Objectives:Assess the use of extracorporeal cardiopulmonary resuscitation (ECPR), compared with manual/mechanical cardiopulmonary resuscitation (CPR), for in-hospital cardiac arrest (IHCA) in pediatric patients with single ventricle (SV) congenital heart disease (CHD). Methods:PRISMA guidelines were followed with PROSPERO registration (CRD42023479671). We searched Medline, Embase, Web of Science, PubMed, and the Cochrane Library for studies published before January 23, 2025. The population included pediatric patients (<18 years old) with IHCA. Two investigators reviewed studies for relevance, extracted data, and assessed risk of bias using the ROBINS-I tool. Certainty of evidence was evaluated using the GRADE framework. Outcomes included short-term and long-term survival and favorable neurological outcome. Results:We identified 20 studies: 15 described ECPR in SV patients without a comparator group, and 5 compared SV ECPR patients vs. SV extracorporeal membrane oxygenation (ECMO) without ECPR (ECMO non-ECPR). Pooled synthesis for survival to hospital discharge was analyzed in 3 observational studies with 91 SV patients (pooled OR 0.66, 95% CI 0.37-1.01) and separately in 2 registry studies with 968 SV patients (OR 0.76, 95% CI 0.35-1.37 and OR 1.06, 95% CI 0.78-1.41) with very low certainty of evidence (downgraded for risk of bias and imprecision). These studies found no significant difference in survival to hospital discharge in ECPR compared to ECMO non-ECPR in pediatric SV patients. No studies were identified that compared pediatric SV patients who received ECPR vs. conventional/manual CPR. Conclusions:There is no direct evidence to either support or refute the use of ECPR during IHCA in pediatric patients with SV CHD, and there is inconclusive evidence to either support or refute the use of ECPR compared to ECMO non-ECPR. Additional research is needed to address the use of ECPR in this specific cardiac population.

The American Heart Association (AHA) introduced public access defibrillation more than 30 years ago. Since then, we have seen the growth of public access defibrillation programs across many settings within communities. However, despite high expectations that the availability of automated external defibrillators (AEDs) and more integrated public access defibrillation programs would dramatically increase cardiac arrest survival, AEDs are used in the United States in only 4% of out‐of‐hospital cardiac arrests and survival rates have remained disappointingly low. In follow‐up to a recent International Liaison Committee on Resuscitation report, an AED Symposium was organized by members of the AHA Emergency Cardiovascular Care Committee to establish a strategic roadmap for AED technology, education and training, and real‐world use of these devices, including integration with public access defibrillation programs to meet the AHA's goal of doubling out‐of‐hospital cardiac arrests survival by 2030. The meeting brought together a diverse group of subject matter experts including representatives from the US Food and Drug Administration, the defibrillator industry, clinicians, and scientists. This paper summarizes the proceedings of the AED symposium and suggests a set of strategic recommendations to ultimately improve survival from cardiac arrest.

Background: Early defibrillation is the foundation of treatment of shockable ventricular arrhythmias (VF, pVT) but optimal energy doses for initial and subsequent shocks in paediatric cardiac arrest remain controversial. Objectives: To assess the use of different energy doses for initial defibrillation in infants, children and adolescents with ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) during cardiac arrest. Methods: A systematic review was performed by the ILCOR Paediatric Life Support Task force. This systematic review was prospectively registered as PROSPERO CRD42024548898. A search of PubMed, EMBASE, and Cochrane Controlled Register of Trials (CENTRAL) was performed for clinical trials and observational studies, published before 1 January 2025, involving cardiac defibrillation in infants and children (excluding newborn infants) in cardiac arrest. Investigators reviewed studies for relevance, extracted data, and assessed risk of bias using the ROBINS-I framework. Critical outcomes included survival to hospital discharge and return of spontaneous circulation. Results were compiled into a Summary of Findings table using the GRADEpro Guideline Development tool. Statistical calculations and Forest plot generation were performed using RevMan. Results: We identified 7 relevant observational studies. The majority of studies involved in-hospital cardiac arrest. The overall certainty of evidence was very low. Critical (survival to hospital discharge, return of spontaneous circulation) and important (termination of VF/pVT) outcomes were not significantly better or worse when initial defibrillation doses of <1.5 J/kg or >2.5 J/kg were used for children in cardiac arrest with a shockable rhythm compared with initial doses approximating 2 J/kg. Conclusions: The current available data suggest that outcomes are not significantly better or worse when initial defibrillation doses of <1.5 J/kg or >2.5 J/kg are used for children in cardiac arrest with a shockable rhythm (VF or pVT) compared with initial doses approximating 2 J/kg. Well-designed randomised trials are needed to address this important question.

OBJECTIVE:Assess prevalence of epinephrine before or during the same minute as defibrillation and association with clinical outcomes in pediatric in-hospital cardiac arrest (IHCA). DESIGN:Retrospective cohort study. SETTING:We used 2000-2020 data from the American Heart Association's Get With the Guidelines-Resuscitation Registry. PATIENTS:Children (< 18 yr) with index IHCA with an initial shockable rhythm of ventricular fibrillation or pulseless ventricular tachycardia and at least one defibrillation attempt. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:The primary exposure was epinephrine administration before or during the same minute as defibrillation. Study outcomes were survival to hospital discharge (primary outcome), return of spontaneous circulation (ROSC) for greater than or equal to 20 min, and survival with favorable neurologic outcome. Propensity-score matching was used for confounding adjustment. Among 492 pediatric IHCA index events with an initial shockable rhythm, median age was 7 years and 351 (71%) were in the ICU. Overall, 232 (47%) children received either epinephrine before defibrillation (29%) or during the same minute as defibrillation (18%). In unadjusted analyses, proportions of survival to hospital discharge (37.1% vs. 51.2%), ROSC (74.6% vs. 84.6%), and survival with favorable neurologic outcome (22.1% vs. 40.4%) were lower in the epinephrine before or during the same minute as defibrillation group. However, in adjusted analyses using propensity score matching with exact matching on time to defibrillation category, epinephrine before or during the same minute as defibrillation was not associated with hospital survival (odds ratio [OR] 0.84, 0.46-1.56), ROSC (OR 0.97, 0.48-1.96), or favorable neurologic outcome (OR 0.52, 0.27-1.00). CONCLUSIONS:Contrary to current guidelines, nearly 50% of pediatric IHCA due to an initial shockable rhythm receive epinephrine before, or during the same minute, as first defibrillation. Although survival outcomes were numerically lower in epinephrine before defibrillation group, the association was not statistically significant.

