Resuscitation Today Summer 2020

Volume 7 No. 1
Summer 2020
Resuscitation Today
A Resource for all involved in the Teaching and Practice of Resuscitation
Celebrating 41 years of support
to the NHS and the Emergency Services
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CONTENTS
CONTENTS
Resuscitation Today
4 EDITORS COMMENT
6 FEATURE Prone CPR during Covid 19 - Prone CPR
10 FEATURE Reflection on NHS Nightingale London
13 NEWS
17 COMPANY NEWS
This issue edited by:
David Halliwell MSc
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RESUSCITATION TODAY - SUMMER 2020
3

EDITORS COMMENT
EDITORS COMMENT
With the Covid Crisis still continuing at the time of writing - the world of
resuscitation has had to adapt and respond to many new realities.
A reduction in aerosol generating procedures, safer skills - upskilling staff in PPE are just a few of
the tasks teams have been asked to perform.
This summer edition focuses on a few of the interesting areas that have started to be adopted or
discussed by the Resus community.
“With the
Covid
Crisis still
continuing
at the time
of writing -
the world of
resuscitation
has had to
adapt and
respond to
many new
realities.”
Conferences have been postponed or cancelled and so we hope that this journal provides some
stimulation for ongoing debates.
The first article looks at Prone resuscitation and suggests that Intensive care staff receive some
training in this as an alternative to traditional CPR. It is a theoretical paper, but none the less very
interesting.
The next original article is from Dr Tim Collins and his team who developed and delivered the
education processes for the NHS Nightingale in London - it’s a privilege to be able to share such
an article, and share a few lessons from this selfless team.
Finally we focus on the covid 19 Resuscitation guidelines themselves - as supplied by the
Resuscitation Council Uk - Note... please continue to monitor the Resuscitation council website to
see if there have been any technical changes since publication of this journal
The autumn edition of Resuscitation Today needs authors and editors - so please get in contact if
you have experiences you would like to share.
David Halliwell MSc
RESUSCITATION TODAY - SUMMER 2020
4

Celebrating 41 years of support
to the NHS and the emergency services
Our thanks goes out to
our wonderful NHS
www.dsmedical.co.uk

FEATURE
PRONE CPR DURING COVID 19 -
PRONE CPR
Hamad Abulla – Senior Resuscitation Officer
As we come out of the managing COVID-19 in some very resourcelimited
critical care settings we have seen a resurgence in clinicians
being required to think differently [1]. One of the key findings suggested
by many in the literature recently is that critically ill COVID-19 patients
seem to benefit from prone position ventilation. This has in turn raised
the profile of new techniques such as the idea of “Prone CPR”.
In the Photo and Diagrams below I have used the Lifecast Body
Simulation Older Person manikin (www.lifecastbodysim.com) to
showcase the best position based on the work by Kwon et al (2017)
and Mazer et al (2003), we used this manikin because he does not have
springs – This manikin uses a circumferential chest recoil system similar
to the rib cage found in human beings.
Papers suggest that Prone CPR was first introduced by McNeil in 1989
and followed by some other authors publishing research papers and
case reports [2, 3], although many of you who have studied resuscitation
may be familiar with many other - ‘Face Down’ resuscitation techniques
including ‘Barrel Rolling’, “Horse Bouncing” and the “Holger Neilson”
method– but these were all focussed on Respiratory Arrest at a time when
Cardiac Arrest was not at all understood. (If you want to see a great video
on this and other techniques - try watching YouTube - “CPR History and
Science of Resuscitation”)
Face down resuscitation is approved by the European Resuscitation
Council, and the American Heart Association (2015)- and is mentioned
in both sets of the 2015 guidelines - with the ERC Evidence citing
both Atkinson (2000) and Brown et al (2001) as part of their evidence
considerations.
Prone CPR is rarely taught outside Neurosurgical or Spinal units, and
did not gain significant widespread traction amongst general medical
professionals, but as already mentioned there are some instances when
there may be little alternative to CPR in the prone position, e.g., cardiac
arrest in neurosurgical patients, when the brain or spinal cord are
exposed during surgery and turning to the conventional supine position
would cause neural damage [3,4].
Photo of 2 Handed Technique on a Lifecast Body – note T7-T10
on the Spinal Column (Rescuer position above the Head)
RESUSCITATION TODAY - SUMMER 2020
6
In a letter to the Author by Mędrzycka-Dąbrowska et al. writing in Critical
Care in 2020 (5) the Polish based authors believe that “cardiac arrest
in a prone-ventilated patient with COVID-19 may be another indication
for commencing CPR without de-proning.” The authors suggest “There
seem to be some undisputable advantages of performing prone
cardiopulmonary resuscitation in this particular group of patients. Firstly,
it would limit the amount of people being exposed to environments
with highly contagious material. Some guidelines suggest that optimal
staffing involved in turning a critically ill prone patient should count
minimum of five people and may take up to 5 min to be completed, and
time during cardiac arrest is of the essence. Secondly, there is a risk of
displacement of the endotracheal tube or even inadvertent extubation of
the trachea which might have disastrous consequences for the patient
and the staff (creating an aerosol-generating incident). Disconnection of
vascular lines as well as injury to the patient and staff might also occur.”
It is often difficult for many of us to teach Prone CPR – since many
manikins are not designed to be used in the prone position, indeed from
our experience the traditional ALS manikins can actually be damaged
when being used for Prone CPR – mainly due to the springs for Chest
Compression being based underneath the sternum itself.
