We have previously reported outcomes for in-hospital cardiac arrest (IHCA) in patients with severe COVID-19 pneumonia.
- Shao F.
- Xu S.
- Ma X.
- et al.
In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China.
Here we report our personal experience of prevention, treatment and staff safety for IHCA patients with severe COVID-19 pneumonia.
All critically-ill patients with COVID-19 should be evaluated for the risk of cardiac arrest. This risk and whether cardiopulmonary resuscitation (CPR) is appropriate should be communicated with patients and their families, especially for those patients with advanced malignancy, severe immunocompromise, severe refractory comorbidities or severe frailty, and before the patient's condition deteriorates further. Early communication will prevent CPR attempts in patients who will not benefit from CPR, and improve outcomes, and reduce the risk to staff.
Asystole was the commonest initial recorded IHCA rhythm observed in our patients. Most cardiac arrests occurred at a relatively stable stage before critical care. All ICU patients and half of ward patients had ECG monitoring at the time of cardiac arrest. Earlier identification of worsening lung injury including with CT scanning and escalation of oxygen therapy including high-flow nasal oxygen, non-invasive ventilation, and early tracheal intubation and invasive mechanical ventilation prior to deterioration and cardiac arrest may have prevented some cardiac arrests. In addition assessment of myocardial injury caused by COVID-19 by monitoring myocardial enzymes, brain natriuretic peptides, and ultrasound, and ECG for arrhythmia may have prevented some cardiac arrests. We observed that cardiac arrest occurred unexpectedly during mobilisation or defecation in several cases. Pulmonary embolism is probably an important cause of IHCA in COVID-19 pneumonia. Vascular Doppler ultrasound showed lower limb deep vein thrombosis in a large proportion of patients with severe COVID-19 in our hospital. Monitoring of platelet count, D-dimer, and cardiolipin antibodies and anticoagulation may be important to reduce cardiac arrest.
In our opinion, medical personnel should wear high-level personal protection equipment (PPE), including N95 masks, gowns, gloves, goggles, visors, and a powered air-purifying respirator at the beginning of each work shift and during CPR. In our experience, the PPE can loosen and the mask can slip during chest compression. Clothing should therefore be loose fitting to prevent tearing during CPR, and rescuers should switch if their mask is slipping. In addition chest compressions in PPE cause more rapid fatigue. The person doing compressions should change more often (e.g. every minute) to limit fatigue, damage to PPE, and slipping of the face mask. The use of a positive pressure respirator hood could be helpful. In addition, a mechanical chest compression device can be used to free rescuers and maintain chest compression quality. Finally, we stopped CPR if no ROSC was achieved within 30 min regardless of the initial cardiac arrest rhythm.
Conflicts of interest
The authors declare no conflicts of interest.
Published online: May 10, 2020
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