AIM:To evaluate the ability of blood-biomarkers, clinical examination, electrophysiology, or neuroimaging, assessed within 14 days from return of circulation to predict good neurological outcome in children following out- or in-hospital cardiac arrest. METHODS:Medline, EMBASE and Cochrane Trials databases were searched (2010-2023). Sensitivity and false positive rates (FPR) for good neurological outcome (defined as either 'no, mild, moderate disability or minimal change from baseline') in paediatric survivors were calculated for each predictor. Risk of bias was assessed using the QUIPS tool. RESULTS:Thirty-five studies (2974 children) were included. The presence of any of the following had a FPR < 30% for predicting good neurological outcome with moderate (50-75%) or high (>75%) sensitivity: bilateral reactive pupillary light response within 12 h; motor component ≥ 4 on the Glasgow Coma Scale score at 6 h; bilateral somatosensory evoked potentials at 24-72 h; sleep spindles, and continuous cortical activity on electroencephalography within 24 h; or a normal brain MRI at 4-6d. Early (≤12 h) normal lactate levels (<2mmol/L) or normal s100b, NSE or MBP levels predicted good neurological outcome with FPR rate < 30% and low (<50%) sensitivity. All studies had moderate to high risk of bias with timing of measurement, definition of test, use of multi-modal tests, or outcome assessment heterogeneity. CONCLUSIONS:Clinical examination, electrophysiology, neuroimaging or blood-biomarkers as individual tests can predict good neurological outcome after cardiac arrest in children. However, evidence is often low quality and studies are heterogeneous. Use of a standardised, multimodal, prognostic algorithm should be studied and is likely of added value over single modality testing.

BACKGROUNDAnnually 15,200 children suffer an in-hospital cardiac arrest (IHCA) in the US. Ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) is the initial rhythm in 10-15% of these arrests. We sought to evaluate the association of number of shocks and early dose escalation with survival for initial VF/pVT in pediatric IHCA.METHODSUsing 2000-2020 data from the American Heart Association’s (AHA) Get with the Guidelines® -Resuscitation (GWTG-R) registry, we identified children > 48 hours of life and ≤ 18 years who had an IHCA from initial VF/pVT and received defibrillation.RESULTSThere were 251 subjects (37.7%) who received a single shock and 415 subjects (62.3%) who received multiple shocks. Baseline and cardiac arrest characteristics did not differ between those who received a single shock versus multiple shocks except for duration of arrest and calendar year. The median first shock dose was consistent with AHA dosing recommendations and not different between those who received a single shock versus multiple shocks. Survival was improved for those who received a single shock compared to multiple shocks. However, no difference in survival was noted between those who received 2, 3, or ≥ 4 shocks. Of those receiving multiple shocks, no difference was observed with early dose escalation.CONCLUSIONSIn pediatric IHCA, most patients with initial VF/pVT require more than one shock. No distinctions in patient or pre-arrest characteristics were identified between those who received a single shock versus multiple shocks. Subjects who received a single shock were more likely to survive to hospital discharge even after adjusting for duration of resuscitation.

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

Background: Contrary to current guidelines, administration of epinephrine before first defibrillation for shockable in-hospital cardiac arrest (IHCA) is common in adults and associated with lower survival. Whether these findings are also present in pediatric IHCA remains unknown. Methods: We used 2000-2020 data from the Get With the Guidelines®—Resuscitation registry to identify children (<18 years) with index IHCA due to an initial shockable rhythm of ventricular fibrillation or pulseless ventricular tachycardia and at least 1 defibrillation attempt. Study outcomes were event survival, defined as return of spontaneous circulation for > 20 minutes, survival to hospital discharge and favorable neurologic survival. Inverse probability of treatment weighting (IPTW) using propensity scores was used to adjust for confounding . Results: Among 492 pediatric IHCA index events (median [IQR] age, 7 years [0.75 to 14 years]; 351 [71%] in the ICU), 142 (29%) children with an initial shockable rhythm received epinephrine before defibrillation. Subjects receiving epinephrine before defibrillation had longer times to defibrillation compared to those receiving defibrillation first (median [IQR]: 4 minutes [2 to 8] vs. 1 minute [0 to 2]). Rates of event survival (72.7% vs. 82.8%), survival to hospital discharge (36.4% vs. 47.9%), and favorable neurologic survival (18.9% vs. 33.1%) were lower in the epinephrine before defibrillation group, Table). However, in adjusted analyses using IPTW, epinephrine before defibrillation was not associated with survival outcomes (Table). Conclusions: Nearly one in three pediatric IHCA with initial shockable rhythm receives epinephrine before defibrillation in contrast with recommended guidelines. However, unlike adults with IHCA, we did not identify a clear association between epinephrine before defibrillation and survival.

