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Are You Up To Date on Cardiopulmonary Resuscitation Guidance?

  • Authors: News Author: Megan Brooks; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 3/11/2022
  • Valid for credit through: 3/11/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

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Target Audience and Goal Statement

This activity is intended for all primary care physicians, critical care specialists, infectious disease specialists, pharmacists, nurses and other healthcare professionals who treat and manage adults with known or suspected COVID-19 infection.

The goal of this activity is to distinguish the best practice in cardiopulmonary resuscitation for patients with known or suspected COVID-19 infection.

Upon completion of this activity, participants will:

  • Identify aerosol-generating procedures during cardiopulmonary resuscitation
  • Distinguish interim guidance regarding cardiopulmonary resuscitation among patients with known or suspected COVID-19 infection
  • Outline implications for the healthcare team


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News Author

  • Megan Brooks

    Freelance writer, Medscape


    Disclosure: Megan Brooks has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline; Johnson & Johnson

Editor/CME Reviewer/Nurse Planner

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.

CME/CE Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

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Are You Up To Date on Cardiopulmonary Resuscitation Guidance?

Authors: News Author: Megan Brooks; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 3/11/2022

Valid for credit through: 3/11/2023


Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to COVID-19 vaccines may be provided in this activity to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context

Survival of cardiac arrest both within the hospital and in the community have declined precipitously since the advent of the pandemic, according to the authors of a recent 2022 interim guidance on CPR/ACLS in known or suspected COVID-19 patients. Several factors could explain these results, such as the severity of SARS-CoV-2 related cardiac arrest, the implementation or termination of resuscitation guidance, local crisis standards of care or patient hesitancy to seek medical care contributing to delays in care.

The provision of prompt chest compressions and defibrillation may also have been delayed due to the additional time required in donning personal protective equipment (PPE) or securing the airway and the PPE may have accelerated rescuer fatigue resulting in decreased CPR quality of which is a lack of PPE or delay in resuscitation resulting from the time required to don PPE.

Experts recommend that the resuscitation team wear PPE for all aerosol-generating procedures (AGPs) involving patients with known or suspected COVID-19. AGPs include chest compressions, defibrillation, bag-mask ventilation, intubation, and positive-pressure ventilation. The current interim guidance highlights specific recommendations for in-hospital resuscitation.

Study Synopsis and Perspective

Based on new and more transmittable COVID-19 strains, declining vaccine effectiveness and feedback from the healthcare community, it became clear that that there was a need to create interim guidance for basic and advanced life support. The American Heart Association, working with the American Academy of Pediatrics, the American Association for Respiratory Care, the Society of Critical Care Anesthesiologists, and the American Society of Anesthesiologists, have issued the 2022 Interim Guidance for Basic and Advanced Life Support in Adults, Children and Neonates with Suspected or Confirmed COVID-19.

The updated guidance was published online January 24th, 2022, in CirculationCardiovascular Quality and Outcomes. The goal was to fully protect healthcare providers who perform resuscitation and highlights specific recommendations for in-hospital resuscitation. The guidance can be considered a best practice statement and have not gone through a formal evidence review and subsequently, cannot be assigned a Class of Recommendation or Level of Evidence. The guidance is based on available scientific evidence at the time of its development and will continue to evolve as the pandemic continues.

Updates in the interim guidance focus on three tenets:

1. Incorporating the most recent Centers for Disease Control and Prevention and World Health Organization guidance

All healthcare providers should wear a respirator (eg, N95) along with other PPE (gown, gloves, and eye protection) for patients with suspected or confirmed COVID-19 infection before performing Aerosol-generating procedures (AGPs) or in a setting where such procedures are regularly performed. This may also apply to patients in cardiac arrest who tested negative for COVID-19 on admission. In the event initial responders are not already wearing appropriate PPE, they should immediately don it and then begin CPR.

(AGPs) include chest compressions, defibrillation, bag-mask ventilation, intubation, and positive-pressure ventilation.

2. Reinforcing resuscitation best practices

Cardiac arrest survival is dependent on early initiation of CPR and performing chest compressions as soon as it is safely possible is recommended. Patients with confirmed or suspected COVID-19 should receive the best resuscitative efforts possible.

3. Ensuring adequate PPE supply

Effective use of PPE is critical for the safety of healthcare providers performing resuscitations, and at this time, all healthcare providers should be following appropriate precautions and should have access to PPE in all clinical settings, regardless of the potential of encountering resuscitation events.

"Healthcare professionals are paramount to the health of communities around the world, especially during a pandemic, and they should be protected while performing healthcare procedures, including resuscitation," Dianne Atkins, MD, pediatric cardiologist, and lead author of the new interim guidance, said in a news release.

"Protecting the health and safety of healthcare professionals remains critical and includes ensuring the recommended [PPE] is available and that healthcare professionals are trained to use it properly," added Dr Atkins, who chairs the AHA emergency cardiovascular care committee.

Circ Cardiovasc Qual Outcomes. Published online January 24, 2022.[1]

Study Highlights

  • In witnessed, sudden arrest, don appropriate PPE and initiate chest compressions immediately. All persons not wearing appropriate PPE should be immediately excused from the room or area.
  • A HEPA filter should be attached to any manual or mechanical ventilation device at the exhalation port.
  • The resuscitation team should defer to the person with the greatest chance for success for intubation to perform the procedure, reducing time to intubation and possibly exposure to COVID-19 for the healthcare team.
  • Endotracheal medications should be avoided, as disconnections may be a source of aerosolization resulting from unfiltered exhalation.
  • Critically ill patients should be moved to negative-pressure rooms, if possible, to minimize the risk to the resuscitation team.
  • Manual compressions can be initiated while patients are in the prone position, with hands centered over the T7-T10 vertebral bodies.
  • Patients may be considered for transition to a supine position with a trained team.
  • During cardiac resuscitation of patients already on mechanical ventilation, the following steps should be taken:
    • FiO2 should be increased to 1.0.
    • Limit pressure or tidal volume to allow for adequate chest rise.
    • Adjust the respiratory rate to 10 breaths/minute for adults, 20 to 30 breaths/minute for infants and children, and 30 breaths/minute for neonates.
  • Routine resuscitation of neonates, including tactile stimulation and placement of pulse oximetry and electrocardiographic leads, is not aerosol-generating.
  • Suction should not be performed routinely for neonates with clear or meconium-stained amniotic fluid.
  • For maternal resuscitation, if spontaneous circulation is not achieved within 5 minutes of arrest, perimortem cesarean delivery should be performed.
  • Oxygenation with intubation should be prioritized earlier among pregnant women with COVID-19.
  • Positive pressure ventilation remains the main resuscitation strategy for newborns for apnea, ineffective breathing, and bradycardia. Chest compressions occur later in the management algorithm for these symptoms.
  • Provider risk may vary based on individual (age/ethnicity/comorbidities/vaccination status) and system factors. Healthcare providers can significantly reduce their risk of infection, especially severe illness or death, by receiving the vaccine and booster against the SARS-CoV-2 virus.

Clinical Implications

  • AGPs during CPR include chest compressions, defibrillation, bag-mask ventilation, intubation, and positive-pressure ventilation.
  • The current interim guidance recommends the following interventions during CPR for patients with known or suspected COVID-19: universal application of HEPA filters to ventilation devices, using the most accomplished person to attempt intubation on such patients, avoiding the use of endotracheal medications, and initiating compressions among patients in the prone position while considering transition to the supine position.
  • Implications for the healthcare team: Health care professionals should work collaboratively as a team to understand the current guidance for CPR among patients with known or suspected COVID-19 infection. All team members should understand their roles.

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