7

Rules of Engagement for

COVID-19 CPR
1. First Rule of COVID-19: Everyone has
COVID-19
• WHO: Up to 80% of COVID-19 cases are asymptomatic

• Ing AJ, Cocks C, Green JP COVID-19: in the footsteps of Ernest Shackleton

Thorax Published Online First:27 May 2020. doi: 10.1136/thoraxjnl-2020-215091
o Cruise ship with 217 passengers got exposed to COVID-19 virus

o Everyone was tested using RT-PCR

o 128 tested positive

o 104 who tested positive were asymptomatic (81%)

1. First Rule of COVID-19: Everyone has
COVID-19
• Symptoms cannot be relied upon to screen COVID-19 cases

• Careful, some patients lie

• CPR is an aerosol generating procedure

• Assume all patients have COVID-19 during CPR

2. Choose your battlefield

• Transfer the patient to a secured location before starting CPR to

protect your team and other patients

• Negative pressure room: Lowest Risk

• Closed/sealed room with HEPA filter

• Open area/well ventilated area with at least 160 L/s air change

• Closed room: Highest risk

3. Protect yourself at all times

• No emergencies during a pandemic, protect yourself first

• No PPE, No CPR

• Incomplete PPE, No CPR

• Improper PPE, No CPR

• Consider if CPR is appropriate to avoid exposure

3. Protect yourself at all times

• Fei Shao et al In-hospital cardiac arrest outcomes among patients with

COVID-19 pneumonia in Wuhan, China Resuscitation June 2020, 151:18-23
o 136 patients COVID-19 confirmed cases that went into cardiac arrest

o 4 survived at 30 days, only 1 was neurologically intact

• Advanced age, multiple co-morbids, and severity of disease are poor

outcome predictors
4. Run a skeletal crew
• Use technology to limit the manpower needed to run a code team
• Mechanical compression devices – relieves the role of compressor
• Mechanical ventilator – relieves the role of ventilator
o Settings for cardiac arrest ventilation: AC mode, TV 6-8 ml/IBW, BUR 10, FiO2 1.0,
Flow trigger: highest number allowed, Alarms OFF
o IBW formula
ü Male: 50 Kg + (2.3 Kg x every inch over 5 ft)
ü Female: 45.5 Kg + (2.3 Kg x every inch over 5 ft)
4. Run a skeletal crew

• Defibrillator pads – relieves the role of defibrillator

• Members of the code team should be healthy. Anyone 50 years old

and up or with co-morbids should be exempted

• Relatives should be kept out of the resuscitation area

5. Control the aerosols
• Absolutely no mouth to mouth or mouth to mask ventilations

• Use passive oxygenation before compressions (e.g NRM covered with a

surgical mask set to 10 LPM)

• Intubation (best option)

o Expert intubator should do it to maximize first pass success
o Use aerosol box/plastic drape
o Use video laryngoscope
5. Control the Aerosols

• LMA
o Use the correct size to create an airtight seal

• BVM
o Use 2 handed, 2 person technique

o Pause compressions during ventilation (30:2 in the adult, 15:2 in pediatric

patients)
5. Control the Aerosols

• ET, LMA, BVM should have always have a viral filter

• Always pause compressions during airway management

• Use closed suctioning system and minimize disconnects

6. Know your alternatives

• HCQ + Azithromycin may prolong QT and cause arrhythmias (e.g

Torsades de Pointes)
o Cardiac arrest/Unstable: Defibrillate then give MgSO4 2 g/IV in 10 ml D5W
over 1-2 minutes. May repeat after 5-10 minutes.

o Stable: MgSO4 2 g in 100 ml D5W over 15 minutes

6. Know your alternatives

• Use Lidocaine instead of Amiodarone for cardiac arrest patients on

HCQ + Azithromycin
o Lidocaine does not prolong QT interval unlike Amiodarone

o First dose: 1-1.5 mg/Kg

o Second dose: 0.5-0.75 mg/Kg

Corrected QT Interval
 Corrected QT Interval
• >475 msecs (prolonged 99th percentile)
• >500 msecs, predisposes to TDP
6. Know your alternatives

• Consider prone CPR only if:

o Patient in prone position already AND intubated

o You have ETCO2 monitoring to check CPR quality (e.g ETCO2 should be at
least 10 during CPR)
7. Debrief

• Discuss as a team what can be improved

• Correct any lapses in safety protocols

• Make sure everyone doffs properly

• Assign a quality “spotter”

• Practice, practice, practice

• Quarantine family members if indicated

7 Rules of Engagement for COVID-19 CPR
1. First rule of COVID-19 CPR: Everyone has COVID-19
2. Choose your battlefield
3. Protect yourself at all times
4. Run a skeletal crew
5. Control the aerosols
6. Know your alternatives
7. Debrief
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