COVID-19-associated cardiac arrest: Difference between revisions

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__NOTOC__
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{{COVID-19}}
{{SI}}
{{Main|COVID-19}}
'''For COVID-19 frequently asked inpatient questions, click [[COVID-19 frequently asked inpatient questions|here]]'''<br>
'''For COVID-19 frequently asked inpatient questions, click [[COVID-19 frequently asked inpatient questions|here]]'''<br>
'''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]'''<br>
'''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]'''<br>
{{SI}}
{{SI}}


{{CMG}}; {{AE}} {{AyeshaFJ}}
{{CMG}}; {{AE}} [[User:Sara Zand|Sara Zand, M.D.]] {{AyeshaFJ}}


{{SK}} Cardiac arrest, In-hospital cardiac arrest, IHCA, Out-of-hospital cardiac arrest, OHCA, Covid-19, SARS-COV-2, Ventricular arrhythmia, pulseless electrical activity, Asystole, Return Of Spontaneouse Circulation, ROSC
==Overview==
==Overview==
[[SARS-COV2]] which causes [[coronavirus disease 2019]] ([[covid-19]]) led to global [[pandemic]] on March 11, 2020, is an enveloped B-[[coronavirus]] transmitted via [[respiratory]] droplets, attached via viral [[spike protein]] to [[angiotensin-converting enzyme 2 receptor]] ([[ACE2 receptor]]) causing [[clinical asyndrome]] of [[coronavirus disease 2019]]. Severe [[covid-19]] may progress to develope [[acute respiratory distress syndrome]], [[cardiovascular]] [[complications]], [[shock]], and [[death]]. [[Cardiac arrest]] is  often unexpected  and acute event may present in every hospitalized [[patient]]. Abnormal [[vital signs]] can be the predictos of [[in-hospital cardiac arrest]]. During the outbreak of [[covid-19]], there were increase reports of [[in-hospital]] [[cardiac arrest]] ([[IHCA]]), [[out-of hospital]] [[cardiac arrest]] ([[OHCA]]), lower rate of successful [[cardiopulmonary resuscitation]] ([[CPR]]), and increased [[mortality]]. 30-days [[mortality]] in [[covid-19]] [[patients]] was increased 3.4 fold in [[OHCA]] and 2.3 fold in [[IHCA]] compared with pre-pandemic period. [[survival]] of [[in-hospital]] [[cardiac arrest]] was poor. Factors related to restricted or delay access to emergency care, late presentation of [[ACS]] or [[heart failure]] in hospital, avoidance of witness [[CPR]] in public due to fear contracting [[covid-19]], as well as the side effects of [[drugs]] and [[thrombotic]] [[complications]] related to [[covid-19]] led to higher [[incidence]] of [[cardiac arrest]] during [[covid-19]] pandemic.


===Out-of-hospital cardiac arrest and Sudden Cardiac Death===
==Historical Perspective==
The [[sudden cardiac death]] is [[defined]] as the [[death]] that occurs within one hour of [[onset]] of [[symptoms]] in [[witnessed]] [[cases]] and within 24 hours of last being seen alive when it is [[unwitnessed]]. [[Out-of-hospital]] [[cardiac arrest]] means [[cessation]] of [[cardiac]] [[mechanical]] [[activity]] that occurs outside of the [[hospital]] setting and is confirmed by the absence of [[signs]] of [[circulation]].
* In December 2019, the [[COVID-19]] outbreak first appeared in China, Wuhan.<ref name="LiuKuo2020">{{cite journal|last1=Liu|first1=Yen-Chin|last2=Kuo|first2=Rei-Lin|last3=Shih|first3=Shin-Ru|title=COVID-19: The first documented coronavirus pandemic in history|journal=Biomedical Journal|year=2020|issn=23194170|doi=10.1016/j.bj.2020.04.007}}</ref>
*In January 2020, the first [[COVID-19]] case was documented in the United States.<ref name="SayreBarnard2020">{{cite journal|last1=Sayre|first1=Michael R.|last2=Barnard|first2=Leslie M.|last3=Counts|first3=Catherine R.|last4=Drucker|first4=Christopher J.|last5=Kudenchuk|first5=Peter J.|last6=Rea|first6=Thomas D.|last7=Eisenberg|first7=Mickey S.|title=Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR|journal=Circulation|year=2020|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.120.048951}}</ref>
* On February 20, 2020, the first case of [[COVID-19]] was documented in the Province of Lodi in Italy.<ref name="BaldiSechi2020">{{cite journal|last1=Baldi|first1=Enrico|last2=Sechi|first2=Giuseppe M.|last3=Mare|first3=Claudio|last4=Canevari|first4=Fabrizio|last5=Brancaglione|first5=Antonella|last6=Primi|first6=Roberto|last7=Klersy|first7=Catherine|last8=Palo|first8=Alessandra|last9=Contri|first9=Enrico|last10=Ronchi|first10=Vincenza|last11=Beretta|first11=Giorgio|last12=Reali|first12=Francesca|last13=Parogni|first13=Pierpaolo|last14=Facchin|first14=Fabio|last15=Bua|first15=Davide|last16=Rizzi|first16=Ugo|last17=Bussi|first17=Daniele|last18=Ruggeri|first18=Simone|last19=Oltrona Visconti|first19=Luigi|last20=Savastano|first20=Simone|title=Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy|journal=New England Journal of Medicine|year=2020|issn=0028-4793|doi=10.1056/NEJMc2010418}}</ref>
* In April 2020, an increase of [[out-of-hospital cardiac arrest]] was reported during the [[COVID-19]] pandemic in Italy by Dr.Enrico Baldi.<ref name="pmid32348640">{{cite journal |vauthors=Baldi E, Sechi GM, Mare C, Canevari F, Brancaglione A, Primi R, Klersy C, Palo A, Contri E, Ronchi V, Beretta G, Reali F, Parogni P, Facchin F, Bua D, Rizzi U, Bussi D, Ruggeri S, Oltrona Visconti L, Savastano S |title=Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy |journal=N Engl J Med |volume=383 |issue=5 |pages=496–498 |date=July 2020 |pmid=32348640 |pmc=7204428 |doi=10.1056/NEJMc2010418 |url=}}</ref>


==Historical Perspective==
* In December 2019, the COVID-19 outbreak first appeared in China, Wuhan.<ref name="LiuKuo2020">{{cite journal|last1=Liu|first1=Yen-Chin|last2=Kuo|first2=Rei-Lin|last3=Shih|first3=Shin-Ru|title=COVID-19: The first documented coronavirus pandemic in history|journal=Biomedical Journal|year=2020|issn=23194170|doi=10.1016/j.bj.2020.04.007}}</ref>
* On February 20, 2020, the first case of COVID-19 was documented in Lodi Province of Italy.<ref name="BaldiSechi2020">{{cite journal|last1=Baldi|first1=Enrico|last2=Sechi|first2=Giuseppe M.|last3=Mare|first3=Claudio|last4=Canevari|first4=Fabrizio|last5=Brancaglione|first5=Antonella|last6=Primi|first6=Roberto|last7=Klersy|first7=Catherine|last8=Palo|first8=Alessandra|last9=Contri|first9=Enrico|last10=Ronchi|first10=Vincenza|last11=Beretta|first11=Giorgio|last12=Reali|first12=Francesca|last13=Parogni|first13=Pierpaolo|last14=Facchin|first14=Fabio|last15=Bua|first15=Davide|last16=Rizzi|first16=Ugo|last17=Bussi|first17=Daniele|last18=Ruggeri|first18=Simone|last19=Oltrona Visconti|first19=Luigi|last20=Savastano|first20=Simone|title=Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy|journal=New England Journal of Medicine|year=2020|issn=0028-4793|doi=10.1056/NEJMc2010418}}</ref>
* In April 2020, An increase in out of hospital cardiac arrest was reported during the COVID-19 pandemy.
==Classification==
==Classification==
There is no established system for the classification of COVID-19-associated cardiac arrest.
[[Cardiac arrest]] associated with [[COVID-19]] may be classified into three subtypes:<ref name="HayekBrenner2020">{{cite journal|last1=Hayek|first1=Salim S|last2=Brenner|first2=Samantha K|last3=Azam|first3=Tariq U|last4=Shadid|first4=Husam R|last5=Anderson|first5=Elizabeth|last6=Berlin|first6=Hanna|last7=Pan|first7=Michael|last8=Meloche|first8=Chelsea|last9=Feroz|first9=Rafey|last10=O’Hayer|first10=Patrick|last11=Kaakati|first11=Rayan|last12=Bitar|first12=Abbas|last13=Padalia|first13=Kishan|last14=Perry|first14=Daniel|last15=Blakely|first15=Pennelope|last16=Gupta|first16=Shruti|last17=Shaefi|first17=Shahzad|last18=Srivastava|first18=Anand|last19=Charytan|first19=David M|last20=Bansal|first20=Anip|last21=Mallappallil|first21=Mary|last22=Melamed|first22=Michal L|last23=Shehata|first23=Alexandre M|last24=Sunderram|first24=Jag|last25=Mathews|first25=Kusum S|last26=Sutherland|first26=Anne K|last27=Nallamothu|first27=Brahmajee K|last28=Leaf|first28=David E|title=In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study|journal=BMJ|year=2020|pages=m3513|issn=1756-1833|doi=10.1136/bmj.m3513}}</ref>
==Pathophysiology==
'''Drug induced'''
 
