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Cardiopulmonary resuscitation during the COVID-19 pandemic:

Maintaining provider and patient safety

Brendon Sen-Crowe, Mason Sutherland, Mark McKenney, Adel

Elkbuli

PII: S0735-6757(20)30907-4
DOI: https://doi.org/10.1016/j.ajem.2020.10.021
Reference: YAJEM 159482

To appear in: American Journal of Emergency Medicine

Received date: 11 August 2020

Revised date: 4 October 2020
Accepted date: 11 October 2020

Please cite this article as: B. Sen-Crowe, M. Sutherland, M. McKenney, et al.,

Cardiopulmonary resuscitation during the COVID-19 pandemic: Maintaining provider and
patient safety, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/
j.ajem.2020.10.021

This is a PDF file of an article that has undergone enhancements after acceptance, such
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that apply to the journal pertain.

© 2018 Published by Elsevier.

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Cardiopulmonary Resuscitation during the COVID-19 Pandemic: Maintaining Provider and

Patient Safety

Brendon Sen-Crowe1, Mason Sutherland1, Mark McKenney, MD, MBA, FACS1,2, Adel Elkbuli,
MD, MPH1

1
Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional

Medical Center, Miami, FL, USA

2
Department of Surgery, University of South Florida, Tampa, FL, USA

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Word count: 800
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Funding: None

Conflicts of interest: Authors declare no competing interests

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Corresponding author:
Dr. Adel Elkbuli
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11750 Bird Road, Miami, FL 33175

Adel.Elkbuli@hcahealthcare.com
Telephone: (786) 637-5287
Fax: (305) 480-6625
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Cardiopulmonary Resuscitation during the COVID-19 Pandemic: Maintaining Provider

and Patient Safety

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COVID-19 patients can develop cardiorespiratory complications including

cardiopulmonary arrest.1-2 Cardiopulmonary resuscitation (CPR) is an aerosol-generating

procedure increasing the risk of caregivers contracting the virus and has prompted

reconsideration of guidelines during this pandemic.2 In this report we aim to summarize the

known outcomes of COVID-19 patients who received CPR, review the current guidelines for

infected patients, and discuss the ethical implications.

A retrospective analysis from China evaluated 136 patients with COVID-19 and in-

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hospital cardiac arrest (IHCA).3 CPR was initiated on the floor in 83.1% of patients and the ICU

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in 16.9%. In 87.5% of patients, the initial cardiac rhythm was asystole, shockable rhythm in

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5.9% and PEA in 4.4%. Return of spontaneous circulation (ROSC) was achieved in 13.2% but
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only one patient achieved a favorable neurological outcome. It was concluded that survival rates

of patients who suffer an IHCA associated with COVID-19 pneumonia were poor.3
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The main concern surrounding whether CPR should be performed on a COVID-19

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patient is aerosolization of viral particles, particularly in the setting of inappropriate PPE.2,4

Several scientific societies including the American Heart Association (AHA) and the American
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College of Emergency Physicians (ACEP) have collaborated to produce an interim guide for
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basic and advanced life support for COVID-19 patients. The AHA launched the COVID-19

Cardiovascular Disease Registry regarding patients with cardiovascular symptoms.5 Analysis of

this data as it becomes available may provide valuable evidence to modify interim CPR

guidelines and improve patient outcomes.

It is critical to evaluate the etiology of cardiac arrest, as CPR on a patient with a non-viral

cause should be performed according to AHA guidelines.6 Among our recommendations for pre-

hospital settings is dispatcher assessment of possible COVID-19 status before EMS arrival using
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screening questionnaires from the AMA and CDC (Figure 1).7,8 Additionally, lay rescuers

utilizing face masks or N95 respirator, can employ early use of an automated defibrillator, and

non-transport should be considered if ROSC is not achieved.2,9 Confirmation of a recent positive

IgG antibody response against SARS-CoV-2 could also warrant CPR in both the pre-hospital and

ED settings.10

Cardiac arrest patients in the ED who have an unknown COVID-19 status should be

assumed infected until proven otherwise. Provider exposure should be minimized with PPE, code

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teams should be activated, and prioritization of oxygen/ventilation strategies which have a lower

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aerosolization risk should be performed.2 Appropriateness of CPR given the patient’s age,