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

OBJECTIVES: To characterize inappropriate shock delivery during pediatric in-hospital cardiac arrest (IHCA). DESIGN: Retrospective cohort study. SETTING: An international pediatric cardiac arrest quality improvement collaborative Pediatric Resuscitation Quality [pediRES-Q]. PATIENTS: All IHCA events from 2015 to 2020 from the pediRES-Q Collaborative for which shock and electrocardiogram waveform data were available. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We analyzed 418 shocks delivered during 159 cardiac arrest events, with 381 shocks during 158 events at 28 sites remaining after excluding undecipherable rhythms. We classified shocks as: 1) appropriate (ventricular fibrillation [VF] or wide complex ≥ 150/min); 2) indeterminate (narrow complex ≥ 150/min or wide complex 100–149/min); or 3) inappropriate (asystole, sinus, narrow complex < 150/min, or wide complex < 100/min) based on the rhythm immediately preceding shock delivery. Of delivered shocks, 57% were delivered appropriately for VF or wide complex rhythms with a rate greater than or equal to 150/min. Thirteen percent were classified as indeterminate. Thirty percent were delivered inappropriately for asystole (6.8%), sinus (3.1%), narrow complex less than 150/min (11%), or wide complex less than 100/min (8.9%) rhythms. Eighty-eight percent of all shocks were delivered in ICUs or emergency departments, and 30% of those were delivered inappropriately. CONCLUSIONS: The rate of inappropriate shock delivery for pediatric IHCA in this international cohort is at least 30%, with 23% delivered to an organized electrical rhythm, identifying opportunity for improvement in rhythm identification training.

BackgroundThe guideline recommended chest compression depth, rate, and recoil are essential factors for the return of spontaneous circulation (ROSC) in cardiopulmonary resuscitation (CPR). A pediatric resuscitation collaboration recently demonstrated that healthcare providers fail to meet the American Heart Association (AHA) guidelines, with the greatest difficulty being in achieving chest compression depth targets in infants. We hypothesized that the use of the heel of one hand [open palm technique (OPT)] will increase chest compression depth in infants compared to standard CPR techniques [two-finger technique (TFT), two thumb-encircling hand technique (TTT)].MethodsA prospective, randomized, single-center study was completed using an infant manikin. Thirty pediatric critical care providers performed 2 min of CPR for each technique followed by 5 min of rest. Each participant completed a survey at the end that assessed the difficulty level in order to assess the feasibility of this new technique.ResultsThe mean chest compression depth for the OPT was significantly deeper compared to TFT (2.61± 0.63 cm vs. 2.25 ± 0.54 cm, p = 0.0004) but not significantly deeper compared to TTT (2.43 ± 0.46 cm, p = 0.0820). OPT was graded as the easiest technique, followed by TTT (2.20 ± 0.76 vs. 3.17 ± 0.95, p < 0.0001) and then TFT (3.38 ± 0.83, p < 0.0001).ConclusionThe use of OPT for infant CPR resulted in improved chest compression depth. OPT was considered the easiest technique compared to standard infant CPR techniques, thus making it feasible to perform. Importantly, all providers failed to meet the AHA infant chest compression depth goal of 4 cm, regardless of the technique. Future research is needed to optimize CPR technique and performance to achieve targeted chest compression depth in infants.

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Introduction: Approximately 15,200 children suffer an in-hospital cardiac arrest (IHCA) annually, and 10-20% will have ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT). Timely defibrillation is critical for shockable rhythms, however current data are lacking on outcomes when > 1 shock is required for termination of VF/pVT. Methods: From the AHA Get With The Guidelines ® -Resuscitation registry, we identified children < 18 years of age who had IHCA from initial VF/pVT and received > 1 shock from 2000-2020. Patients were analyzed according to total number of shocks received: 2 shocks, 3 shocks, or > 4 shocks. Multivariable logistic regression models were used to test the association between number of shocks and return of spontaneous circulation (ROSC), survival to hospital discharge, and survival to hospital discharge with favorable neurologic outcome. Results: 436 patients met inclusion criteria and received > 1 shock for VF/pVT. Median age was 8 years [IQR, 0.9,15.0]. Patients that required > 4 shocks were older patients (11 years [1.0-15.0; p=0.013]). A higher percentage of patients receiving > 4 shocks had renal insufficiency (14% vs. 7% for 2 shocks vs. 6% for 3 shocks, p = 0.041). Patients receiving > 4 shocks vs. 2 shocks were less likely to achieve ROSC (OR 0.40 [0.23,0.68]; p=0.0009). There was no statistically significant difference in survival to hospital discharge for patients receiving 2 shocks (42%), 3 shocks (39%), or > 4 shocks (32%) or survival to hospital discharge with favorable neurologic outcome. Conclusion: There was no significant association between the number of shocks and survival to hospital discharge or survival to hospital discharge with favorable neurologic outcome. ROSC was significantly less in patients with > 4 shocks for VF/pVT compared to 2 shocks. Further research is needed to characterize energy dosing when > 1 shock is needed for VF/pVT.

Children, adolescents, and young adults with conditions such as cardiomyopathies and channelopathies are at higher risk of sudden cardiac death caused by lethal arrhythmias, especially ventricular fibrillation. Timely defibrillation saves lives. Patients thought to be at significantly high risk of sudden death typically undergo placement of an implantable cardioverter-defibrillator. Patients thought to be at lower risk are typically followed medically but do not undergo implantable cardioverter-defibrillator placement. However, low risk does not equal no risk. Compared with the general population, many of these patients are at significantly higher risk for lethal arrhythmias. We make the case that such individuals and families will benefit from having an at-home automatic external defibrillator. Used in conjunction with conventional measures such as training on cardiopulmonary resuscitation, an at-home automatic external defibrillator could lead to significantly shortened time to defibrillation with better overall and neurological survival. We recommend that the cost of such home automatic external defibrillators should be covered by medical insurance.