Photo of 2 Handed Technique on a Lifecast Body – note T7-T10
on the Spinal Column (Rescuer position above the Head)
Using detailed Tomography scans to arrive at the best position for CPR
Kwon et al suggest– “to establish the Optimal hand position level for
cardiac compression during prone cardiopulmonary resuscitation and
distribution of the level of the largest left ventricular (LV) cross-sectional
area in relation to an anatomic landmark.
Each black dot on the drawing above represents the level of largest LV
cross-sectional area in each patient. This level was located at 1 vertebral
segment above the inferior angel of the scapula in 1% of patients, at

FEATURE
2 Handed Technique for Prone Cpr Compression from a position
Below the Head
the same level in 23%, 1 vertebral segment below in 45%, 2 vertebral
segments below in 27%, and 3 vertebral segments below in 4%.”
In CPR studies we know that there are many key considerations, but
the compression / decompression of the Left Ventricle during chest
compression (LV) in order to generate a stroke volume (SV) through the
Left Ventricular Outflow Tract (LVOT) to perfuse both the heart the brain
and the rest of the organs is seen as one of the key targets of CPR.
Source
Optimizing Prone Cardiopulmonary Resuscitation: Identifying the
Vertebral Level Correlating with the Largest Left Ventricle Cross-
Sectional Area via Computed Tomography Scan
Anaesthesia & Analgesia124(2):520-523, February 2017.
• Therefore the Authors of the Kwon et al 2017 study concluded that
the hand position associated with greatest LV cross-sectional area
was thus 1 vertebral segment below the inferior angle of the scapula.
In 2003 Mazer et al (9) concluded CPR in the hands in the standard
position over the T7/10 area worked best.
Technique – The traditional 2 handed technique can be used but only if
you are ruling out spinal damage – This would be on the Vertebra T7-10 –
compressing downwards for the standard 6 cm used in more traditional CPR.
Where there are concerns about compression on the Vertebral bodies
themselves we can use a bilateral hand position as shown in the
Diagram - one hand on each side of the Thoracic vertebra T7-10.
During prone-CPR, chest compressions may be performed placing
hands over each scapula or over the thoracic spine with or without
counter-pressure on the sternum itself, but we would suggest that some
solid base to the front of the chest is required. As a word of warning
- From our findings - 2 Handed Prone CPR is Exhausting and can be
somewhat painful on the wrists – due to the lack of support offered
to one hand from another. CPR from the side position is also virtually
impossible if undertaking this procedure with the hands not positioned
on the spine.
Pad Positioning
Successful defibrillation has also been described with several
defibrillator pad positions [6], although traditional Anterior – Posterior
Pad positioning appears to be preferred by many clinicians.
To summarise – as we regroup emotionally in the Resuscitation and
Critical Care world, and we begin to consider the effects of Covid 19
In the current epidemiological situation, our understaffed ICU and
resuscitation teams should begin to be routinely prepared for the
situations which are far from the daily routine. Clinical Simulation should
use manikins that are Prone CPR compliant, and staff should gain the
skills of both standard and non standard resuscitation.
Whilst the effectiveness of CPR in the prone position is not completely
known, we have had to ensure that the skill of prone-CPR should be
given a consideration during a sudden cardiac arrest in COVID-19 victims
who are being prone-ventilated. We urge critical care and resuscitation
teams to choose manikins that are designed to accommodate Prone CPR
techniques. We ask our resuscitation colleagues to practice and test the
logistics required to safely perform CPR in this way.
Hamad Abdulla is a senior Resuscitation officer in the Bahrain Defence
Forces Hospital – Southern Bahrain
References
1. Siow WT, Liew MF, Shrestha BR, et al.(2020) Managing COVID-19 in resourcelimited
settings: critical care considerations. Crit Care. 2020;24:167.
2. McNeil E. (1989) Re-evaluation of cardiopulmonary resuscitation. Resuscitation.
1989;18:1–5.
3. Atkinson MC. (2000) The efficacy of cardiopulmonary resuscitation in the prone
position. Crit Care Resusc. 2000;2:188–90.
4. J. Brown, J. Rogers, J. Soar. (2001) Cardiac arrest during surgery and ventilation
in the prone position: a case report and systematic review. Resuscitation.
2001;50:233-238
5. Mędrzycka-Dąbrowska et al. Critical Care (2020) 24:258 https://doi.org/10.1186/
s13054-020-02970-y
6. Feix B, Sturgess J. (2014) Anaesthesia in the prone position. Contin Educ Anaesth
Crit Care Pain. 2014;14(6):291
7. Edelson et al.: Interim Guidance for Life Support for COVID-19 . (2020) Circulation
– American Heart Association
8. Kwon, Min-Ji BS*; Kim, Eun-Hee MD†; Song, In-Kyung MD†; Lee, Ji-Hyun
MD†; Kim, Hee-Soo MD, PhD†; Kim, Jin-Tae MD, PhD† (2017) Optimizing Prone
Cardiopulmonary Resuscitation: Identifying the Vertebral Level Correlating With
the Largest Left Ventricle Cross-Sectional Area via Computed Tomography Scan
Anaesthesia & Analgesia: February 2017 - Volume 124 - Issue 2 - p 520-523
9. Mazer SP, Weisfeldt M, Bai D, Cardinale C, Arora R, Ma C, Sciacca RR, Chong D
and Rabbani LE. (2003) Reverse CPR: a pilot study of CPR in the prone position.
Resuscitation. 2003;57:279-285.
