Respiratory infections can be transmitted through respiratory droplets (measuring 5−10 µm in diameter) or droplet nuclei (measuring < 5 µm in diameter).1 Transmission through droplets takes place via the following mechanisms: direct / close contact (< 1−2 m) with a symptomatic individual, secondary to exposure of the conjunctival and airway mucosa to respiratory droplets; or indirect contact with fomites (objects or surfaces) contaminated by respiratory droplets in the surroundings of the patient.

Airborne transmission through droplet nuclei is different, and is related to persistent suspension in the air of these minute droplets during prolonged periods of time.

According to data from the World Health Organization (WHO), SARS-CoV-2 can fundamentally transmit between people through respiratory droplets and contact. In this context, and in addition to the standard precautions, protective measures should include specific protective elements against transmission through contact and through respiratory droplets. In the case of SARS-CoV-2, such transmission may occur under specific conditions characterized by the generation of aerosols, through procedures that can mechanically induce their generation and dispersion (manual ventilation with mask and self-inflating balloon, nebulization, aspiration of secretions or noninvasive mechanical ventilation) or procedures which generate aerosols directly within the airway (orotracheal intubation, chest compression during CPR maneuvering).1–3

In addition to the standard measures, the specific protective considerations when evaluating CA in a patient with suspected or confirmed SARS-CoV-2 infection should include measures against transmission though contact, through respiratory droplets, and in relation to aerosol-generating activities.4,5

As regards personal protective equipment (PPE), due consideration must be made of the aforementioned mechanisms of transmission, with the inclusion of:

The purpose of these elements is to protect against splashing by biological fluids or secretions during resuscitation maneuvering. Furthermore, in situations of high viral transmission risk, it seems reasonable and prudent to intensify the protective measures.6,7

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  We recommend the use of integral protective equipment such as full body suits or long-sleeved impermeable suits that can be combined with integrated or removable hoods for protection of the head, and shoe coverings. If full body suits or long-sleeved impermeable suits are not available, the use of clinical aprons made of plastic or some other impermeable material should be considered.6

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  We recommend the use of double gloves during airway access procedures, followed by disposal of the outer gloves.8

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  When evaluating an individual with COVID-19 who suffers clinical deterioration, we recommend the use of surgical masks or, ideally, FPP2 masks, regardless of the location of the patient.9

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  Since CPR involves techniques capable of generating aerosols with a high viral transmission risk, we recommend the use of FPP2 masks or, ideally, FPP3 masks, regardless of the location of the patient.7,8

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  It is advisable to remove the respiratory protective equipment last, once the rest of the PPE elements have been removed and, if possible, outside the patient room.6,7

We recommend the use in all cases of disposable eye protection devices such as integral goggles (preferably), screens or hoods - both when evaluating patients with suspected or confirmed SARS-CoV-2 that suffer clinical worsening, and during CPR maneuvering, which can generate aerosols. Eye protective measures are advised due to the risk of eye contamination from splashing or droplets.7,9

Ideally, disposable equipment should be used. If this is not possible, then the protective equipment is to be placed in adequate bags or containers for decontamination following the instructions of the manufacturer.6–9

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  It is advisable to clearly inform about the infectious status of the patient with CA at the time of activation of the resuscitation team, whenever new members are incorporated to the team, and when moving the patient to the Unit of destination.10–12

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  We recommend keeping the number of people conforming the resuscitation team as low as possible in order to minimize exposure.7,8,10,12

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  All members of the resuscitation team involved in dealing with the patient must make use of the recommended PPE, following the established fitting and removal standards and protocols, and always under due supervision.6–8,10,12 It is crucial for ALL the healthcare staff involved in addressing CA to have received the necessary training – ideally based on clinical simulation methods – for use of the EPI.7

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  Ideally, the utilization of disposable / single-use PPE is advised. If this is not possible, then disinfection of the equipment is to be considered, with strict adherence to the recommendations of the manufacturer.6–8

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  It is advisable to have resuscitation kits with all the basic material to perform complete advanced resuscitation, together with adequate PPE for each member of the team dealing with CA.10 In order to prevent cross-contamination, it is advisable to avoid moving CA karts, defibrillators, etc. between different areas of the hospital.

When dealing with any patient admitted to hospital, and from the time of arrival, an individualized management strategy should be planned according to the clinical conditions of the patient, the general recommendations adapted to the local setting, the wishes of the patient, and the criteria of the specialists at all the healthcare levels involved in management of the patient – including the consideration of non-resuscitation instructions.13–17

The SEMICYUC and other scientific societies have proposed a care priority model based on the patient capacity to survive conditioned to the clinical situation, comorbidities and availability of resources, seeking to secure the maximum possible benefit for the largest number of individuals possible in abidance with the principles of proportionality and distributive fairness.15Table 2 summarizes this model, adding specific considerations referred to non-resuscitation instructions for each priority.