Importance: Automated external defibrillator (AED) use is increasing, but use in children is uncommon. A growing literature of use in children by lay rescuers warrants review. Objective: A systematic review of AED effectiveness in children experiencing out-of-hospital cardiac arrest (OHCA). Data Sources: PubMed, EMBASE, Cochrane Register of Controlled Trials. Study Selection: Children, ages 0-18, experiencing OHCA with an AED applied by a lay rescuer. Control population: children with no AED application. Data Extraction and Synthesis: Results are reported according to PRISMA guidelines. Two authors independently reviewed all titles and abstracts of references identified by the search strategy, then generated a subset which all authors reviewed. Main Outcomes and Measures: Critical outcomes were survival with Cerebral Performance Category (CPC) 1-2 at hospital discharge or 30 days and survival to hospital discharge. Results: Population: age categories: <1 year, 1-12 years, 13-18 years. Lay rescuer AED application resulted in improved survival with CPC 1-2 at hospital discharge or 30 days to hospital discharge in age groups 1-12 and 13-18 years (RR 3.84 [95 % CI 2.69-5.5], RR 3.75 [95 %CI 2.97-4.72]), respectively and hospital discharge in both groups(RR 3.04 [95 % CI 2.18-4.25], RR 3.38 [95 % CI 2.17-4.16]), respectively. AED use with CPR improved CPC 1-2 at hospital discharge and hospital discharge (RR 1.49 [95 % CI 1.11-1.97], RR 1.55[1.12-2.12]). Conclusions: AED application by lay rescuers is associated with improved survival with a CPC of 1-2 at 30 days, and improved survival to hospital discharge for children 1-18 years. There are limited data for children < 1 year.

This article aims to provide guidance to health care workers for the provision of basic and advanced life support to children and neonates with suspected or confirmed coronavirus disease 2019 (COVID-19). It aligns with the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular care while providing strategies for reducing risk of transmission of severe acute respiratory syndrome coronavirus 2 to health care providers. Patients with suspected or confirmed COVID-19 and cardiac arrest should receive chest compressions and defibrillation, when indicated, as soon as possible. Because of the importance of ventilation during pediatric and neonatal resuscitation, oxygenation and ventilation should be prioritized. All CPR events should therefore be considered aerosol-generating procedures. Thus, personal protective equipment (PPE) appropriate for aerosol-generating procedures (including N95 respirators or an equivalent) should be donned before resuscitation, and high-efficiency particulate air filters should be used. Any personnel without appropriate PPE should be immediately excused by providers wearing appropriate PPE. Neonatal resuscitation guidance is unchanged from standard algorithms, except for specific attention to infection prevention and control. In summary, health care personnel should continue to reduce the risk of severe acute respiratory syndrome coronavirus 2 transmission through vaccination and use of appropriate PPE during pediatric resuscitations. Health care organizations should ensure the availability and appropriate use of PPE. Because delays or withheld CPR increases the risk to patients for poor clinical outcomes, children and neonates with suspected or confirmed COVID-19 should receive prompt, high-quality CPR in accordance with evidence-based guidelines.