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comorbidities, illness severity, and likelihood of successful resuscitation should be considered.2
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Recommended disqualifying criteria for CPR includes confirmed COVID-19 status with

insufficient provider PPE, significant comorbidities, advanced age, and variables which confer a
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low success (Figure 1).11,12 If a COVID-19 patient has progressed to severe ARDS and suffers a
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cardiac arrest, there should be consideration of abstaining from performing CPR (Figure 1).13 In

these scenarios, the risk of virus aerosolization and transmission during CPR may outweigh the
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very low chances of success.14

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Patients in the ED who undergo endotracheal intubation represent a population with a

particularly high risk of virus transmission. The presence of endotracheal intubation in

combination with chest compressions generates a large amount of aerosol and must be

approached with caution.15 We recommend the use of high-efficiency particulate absorbing

(HEPA) filters to reduce virus aerosolization during chest compressions and mechanical

ventilation.16-17 Additionally, if known or suspected COVID-19 patients develop shockable

electrical rhythms such as ventricular fibrillation or pulseless ventricular tachycardia, our

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recommendation is for immediate defibrillation without chest compressions as previous studies

have not demonstrated any increased benefit for CPR before defibrillation (Figure 1).6,18-19

Physicians have a moral and ethical obligation to maintain the health of their patients,

coworkers, and themselves.20,21 As every physician has sworn the Hippocratic Oath and operates

according to the ethical principle of non-maleficence, they face a dilemma when treating patients

with known/suspected COVID-19. If CPR is not performed when indicated, it can be argued the

physician was negligent. However, it can also be argued that physicians who perform CPR may

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increase the chance of transmitting the virus to others, which could be viewed as inadvertently

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doing harm.2 Given the risks that resuscitation poses to healthcare workers, there is a moral

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imperative to identify deteriorating patients with COVID-19 and to support their breathing prior
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to arrest. Additionally, COVID-19 patients should have documentation of DNR order

preferences in order for physicians to comply with patient wishes.22

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The idea that there is little harm in attempting CPR is beginning to shift to that of
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questionable benefit and potential significant harm. As there is no single answer for all

situations, healthcare providers need to use their best judgement to optimize patient outcomes. If
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a patient infected with COVID-19 deteriorates into cardiac arrest and physicians deem the
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chances of survival are dismal, then withholding CPR may be appropriate.13,23 We must adopt

practices that provide for the best patient outcomes while minimizing harm to both patients and

healthcare workers.
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References
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coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506. doi:10.1016/S0140-
6736(20)30183-5
2. Edelson DP, Sasson C, Chan PS, et al. Interim Guidance for Basic and Advanced Life
Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the
Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult
and Pediatric Task Forces of the American Heart Association. Circulation. 2020;141(25):e933-
e943. doi:10.1161/CIRCULATIONAHA.120.047463
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4. McIsaac, Sarah, Wax, Randy, Long, Brit, Hicks, Christopher, Vaillancourt, Christian, Ohle R.
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5. COVID-19 CVD Registry. www.heart.org. https://www.heart.org/en/professional/quality-

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improvement/covid-19-cvd-registry. Accessed July 20, 2020.
6. Highlights of the 2015 American Heart Association Guidelines Update for CPR and ECC.
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American Heart Association. https://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-
AHA-Guidelines-Highlights-English.pdf. 2015. Accessed July 19th, 2020.
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7. Use this COVID-19 screening script when reopening your practice. American Medical
Association. https://www.ama-assn.org/practice-management/sustainability/use-covid-19-
screening-script-when-reopening-your-practice. Published May 15, 2020. Accessed July 20,
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13, 2020. Accessed July 20, 2020.

