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Rev Bras Anestesiol. 2020;xxx(xx):xxx---xxx
1

NARRATIVE REVIEW

2 Recommendations for Cardiopulmonary Resuscitation

3 (CPR) of patients with suspected or confirmed
4 COVID-19夽
5 Q1 Sérgio Timerman a,b,c , Hélio Penna Guimarães c,d,e,f,∗ ,
6 Roseny dos Reis Rodrigues e,g , Thiago Domingos Corrêa c,e , Daniel Ujakow Correa
7 Schubert h,i , Ana Paula Freitas d,j,k,l , Álvaro Rea Neto m,n,o , Thatiane Facholi
8 Polastri p , Matheus Fachini Vane q,r , Thomaz Bittencourt Couto s,t,u,v , Antonio Carlos
9 Aguiar Brandão c,w,x,y , Natali Schiavo Giannetti a , Maria José Carvalho Carmona z , Thiago
10 Timerman A , Ludhmila Abrahão Hajjar B,C,D,E , Fernando Bacal C,F , Marcelo Queiroga C,G

a
11 Faculdade de Medicina da Universidade de São Paulo (FMUSP), Hospital das Clínicas, Instituto do Coração (InCor), Centro de
12 Treinamento de Emergências Cardiovasculares e Ressuscitação e do Time de Resposta Rápida, São Paulo, SP, Brazil
b
13 Sociedade Brasileira de Cardiologia, Centro de Treinamento, Rio de Janeiro, RJ, Brazil
c
14 Universidade de São Paulo (USP), Ciências, São Paulo, SP, Brazil
d
15 Associação Brasileira de Medicina de Emergência (ABRAMEDE), Fortaleza, CE, Brazil
e
16 Hospital Israelita Albert Einstein, Departamento de Pacientes Graves (DPG), São Paulo, SP, Brazil
f
17 Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina, Departamento de Medicina, São Paulo, SP, Brazil
g
18 Universidade de São Paulo (USP), Medicina, São Paulo, SP, Brazil
h
19 Instituto D’Or de Pesquisa e Ensino-RJ, Rio de Janeiro, RJ, Brazil
i
20 Hospital Estadual Getúlio Vargas, SES-RJ, Emergencista da Sala Vermelha, Rio de Janeiro, RJ, Brazil
j
21 Hospitais Mãe de Deus, Departamento de Emergência, Porto Alegre, RS, Brazil
k
22 Hospital de Pronto Socorro de Porto Alegre, Residência de Medicina de Emergência, Porto Alegre, RS, Brazil
l
23 Universidade Federal do Rio Grande do Sul (UFRGS), Ciências Médicas, Porto Alegre, RS, Brazil
m
24 Associação de Medicina Intensiva Brasileira (AMIB), Comitê de Medicina Intensiva Cardiológica, São Paulo, SP, Brazil
n
25 Universidade Federal do Paraná (UFPR), Medicina, Curitiba, PR, Brazil
o
26 Centro de Estudos e Pesquisas em Terapia Intensiva (Cepeti), Curitiba, PR, Brazil
p
27 Faculdade de Medicina da Universidade de São Paulo (FMUSP), Hospital das Clínicas, Instituto do Coração (InCor), American
28 Heart Association do Centro de Treinamento de Emergências Cardiovasculares e Ressuscitação, São Paulo, SP, Brazil
q
29 Universidade de São Paulo (USP), Hospital das Clínicas (HC), Faculdade de Medicina (FM), São Paulo, SP, Brazil
r
30 Faculdade de Ciências Médicas de São José dos Campos (HUMANITAS), São José dos Campos, SP, Brazil

夽
Associação Brasileira de Medicina de Emergência (ABRAMEDE), Sociedade Brasileira de Cardiologia (SBC), Associação de Medicina Intensiva
Brasileira (AMIB), Sociedade Brasileira de Anestesiologia (SBA), Associacao Medica Brasileira-AMB.
∗ Corresponding author.