HomeCirculation: Cardiovascular Quality and OutcomesVol. 15, No. 42022 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac 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 in Collaboration With the American Academy of Pediatrics, American Association for Respiratory Care, the Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessReview ArticlePDF/EPUB2022 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac 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 in Collaboration With the American Academy of Pediatrics, American Association for Respiratory Care, the Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists Dianne L. Atkins, MD, Comilla Sasson, MD, PhD, Antony Hsu, MD, Khalid Aziz, MBBS, BA, MA, Med (IT), Lance B. Becker, MD, Robert A. Berg, MD, Farhan Bhanji, MD, Steven M. Bradley, MD, MPH, Steven C. Brooks, MD, MHSc, Melissa Chan, MD, Paul S. Chan, MD, MS, Adam Cheng, MD, Brian M. Clemency, DO, MBA, Allan de Caen, MD, Jonathan P. Duff, MD, Med, Dana P. Edelson, MD, MS, Gustavo E. Flores, MD, NRP, Susan Fuchs, MD, Saket Girotra, MD, SM, Carl Hinkson, MS, RRT-ACCS, Benny L. Joyner Jr, MD, MPH, Beena D. Kamath-Rayne, MD, MPH, Monica Kleinman, MD, Peter J. Kudenchuk, MD, Javier J. Lasa, MD, Eric J. Lavonas, MD, MS, Henry C. Lee, MD, Rebecca E. Lehotzky, PhD, Arielle Levy, MD, Med, Mary E. McBride, MD, Med, Garth Meckler, MD, MSHS, Raina M. Merchant, MD, MSHP, Vivek K. Moitra, MD, MHA, Vinay Nadkarni, MD, MS, Ashish R. Panchal, MD, PhD, Mary Ann Peberdy, MD, Tia Raymond, MD, Kathryn Roberts, MSN, RN, Michael R. Sayre, MD, Stephen M. Schexnayder, MD, Robert M. Sutton, MD, MSCE, Mark Terry, MPA, Alexis Topjian, MD, MSCE, Brian Walsh, PhD, RRT, David S. Wang, MD, Carolyn M. Zelop, MD, Ryan W. Morgan, MD, MTR and on behalf of the Emergency Cardiovascular Care Committee and Get With the Guidelines-Resuscitation, Adult and Pediatric Task Forces of the American Heart Association in Collaboration With the American Academy of Pediatrics, American Association for Respiratory Care, American Society of Anesthesiologists, and the Society of Critical Care Anesthesiologists Dianne L. AtkinsDianne L. Atkins Correspondence to: Dianne L. Atkins, MD, Division of Pediatric Cardiology, Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242. Email E-mail Address: [email protected] https://orcid.org/0000-0001-6123-3105 Carver College of Medicine, University of Iowa (D.L.A., S.G.). , Comilla SassonComilla Sasson https://orcid.org/0000-0002-9922-6637 American Heart Association, Dallas, TX (C.S., R.E.L.). , Antony HsuAntony Hsu St Joseph Mercy Hospital, Ann Arbor, MI (A.H.). , Khalid AzizKhalid Aziz University of Alberta, Edmonton, Canada (K.A.). , Lance B. BeckerLance B. Becker Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, NY (L.B.B.). , Robert A. BergRobert A. Berg https://orcid.org/0000-0001-5529-9431 The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine (R.A.B., V.N., A.T., R.W.M., R.M.S.). , Farhan BhanjiFarhan Bhanji McGill University, Montreal, QC, Canada (F.B.). , Steven M. BradleySteven M. Bradley https://orcid.org/0000-0003-4006-6760 Minneapolis Heart Institute, Healthcare Delivery Innovation Center, MN (S.M.B.). , Steven C. BrooksSteven C. Brooks https://orcid.org/0000-0002-4592-4974 Queen’s University, Kingston, ON, Canada (S.C.B.). , Melissa ChanMelissa Chan University of British Columbia, BC Children’s Hospital, Vancouver, BC, Canada (M.C., G.M.). , Paul S. ChanPaul S. Chan https://orcid.org/0000-0002-5185-3367 Mid America Heart Institute and the University of Missouri-Kansas City, MO (P.S.C.). , Adam ChengAdam Cheng Alberta Children’s Hospital, University of Calgary, AB, Canada (A.C.). , Brian M. ClemencyBrian M. Clemency https://orcid.org/0000-0002-7610-3087 University at Buffalo, NY (B.M.C.). , Allan de CaenAllan de Caen Stollery Children’s Hospital, University of Alberta, Edmonton, Canada (A.d.C., J.P.D.). , Jonathan P. DuffJonathan P. Duff Stollery Children’s Hospital, University of Alberta, Edmonton, Canada (A.d.C., J.P.D.). , Dana P. EdelsonDana P. Edelson University of Chicago, IL (D.P.E.). , Gustavo E. FloresGustavo E. Flores Emergency & Critical Care Trainings, San Juan, Puerto Rico (G.E.F.). , Susan FuchsSusan Fuchs Ann & Robert H. Lurie Children’s Hospital, Chicago, IL (S.F., M.E.M.). , Saket GirotraSaket Girotra https://orcid.org/0000-0002-4784-4513 Carver College of Medicine, University of Iowa (D.L.A., S.G.). , Carl HinksonCarl Hinkson Providence Regional Medical Center, Everett, WA (C.H.). , Benny L. Joyner JrBenny L. Joyner Jr University of North Carolina at Chapel Hill, NC (B.L.J.). , Beena D. Kamath-RayneBeena D. Kamath-Rayne https://orcid.org/0000-0002-8482-4802 Global Newborn and Child Health, American Academy of Pediatrics, Itasca, IL (B.D.K.-R.). , Monica KleinmanMonica Kleinman Boston Children’s Hospital, MA (M.K.). , Peter J. KudenchukPeter J. Kudenchuk https://orcid.org/0000-0003-1855-1102 University of Washington, Seattle (P.J.K., M.R.S.). , Javier J. LasaJavier J. Lasa Texas Children’s Hospital, Houston (J.J.L.). , Eric J. LavonasEric J. Lavonas Denver Health and Hospital Authority, CO (E.J.L.). , Henry C. LeeHenry C. Lee Stanford University, CA (H.C.L.). , Rebecca E. LehotzkyRebecca E. Lehotzky American Heart Association, Dallas, TX (C.S., R.E.L.). , Arielle LevyArielle Levy https://orcid.org/0000-0001-7644-0633 Sainte-Justine Hospital University Center, University of Montreal, QC, Canada (A.L.). , Mary E. McBrideMary E. McBride Ann & Robert H. Lurie Children’s Hospital, Chicago, IL (S.F., M.E.M.). , Garth MecklerGarth Meckler University of British Columbia, BC Children’s Hospital, Vancouver, BC, Canada (M.C., G.M.). , Raina M. MerchantRaina M. Merchant The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine (R.A.B., V.N., A.T., R.W.M., R.M.S.). University of Pennsylvania, Philadelphia, PA (R.M.M.). , Vivek K. MoitraVivek K. Moitra College of Physicians & Surgeons of Columbia University, NY (V.K.M.). , Vinay NadkarniVinay Nadkarni https://orcid.org/0000-0002-3794-5599 The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine (R.A.B., V.N., A.T., R.W.M., R.M.S.). , Ashish R. PanchalAshish R. Panchal https://orcid.org/0000-0001-7382-982X The Ohio State University Wexner Medical Center, Columbus, OH (A.R.P.). , Mary Ann PeberdyMary Ann Peberdy Virginia Commonwealth University, Richmond, VA (M.A.P.). , Tia RaymondTia Raymond https://orcid.org/0000-0001-9454-8410 Medical City Children’s Hospital, Dallas, TX (T.R.). , Kathryn RobertsKathryn Roberts Joe DiMaggio Children’s Hospital, Hollywood, FL (K.R.). , Michael R. SayreMichael R. Sayre https://orcid.org/0000-0003-0322-3181 University of Washington, Seattle (P.J.K., M.R.S.). , Stephen M. SchexnayderStephen M. Schexnayder Arkansas Children’s Hospital, Little Rock, AR (S.M.S.). , Robert M. SuttonRobert M. Sutton The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine (R.A.B., V.N., A.T., R.W.M., R.M.S.). , Mark TerryMark Terry National Registry of Emergency Medical Technicians, Columbus, OH (M.T.). , Alexis TopjianAlexis Topjian Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, NY (L.B.B.). , Brian WalshBrian Walsh https://orcid.org/0000-0003-3352-8816 Children’s Hospital Colorado, Aurora, CO (B.W.). , David S. WangDavid S. Wang Columbia University Irving Medical Center, NY (D.S.W.). , Carolyn M. ZelopCarolyn M. Zelop https://orcid.org/0000-0002-3077-6083 NYU School of Medicine and The Valley Hospital, NY (C.M.Z.). , Ryan W. MorganRyan W. Morgan https://orcid.org/0000-0003-1664-5316 The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine (R.A.B., V.N., A.T., R.W.M., R.M.S.). and on behalf of the Emergency Cardiovascular Care Committee and Get With the Guidelines-Resuscitation, Adult and Pediatric Task Forces of the American Heart Association in Collaboration With the American Academy of Pediatrics, American Association for Respiratory Care, American Society of Anesthesiologists, and the Society of Critical Care Anesthesiologists Originally published24 Jan 2022https://doi.org/10.1161/CIRCOUTCOMES.122.008900Circulation: Cardiovascular Quality and Outcomes. 