2021 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19

HomeCirculation: Cardiovascular Quality and OutcomesVol. 14, No. 102021 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19 Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUB2021 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19 Antony Hsu, Comilla Sasson, Peter J. Kudenchuk, Dianne L. Atkins, Khalid Aziz, Lance B. Becker, Robert A. Berg, Farhan Bhanji, Steven M. Bradley, Steven C. Brooks, Melissa Chan, Paul S. Chan, Adam Cheng, Brian M. Clemency, Allan de Caen, Jonathan P. Duff, Dana P. Edelson, Gustavo E. Flores, Susan Fuchs, Saket Girotra, Carl Hinkson, Benny L. Joyner Jr, Beena D. Kamath-Rayne, Monica Kleinman, Javier J. Lasa, Eric J. Lavonas, Henry C. Lee, Rebecca E. Lehotzky, Arielle Levy, Mary E. Mancini, Mary E. McBride, Garth Meckler, Raina M. Merchant, Vivek K. Moitra, Ryan W. Morgan, Vinay Nadkarni, Ashish R. Panchal, Mary Ann Peberdy, Tia Raymond, Kathryn Roberts, Michael R. Sayre, Stephen M. Schexnayder, Robert M. Sutton, Mark Terry, Brian Walsh, David S. Wang, Carolyn M. Zelop, Alexis Topjian 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 College of Emergency Physicians, American Society of Anesthesiologists, and the Society of Critical Care Anesthesiologists Antony HsuAntony Hsu https://orcid.org/0000-0002-9389-7501 Department of Emergency Medicine, St. Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI (A.H.). Search for more papers by this author , Comilla SassonComilla Sasson Correspondence to: Comilla Sasson, MD, PhD, American Heart Association, 7272 N Greenville Ave, Dallas, TX 75231. Email E-mail Address: [email protected] https://orcid.org/0000-0002-9922-6637 ECC Science & Innovation, American Heart Association, Dallas, TX (C.S., R.E.L.). Search for more papers by this author , Peter J. KudenchukPeter J. Kudenchuk https://orcid.org/0000-0003-1855-1102 Department of Medicine/Division of Cardiology (P.J.K.), University of Washington, Seattle. Search for more papers by this author , Dianne L. AtkinsDianne L. Atkins Stead Family Department of Pediatrics (D.L.A), Carver College of Medicine, University of Iowa. Search for more papers by this author , Khalid AzizKhalid Aziz Division of Newborn Medicine, Department of Pediatrics, University of Alberta, Edmonton, Canada (K.A.). Search for more papers by this author , Lance B. BeckerLance B. Becker Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, NY (L.B.B.). Search for more papers by this author , Robert A. BergRobert A. Berg https://orcid.org/0000-0001-5529-9431 Department of Anesthesiology and Critical Care Medicine, Children′s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine (R.A.B., R.W.M., V.N., R.M.S., A.T.). Search for more papers by this author , Farhan BhanjiFarhan Bhanji Department of Pediatrics, McGill University, Montreal, QC, Canada (F.B.). Search for more papers by this author , Steven M. BradleySteven M. Bradley https://orcid.org/0000-0003-4006-6760 Minneapolis Heart Institute, Healthcare Delivery Innovation Center, MN (S.M.B.). Search for more papers by this author , Steven C. BrooksSteven C. Brooks Department of Emergency Medicine, Queen′s University, Kingston, ON, Canada (S.C.B.). Search for more papers by this author , Melissa ChanMelissa Chan Department of Pediatrics and Department of Pediatric Emergency Medicine, BC Children′s Hospital, University of British Columbia, Vancouver, Canada (M.C., G.M.). Search for more papers by this author , Paul S. ChanPaul S. Chan https://orcid.org/0000-0002-5185-3367 Department of Internal Medicine, Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City (P.S.C.). Search for more papers by this author , Adam ChengAdam Cheng Department of Paediatrics, Alberta Children′s Hospital, University of Calgary, Canada (A.C.). Search for more papers by this author , Brian M. ClemencyBrian M. Clemency https://orcid.org/0000-0002-7610-3087 Department of Emergency Medicine, University at Buffalo, NY (B.M.C.). Search for more papers by this author , Allan de CaenAllan de Caen Division of Critical Care, Department of Pediatrics, Stollery Children′s Hospital, University of Alberta, Edmonton, Canada (A.d.C., J.P.D.). Search for more papers by this author , Jonathan P. DuffJonathan P. Duff Division of Critical Care, Department of Pediatrics, Stollery Children′s Hospital, University of Alberta, Edmonton, Canada (A.d.C., J.P.D.). Search for more papers by this author , Dana P. EdelsonDana P. Edelson Section of Hospital Medicine, University of Chicago, IL (D.P.E.). Search for more papers by this author , Gustavo