* Since the [[COVID-19]] [[pandemic]], several [[pharmacological]] [[therapies]] have been proposed, one of them is of two [[anti-malarial]] and [[antirheumatic]] drugs called [[Chloroquine]] or [[Hydroxychloroquine]].
* Due to their cost-effectiveness and easy availability, there is a surge in the use of [[Chloroquine]] and [[Hydroxychloroquine]], with or without [[Azithromycin]]. The [[clinical trials]] in order to estimate their [[efficacy]] are still in the preliminary stage, however, a notable concern is of their [[cardiac]] [[adverse effects]].
* This includes [[QT prolongation]] and [[Torsade de pointes]] (TdP) leading to [[sudden cardiac death]].
* The risk is there when these drugs are prescribed separately, however it increases several folds when these drugs are administered together, especially in patients with underlying [[hepatic]] [[disease]] or [[renal failure]].
 
'''Genetic susceptibility:'''
 
* [[Epidemiological]] studies have shown that [[African Americans]] have higher [[COVID-19]] associated [[morbidity]] and [[mortality]] as compared to people from other [[ethnic]] groups.
* Recent [[studies]] show that this [[ethnic]] [[predilection]] is due to the [[genetic]] [[factors]] which contribute to a common [[ion channel]] [[variant]] [[p.Ser1103Tyr-SCN5A]] which confer an increased [[risk]] of [[drug-induced]] [[long QT syndrome]] ([[DI-LQTS]]) and [[drug-induced]] [[sudden cardiac death]] (DI-SCD).  
* p.Ser1103Tyr-SCN5A generates late or persistent sodium current which is further aggravated by [[hypoxia]] or [[respiratory acidosis]] secondary to [[lungs]] involvement in [[COVID-19]].
* This has and has been linked to an increased [[risk]] of [[ventricular arrhythmia]] (VA) such as [[torsade de pointes]] and [[sudden cardiac death]] ([[SCD]]) in [[African Americans]].


'''Cytokine storm and heart damage:'''
* [[Pulseless electrical activity]] (49.8%)
* [[Bradyarrhythmia]] and [[asystolic]] arrest (23.8%)
* [[Ventricular tachycardia]](8.3%)
* [[Ventricular fibrillation]](3.8%)


'''Pre-existing heart disease'''
==Causes==
==Causes==
*COVID-19 associated cardiac arrest may occur due to the following causes:
The potential [[causes]] of [[ventricular tachyarrhythmia]] and [[sudden cardiac death]] in [[COVID-19]] include:<ref name="pmid32380288">{{cite journal |vauthors=Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ |title=Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans |journal=Heart Rhythm |volume= |issue= |pages= |date=May 2020 |pmid=32380288 |pmc=7198426 |doi=10.1016/j.hrthm.2020.04.045 |url=}}</ref>
** Acute respiratory distress syndrome
** Myocardial injury
** Ventricular arrhythmias
** Shock
==Epidemiology and Demographics==
'''Incidence'''


There is a two-times rise in the [[incidence]] of Out of [[hospital]] [[Sudden cardiac arrest]] (OHCA) during the [[COVID-19]] [[pandemic]] as compared to the non-pandemic time period.
* Hypercytokinemia
* Administration of drugs causing [[QT interval]] prolongation  such as [[hydroxychloroquine]] ± [[azithromycin]], [[lopinavir]], and [[ritonavir]]<ref name="MehraDesai2020">{{cite journal|last1=Mehra|first1=Mandeep R|last2=Desai|first2=Sapan S|last3=Ruschitzka|first3=Frank|last4=Patel|first4=Amit N|title=RETRACTED: Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis|journal=The Lancet|year=2020|issn=01406736|doi=10.1016/S0140-6736(20)31180-6}}</ref>


'''Mortality'''
*Concurrent use of drugs causing [[QT interval]] prolongation, such as antiemetics,[[fluoroquinolones]],[[SSRIs]]
*Electrolyte abnormalities such as [[hypokalemia]] and [[hypomagnesemia]]
*High-risk comorbidity condition such as [[Congestive heart failure]], [[chronic kidney disease]], [[diabetes mellitus]], and [[chronic obstructive pulmonary disease]]
*[[Inherited arrhythmia syndromes]]
*
*Increased [[sympathetic]] activity
* Inhibition of [[CYP450]]
* Direct myocardial injury or [[SARS-CoOV-2|SARS-COV-2]] [[myocarditis]]
*Acute cardiac events ([[acute coronary syndrome]], [[decompensated heart failure]], arrhythmia)
* Thromboembolic events related to [[COVID-19]] ([[pulmonary embolism]], [[acute coronary syndrome]])<ref name="KlokKruip2020">{{cite journal|last1=Klok|first1=F.A.|last2=Kruip|first2=M.J.H.A.|last3=van der Meer|first3=N.J.M.|last4=Arbous|first4=M.S.|last5=Gommers|first5=D.A.M.P.J.|last6=Kant|first6=K.M.|last7=Kaptein|first7=F.H.J.|last8=van Paassen|first8=J.|last9=Stals|first9=M.A.M.|last10=Huisman|first10=M.V.|last11=Endeman|first11=H.|title=Incidence of thrombotic complications in critically ill ICU patients with COVID-19|journal=Thrombosis Research|volume=191|year=2020|pages=145–147|issn=00493848|doi=10.1016/j.thromres.2020.04.013}}</ref>
*[[Hypoxia]]


