COVID-19 Has Turned Cardiac Resuscitation Upside Down

Amal Mattu, MD


January 27, 2021

On October 20, 2020, the American Heart Association (AHA) released online its latest update of the Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. The update included no major or groundbreaking changes from the 2015 guidelines, and it did not address the COVID-19 pandemic, which has turned many traditional concepts of resuscitation upside down.

Fortunately, in April 2020, the AHA issued Interim Guidance for Basic and Advanced Life Support, which addresses many modifications of the guidelines in patients with known or suspected COVID-19. Now that we are in the throes of a third wave of the pandemic, it is a good time to review those recommendations, with an emphasis on the modifications, in caring for patients with cardiac arrest and known or suspected COVID-19.

At the time of this writing, more than 24 million Americans have been infected with SARS-CoV-2 and over 400,000 have died. It is estimated that 5% of infected patients become critically ill, and up to 40% of these will die.The actual overall mortality of those who are infected is uncertain but varies by age and overall is probably less than 2%. This is a relatively low mortality rate, but because of the tremendous number of infected individuals, a large absolute number of patients die. Not surprisingly, a rise in out-of-hospital cardiac arrests has been noted in major metropolitan centers.

Caring for patients with known or suspected COVID-19 who are critically ill or in cardiac arrest is a challenge. Providers must protect themselves and their colleagues to avoid virus exposure and infection while at the same time delivering effective care to the patient. To address this challenge, the AHA issued its recommendations.

The following is a list of key recommendations for managing adult cardiac arrest, with an emphasis on modifications in caring for the patient with known or suspected COVID-19.

Providers should make every effort to reduce their own exposure to COVID-19. Exposed or infected providers further decrease the workforce that is caring for these patients. The number of personnel in the room should be limited to the minimum necessary to deliver care. This includes an emphasis on the use of mechanical devices for chest compressions when they are available.

Prioritize oxygenation and ventilation strategies that lower the risk for aerosolization of virus particles. After initial rhythm assessment and defibrillation, when indicated, patients should be endotracheally intubated with a cuffed tube as soon as feasible. Pause chest compressions in order to intubate.

This is a major departure from previous recommendations, which emphasized the need to minimize interruptions in compressions and allowed for delayed intubation in favor of simple bag-valve-mask (BVM) ventilation. In addition:

  • Endotracheal intubation should be performed by the most experienced operator to minimize the time to securing the airway.

  • Video laryngoscopy is recommended over direct laryngoscopy to reduce the intubator's exposure to aerosolized particles.

The endotracheal tube should be connected to a ventilator with a high-efficiency particulate air (HEPA) filter when available. A HEPA filter should always be securely attached to any manual or mechanical device in the path of any exhaled gas before any breaths are administered.

BVM ventilations should be avoided, if possible, because of the risk for aerosolization of virus particles. If intubation cannot be achieved early, passive oxygenation with a non-rebreather mask covered by a surgical mask is a reasonable option, or BVM ventilation with a HEPA filter and a tight seal can be used as a last resort.

If intubation is delayed, consider manual ventilation with a supraglottic airway or bag-mask device with a HEPA filter.

Once the patient is intubated and connected to the ventilator, minimize disconnections in this closed circuit to reduce aerosolization.

Consider the appropriateness of starting and continuing resuscitation. None of us likes giving up during a cardiac arrest, but now more than ever, we must remember the potential harm to our staff when continuing with futile resuscitations. When there is no shockable rhythm, consider early termination of efforts. Consider these prepandemic statistics to put things in perspective:

  • If the patient has no return of spontaneous circulation (ROSC) after three cycles of cardiopulmonary resuscitation (CPR), no shocks, and the arrest was unwitnessed by emergency medicine services (EMS) personnel, the likelihood of survival is 1%.

  • If the patient has no ROSC by hospital arrival and no prehospital shock, the 30-day survival is 0.03%.

Recent data have demonstrated that rates of ROSC and survival from out-of-hospital cardiac arrest have fallen further during the COVID-19 pandemic. The reasons for this are multifactorial but may include a reluctance of bystanders to perform CPR; social distancing causing more arrests to be unwitnessed; changes in EMS protocols or other factors that lead to delays in EMS intervention; or disease-related factors (COVID-19–related cardiac or pulmonary insult).


The COVID-19 pandemic has certainly turned upside down a great deal of what we learned about resuscitation of critically ill patients and those in cardiac arrest. In my opinion, the largest modifications of traditional care are:

  1. The early emphasis on securing a definitive airway rather than simply BVM ventilation;

  2. The recommendation to pause compressions during the intubation; and

  3. The push to seriously consider the appropriateness of starting and continuing resuscitation.

All of these measures prioritize the safety of the providers over the patient.

The interim guidelines did not address any modifications in the use of medications during cardiac arrest. Emerging literature indicates that a possibly significant cause of malignant arrhythmias in COVID-19 is the prolonged QT interval. There are several contributing factors: Severe inflammation that occurs during the COVID-19 infection itself can cause a prolonged QT interval; diarrhea and dehydration can produce hypokalemia and hypomagnesemia, which lead to a prolonged QT interval; COVID-19 can produce kaliuresis, leading to a prolonged QT interval; and many medications, when administered concurrently (eg, ondansetron, hydroxychloroquine, azithromycin), can further prolong the QT interval.

With these factors in mind, it would seem prudent to avoid amiodarone, which may further prolong the QT interval, and have a low threshold to administer magnesium in patients with cardiac arrest, although this has not been studied.

It will be interesting to watch the resuscitation guidelines continue to evolve as we learn more about COVID-19 in the coming months. Remember the common saying: You can't take care of others unless you take care of yourself (and your staff) first.

Amal Mattu, MD, is a professor, vice chair of education, and co-director of the emergency cardiology fellowship in the department of emergency medicine at the University of Maryland School of Medicine in Baltimore.

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