Emergency Medical Services (EMS) Agency

CASE OF THE MONTH — MAY 2020

Case Presentation:

Paramedics are dispatched to the home of a 52-year-old female in cardiac arrest.  The patient is found on her bedroom floor and her husband is performing chest compressions with dispatcher assistance (citizen CPR in progress).  EMS assumes care of the patient and further history is obtained from the husband. 

The husband reports that both he and his wife were diagnosed with COVID-19 earlier in the week.  He has been improving, but overnight, his wife had increased difficulty breathing.  She has a history of COPD.  He found her unresponsive on the floor when he woke up this morning and called 911.

Given the current COVID-19 pandemic, considerations should be made to don appropriate PPE prior to arrival, including an N95 mask, gloves, gown and eye protection, so that time critical care can be administered upon arrival without delay.  One must assume that all patients may have COVID-19.  For a dispatch complaint of cardiac arrest, it is prudent to arrive in full PPE for both contact and airborne precautions. Once the initial assessment is performed with appropriate PPE in place, and cardiac arrest is confirmed, resuscitation should begin, so that the patient has the best chance at a favorable outcome.  Only the necessary personnel should be within 6 feet of the patient to minimize exposure.

The husband is performing citizen CPR with prearrival instructions from dispatch when EMS arrives.  One paramedic with full PPE assesses the scene on arrival and confirms cardiac arrest.  Resuscitation is continued by the EMS team.  Citizen CPR is documented.  The initial rhythm on the monitor is PEA at a rate of 20 bpm.  In accordance with TP-1210, Cardiac Arrest, Epinephrine (0.1 mg/mL) 1mg IV is administered in addition to Normal Saline and airway management with bag-mask ventilation (BMV) with a viral filter applied.

Aerosol generating procedures (AGPs) in cardiac arrest resuscitation include chest compressions, BMV, suctioning, and advanced airway placement.  Resuscitation should be delivered as determined by the needs of the patient, including the use of AGPs when indicated.  In this case, cardiac arrest resuscitation should be initiated and continued according to existing policies and protocols.  There are no differences in the management for patients with confirmed COVID-19.  However, during the pandemic, since all patients may have COVID-19, it is important for EMS providers to wear PPE for all cardiac arrest resuscitations (N95 mask, eye protection, and gowns when gowns are available) consistent with airborne and contact precautions.  Goggles are preferred eyewear if available.  A face shield can be worn if available for additional protection, particularly by the airway operator.  For all positive pressure ventilation (BMV, advanced airway), the use of a viral filter is strongly advised, and should be used whenever available to limit the spread of viral particles.

The patient has return of spontaneous circulation (ROSC) after 2 cycles of CPR.  A hypoxic arrest is suspected.  Paramedics have difficulty maintaining oxygenation and ventilation with BMV so a King LT advanced airway is placed during post-ROSC stabilization.

Upon obtaining ROSC, all cardiac arrest patients should be stabilized on scene prior to transport.  Approximately 60% of patients will re-arrest after ROSC.  Therefore, stabilization measures including the administration of IV fluids, preparing for the use of push-dose epinephrine, and advanced airway placement when indicated, should be performed. For suspected or confirmed COVID-19 patients, a King Airway is preferred over endotracheal intubation to limit the time of insertion and close airway proximity, and to reduce potential exposure to viral particles during advanced airway placement.

Cardiac arrest patients should be transported after sustained ROSC is maintained following on-scene stabilization.  As per TP-1210, Cardiac Arrest, Base Contact is required prior to transport for all patients in cardiac arrest who do not meet criteria for determination of death.  In general, patients who have NOT maintained ROSC after resuscitation and stabilization should NOT be transported unless the Base Physician determines that futility has not been met and that transport is indicated.  Should the patient re-arrest resuscitation should begin again immediately on scene and Base Contact should be made for a decision on timing of transport or termination of resuscitation by the Base Physician in accordance with Ref. No. 814. 

 

For patients who are transported, patient handoff procedures are important to consider prior to arrival at the hospital.  Notify the receiving facility of EMS arrival with a cardiac arrest patient with ROSC.  In this case, share that the patient has confirmed COVID-19 by history.  An agreed upon handoff location should be confirmed with the receiving facility.  EMS must maintain PPE until patient handoff is complete.  Some handoffs may occur outside the hospital facility while others may occur inside with EMS assisting with patient transfer onto the hospital bed.   If entering the hospital for patient handoff, pause AGPs prior to entry into the emergency department.  AGPs may be resumed once the patient is roomed.  To minimize the pause in required AGPs, the notification process should facilitate direct transfer to a room so as not to delay care.  The EMS Agency recommends pausing ventilations via BMV and King airway even if a viral filter is in place because these devices may have an incomplete seal.  If a patient is intubated with an endotracheal tube and a viral filter, one can continue ventilations and chest compressions upon hospital entry during the patient handoff process since the endotracheal tube should create a complete seal during ventilation and, with the viral filter attached, minimize aerosolization of the virus.

The patient is stabilized on-scene and maintains ROSC during transport.  EMS notifies the receiving hospital and arrangements are made for a patient handoff inside the emergency department (ED).  The patient is delivered directly to an appropriate room in the ED upon EMS arrival.  Ventilations are paused briefly while the patient is in transit in the ED hallway since a King LT airway is in place.  The patient has sustained ROSC in the ED and is admitted to the ICU for further care.  EMS doffs PPE following patient handoff and return to service after ambulance decontamination.

  1. Consider PPE needs when responding to all calls.  Arrive ready so that time critical care can be delivered as indicated.
  2. Ensure that PPE including an N95 mask, eye protection, and gown (when available) are used when performing high risk aerosol generating procedures.
  3. Suspected COVID-19 status should not limit care delivered by EMS personnel.  Resuscitate cardiac arrest patients promptly as one would always do, but with appropriate PPE.
  4. Stabilize ROSC patients on scene prior to transport.  Patients without ROSC should NOT be transported unless it is determined that transport is indicated by the Base Physician.
  5. Coordinate patient handoff procedures prior to arrival with the receiving hospital.

Author:  Dr. Denise Whitfield, MD