2022;15Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 24, 2022: Ahead of Print The American Heart Association, along with its collaborating organizations American Academy of Pediatrics, American Association for Respiratory Care, American Society of Anesthesiologists, and the Society of Critical Care Anesthesiologists, is committed to providing the most up-to-date evidence-based guidelines on resuscitation and supporting the health care providers that provide these interventions. At times, there is a need for an interim statement based on new data or, in the case of this pandemic, a rapidly changing environment. Interim guidance may arise from a scientific review of a single topic, or the need for a best-practice statement because of new or urgent public health initiatives. Based on evolving epidemiological reports, emergence of new and more transmissible strains of the coronavirus, declining vaccine effectiveness,1 as well as recent feedback from the health care provider community, it became clear that the guidance developed in the spring of 2021 and published in October 20212 needed to be updated to emphasize fully protecting health care providers who perform resuscitation. Our overall guiding principles and goals in providing this interim guidance are to achieve the best possible resuscitation outcomes and simultaneously ensure optimal protection for health care providers. Language has been clarified in this updated interim guidance to adhere to this guiding principle. Interim guidance will continue to evolve as the pandemic continues to ensure our guidance reflects the best, most up-to-date science and available evidence to guide best practices.This guidance is based on available scientific evidence at the time of its development, recommendations from public health organizations, and expert opinion; it should be adapted locally on the basis of current disease burden and resource availability. The interim guidance is not a guidelines statement which is based on a formal evidence review. Thus, the revisions have not undergone a systematic review process and cannot be assigned a Class of Recommendation or Level of Evidence.3 This guidance can be considered similar to a best practice statement. These revisions should always be adapted to changing public health recommendations and local protocols and resources.The writing group was comprised primarily of authors from the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,3 the Emergency Cardiovascular Care Committee, and the Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces. Additional writing group members were nominated by the collaborating organizations. Potential conflicts of interest are included in the Disclosures section of this article.We developed this consensus guidance through conference call of the entire author group, one-to-one and small group conferences, and group/personal email exchanges. The final documents were reviewed by a smaller group of experienced authors who had previously been first authors on American Heart Association (AHA) statements or guidelines. All authors and organizational liaisons participated in each step of the submission, revision, and final review process. The discussions were centered on healthcare provider protection, reducing provider risk, and appropriate use of personal protective equipment (PPE). The remainder of the 2021 Interim Guidance is included in this document for the convenience of the reader, to have the most current guidance in one document.2The changes in the interim guidance are focused on these 3 tenets:Incorporating the most recent Center for Disease Control and Prevention (CDC) and World Health Organization guidance: All health care providers should wear a respirator (eg, N95) along with other PPE (gown, gloves, and eye protection) for patients with suspected or confirmed COVID-19 infection, when performing aerosol-generating procedures (AGPs) or in a setting where AGPs are regularly performed.4,5 The definition of suspected cases should be consistent with the most current definitions from relevant public health officials as well as local standards and protocols. This includes donning appropriate PPE (including respirator) before performing the components of resuscitation that are aerosol generating, which include but are not limited to: chest compressions, defibrillation, bag-mask ventilation, intubation and positive-pressure ventilation. In the event, initial responders are not already wearing appropriate PPE, they should immediately don it and then begin CPR. As PPE recommendations change, health care providers should continue to follow the most-up-to-date recommendations from the World Health Organization, CDC, and regional health authorities and local institutions.Reinforce resuscitation best practices: Cardiac arrest survival rates have decreased dramatically during the COVID-19 pandemic.6 Out-of-hospital cardiac arrest survival in 2020 also declined in regions/time frames that did and did not have significant COVID infection rates. The reasons for this decline are both unclear and complex. Cardiac arrest survival is dependent on early initiation of CPR and we continue to recommend chest compressions as soon as is safely possible. We believe patients with confirmed or suspected COVID-19 should receive the best resuscitative efforts possible7 and we are committed to both the training of health care providers, and rigorous evaluation of the evidence to ensure our CPR and First Aid guidelines support best practices.Ensure adequate PPE supply: At this time, all health care providers should be following appropriate precautions and should have access to PPE in all clinical settings, regardless of the potential of encountering resuscitation events. Effective use of PPE is critical for the safety of health care providers performing resuscitations. Health care organizations should continue to secure appropriate PPE as available, ensure training regarding appropriate application and use of PPE, reinforce effective use of PPE, and create systems so that health care providers have immediate access to appropriate PPE when emergency care is required.International data early during the COVID-19 pandemic described worse