Resuscitation

#### Cardiopulmonary Resuscitation (CPR)

- Cardiopulmonary Resuscitation (CPR) in an austere environment is not an appropriate use of resources unless the etiology for the arrest is immediately apparent and/or rapidly reversible.
- Significant aerosol generation occurs during CPR of a COVID-19 patient. Anticipate providers involved will become infected with disease.
- If CPR is performed, the wear best available PPE before patient contact, surgical mask placed over patient’s airway until a definitive airway is secured, & the number of PPE protected personnel involved should be minimized to 1 or 2.

#### Manage Hemodynamics & Fluids

- Coordinate invasive pressure monitoring and procedures early, especially if considering advanced ARDS management techniques and/or evidence of impending distributive shock.
- Under sterile technique, establish central access early in anticipation of the need for continuous vasopressors.
- Multiple peripheral IVs likely needed for infusions of sedatives, analgesia, antibiotics.
- A conventional central venous catheter can be placed through an introducer catheter (i.e. Cordis) to increase number of infusion ports during the initial insertion.
- Excessive fluid resuscitation likely harmful, careful assessment of volume responsiveness required. If available, patient stable not on vasopressors, and evacuation is significantly delayed, may use loop diuretics to gain net-even volume.
- ∎Development of arrhythmias and dilated cardiomyopathy with cardiogenic shock may develop in severely ill COVID-19 patients due to systemic inflammation, stress, or a direct viral myocarditis requiring vasopressors. Manage arrhythmias as per ACLS guidelines.
- Unexpected change in vital signs trends or hypotension out of proportion to sedation and PEEP indicates shock. Development of jugular venous distension and cool mottled extremities may indicate cardiogenic shock. Limited transthoracic echocardiography may be useful to determine shock cause.
- Utilize measures of volume responsiveness (urine output, pulse pressure variation, and blood pressure response to passive straight leg raise) to help guide the need for further fluid resuscitation. Note: An increase of EtCO2 of >5% OR 3mmHg after passively raising a patient’s legs up 45 degrees from a fully supine position suggests volume responsiveness.
- Norepinephrine is first line vasopressor for shock. Vasopressors should be titrated to a MAP goal of greater than or equal to 65mmHg.