Basic Life Support &

Advanced Life Support Communique during the COVID-19 Pandemic

AHCSA | BLS & ALS Communique during the COVID-19 Pandemic 1

Basic Life Support and Advanced Life Support; Communique during the COVID-19 Pandemic

Introduction The current COVID-19 pandemic has caused a high level of concern to health care workers and the wider

community, with ongoing uncertainty and variation in practice around the world concerning the optimal

clinical approach to resuscitative procedures in known or suspected COVID-19 patients.

In the context of Primary Health Care (PHC) clinics, be they metropolitan, rural or remote based, there is

another dimension outside of hospital settings that adds further or amended considerations.

The danger to the first responders and Health Care team is the risk of potential transmission of the virus

during resuscitative procedures, hence the critical importance of the use of Personal Protective Equipment

(PPE) and an awareness of the potential of generating aerosols in using supportive treatments.

The Key aim is to provide basic resuscitation as per recommended guidelines, with adaptions to mitigate

risks.

Key Points The Australian Resuscitation Council, 2020, has issued a communique from ANZCOR (Australian and New

Zealand Committee on Resuscitation) in regard to CPR in present pandemic situation; https://resus.org.au/

Their key message is that underlying principles for CPR remain the same:

Any Attempt at Resuscitation is better than No Attempt.

What has changed with this COVID-19 pandemic is the risk to rescuers.

Healthcare workers should be provided with appropriate PPE to perform their roles.

Note, many sudden cardiac arrests occur in the presence of family members, and many will be

unrelated to COVID-19. For lay rescuers who are unable or unwilling to do rescue breathing,

compression only CPR is acceptable.

After any attempts at resuscitation, please adhere to current advice about hand washing, cleaning

and decontamination

Key Considerations for both Basic Life Support (BLS) & Advanced Life Support (ALS) The question posed in many approaches is to ascertain if resuscitation is appropriate.

The considerations for such action will vary greatly from situation to situation and is a decision made by the health care team with full knowledge of each situation.

Aerosol generation: Chest compressions, assisted ventilation, and advanced airway manoeuvres

are all considered potentially aerosol-generating procedures, and should only be performed by

responders in airborne PPE (P2/N95 mask, gown, gloves, eye protection, hair covering)

Defibrillation is not considered an aerosol-generating procedure and can be performed by

responders wearing droplet precautions (surgical mask, gloves, gown, eye protection) as long as the

patient’s mouth and nose are covered and no chest compressions

As cardiac arrest is a time-sensitive condition, where delays to treatment reduce the likelihood of a

good patient outcome, an alternative approach is to perform defibrillation prior to donning

personal protective equipment if the arrest is witnessed and a defibrillator is immediately available,

and the patients mouth, and nose are covered

Thorough preparation in being prepared in responding to cardiac arrest situations, should include

access to full PPE gear in responder packs and on Emergency trolleys, including hand wash.

Consider permitting time for donning before you get to an out of clinic response. The opportunity

to don appropriate PPE prior to arrival at the scene will minimise delays to response.

AHCSA | BLS & ALS Communique during the COVID-19 Pandemic 2

Basic Life Support Defined: The preservation of life by the initial establishment of, and/or maintenance of, airway, breathing,

circulation and related emergency care, including use of an AED (ARC, 2020).

DANGER: the key danger is to the first responder and the need to protect themselves from potential cross

contamination in performing BLS. The main risk in transmission is in aerosol generating procedures which is

likely to be limited in the initial response.

Use of PPE as available. First responders should be wearing at least a surgical mask, eye protection

and gloves.

Consider placing a mask (or cloth) over the face of the person being attended to

RESPONSE: check for Response from a distance

SEND FOR HELP: Minimise the number of responders/persons in the room/close vicinity. Any available

bystanders should support maintaining necessary infection control measures where possible.

BREATHS: no rescue breaths with the exception for children, the Advanced Paediatric Life Support (APLS)

recommendation is that due to the most common scenario that hypoxia precipitates a cardiac arrest,

effective ventilation is a priority.

In contrast to the advice in adults in the out-of-hospital setting, APLS recommends that in the current

COVID-19 pandemic, health care professionals and lay rescuers who are willing, trained and able to do so,

should continue to deliver rescue breaths to children in addition to chest compressions. If rescuers are

untrained or unwilling to perform rescue breaths, chest compression only CPR is preferable to no CPR

(APLS, 2020)

COMPRESSIONS: only, exception for children to include breaths as above

DEFIBRILLATION: attach and follow instructions (see table) or insert flowchart reference

POST RESUS CARE: including adhering to all cleaning and disinfecting recommendations

BASIC LIFE SUPPORT

DANGER Protection of responder is priority

Don PPE

RESPONSE Look for response

SEND for Help

Send for Help

Limit the number of persons

Provide infection control support measures

AIRWAY Check and observe

BREATHING No rescue breaths (except for children)

COMPRESSIONS START CPR 30 compressions

Continue until responsive or other decision as directed

DEFIBRILLATION Attach Defibrillatorand follow instructions

POST RESUS CARE

Equipment requirements: If using pocket masks ensure availability of disposable filters

AHCSA | BLS & ALS Communique during the COVID-19 Pandemic 3

Advanced Life Support Defined: The provision of effective airway management, ventilation of the lungs and production of a

circulation by means of techniques additional to those of BASIC LIFE SUPPORT. These techniques may

include, but not be limited to, advanced airway management, vascular access/drug therapy and

defibrillation (ARC, 2020).