survival outcomes for both out-of-hospital and in-hospital cardiac arrests compared with prior years.6–10 This worsening of outcomes may have been multifactorial; the severity of SARS-CoV-2 related cardiac arrest, the implementation of termination of resuscitation guidance, local crisis standards of care or patient hesitancy to seek medical care contributing to delays in care.11 The provision of prompt chest compressions and defibrillation may also have been delayed due to the additional time required in donning PPE or securing the airway and the PPE may have accelerated rescuer fatigue resulting in decreased CPR quality.12,13 Concerns that resuscitation from cardiac arrest due to COVID-19 may be futile may have led to earlier termination of resuscitative efforts and overwhelmed Emergency Medical Services systems may have had insufficient resources to respond to increased number of calls for arrests in regions with high rates of COVID-19.6,14 Lastly, significant delays in presentation for medical care, such as a tripling of the time from onset of chest pain to presentation to emergency care, may have contributed to an increase in out-of-hospital cardiac arrests rates during the pandemic as compared with before the pandemic.15With increased scientific knowledge, a more stable PPE supply chain and increasing availability of vaccines for healthcare providers and the general public, application of the best resuscitation science available must be once again assessed and prioritized. The following guidance should be applied to patients with suspected or confirmed COVID-19 infection (Figures 1 through 8).Download figureDownload PowerPointFigure 1. Summary of adjustments to cardiopulmonary resuscitation (CPR) algorithms in patients with suspected or confirmed COVID-19. AED indicates automated external defibrillator; AGP, aerosol generating procedure; HEPA, high-efficiency particulate air; and PPE, personal protective equipment. (Continued )Download figureDownload PowerPointFigure 2. Frequently asked questions. AGP indicates aerosol generating procedure; CPR, cardiopulmonary resuscitation; and PPE, personal protective equipment.Download figureDownload PowerPointFigure 3. Adult basic life support algorithm for health care providers for suspected or confirmed COVID-19. AED indicates automated external defibrillator; AGP, aerosol generating procedure; HEPA, high-efficiency particulate air; and PPE, personal protective equipment.Download figureDownload PowerPointFigure 4. Adult cardiac arrest algorithm for patients with suspected or confirmed COVID-19 (ventricular fibrillation [VF]/pulseless ventricular tachycardia [pVT]/asystole/pulseless electrical activity [PEA]). AGP, aerosol generating procedure; CPR, cardiopulmonary resuscitation; ET, endotracheal; HEPA, high-efficiency particulate air; IO, intraosseous; PPE, personal protective equipment; and ROSC, return of spontaneous circulation.Download figureDownload PowerPointFigure 5. Cardiac arrest in pregnancy in-hospital acls algorithm for patients with suspected or confirmed COVID-19. ACLS, advanced cardiovascular life support; AGP, aerosol-generating procedures; BLS, basic life support; CPR, cardiopulmonary resuscitation; ET, endotracheal; HEPA, high-efficiency particulate air; IV, intravenous; PPE, personal protective equipment; and ROSC, return of spontaneous circulation.Download figureDownload PowerPointFigure 6. Pediatric basic life support algorithm for health care provider—single rescuer for suspected or confirmed COVID-19. AED indicates automated external defibrillator; ALS, advanced life support; CPR, cardiopulmonary resuscitation; HEPA, high-efficiency particulate air; HR, heart rate; and PPE, personal protective equipment.Download figureDownload PowerPointFigure 7. Pediatric basic life support algorithm for health care providers—2 or more rescuers for suspected or confirmed COVID-19. AED indicates automated external defibrillator; ALS, advanced life support; CPR, cardiopulmonary resuscitation; HEPA, high-efficiency particulate air; HR, heart rate; and PPE, personal protective equipment.Download figureDownload PowerPointFigure 8. Pediatric cardiac arrest algorithm for patients with suspected or confirmed COVID-19. AGP, aerosol-generating procedures; CPR, cardiopulmonary resuscitation; ET, endotracheal; HEPA, high-efficiency particulate air; IO, intraosseous; IV, intravenous; PEA, pulseless electrical activity; PPE, personal protective equipment; ROSC, return of spontaneous circulation; VF, ventricular fibrillation; and pVT, pulseless ventricular tachycardia.Reduce Provider RiskRationaleEffective use of PPE is critical for the safety of health care providers performing resuscitations. Health care organizations should continue to secure appropriate PPE as available, ensure training regarding appropriate application and use of PPE, reinforce effective use of PPE, and create systems so that health care providers have immediate access to appropriate PPE when emergency care is required. Frontline health care providers are at significant risk for contracting respiratory illnesses due to frequent contact with symptomatic patients. Adequate PPE including N-95 masks or positive air pressure respirators, especially during AGPs, can reduce the risk of coronavirus transmission.24 Provider risk may vary based on individual (age/ethnicity/comorbidities/vaccination status) and system factors. Health care providers can significantly reduce their risk of infection, especially severe illness or death, by receiving the vaccine and booster against the SARS-CoV-2 virus.16–18 The American Heart Association strongly encourages all health care providers to receive the vaccines and comply with updated recommendations for boosters.Reduce Provider Exposure and Provide Timely CareRationaleThe data regarding which procedures are aerosol generating are conflicting and continue to develop. CPR is considered to be aerosol-generating.25 SARS-CoV-2 is transmitted primarily by respiratory droplets and aerosols, with little transmission by fomites.5,26,27 Rapid initiation of chest compressions is critical for successful resuscitation. Health care providers should wear a respirator (eg, N95) along with other PPE (gown, gloves, and eye protection) for patients with suspected or confirmed COVID-19 infection, when performing AGPs or in a setting where AGPs are regularly performed. This includes donning appropriate PPE (including respirator) before performing the components of resuscitation that are aerosol generating, which include but are not limited to: chest compressions, defibrillation, bag-mask ventilation, intubation, and positive-pressure ventilation. In the event initial responders are not already wearing appropriate PPE, they should immediately don it and then begin CPR. As PPE recommendations change, health care providers should continue to follow the most-up-to-date recommendations from the World Health Organization, CDC, and regional health authorities and local institutions.The case definitions of suspected and confirmed COVID-19 have changed over time.28 The incidence of COVID-19 disease has shifted rapidly over time with uneven