Publisher’s Note
The techniques mentioned in this article and their content are published
for academic debate and do not constitute a guideline recommendation.
Photos Courtesy of www.lifecastbodysim.com #thisisamanikin
RESUSCITATION TODAY - SUMMER 2020
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FEATURE
MEET A FEW OF OUR GROWING FAMILY
REFLECTION ON NHS NIGHTINGALE
LONDON
by Dr Tim Collins EdD, MSc, BSc, PGCLT, RN, Colette Laws-Chapman Pg Dip Advanced Practice, RN RNT
& Louise Houslip BSc, RN
COVID-19 Extreme Education in Extreme
Circumstances! A reflection on NHS
Nightingale London
The impact of COVID-19 across the globe has been unprecedented
with extraordinary demands place upon healthcare professionals and
organisations. During this pandemic hospitals and clinicians have had
to adopt unique and innovative strategies to deal with the mass number
of patients requiring hospitalisation and critical care treatment. With
the initial scientific modelling suggesting that the UK would not have
For enough further information critical care capacity or to arrange for the ainflux demonstration, of COVID-19 please patients, contact: an what was achieved in terms of adapting an exhibition centre into a fully
Lifecast emergency Bodysurge Simulation planning Ltd, approach Workshop was taken 6, Elstree and the TV cancellation & Film Studios, London functional WD6 hospital 1JGwithin 9 days was truly remarkable and was testimony
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Enquiries: 01202 823 175 or 01202 8324 2376
hospital escalation plans, the Government instructed the construction of collaboration. Ironically the last time we had been to the Excel was to
E-mail: info@lifecastbodysim.com www.lifecastbodysim.com
temporary NHS Nightingale hospitals to add extra critical care capacity. attend the Intensive Care Society (ICS) State of the Art Congress. Never
The first of these hospitals was NHS Nightingale in London that was
constructed in the Excel London Exhibition Centre. The hospital
was announced on the 24th March 2020 but required considerable
construction and adaptation by engineers, construction workers and
the British Armed Forces. The hospital officially opened on the 3rd April
under the responsibility and governance of Barts Health NHS Trust and
took its first patients on the 7th April 2020. The hospitals initial capacity
was for 500 patients which could be expanded to take 4,000 patients,
which at full capacity would require in excess of 16,000 workforce to
staff and run the hospital what would be the largest hospital in the UK.
Regardless of any criticism that the NHS Nightingale was afforded,
in our dreams, whilst attending the ICS congress learning about the latest
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FEATURE
research in critical care would we have thought we would be returning to
support with the development of a new critical care hospital in the Excel.
our eyes demonstrates what is great about the NHS creating a team
with a common mission to unite for our patients and support the NHS!
Working as part of a multi-professional team, we were contributors to There were lots of challenges and successes on the way. Initially the
the NHS Nightingale London Education Faculty that was responsible education centre was set up in the Excel, but it soon became evident
for establishing and delivering education to support the orientation and that the large numbers of people requiring education and the layout
induction of the multi-professional clinical and volunteer workforce. out of the rooms meant it was extremely difficult to maintain social
The design of the education programme included the use of variety of distancing practices. This then led to the education facility being moved
delivery modalities including didactic, simulation, workshops, clinical south of the Thames to The 02 Arena. Similar to the Excel, we had all
skills stations, discussion groups and debriefing as well as bedside seen lots of iconic bands at The 02 and never thought we would be
clinical coaching and induction. The multi-professional faculty of sharing The 02 arena floor, following in the footsteps of some of the
educators consisting of 300 volunteer Doctors, Nurses, Allied Health greatest performers in the world but now it was our turn to put on a
Professionals and technical staff were from all areas of healthcare performance! The 02 arena provided sufficient space to allow social
and healthcare education, from trainee status to retired. In addition, distancing and was quickly established to allow up to 600 learners
we had expertise from NHS Learning & Development and Health to attend the Nightingale Education Induction day. The curriculum
Education England staff and other agencies. It was impressive but involved sessions relating to corporate & clinical induction, COVID-19
also reassuring at the same time, that the faculty had specific expertise Resuscitation, Simulation, Critical Care Clinical and patient care Skills,
from psychological and well-being practitioners who were able to Communication and Psychological PPE and well-being. Attendees
provide self-care support and well-being for both learners and faculty. were streamlined depending on their experience or anticipated role
The education faculty were supported by a core education team of 20 within critical care and then allocated to a curriculum pathway which
Education & HR leads and 400 volunteers from the Mayor of London’s was designed to meet their skill set and expertise. The groups were
Team London volunteers and NHS redeployed staff whom provided multi-professional that consisted of current critical care practitioners to
valuable support with co-ordination of groups, delegate registration and volunteers who may have no background or training in healthcare such
attendee pathways. On reflection, the mobilisation of this education as musicians and airline cabin crew.
faculty who had previously not worked together, that had to urgently
Moniventdesign, Ad - develop MDT/Lifecast and implement A4 June an education 2020 a..pdf:Layout curriculum within 51 days 12/6/20 is As a team 14:05 we were Page responsible 1 for designing and writing the simulation
testimony to their phenomenal teamwork, dedication and commitment. curriculum as part of the NHS Nightingale London induction curriculum.
We felt extremely proud and humbled to be part of this team which in We designed a suite of 10 simulation scenarios with lesson plans, which
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FEATURE
the faculty would use depending upon the experience of the group
and pathway they had been streamed into. The simulation lesson
plans focused upon clinical scenarios and non-technical skills. The
aim of the education was to prepare learners for anticipated COVID-19
emergencies through developing effective bedside problem-solving
skills whilst developing social and cognitive skills to enhance team
working and patient safety within the NHS Nightingale.