DANGER: As described in BLS regarding use of PPE, considerations must made in regards to aerosol

generating treatments.

Health care workers are encouraged to become familiar with and adhere to local guidleines which describe

the PPE that should be worn for aerosol generating procedures as per expert recommendations . The ideal

appropriate PPE for all resuscitaions that involve chest compressions , is a P2/N95 mask, gown, goggles,

gloves and hair covering

CPR: Compressions only with exception of children, as per APLS recommendations

ATTACH MONITOR DEFIBRILLATOR:Proceed as per recommnded Guidleines (ARC guidleines)

AIRWAY: The risk associated with aerosol-generating procedures (AGPs) should, where practical be

minimised and the following recommendations considered:

Preferentially allocating the most experienced clinician to manage the airway Do not attempt to clear the airway using any methods other than head tilt or chin lift Suctioning of the airway should not occur through an open suction device (i.e. Yankauer sucker)

until in an appropriate room with airborne PPE. A supraglottic airway (i.e. LMA) is preferred to a face mask, as it is thought to reduce the risk of

aerosols Pause compressions before inserting a supraglottic airway or attempting to intubate Recognising that a cuffed Endotracheal tube (ETT) is preferable to a supraglottic airway (LMA),

which is preferable to Bag Valve Mask Ventilation (BVM)

VENTILATION:

If using BVM, a two person technique with an oropharyngeal airway, is recommended as an option to increase the seal and minimise aerosol production

Addition of appropriate viral filters on all airway devices inclusive of Bag Valve Mask, Supraglottic airway or ETT where available and as close to the patient as possible. Take care to ensure that all connections are secure and consider the use of reinforcing tape.

ADVANCED LIFE SUPPORT COVID-19 considerations for COVID-19 suspected or confirmed case

CPR Compressions only (exception for children)

MONITOR/DEFIBRILLATOR Attach and follow algorithim

AIRWAY Minimising aerosol generation as practical and contextual

VENTILATION Minimising aerosol generation as practical and contextual

Continue CPR Follow ALS algorithim

POST RESUS

Equipment requirements: HME filters as a minimum

AHCSA | BLS & ALS Communique during the COVID-19 Pandemic 4

References Advanced Paediatric Life Support, 2020. APLS Statement on Paediatric Ewesuscitaion during the COVID-19

Pandemic. Accessed https://apls.org.au/

Australian College of Emergency Medicine. Adult Cardiac Arrest Managemen. Accessed.

https://acem.org.au/Content-Sources/Advancing-Emergency-Medicine/COVID-19/Resources/Clinical-

Guidelines/Adult-Cardiac-Arrest-Management

Australian Resuscitation Council, April 2020. Resuscitation during the COVID-19 Pandemic, accessed

https://resus.org.au/World Health Organisation. 2020 Modes of transmission of virus causing COVID-

19:implications for IPC precaution recommendations.

Couper K, Taylor-Phillips S, Grove A, Freeman K, Osokogu O, Court R, Mehrabian A, Morley P, Nolan JP, Soar

J, Berg K, Olasveengen T, Wychoff M, Greif, R, Singletary N, Castren M, de Caen A, Wang T, Escalante R,

Merchant R, Hazinski M, Kloeck D, Heriot G, Neumar R, Perkins GD on behalf of the International Liaison

Committee on Resuscitation.

COVID-19 infection risk to rescuers from patients in cardiac arrest.

Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison

Committee on Resuscitation (ILCOR), 2020 March 30. Available from: http://ilcor.org

WHO reference number: WHO/2019-nCoV/Sci_Brief/Transmission_modes/2020.2 Accessed

https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-

implications-for-ipc-precaution-recommendations

BASIC LIFE SUPPORT COVID-19 considerations for COVID-19 suspected or confirmed cases

Dangers? Protection of responder is priority

Responsive? Look for response

Open Airway Check and observe

Normal Breathing? No rescue breaths (except for children)

Attach Defibrillator (AED) Follow instructions

Send for help Limit the number of persons

Provide infection control

Continue CPR until responsiveness or normal breathing occurs and provide post-resus care

Start CPR 30 compressions and continue until responsive

or other decision as directed

CPR for 2 minutes

ADVANCED LIFE SUPPORT COVID-19 considerations for COVID-19 suspected or confirmed cases

Non-Shockable Shockable

Shock

CPR for 2 minutes

Attach

Defibrillator / Monitor and follow algorithm

Start CPR Compressions only (exception for children)

Appropriate PPE

VENTILATION: Use interventions that minimise

aerosol generation. If using BVM,

a 2 person technique with

oropharyngeal airway, is

recommended with the addition

of viral filters

Post Resuscitation Care

Return of Spontaneous circulation?

Assess Rhythm

AIRWAY: Use interventions

that minimise aerosol generation.

A supraglottic airway (i.e. LMA) is

preferred to a face mask; a cuffed

Endotracheal Tube (ETT) is

preferable to a supraglottic airway

(LMA), which is preferable to BVM