There is a significant increase in the [[mortality rate]] of the OHCA [[patients]].<ref name="pmidPMID: 32473113">{{cite journal| author=Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C | display-authors=etal| title=Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. | journal=Lancet Public Health | year= 2020 | volume= | issue= | pages= | pmid=PMID: 32473113 | doi=10.1016/S2468-2667(20)30117-1 | pmc=7255168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32473113  }} </ref>
==Pathophysiology==
* The [[pathogenesis]] of [[cardiac arrest]] associated with [[COVID-19]] is characterized by cytokine storm, especially elevation of [[IL-6]].<ref name="LazzeriniLaghi-Pasini2018">{{cite journal|last1=Lazzerini|first1=Pietro Enea|last2=Laghi-Pasini|first2=Franco|last3=Boutjdir|first3=Mohamed|last4=Capecchi|first4=Pier Leopoldo|title=Cardioimmunology of arrhythmias: the role of autoimmune and inflammatory cardiac channelopathies|journal=Nature Reviews Immunology|volume=19|issue=1|year=2018|pages=63–64|issn=1474-1733|doi=10.1038/s41577-018-0098-z}}</ref>
* [[IL-6]] directly blocks hERG/K<sub>v</sub>11.1 [[potassium channels]] and causes [[APD prolongation|action potential depolarization(APD) prolongation]] and [[ventricular repolarization]].
* [[IL-6]] induces hyperactivity of [[cardiac]] sympathetic nerve.
*[[Hypoxia]] causes myocardial injury and ventricular repolarization.
*[[IL-6]] inhibits cytochrome P450 enzyme involved in metabolism of some [[QTc]] prolongation drugs.<ref name="DrigginMadhavan2020">{{cite journal|last1=Driggin|first1=Elissa|last2=Madhavan|first2=Mahesh V.|last3=Bikdeli|first3=Behnood|last4=Chuich|first4=Taylor|last5=Laracy|first5=Justin|last6=Biondi-Zoccai|first6=Giuseppe|last7=Brown|first7=Tyler S.|last8=Der Nigoghossian|first8=Caroline|last9=Zidar|first9=David A.|last10=Haythe|first10=Jennifer|last11=Brodie|first11=Daniel|last12=Beckman|first12=Joshua A.|last13=Kirtane|first13=Ajay J.|last14=Stone|first14=Gregg W.|last15=Krumholz|first15=Harlan M.|last16=Parikh|first16=Sahil A.|title=Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic|journal=Journal of the American College of Cardiology|volume=75|issue=18|year=2020|pages=2352–2371|issn=07351097|doi=10.1016/j.jacc.2020.03.031}}</ref>
* <nowiki/><nowiki/><nowiki/>[[Hydroxychloroquine]] and [[lopinavir/ritonavir]]  inhibit [[HERG-K+ channe|HERG-K<sup>+</sup> channe]]<nowiki/>l and increase  both ventriculat repolarization and  the level of other QTc prolongation drugs.'''<ref name="DrigginMadhavan2020">{{cite journal|last1=Driggin|first1=Elissa|last2=Madhavan|first2=Mahesh V.|last3=Bikdeli|first3=Behnood|last4=Chuich|first4=Taylor|last5=Laracy|first5=Justin|last6=Biondi-Zoccai|first6=Giuseppe|last7=Brown|first7=Tyler S.|last8=Der Nigoghossian|first8=Caroline|last9=Zidar|first9=David A.|last10=Haythe|first10=Jennifer|last11=Brodie|first11=Daniel|last12=Beckman|first12=Joshua A.|last13=Kirtane|first13=Ajay J.|last14=Stone|first14=Gregg W.|last15=Krumholz|first15=Harlan M.|last16=Parikh|first16=Sahil A.|title=Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic|journal=Journal of the American College of Cardiology|volume=75|issue=18|year=2020|pages=2352–2371|issn=07351097|doi=10.1016/j.jacc.2020.03.031}}</ref>
*[[Hydroxychloroquine]] inhibits [[CYP2D6]] ([[cytochrome P450]] 2D6) ,then the level of [[antipsychotics]],[[antidepressants]] and [[antihistamins]] increase.'''<ref name="DrigginMadhavan2020">{{cite journal|last1=Driggin|first1=Elissa|last2=Madhavan|first2=Mahesh V.|last3=Bikdeli|first3=Behnood|last4=Chuich|first4=Taylor|last5=Laracy|first5=Justin|last6=Biondi-Zoccai|first6=Giuseppe|last7=Brown|first7=Tyler S.|last8=Der Nigoghossian|first8=Caroline|last9=Zidar|first9=David A.|last10=Haythe|first10=Jennifer|last11=Brodie|first11=Daniel|last12=Beckman|first12=Joshua A.|last13=Kirtane|first13=Ajay J.|last14=Stone|first14=Gregg W.|last15=Krumholz|first15=Harlan M.|last16=Parikh|first16=Sahil A.|title=Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic|journal=Journal of the American College of Cardiology|volume=75|issue=18|year=2020|pages=2352–2371|issn=07351097|doi=10.1016/j.jacc.2020.03.031}}</ref>
*[[Ritonavir]] inhibits [[CYP3A4]] ([[cytochrome P450 3A4]]), then the level of [[azols antifungals]], [[macrolides]] (particulary [[azithromycin]]), [[antidepressants]],[[antihistamines]], [[fluoroquinolones]] increase.'''<ref name="DrigginMadhavan2020">{{cite journal|last1=Driggin|first1=Elissa|last2=Madhavan|first2=Mahesh V.|last3=Bikdeli|first3=Behnood|last4=Chuich|first4=Taylor|last5=Laracy|first5=Justin|last6=Biondi-Zoccai|first6=Giuseppe|last7=Brown|first7=Tyler S.|last8=Der Nigoghossian|first8=Caroline|last9=Zidar|first9=David A.|last10=Haythe|first10=Jennifer|last11=Brodie|first11=Daniel|last12=Beckman|first12=Joshua A.|last13=Kirtane|first13=Ajay J.|last14=Stone|first14=Gregg W.|last15=Krumholz|first15=Harlan M.|last16=Parikh|first16=Sahil A.|title=Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic|journal=Journal of the American College of Cardiology|volume=75|issue=18|year=2020|pages=2352–2371|issn=07351097|doi=10.1016/j.jacc.2020.03.031}}</ref>'''
* Intrinsic genetic susceptibility ([[Ser1103Tyr-SCN5A]]) in African-Americans [[COVID-19]] patients has been associated with increased risk of [[Torsades de pointes]] [[arrhythmia]].<ref name="pmid32359771">{{cite journal |vauthors=Giudicessi JR, Noseworthy PA, Friedman PA, Ackerman MJ |title=Urgent Guidance for Navigating and Circumventing the QTc-Prolonging and Torsadogenic Potential of Possible Pharmacotherapies for Coronavirus Disease 19 (COVID-19) |journal=Mayo Clin. Proc. |volume=95 |issue=6 |pages=1213–1221 |date=June 2020 |pmid=32359771 |pmc=7141471 |doi=10.1016/j.mayocp.2020.03.024 |url=}}</ref>


'''Age'''
== Differentiating inherited cardiac arrest from other causes of cardiac arrest ==
 
* To view the differential diagnosis of COVID-19-associated cardiac arrest [[COVID-19 associated cardiac arrest differential diagnosis|click here]].
Mean [[age]] 69.7 years is observed among [[patients]] who experienced Out of [[hospital]] [[Sudden cardiac arrest]] (OHCA) .<ref name="pmidPMID: 32473113">{{cite journal| author=Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C | display-authors=etal| title=Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. | journal=Lancet Public Health | year= 2020 | volume= | issue= | pages= | pmid=PMID: 32473113 | doi=10.1016/S2468-2667(20)30117-1 | pmc=7255168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32473113 }} </ref> .  
* To view the differential diagnosis of [[COVID-19]] [[COVID-19 differential diagnosis|click here]].
==Epidemiology and Demographics==
===Incidence===
* The [[incidence]] of out-of hospital [[cardiac arrest]] was estimated to be 10,000 cases per 100,000 [[covid-19]] [[patients]].<ref name="pmid33629117">{{cite journal| author=Sandroni C, Skrifvars MB, Nolan JP| title=The impact of COVID-19 on the epidemiology, outcome and management of cardiac arrest. | journal=Intensive Care Med | year= 2021 | volume= 47 | issue= 5 | pages= 602-604 | pmid=33629117 | doi=10.1007/s00134-021-06369-3 | pmc=7904033 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33629117 }} </ref>
* The [[incidence]] of [[in-hospital]] [[cardiac arrest]] was estimated to be 16,000 per 100,000 [[covid-19]] [[patients]].


'''Gender'''
===Mortality===
*There is a significant increase in the [[mortality rate]] of the [[OHCA]] in [[covid-19]] [[patients]].<ref name="pmidPMID: 32473113">{{cite journal| author=Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C | display-authors=etal| title=Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. | journal=Lancet Public Health | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32473113 | doi=10.1016/S2468-2667(20)30117-1 | pmc=7255168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32473113  }} </ref>


Studies show that [[males]] have a slightly higher [[incidence]] of Out of hospital Sudden cardiac arrest (OHCA) as compared to the [[females]].<ref name="pmidPMID: 32473113">{{cite journal| author=Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C | display-authors=etal| title=Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. | journal=Lancet Public Health | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32473113 | doi=10.1016/S2468-2667(20)30117-1 | pmc=7255168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32473113  }} </ref>
===Age===
*The mean [[age]] observed among [[patients]] who experienced out-of-[[hospital]] [[Sudden cardiac arrest]] (OHCA) is 69.7 years.<ref name="pmidPMID: 32473113">{{cite journal| author=Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C | display-authors=etal| title=Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. | journal=Lancet Public Health | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32473113 | doi=10.1016/S2468-2667(20)30117-1 | pmc=7255168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32473113  }} </ref> .
===Gender===
*Studies showed that [[male|males]] have a slightly higher [[incidence]] of out-of-hospital [[sudden cardiac arrest]] ([[OHCA]]) as compared to the [[females]].<ref name="pmidPMID: 32473113">{{cite journal| author=Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C | display-authors=etal| title=Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. | journal=Lancet Public Health | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32473113 | doi=10.1016/S2468-2667(20)30117-1 | pmc=7255168 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32473113  }} </ref>
===Race===