The clinical simulations focused specifically upon COVID-19 adaptions
to care which included emergency de-proning following ET tube
dislodgement, ventilation failure, COVID-19 Advanced Life Support
in breach of PPE, Inter-hospital transfer of a patient for ECMO and
deteriorating patient. For learners with no or limited critical care
experience, the modality of simulation was used to orientate them to
an invasive ventilated patient and equipment that is used within critical
care. The non-technical skills focused upon verbal and non-verbal
communication with focus on working with PPE insitu and providing
critical care in a large acoustically challenging exhibition hall that was not
originally constructed as a hospital. Other non-technical skills focused
upon leadership with emphasis placed on working with new team
members they were not familiar with or knowing their clinical expertise. All
learners were taught the principles of using a graded assertive escalation
approach, closed loop communication and the use of SBAR.
Providing simulation in The 02 arena provided social distancing and
multiple concurrent simulation opportunities but also challenges. We
had an extremely large space to provide simulation but the acoustics
in the arena were challenging, making it difficult to establish rapport
and to hear debriefs. The positive outcome of the Simulation area
transferring to The 02 was that we were able to replicate the design of
the Nightingale wards, an open critical care area in a noisy and large
exhibition hall, which allowed learners the opportunity to experience as
close to clinical reality as possible. Due to time restrictions, the decision
was made to use the plus/delta method of facilitating simulation debrief
as this provided a swift but outcome-based simulation debrief. This
debrief method was also chosen as we did not know in advance the
expertise of the faculty and this model allows novice and experts to
debrief to successful outcome. The faculty had to be skilled to adapt to
the individual needs of learners and we implemented a rapid learning
improvement cycle with daily faculty briefings to allow feedback and
improvements to be incorporated into the curriculum following learning
incidents from the hospital as well as learner evaluations.
RESUSCITATION TODAY - SUMMER 2020
The evaluation feedback from the learners was extremely positive with
comments from attendees indicating that the education was relevant and
pertinent for preparing them for their roles in the hospital. Overall in excess
of 2700 people went through the education programme, which was stood
down on 13th May 2020. Currently, the Nightingale is in hibernation but
if extra capacity is required due to an additional surge in COVID patients,
the hospital could be re-opened, and the education programme restarted
within short notice should the call to action be requested.
Being a part of this project was a huge personal learning journey for
us and we were privileged to witness what can be achieved within a
short time frame, with the commitment and dedication from a multiprofessional
team. We have to acknowledge all the NHS Nightingale
Education Faculty who all played their role in bringing this curriculum
together. We all certainly went on a learning journey together.
12

NEWS
Updated RCUK Statement on
PHE PPE Guidance:
RCUK recognises the statements made
by Public Health England (PHE) on 24
and 27 April on the issue of NERVTAG’s
consideration of chest compressions
as potential AGPs and the associated
guidance to NHS Trusts. NERVTAG’s
appraisal focuses purely on the theoretical
science of AGPs, without appropriate
consideration of the clinical realities of
conducting repeated chest compressions
as part of a resuscitation attempt.
RCUK’s principal focus throughout the
Covid-19 pandemic has been to balance the
potential for positive outcomes for patients
with safety for Health Care Professionals
(HCPs). RCUK guidance is in accordance
with international best practice issued by
organisations such as WHO, ILCOR, European
CDC and ERC. In the absence of high-quality
evidence to state that anything less than AGP
PPE is sufficient for healthcare professional
safety, Resuscitation Council UK maintains
its belief that AGP PPE provides the safest
level of protection when administering chest
compressions, CPR, and advanced airway
procedures in known or suspected COVID-19
patients. For this reason, we welcome the fact
that PHE’s guidance of 24 April now aligns with
that of RCUK, inasmuch as it allows Trusts to
opt for AGP levels of PPE if they consider this
appropriate to best ensure HCP safety.
We recommend that Trusts adopt this
approach, thereby seeking to ensure
appropriate protection for their staff. We would
also urge HCPs engaged in resuscitation
in Covid-19 circumstances to highlight this
aspect of the amended PHE guidance to their
Trusts, to best ensure their safety and that of
their colleagues and families.
Resuscitation Council UK
Statement on COVID-19
in relation to CPR and
resuscitation in acute
hospital settings
This statement is for healthcare
professionals who are performing CPR
in an acute hospital setting.
1. Purpose
1.1. Resuscitation Council UK has received
several enquiries concerning the risks
of COVID-19 during cardiopulmonary
resuscitation (CPR).
1.2. This statement provides specific guidance
for healthcare workers (HCWs) on CPR in
healthcare settings for patients with suspected
or confirmed COVID-19.
1.3. This supplements guidance available from
the Department of Health and Social Care
(DHSC) and Public Health England (PHE)
(https://www.gov.uk/government/collections/
wuhan-novel-coronavirus) as well as Public
Health Wales (https://phw.nhs.wales/news/
public-health-wales-statement-onnovelcoronavirus-outbreak/),
Health Protection
Scotland (HPS) (https://www.hps.scot.nhs.
uk/a-to-zof-topics/covid-19/) and Department
of Health Northern Ireland (DHNI) https://www.
healthni.gov.uk/coronavirus\, and may change
based on increasing experience in the care of
patients with COVID-19, as well as the effect of
the outbreak on health services. It is therefore
important to always check the latest guidance
on the DHSC/PHE/PHW/HPS/DHNI websites.