E-mail: helio.guimaraes@einstein.br (H.P. Guimarães).

https://doi.org/10.1016/j.bjane.2020.06.007
© 2020 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Anestesiologia. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Timerman S, et al. Recommendations for Cardiopulmonary Resuscitation (CPR)1-of
BJANE 74380 --10
patients with suspected or confirmed COVID-19. Rev Bras Anestesiol. 2020. https://doi.org/10.1016/j.bjane.2020.06.007
 +Model
BJANE 74380 1---10 ARTICLE IN PRESS
2 S. Timerman et al.
s
31 Sociedade Brasileira de Anestesiologia (SBA), Curso Suporte Avançado de Vida Anestesia (SAVA), Rio de Janeiro, RJ, Brazil
t
32 Sociedade Brasileira de Anestesiologia (SBA), Rio de Janeiro, RJ, Brazil
u
33 Universidade Estadual Paulista (UNESP), Anestesiologia, Botucatu, SP, Brazil
v
34 Universidade do Vale do Sapucaí (UNIVÀS), Pouso Alegre, MG, Brazil
w
35 Hospital Israelita Albert Einstein, Centro de Simulação Realística, São Paulo, SP, Brazil
x
36 Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, SP, Brazil
y
37 Faculdade de Medicina da Universidade de São Paulo (FMUSP), Hospital das Clínicas, Instituto da Criança e do Adolescente (ICr),
38 São Paulo, SP, Brazil
z
39 Faculdade de Medicina da Universidade de São Paulo (FMUSP), Hospital das Clínicas, Diretora da Divisão de Anestesiologia do
40 Instituto Central, São Paulo, SP, Brazil
A
41 Intensivista do Hospital Sancta Maggiore, Cursos BLS e ACLS da AHA, São Paulo, SP, Brazil
B
42 Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
C
43 Sociedade Brasileira de Cardiologia (SBC), Rio de Janeiro, RJ, Brazil
D
44 Instituto do Câncer do Estado de São Paulo (ICESP), São Paulo, SP, Brazil
E
45 Instituto do Coração (InCor), São Paulo, SP, Brazil
F
46 Faculdade de Medicina da Universidade de São Paulo (FMUSP), Hospital das Clínicas, Instituto do Coração (InCor), Núcleo de
47 Transplantes, São Paulo, SP, Brazil
G
48 Hospital Alberto Urquiza Wanderley, Departamento de Cardiologia Intervencionista, João Pessoa, PE, Brazil

49 Received 27 April 2020; accepted 2 June 2020

50

51 KEYWORDS Abstract: The care for patients suffering from cardiopulmonary arrest in a context of a COVID-
52
Cardiopulmonary 19 pandemic has particularities that should be highlighted. The following recommendations
53
resuscitation; from the Brazilian Association of Emergency Medicine (ABRAMEDE), the Brazilian Society of
54
Heart arrest; Cardiology (SBC) and the Brazilian Association of Intensive Medicine (AMIB) and the Brazilian
55
Advanced cardiac life Society of Anesthesiology (SBA), associations and societies official representatives of specialties
56
support; affiliated to the Brazilian Medical Association (AMB), aim to guide the various assistant teams,
57
Arrest, in a context of little solid evidence, maximizing the protection of teams and patients.
58
cardiopulmonary It is essential to wear full Personal Protective Equipment (PPE) for aerosols during the care
59 of Cardiopulmonary Resuscitation (CPR) and it is imperative to consider and treat the poten-
60 tial causes in these patients, especially hypoxia and arrhythmias caused by changes in the QT
61 interval or myocarditis. The installation of an advanced invasive airway must be obtained early
62 and the use of High Efficiency Particulate Arrestance (HEPA) filters at the interface with the
63 valve bag is mandatory situations of occurrence of CPR during mechanical ventilation and in
64 a prone position demand peculiarities that are different from the conventional CPR pattern.
65 Faced with the care of a patient diagnosed or suspected of COVID-19, the care follows the
66 national and international protocols and guidelines 2015 ILCOR (International Alliance of Resus-
67 citation Committees), AHA 2019 Guidelines (American Heart Association) and the Update of
68 the Cardiopulmonary Resuscitation and Emergency Care Directive of the Brazilian Society of
69 Cardiology 2019.
70 © 2020 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Anestesiologia.
71 This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
72 licenses/by-nc-nd/4.0/).

