ACEP COVID-19 Field Guide

Author: Jeffrey M. Goodloe, MD, FACEP, Hillcrest Medical Center Emergency Center, Tulsa, Oklahoma; Professor of Emergency Medicine, EMS Section Chief/Director of the Oklahoma Center for Prehospital and Disaster Medicine, University of Oklahoma School of Community Medicine; Chief Medical Officer, Medical Control Board, EMS System, Metropolitan Oklahoma City, Tulsa, Oklahoma; Medical Director, Oklahoma Highway Patrol

EMS personnel are at risk of exposure to infection during patient resuscitations. Their contact with patients is high, multiple personnel are involved on scene and en route, they work close to patients’ airways, and they are confined to a personal residence or ambulance. Protecting EMS personnel from infectious diseases during cardiac arrest resuscitations is of natural concern to clinicians, physician medical directors, and administrative leaders.

Important principles of cardiocerebral perfusion are unchanged for potentially infectious patients. Providing high-quality CPR and aggressively treating shockable dysrhythmias with automated external or manual defibrillators remain essential. COVID-19 has brought a renewed appreciation for achieving safe airway management, with “safe” being defined as effective oxygenation and ventilation for patients while limiting personnel’s exposure to respiratory secretions and exhalation streams.

Some EMS physician medical directors favor early intubation (via video laryngoscopy, if available) by the most experienced advanced life support personnel on scene, citing a reduction in exhalation volumes outside a contained airway circuit using a cuffed endotracheal tube. In basic life support systems, in systems with larger numbers of paramedics, or when fewer patients require invasive airway placement, other protocols have favored a supraglottic airway, placed per manufacturer and local policy directions. Bag-valve-mask ventilations can prove challenging because of complications from the face mask seal. An incomplete face mask seal interface can unintentionally contribute to exhalation stream exposures. Regardless of the airway management strategy employed, continuous care should be taken to reduce any unnecessary exhalation stream exposure, and all systems should be used with an exhalation filter and end-tidal CO₂ detector, if available.

The American Heart Association has released algorithms for suspected or confirmed COVID-19 patients in sudden cardiopulmonary arrest. These algorithms are applicable to basic and advanced life support that uses single or multiple rescuers for children and adults. The basic principles apply when treating any patient with a potentially infectious respiratory disease. For more information on this guidance, see “Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19: from the Emergency Cardiovascular Care Committee and Get With the Guidelines^®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association.”