E. FloresGustavo E. Flores Emergency and Critical Care Trainings, San Juan, Puerto Rico (G.E.F.). Search for more papers by this author , Susan FuchsSusan Fuchs Division of Emergency Medicine (S.F.), Department of Pediatrics, Northwestern University/Ann & Robert H. Lurie Children′s Hospital, Chicago, IL. Search for more papers by this author , Saket GirotraSaket Girotra https://orcid.org/0000-0002-4784-4513 Department of Internal Medicine and Division of Cardiovascular Diseases (S.G.), Carver College of Medicine, University of Iowa. Search for more papers by this author , Carl HinksonCarl Hinkson Respiratory Care, Providence Regional Medical Center, Everett, WA (C.H.). Search for more papers by this author , Benny L. Joyner JrBenny L. Joyner Jr Departments of Pediatrics, Anesthesiology & Social Medicine, University of North Carolina at Chapel Hill (B.L.J.). Search for more papers by this author , 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.). Search for more papers by this author , Monica KleinmanMonica Kleinman Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children′s Hospital, MA (M.K.). Search for more papers by this author , Javier J. LasaJavier J. Lasa Cardiovascular Intensive Care Unit, Texas Children′s Hospital, Baylor College Of Medicine, Houston (J.J.L.). Search for more papers by this author , Eric J. LavonasEric J. Lavonas Department of Emergency Medicine, Denver Health and Hospital Authority, CO (E.J.L.). Search for more papers by this author , Henry C. LeeHenry C. Lee Division of Neonatology, Stanford University, CA (H.C.L.). Search for more papers by this author , Rebecca E. LehotzkyRebecca E. Lehotzky ECC Science & Innovation, American Heart Association, Dallas, TX (C.S., R.E.L.). Search for more papers by this author , Arielle LevyArielle Levy Department of Pediatrics and Department of Pediatric Emergency Medicine, Sainte-Justine Hospital University Center, University of Montreal, QC, Canada (A.L.). Search for more papers by this author , Mary E. ManciniMary E. Mancini College of Nursing, University of Texas at Arlington (M.E. Mancini). Search for more papers by this author , Mary E. McBrideMary E. McBride Divisions of Cardiology and Critical Care Medicine (M.E. McBride), Department of Pediatrics, Northwestern University/Ann & Robert H. Lurie Children′s Hospital, Chicago, IL. Search for more papers by this author , Garth MecklerGarth Meckler Department of Pediatrics and Department of Pediatric Emergency Medicine, BC Children′s Hospital, University of British Columbia, Vancouver, Canada (M.C., G.M.). Search for more papers by this author , Raina M. MerchantRaina M. Merchant Department of Emergency Medicine, University of Pennsylvania, Philadelphia (R.M.M.). Search for more papers by this author , Vivek K. MoitraVivek K. Moitra Department of Anesthesiology, Division of Critical Care Medicine, Columbia University Irving Medical Center, New York, NY (V.K.M., D.S.W.). Search for more papers by this author , Ryan W. MorganRyan W. Morgan https://orcid.org/0000-0003-1664-5316 Department of Anesthesiology and Critical Care Medicine, Children′s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine (R.A.B., R.W.M., V.N., R.M.S., A.T.). Search for more papers by this author , Vinay NadkarniVinay Nadkarni https://orcid.org/0000-0002-3794-5599 Department of Anesthesiology and Critical Care Medicine, Children′s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine (R.A.B., R.W.M., V.N., R.M.S., A.T.). Search for more papers by this author , Ashish R. PanchalAshish R. Panchal https://orcid.org/0000-0001-7382-982X Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus (A.R.P.). Search for more papers by this author , Mary Ann PeberdyMary Ann Peberdy Division of Cardiology, Virginia Commonwealth University, Richmond (M.A.P.). Search for more papers by this author , Tia RaymondTia Raymond https://orcid.org/0000-0001-9454-8410 Department of Pediatrics and Pediatric Cardiac Critical Care, Medical City Children′s Hospital, Dallas, TX (T.R.). Search for more papers by this author , Kathryn RobertsKathryn Roberts Center for Nursing Excellence, Education & Innovation, Joe DiMaggio Children′s Hospital, Hollywood, FL (K.R.). Search for more papers by this author , Michael R. SayreMichael R. Sayre https://orcid.org/0000-0003-0322-3181 Department of Emergency Medicine (M.R.S.), University of Washington, Seattle. Search for more papers by this author , Stephen M. SchexnayderStephen M. Schexnayder Departments of Critical Care Medicine and Emergency Medicine, Arkansas Children′s Hospital, Little Rock (S.M.S.). Search for more papers by this author , Robert M. SuttonRobert M. Sutton Department of Anesthesiology and Critical Care Medicine, Children′s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine (R.A.B., R.W.M., V.N., R.M.S., A.T.). Search for more papers by this author , Mark TerryMark Terry National Registry of Emergency Medical Technicians, Columbus, OH (M.T.). Search for more papers by this author , Brian WalshBrian Walsh https://orcid.org/0000-0003-3352-8816 Respiratory Care, Children′s Hospital Colorado, Aurora (B.W.). Search for more papers by this author , David S. WangDavid S. Wang Department of Anesthesiology, Division of Critical Care Medicine, Columbia University Irving Medical Center, New York, NY (V.K.M., D.S.W.). Department of Obstetrics and Gynecology, New York, NY (D.S.W.). Search for more papers by this author , Carolyn M. ZelopCarolyn M. Zelop https://orcid.org/0000-0002-3077-6083 NYU School of Medicine, New York, NY and The Valley Hospital, Ridgewood, NJ (C.M.Z.). Search for more papers by this author , Alexis TopjianAlexis Topjian Department of Anesthesiology and Critical Care Medicine, Children′s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine (R.A.B., R.W.M., V.N., R.M.S., A.T.). Search for more papers by this author 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 College of Emergency Physicians, American Society of Anesthesiologists, and the Society of Critical Care Anesthesiologists Search for more papers by this author Originally published13 Oct 2021https://doi.org/10.1161/CIRCOUTCOMES.121.008396Circulation: Cardiovascular Quality and Outcomes. 2021;14Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: October 13, 2021: Ahead of Print In April 2020, the American Heart Association (AHA) Emergency Cardiovascular Care (ECC) Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces published their Interim Guidance for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) at the start of the SARS-CoV-2 pandemic. In October 2020, the AHA published new cardiopulmonary resuscitation (CPR) guidelines with the latest evidence-based algorithms and recommendations for Basic Life Support, Advanced Cardiac Life Support, Pediatric Advanced Life Support, Neonatal Advanced Life Support, and Maternal Cardiac Arrest Resuscitation.1As the COVID-19 pandemic continues into 2021 and beyond, there is now a more accurate understanding of the transmissibility of SARS-CoV-2, a stabilizing of personal protective equipment (PPE) availability, and widespread vaccination of health care providers and some communities prompting the committee and task forces to update the initial interim guidance.2 Both nationally and internationally, the prevalence of COVID-19 and variants, vaccination, and risk of transmission are variable, and individual systems and settings can utilize this guidance to match local risk. While the initial interim guidance was focused on the use of PPE, as well as early intubation and control of the airway to decrease potential transmission risk to medical personnel, the updated 2021 interim guidance now aligns with the 2020 AHA guidelines for CPR and ECC with the provision of appropriate PPE usage and aerosol control for suspected and confirmed COVID-19 patients in settings where vaccinations have been readily adopted.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.3–6 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.7 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.8,9 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-19.3,10,11 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.12With increased scientific knowledge, a more stable PPE supply chain, and vaccination of frontline health care 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). The standard 2020 CPR algorithms and recommendations for resuscitation should apply to those patients who are known to be COVID-19 negative.Download figureDownload PowerPointFigure 1. Summary of adjustments to cardiopulmonary resuscitation (CPR) algorithms in patients with suspected or confirmed coronavirus disease 2019 (COVID-19).13–15 AGP indicates aerosol generating procedure; HEPA, high efficiency particulate air; PPE, personal protective equipment; and SARS-CoV-2, severe acute respiratory syndrome coronovirus 2.Download figureDownload PowerPointFigure 2. Frequently asked questions. AGP indicates aerosol generating procedure; and COVID-19, coronavirus disease 2019.Download figureDownload PowerPointFigure 3. Adult basic life support algorithm for health care providers for suspected or confirmed coronavirus