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Updated: July 13, 2020

How can someone safely do CPR in community settings throughout the COVID-19 pandemic?

Summary

The following is a summary of evidence sources that provide high quality information on how to safely perform cardiopulmonary resuscitation (CPR) in a community setting during the COVID-19 pandemic. For additional information about each of the sources, see the Table below.

A review on COVID-19 in cardiac arrest and infection risk to rescuers, based on the limited evidence available, concluded it is unclear whether chest compressions or defibrillation are aerosolizing procedures and the risk of transmission of COVID-19 to lay rescuers [1]. The authors of two single studies and one guidance from the European Resuscitation Council state that bystanders should protect themselves regardless from the risk of COVID-19 transmission from an infected patient and should be acutely aware of potential risks if they are at high-risk of a poor outcome in the event of transmission (e.g., any comorbidities) [2,4,5]. The Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR single study states that bystanders should prioritize rapid identification of cardiac arrest by looking for the absence of signs of life and normal breathing without the look, listen and feel technique [4]. A review, two single studies and one guidance document encourages bystanders to use automated external defibrillator (AEDs), and/or use compression only CPR, and use personal protective equipment (PPE) to reduce risk of rescuer and/or victim [1,4,5,6]
  
Guidance from the European Resuscitation Council COVID-19 and the American Heart Association recommend that basic life support for suspected or confirmed COVID-19 are: 1) identify if person is unresponsive and not breathing normally, assess responsiveness by shaking and shouting and assess normal breathing visually but do not open the airway and do not place face next to victims’ mouth/nose; 2) if unresponsive and not breathing normally, call emergency medical services; 3) if possible, use a phone with a hand-free option to communicate with the emergency medical dispatch centre during CPR; 4) consider placing a cloth/towel over the person’s mouth and nose before performing chest compressions and public-access defibrillation; 5) follow instructions by emergency medical dispatch centre; and 6) after providing CPR, lay rescuers should wash hands thoroughly with soap and water or disinfect with an alcohol-based hand-gel as soon as possible [2,6]. This guidance also offers recommendations for children, which include: 1) assess breathing visually (chest rise), optionally by placing a ‘hand on the belly’ but do not approach victim’s mouth or nose; 2) if there are two or more rescuers, a second rescuer should call Emergency Medical Services immediately; and 3) place a surgical mask over the child’s mouth and nose, then provide at least compression-only CPR 2. Use of a cloth is not advised due to potential risk of airway obstruction and/or restriction of passive air movement; 4) unless a primary cardiac origin is likely (‘sudden witnessed collapse’), rescuers should open the airway and provide rescue breaths, if willing and able, knowing this likely increases risk of infection but can significantly improve outcome; and 5) if trained, use an AED 2

Evidence

What‘s Trending on Social Media and Media

The Heart and Stroke Foundation has issued a modification to public hands-only CPR during the COVID-19 pandemic. The modified steps include: 1) check for signs of cardiac arrest by observing if the person is breathing; 2) call 9-11; 3) prevent contamination by laying a cloth, towel ro clothing over the person’s mouth; 4) provide hands-only CPR; and 5) use an automated external defibrillator, if available. 
 
 @HeartCPR is the official twitter account for the American Heart Association CPR and First Aid. This account provides daily tweets that help teach the public how to properly administer CPR and other life-saving strategies during COVID-19. 

Organizational Scan

As per Ontario Health (25th March 2020), cardiopulmonary resuscitation is an aerosol generating medical procedure (AGMP) [7]. In patients with suspected or confirmed COVID-19, it should only be undertaken with reasonable prospects of success. If cardiopulmonary resuscitation is attempted, aerosol precautions, including an N95 mask must be used. While chest compression and AED use are not AGMPs, procedures in cardiopulmonary resuscitation, such as Endotracheal intubation, and manual ventilation are AGMPs and must be undertaken only with aerosol precautions, including an N95 mask. 
The Centre for Disease Control has suggested that Emergency Medical Service clinicians should exercise caution if a potentially aerosol-generating procedure such as resuscitation involving emergency intubation or cardiopulmonary resuscitation (CPR) is necessary, and if possible, to consult with medical control before performing these procedures for specific guidance [8]

Review of Evidence

Resource Type/Source of Evidence Last Updated
COVID-19 in cardiac arrest and infection risk to rescuers: A systematic review
— Couper et al.
Systematic Review

The review notes that it is uncertain whether chest compressions or defibrillation cause aerosol generation or transmission of COVID-19 to rescuers. In developing practice recommendations, guideline writers must balance an unknown potential infection risk to rescuers against the known risk to the patient from treatment delays. 