Due to the complexity of SARS-CoV-2 infection and the work overload of Intensive Care Units (ICUs), it is not uncommon in areas and wards outside critical care to find patients in more serious condition than usual. These patients must be closely monitored to detect possible clinical worsening, provide timely and opportune treatment, and not delay transfer to the ICU, as part of the measures for preventing CA in high-risk individuals.13

In comparison with the classical practice of alerting the team on duty when extreme monitoring data are detected, monitoring based on early alert scales – particularly the NEWS2 scale – can contribute to the early identification of patients at risk of suffering a poor course and of needing critical care.18,19

The first step in patient evaluation is implementation of the pertinent general and specific protection measures, already commented above, allowing a safe approach to patients with clinical worsening, and limiting the intervention to the minimum necessary number of staff members, in order to reduce contacts.16,20,21

At the time when patient worsening is detected, help from the nearest colleague is to be requested, with the evaluation of vital signs.16,22

If no such signs are present, the support team is to be notified immediately, explaining the COVID-19 status of the patient with CA, and CPR is to be started following the corresponding in-hospital protocol.

In the presence of vital signs, the exploration is to be completed with the D-ABCDE approach (Appendix B Fig. 2 and 3 of the supplementary material), which proposes the structured evaluation and management of the clinical problems in order of priority referred to vital body systems, with the purpose of ensuring prompt detection and treatment of those problems that may prove fatal over the short term – arresting patient worsening and the development of CA, and gaining time to allow a duly trained team to start definitive management.5,8,23,24

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  Before starting resuscitation maneuvering, the team must make use of PPE affording adequate protection against techniques with a high aerosol generation potential.

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  Once adequately protected, the presence of CA is to be confirmed, assessing the patient response to stimuli and the presence of spontaneous ventilation and pulse. The “see, hear, feel” maneuver for assessing the presence of breathing is not advised,16,22 since it implies closeness between the airway of the healthcare professional and that of the patient. This risk can be avoided by reliable explorations made at a greater distance, such as palpation or inspection of chest breathing motion.

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  Guarantee a safe environment.

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  The members of the resuscitation team should be limited to the minimum number needed to assist the patient. If the intervention of other non-healthcare staff proves necessary, they should make use of PPE if coming into contact with the patient.

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  Following the confirmation of CA, we recommend early activation of the advanced life support (ALS) team, placing priority on oxygenation and isolation of the airway with an endotracheal tube and cuff.

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  D-ABCDE approach.

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  Early activation of the ALS team is required: place priority on oxygenation and advanced airway management, ideally using an endotracheal tube with cuff.

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  It is advisable to have a CPR kit / bag with the material needed for ALS, dedicated exclusively to that COVID-19 area.

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  The members of the resuscitation team should be limited to the minimum number needed to assist the patient.

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  If the patient is subjected to invasive monitoring, cardiac arrest will be considered when all the screen tracings are flat (artery, central venous pressure [CVP], pulsioximetry, capnography).25,26

The idea of cardiopulmonary resuscitation in prone decubitus (P-CPR) was first proposed by McNeil in 1989.29 Since then a number of studies and experiences have been published on this subject.30–34

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  Intubated patients in prone decubitus:

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    In order to avoid the generation of aerosols and minimize viral transmission during CPR, we recommend starting chest compression with compression on the thoracic spine without sternal support, over vertebral segments T7-T10.12,35

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    After obtaining signs of return of spontaneous circulation (RSC), we advise returning the patient to supine decubitus.

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  Non-intubated patients in prone decubitus:

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    We recommend placing the patient in supine decubitus and continuing CPR.12

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  Patients in prone decubitus in the operating room:

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    If compression over the thoracic spine is contraindicated (surgical incision, known previous lesions), we recommend the two-hands technique in the space between the scapula and the dorsal spine.33

We should follow the recommendations in the general considerations regarding the defibrillation of patients with suspected or confirmed SARS-CoV-2 infection. In this case, placement of the adhesive patches will differ, positioning them on the left axillary midline and right scapula, or in both axillary regions.35

There are not enough data on the use of extracorporeal membrane oxygenation (ECMO) for the rescue of patients with SARS-CoV-2 infection.12 The approach depends on the experience of the center and its conditions in terms of the number of available ICU beds, since the current pandemic generates a great healthcare burden, with scarce available resources.

There is no evidence to suggest a change in the indications, timing of administration or dosage of drugs with respect to the general algorithm.

It is important to remember that patients with SARS-CoV-2 infection are often treated with drug substances that prolong the QT interval (hydroxychloroquine, antiretrovirals, azithromycin, levofloxacin, metoclopramide, etc.) or predispose to the appearance of conduction block (darunavir/cobicistat), either alone or in combination with amiodarone.

