ABC | Volume 114, Nº6, June 2020

Statement Guimarães et al. Position Statement: Cardiopulmonary Resuscitation of Patients with Confirmed or Suspected COVID-19 – 2020 Arq Bras Cardiol. 2020; 114(6):1078-1087 Content Abstract ..............................................................................................1080 1. Introduction ...................................................................................1080 2. Prevention of Cardiac Arrest .......................................................1080 3. Decision-making ...........................................................................1080 4. Guidance on Precautions ............................................................1081 5. First Response ..............................................................................1081 6. Airway Management ....................................................................1081 7. Chest Compressions ....................................................................1083 8. Cardiopulmonary Resuscitation in the Prone Position ..........1083 9. Post-cardiac Arrest Care ..............................................................1084 10. Specific Guidance for Prehospital Care ..................................1084 11. Training and Debriefing .............................................................1085 References .........................................................................................1087 1. Introduction Cardiopulmonary resuscitation (CPR) is perhaps the most extreme emergency procedure that can be required in a patient with coronavirus disease 2019 (COVID-19). In this setting, special caution is warranted, particularly regarding the increased risk of aerosol generation during chest compressions and ventilation, which poses a substantial hazard of rescuer contamination. Considering the lack or inaccessibility of robust evidence on best practices in this novel scenario, the Brazilian Association of Emergency Medicine (ABRAMEDE), Brazilian Society of Cardiology (SBC), Brazilian Association of Intensive Care Medicine (AMIB), and Brazilian Society of Anesthesiology (SBA), all official societies representing the corresponding medical specialties affiliated with the Brazilian Medical Association (AMB), have issued this position statement containing specific recommendations for the management of cardiac arrest in patients with confirmed or suspected COVID-19. In all other cases, the 2015 guidelines of the International Alliance of Resuscitation Committees (ILCOR), the 2019 American Heart Association (AHA) guidelines,¹ and the 2019 Update to the Brazilian Society of Cardiology Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Guideline 2 apply. 2. Prevention of Cardiac Arrest • All patients with suspected or confirmed COVID-19 who are at increased risk of acute deterioration or cardiac arrest should be appropriately flagged to the local rapid response team (RRT) or whichever other team has been designated to provide code response. 3-5 The use of severity scores and tracking systems, as well as the use of a “code yellow” system for identification of patients who are periarrest, allow early detection of critically ill patients and can optimize the care of cardiac arrest when it does occur; 2,5 • Assessment of the potential difficulty of laryngoscopy/ intubation must be performed on admission to the hospital and/or Intensive Care Unit (ICU) and recorded appropriately in the patient’s medical record. Scores such as MACOCHA ( Mallampati, obstructive Apnea syndrome, reduced Cervical mobility, limited mouth Opening, Coma, severe Hypoxemia, and non-Anesthesiologist operator ) or mnemonics such as LEMON ( Look, Evaluate, Mallampati, Obstruction, Neck ) can assist in determination of the difficult airway, activation of appropriate support, and prompt a request for a difficult airway trolley or cart; 6,7 • Considering that two therapies currently under evaluation as potential treatments for COVID-19, chloroquine and hydroxychloroquine, may prolong the QT interval in up to 17% of patients, it is essential to consider the risk of severe polymorphic ventricular arrhythmias – especially torsades de pointes – and consequent occurrence of cardiac arrest with shockable rhythms; 4,8-10 • The patients most at risk of polymorphic tachycardias in this context are older adults; women; and those with COVID-related myocarditis, heart failure, liver or kidney dysfunction, electrolyte disturbances (particularly hypokalemia and hypomagnesemia), and bradycardia. Identification of patients who already have a prolonged (> 500 ms) corrected QT interval (QTc) at baseline is Abstract Care for patients with cardiac arrest in the context of the coronavirus disease 2019 (COVID-19) pandemic has several unique aspects that warrant particular attention. This joint position statement by the Brazilian Association of Emergency Medicine (ABRAMEDE), Brazilian Society of Cardiology (SBC), Brazilian Association of Intensive Care Medicine (AMIB), and Brazilian Society of Anesthesiology (SBA), all official societies representing the corresponding medical specialties affiliated with the Brazilian Medical Association (AMB), provides recommendations to guide health care workers in the current context of limited robust evidence, aiming to maximize the protection of staff and patients alike. It is essential that full aerosol precautions, which include wearing appropriate personal protective equipment, be followed during resuscitation. It is also imperative that potential causes of cardiac arrest of particular interest in this patient population, especially hypoxia, cardiac arrhythmias associated with QT prolongation, and myocarditis, be considered and addressed. An advanced invasive airway device should be placed early. Use of HEPA filters at the bag-valve interface is mandatory. Management of cardiac arrest occurring during mechanical ventilation or during prone positioning demands particular ventilator settings and rescuer positioning for chest compressions which deviate from standard cardiopulmonary resuscitation techniques. Apart from these logistical issues, care should otherwise follow national and international protocols and guidelines, namely the 2015 International Liaison Committee on Resuscitation (ILCOR) and 2019 American Heart Association (AHA) guidelines and the 2019 Update to the Brazilian Society of Cardiology Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Guideline. 1080