CARDIOPULMONARY

RESUSCITATION IN
COVID-19
Prof. Dr. dr. Syafri K Arif, SpAn, KIC, KAKV
 CARDIOPULMONARY RESUSCITATION

Annual incidence of Those with non-

cardiac arrests in CPR is a complex cardiac causes of
adults is 1-10 per intervention comprising cardiac arrest have
1000 airway management, worse outcomes
ventilation, chest
Survival rate from compressions, drug
therapy, and Considered as
shockable rhythm
defibrillation airborne generating
is 2-3 times higher
particles procedure
than non shockable
(15%  50%)
Documented viral transmission during
CPR

Emerging Infectious Diseases

Vol. 10, No. 2, 2004
 “CPR and endotracheal intubation
are aerosol-generating procedures”

Changes in thoracic pressure during chest compressions

generate airflow and small exhaled tidal volumes 
Droplets and airborne particles

Couper K, et al. COVID-19 in cardiac arrest and

Defibrillator  Unknown / Less clear
infection risk to rescuers: A systematic review.
Resuscitation. 2020
 The current
dilemma..

Healthcare staff in the West Midlands have been told not to start chest
compressions or ventilation in patients who are in cardiac arrest if they
have suspected or diagnosed covid-19 unless they are in the emergency
department and staff are wearing full personal protective equipment (PPE)
 The current
dilemma..

There are many patients who are awaiting test results

and who are treated as though they have COVID-19

If it turns out they don’t have COVID-19, and no resuscitation

attempt is made, that would be distressing
 “Primum non nocere”
First, do no harm!
-Hippocrates

Then Now
Doctor TO patient Doctor AND patient

“Make sure you, the victim, and any bystanders are safe”
This pandemic has changed the risk-benefit balance for CPR

From “there is no harm in trying”

To “there is little benefit to the patient, and potentially

significant harm to staff”
CPR ON COVID
PRINCIPLE
 Identify patients who
would not want CPR

Older adults with chronic, life-limiting illnesses

Conversations should occur before admission

facilitate completion of physician order for
life-sustaining treatments (POLST) forms
Clarify which COVID-19 patients are
least likely to benefit from CPR

• Older age
• Severe refractory hypoxemia (SpO <80% on FiO2 100% and PEEP >15)
• Higher sequential organ failure assessment (SOFA) score
• Elevated d-dimer
• Severe lymphopenia
• Elevated troponin
• Elevated creatinine
• High inflammatory markers
 According to the Centers for Disease Control and
Prevention (CDC), aerosolizing procedures should be
performed with personal protective equipment (PPE)

Eye protection
N95 respirators
Gloves
Gowns

In airborne infection isolation

rooms
(AIIR)
 APD Tingkat 3

Kegiatan yang menimbulkan

aerosol pada pasien kecurigaan
atau terkonfirmasi COVID-19
 CODE BLUE activation

• Visually inspect for absence of signs of life 

unresponsive / gasping
• Do not auscultate or listen/feel for breath sounds
• Palpate femoral or brachial pulse to confirm
 When cardiac arrest is confirmed, CPR
should be done as safely as possible

All healthcare providers must don full PPE

(including N95s) before entering the room
even if it delays resuscitation efforts

Hospitals should add PPE to code carts and

equipping all Code Blue team members with
full PPE at the start of their shifts
 Prioritize airway over compression
with minimal aerosolization

• Passive oxygenation with nonrebreathing

face mask  Do not bag mask ventilate
• HEPA filter
• Intubate with a cuffed tube
• Supraglottic airway device
• Pause chest compressions to intubate
• Use videolaryngoscopy
 Limit staff exposure:
Use mechanical CPR devices
(LUCAS)

Early defibrillation of a shockable

rhythm has a high chance of success
 defib before compression
In-Hospital Cardiac
Arrest (IHCA)
Close the door to prevent airborne contamination

Intubated patients:

• Consider leaving the patient on a mechanical ventilator with HEPA filter

• Adjust the ventilator settings to allow for asynchronous ventilation

Ensure endotracheal tube/tracheostomy and ventilator

circuit security to prevent unplanned extubation

ROSC  set ventilator settings as appropriate to

patients’ clinical condition
 Proned patients at the time of arrest

Without With
advanced airway advanced airway

Attempt to place in the Avoid turning the patient to the

supine position for supine position  risk of equipment
continued resuscitation disconnections and aerosolization
 What if.. A patient was
admitted to ED with cardiac
arrest
and unknown COVID-19
status?
 Call Code Blue
 Donning PPE
 Place surgical mask on patient
 Move patient to negative pressure room if
possible or close the door
 Defib as instructed
 Code Blue team arrives and will proceed as
per Code Blue protocol for suspected and
known COVID-19
 Summary

CPR ON
COVID-19
Challenges and
potential solutions

DeFilippis et al. Cardiopulmonary Resuscitation During the COVID-19 Pandemic: A View from Trainees on the Frontline. AHA. 2020
 Conclusion

To know when “NOT TO DO” something is often much

harder than “DOING” something

In a pandemic, ways of working and risk assessment

must change, “Do no harm” is a necessary but
insufficient principle

We must adopt practices that ensure best

outcomes and minimise harm for patients with
COVID-19 and for the health professionals
 Not commencing chest
compressions on any patient is one
of the most difficult decisions a
clinician could ever make

We should focus on the

prevention of cardiac arrest
and the early reversal of complications
THANK
YOU

17.05.2020