73 PALAVRAS-CHAVE Recomendações para Ressuscitação Cardiopulmonar (RCP) de pacientes com

74 Ressuscitação diagnóstico ou suspeitos de COVID-19
cardiopulmionar;
75
Parada cardíaca; Resumo A atenção ao paciente vítima de parada cardiorrespiratória em um contexto de
76
Suporte avançado de pandemia de COVID-19 possui particularidades que devem ser ressaltadas. As seguintes
77
vida cardiopulmonar; recomendações da Associação Brasileira de Medicina de Emergência (ABRAMEDE), Sociedade
78
Cardiopulmonar, Brasileira de Cardiologia (SBC), Associação de Medicina Intensiva Brasileira (AMIB) e Sociedade
79
parada Brasileira de Anestesiologia (SBA), associações e sociedades representantes oficiais de espe-
80 cialidades afiliadas a Associação Medica Brasileira (AMB), têm por objetivo orientar as diversas
81 equipes assistentes, em um contexto de poucas evidências sólidas, maximizando a proteção das
82 equipes e dos pacientes.
83 É fundamental a paramentação completa com Equipamentos de Proteção Individual (EPIs)
84 para aerossóis durante o atendimento de Parada Cardiorrespiratória (PCR), e imperativo que se
85 considerem e tratem os potenciais causas nesses pacientes, principalmente hipóxia e arritmias

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86 causadas por alterações no intervalo QT ou miocardites. A instalação de via aérea invasiva

87 avançada deve ser obtida precocemente e o uso de filtros High Efficiency Particulate Arrestance
88 (HEPA) na interface com a bolsa-válvula é obrigatório; situações de ocorrência de PCR durante
89 a ventilação mecânica e em posição pronada demandam peculiaridades distintas do padrão
90 convencional de PCR. Frente ao atendimento de um paciente com diagnóstico ou suspeito de
91 COVID-19, o atendimento segue em acordo com os protocolos e diretrizes nacionais e interna-
92 cionais 2015 ILCOR (Aliança Internacional dos Comitês de Ressuscitação), Diretrizes AHA 2019
93 (American Heart Association) e a Atualização da Diretriz de Ressuscitação Cardiopulmonar e
94 Cuidados de Emergência da Sociedade Brasileira de Cardiologia 2019.
95 © 2020 Publicado por Elsevier Editora Ltda. em nome de Sociedade Brasileira de Anestesiologia.
96 Este é um artigo Open Access sob uma licença CC BY-NC-ND (http://creativecommons.org/
97 licenses/by-nc-nd/4.0/).

98 Introduction Table 1 MACOCHA Score.

Parameter Score
99 Cardiopulmonary Resuscitation (CPR) is a procedure per-
100 formed during extreme emergency situations and can occur Mallampati II or IV 5
101 for patients with COVID-19. Thus, it requires special atten- Obstructive sleep apnea 2
102 tion due to the high risk of aerosol generation during chest Reduced cervical mobility 1
103 compressions and ventilation, causing considerable risk of Mouth opening < 3 cm 1
104 contaminating the team. Coma 1
105 Bearing in mind this scenario, in which solid evidence Oximetry < 80% 1
106 is scarcely documented or accessible, the Brazilian Asso- Non-anesthetist physician 1
107 ciation of Emergency Medicine (ABRAMEDE), the Brazilian
108 Society of Cardiology (SBC), the Brazilian Society of Inten-
109 sive Care (AMIB), and the Brazilian Society of Anesthesiology cases, it is essential to register the risk for severe polymor- 140

110 (SBA), official representatives of the specialties affiliated phic ventricular arrhythmias, especially torsades de pointes, 141

111 to the Brazilian Medical Association (AMB), present the fol- and consequent CPA with shockable rhythms.4,12---19 142

112 lowing practices aimed specifically at care of patients with In this scenario, the patients at a higher risk associated 143

113 suspected or confirmed COVID-19. The 2015 ILCOR (Interna- with polymorphic tachycardia are the elderly, females, with 144

114 tional Alliance of Resuscitation Committees) and AHA 2019 COVID-19-associated myocarditis, or with cardiac failure, 145

115 (American Heart Association)1 guidelines, and the Updated liver or kidney dysfunction, electrolyte disorders (particu- 146

116 Cardiopulmonary Resuscitation and Emergency Care 2019 larly potassium and magnesium) or bradycardia. It is critical 147

117 Guideline of the Brazilian Society of Cardiology remain for to identify patients that already have QT interval corrected 148

