Re: Covid-19: Doctors are told not to perform CPR on patients in cardiac arrest
Dear Editor,
Between hubris and hysteria: a response to BMJ 2020; 368:m1282
Currently, SARS-CoV-2 virus has a stranglehold over Europe after having submerged the world. Primarily, covid-19 jeopardizes the socioeconomic system. All of a sudden the pandemic becomes a major challenge to health care systems that additionally have to tackle a declining influenza epidemic. Severely sick patients are admitted to hospital at a progressive rate and when necessitating invasive respiratory and circulatory treatment a prolonged stay at an intensive care unit is likely. Pre-hospital triage is of paramount importance during a pandemic. Ideally, patients should stay at home as long as reasonable. When the disease aggravates ambulance personnel shielded with gowns, gloves, masks and protective goggles should bring the patients to upstream facilities of hospitals, where adequate protected hospital staff can take over. However, reality can suddenly deviate from this idealized situation. And how to identify spread of misinformation when even experts lack experience based on this novel disease?
The postulation “We have to be safe” in a situation where we cannot completely eliminate the risk of contamination is hypocritical.1 No doubt, self-protection is vital. Emergency physicians and rescue personnel have to wear personal protective equipment before coming into close contact with suspected covid-19 patients. Resuscitation is an aerosol generating procedure even with chest compression only CPR. When attempting CPR, rapid intubation without preceding bag-mask ventilation should be pursued. A filter between ventilation hoses and tracheal tube is obligatory. Frequently, neurological outcome is poor in patients who sustained hypoxic-ischaemic brain injury (HIBI) from cardiac arrest (CA).2 However, hypoxaemia and acute right heart failure are not the only causes of CA in diagnosed covid-19 patients.3 We are extremely stressed about CPR in patients with covid-19-associated CA but would be less restrictive in patients with influenza-associated CA. We should not easily jettison principles of emergency care as long as medical and human resources remain, CPR decisions have to be made on a case-by-case basis. However, clashed in an obscure situation with an unknown progression, the crisis will subside.
1 Mahase E, Kmietowicz Z. Covid-19: Doctors are told not to perform CPR on patients in cardiac arrest. BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1282
2 Sandroni C, D’Arrigo S, Nolan JP. Prognostication after cardiac arrest. Critical Care 2018;22:150. https://doi.org/10.1186/s13054-018-2060-7
3 Agård A, Hermerén G, Herlitz J. Should cardiopulmonary resuscitation be performed on patients with heart failure? The role of the patient in the decision-making process. J Intern Med. 2000;248(4):279-86.
Rapid Response:
Re: Covid-19: Doctors are told not to perform CPR on patients in cardiac arrest
Dear Editor,
Between hubris and hysteria: a response to BMJ 2020; 368:m1282
Currently, SARS-CoV-2 virus has a stranglehold over Europe after having submerged the world. Primarily, covid-19 jeopardizes the socioeconomic system. All of a sudden the pandemic becomes a major challenge to health care systems that additionally have to tackle a declining influenza epidemic. Severely sick patients are admitted to hospital at a progressive rate and when necessitating invasive respiratory and circulatory treatment a prolonged stay at an intensive care unit is likely. Pre-hospital triage is of paramount importance during a pandemic. Ideally, patients should stay at home as long as reasonable. When the disease aggravates ambulance personnel shielded with gowns, gloves, masks and protective goggles should bring the patients to upstream facilities of hospitals, where adequate protected hospital staff can take over. However, reality can suddenly deviate from this idealized situation. And how to identify spread of misinformation when even experts lack experience based on this novel disease?
The postulation “We have to be safe” in a situation where we cannot completely eliminate the risk of contamination is hypocritical.1 No doubt, self-protection is vital. Emergency physicians and rescue personnel have to wear personal protective equipment before coming into close contact with suspected covid-19 patients. Resuscitation is an aerosol generating procedure even with chest compression only CPR. When attempting CPR, rapid intubation without preceding bag-mask ventilation should be pursued. A filter between ventilation hoses and tracheal tube is obligatory. Frequently, neurological outcome is poor in patients who sustained hypoxic-ischaemic brain injury (HIBI) from cardiac arrest (CA).2 However, hypoxaemia and acute right heart failure are not the only causes of CA in diagnosed covid-19 patients.3 We are extremely stressed about CPR in patients with covid-19-associated CA but would be less restrictive in patients with influenza-associated CA. We should not easily jettison principles of emergency care as long as medical and human resources remain, CPR decisions have to be made on a case-by-case basis. However, clashed in an obscure situation with an unknown progression, the crisis will subside.
1 Mahase E, Kmietowicz Z. Covid-19: Doctors are told not to perform CPR on patients in cardiac arrest. BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1282
2 Sandroni C, D’Arrigo S, Nolan JP. Prognostication after cardiac arrest. Critical Care 2018;22:150. https://doi.org/10.1186/s13054-018-2060-7
3 Agård A, Hermerén G, Herlitz J. Should cardiopulmonary resuscitation be performed on patients with heart failure? The role of the patient in the decision-making process. J Intern Med. 2000;248(4):279-86.
Competing interests: No competing interests