On April 2, 2020, the American Heart Association (AHA) in conjunction with the American Academy of Pediatrics (AAP) released an interim guidance on resuscitation care specifically for pediatric patients with known or suspected coronavirus disease 2019 (COVID-19).

“As the COVID-19 pandemic continues to impact more communities in the [United States] it’s important for all caregivers and first responders to understand how to provide critical care to infants, children, and adolescents in the safest way possible,” said Susan Fuchs, MD, FAAP, a practicing pediatric emergency physician and co-editor of the Pediatric Education for Prehospital Providers (PEPP) 4th Edition.

This guidance for pediatric healthcare providers (HCPs) and first responders aims to minimize the risk for transmission of SARS-CoV-2, the novel virus that causes COVID-19. The recommendations are primarily informed by guidelines from the United States Centers for Disease Control and Prevention (CDC).

According to the guidance, “it is recommended that HCPs adopt standard and transmission-based precautions when caring for patients with known or suspected COVID-19, including adequate hand hygiene and the use of personal protection equipment (PPE; ie, respirators or facemasks, eye protection, gloves and gowns) before entering a patient’s room or care area.” In cases of shortages, gowns should be prioritized for use during aerosol-generating procedures. Patients with known or suspected COVID-19 should be placed in single-person rooms with the door closed.


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Aerosol-Generating Procedures

Aerosol-generating procedures, such as cardiopulmonary resuscitation, endotracheal intubation, and non-invasive ventilation, “should be performed in airborne infection isolation rooms (AIIRs) with HCPs using adequate respiratory protection such as N95 respirators or those with a higher level of protection. A limited number of providers should be present for the procedure, and the AIIRs should be cleaned and disinfected after the procedure,” noted the guidance

In patients requiring intubation, rapid sequence intubation should be adopted. Procedures including bag-valve mask, nebulizers, and noninvasive positive pressure ventilation should be avoided, as these procedures may generate aerosols. In patients with acute respiratory failure, endotracheal intubation should be adopted directly to reduce the risk of disease transmission with noninvasive ventilation.  

Guidance for First Responders

The new guidance recommends that emergency medical dispatchers determine whether the call pertains to a child who may have signs or symptoms or risk factors for COVID-19.

If a child is suspected of having COVID-19, all personal—the prehospital care providers and healthcare facilities—should be notified in advance. Emergency medical service (EMS) clinicians should also follow standard precautions and use PPE.

If the status of the child is not known by the dispatcher, the EMS team should exercise precautions when responding to patients with signs of respiratory infection, including maintaining a distance of ≥6 feet, if possible. 

Once in the ambulance, the patient should be given a face mask and separated from other individuals as much as possible, including from the driver who should be isolated from the patient compartment. During transport, the number of people riding in the ambulance should be limited to minimize possible exposure; family and personnel should wear facemasks.

“For aerosol-generating procedures needed to be conducted during EMS transport, bag-valve masks and other ventilator equipment should have high-efficiency particulate air filtration for expired air,” noted the guidelines.  Once the transport is completed, the ambulance or transport vehicle must be cleaned completely.

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“The American Heart Association understands the difficulty in caring for pediatric patients during this challenging time, especially when resuscitation is needed,” stated Comilla Sasson, MD, PhD, FAHA, FACEP, a practicing emergency room physician and vice-president for emergency cardiovascular care science and innovation at the American Heart Association. “Together with the American Academy of Pediatrics, we are doing everything we can to make it easier by offering guidance to minimize the spread of COVID-19.”

Additional information and resources from the AHA on COVID-19 can be accessed here.

References

Interim guidance for pediatric resuscitation care to reduce COVID-19 transmission [press release]. American Heart Association. https://newsroom.heart.org/news/interim-guidance-to-reduce-covid-19-transmission-during-resuscitation-care. Published April 2, 2020. Accessed April 10, 2020.