial transmission of severe fever with
thrombocytopenia syndrome in Korea. Clinical Infectious Diseases 2015;60:1681-3.
14. Knapp J, MA W, E. P. Transmission of tuberculosis during cardiopulmonary resuscitation.
Focus on breathing system filters. Notfall und Rettungsmedizin 2016;19:48-51.
15. Nam HS, Yeon MY, Park JW, Hong JY, Son JW. Healthcare worker infected with Middle East
Respiratory Syndrome during cardiopulmonary resuscitation in Korea, 2015. Epidemiol Health
2017;39:e2017052.
16. Deakin CD, O’Neill JF, Tabor T. Does compression-only cardiopulmonary resuscitation
generate adequate passive ventilation during cardiac arrest? Resuscitation 2007;75:53-9.
17. Simonds AK, Hanak A, Chatwin M, et al. Evaluation of droplet dispersion during non-invasive
ventilation, oxygen therapy, nebuliser treatment and chest physiotherapy in clinical practice:
implications for management of pandemic influenza and other airborne infections. Health
Technol Assess 2010;14:131-72.
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