118 all other cases. (QTc), prolonged (superior to 500 ms) with daily ECG mon- 149

itoring while taking drugs that can promote or accentuate 150

such abnormality.4,12,13,18---20 151

119 Prevention of cardiopulmonary arrest (CPA)

When do we start cardiopulmonary 152

120 Any patient with suspected or confirmed COVID-19 who is at resuscitation? 153
121 higher risk of acute deterioration or cardiopulmonary arrest
122 should be appropriately flagged to Rapid Response Teams
Decision making processes for starting CPR or not should 154
123 (RRT) or teams that, potentially, can carry out care.2---6
continue to be on a case by case basis at pre-hospital 155
124 Severity scores and attention code screening and trigger-
care services, emergency departments and ICUs. Benefits 156
125 ing systems allow for the early detection of severe patients
to patient, safety and exposure of the team, and poten- 157
126 and can optimize any possible CPA care.7---9
tial futility of maneuvers should be taken into account. 158
127 Potentially difficult laryngoscopy/tracheal intubation
CPR should always be performed, unless, previously defined 159
128 should be anticipated upon patient admission to hospi-
guidelines indicate the contrary.1,2 160
129 tal and/or Intensive Care Units (ICU) and be recorded
‘‘Do Not Resuscitate’’ (DNR) decisions/guidelines should 161
130 on the patient chart. Scores such as MACOCHA (Table 1)
be appropriately documented and conveyed to teams. Pal- 162
131 or mnemonic ones, such as LEMON (‘‘Look, Evaluate,
liative and terminal care should follow local and institutional 163
132 Mallampati, Obesity/Obstruction and Neck’’) can help
policies.1---3 164
133 determine a difficult airway, and anticipate triggering sup-
134 port and request for difficult airway equipment.3,7,8,10---14 The
135 MACOCHA score ranges from 0 (easy) to 12 (very difficult). Precaution guidelines 165

136 A MACOCHA > 3 indicates difficult airway.

137 Considering therapies under assessment phase, such as, The precaution defined as STANDARD + AEROSOL is indi- 166

138 for example, chloroquine or hydroxychloroquine, and their cated for all resuscitation team members in order to assure 167

139 potential risk of prolonging the QT interval in up to 17% of adequate individual protection (according to patient with 168

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169 COVID-19 care guidelines) during CPR. The timely availabil-

170 ity of Personal Protection Equipment (PPEs) packs, such as
171 gowning items in the crash cart, will allow for less delay to
172 start chest compressions and care continuity.2,4,6---9 The PPE
173 pack should include: cap, N95 mask, protection goggles, face
174 shield, impermeable gown, disposable elbow-length gloves
175 and shoe covers. Even if there is a delay in starting chest
176 compressions, team safety is a priority and appropriate use
177 of PPEs is indispensable for those involved in CPA care.2,4,6---9
178 The number of professionals at point of care should also
179 be reduced or restricted in this scenario, preferably not
180 more than five individuals.
181 Hand hygiene has an important role in reducing transmis-
182 sion of COVID-19; it should be performed adequately, with
183 soap and water (if soiled) or alcohol gel, for at least 20 − 30
184 seconds.2,16
Figure 1 BVM device with HEPA filter.
Source: Authors’ personal archives.
185 Initial care
reported in current publications on COVID-19.2,3,15,19 Addi- 228
186 CPA detection should follow the ILCOR/AHA and SBC tional CPA causes described are torsade de pointes-type 229
187 standard recommendations, and starts by assessing respon- polymorphic ventricular tachycardia (associated with pro- 230
188 siveness, breathing (only checking respiratory movements) longed QT triggered by drugs used to treat COVID-19), 231
189 and presence of central pulse.1,3 cardiac tamponade (associated with myocarditis), and pneu- 232
190 For adults, CPR should start by continuous chest compres- mothorax (associated with mechanical ventilation). 233
191 sions. If the patient still does not have an invasive/advanced
192 installed airway (orotracheal tube, extra glottic device), a
193 low flow oxygen mask or surgical mask, or sheet/towel over Airway management 234

194 patient’s mouth and nose should be maintained, until an

195 invasive airway is installed12 ; chest compressions can trig- Ventilation with Bag-Valve-Mask (BVM) or bag-endotracheal 235

196 ger elimination of aerosols and should be started following tube should be avoided due to high risk of aerosol gener- 236

197 the above recommendations. ation and team contamination.2,14---16 If BMV ventilation is 237