'''Race'''
* A higher [[incidence]] has been seen among [[African-Americans]] as compared to [[Caucasians]].<ref name="pmidPMID: 32380288">{{cite journal| author=Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ| title=Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans. | journal=Heart Rhythm | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32380288 | doi=10.1016/j.hrthm.2020.04.045 | pmc=7198426 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32380288  }} </ref>


A higher [[incidence]] is seen among [[African-Americans]] as compared to the [[Caucasians]].<ref name="pmidPMID: 32380288">{{cite journal| author=Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ| title=Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans. | journal=Heart Rhythm | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32380288 | doi=10.1016/j.hrthm.2020.04.045 | pmc=7198426 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32380288  }} </ref>
==Risk Factors==
==Risk Factors==
* Common [[risk factors]] in the development of arrhythmia and [[cardiac arrest]] in [[COVID-19]] are:<ref name="pmid32244059">{{cite journal |vauthors=Wu CI, Postema PG, Arbelo E, Behr ER, Bezzina CR, Napolitano C, Robyns T, Probst V, Schulze-Bahr E, Remme CA, Wilde AAM |title=SARS-CoV-2, COVID-19, and inherited arrhythmia syndromes |journal=Heart Rhythm |volume= |issue= |pages= |date=March 2020 |pmid=32244059 |pmc=7156157 |doi=10.1016/j.hrthm.2020.03.024 |url=}}</ref>
** [[Fever]]
** [[Stress]]
** [[Electrolytes disturbances]]
** Side effect of [[medications]]
** Age ≥65
**[[Male]] gender


* The most common identified [[risk factors]] for cardiac arrest in patients with [[COVID-19]] infection are:
* Factors associated with increased [[out of hospital]] [[cardiac arrest]] during [[covid-19]] pandemic include: <ref name="pmid33629117">{{cite journal| author=Sandroni C, Skrifvars MB, Nolan JP| title=The impact of COVID-19 on the epidemiology, outcome and management of cardiac arrest. | journal=Intensive Care Med | year= 2021 | volume= 47 | issue= 5 | pages= 602-604 | pmid=33629117 | doi=10.1007/s00134-021-06369-3 | pmc=7904033 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33629117  }} </ref>
*To view the risk factors of COVID-19, [[COVID-19 risk factors|click here]].
*: Increased non-shockable [[rhythm]] at home
*: Restricted or delay access to emergency care
*: Longer response time by [[EMS]] due to increased workload
*: Delay seeking medical care due to fear contracting [[covid-19]] in [[hospital]]
*: Decrease hospitalization of [[ACS]] and [[heart failure]]  due to fear contracting [[covid-19]] in [[hospital]] leading to increased severity of [[acute coronary syndrome]] and [[heart failure]] and [[cardiac arrest]]


==Screening==
==Screening==
 
* To view [[screening]] for [[COVID-19]], [[COVID-19 screening|click here]].
 
*To view screening for COVID-19, [[COVID-19 screening|click here]].<br />
 
==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==


* Early clinical features before developing [[anosmia]] related to [[COVID-19]] include [[cough]], [[fever]], and [[Arthralgia|arthralgias]].
* The proportion of [[patients]] who developed [[out of hospital cardiac arrest|out-of-hospital cardiac arrest]] (OHCA) increased during the [[covid-19|COVID-19]] pandemic and was affected by aggravation of underlying [[comorbidities]], late presentation of acute [[STEMI]] ([[ST elevation myocardial infarction]]) due to fear of being infected in hospital, and avoidance of bystander [[cardiopulmonary rescucitation|cardiopulmonary resuscitation]] in [[public]] due to fear of [[infection]].<ref name="TamCheung2020">{{cite journal|last1=Tam|first1=Chor-Cheung Frankie|last2=Cheung|first2=Kent-Shek|last3=Lam|first3=Simon|last4=Wong|first4=Anthony|last5=Yung|first5=Arthur|last6=Sze|first6=Michael|last7=Lam|first7=Yui-Ming|last8=Chan|first8=Carmen|last9=Tsang|first9=Tat-Chi|last10=Tsui|first10=Matthew|last11=Tse|first11=Hung-Fat|last12=Siu|first12=Chung-Wah|title=Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment–Elevation Myocardial Infarction Care in Hong Kong, China|journal=Circulation: Cardiovascular Quality and Outcomes|volume=13|issue=4|year=2020|issn=1941-7713|doi=10.1161/CIRCOUTCOMES.120.006631}}</ref><ref name="ScquizzatoOlasveengen2020">{{cite journal|last1=Scquizzato|first1=Tommaso|last2=Olasveengen|first2=Theresa Mariero|last3=Ristagno|first3=Giuseppe|last4=Semeraro|first4=Federico|title=The other side of novel coronavirus outbreak: Fear of performing cardiopulmonary resuscitation|journal=Resuscitation|volume=150|year=2020|pages=92–93|issn=03009572|doi=10.1016/j.resuscitation.2020.03.019}}</ref>
 
* In the setting of [[in-hospital]] [[cardiac arrest]],  Only 12% of [[patients]] survived to hospital discharged after [[cardiopulmonary resuscitation]] and only 7% of [[patients]] discharged with normal or mildly impaired [[neurologic]] status.<ref name="HayekBrenner2020">{{cite journal|last1=Hayek|first1=Salim S|last2=Brenner|first2=Samantha K|last3=Azam|first3=Tariq U|last4=Shadid|first4=Husam R|last5=Anderson|first5=Elizabeth|last6=Berlin|first6=Hanna|last7=Pan|first7=Michael|last8=Meloche|first8=Chelsea|last9=Feroz|first9=Rafey|last10=O’Hayer|first10=Patrick|last11=Kaakati|first11=Rayan|last12=Bitar|first12=Abbas|last13=Padalia|first13=Kishan|last14=Perry|first14=Daniel|last15=Blakely|first15=Pennelope|last16=Gupta|first16=Shruti|last17=Shaefi|first17=Shahzad|last18=Srivastava|first18=Anand|last19=Charytan|first19=David M|last20=Bansal|first20=Anip|last21=Mallappallil|first21=Mary|last22=Melamed|first22=Michal L|last23=Shehata|first23=Alexandre M|last24=Sunderram|first24=Jag|last25=Mathews|first25=Kusum S|last26=Sutherland|first26=Anne K|last27=Nallamothu|first27=Brahmajee K|last28=Leaf|first28=David E|title=In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study|journal=BMJ|year=2020|pages=m3513|issn=1756-1833|doi=10.1136/bmj.m3513}}</ref<ref name="HayekBrenner2020">{{cite journal|last1=Hayek|first1=Salim S|last2=Brenner|first2=Samantha K|last3=Azam|first3=Tariq U|last4=Shadid|first4=Husam R|last5=Anderson|first5=Elizabeth|last6=Berlin|first6=Hanna|last7=Pan|first7=Michael|last8=Meloche|first8=Chelsea|last9=Feroz|first9=Rafey|last10=O’Hayer|first10=Patrick|last11=Kaakati|first11=Rayan|last12=Bitar|first12=Abbas|last13=Padalia|first13=Kishan|last14=Perry|first14=Daniel|last15=Blakely|first15=Pennelope|last16=Gupta|first16=Shruti|last17=Shaefi|first17=Shahzad|last18=Srivastava|first18=Anand|last19=Charytan|first19=David M|last20=Bansal|first20=Anip|last21=Mallappallil|first21=Mary|last22=Melamed|first22=Michal L|last23=Shehata|first23=Alexandre M|last24=Sunderram|first24=Jag|last25=Mathews|first25=Kusum S|last26=Sutherland|first26=Anne K|last27=Nallamothu|first27=Brahmajee K|last28=Leaf|first28=David E|title=In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study|journal=BMJ|year=2020|pages=m3513|issn=1756-1833|doi=10.1136/bmj.m3513}}</ref>
*To view natural history, complications, and prognosis of COVID-19, [[COVID-19 natural history, complications and prognosis|click here]].
*30-days [[mortality]] in [[covid-19]] [[patients]] was increased 3.4 fold in [[OHCA]] and 2.3 fold in [[IHCA]], compared with prepandemic period.<ref name="pmid33543259">{{cite journal| author=Sultanian P, Lundgren P, Strömsöe A, Aune S, Bergström G, Hagberg E | display-authors=etal| title=Cardiac arrest in COVID-19: characteristics and outcomes of in- and out-of-hospital cardiac arrest. A report from the Swedish Registry for Cardiopulmonary Resuscitation. | journal=Eur Heart J | year= 2021 | volume= 42 | issue= 11 | pages= 1094-1106 | pmid=33543259 | doi=10.1093/eurheartj/ehaa1067 | pmc=7928992 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33543259  }} </ref>
* Prognosis was poor in  critically [[ill]] [[Covid-19]] [[patients]] with [[pulseless electrical activity]] or [[asystole]], [[patients]] older than 80 years  with [[comorbidities]].<ref name="HayekBrenner2020">{{cite journal|last1=Hayek|first1=Salim S|last2=Brenner|first2=Samantha K|last3=Azam|first3=Tariq U|last4=Shadid|first4=Husam R|last5=Anderson|first5=Elizabeth|last6=Berlin|first6=Hanna|last7=Pan|first7=Michael|last8=Meloche|first8=Chelsea|last9=Feroz|first9=Rafey|last10=O’Hayer|first10=Patrick|last11=Kaakati|first11=Rayan|last12=Bitar|first12=Abbas|last13=Padalia|first13=Kishan|last14=Perry|first14=Daniel|last15=Blakely|first15=Pennelope|last16=Gupta|first16=Shruti|last17=Shaefi|first17=Shahzad|last18=Srivastava|first18=Anand|last19=Charytan|first19=David M|last20=Bansal|first20=Anip|last21=Mallappallil|first21=Mary|last22=Melamed|first22=Michal L|last23=Shehata|first23=Alexandre M|last24=Sunderram|first24=Jag|last25=Mathews|first25=Kusum S|last26=Sutherland|first26=Anne K|last27=Nallamothu|first27=Brahmajee K|last28=Leaf|first28=David E|title=In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study|journal=BMJ|year=2020|pages=m3513|issn=1756-1833|doi=10.1136/bmj.m3513}}</ref>'''.<ref name="pmid32283117">{{cite journal |vauthors=Shao F, Xu S, Ma X, Xu Z, Lyu J, Ng M, Cui H, Yu C, Zhang Q, Sun P, Tang Z |title=In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China |journal=Resuscitation |volume=151 |issue= |pages=18–23 |date=June 2020 |pmid=32283117 |pmc=7151543 |doi=10.1016/j.resuscitation.2020.04.005 |url=}}</ref>''
* [[Survival rate]] after [[out-of-hospital]] [[cardiac arrest]] during the pandemic was 8.8%.
* [[Mortality rate]] of [[patients]] with [[COVID-19]] is approximately 1-2%'''<ref name="pmid32109013">{{cite journal |vauthors=Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS |title=Clinical Characteristics of Coronavirus Disease 2019 in China |journal=N. Engl. J. Med. |volume=382 |issue=18 |pages=1708–1720 |date=April 2020 |pmid=32109013 |pmc=7092819 |doi=10.1056/NEJMoa2002032 |url=}}</ref>'''


