RCUK Statements on COVID-19, CPR and Resuscitation

COVID-19: FAQs for Healthcare Professionals

In response to the COVID-19 pandemic, Resuscitation Council UK has produced a series of resources for healthcare professionals.

Here, you'll find answers to many of the questions we've received on our guidance for healthcare professionals during COVID-19. This page is being regularly updated with new answers.

Resuscitation Council UK is aiming to provide the most up-to date advice based on liaising with colleagues in Europe through the European Resuscitation Council (ERC) and the International Liaison Committee on Resuscitation (ILCOR), and reviews of the most up to date advice from around the world. 

Rescuer and team safety has been our first priority for CPR in all our guidance before the COVID-19 pandemic and continues to be now. 

Guidance is based on  many considerations including the scientific evidence, the feasibility and acceptability of interventions, and values and preferences. Rescuer and team safety has been the long-held first priority for CPR in all our guidance before the COVID-19 pandemic and continues to be during the pandemic. Resuscitation Council UK has not been involved in the PHE guidance regarding personal protective equipment (PPE) and aerosol generating procedures (AGPs). We have posted a statement about this which you can read here.

(Published 5 May 2020)

Resuscitation Council UK has produced guidance on  resuscitation in healthcare settings, the community, for children, about decisions regarding CPR (e.g. ReSPECT process) and for those teaching CPR. All guidance can be found here.

(Published 31 March 2020)

This is the subject of an International Liaison Committee on Resuscitation (ILCORreview. The current position of RCUK is that chest compressions are an AGP and staff should wear PPE for AGPs. International guidelines currently list CPR as an AGP but they do not universally make clear which steps of the CPR process (e.g., defibrillation, chest compression, airway and ventilation) are AGP.

WHO
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/health-workers

ERC
https://erc.edu/covid

ANZICS
https://www.anzics.com.au/wp-content/uploads/2020/04/ANZI_3367_Guidelines_V2.pdf


(Published 31 March 2020)

Airway interventions are AGPs. Resuscitation Council UK's airway guidance follows the guidance of UK Critical Care and Anaesthesia bodies. The most up to date guidance for healthcare staff is available at: https://icmanaesthesiacovid-19.org/

(Published 31 March 2020)

Resuscitation Council UK is aiming to limit the number of changes in the advice it gives. This pandemic is a new situation; while rapid changes can be frustrating, these changes in advice may be appropriate given the fast-moving circumstances. For the latest guidance keep checking our COVID-19 page and our social media feeds.

(Published 31 March 2020)

Most (over 80%) of out-of-hospital cardiac arrests occur in the home, and the proportion will most likely be higher during the pandemic as more people stay at home. Most people will therefore be doing chest compressions on someone they already know and probably had contact with.  The guidance to cover the mouth and nose with a cloth and start chest compressions will minimise the risk of droplets but will not guarantee prevention of viral transmission.  For adults, we have recommended against the use of mouth-to-mouth rescue breaths to reduce the risk of infection. RCUK accepts that resuscitation of strangers in public places does pose greater uncertainty and risk. As always during all CPR, the first priority should be personal safety. This might mean not starting chest compressions in some circumstances whilst awaiting a defibrillator.  

(Published 31 March 2020)

The guidance is for all those who might have COVID-19 - ie. confirmed and unconfirmed cases. As the number of cases of COVID-19 increase it will become hard to know who does and does not have COVID-19. Healthcare settings are treating all individuals as suspected COVID-19 patients.

(Published 31 March 2020)

This algorithm is a modification of the 2015 ALS Algorithm that is currently taught and used in the UK. The algorithm and supporting materials are available here.

Our answers to this question were compiled from a series of questions we received on this subject.

What are the phases of the algorithm? Can you explain them?

This algorithm aims for the best outcomes for patients and minimise the risks to rescuers when resuscitating patients with COVID-19 or suspected COVID-19.

  • Phase 1 emphasises the need for decisions prior to the time of cardiac arrest and that all patients in a healthcare setting should have a prior decision for or not for a CPR attempt. As for the existing non-COVID algorithm prevention of cardiac arrest is not part of the algorithm. The RCUK strongly support use of NEWS2 and treatment planning using the ReSPECT process to minimise the requirement for CPR.
  • Phase 2 refers to the assessment and if the rhythm is shockable, defibrillation attempts. Rhythm assessment and defibrillation is not an aerosol generating procedure (AGP) and requires personal protective equipment (PPE) against droplets (Level 2 PPE)  as opposed to AGPs (Level 3 PPE).
  •  Phase 3 refers to starting chest compressions and airway interventions that are AGPs and require PPE for AGPs. Once Phase 3 starts all those involved in the resuscitation attempt must have AGP PPE. Everyone else must be outside the room or distance themselves (the precise safe distance is unknown and likely to be more than 2 metres, and will depend on airflow and other factors).

What happens whilst waiting staff to don PPE for AGPs or the defibrillator to arrive? The initial response is not covered.

The priority is staff safety, and this means that the time taken to don PPE and ensure staff safety is an acceptable part of the resuscitation process. To avoid delays in hospital, patients at risk of cardiac arrest should be cared for in clinical areas where they have appropriate monitoring and availability of equipment and PPE. If staff are wearing PPE for AGPs, they can start chest compressions and airway management whilst awaiting the arrival of a defibrillator.