198 CPR for children should be performed with chest com- absolutely required, mask sealing technique should always 238

199 pressions and lung ventilation with a Bag-Valve-Mask (BVM) involve two professionals, and an oropharyngeal airway 239

200 device connected to a HEPA-High Efficiency Particulate Air (Guedel airway) be used. In this case, perform 30 chest 240

201 filter until a definitive airway is obtained, given that CPA compressions and two ventilations for adults and 15 chest 241

202 in pediatrics occurs, most of the time, due to a secondary compressions and two ventilations for children, until an 242

203 respiratory cause and CPR only with chest compressions is invasive airway is established, when one ventilation every 243

204 less efficacious in this population.1,21,22 If equipment is not 6 seconds is recommended for adults and children. Use of 244

205 available, a reasonable alternative is CPR only with chest HEPA filters connected between the mask and bag is recom- 245

206 compressions, keeping the patient with a surgical mask or mended (Figs. 1, 2, and 3). 246

207 sheet/towel over the mouth.23 As hypoxia is considered one of the main causes of CPA in 247

208 For pre-hospital CPA care, in the absence of a medi- patients with COVID-19, invasive airway access should be the 248

209 cal professional, hands-only CPR is recommended; the care priority to isolate airways and decrease likelihood of aerosol 249

210 described above on protection of patient’s mouth to avoid generation, consequently, with less contamination of team 250

211 aerosolization also remains recommended.4,9,12,13 and best ventilation/oxygenation standard.15---19 During air- 251

212 Monitoring to determine rhythm/modality of arrest way management, chest compressions should be interrupted 252

213 (shockable or non-shockable) should be done as soon as pos- to protect the team and we suggest managing airways dur- 253

214 sible as to not delay defibrillation of a shockable rhythm and ing pulse presence checking to reduce interval without chest 254

215 the establishment of the appropriate algorithm.1,3 compressions. 255

216 Airway access or other procedures should not postpone Video laryngoscopy with a more acute angle shape blade 256

217 defibrillation of shockable-rhythms.1,3,14 should be the first choice for fast, safe and definitive air- 257

218 If a patient is wearing an oxygen face mask before CPA, way access. In case of failure, help/support of a second 258

219 keep it on until intubation, but without high flow oxygen physician should be requested immediately; upon a second 259

220 (6 − 10 L.min-1 maximum) so as to not increase the risk attempt, video laryngoscopy again should be prioritized.17---19 260

221 of generating aerosol; if the patient is not with the air- For children, it is recommended to perform the video laryn- 261

222 way device, the professional should put a surgical mask or goscopy with a blade adequate to the child’s age, with no 262

223 sheet/towel over the victim’s mouth and nose and perform requirement of more acute angulation.23 263

224 continuous chest compressions. In the impracticality or intubation failure, we rec- 264

225 Any reversible causes of CPA should be identified and ommend using extra glottic devices (laryngeal tube or 265

226 treated before considering to interrupt CPR, particularly laryngeal mask that enable orotracheal intubation using 266

227 hypoxia, acidosis and coronary thrombosis, causes often the device itself), that allow both mechanical ventilation 267

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Figure 4 Hand placement for compressions on patients in

prone position.22 .

airway sealing pressure and that can be used as a conduit 280

that facilitates orotracheal intubation through it (LMA fast 281

track or Air-Q). It is opportune to remember that with 282

an extra glottic device, it is important to close and seal 283

the patientś mouth using towels, sponge gauzes or surgical 284

masks to reduce aerosolization. 285

CPA for patients on mechanical ventilation 286

Figure 2 Patient intubated with BVM + HEPA filter and occlu-
sion of mouth with mask.
Source: Authors’ personal archives. When CPA occurs in patients on mechanical ventilation, 287

patient must be connected to ventilator, and a closed ven- 288

tilation circuit used. Ventilator parameters should be set as 289

follows: 290

• Volume, assisted-controlled mode, adjusted to 6 mL.kg-1 291

of predicted patient weight; 292

• 100% inspired oxygen fraction; 293

• Respiratory rate roughly 10 ventilations/minute and inspi- 294

ratory time of one second; 295

• Flow triggering: turn off sensitivity; if not possible, 296

change to sensitivity pressure mode and adjust to the 297

least sensitive pressure possible (varies according to ven- 298

tilator from -15 to -20 cm H2 O); 299

• Positive end Expiration Pressure (PEEP) of zero; 300

• Adjust alarms to maximum and minimum tidal volume 301

alarms allowed by equipment; maximum pressure alarms 302

Figure 3 Patient with extra glottic device, occlusion of mouth of 60 cm H2 O and minimum of 1 or 0 cm H2 O; minute 303

with mask and HEPA filter. volume alarms should allow maximum and minimum for 304