==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
===Diagnostic Criteria===
 
* The diagnosis of sudden cardiac death is made when the following diagnostic criteria are met:
*
*To view the study of choice for diagnosis of COVID-19, [[COVID-19 diagnostic study of choice|click here]].<br />
===History and Symptoms===
*To view the history and symptoms of COVID-19, [[COVID-19 history and symptoms|click here]].
===Physical Examination===
* To view the complete physical examination in COVID-19, [[COVID-19 physical examination|click here]].


===Laboratory Findings===
:* Prodromes phase occurring weeks or months before an event includes: new or worsening cardiovascular symptoms([[chest pain]], [[dyspnea]], [[palpitations]], fatigability)
:* Onset of terminal event occurring one hour before cardiac arrest includes: abrupt change in clinical status([[arrhythmia]], hypotension, [[chest pain]], [[dyspnea]], lightheadness)
:* Cardiac arrest includes: sudden collapse, loss of effective [[circulation]], loss of consciousness
:*[[Biologic death]]: failure of [[Cardiopulmonary resuscitation|resuscitatio]]<nowiki/>[[Cardiopulmonary resuscitation|n]] or failure of electrical, mechanical, or CNS function after initial [[resuscitation]]
=== Symptoms ===
* Symptoms before [[cardiac arrest]] in [[COVID-19]]  may include the following:
**[[Chest pain]]
**[[Palpitation]]
**[[Dyspnea]]
**[[Lightheadness]]


* [[Laboratory diagnosis of virus|Laboratory testing]] and self-isolation should be made in patients who present with [[anosmia]], even if this is found as an isolated [[symptom]].<ref name="pmid32563019" />
=== Physical Examination ===
* To view the laboratory findings on COVID-19, [[COVID-19 laboratory findings|click here]].
There is no specific finding associated with physical examination with cardiac arrest in [[COVID-19]].
=== Laboratory Findings ===
* An elevated concentration of serum cardiac troponinI was detected in severe [[COVID-19-associated diabetes mellitus|COVID-19]] patients with cardiac complications. <ref name="pmid32382587">{{cite journal |vauthors=Paul P |title=Cardiac Troponin-I may be a predictor of complications and mortality in COVID-19 patients |journal=Curr Med Res Pract |volume= |issue= |pages= |date=May 2020 |pmid=32382587 |pmc=7204698 |doi=10.1016/j.cmrp.2020.05.001 |url=}}</ref>
=== Imaging Findings ===
There are no imaging study findings associated with cardiac arrest in [[COVID-19]].


===Electrocardiogram===
===Electrocardiogram===
* Findings on [[EKG]] during [[in-hospital]] [[cardiac arrest]] ([[IHCA]]) with [[COVID-19]] infection include:<ref name="pmid32283117" />
**[[Asystole]] (89.7%)
**[[Pulseless electrical activity]] (4.4%)
**Shockable rhythm (5.9%)


** A [[patient]] experiencing [[sudden cardiac death]] can have [[ventricular fibrillation]] associated [[ECG]] changes such as [[ventricular tachycardia]] with [[irregular rhythm]] and indiscernible [[P waves]] or [[QRS complexes]].
<br />
**[[Heart block]].<ref name="pmidPMID: 29967683">{{cite journal| author=Srinivasan NT, Schilling RJ| title=Sudden Cardiac Death and Arrhythmias. | journal=Arrhythm Electrophysiol Rev | year= 2018 | volume= 7 | issue= 2 | pages= 111-117 | pmid=PMID: 29967683 | doi=10.15420/aer.2018:15:2 | pmc=6020177 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29967683  }} </ref>
* Another study showed the most common [[EKG]] findings during inhospital cardiac arrest was [[pulseless electrical activity]](49.8%), [[asystole]](23.8%), shockable rhthm(12.6%).<ref name="HayekBrenner2020">{{cite journal|last1=Hayek|first1=Salim S|last2=Brenner|first2=Samantha K|last3=Azam|first3=Tariq U|last4=Shadid|first4=Husam R|last5=Anderson|first5=Elizabeth|last6=Berlin|first6=Hanna|last7=Pan|first7=Michael|last8=Meloche|first8=Chelsea|last9=Feroz|first9=Rafey|last10=O’Hayer|first10=Patrick|last11=Kaakati|first11=Rayan|last12=Bitar|first12=Abbas|last13=Padalia|first13=Kishan|last14=Perry|first14=Daniel|last15=Blakely|first15=Pennelope|last16=Gupta|first16=Shruti|last17=Shaefi|first17=Shahzad|last18=Srivastava|first18=Anand|last19=Charytan|first19=David M|last20=Bansal|first20=Anip|last21=Mallappallil|first21=Mary|last22=Melamed|first22=Michal L|last23=Shehata|first23=Alexandre M|last24=Sunderram|first24=Jag|last25=Mathews|first25=Kusum S|last26=Sutherland|first26=Anne K|last27=Nallamothu|first27=Brahmajee K|last28=Leaf|first28=David E|title=In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study|journal=BMJ|year=2020|pages=m3513|issn=1756-1833|doi=10.1136/bmj.m3513}}</ref>
**[[Pulseless electrical activity]].<ref name="pmidPMID: 29967683">{{cite journal| author=Srinivasan NT, Schilling RJ| title=Sudden Cardiac Death and Arrhythmias. | journal=Arrhythm Electrophysiol Rev | year= 2018 | volume= 7 | issue= 2 | pages= 111-117 | pmid=PMID: 29967683 | doi=10.15420/aer.2018:15:2 | pmc=6020177 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29967683  }} </ref>
*Other abnormal [[EKG Abnormalities in central nervous system disease|EKG]] findings include [[QT prolongation]]. [[ECG]] shows [[corrected QT interval]] ([[QTc]]) more than 500 ms.<br />
**Other abnormal [[ECG]] findings include [[QT prolongation]]. [[ECG]] shows [[corrected QT interval]] ([[QTc]]) more than 500 ms..
**[[Asystole]].<ref name="pmidPMID: 29967683">{{cite journal| author=Srinivasan NT, Schilling RJ| title=Sudden Cardiac Death and Arrhythmias. | journal=Arrhythm Electrophysiol Rev | year= 2018 | volume= 7 | issue= 2 | pages= 111-117 | pmid=PMID: 29967683 | doi=10.15420/aer.2018:15:2 | pmc=6020177 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29967683  }} </ref> <ref name="pmidPMID: 29997977">{{cite journal| author=Parish DC, Goyal H, Dane FC| title=Mechanism of death: there's more to it than sudden cardiac arrest. | journal=J Thorac Dis | year= 2018 | volume= 10 | issue= 5 | pages= 3081-3087 | pmid=PMID: 29997977 | doi=10.21037/jtd.2018.04.113 | pmc=6006107 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29997977  }} </ref>
 
