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Pediatric Advanced Life Support (PALS) Cardiac Arrest Algorithm with Suspected or Confirmed COVID-19

Frontline healthcare providers are at significant risk for contracting respiratory illnesses due to frequent contact with symptomatic patients. Adequate PPE, including N-95 masks or positive air pressure respirators, especially during aerosol-generating procedures (AGPs), can reduce the risk of coronavirus transmission. We know that provider risk may vary based on age/ethnicity/comorbidities/vaccination status and system factors.

In the witnessed sudden arrest, initiate chest compressions immediately and, if not already masked, the provider should don their mask without delaying or interrupting compressions. If immediately available, a face covering for the patient may be considered but should not delay or interrupt compressions.

Ventilations are suspected to be aerosol-generating. Upon arrival, providers wearing appropriate PPE for AGPs should excuse providers without risk-matched PPE.

In VF/pVT defibrillate as soon as indicated. Masking of the unvaccinated provider and patient may reduce the uncertain transmission risk following defibrillation but should not prevent or delay defibrillation. Patient masks are not needed if providers are wearing appropriate PPE for AGPs.

A HEPA filter should be securely attached to any manual or mechanical ventilation device along with the exhalation port before all ventilation devices such as, but not limited to, bag-mask-valve, supraglottic airway devices, endotracheal tubes, and ventilator mechanical circuits. Alternatively, a low-dead space viral filter or a heat and moisture exchanging filter with >99.99% viral filtration efficiency may be placed between the ventilation device and the airway. When changing ventilation devices, the viral filter or the heat and moisture exchanging filter should remain attached to the airway.

Secure placement of a supraglottic airway with HEPA filters can help maximize chest compression fraction and control aerosol generation before endotracheal intubation.

Agonal breathing has been observed during early phases of cardiac arrest and may be seen during resuscitation, particularly during transient periods of restored spontaneous circulation. In such cases, consider passive oxygenation overlaid with a surgical facemask (if readily available) when a bag-mask device or an advanced airway with a HEPA filter is not utilized.

Before intubation, ventilate with a bag-mask-HEPA filter and a tight seal using a practiced 2-person technique, ideally. The second team member can help provide extra support for additional procedures such as compressions once the airway is established.

Assign the intubator with the highest chance of first-pass success using the method the intubator is most comfortable with while protected with appropriate PPE for AGPs. Intubate with a cuffed endotracheal tube to minimize aerosolization of respiratory particles.

Consider using video laryngoscopy if available and if the operator is experienced with this technique as this may reduce direct exposure of the intubator to respiratory aerosols.

Crowd control for effective direction of resuscitation by the minimum number of people required is advised. Closing the door to the resuscitation area, when possible, may minimize airborne contamination of adjacent indoor space.

For more information on the AHA 2021 COVID-19 Guidelines:

Disclaimer: This video is for educational purposes only, and is not intended as medical advice. While we strive for 100% accuracy, errors may occur, and medications or protocols may change over time.



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