Source: Authors’ personal archives. each device; respiratory rate alarm adjusted to maximum 305

allowed and 60 second apnea time; 306

268 using closed-circuit and capnography, until possibility of • The same parameters should be adjusted for children. 307

269 appropriate definitive airway access (tracheal intubation or Assess continuously if the ventilator is managing to 308

270 cricostomy).17---19 For children, the laryngeal mask adequate keep those parameters without self-triggering by chest 309

271 to the patientś weight should be the extra glottic device compression, generating hyperventilation and air trap- 310

272 preferably used.23 ping with excessive pressures (systematically above 60 cm 311

273 In Brazil, insertion of extra glottic devices is within the H2 O). For children, it may be necessary to disconnect from 312

274 scope of physicians and nurses, can be an option for secur- ventilator --- in this case, bag-valve connected to HEPA 313

275 ing airway, and can be performed by nurses at pre-hospital filter should be used; 314

276 intermediate support units, provided they are properly • Some ventilators have a ‘‘CPR/CPA’’ function that adjusts 315

277 trained for the procedure.1,3 alarm limits automatically and triggers the parameters 316

278 Among extra glottic devices available, whenever possi- aligned above. Installation of one HEPA filter in the 317

279 ble, priority should be given to a device that offers higher circuit after orotracheal tube and another in the expi- 318

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Figure 5 Position suggested for defibrillation paddles.

319 ratory limb of the circuit is recommended for mechanical • If the patient is in horizontal supine position, perform 351

320 ventilation17---19 ; compressions in the center of the chest, in the lower half 352

321 • Strong straight forceps are important for tube clamping of the sternum bone; 353

322 upon need to change breathing circuits/ventilators (bag- • If professionals understand the specificities of wear- 354

323 valve mask to mechanical ventilator circuit, for example), ing PPE for aerosolization, the high physical demand 355

324 aimed at minimizing aerosolization; of maneuvers, exhaustion potential, and need to mini- 356

325 • When using defibrillation, for team and patient safety, mize team present during resuscitation, we suggest using 357

326 preferably always use adhesive paddles that do not mechanical CPR devices for adults, if available. 358

327 require disconnection to ventilator to release shock. For

328 manual defibrillation paddles, shock should be released
329 after putting the ventilator on stand-by mode and dis-
Resuscitation in prone position 359

330 connecting the breathing circuit from the ventilator at

331 HEPA filter, keeping the filter connected to the orotra- If the patient is in prone position without an invasive airway 360

332 cheal tube. installed, we recommend positioning the patient quickly 361

into the supine position, establish CPR maneuvers, and 362

install an invasive airway as soon as possible, preferably by 363

333 Chest compressions orotracheal intubation. 364

If the patient is already intubated and on mechanical 365

ventilation, it is recommended to begin cardiopulmonary 366

334 High quality chest compressions should be performed to
resuscitation maneuvers with the patient still in prone; the 367
335 guarantee:
reference point for placing hands follows the projection of 368

the same place of chest compressions (T7-10 interscapular 369

336 • Rate of 100 to 120 compressions/minute; region) (Fig. 4). We recommend that attempts to resusci- 370

337 • Depth of at least 5 cm (avoiding compressions deeper than tate the patient be performed at maximum security when 371

338 6 cm) for adults; turning the patient, avoiding disconnection of the ventilator 372

339 • Depth of 1/3 of the anteroposterior chest diameter for and risk of aerosolization. If adhesive defibrillator paddles 373

340 infants; and 1/3 of the anteroposterior chest diameter or are available, they should be adhered in the anteroposte- 374

341 at least 5 cm for children; rior position (Fig. 5).20,21,23,24 If not available, defibrillation Q2 375
342 • Allow chest to fully return after each compression and should be attempted putting the external paddle on the 376

343 avoid leaning on victim’s chest; dorsal region and the apical paddle on patient’s side. We 377

344 • Minimize compression interruptions, pausing maximum of recommend that efficacy of CPR be assessed using expired 378

