The new modifications that were applied to the ACLS algorithm
I think it should be added clearly that endotracheal tube or the supra-glottic device should be connected first to the bacterial/viral filter before its insertion inside the trachea or the pharynx. This will limit possibility of viral transmission if the patient was coughing.
Muscle relaxants usage is preferred if the incubator is experienced in intubation.
Paralysis is the key to avoid cough
and cuff up before the first bag breathing
Glycopyrrolate may be recommended in this protocol to be used in a very early stage to reduce aerosol generation.
1. PPE should be described well. As CPR in COVID patients is an aerosol generating procedure, we need all the PPEs including N95 mask, google, isolation gown, and gloves.
2. We don't have to wait for two minutes to treat underlying cause if there is, like hypoglycemia, hypokalemia
3. We don't have to administer amiodarone or lidocaine routinely if there is no specific indication.
First step at a witnessed arrest that the rescue team has enough time to "jump in" a PPE, including at least FFP2 NK95 mask, double gloves, isolation gown, googles/total face plexi cover, single use surgical cap. This means max. 1 min of delay. Second, to secure airway is to be done under neuromuscular blockade given through RSI. For ETi chest compression should be interrupted, HME filter is to be connected to the tube before insertion.
If victim is already intubated..focus should be to maintain close circuit. Continue to ventilate through ventilator. If non-intubated focus should be RSI with minimal interruption in chest compression.
The main objective of the COVID19 CARDIAC ARREST management is to recover the patient with full organic and neurological function and cardiac arrest management of a Covid19 patient depends where the code has occurred. When this happens in ER, ICU or OT, it is supposed that all staff should be wearing full PPE´s; but what about when the cardiac arrest happens in a clinical ward? As it is stated in the Chain of Survival, EARLY RECOGNITION, EARLY CPR, and EARLY DEFIBRILLATION are essential steps of BLS to achieve the best results. Once the cardiac arrest has been recognized, CHEST COMPRESSION ONLY CPR can be done with minimum PPE´s if the head of the patient can be covered with a towel to minimize the burden of a AGP, meanwhile it is attached the paddles and cardiac monitor to diagnose the cardiac rhythm. Remember that every 10 seconds you stop the chest compression and delay the defibrillation, the probability to survive decreases in about 20 %. Many factors are influencing the worst results of surviving during a cardiac arrest in COVID19 patients as is stated in
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. doi:10.1016/j.resuscitation.2020.04.005.
and
Sheth V, Chishti I, Rothman A, et al. Outcomes of in-hospital cardiac arrest in patients with COVID-19 in New York City [published online ahead of print, 2020 Jul 21]. Resuscitation. 2020;155:3-5. doi:10.1016/j.resuscitation.2020.07.011.
It may be the most proper way of response to COVID19 CARDIAC ARREST hasn´t been established. But, I insist in optimizing BLS taking into account if the PPE´s are being used in a properly way or not. The other part of the history is the ACLS protocol applied by the Code Blue Team.
THE TRUTH MAY BE
OUTSIDE IN ANYWHERE.
Unless patient is admitted outside the ICU, all ICU patients with COVID-19 should have a clear discussion about "Do Not Resuscitate (DNR)" orders.
Following are helpful guidelines for resuscitations in COVID-19 patients and precautions by rescuers:
1. Presentation Resuscitation in Covid-19 patients
2. Article COVID-19 cardiopulmonary resuscitation: Guidelines and modifications
3. Article COVID-19 in cardiac arrest and infection risk to rescuers: A...
4. Article Cardiac Arrest in the COVID-19 Era
Endre Zima is absolutely correct, and the insertion of filters on the ET tube prior to insertion precludes the use of stylets. The best solution is to use full PPE-AGP and if there is a possibility of videolaryngoscopy to increase the effectiveness of intubation while reducing the duration of the procedure.
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