Why is there an emphasis on defibrillation and repeated shock attempts in the COVID-19 ALS algorithm?

This is for a number of reasons:

a. Patients with a shockable rhythm treated with early defibrillation have the best survival rates and this group has been prioritised in the algorithm. This is the case for both in- and out-of-hospital cardiac arrest. (See supporting information from ICNARC and Warwick)

b. Rhythm assessment and defibrillation is not an aerosol generating procedure (AGP) and requires personal protective equipment (PPE) against droplets (Level 2 PPE) as opposed to AGPs (Level 3 PPE).


c. In an ideal situation there would be a period of chest compression between shock attempts. We have recommended up to 3 shock attempts whilst awaiting colleagues with the correct PPE. If rescuers already have PPE against AGPs (Level 3 PPE), chest compressions can be given between shocks as is usual practice.

The algorithm states give up to three shocks without chest compressions in between. How do we do three shocks with an AED?

The ALS algorithm is specifically for use with a manual defibrillator. If the only defibrillator available is an AED, it will give a first shock if the rhythm is shockable – this first shock will have the highest success rate. As soon as staff with PPE for AGPs are available chest compressions can start.

How do I deliver the up to 3 shocks as described in the COVID-19 ALS algorithm?

Place pads on the patient’s chest and give the first shock with a manual defibrillator as usual. Assess the rhythm after the shock is given. If the rhythm remains shockable give a further shock. If there is a potential perfusing rhythm check for a pulse. If there is a non-shockable rhythm start chest compressions once rescuers with PPE for AGPs are available. All rescuers without PPE for AGPs should distance themselves from the resuscitation attempt when compressions or airway interventions start.

Most COVID-19 patients will be hypoxic and have a non-shockable rhythm. I am concerned that they will not receive optimal management.

Resuscitation Council UK has maintained its long-held position that the safety of rescuers is the first priority. This means that the time taken to ensure the team is safe is an accepted part of the process of resuscitation.  To avoid delays in starting CPR, all efforts must be made to avoid the need for CPR (e.g., use of NEWS2 to recognise treat and prevent cardiac arrest, and DNACPR decisions), and if cardiac arrest occurs CPR is performed safely and effectively. This does mean patients at risk of cardiac arrest need to be cared for in an appropriate clinical area that has staff and PPE available.

Hypoxaemic cardiac arrest is not usually a sudden or unexpected event so in many cases there will be an opportunity to intervene prior to cardiac arrest.

Once cardiac arrest occurs survival is poor. For example survival to hospital discharge with good neurological outcome was less than 1% for in-hospital cardiac arrest patients with COVID-19 in a case series from Wuhan China see https://doi.org/10.1016/j.resuscitation.2020.04.005

Why does the COVID algorithm still include extracorporeal CPR as a consideration?

Resuscitation Council UK accepts that this option is not available or feasible in most settings where ALS is carried out. This was the case prior to the COVID-19 pandemic and remains so. It is only available in very specialist settings and the clinicians in these settings will continue to have the expertise as to which patients they use this intervention.

Why does the COVID-19 algorithm section on post cardiac arrest treatment target an oxygen saturation of 94-98% when lower targets are recommended in those with acute lung injury?

The post resuscitation care targets are unchanged from the pre-COVID-19 algorithm. Acute lung injury and aspiration induced lung injury occurs in patients after cardiac arrest and intensive care clinicians already adjust oxygen targets when necessary.  This will be the same for patients with an acute lung injury caused by COVID-19. For example, the Surviving Sepsis have suggested an upper oxygen target of 96% in its current COVID-19 Guidelines.


(Published 31 March 2020)

Depending on the cause and time point during CPR, CPR can start with the patient in the prone position. Specifically:

  • a. Chest compressions can be started by compressing the spine in between the scapulae (shoulder blades). The same compression rate (100-120/min) and depth of compression (5-6 cm) as conventional chest compression should be used. Aim for a diastolic pressure of 25 mmHg on the arterial line.
  • b. If the cardiac arrest rhythm is shockable, attempt defibrillation by placing the defibrillator pads in a bi-axillary (both armpits in the mid-axillary line) or antero-posterior (front and back) position.
  • c. If there is a problem with the airway (e.g. displacement of tracheal tube), it will be necessary to rapidly turn the patient supine – this requires practice and should be planned for in units managing prone patients with COVID-19.
  • d. If initial attempts at resuscitation are unsuccessful, or chest compressions are ineffective turn the patient supine to facilitate resuscitation.
  • e. It may be possible to continue mechanical ventilation during continuous chest compressions by making adjustments to the ventilator settings and not disconnect the ventilator. Set the ventilator at 10 breaths per minute. If there is a need to break the circuit, follow guidance for disconnection to minimise aerosol generation. See: https://icmanaesthesiacovid-19.org/ for more information.
  • f. This guidance is adapted from existing RCUK guidance for resuscitation during surgery in prone patients.

(Published March 31 2020)

We recognise that Community Hospitals cover a diverse range of settings and clinical work. Our existing guidance can be adapted locally. 

Local policy is key. We would advise CPR is an AGP, therefore our current guidance on AGP PPE stands.

For staff who are working remotely (e.g. in patients' homes), we would recommend following our community guidance.

(Published 31 March 2020)

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