1.4. COVID-19 is thought to spread in a way
similar to seasonal influenza; from person-toperson
through close contact and droplets.
Standard principles of infection control and
droplet precautions are the main control
strategies and should be followed rigorously.
Aerosol transmission can also occur.
Attention to hand hygiene and containment
of respiratory secretions produced
by coughing and sneezing are the
cornerstones of effective infection control.
1.5. All HCWs managing those with suspected
or confirmed COVID-19 must follow local and
national guidance for infection control and the
use of PPE.
1.6. During CPR, there is always the potential
for rescuers to be exposed to bodily fluids,
and for procedures (e.g. tracheal intubation or
ventilation) to generate an infectious aerosol.
Individual healthcare organisations should
carry out local risk assessments, based on the
latest guidance from the DHSC/PHE regarding
PPE for HCWs to develop local guidance.
1.7. Resuscitation team members must be
trained to put on/remove PPE safely (including
respirator-fit testing) and to avoid selfcontamination.
Click here for further advice on
PPE from the DHSC.
2. Guidance on CPR in patients with a
COVID-19 like illness or a confirmed case of
COVID-19 in acute hospital settings.
2.1. Patients with a COVID-19 like illness, who
are at risk of acute deterioration or cardiac
arrest, should be identified early. Appropriate
steps to prevent cardiac arrest and avoid
unprotected CPR should be taken. Use of
physiological track-and-trigger systems (e.g.
NEWS2) will enable early detection of acutely
ill patients. Patients for whom a ‘do not attempt
cardiopulmonary resuscitation’ (DNACPR)
and/or other similar decision is appropriate
should also be identified early.
2.2. The locally/nationally agreed minimum
level of PPE must be used to assess a patient,
start chest compressions and establish
monitoring of the cardiac arrest rhythm. For
more information, please view our infographic
on the resuscitation of COVID-19 patients in
hospital: https://www.resus.org.uk/_resources/
assets/attachment/full/0/36100.pdf
2.3. The need to don PPE may delay CPR
in patients with COVID-19. Review of the
processes involved (including the availability of
Aerosol Generating Procedure (AGP) PPE kits
on resuscitation trolleys), along with training
and practice, will minimise these delays.
Staff safety is paramount. In a cardiac arrest
of presumed hypoxic aetiology (including
paediatric events), early ventilation with oxygen
is usually advised. Any airway intervention
performed without the correct PPE protection
will subject the rescuer to a significant risk of
infection. Consequently, we recommend even
in presumed hypoxic arrest starting with chest
compressions.
2.4. Recognise cardiac arrest. Look for the
absence of signs of life and normal breathing.
Feel for a carotid pulse if trained to do so. Do
not listen or feel for breathing by placing your
ear and cheek close to the patient’s mouth.
When calling 2222, state the risk of COVID-19.
2.5. If a defibrillator is readily available defibrillate
shockable rhythms rapidly prior to starting chest
compressions. The early restoration of circulation
may prevent the need for further resuscitation
measures. Local guidance must be followed
about equipment entering the area.
RESUSCITATION TODAY - SUMMER 2020
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NEWS
RESUSCITATION TODAY - SUMMER 2020
2.6. Full Aerosol Generating Procedure (AGP)
Personal Protective Equipment (PPE) must
be worn by all members of the resuscitation/
emergency team before entering the room.
Sets of AGP PPE must be readily available
where resuscitation equipment is being locally
stored. No chest compressions or airway
procedures such as those detailed below
should be undertaken without full AGP PPE.
Once suitably clothed, start compressiononly
CPR and monitor the patient’s cardiac
arrest rhythm as soon as possible. Do not do
mouth-tomouth ventilation or use a pocket
mask. If the patient is already receiving
supplemental oxygen therapy using a face
mask, leave the mask on the patient’s face
during chest compressions as this may
limit aerosol spread. If not in situ, but one is
readily available, put a simple oxygen mask
on the patient’s face. Restrict the number of
staff in the room (if a single room). Allocate a
gatekeeper to do this.
2.7. Airway interventions (e.g. supraglottic
airway (SGA) insertion or tracheal intubation)
must be carried out by experienced
individuals. Individuals should use only the
airway skills (e.g. bag-mask ventilation) for
which they have received training. For many
HCWs this will mean two-person bagmask
techniques with the use of an oropharyngeal
airway. Tracheal intubation or SGA insertion
must only be attempted by individuals who
are experienced and competent in this
procedure.
2.8. Identify and treat any reversible causes
(e.g. severe hypoxaemia) before considering
stopping CPR. Discussion should be
maintained throughout the resuscitation event
and early planning of the post resuscitation
phase undertaken. Contact senior help and
gain advice from critical care partners as part
of the planning.
2.9. Dispose of, or clean, all equipment used
during CPR following the manufacturer’s
recommendations and local guidelines. Any
work surfaces used for airway/resuscitation
equipment will also need to be cleaned
according to local guidelines. Specifically,
ensure equipment used in airway interventions
(e.g. laryngoscopes, face masks) is not left
lying on the patient’s pillow, but is instead
placed in a tray. Do not leave the Yankauer
sucker placed under the patient’s pillow;
instead, put the contaminated end of the
Yankauer inside a disposable glove.
2.10. Remove PPE safely to avoid selfcontamination
and dispose of clinical
waste bags as per local guidelines. Hand
hygiene has an important role in decreasing
transmission. Thoroughly wash hands with
soap and water; alternatively, alcohol hand rub
is also effective.