Last Updated: April 19, 2020
European Resuscitation Council COVID-19 Guidelines
— European Resuscitation Council
Professional Organization Guidance

This guideline states that lay bystanders should protect themselves and avoid action with a high risk of transmission, especially if they themselves are at high-risk of poor outcome in the event of transmission (e.g., elderly, chronic lung disease, heart disease).   Recommendations for basic life support for suspected or confirmed COVID-19 are: 1) identify if person is unresponsive and not breathing normally, assess responsiveness by shaking and shouting and assess normal breathing visually but do not open the airway and do not place face next to victims’ mouth/nose; 2) if unresponsive and not breathing normally, call emergency medical services; 3) if possible, use a phone with a hand-free option to communicate with the emergency medical dispatch centre during CPR; 4) consider placing a cloth/towel over the person’s mouth and nose before performing chest compressions and public-access defibrillation; 5) follow instructions by emergency medical dispatch centre; and 6) after providing CPR, lay rescuers should wash hands thoroughly with soap and water or disinfect with an alcohol-based hand-gel as soon as possible. Contact local health authorities to inquire about screening.   Recommendations for children: 1) assess breathing visually (chest rise), optionally by placing a ‘hand on the belly’ but do not approach victim’s mouth or nose; 2) if there are two or more rescuers, a second rescuer should call EMS immediately; 3) place a surgical mask over the child’s mouth and nose, then provide at least compression-only CPR. Use of a cloth is not advised due to potential risk of airway obstruction and/or restriction of passive air movement; 4) unless a primary cardiac origin is likely (‘sudden witnessed collapse’), rescuers should open the airway and provide rescue breaths, if willing and able, knowing this likely increases risk of infection but can significantly improve outcome; 5) if trained, use an automated external defibrillator (AED). 

Last Updated: April 23, 2020
Resuscitation Council UK Statement on COVID-19 in relation to CPR and resuscitation in first aid and community settings
— Resuscitation Council United Kingdom
Professional Organization

The Resuscitation Council of United Kingdom released a statement on COVID-19 and resuscitation in community settings advising to recognise cardiac arrest only by looking for the absence of signs of  life and normal breathing, without the look, listen, and feel technique. 

Last Updated: May 12, 2020
Cardiopulmonary Resuscitation During COVID-19 Pandemic A View From Trainees on the Front Line
— DeFilippis et al.
Single Study

This study describes that there are concerns about clinical safety during CPR because it is an aerosol generating procedure. All healthcare providers must don full PPE (including N95s) before  entering the room even if it delays resuscitation efforts. Add PPE to code carts and equip all code  blue team members with full PPE at the start of their shifts. 

Last Updated: June 8, 2020
Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR
— Sayre et al.
Single Study

This study stresses the importance of balance depending on risk of COVID-19 transmission from infected patients and the disease’s prevalence among all out-of-hospital cardiac arrests (OHCAs). The study authors recommend telecommunicators and bystanders prioritize rapid identification of cardiac arrest and proceed immediately to chest compressions and use of a defibrillator. Delaying bystander CPR to implement PPE should only be considered when the prevalence of COVID-19 is substantially increased.  

Last Updated: June 3, 2020
Interim Guidance for Basic and Advanced Life Support in Adults, Children and Neonates With Suspected or Confirmed COVID-19
— Edelson et al.
Guidance

This guidance from the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association states that when out-of-hospital cardiac arrest occurs at home, lay rescuers are likely to already have been exposed to COVID-19.     For adults, this guidance recommends lay rescuers perform at least hands-only CPR, if willing and able, especially if they are household members of the victim. For children, this guidance recommends lay rescuers perform chest compressions and mouth-to-mouth ventilation, if willing and able, especially if they are household members of the victim.  For both adults and children, use of a face mask or cloth covering the mouth and nose of the rescuer and/or victim may reduce risk of transmission to a non-household bystander. If available, lay rescuers are recommended to use an automated external defibrillator (AED) as it is not expected to be a highly aerosolizing procedure. 

Last Updated: April 8, 2020
Personal Protective Equipment (PPE) use during the COVID-19 Pandemic
— Ontario Health
Organizational Scan Last Updated: March 24, 2020
Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States
— CDC: Centers for Disease Control and Prevention
Organizational Scan Last Updated: March 9, 2020
Disclaimer: The summaries provided are distillations of reviews that have synthesized many individual studies. As such, summarized information may not always be applicable to every context. Each piece of evidence is hyperlinked to the original source.

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