Why would you order a COVID-19 (Coronavirus Disease 2019) test in a patient presenting to the Emergency Department (ED) in cardiac arrest?

From the Guidelines

I would order a COVID-19 test in a patient presenting to the Emergency Department (ED) in cardiac arrest primarily for infection control purposes and to guide post-resuscitation management. During resuscitation efforts, healthcare providers are in close proximity to the patient and performing aerosol-generating procedures like intubation, which creates significant exposure risk if the patient has COVID-19, as highlighted in the 2022 interim guidance to health care providers for basic and advanced cardiac life support in adults, children, and neonates with suspected or confirmed COVID-19 1. Knowing the patient's COVID status helps determine appropriate isolation precautions for staff and other patients. Additionally, if resuscitation is successful, COVID-19 status will influence subsequent management decisions, including medication choices, ventilation strategies, and disposition planning. COVID-19 can directly contribute to cardiac arrest through mechanisms like hypoxemia, myocarditis, arrhythmias, or massive pulmonary embolism, so identifying it may help determine the underlying cause of arrest. While the test result won't be immediately available during the initial resuscitation, the information becomes valuable for ongoing care and helps protect healthcare workers and other patients from potential transmission.

Some key considerations in the management of cardiac arrest in patients with suspected or confirmed COVID-19 include:

• The use of personal protective equipment (PPE) for healthcare providers, including respirators, gowns, gloves, and eye protection, as recommended by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) 1
• The performance of aerosol-generating procedures, such as intubation and bag-mask ventilation, with caution and with the use of HEPA filters to minimize the risk of transmission 1
• The importance of early initiation of CPR and the use of automated external defibrillators (AEDs) in patients with cardiac arrest, as emphasized in the 2022 interim guidance 1

Overall, ordering a COVID-19 test in a patient presenting to the ED in cardiac arrest is crucial for ensuring the safety of healthcare workers and other patients, as well as for guiding post-resuscitation management and determining the underlying cause of the cardiac arrest. The most recent and highest quality study on this topic is the 2022 interim guidance to health care providers for basic and advanced cardiac life support in adults, children, and neonates with suspected or confirmed COVID-19, published in the journal Circulation 1.

From the Research

Ordering a COVID-19 Test in Cardiac Arrest Patients

• The decision to order a COVID-19 test in a patient presenting to the Emergency Department (ED) in cardiac arrest is crucial in determining the appropriate course of treatment and minimizing the risk of transmission to healthcare workers 2, 3, 4, 5, 6.
• According to the Australasian College for Emergency Medicine, in a setting of low community transmission, most cardiac arrests are not due to COVID-19, but it is still essential to take precautions to minimize the risk of transmission 2.
• The European Resuscitation Council COVID-19 guidelines executive summary suggests that treatment should be informed by a dynamic risk assessment, considering current COVID-19 prevalence, the person's presentation, likelihood that treatment will be effective, availability of personal protective equipment (PPE), and personal risks for those providing treatment 6.
• The American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular care recommend that patients with suspected or confirmed COVID-19 and cardiac arrest should receive chest compressions and defibrillation, when indicated, as soon as possible, while prioritizing oxygenation and ventilation 5.

Rationale for Testing

• The primary rationale for ordering a COVID-19 test in a cardiac arrest patient is to determine the cause of the cardiac arrest and to guide treatment, while also minimizing the risk of transmission to healthcare workers 3, 4.
• COVID-19 has resulted in significant morbidity and mortality worldwide, and cardiac arrest is a potential complication of the disease 3.
• The risk of contagion to healthcare personnel is low, assuming appropriate personal protective equipment is used, and vaccination with boosting provides further protection against contagion for the healthcare personnel involved in cardiac arrest resuscitation 3.

Implications for Healthcare Workers

• Healthcare workers should take precautions to minimize the risk of transmission, including wearing personal protective equipment (PPE) and following proper infection control protocols 2, 5, 6.
• The use of mechanical chest compression devices and minimizing the staff involved in resuscitation can also help reduce the risk of transmission 2.
• Regular PPE and advanced life support training, as well as access to in situ simulation sessions and extensive debriefing after actual resuscitations, are essential for ensuring safe, timely, and effective management of patients with cardiac arrest in the COVID-19 era 2.