geographic distribution.29 The definition of suspected cases should be consistent with the most current definitions from relevant public health officials as well as local standards and protocols. Continuous use of an N-95 respirator and eye protection should be considered when the patient’s COVID-19 status is unknown and resuscitation involves AGPs to which compressors and other personnel will be exposed.4 This may apply to patients who initially tested negative for COVID-19 on admission to the hospital and suffer a cardiac arrest during the hospitalization. Initiate chest compressions without delay or interruption while wearing appropriate PPE. All persons not wearing appropriate PPE should be immediately excused from the room or area. Provided there is sufficient PPE, additional compressors may be required due to increased fatigue or potential for N-95 respirator slippage resulting from compressions.30–32 The application of mechanical compression devices can reduce the number of health care providers required for compressions; however, these devices may not be appropriate or available for morbidly obese adults, infants, children, and small adolescents or for all clinical scenarios.33 Training and regular practice in the use and rapid application of mechanical compressions devices is required to minimize the early no-flow time and to ensure proper application and utilization of the device.23 Although the clinical use of mechanical devices has not demonstrated improvement in outcome compared to manual CPR, it may reduce the number of additional staff who are needed to participate in the resuscitation event.21,22As not every resuscitation space has negative pressure ventilation, closing the door may help limit contamination of adjacent indoor spaces. In out-of-hospital cardiac arrest, taking measures to better ventilate a confined space such as opening windows or doors may reduce the local concentration of aerosols for health care providers if this does not risk contamination of other spaces in the adjacent vicinity. In addition, some health care organizations may have continued shortages in PPE supply, low vaccination rates among staff, and personnel limitations; this guidance needs to be adapted to local protocols with consideration of current COVID-19 disease burden and resource availability.Specific Additional Resuscitation StrategiesRationaleThe experimental evidence evaluating the aerosol generating potential of chest compressions and defibrillation is extremely limited, conflicting, based on small human and animal studies.34–37 The CDC considers cardiopulmonary resuscitation and all of its components (eg, chest compression, ventilation, and defibrillation) aerosol generating. Therefore, all health care providers should wear appropriate PPE when performing CPR. When actively ventilating using bag-mask ventilation, a supraglottic airway or an endotracheal tube, a HEPA filter on the ventilation exhaust port can capture aerosolized particles. Endotracheal intubation should be timed with having sufficient PPE-protected personnel to perform the procedure.Situation- and Setting-Specific ConsiderationsBelow we describe several specific scenarios related to resuscitation care and their application to the COVID-19 pandemic. We provide these comments covering topics such as prone position, starting/stopping CPR, pregnancy, compression devices, and postarrest care to give readers insight in to the complex discussion that occurred among committee members during each of the interim guidance documents of 2020 and 2021.2,38 A comprehensive and evidenced-based review on each of these distinct scenarios is beyond the scope of this interim guidance, but additional discussion on these topics can be found in the AHA 2020 Guidelines.23Pediatric and Adult Cardiac ArrestsIn witnessed, sudden arrest, don appropriate PPE and initiate chest compressions immediately. All persons not wearing appropriate PPE should be immediately excused from the room or area.Ventilations, which are prioritized in pediatric arrests, are considered aerosol generating. All rescuers should wear appropriate PPE for AGPs. All persons not wearing appropriate PPE should be immediately excused from the room or area.Defibrillate as soon as indicated when providers are wearing appropriate PPE for AGPs.A HEPA filter should be securely attached to any manual or mechanical ventilation device along the exhalation port before all ventilation devices such as, but not limited to: bag-mask-valve, supraglottic airway devices, endotracheal tubes, and ventilator mechanical circuits. Alternatively, a low-dead space viral filter or a heat and moisture exchanging filter with >99.99% viral filtration efficiency may be placed between the ventilation device and the airway. The viral filter or the heat and moisture exchanging filter should remain attached to the airway when changing ventilation devices.Secure placement of a supraglottic airway with HEPA filters can help maximize chest compression fraction and control aerosol generation before endotracheal intubation.Before intubation, ventilate with a bag-mask-HEPA filter and a tight seal using practiced 2-person technique, ideally. The second team member can help provide extra support for additional procedures such as compressions once the airway is established.Assign the intubator with the highest chance of first pass success using the method the intubator is most comfortable with while protected with appropriate PPE for AGPs. Intubate with a cuffed endotracheal tube to minimize aerosolization of respiratory particles.Consider use of video laryngoscopy if available and if the operator is experienced with this technique as this may reduce direct exposure of the intubator to respiratory aerosols. Currently, there is no evidence of a difference in transmission risk using video versus direct laryngoscopy in the setting of providers wearing appropriate PPE for AGPs.As in any resuscitation, maximize the chest compression fraction, pausing only to facilitate intubation if needed. Minimizing noncompression time can require team-based instruction including pulse checks, advanced airway placement, and focused ultrasound evaluation coordinated with pulse checks and other necessary interruptions.Avoid endotracheal administration of medications; disconnections may be a source of aerosolization due to unfiltered exhalation.PrearrestClosely monitor for signs and symptoms of clinical deterioration to minimize the need for emergency intubations which put patients and providers at higher risk.Address advanced care directives and goals of care with all patients with suspected or confirmed COVID-19 (or proxy) on hospital arrival and with any subsequent significant change in clinical status.If the patient is at risk for cardiac arrest, consider proactively moving the patient to a negative-pressure room/unit, if available, to minimize risk of exposure to rescuers during a resuscitation.Close the door, when possible, to prevent airborne contamination of adjacent indoor space. Conversely, for out-of-hospital cardiac arrests, ventilating confined spaces by opening windows or doors may help dis