9. Interim Recommendations for Emergency Medical Services (EMS) Systems and 911 Public
Safety Answering Points/Emergency Communication Centers (PSAP/ECCs) in the United
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States During the Coronavirus Disease (COVID-19) Pandemic. Centers for Disease Control and
Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for-ems.html. Published
July 15, 2020. Accessed July 20, 2020.
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11. van de Glind EM, van Munster BC, van de Wetering FT, van Delden JJ, Scholten RJ, Hooft
L Pre-arrest predictors of survival after resuscitation from out-of-hospital cardiac arrest in the
elderly a systematic review. BMC Geriatr. 2013;13:68. Published 2013 Jul 3. doi:10.1186/1471-
2318-13-68
12. Kramer DB, Lo B, Dickert NW. CPR in the Covid-19 Era - An Ethical Framework. N Engl J
Med. 2020 Jul 9;383(2):e6. doi: 10.1056/NEJMp2010758. Epub 2020 May 6. PMID: 32374958.
13. Chiumello D, Brochard L, Marini JJ, et al. Respiratory support in patients with acute
respiratory distress syndrome: an expert opinion. Crit Care. 2017;21(1):240. Published 2017
Sep 14. doi:10.1186/s13054-017-1820-0
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15. Mahase E, Kmietowicz Z. Covid-19: Doctors are told not to perform CPR on patients in
cardiac arrest. BMJ. 2020;368(March):m1282. doi:10.1136/bmj.m1282
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resource-poor settings?. Resuscitation. 2020;151:118. doi:10.1016/j.resuscitation.2020.04.016
17. Reisman RE, Mauriello PM, Davis GB, Georgitis JW, DeMasi JM. A double-blind study of
the effectiveness of a high-efficiency particulate air (HEPA) filter in the treatment of patients with
perennial allergic rhinitis and asthma. J Allergy Clin Immunol. 1990;85(6):1050-1057.
doi:10.1016/0091-6749(90)90050
18. Christopherson DA, Yao WC, Lu M, Vijayakumar R, Sedaghat AR. High-Efficiency
Particulate Air Filters in the Era of COVID-19: Function and Efficacy [published online ahead of
print, 2020 Jul 14]. Otolaryngol Head Neck Surg. 2020;194599820941838.
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19. Koike S, Tanabe S, Ogawa T, et al. Immediate defibrillation or defibrillation after

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20. Huang Y, He Q, Yang LJ, Liu GJ, Jones A. Cardiopulmonary resuscitation (CPR) plus
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Database Syst Rev. 2014;2014(9):CD009803. Published 2014 Sep 12.
doi:10.1002/14651858.CD009803.pub2.
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21. McConnell D. Balancing the duty to treat with the duty to family in the context of the COVID-
19 pandemic. J Med Ethics. 2020;46(6):360-363. doi:10.1136/medethics-2020-106250
20. Kramer JB, Brown DE, Kopar PK. Ethics in the Time of Coronavirus: Recommendations in
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the COVID-19 Pandemic. J Am Coll Surg. 2020. doi: 10.1016/j.jamcollsurg.2020.04.004

22. DeFilippis EM, Ranard LS, Berg DD. Cardiopulmonary Resuscitation During the COVID-19
Pandemic: A View from Trainees on the Frontline. Circulation. 2020:1-8.
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doi:10.1161/circulationaha.120.047260
23. Phua J, Weng L, Ling L, et al. Intensive care management of coronavirus disease 2019
(COVID-19): challenges and recommendations [published correction appears in Lancet Respir
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Med. 2020 May;8(5):e42]. Lancet Respir Med. 2020;8(5):506-517. doi:10.1016/S2213-

2600(20)30161-2
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Cardiac Arrest

Pre-hosptial In-hospital ED

• COVID-19 (-) • COVID-19 (+) • COVID-19 (-) • COVID-19 (+)

status or unkown and lack of status or unknown and lack of
COVID-19 status appropriate PPE COVID-19 status appropriate PPE
with with code team
EMS/bystanders • Shockable •Unknown
rhythym wearing COVID status an
donning appropriate appropriate PPE
PPE (defibrillate history of severe
instead) •No recent contact cardiac disease
• Identifiable non- with COVID (+)

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viral cause for • Recent contact • Shockable
with COVID (+) patients ryhthym
cardiac arrest
patients • No endotracheal (defibrillate

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• No recent contact intubation or instead)
with COVID (+) placement of
patients • Identified ARD
CPR Not HEPA filter on
• History of
• Recent positive
IgG antibody test
against SARS-CoV- -p
Recommended existing intubation
• Recent positive
IgG antibody test
difficult
resuscitations
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2 against SARS- • Low probabilit
CoV-2 of successful
resuscitation give
disease severity,
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CPR Recommended
age, and previou
CPR Recommended cognitive status
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CPR Not
Recommended
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Figure 1. Flowchart of CPR Recommendations During the COVID-19 Pandemic.

Abbreviations: EMS = Emergency Medical Services. PPE = Personal Protective Equipment.
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HEPA = High-Efficiency Particulate Absorbing. ARDS = Acute Respiratory Distress Syndrome,

ED = Emergency Department.
Figure 1