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 • If no adhesive pads are available, manual defibrillation can be attempted by placing the sternal paddle on the dorsal region and the apical paddle on the patient’s flank (Figure 5). It is recommended that the effectiveness of CPR be assessed by end-tidal CO 2 monitoring (partial pressure of carbon dioxide > 10 mmHg) and invasive blood pressure monitoring (diastolic blood pressure > 20 mmHg). It bears stressing that evidence for this maneuver is still unclear and, whenever possible, the patient should be de-proned, as the supine position is best suited for high-quality CPR and adequate ventilation. 9. Post-cardiac Arrest Care • If the patient is not already in intensive care, an ICU bed with respiratory isolation should be requested even before return of spontaneous circulation (ROSC) is achieved; 3,15,16 • All equipment used during CPR should be disposed of or sanitized following manufacturer recommendations and institutional or local guidelines; 3 • All surfaces onto which airway/resuscitation equipment was placed must also be cleaned as per local guidelines. Check that no airway management devices (including laryngoscopes and face masks) have been left on the bed. All equipment should be left on the intubation tray if possible; 3.18 • After the code, team members should doff all PPE safely, avoiding self-contamination. 3,15 Particular attention is required during this step, which is when contamination of health care workers is most likely to occur (through contact with patient secretions and respiratory droplets). 10. Specific Guidance for Prehospital Care • In the prehospital environment, CPR should never be attempted in patients with suspected or confirmed COVID-19 who present with obvious signs of death; 3 • Prehospital care providers should follow standard + aerosol precautions when caring for patients with suspected or confirmed COVID-19; • The population should be instructed to notify the dispatcher if the victim is suspected to have COVID-19 when calling an ambulance. This allows prehospital care providers to don appropriate PPE before arrival at the scene. Emergency medical service dispatchers and physician regulators/medical directors are strongly advised to conduct active case-finding of COVID-19 by inquiring about flu-like symptoms, fever, and dyspnea during calls; • CPR should be limited to continuous chest compressions. Mouth-to-mouth ventilation, even with use of a pocket CPR mask, should never be performed for patients with suspected or confirmed COVID-19; 3 • Considering that most out-of-hospital cardiac arrests occur at home, in pediatric out-of-hospital arrests, the lay rescuer will most likely be a parent, family member, or caregiver who will already be in close contact with the child and thus exposed to respiratory secretions. In this case, the lay rescuer should be instructed to perform compressions and consider mouth-to- mouth ventilation if he or she is able and willing to do so, since most pediatric arrests are secondary to respiratory causes; 23 • Hands-only CPR is a reasonable alternative if the rescuer is unable or unwilling to provide mouth-to-mouth resuscitation or has not had close contact with the child before; 17 • The rescuer should cover the victim’s mouth and nose with a cloth or towel (or, if available, place a mask delivering low-flow oxygen) to prevent suspension of aerosols generated during CPR; • Do not delay defibrillation. Early use of an automated external defibrillator (AED) significantly increases the odds of survival and does not increase the risk of COVID-19 transmission; • Positive-pressure BVM ventilation should be avoided at all cost. If absolutely necessary, it must always be performed by two providers, one of whom will be exclusively responsible for sealing themask to the patient’s face, using themost suitable grip technique to avoid air leak. A BVM may only be used if a HEPA filter is available and has been placed at the bag-valve interface. • In children, CPR should preferably consist of chest compressions and BVM ventilation (always with a HEPA filter); • Otherwise, prehospital airway management should follow the aforementioned recommendations for in-hospital care – namely, ensuring that a BVMand any other ventilation devices are equipped with HEPA filters and that an advanced airway device (tracheal tube or extraglottic airway) is placed as early as possible; • Open the rear doors of the transport vehicle and activate the heating, ventilation, and air conditioning (HVAC) system during any aerosol-generating procedures (do this away from pedestrian traffic); • Family members or chaperones may not ride along in the ambulance in the same compartment as the patient. According toMinistry of Health recommendations, patients with suspected or confirmed COVID-19 are not allowed any chaperones who may be at risk of contamination. It is suggested that companions or chaperones be instructed to make their own way to the health facility; • If the transport vehicle lacks an isolated driver compartment, the outside air vents in the driver’s area should be opened and the rear exhaust fans turned on at the highest setting. Figure 5 – Suggested paddle position for manual defibrillation of a patient in the prone position. 23 1084