===X-ray===
*There are no typical x-ray findings for cardiac arrest due to [[COVID-19]].
* To view the x-ray finidings on COVID-19, [[COVID-19 x ray|click here]].<br />
 
===Echocardiography or Ultrasound===
 
* There are no typical [[Echocardiography|echocardiographic]] findings for cardiac arrest due to [[COVID-19]].
* To view the echocardiographic findings on COVID-19, [[COVID-19 echocardiography and ultrasound|click here]].<br />
 
===CT scan===
 
* There are no typical CT scan findings for cardiac arrest due to [[COVID-19]].
*To view the CT scan findings on COVID-19, [[COVID-19 CT scan|click here]].
 
===MRI===
* There are no typical MRI findings for cardiac arrest due to [[COVID-19]].
* To view the MRI findings on COVID-19, [[COVID-19 MRI|click here]].<br />
 
===Other Imaging Findings===
 
*  There are no other imaging findings for cardiac arrest due to [[COVID-19]].
* To view other imaging findings on COVID-19, [[COVID-19 other imaging findings|click here]].<br />
 
===Other Diagnostic Studies===
* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]].<br />


==Treatment==
==Treatment==
 
*The mainstay of therapy for [[COVID-19]]-related [[cardiac arrest]] is [[cardiopulmonary resuscitation]] with attention to the following points:<ref name="EdelsonSasson2020">{{cite journal|last1=Edelson|first1=Dana P.|last2=Sasson|first2=Comilla|last3=Chan|first3=Paul S.|last4=Atkins|first4=Dianne L.|last5=Aziz|first5=Khalid|last6=Becker|first6=Lance B.|last7=Berg|first7=Robert A.|last8=Bradley|first8=Steven M.|last9=Brooks|first9=Steven C.|last10=Cheng|first10=Adam|last11=Escobedo|first11=Marilyn|last12=Flores|first12=Gustavo E.|last13=Girotra|first13=Saket|last14=Hsu|first14=Antony|last15=Kamath-Rayne|first15=Beena D.|last16=Lee|first16=Henry C.|last17=Lehotsky|first17=Rebecca E.|last18=Mancini|first18=Mary E.|last19=Merchant|first19=Raina M.|last20=Nadkarni|first20=Vinay M.|last21=Panchal|first21=Ashish R.|last22=Peberdy|first22=Mary Ann R.|last23=Raymond|first23=Tia T.|last24=Walsh|first24=Brian|last25=Wang|first25=David S.|last26=Zelop|first26=Carolyn M.|last27=Topjian|first27=Alexis A.|last28=Starks|first28=Monique Anderson|last29=Bobrow|first29=Bentley J.|last30=Chan|first30=Melissa|last31=Berg|first31=Katherine|last32=Duff|first32=Jonathan P.|last33=Joyner|first33=Benny L.|last34=Lasa|first34=Javier J.|last35=Levy|first35=Arielle|last36=Mahgoub|first36=Melissa|last37=O’Connor|first37=Michael F.|last38=Hoover|first38=Amber V.|last39=Rodriguez|first39=Amber J.|last40=Meckler|first40=Garth|last41=Roberts|first41=Kathryn|last42=Mohr|first42=Nicholas M.|last43=Nassar|first43=Boulos|last44=Rubinson|first44=Lewis|last45=Sutton|first45=Robert M.|last46=Schexnayder|first46=Stephen M.|last47=Kleinman|first47=Monica|last48=de Caen|first48=Allan|last49=Morgan|first49=Ryan|last50=Bhanji|first50=Farhan|last51=Fuchs|first51=Susan|last52=Terry|first52=Mark|last53=McBride|first53=Mary|last54=Levy|first54=Michael|last55=Cabanas|first55=Jose G.|last56=Tan|first56=David K.|last57=Moitra|first57=Vivek K.|last58=Szokol|first58=Joseph W.|title=Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19|journal=Circulation|volume=141|issue=25|year=2020|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.120.047463}}</ref>
*'''Cardiopulmonary resuscitation'''
**Wearing personal protective equipment (PPE) before entering the room or on the scene.
 
** Limiting the personnel in the room or on the scene
:*Immediate [[basic life support]] or [[advanced cardiac life support]] with an automatic [[external defibrillator]] is essential to safe the life of the [[patient]]. If the [[COVID-19]] [[infection]] was confirmed, the [[EMS]] personnel is instructed to wear [[personal protective equipment]] ([[PPE]]) before performing [[cardiopulmonary resuscitation]].
**Using high-efficacy particulate air filter for ventilator
*'''Implantable Cardioverter Defibrillator (ICD)'''
** Intubating with a [[cuffed tube]]
 
** Stopping chest compression for intubation
:*An [[Implantable cardioverter defibrillator]] ([[ICD]]) is the preferred [[therapeutic]] modality in most [[survivors]] of [[sudden cardiac death]]. This [[device]] does not prevent the [[recurrence]] of [[arrhythmia]], instead, it [[terminates]] them in case if they do recur.
** Using bag-mask device before intubation
*'''Pharmacologic therapy in survivors of sudden cardiac arrest'''
** Using non-rebreathing face mask instead of bag-mask for short term oxygenation
 
:*'''Antiarrhythmic drugs:''' [[Amiodarone]] is the most effective for [[preventing]] recurrent [[ventricular tachyarrhythmias]]. It is recommended to immediately give [[Amiodarone]] following an event of [[sudden cardiac arrest]] in patients with [[recurrent ventricular tachyarrhythmias]] as well as for those who have refused [[Implantable]] [[Cardioverter Defibrillator]] ([[ICD]]).
:*'''Beta blocker:'''It is recommended that almost all [[patients]] who survive an episode of [[sudden cardiac arrest]] should receive a [[beta-blocker]] as part of their [[therapy]] in combination with an [[antiarrhythmic drug]], particularly in those [[patients]] who have survived [[sudden cardiac death]] due to [[ventricular tachycardia]] or [[ventricular fibrillation]]. [[Beta-blockers]] has shown to [[reduce]] the future [[incidence]] of [[sudden cardiac death]].


==Prevention==
==Prevention==
Effective measures for the [[primary prevention]] of [[ventricular arrhythmia]]  during using [[hydroxychloroquine]] in the setting of long QT syndrome or aquired LQTS or heart rate <50/min or receiving [[azithromycin]], [[remdesivir]], [[lopinavir]], [[ritonavir]], include [[EKG]] and [[QTc]] measurement.<ref name="pmid32244059">{{cite journal |vauthors=Wu CI, Postema PG, Arbelo E, Behr ER, Bezzina CR, Napolitano C, Robyns T, Probst V, Schulze-Bahr E, Remme CA, Wilde AAM |title=SARS-CoV-2, COVID-19, and inherited arrhythmia syndromes |journal=Heart Rhythm |volume= |issue= |pages= |date=March 2020 |pmid=32244059 |pmc=7156157 |doi=10.1016/j.hrthm.2020.03.024 |url=}}</ref>
* If QTc ≥500 ms, consult with a cardiologist.
* If QTc<500ms, start [[hydroxychloroquine]] and repeat [[EKG]]  after 1-3 days.
* After starting the first dose of [[hydroxychloroquine]],  If any of the following factors were present repeat [[EKG]] after 4 hours:
**[[QTc]]≥500mse
**Increased [[QTc]]>60ms
**[[Ventricular ectopy]]
* Treatment of [[hypokalemia]] due to [[diarrhea]] associated [[COVID-19]] ,which prolonges [[QT interval]] is another measurement to be considered.
*Effective measures for the primary prevention of [[ventricular arrhythmia]] in [[brugada]] syndrome is starting [[acetaminophen]] or [[parastamol]] immediately if there is  sign of [[fever]] and also self-isolation.


