Updated May 2, 2020
These contents have been adapted from the COVID-19 practice updates and created for your ease of use. They will be updated as new practice guidelines are released. Please refer to the complete guidelines within the linked document(s) for full detail.
We recognize that hospitals and Health Authorities have differing approaches and directives with regards to managing patients during the pandemic. Paramedics are asked to please follow BCEHS procedures whenever possible.
Patients transported to hospital without return of pulses, despite efforts of resuscitation by paramedics, should be assessed in the ambulance bay at the emergency department by a physician wearing appropriate PPE. The physician will then determine if resuscitation should continue, or if resuscitation should be discontinued and pronouncement of death should occur in the ambulance, rather than bringing the patient into the emergency department.
Communication, crew resource management and leadership during the management of a cardiac arrest is paramount, however, with the additional PPE requirements and stress of the situation it is acknowledged that communication can be difficult. To provide support to paramedics managing cardiac arrest an updated cardiac arrest checklist is now available in the BCEHS Handbook which will assist in improving team situational awareness, leadership, and communication during the resuscitation.
1) Instructions provided to bystanders by BCEHS 911 Emergency Medical Call Takers (EMCTs) for bystanders attending a pediatric patient suspected to be in cardiac arrest will include instructions on mouth-to-mouth ventilation if the bystander is willing and able. If the bystander is not willing or not able, the usual process of covering the patient’s mouth with a cloth should be implemented with compression-only CPR
2) All responders (FR, EMR, PCP and ACP) must ensure appropriate PPE is donned prior to entering the scene of a suspected pediatric cardiac arrest without exception
3) Where possible, the number of responders in the immediate vicinity of the patient should be limited to those providing essential patient care
4) Chest compressions and ventilations should be provided at a ratio of 15:2, with pauses to allow for ventilation
5) When providing positive pressure ventilation (PPV) ensure a tight seal on the BVM face mask and ALWAYS use an in-line viral filter. If there are only two responders on scene, consider having one provider maintain a two hand seal at all times and the chest compressor deliver the ventilations during the pauses for ventilations
6) Where available, a pediatric i-Gel may be a preferable airway management strategy if sufficient face mask seal is difficult to obtain or maintain
7) Endotracheal intubation should not be performed in pediatric patients who do not show signs of puberty, generally those less than 12 years old. If you are presented with a patient who does not align with this care plan, contact CliniCall to discuss
8) Direct laryngoscopy is permitted in pediatric patients ONLY for the removal of foreign body airway obstruction
9) Initiate appropriate resuscitation on scene (airway management/ventilations, chest compressions, and defibrillation as required) and then consider expedited transport to and appropriate hospital
Cardiac arrest should be presumed in the absence of all other signs of life.
Don PPE before commencing CPR and defibrillation.
Place a surgical mask, OR no-flow (0 lpm) oxygen mask, on the patient prior to chest compressions (chest compressions are aerosol generating events).
After commencement of chest compression-only CPR, the next priority should be rhythm analysis and defibrillation (if indicated).
Perform airway interventions after the first rhythm analysis +/- defibrillation. The airway should be managed by the most experienced and competent individuals.
When placing the i-Gel, briefly pause compressions. This should be followed by compressions with ventilation pauses (30:2) to allow for ventilation without compression. Always use filters on your BVM and for ventilation with an iGel.
CliniCall will have a higher threshold for recommending no transport of ANY adult patient in cardiac arrest. Contact CliniCall at 15 minutes or earlier if ALL early discontinuation criteria are met:
Unwitnessed cardiac arrest, and;
No shocks delivered, and;
No period of return of spontaneous circulation (ROSC).
Discontinuation may be advised by CliniCall EVEN in the setting of suspected reversible causes, unless exceptional circumstances are present (severe hypothermia, certain poisonings, massive pulmonary embolism, etc.).
Traumatic arrest, early discontinuation is likely unless a penetrating injury in the cardiac window is present, or paramedics witness the loss of vital signs, and there is < 10 minutes to the nearest emergency department.
Patients with intermittent periods of ROSC are likely to be discontinued on scene.
If transport IS recommended, CliniCall should provide advanced notice to the receiving hospital. If sustained ROSC is obtained, the paramedic crew should contact the local hospital as per normal procedure.
If a patient with sustained ROSC re-arrests en-route to hospital, 10 minutes of resuscitation should be provided prior to contacting CliniCall.
ALL paramedics (EMR, PCP, ACP) should ensure early contact (15 minutes) with CliniCall to discuss appropriateness of continuing resuscitation efforts.
If a supraglottic airway (iGel or King-LTD) is not being utilized in a cardiac arrest (EMR / FR), crews are asked to:
Maintain a good seal with two-person bag valve mask (BVM) even when not actively ventilating
Pause chest compressions to ventilate (30:2)
Ensure viral filter is in place
Identify and treat any treatable causes.
Contact CliniCall early to discuss treatment options.