Although the contraindication of amiodarone in combination with these drugs is referred to chronic treatments, we should consider the alternative use of lidocaine.24,36 If CA is suspected to be secondary to ventricular fibrillation / pulseless ventricular tachycardia due to QT prolongation or torsades de pointes, amiodarone would be contraindicated, and the use of magnesium sulfate would be advisable.

When considering and correcting the cause of CA, hypoxia, thrombosis and drug toxicity – particularly due to the direct effect of antivirals and interactions with them – are of particular importance. Clinical suspicion and the ultrasound findings are the basis of the diagnosis, particularly in relation to pulmonary thromboembolism. Management does not differ from that applicable in other patients, beyond the aspects mentioned in the section on drug toxicity in treatment of the infection.13Table 3 summarizes the most prevalent reversible causes in patients with SARS-CoV-2 infection.

The suspension of CPR is guided by the same considerations as in CA due to other causes. The decision should be made once it becomes clear that continuing CPR will not prove successful.17

Regarding the initial considerations to be taken into account before CA, we recommend the following12,16,37:

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    The start of CPR may be delayed due to difficulties in continuous physical presence monitoring and the need to make use of PPE.

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    The staff must be aware that in the case of CA, the number of resuscitators should be limited to a maximum of four. Cardiopulmonary resuscitation should only begin once the resuscitators have put on their PPE, which in turn must be effective in protecting against aerosols.

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    We recommend having the CPR and difficult airway intubation material at hand and near to all critically ill children with coronavirus infection. Each Unit should establish the adequate place and make sure that all the staff members are familiarized with the location and content.

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    We suggest CA and CPR simulations in children with SARS-CoV-2 infection, ideally in the work setting and with the routine human and material resources.

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    In the presence of treatment adaptation – limitation instructions including the non-initiation of CPR, the decision is to be reflected in the case history and must be known to the assisting professionals.

In order to adapt care in children with CA, a number of different scenarios can be described12,16,37:

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  It should be considered by default that the child may be infected with SARS-CoV-2, and thus represents a contagion risk for the resuscitators.

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  We recommend the general sequence of basic CPR, with some modifications, and remembering the priority of ventilation in pediatric CPR.38

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  If the resuscitators live with the child, they are likely to also be infected; the general sequence of basic CPR therefore can be applied.

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  The “see, hear, feel” maneuver should be simplified, reducing it to only “see”, in order to reducing the risk of contagion.

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  Mouth-to-mouth or mouth-to-mouth/nose insufflation can be done through a surgical mask or, if not available, using a cloth mask or piece of clothing.

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  If the resuscitator is not willing to perform ventilations, at least continuous chest compressions should be made.

In a healthcare center: assistance by professionals with resources. Advanced life support

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  The person assisting the child should alert his/her colleagues and start CPR immediately. We recommend keeping the number of resuscitators to the minimum necessary. In general, it is advisable to limit the team to four people, who should put on their aerosol-proof PPE before beginning CPR, and should start intervening as they become adequately prepared.

Example of the distribution of roles with four resuscitators:

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  Non-intubated patient. Supervisor: coordination and supervision of PPE; Supervisor + Resuscitator 2: airway and ventilation; Resuscitator 3: chest compression; Resuscitator 4: monitoring and administration of drugs and fluids.39

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  Intubated patient. Supervisor: coordination and contact with the exterior; Resuscitator 2: connection-adjustment of the respirator, monitoring-defibrillation and takeover of chest compression; Resuscitator 3: chest compression; Resuscitator 4: administration of drugs and fluids, and recording of events.39

General care of the newborn infant with suspected or confirmed SARS-CoV-2 infection in the delivery room should follow the current algorithms referred to stabilization, transition support, resuscitation and oxygen therapy,40 taking into account the following particularities:

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  It is advisable to reinforce the newborn infant and healthcare staff isolation and protection measures during delivery and possible transfer.41 Transfer to and stay in the Neonatal Intensive Care Unit (NICU) should be in a closed incubator.

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  We recommend minimizing aerosol-generating procedures such as the aspiration of secretions.

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  The indicated ventilation device remains a T-piece respirator, with the fitting of a filter to the mask. As an alternative, use can be made of a self-inflating bag, likewise equipped with a filter.

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  Early intubation and videolaryngoscopy are not indicated in these cases, though protection of the resuscitator with a face screen is necessary. Tubes without a balloon are to be used (and if equipped with a balloon, the latter should not be insufflated).

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  If necessary, surfactant can be administered using a closed system.

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  No recommendation has been established on CPR based on extracorporeal cardiopulmonary support in this situation; the indication should be decided on an individualized basis.