*[[Identification]] and [[treatment]] of [[acute]] [[reversible]] causes of [[sudden cardiac death]].
*Evaluation and management of [[structural]] [[heart disease]] and [[arrhythmia]].<ref name="pmidPMID: 29967683">{{cite journal| author=Srinivasan NT, Schilling RJ| title=Sudden Cardiac Death and Arrhythmias. | journal=Arrhythm Electrophysiol Rev | year= 2018 | volume= 7 | issue= 2 | pages= 111-117 | pmid=PMID: 29967683 | doi=10.15420/aer.2018:15:2 | pmc=6020177 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29967683  }} </ref>
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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Latest revision as of 07:52, 15 November 2021

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Main article: COVID-19

For COVID-19 frequently asked inpatient questions, click here
For COVID-19 frequently asked outpatient questions, click here

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D. Ayesha Javid, MBBS[2]

Synonyms and keywords: Cardiac arrest, In-hospital cardiac arrest, IHCA, Out-of-hospital cardiac arrest, OHCA, Covid-19, SARS-COV-2, Ventricular arrhythmia, pulseless electrical activity, Asystole, Return Of Spontaneouse Circulation, ROSC

Overview

SARS-COV2 which causes coronavirus disease 2019 (covid-19) led to global pandemic on March 11, 2020, is an enveloped B-coronavirus transmitted via respiratory droplets, attached via viral spike protein to angiotensin-converting enzyme 2 receptor (ACE2 receptor) causing clinical asyndrome of coronavirus disease 2019. Severe covid-19 may progress to develope acute respiratory distress syndrome, cardiovascular complications, shock, and death. Cardiac arrest is often unexpected and acute event may present in every hospitalized patient. Abnormal vital signs can be the predictos of in-hospital cardiac arrest. During the outbreak of covid-19, there were increase reports of in-hospital cardiac arrest (IHCA), out-of hospital cardiac arrest (OHCA), lower rate of successful cardiopulmonary resuscitation (CPR), and increased mortality. 30-days mortality in covid-19 patients was increased 3.4 fold in OHCA and 2.3 fold in IHCA compared with pre-pandemic period. survival of in-hospital cardiac arrest was poor. Factors related to restricted or delay access to emergency care, late presentation of ACS or heart failure in hospital, avoidance of witness CPR in public due to fear contracting covid-19, as well as the side effects of drugs and thrombotic complications related to covid-19 led to higher incidence of cardiac arrest during covid-19 pandemic.

Historical Perspective

  • In December 2019, the COVID-19 outbreak first appeared in China, Wuhan.[1]
  • In January 2020, the first COVID-19 case was documented in the United States.[2]
  • On February 20, 2020, the first case of COVID-19 was documented in the Province of Lodi in Italy.[3]
  • In April 2020, an increase of out-of-hospital cardiac arrest was reported during the COVID-19 pandemic in Italy by Dr.Enrico Baldi.[4]

Classification

Cardiac arrest associated with COVID-19 may be classified into three subtypes:[5]

Causes

The potential causes of ventricular tachyarrhythmia and sudden cardiac death in COVID-19 include:[6]

Pathophysiology

Differentiating inherited cardiac arrest from other causes of cardiac arrest

  • To view the differential diagnosis of COVID-19-associated cardiac arrest click here.
  • To view the differential diagnosis of COVID-19 click here.

Epidemiology and Demographics

Incidence

Mortality

Age

Gender

Race

Risk Factors

Screening

Natural History, Complications, and Prognosis

Diagnosis

Diagnostic Criteria

  • The diagnosis of sudden cardiac death is made when the following diagnostic criteria are met:
  • Prodromes phase occurring weeks or months before an event includes: new or worsening cardiovascular symptoms(chest pain, dyspnea, palpitations, fatigability)
  • Onset of terminal event occurring one hour before cardiac arrest includes: abrupt change in clinical status(arrhythmia, hypotension, chest pain, dyspnea, lightheadness)
  • Cardiac arrest includes: sudden collapse, loss of effective circulation, loss of consciousness
  • Biologic death: failure of resuscitation or failure of electrical, mechanical, or CNS function after initial resuscitation

Symptoms

Physical Examination

There is no specific finding associated with physical examination with cardiac arrest in COVID-19.

Laboratory Findings

  • An elevated concentration of serum cardiac troponinI was detected in severe COVID-19 patients with cardiac complications. [21]

Imaging Findings

There are no imaging study findings associated with cardiac arrest in COVID-19.

Electrocardiogram


Treatment

  • The mainstay of therapy for COVID-19-related cardiac arrest is cardiopulmonary resuscitation with attention to the following points:[22]
    • Wearing personal protective equipment (PPE) before entering the room or on the scene.
    • Limiting the personnel in the room or on the scene
    • Using high-efficacy particulate air filter for ventilator
    • Intubating with a cuffed tube
    • Stopping chest compression for intubation
    • Using bag-mask device before intubation
    • Using non-rebreathing face mask instead of bag-mask for short term oxygenation

Prevention

Effective measures for the primary prevention of ventricular arrhythmia during using hydroxychloroquine in the setting of long QT syndrome or aquired LQTS or heart rate <50/min or receiving azithromycin, remdesivir, lopinavir, ritonavir, include EKG and QTc measurement.[15]

