Aerosol Generating Medical Procedures

Airborne transmission is possible when AGMPs are performed. AGMPs include advanced airway insertion, bag-valve-mask (BVM) ventilations, chest compressions, open airway suctioning and tracheostomy care, nebulized treatments, and noninvasive positive pressure ventilation. These procedures should be avoided, unless absolutely necessary.^{9,Reference Murthy, Gomersall and Fowler13} Paramedics should consider alternatives, such as a metered-dose inhaler or parenteral administration of medications (e.g., intramuscular epinephrine), or withholding care in less severe cases.

Cardiac arrest

When providing ventilations by means of BVM, paramedics should use a two-handed approach (one person holding the mask and another squeezing the bag) to ensure a good seal is being maintained.⁹ In general, two-handed BVM should not lead to exposure of additional paramedics.

Early placement of an advanced airway should be considered. The risk of exposure during intubation may be minimized by using the most experienced and skilled paramedic, video laryngoscopy, a bougie, and pausing chest compressions. This will provide more protection to responders as postintubation ventilation (with appropriate filter and airway cuff pressure) can limit exposure to secretions.^{Reference Murthy, Gomersall and Fowler13}

Supraglottic airways (SGAs) may offer an alternative to endotracheal intubation, which may limit exposure during placement. It is not known if SGAs reduce exposure or provide the same level of protection as intubation, but these devices should be considered when a good mask seal with BVM is difficult to achieve (e.g., transportation).

Figure 1. What Paramedics Need to Know infographic.

There is no evidence on outcomes or specific interventions for out-of-hospital cardiac arrests related to COVID-19. Even though patients may have COVID-19, it is important to consider other pathologies of cardiac arrest. Keep a broad differential diagnosis! Paramedics should initiate resuscitation as per standard practice, and use previously validated termination of resuscitation (TOR) rules to limit transportation of nonviable patients. Application of a TOR rule will limit the time of exposure and avoid transfer of futile patients to hospital. In the event of a prolonged surge event that limits intensive care unit (ICU) bed availability, anticipate changes in your protocols that may limit the conditions under which you initiate resuscitation.

Hypoxemia

Paramedics should consider slowly titrating supplemental oxygen flow rates to achieve an oxygen saturation of >94%. Then once stable, target an SpO2 of 90%.^{9,Reference Murthy, Gomersall and Fowler13} Oxygen flow rates >5–6 L/min are considered aerosol generating and the patient should be switched to a high concentration/low flow mask with an exhalation filter.

Intranasal medications

Paramedics should use alternative routes of administration (eg.,. intravenous, intramuscular, or subcutaneous) for medication administration. For opioid emergencies, if other routes are not accessible, intranasal naloxone should be prioritized over BVM ventilations. If administered appropriately, the risk for transmission is low, as it produces large droplets which fall into the nasopharynx rather than forming aerosol suspension in the air.

ST-elevation myocardial infarction

All ST-elevation myocardial infarction (STEMI) patients should be screened for COVID-19. Patients should be transported to the designated percutaneous coronary intervention (PCI) center regardless of COVID-19 status, pending discussion with the interventional cardiologist. The receiving center should be notified early for all positive patients to ensure staff are adequately prepared. Systems should attempt to minimize “false positive” STEMI activations. Patients may be redirected to the emergency department first, as COVID-19 has been associated with myocarditis, which may mimic STEMI on electrocardiogram. Finally, should the PCI lab and medical system become overwhelmed, consideration of thrombolytic therapy may occur in some areas.^{Reference Wood, Sathananthan and Gin14}

Long-term care setting

Paramedics should wear PPE for all calls into long-term care (LTC) settings regardless of the patient's complaint. Patients in LTC settings can have atypical symptoms of COVID-19 infection or be asymptomatic.^{Reference Kimball, Hatfield and Arons15} It is important to consider that staff can also be contagious.

Patients should only be transported to hospital when there is a need for a higher level of care than what the LTC setting can provide, not for the purpose of COVID-19 testing. Facilities should contact their local public health unit for guidance or consider using community paramedics to perform testing.^{Reference Glauser16}

Patients with mild symptoms should not be transported to hospital. However, this can be problematic if patients require isolation or a negative pressure room. If unsure, paramedics should contact online medical control for advice. Whether or not to transport more severely ill patients depends on local ICU capacity and COVID-19 disease activity. These decisions should be discussed at a local level. Transport and treatment decisions should be patient-centered and focused around goals of care. Ensure you have the most up-to-date version of the patients’ advanced directives, as their wishes might have changed with the pandemic.^{Reference Curtis, Kross and Stapleton17} Paramedics should consider the patient's and/or substitute decision-makers request not to transport the patient to hospital.

Arrival and transfer of care at hospital

Paramedics should prenotify all receiving hospitals if a patient is suspected of having COVID-19. Resuscitation and other treatment should be continued in the ambulance until directed by receiving staff. Paramedics must be mindful when passing other stretcher patients, colleagues, and other health care providers who are not wearing PPE. Only providers with appropriate PPE should maneuver the stretcher.

While moving a patient between the ambulance and the resuscitation room, steps must be taken to minimize or eliminate aerosol and respiratory droplets. The patient can continue to receive supplemental oxygen and chest compressions, but manual ventilations should be withheld unless the patient has been intubated.

After the call, paramedics should remove their PPE in a designated area under observation of a trained observer. This ensures that proper procedures are being followed to limit any cross-contamination.