Should CPR be delayed until all personnel have donned PPE

Posted on May 18, 2020 by Gemma Percival

Summary

Healthcare providers should donn appropriate PPE prior to initiating resuscitation of a patient with confirmed or suspected COVID-19 (1, 2) or when a reliable history cannot be obtained (2). Prioritizing PPE is essential, even if it delays resuscitation (3). A provider in only droplet/contact PPE can complete a pulse check and initial defibrillation, if indicated (2, 4). However, for Aerosol Generating Procedures (AGP), such as chest compressions, bag mask ventilation, or intubation airborne precautions are required (1, 2, 4). Recommendations for PPE during a Code Blue of non-COVID, non-suspected, and low risk patients vary across organizations. Providers should, therefore, follow their own organizational policies and procedures in these situations.

I.   Background

“A Protected Code Blue (PCB)  is an emergency response to a life-threatening illness in a patient with a suspected or confirmed novel respiratory or communicable illness. The PCB shifts the mentality away from patient outcome and puts healthcare provider safety front and centre. The decision to initiate a PCB is based on suspected or confirmed presence of a novel respiratory illness. If a reliable history of this cannot be obtained, PCB should be initiated.”(2)

 

Protected Code Blue Infographic

II.   Guidelines

The American Heart Association released revised cardiac arrest algorithms that prioritize PPE in patients with suspected or confirmed COVID-19 (1, 5). 

Cardiac Arrest Algorithm for Suspected or Confirmed COVID-19 Patients

 

Key Points

  1. Before entering the room, all providers should donn PPE to guard against both airborne and droplet particles, even if this delays resuscitation efforts (1, 5).
  2. A safety officer is recommended to ensure strict adherence to safe donning and doffing (2).
  3. Since the availability of suitable PPE in sufficient quantities at the site of the arrest may not be guaranteed, the use of PPE pre-made kits should be considered, to travel with the response team or to be stored with code carts (6).

III.   COVID negative, not suspected, or low risk

  • In some organizations all patients requiring code blue interventions are considered potentially COVID-19 positive, thus, airborne precautions are required before commencing AGPs. In other organizations contact/droplet precautions are used with COVID negative and other low risk patients. 


Non-COVID Initial Code Blue PPE 

COVID Suspected or Confirmed Initial Code Blue PPE

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. Edelson, DP et al. 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. Circulation, 2020 Apr 9 [cited 2020 May 18]. Available from: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.047463
  2. McIsaac S et al. Just the Facts: Protected code blue – Cardiopulmonary resuscitation in the emergency department during the coronavirus disease 2019 pandemic [Internet]. CJEM. 2020 Apr 24 [cited 2020 May 18]. Available from: https://www.cambridge.org/core/journals/canadian-journal-of-emergency-medicine/article/just-the-facts-protected-code-blue-cardiopulmonary-resuscitation-in-the-emergency-department-during-the-covid19-pandemic/08B4CDEA659A52F3E1B7F4834C893E67
  3. McMullan, JT. Updated Adult, Pediatric, and Neonatal Resuscitation Guidelines in the Age of COVID-19 [Internet]. NEJM: Guideline Watch. 2020 Apr 9 [cited 2020 May 18]. Available from: https://www.jwatch.org/na51382/2020/04/23/updated-adult-pediatric-and-neonatal-resuscitation
  4. Kovas G, Law, JA, Witter T.  Airway Management Guidelines for Patients with Known or Suspected COVID-19 Infection Version 3.7 [Internet]. AIME Airway. 2020 April 28 [cited 2020 May 4]; Available from:  https://aimeairway.ca/announcement/120/airway-management-guidelines-for-patients-with-known-or-suspected-covid-19-infection-version-3-7
  5. Heart and Stroke Foundation of Canada. Updated CPR algorithms in COVID-19 patients [Internet]. 2020 [cited 2020 May 18]. Available from: https://cpr.heartandstroke.ca/s/article/COVID-19-Interim-CPR-Algorithms?language=en_US
  6. Alberta Health Services. Care of the Adult Critically Ill COVID-19 Patient [Internet]. 2020 April 16 [cited 2020 May 18]. Available from: https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-covid-19-care-adult-critically-ill.pdf
  7. Island Health. Responding to Code Blue situations in acute care [Internet]. 2020 Apr 30 [cited 2020 May 18]. Available from: https://medicalstaff.islandhealth.ca/personal-protective-equipment-ppe-use-responding-code-blue-situations-acute-care

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.