disease 2019 (COVID-19).Download figureDownload PowerPointFigure 4. Adult cardiac arrest algorithm for patients with suspected or confirmed coronavirus disease 2019 (COVID-19; VF/pVT/asystole/PEA).Download figureDownload PowerPointFigure 5. Cardiac arrest in pregnancy in-hospital Advanced Cardiac Life Support (ACLS) algorithm for patients with suspected or confirmed coronavirus disease 2019 (COVID-19).Download figureDownload PowerPointFigure 6. Pediatric basic life support algorithm for health care provider—single rescuer for suspected or confirmed coronavirus disease 2019 (COVID-19).Download figureDownload PowerPointFigure 7. Pediatric basic life support algorithm for health care providers—2 or more rescuers for suspected or confirmed coronavirus disease 2019 (COVID-19).Download figureDownload PowerPointFigure 8. Pediatric cardiac arrest algorithm for patients with suspected or confirmed coronavirus disease 2019 (COVID-19).Reduce Provider RiskRationaleFrontline 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 aerosol generating procedures (AGPs), can reduce the risk of coronavirus transmission.16 Provider risk may vary based on individual (age/ethnicity/comorbidities/vaccination status) and system factors. Health care organizations may need to consider redoubling efforts to maintain a sufficient supply of PPE for AGPs if vaccination of their staff is incomplete as only full vaccination of health care providers ensures an extremely low rate of infection.15 Even as immunity to SARS-CoV-2 is achieved with health care provider vaccination, it is reasonable for health care providers to continue taking appropriate precautions against COVID-19 and its variants since CPR includes AGPs and vaccination rates of health care providers remain below 100%.17,18 On the other hand, the risk to the patient by withholding or delaying the response for cardiac arrest is extremely high compared with the much lower risk that the resuscitation provider will contract COVID-19 and develop serious illness. This risk is particularly low in the vaccinated or unvaccinated provider who provides care while wearing appropriate PPE for AGPs.19 Although the effectiveness of available vaccines has been demonstrated against the wild-type SARS-CoV-2 and variants of concern, breakthrough infections, which are usually not life threatening, may still occur. Boosters addressing emerging variants of concern may be required.15,20Reduce Provider Exposure and Provide Timely CareRationaleThe data regarding which procedures are aerosol generating are conflicting and continue to develop. Some components of CPR are suspected to be aerosol generating.21 SARS-CoV-2 is transmitted primarily by respiratory droplets and aerosols, with little transmission by fomites.22–24 Rapid initiation of chest compressions is critical for successful resuscitation and, in light of the low incidence of documented transmission to health care providers to date, is likely low risk to the compressor.25–27 In witnessed sudden arrests of patients with suspected or confirmed COVID-19, chest compressions should not be delayed. Chest compressions can be performed initially by a chest compressor with or without a surgical mask until relieved by responders with appropriate PPE for AGPs. Although data continue to develop, in light of the low incidence of documented transmission to health care providers to date, chest compressions should not be delayed for retrieval and application of a mask or face covering for either the patient or provider. Masks may be considered for providers once compressions have started and before the arrival of responders with appropriate PPE for AGPs.28 Unless there are active efforts to maintain an open airway, it is typically occluded in the unconscious patient with minimal air movement during chest compressions.29The case definitions of suspected and confirmed COVID-19 have changed over time.30 For communities and facilities with a higher prevalence of COVID-19 and lower immunization rates, the 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 AGP interventions to which compressors and other personnel will be exposed. Provided there is sufficient PPE, additional compressors may be required due to increased fatigue or potential for N-95 respirator slippage resulting from compressions.31–33 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.34 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. Although the clinical use of mechanical devices has not demonstrated improvement in outcome compared with manual CPR, it may reduce the number of