345 10 seconds to perform two ventilations. Consider attaining CO2 (PCO2 > 10 mmHg) and invasive blood pressure (consid- 379

346 the highest chest compression fraction possible, aimed at ering diastolic pressure values over 20 mmHg). It is worth 380

347 605 − 80% minimum; mentioning that evidence for this maneuver is still uncertain 381

348 • Take turns with another emergency care professional and, whenever possible turning from prone to supine posi- 382

349 every 2 minutes to avoid weariness and bad quality com- tion, more appropriate for high quality CPR and adequate 383

350 pressions; ventilation, it should be carried out. 384

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COVID-19 Resuscitation 7

Algoritmo de tratamento da Parada Cardiorrespiratória Pediátrica

em Paciente com Suspeita ou Confirmação de COVID-19

Paramentação aerossóis Qualidade RCP

Limitar nùmero de pessoas Compressões rápidas 100-120/min e
fortes (1/3 diâmetro antero-posterior) e
permitir retomo do tórax
Minimizar interrupções
Evitar hiperventilação
Inicie RCP Mudar compressor a cada 2 min
Ventile com BVM com filtro HEPA Se sem via aérea avançada 15:2
Monitor/Desfibrilador
Prepare-se para intubar
Paramentação aerossóis
Avental impermeável, máscara N95,
luvas, touca e faceshield

AESP Desfibrilação
FV / TV SIM Ritmo Chocável NÃO
Assistolia 2 j/kg primeiro choque, 4 j/kg segundo
choque e 4 a 10 j/kg ou dose de adulto
nas doses subsequentes
Pás adesivas: choque sem retirar da vm
Pás manuais: deixar ventilador em pausa
e desconectar mantendo filtro no tubo
antes de chocar
Priorize Intubação / Reinicie RCP
Se falha de intubação utilize máscara laringea ou BVM com filtro HEPA
Acople a ventilação mecânica assim que possivel Via aérea avançada
Evitar desconexão circuito
VM - Volume controlado 6ml/kg, Fi 100%,
Ti 1s, PEEP 0-5, 10, gatilho menos
sensivel possivel e liberar alarmes
Não comprimir durante intubação
intubação pelo médico mais experiente
RCP 2 min
RCP 2 min Videolaringoscopia se disponivel
Acesso IV / IO
Acesso IV / IO Cãnula com cuff
Epinefrina cada 3-5 min
Usar capnógrafo para confirmar
Após via aérea avançada ventilar 10/min

Ritmo Chocável NÃO Ritmo Chocável SIM

Drogas
Epinefrina dose IO/IV:
Repetir a cada 3-5 minutos
Amiodarona dose IO/IV:
SIM NÃO 5 mg/kg bolus na PCR, pode repetir até 2
vezes em FV/TV refratária ou
Lidocaína dose IO/IV: Ataque 1 mg/kg
RCP 2 min RCP 2 min Manutenção começar após mais de
Epinefrina cada 3-5 min Tratar causas 15 min da dose inicial)
reversíveis

Retorno da circulaçãp es[pmtâmea

(RCE)
Ritmo Chocável NÃO Ritmo Chocável SIM Pulso presente e curva de pressão arterial
espontânea se PA invasiva

SIM NÃO Causas Reversiveis

6Hs - Hipovolemia, Hipóxia,íon
Hidrogenio (acidose), Hipoglicemia,
RCP 2 min
Hipo/hiperkalemia e Hipotermia
Amiodarona ou
5Ts - Tamponamento, Tensão no tórax
Lidocaína
(pneumotórax), Tóxicos, Trombose
Tratar causas
pulmonar (TEP) e Trombose coronária
reversiveis
(IAM)

Se sem sinais de RCE inicie
atendimento de AESP/Assistolia
Se RCE inicle cuidados pós parada
Prona
Se não intubado: Despronar e RCP
Inicie atendimento
de FV /TV SE intubado: compressão prona em
T7-T10 e somente despronar se possivel
fazê-lo sem risco de desconexão de
quipamentos

Figure 6 PCR Care Algorithm for patients with suspected or confirmed COVID-19.