2.11. Post resuscitation debrief is important
and should be planned.
Paediatric advice
We are aware that paediatric cardiac arrest is
unlikely to be caused by a cardiac problem
and is more likely to be a respiratory one,
making ventilations crucial to the child’s
chances of survival. However, for those not
trained in paediatric resuscitation, the most
important thing is to act quickly to ensure
the child gets the treatment they need in the
critical situation.
The Resuscitation Council UK Statement on
COVID-19 in relation to CPR and resuscitation
in healthcare settings advice for in-hospital
cardiac arrest is relevant to all ages. Mouth to
mouth ventilations should not be necessary
as equipment is available for bag-mask
ventilation/intubation and must be immediately
available for any child/infant at risk of
deterioration/cardiac arrest in the hospital
setting.
Resuscitation Council UK
statement on COVID – 19 in
relation to non-acute hospital
settings
This statement is for healthcare workers
(HCWs) who are performing CPR in nonacute
hospital settings.
These include, but are not limited to,
community hospitals, mental health, learning
disability and autism in- patient settings, or
alternatively could be described as categories
4 – 8 in the most recent hospital census1.
Each hospital should review the level of care
they can provide, and the response provided
in order to decide if this is the level of guidance
required for their staff.
1. Purpose
1.1. COVID-19 is thought to spread in a way
similar to seasonal influenza; from person-toperson
through close contact and droplets.
Standard principles of infection control and
droplet precautions are the main control
strategies and should be followed rigorously.
Aerosol transmission can also occur.
Attention to hand hygiene and containment of
respiratory secretions produced by coughing
and sneezing are the cornerstones of effective
infection control.
1.2. All HCWs managing those with suspected
or confirmed COVID-19 must follow local and
national guidance for infection control and the
use of PPE.
1.3. During CPR, there is always the potential
for rescuers to be exposed to bodily fluids,
and for procedures (e.g. chest compressions,
tracheal intubation or ventilation) to generate
an infectious aerosol or droplets. Individual
healthcare organisations should carry out
local risk assessments, based on the latest
guidance from RCUK/DHSC/PHE regarding
PPE for HCWs to develop local guidance.
1.4. Resuscitation team members must be
trained to put on/remove PPE safely (including
respirator fit testing where appropriate) and to
avoid self-contamination. For more information
-https://www.gov.uk/government/publications/
covid-19-personal-protective-equipment-useforaerosol-generating-procedures
2. Guidance on CPR in patients with a
COVID-19 like illness or a confirmed case of
COVID-19 in nonacute hospital settings
2.1 Resuscitation is an invasive medical
procedure and should only be provided after
careful consideration with the patient of the
benefits and burdens provided by resuscitation.
These discussions should be compliant with
mental capacity act and may require the
involvement of a Lasting Power of Attorney.
Conversations and treatment escalation planning
must be a priority. Where appropriate patients
should have an individual emergency care
treatment plan which includes recommendations
for the appropriateness of cardiopulmonary
resuscitation. If appropriate, ensure “do
not attempt cardiopulmonary resuscitation”
(DNACPR) decisions are well documented and
communicated.
2.2 Staff should follow PPE guidance for HCWs
while delivering care within 2 metres (minimum
fluid resistant surgical mask, gloves, apron, eye
protection). This will provide protection for droplet
transmission and contamination from surfaces.
14

NEWS
2.3 The non-acute hospital setting must source
and stock Level 3 PPE equipment (disposable
gloves, disposable gown, filtering face piece
(FFP3) respirator, disposable eye protection)
for use in a cardiac arrest if such an event is
likely to occur. Staff must be trained in its use
and the equipment stored with resuscitation
equipment so that it is easily accessible at the
time of need.
2.4 Identify as early as possible any patients
who are at risk of acute deterioration or
cardiac arrest. Take appropriate steps to
prevent cardiac arrest and avoid unprotected
CPR. Use of physiological track-and-trigger
systems (e.g. NEWS2) will enable early
detection of acutely ill patients. For those for
whom resuscitation would be inappropriate,
decisions must be made and communicated.
Consider discussion with acute hospitals
on the need to transfer the patient for acute/
advanced medical care.
2.5 In a situation when a patient is
unresponsive, it is important to minimise the
risk of droplet transmission.
Assessment includes –
• Look for the absence of signs of life and
normal breathing. Do not listen or feel for
breathing by placing your ear and cheek
close to the patient’s mouth
• Feel for a carotid pulse if trained to do so
• Shout for help early so helpers can start to
don Level 3 PPE if needed
• If a patient is unresponsive and not
breathing normally, call the resuscitation
team (if available) and/or the ambulance
service in accordance with local protocols
• When calling, state the risk of COVID-19.
2.6 Whilst awaiting helpers to don Level 3 PPE,
the rescuer should attach a defibrillator to
assess the initial rhythm and administer up to 3
shocks if an initial shockable rhythm is present,
as early defibrillation has a high chance of
success. If using a manual defibrillator, deliver
up to 3 shocks, as indicated. If using an AED,
administer shocks as guided by the AED. Early
defibrillation for a shockable cardiac arrest
gives the best chance of survival.
2.7 Do not deliver chest compression or
ventilation unless wearing Level 3 PPE (FFP3
mask, eye /face protection, fluid-resistant
long-sleeved gown, gloves). These are
considered an aerosol generating procedure
which requires Level 3 PPE for all those in the
immediate vicinity of the resuscitation attempt.
