Cardiopulmonary Resuscitation

Patients With or Under Investigation for COVID-19

 

Background

The purpose of this protocol to describe the procedures, personnel and equipment required to safely perform cardiopulmonary resuscitation on a patient diagnosed or under investigation for COVID-19 who are receiving intensive care.

 

Code Status

Providers managing critically ill COVID-19 patients should have frank discussions with these patients or their health-care surrogates about the risks and benefits of CPR, including that CPR may be delayed in order to ensure safe donning of PPE prior to entry into the room. Proper discussion and documentation (including easily visible signage at the door) of code status should be viewed as a key measure to protect HCWs and the community at large.

 

Determination of Futility

The code blue can be stopped by the team leader at any point during the resuscitation – including prior to entering the patient’s room – if the responding physician feels that the chances of a successful resuscitation are very low and outweigh the risks of spread of COVID-19 to hospital staff and the community at large.

 

Abbreviations

  • PPE – personal Protective Equipment

  • BVM – bag valve mask ventilation (delivered through Ambu-Bag)

  • LMA – laryngeal mask airway

  • ETT – endotracheal tube

  • ROSC – return of spontaneous circulation

  • HCW – health Care Workers, broad category which includes any staff member who participates in direct patient care.

  • PAPR – powered air-purifying respirator

  • N95 masks – masks that are appropriate PPE for airborne isolation, provided the employee has undergone certified fit testing within one year

PPE

  • CPR is one of the most dangerous aerosol-generative procedures performed during the care of patients with COVID-19. Full ACE PPE is required for all providers in the room

 

Equipment

  • COVID-19 Airway Kit (see Airway Management protocol here)

  • PPE

  • Code Blue Equipment

    • At least 2 dedicated COVID-19 crash carts should ideally be stored in a negative pressure room and readily available. 

    • Other reusable medical equipment used in the course of the code blue will be cleaned afterword per manufacturers’ protocols prior to other clinical uses.

 

 

Team Members & Roles

Facility MICU/CCU/SICU nurses will fill nursing roles during a code blue response, to include medication administration, defibrillation, recording, timing, and obtaining intravenous or intraosseous access.

  • In the Room:

    • 1 Code Team Leader. This role will generally be filled by Staff Intensivists, Hospitalists, Cardiologists, Anesthesiologists, or Emergency Department physicians. Responsibilities include directing the code, recording time, deciding futility, and orchestrating post-code care. Due to limited staffing, appropriately trained housestaff may assist in code blues and Tele-ICU may participate if patient is in the MICU/CCU/SICU or on the non-ICU wards.

    • 1 RT (in room) should bring all equipment necessary for intubation into the room at one time. This RT can intubate in a code blue situation if a physician is not available

    • 1 ICU nurse administering medications

    • 3 ICU nurses rotating chest compressions every 2 minutes. If IV access or defibrillation is needed, 1 of the 3 ICU nurses doing chest compressions will establish IV access or prepare the defibrillator. Recording and timing will be recorded by Tele-ICU. 

    • Other Health Care Workers may be required for appropriate care of the patient, but should be minimized as much as possible and limited to only those who have received the appropriate PPE training.

  • Outside the Room:

    • 1 Nurse will remain outside the door to be the designated handoff nurse.

    • 1 Runner will be stationed outside the door during code blue to obtain necessary supplies and medications not readily available in the crash cart.  The runner will utilize the ante-room door.

    • 1 Pharmacist outside of the room will attend codes and distribute medications and supplies from crash carts.  The medications will be handed to the nurse acting as the runner.  The runner will hand medications to the medication nurse.

    • 1 Circulating RT should bring and prepare the ventilator outside the door. If ROSC and patient is intubated, one of the nurses in the room will bring the ventilator inside the room, handoff to the RT in the room, and briefly Ambu-bag the patient via an endotracheal tube.

Code Blue Procedure

  • Follow AHA ACLS guidelines for cardiac arrest (here)

 

Airway Management

Housestaff or other trainees should not participate in the airway management of these patients. When a privileged staff member is not immediately available at the clinical area, chest compressions should begin after donning ACE PPE.








 

  • If the patient is not-intubated

    • A 100% nonrebreather mask be placed on the patient. BVM should NOT be initiated due to risk of aerosolization.

    • In the meantime, the provider managing the airway should prepare for intubation

    • In select circumstance, a supraglottic airway (King, LMA) may be placed. However, risk of aerosolization remains high if seal is imperfect.

  • If the patient is intubated

    • The ventilator should be not be disconnected from the ETT

      • DO NOT DISCONNECT THE VENT. Disconnecting the vent circuit produces a major acute aerosol exposure. Goal is to maintain closed circuit, but also avoid triggering the vent during compressions. Safest preference is to keep patients connected to vent whenever possible. 

      • The Hamilton G5 currently does not have a CPR mode. Our strategy is to switch to PS and give mandatory breaths (click lung icon) at 30:2. RT will observe quality of mechanical breaths and may switch to BV-ETT if necessary. 

      • If BV-ETT is necessary, the code RT may connect BV to the end of the HME/filter (as shown in picture above).

Layout of Code Blue team members and roles.

Proposed algorithm for airway management in COVID-19 patients undergoing CPR

Information presented on this website does not reflect the views or positions of the US Veterans Health Administration, Emory Healthcare, or its affiliated institutions. This is a rapidly evolving field. As such. the content on this site is being updated daily and protocols will be updated in real time.  The purpose of this site is to provide a centralized resource for ICU topics and protocols to promote the well-being of hospitalized or critically ill patients suffering from COVID-19.  Defer to your institutional guidelines for all clinical practice decisions.

 

© 2020  Victor Tseng, MD