additional staff who are needed to participate in the resuscitation event.35,36As 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 StrategiesRationaleIt remains unclear whether defibrillation itself is an AGP; however, preliminary animal data suggest chest compressions following defibrillation may be aerosol generating.37 On the other hand, case-control and retrospective cohort studies of other infectious agents spread by aerosolization indicate that the relative risk of transmission during defibrillation is minimal.38 A surgical mask on a patient with COVID-19 may help deflect exhaled respiratory particles that can pass through some oxygen-delivering masks. However, mask availability should not delay or prevent time-sensitive lifesaving therapies like chest compressions or defibrillation. When actively ventilating using bag-mask ventilation, a supraglottic airway, or an endotracheal tube, a high-efficiency particulate air (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 ConsiderationsPediatric and Adult Cardiac ArrestsIn the witnessed sudden arrest, initiate chest compressions immediately and, if not already masked, the provider should don their mask without delaying or interrupting compressions. If immediately available, a face covering for the patient may be considered but should not delay or interrupt compressions.Ventilations that are prioritized in pediatric arrests are suspected to be aerosol generating. Upon arrival, providers wearing appropriate PPE for AGPs should excuse providers without risk-matched PPE.Defibrillate as soon as indicated. Masking of the unvaccinated provider and patient may reduce the uncertain transmission risk following defibrillation but should not prevent or delay defibrillation. Patient masks are not needed if 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.Agonal breathing has been observed during early phases of cardiac arrest and may be seen during resuscitation particularly during transient periods of restored spontaneous circulation. In such cases, consider passive oxygenation overlaid with a surgical facemask (if readily available) when a bag-mask device or an advanced airway with a HEPA filter is not being utilized.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 that 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 disperse aerosolized particles if this does not risk exposure of others in the vicinity and not already in an outdoor setting.Out-of-Hospital Cardiac ArrestGuidance regarding Emergency Medical Services and lay rescuer is described in detail in other literature.39,40For the out-of-hospital, public, cardiac arrest chest compressions should be immediately initiated. It is reasonable for the compressor to don a mask immediately, but initiation of chest compressions should not be delayed. Delays due to mask retrieval may increase the risk of death for the patient from delayed CPR while providing little benefit to the provider.If immediately available, placing a face covering on a known COVID-19 patient may reduce the uncertain risk of aerosol exposure from compressions following defibrillation but should not prevent or delay defibrillation or chest compressions and is unnecessary for providers in appropriate PPE for AGPs.Before or upon arrival, Emergency Medical Service providers should rapidly don appropriate PPE for AGPs without delay or interruption of chest compressions and excuse unprotected persons from the immediate scene of care as soon as possible.Pediatric arrests occur primarily from respiratory causes, and ventilation is a lifesaving priority. Since ventilation of suspected and confirmed COVID-19 pediatric arrests poses a transmission risk, HEPA-filtered ventilation and health care provider masking, when available, can reduce the risk of transmission during CPR until providers arrive wearing appropriate PPE for AGPs.In-Hospital Cardiac ArrestCrowd control for effective direction of resuscitation by the minimum number of people required is advised. Closing the door to the resuscitation area, when possible, may minimize airborne contamination of adjacent indoor space. Health care personnel should continue to wear appropriate PPE for clinical care including masks, eye protection, and gloves as recommended by the Centers for Disease Control and Prevention.41 The standard 2020 AHA guidelines for CPR and ECC should apply to those patients who are known to be COVID-19 negative.1Patients Who Are Intubated Before ArrestConsider leaving the patient on a mechanical ventilator with a HEPA filter to maintain a closed circuit and to red