2.8 In some hospitals, HCWs will have
additional airway management skills and will
be able to take over CPR as soon as their
PPE Level 3 is donned. In other trusts, this
Advanced Life Support (ALS) response will
be provided via the ambulance service, or
resuscitation team. Every non-acute hospital
as defined above with HCWs that have
additional airway management training or any
form of on-site resuscitation team must ensure
via risk assessment the appropriate amount
of Level 3 PPE is available and accessible on
site.
2.9 As soon as helpers in level 3 PPE arrive,
the first rescuer must withdraw to a safe
distance of over 2 metres.
2.10 For cardiac arrest due to ligature, it is
imperative that the ligature is removed as soon
as safely possible. Hospitals with patients at
high risk of such a situation should ensure that
they have staff trained to provide emergency
ventilation (e.g. delivery of assisted ventilation
with a bag-valvemask), as well as an adequate
supply of level 3 PPE to facilitate this response
safely. Due to the potential hypoxic nature of
the cardiac arrest, it is particularly important
that the advanced life support team is called
as soon as possible.
3. Post event considerations
3.1 Follow PHE hygiene guidance for safely
removing PPE. Remove PPE safely to avoid
self contamination and dispose of clinical
waste bags as per local guidelines. Hand
hygiene has an important role in decreasing
transmission. Thoroughly wash hands with
soap and water; alternatively, alcohol hand rub
is also effective.
3.2 Dispose of, or clean, all equipment used
during CPR following the manufacturer’s
recommendations and local guidelines. Any
work surfaces used for airway/resuscitation
equipment will also need to be cleaned
according to local guidelines. Specifically,
ensure equipment used in airway interventions
(e.g. laryngoscopes, face masks) is not left
lying on the patient’s pillow but is instead
placed in a tray. Do not leave the Yankauer
sucker placed under the patient’s pillow;
instead, put the contaminated end of the
Yankauer inside a disposable glove. 3.3 Team
debrief at the end of the resuscitation attempt.
Additional information
This supplements guidance available from
the Department of Health and Social Care
(DHSC) and Public Health England (PHE) as
well as Public Health Wales, Health Protection
Scotland (HPS) and Department of Health
Northern Ireland (DHNI), and may change
based on increasing experience in the care of
patients with COVID-19, as well as the effect of
the outbreak on health services. It is therefore
important to always check the latest guidance
on the DHSC/PHE/PHW/HPS/DHNI websites.
1
The most recent hospital census lists the
following healthcare categories -
1. General acute hospital
2. Specialist hospital (acute only)
3. Mixed service hospital
4. Mental Health (including Specialist services)
5. Learning Disabilities
6. Mental Health and Learning Disabilities
7. Community hospital (with inpatient beds)
8. Other inpatient
9. Other Reportable Site
Resuscitation Council UK
Statement on COVID-19
in relation to CPR and
resuscitation for those
teaching resuscitation
techniques
This statement is for anyone who is
teaching CPR/defibrillation among other
resuscitation techniques.
1. Purpose
1.1. Resuscitation Council UK has received
several enquiries concerning the risks
of COVID-19 during cardiopulmonary
resuscitation (CPR).
1.2. This supplements guidance available from
the Department of Health and Social Care (DHSC)
and Public Health England (PHE) (https://www.
gov.uk/government/collections/wuhan-novelcoronavirus)
as well as Public Health Wales
(https://phw.nhs.wales/news/public-health-walesstatement-on-novel-coronavirus-outbreak/),
Health
Protection Scotland (HPS) (https://www.hps.scot.
nhs.uk/a-to-z-of-topics/covid-19/) and Department
RESUSCITATION TODAY - SUMMER 2020
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15

NEWS
RESUSCITATION TODAY - SUMMER 2020
of Health Northern Ireland (DHNI) https://www.
health-ni.gov.uk/coronavirus\, and may change
based on increasing experience in the care of
patients with COVID-19, as well as the effect of
the outbreak on health services. It is therefore
important to always check the latest guidance
on the DHSC/PHE/PHW/HPS/DHNI websites.
1.3 COVID-19 is thought to spread in a way
similar to seasonal influenza; from person-toperson
through close contact and droplets.
Standard principles of infection control and
droplet precautions are the main control
strategies and should be followed rigorously.
Aerosol transmission can also occur.
Attention to hand hygiene and containment
of respiratory secretions produced
by coughing and sneezing are the
cornerstones of effective infection control.
2. Guidance for all Training settings
2.1 The main infection risk in a classroom
full of learners is contact with other people
and/or surfaces rather than the manikin
itself. Learners always need to observe a
high standard of handwashing, with alcohol
gel (or wipes if gel unavailable) provided in
addition to handwashing facilities.
2.2 Learners should be reminded to cough/
sneeze into a tissue and dispose of this
into a bin immediately, washing hands
afterwards. Alternatively, coughing/sneezing
into the bent elbow if no tissue available.
2.3 Where individuals are exhibiting symptoms
typical of flu, a cold or have been in close
contact with someone who has the COVID-19
infection then they should exclude themselves
from the course. Likewise if an individual
has travelled to/from the countries/regions
as listed in https://www.gov.uk/government/
publications/covid-19-specified-countries-andareas/covid-19-specified-countries-and-areaswith-implications-for-returning-travellers-orvisitors-arriving-in-the-uk
they should act on
the advice dependent on whether they were a
category 1 or 2 traveller.