References

  1. ↑ Liu, Yen-Chin; Kuo, Rei-Lin; Shih, Shin-Ru (2020). "COVID-19: The first documented coronavirus pandemic in history". Biomedical Journal. doi:10.1016/j.bj.2020.04.007. ISSN 2319-4170.
  2. ↑ Sayre, Michael R.; Barnard, Leslie M.; Counts, Catherine R.; Drucker, Christopher J.; Kudenchuk, Peter J.; Rea, Thomas D.; Eisenberg, Mickey S. (2020). "Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR". Circulation. doi:10.1161/CIRCULATIONAHA.120.048951. ISSN 0009-7322.
  3. ↑ Baldi, Enrico; Sechi, Giuseppe M.; Mare, Claudio; Canevari, Fabrizio; Brancaglione, Antonella; Primi, Roberto; Klersy, Catherine; Palo, Alessandra; Contri, Enrico; Ronchi, Vincenza; Beretta, Giorgio; Reali, Francesca; Parogni, Pierpaolo; Facchin, Fabio; Bua, Davide; Rizzi, Ugo; Bussi, Daniele; Ruggeri, Simone; Oltrona Visconti, Luigi; Savastano, Simone (2020). "Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy". New England Journal of Medicine. doi:10.1056/NEJMc2010418. ISSN 0028-4793.
  4. ↑ Baldi E, Sechi GM, Mare C, Canevari F, Brancaglione A, Primi R, Klersy C, Palo A, Contri E, Ronchi V, Beretta G, Reali F, Parogni P, Facchin F, Bua D, Rizzi U, Bussi D, Ruggeri S, Oltrona Visconti L, Savastano S (July 2020). "Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy". N Engl J Med. 383 (5): 496–498. doi:10.1056/NEJMc2010418. PMC 7204428 Check |pmc= value (help). PMID 32348640 Check |pmid= value (help).
  5. ↑ 5.0 5.1 5.2 Hayek, Salim S; Brenner, Samantha K; Azam, Tariq U; Shadid, Husam R; Anderson, Elizabeth; Berlin, Hanna; Pan, Michael; Meloche, Chelsea; Feroz, Rafey; O’Hayer, Patrick; Kaakati, Rayan; Bitar, Abbas; Padalia, Kishan; Perry, Daniel; Blakely, Pennelope; Gupta, Shruti; Shaefi, Shahzad; Srivastava, Anand; Charytan, David M; Bansal, Anip; Mallappallil, Mary; Melamed, Michal L; Shehata, Alexandre M; Sunderram, Jag; Mathews, Kusum S; Sutherland, Anne K; Nallamothu, Brahmajee K; Leaf, David E (2020). "In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study". BMJ: m3513. doi:10.1136/bmj.m3513. ISSN 1756-1833.
  6. ↑ Giudicessi JR, Roden DM, Wilde A, Ackerman MJ (May 2020). "Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans". Heart Rhythm. doi:10.1016/j.hrthm.2020.04.045. PMC 7198426 Check |pmc= value (help). PMID 32380288 Check |pmid= value (help). Vancouver style error: initials (help)
  7. ↑ Mehra, Mandeep R; Desai, Sapan S; Ruschitzka, Frank; Patel, Amit N (2020). "RETRACTED: Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis". The Lancet. doi:10.1016/S0140-6736(20)31180-6. ISSN 0140-6736.
  8. ↑ Klok, F.A.; Kruip, M.J.H.A.; van der Meer, N.J.M.; Arbous, M.S.; Gommers, D.A.M.P.J.; Kant, K.M.; Kaptein, F.H.J.; van Paassen, J.; Stals, M.A.M.; Huisman, M.V.; Endeman, H. (2020). "Incidence of thrombotic complications in critically ill ICU patients with COVID-19". Thrombosis Research. 191: 145–147. doi:10.1016/j.thromres.2020.04.013. ISSN 0049-3848.
  9. ↑ Lazzerini, Pietro Enea; Laghi-Pasini, Franco; Boutjdir, Mohamed; Capecchi, Pier Leopoldo (2018). "Cardioimmunology of arrhythmias: the role of autoimmune and inflammatory cardiac channelopathies". Nature Reviews Immunology. 19 (1): 63–64. doi:10.1038/s41577-018-0098-z. ISSN 1474-1733.
  10. ↑ 10.0 10.1 10.2 10.3 Driggin, Elissa; Madhavan, Mahesh V.; Bikdeli, Behnood; Chuich, Taylor; Laracy, Justin; Biondi-Zoccai, Giuseppe; Brown, Tyler S.; Der Nigoghossian, Caroline; Zidar, David A.; Haythe, Jennifer; Brodie, Daniel; Beckman, Joshua A.; Kirtane, Ajay J.; Stone, Gregg W.; Krumholz, Harlan M.; Parikh, Sahil A. (2020). "Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic". Journal of the American College of Cardiology. 75 (18): 2352–2371. doi:10.1016/j.jacc.2020.03.031. ISSN 0735-1097.
  11. ↑ Giudicessi JR, Noseworthy PA, Friedman PA, Ackerman MJ (June 2020). "Urgent Guidance for Navigating and Circumventing the QTc-Prolonging and Torsadogenic Potential of Possible Pharmacotherapies for Coronavirus Disease 19 (COVID-19)". Mayo Clin. Proc. 95 (6): 1213–1221. doi:10.1016/j.mayocp.2020.03.024. PMC 7141471 Check |pmc= value (help). PMID 32359771 Check |pmid= value (help).
  12. ↑ 12.0 12.1 Sandroni C, Skrifvars MB, Nolan JP (2021). "The impact of COVID-19 on the epidemiology, outcome and management of cardiac arrest". Intensive Care Med. 47 (5): 602–604. doi:10.1007/s00134-021-06369-3. PMC 7904033 Check |pmc= value (help). PMID 33629117 Check |pmid= value (help).
  13. ↑ 13.0 13.1 13.2 Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C; et al. (2020). "Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study". Lancet Public Health. doi:10.1016/S2468-2667(20)30117-1. PMC 7255168 Check |pmc= value (help). PMID 32473113 PMID: 32473113 Check |pmid= value (help).
  14. ↑ Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ (2020). "Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans". Heart Rhythm. doi:10.1016/j.hrthm.2020.04.045. PMC 7198426 Check |pmc= value (help). PMID 32380288 PMID: 32380288 Check |pmid= value (help).
  15. ↑ 15.0 15.1 Wu CI, Postema PG, Arbelo E, Behr ER, Bezzina CR, Napolitano C, Robyns T, Probst V, Schulze-Bahr E, Remme CA, Wilde A (March 2020). "SARS-CoV-2, COVID-19, and inherited arrhythmia syndromes". Heart Rhythm. doi:10.1016/j.hrthm.2020.03.024. PMC 7156157 Check |pmc= value (help). PMID 32244059 Check |pmid= value (help). Vancouver style error: initials (help)
  16. ↑ Tam, Chor-Cheung Frankie; Cheung, Kent-Shek; Lam, Simon; Wong, Anthony; Yung, Arthur; Sze, Michael; Lam, Yui-Ming; Chan, Carmen; Tsang, Tat-Chi; Tsui, Matthew; Tse, Hung-Fat; Siu, Chung-Wah (2020). "Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment–Elevation Myocardial Infarction Care in Hong Kong, China". Circulation: Cardiovascular Quality and Outcomes. 13 (4). doi:10.1161/CIRCOUTCOMES.120.006631. ISSN 1941-7713.
  17. ↑ Scquizzato, Tommaso; Olasveengen, Theresa Mariero; Ristagno, Giuseppe; Semeraro, Federico (2020). "The other side of novel coronavirus outbreak: Fear of performing cardiopulmonary resuscitation". Resuscitation. 150: 92–93. doi:10.1016/j.resuscitation.2020.03.019. ISSN 0300-9572.
  18. ↑ Sultanian P, Lundgren P, Strömsöe A, Aune S, Bergström G, Hagberg E; et al. (2021). "Cardiac arrest in COVID-19: characteristics and outcomes of in- and out-of-hospital cardiac arrest. A report from the Swedish Registry for Cardiopulmonary Resuscitation". Eur Heart J. 42 (11): 1094–1106. doi:10.1093/eurheartj/ehaa1067. PMC 7928992 Check |pmc= value (help). PMID 33543259 Check |pmid= value (help).
  19. ↑ 19.0 19.1 Shao F, Xu S, Ma X, Xu Z, Lyu J, Ng M, Cui H, Yu C, Zhang Q, Sun P, Tang Z (June 2020). "In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China". Resuscitation. 151: 18–23. doi:10.1016/j.resuscitation.2020.04.005. PMC 7151543 Check |pmc= value (help). PMID 32283117 Check |pmid= value (help).
  20. ↑ Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui D, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS (April 2020). "Clinical Characteristics of Coronavirus Disease 2019 in China". N. Engl. J. Med. 382 (18): 1708–1720. doi:10.1056/NEJMoa2002032. PMC 7092819 Check |pmc= value (help). PMID 32109013 Check |pmid= value (help). Vancouver style error: initials (help)
  21. ↑ Paul P (May 2020). "Cardiac Troponin-I may be a predictor of complications and mortality in COVID-19 patients". Curr Med Res Pract. doi:10.1016/j.cmrp.2020.05.001. PMC 7204698 Check |pmc= value (help). PMID 32382587 Check |pmid= value (help).
  22. ↑ Edelson, Dana P.; Sasson, Comilla; Chan, Paul S.; Atkins, Dianne L.; Aziz, Khalid; Becker, Lance B.; Berg, Robert A.; Bradley, Steven M.; Brooks, Steven C.; Cheng, Adam; Escobedo, Marilyn; Flores, Gustavo E.; Girotra, Saket; Hsu, Antony; Kamath-Rayne, Beena D.; Lee, Henry C.; Lehotsky, Rebecca E.; Mancini, Mary E.; Merchant, Raina M.; Nadkarni, Vinay M.; Panchal, Ashish R.; Peberdy, Mary Ann R.; Raymond, Tia T.; Walsh, Brian; Wang, David S.; Zelop, Carolyn M.; Topjian, Alexis A.; Starks, Monique Anderson; Bobrow, Bentley J.; Chan, Melissa; Berg, Katherine; Duff, Jonathan P.; Joyner, Benny L.; Lasa, Javier J.; Levy, Arielle; Mahgoub, Melissa; O’Connor, Michael F.; Hoover, Amber V.; Rodriguez, Amber J.; Meckler, Garth; Roberts, Kathryn; Mohr, Nicholas M.; Nassar, Boulos; Rubinson, Lewis; Sutton, Robert M.; Schexnayder, Stephen M.; Kleinman, Monica; de Caen, Allan; Morgan, Ryan; Bhanji, Farhan; Fuchs, Susan; Terry, Mark; McBride, Mary; Levy, Michael; Cabanas, Jose G.; Tan, David K.; Moitra, Vivek K.; Szokol, Joseph W. (2020). "Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19". Circulation. 141 (25). doi:10.1161/CIRCULATIONAHA.120.047463. ISSN 0009-7322.


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