385 Post-CPR • Dispose or clean all the equipment used during CPR, 389

following manufacturer recommendations and local orga- 390

386 • Anticipate intensive care unit request for bed with respi- nization guidelines.2 391

387 ratory isolation or cohort area before patient returns to • Any surfaces used to place airway/resuscitation equip- 392

388 spontaneous breathing.1---3,16,18 ment will also have to be cleaned according to local 393

Please cite this article in press as: Timerman S, et al. Recommendations for Cardiopulmonary Resuscitation (CPR)1-of
BJANE 74380 --10
patients with suspected or confirmed COVID-19. Rev Bras Anestesiol. 2020. https://doi.org/10.1016/j.bjane.2020.06.007
 +Model
BJANE 74380 1---10 ARTICLE IN PRESS
8 S. Timerman et al.

Figure 7 PCR Care Algorithm for pediatric patients with suspected or confirmed COVID-19.

394 guidelines. Check if equipment used to handle airways • After care, doff PPE safely, avoiding self- 397

395 (laryngoscope, facial masks, for example) was not left on contamination.2,16 Total attention should be given 398

396 patient’s bed. Try to leave equipment on a tray.2,14 during this step, because most contamination of health 399

Please cite this article in press as: Timerman S, et al. Recommendations for Cardiopulmonary Resuscitation (CPR)1-of
BJANE 74380 --10
patients with suspected or confirmed COVID-19. Rev Bras Anestesiol. 2020. https://doi.org/10.1016/j.bjane.2020.06.007
 +Model
BJANE 74380 1---10 ARTICLE IN PRESS
COVID-19 Resuscitation 9

400 professionals occurs at this point by contact with Patients with suspected or confirmed COVID-19 cannot 457

401 secretions and aerosols. risk company of contamination, according to Ministry of 458

Health guidelines. We suggest that accompanying individ- 459

uals be oriented to go to the reference health unit on their 460

402 Pre-hospital guidelines own for further information. 461

• If the vehicle does not have an isolated driver compart- 462

403 • CPR should not be initiated in the pre-hospital environ- ment, open external air exits in the driver area and turn 463
404 ment on patients with suspected or confirmed COVID-19 on back exhaustion ventilators to a higher setting. 464
405 and obvious signs of death.1,3
406 • Professionals should follow standard + aerosol precaution
407 for care of victims with suspected or confirmed COVID-19. Training and debriefing 465

408 • Orient the population when calling 192, that they should
409 inform if the victim is a suspected COVID-19 case; this Debrief at the end of each procedure in order to provide 466

410 will facilitate previous gowning of the care team. We improvements and team development.1,3 Training skills for 467

411 suggest that telephone operators and regulators of emer- correct gowning and, mainly, PPE doffing and CRA care drills 468

412 gency medical services carry out active search for these should be performed as early as possible with all teams 469

413 patients, asking about flu-like symptoms, fever, and dys- involved in care of patients with suspected or confirmed 470

414 pnea. COVID-19.16---19 471

415 • Perform ongoing compressions. Mouth-to-mouth breath- Training and continuous education are imperative 472

416 ing and using a pocket mask should not be performed on (Figs. 6 and 7), aimed at protecting teams and safer patient 473

417 patients with suspected or confirmed COVID-19.2 care. We strongly recommend using realistic drilling envi- 474

418 • Taking into account that most out of hospital cardiores- ronment scenarios and at distance educational resources. 475

419 piratory arrests occur at home, in the case of pediatric

420 out of hospital CRA, lay emergency caregiver most prob-
Funding 476
421 ably is a member of the family or child caretaker, already
422 in close contact with and exposed to secretions. In this
423 case, the lay emergency caregiver should perform com- Institutional. 477

424 pressions and consider mouth-to-mouth breathing, if able

425 and willing to do so, given most pediatric arrests are due Conflicts of interest 478
426 to a respiratory cause.23
The authors declare no conflicts of interest. Q3 479
427 CPR only with compressions is a reasonable alternative if
428 emergency caregiver is not able to ventilate or has not been
429 in previous close contact with the child.23 References 480

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patients with suspected or confirmed COVID-19. Rev Bras Anestesiol. 2020. https://doi.org/10.1016/j.bjane.2020.06.007
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Please cite this article in press as: Timerman S, et al. Recommendations for Cardiopulmonary Resuscitation (CPR)1-of
BJANE 74380 --10
patients with suspected or confirmed COVID-19. Rev Bras Anestesiol. 2020. https://doi.org/10.1016/j.bjane.2020.06.007