3. Actions to take when taking a training
session
3.1 If teaching CPR only sessions, (not
formal First Aid courses) we would suggest
teaching compression only CPR. If COVID-19
is suspected, the rescuer should alert the
ambulance service when calling 999.
3.2 If teaching basic CPR in hospital,
teach compression only CPR until help and
ventilation equipment arrives. If appropriate,
training in bag-mask ventilation techniques
can take place.
3.3 Wipe the chest, forehead and face of
the manikin using disinfectant/alcohol wipes
between learners and allow the surface to
dry naturally before the next learner takes
their turn.
4. If teaching formal First Aid courses
which require assessment of rescue
breaths
4.1 Replace and dispose of manikin lungs
and airways after each training session
4.2 Wipe the face of the manikin with 70%
alcohol wipes after each learner uses it and
allow the surface to dry naturally before the
next learner takes their turn
4.3 Students may use individual face
shields if they so wish and they should
be disposed of safely at the end of the
session. The manikin chest, forehead
and face can still be wiped to reduce the
likelihood of hand to hand contamination.
4.4 Where appropriate, learners can use a
pocket mask for ventilation practice which
must be fully cleaned or discarded after the
session (one - way valves may be removed.
If kept in place, it must be discarded at the
end of the session). If using pocket masks,
these must be for individual use only.
4.5 General infection control measures
must be observed, and where appropriate,
the learner can be given their own manikin
or can practice rescue breaths last in the
group. If the course runs over a number of
days, it may be possible that once the skill
has been assessed as satisfactory, they
do not need to demonstrate this during the
remainder of the course.
4.6 Clean manikin heads with an
appropriate surfactant/disinfectant solution
after completion of each training session.
5. Teaching rescue breaths/mouth-tomouth
ventilations
5.1 RCUK guidelines 2015 state - “If you
are untrained or unable to do rescue
breaths, give chest compression only CPR
(i.e. continuous compressions at a rate of at
least 100–120 min-1)”
5.2 Compression only CPR is much better
than no CPR
5.3 We are aware that paediatric cardiac
arrest is unlikely to be caused by a
cardiac problem and is more likely to be
a respiratory one, making ventilations
crucial to the child’s chances of survival.
However, for those not specifically trained in
paediatric resuscitation, the most important
thing is to act quickly to ensure the child
gets the treatment they need in the critical
situation.
6. RCUK Course Centres
6.1 We are aware of a number of issues
that might impact on our Course Centres.
This includes, not exclusively, the impact of
COVID-19 on the service provision, faculty
having to pull out of the programme either
for service or personal health reasons and
resuscitation department members having
to divert expertise to the clinical area.
6.2 For advice on a specific course, please
call the RCUK office and speak to one
of the Course Managers. Outside hours,
please send your question via the ticketing
system, marking the enquiry urgent and
putting Courses/COVID-19 into the subject
heading. We will be able to talk about
course cancellation and the rescheduling of
courses on an individual basis.
6.3 We would advise Centres to ask that
Candidates who have symptoms of cough,
cold and/or temperature prior to the course,
or have been in contact with a potentially
infected person, to exclude themselves
from the course and that the Centre looks
favourably on allowing them to transfer their
place to a later date.
6.4 If a candidate who has attended a
course subsequently finds they have
symptoms, they should let the Course
Centre know. The Course Centre should
alert all other Candidates to the situation
and local Trust management.
4 March 2020
16

COMPANY NEWS
Certification gives Monivent
the right to CE-mark
Monivent Neo100
Monivent, which develops, manufactures
and sells medical technology products
with the aim of improving the emergency
care provided to newborn children in need
of respiratory support at birth, announces
that the company’s notified body RISE has
issued EC certificate for Monivent Neo100.
The certification gives the company the
right to CE-mark the product, which is
required to sell Monivent Neo100 on the
European market.
Monivent Neo100 is a non-invasive monitoring
device measuring the airflow given to the baby.
Instant feedback throughout the ventilation
enables the caregiver to make simple
adjustments to ensure a better treatment within
recommended guidelines. Monivent Neo100
is an add-on to existing manual ventilation
equipment and comprises of sharp technical
solutions, simple interfaces and wireless data
transfer for maximum ease of use and minimal
impact on current practices. Monivent guides
and supports the caregiver during manual
ventilation of newborns to ensure a safe and
gentle resuscitation with reduced risk of injury.
Monivent is a young MedTech start-up based
in Gothenburg, Sweden. Monivent aim to
increase patient safety for newborn babies
requiring help to start breathing at birth. 3-6%
of all newborns require manual ventilation at
birth, when air is manually forced down the
baby’s lungs using different manual ventilation
equipment. Sub-optimal treatment, using too
little or too much air, may cause brain damage
or chronic lung injury. Yet there are no good
tools available to ensure that an effective but
still gentle treatment is given.
MDT Global Solutions LTD.
appointed as exclusive UK &
Ireland distribution partner
for Archeon Medical
The agreement covers the distribution
of their innovative EOlife ® Ventilation
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breath to breath monitoring of ventilations
to ensure that safe, effective & consistent
volumes are delivered to patients
requiring emergency ventilatory support.
The ground-breaking EOlife device can
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For further details, please contact us:
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Resuscitation Today
Volume 7 No. 1
Summer 2020
Resuscitation Today
A Resource for all involved in the Teaching and Practice of Resuscitation
We trust you have enjoyed reading the
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will equally be of interest.
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RESUSCITATION TODAY - SUMMER 2020
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17