ACEP COVID-19 Field Guide

Author: Jeffrey M. Goodloe, MD, FACEP, Hillcrest Medical Center Emergency Center, Tulsa, Oklahoma; Professor of Emergency Medicine, EMS Section Chief/Director of the Oklahoma Center for Prehospital and Disaster Medicine, University of Oklahoma School of Community Medicine; Chief Medical Officer, Medical Control Board, EMS System, Metropolitan Oklahoma City, Tulsa, Oklahoma; Medical Director, Oklahoma Highway Patrol

While myriad patient illnesses and injuries encountered by EMS personnel still occur in this time of COVID-19, additional focus is understandably now on the dynamics of cardiac arrest resuscitation, factoring in the baseline intensity of patient contact by multiple personnel on-scene and enroute. The important principles of cardio-cerebral perfusion, through continuity of high-quality CPR, and aggressively seeking out shockable dysrhythmias of pulseless ventricular tachycardia or ventricular fibrillation, via automated external defibrillators (AEDs) or manual defibrillators, remain. COVID-19 brings the need for additional considerations related to the safest possible airway management strategies and exposure to respiratory secretions and exhalation streams to all personnel involved.

Some EMS physician medical directors currently favor early intubation (via video laryngoscopy, if available) by the most experienced ALS personnel on scene, citing a reduction in exhalation volumes outside a contained airway circuit of a cuffed endotracheal tube, exhalation filter, end-tidal CO₂ detector, and bag-valve-mask (BVM) or mechanical ventilator. In BLS EMS systems or in systems with larger numbers of paramedics, as compared to smaller numbers of patients requiring invasive airway placement, treatment protocols favor placement of a supraglottic airway, placed per manufacturer and local policy directions, with an exhalation filter, end-tidal CO₂ detector if available, and BVM or mechanical ventilator. BVM ventilations can prove challenging due to face-mask seal complications. An incomplete face-mask seal interface can unintentionally contribute to concerning exhalation stream exposures to EMS personnel. Regardless of the airway management strategy employed, continuous care should be taken to reduce any exhalation stream exposure to the involved personnel.

The American Heart Association recently released algorithms for suspected or confirmed COVID-19 patients in sudden cardiopulmonary arrest. These are applicable to basic life support and single or multiple rescuers — adult and pediatric, pediatric advanced life support, and advanced cardiac life support. These algorithms are published in the "Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19: from the Emergency Cardiovascular Care Committee and Get With the Guidelines^®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: supporting organizations: American Association of Critical Care Nurses and National EMS Physicians."

Field termination of resuscitation of the suspected or confirmed COVID-19 cardiopulmonary arrest patient involves multiple ethical considerations. Many EMS systems are employing a shortened time of resuscitation, factoring in typical variables of witnessed or unwitnessed arrest, if bystander CPR was provided prior to first EMS arrival, the dysrhythmias encountered, responses to resuscitative interventions, and if available, trends in capnometry or preferred waveform capnography. In the situation of a laboratory confirmed COVID-19 patient that declines into sudden cardiopulmonary arrest, some EMS physician medical directors are utilizing early research findings that portend a particularly grim prognosis and avoiding initiation of resuscitation. Such decisions should be the purview of the respective jurisdictional EMS physician medical director(s), with cited evidence-based resources.