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 paramount, and ECG monitoring should be performed daily as long as QT-prolonging drugs are used. 4,8-10 3. Decision-making • The decision of whether or not to initiate CPRmust continue to be made on an individualized basis, be it during prehospital care, in the emergency department, or in the ICU. The potential benefits for the patient, the safety and exposure hazards of the code team, and the potential for futility of resuscitationmaneuvers must be taken into account. Nevertheless, CPR should always be performed unless advance directives clearly state otherwise; 1,2 • “Do not attempt CPR” (DNACPR) or “not for CPR” decisions/ directives must be properly documented and communicated to the team. Palliative and end-of-life care should follow local and institutional policy. 1,2 4. Guidance on Precautions • Standard + aerosol precautions are recommended for all members of the code team in order to ensure adequate personal protection. Prompt availability of Personal Protective Equipment (PPE), e.g., by keeping PPE kits ready in every crash cart or trolley, minimizes the delay in initiating chest compressions and helps maintain continuity of care. 3,4,11-14 Each PPE kit must include an N95 filtering facepiece respirator, face shield, waterproof gown, cap, long-cuff disposable gloves, and goggles; • The safety of the code team should be the utmost priority even if this means delaying chest compressions, and all thosewho respond to the codemust first don appropriate PPE. In particular, CPR should not be started on any patient with suspected or confirmed COVID-19 until the code team is fully attired with appropriate PPE; 3,4,11-14 • The number of team members at the site of the code (if it is an enclosed space such as a private room or cubicle) should be restricted; 2,4,15,16 • Hand hygiene plays an important role in reducing the transmission of COVID-19. All team members must wash their hands with soap and water (only when visibly soiled) or use an alcohol-based hand sanitizer; 3,15 • Adherence to all applicable federal (Ministry of Health) and local government guidelines is mandatory. 5. First Response • Recognition of cardiac arrest should follow ILCOR/AHA and Brazilian Society of Cardiology guidelines. Assessment should start by checking for responsiveness, breathing (chest rise and fall), and presence of a central pulse; 1,2 • In adults, CPR should begin with continuous chest compressions. If the patient does not already have an invasive or advanced airway (orotracheal tube or extraglottic airway device) in place, a mask delivering low-flow oxygen or a towel should be placed over the patient’s mouth and nose before initiating compressions and kept in place until an invasive airway is secured, 8 as chest compressions can generate aerosols; • In children, CPR should preferably consist of compressions and ventilation with a bag-valve-mask (BVM) coupled to a high- efficiency particulate arrestance (HEPA) filter until a definitive airway is established, since pediatric arrest is most commonly of respiratory etiology, and compression-only CPR is known to be less effective in this population. 3 If a BVM with HEPA filter is not available, compression-only CPRwith a standard oxygenmask or towel covering the patient’s mouth is a reasonable alternative; 17 • Despite the guidance of some emergency medical services that prehospital care of cardiac arrest in the absence of amedical professional (lay rescuer CPR) should be limited to hands-only CPR, the recommendation that the patient’s oral cavity be sealed to prevent aerosol generation as described above still stands; 4,8,9,14 • Cardiac monitoring should be placed as soon as possible to ascertain whether there is a shockable rhythm, so as not to delay defibrillation if appropriate and provide guidance as to the optimal resuscitation algorithm to follow; 1,2 • Defibrillation of a shockable rhythm should never be delayed to secure the airway or for other procedures; 1,2 • If the patient already had a face mask in place to deliver supplemental oxygen before cardiac arrest occurred, it should be kept on until intubation, but delivering low-flow oxygen only (6– 10 L/min at most); higher flow rates may be aerosol-generating; • If the patient does not have any airway device in place, the rescuer should place a cloth or towel over the patient’s mouth and nose and begin continuous compressions; •Before considering termination of CPR, any reversible causes should be identified and addressed, with particular emphasis on hypoxia, acidemia, and coronary thrombosis – all cited as common causes of death in recent publications on COVID-19. 3 Additionally, polymorphic torsades de pointes -type ventricular tachycardia (associated with QT prolongation, which is known to be caused by drugs under investigation as potential COVID-19 treatments) and cardiac tamponade (associatedwithmyocarditis), as well as ventilation-induced pneumothorax, have all been described as causes of cardiac arrest. 6. Airway Management • BVM or bag-valve-tube (BVT) ventilation should be avoided, due to the high risk of aerosol generation and staff contamination. 3,15,18,19 If BVM ventilation is absolutely necessary, two rescuers should always be present to allow a two-handed mask seal, and an oropharyngeal (Guedel) cannula should be placed. In this case, 30 compressions and two breaths should be performed in adults and 15 compressions and two breaths in children until an invasive airway has been established, at which point the ratio should switch to continuous compressions and one breath every 6 seconds for adults and children alike. Placement of a HEPA filter between the mask and the bag is recommended (Figures 1 to 3); •Considering that hypoxia is one of themain causes of cardiac arrest in patients with COVID-19, invasive airway access should be prioritized for isolation purposes, due to the lower likelihood of aerosol generation and, consequently, staff contamination, as well as the possibility of achieving better ventilation and oxygenation patterns. 15,16,19-21 During airway instrumentation, chest compressions should be halted to protect the code team. It is suggested that airway instrumentation be performed or attempted during pulse checks, to reduce hands-off time. It is 1081