The following is a short summary of the available evidence on how to safely perform cardiopulmonary resuscitation (CPR) in a community setting during the COVID-19 pandemic. One systematic review, one national guidance, one provincial guidance, guidance from two professional organization guidelines, two single studies and one perspective piece were identified to answer this question and were used in this REAL Summary. 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 (April 2020), concluded it is unclear whether chest compressions or defibrillation are aerosolizing procedures and the risk of transmission of COVID-19 to lay rescuers and that these conclusions are based on limited evidence . The authors of two single studies, one from the European Resuscitation Council and one guidance from the Resuscitation Council United Kingdom 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) [4-7]. A single study on the Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR (June 2020) 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 (i.e., look for signs of breathing) . A review, one single study and one guidance document encourages bystanders to use automated external defibrillator (AEDs) and/or use compression only to CPR and use personal protective equipment (PPE) to reduce risk to rescuer/victim [1,4,6]. Additionally, information from CPR in the Covid-19 Era – An Ethical Framework (July 2020) and Alberta Health Services (July 2020) discuss ethical considerations surrounding both the person in crisis and the rescuer respectively. It is important to: 1) acknowledge goals of care and do not resuscitate status; 2) forgo CPR in certain circumstances; and 3) ensure that the safety of the healthcare personnel justifies selective constraints on resuscitation . When making a decision, it may be helpful to ask the following: 1) Do the benefits justify the risks?; 2) Am I willing to assume the risk to myself and others around me?; and 3) Does my decision treat people fairly? .
Guidance from the European Resuscitation Council COVID-19 (April 2020) recommends that basic life support for suspected or confirmed COVID-19 are: 1) to identify if the 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 victim’s 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 . This guidance also offers recommendations for children, which include to: 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, and then provide at least compression-only CPR – use of a cloth is not advised with children 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 chance of survival; and 5) if trained, use an AED . If mouth-to-mouth ventilation is performed, no additional actions need to be taken other than monitoring yourself for symptoms of COVID-19 over the following 14-day period, unless the individual had been confirmed to be positive in the last 10 days .
What‘s Trending on Social Media and Media
The Heart and Stroke Foundation (April 2020) has issued a modification to public hands-only CPR during the COVID-19 pandemic. The modified steps include: 1) checking for signs of cardiac arrest by observing if the person is breathing; 2) calling 9-11; 3) preventing contamination by laying a cloth, towel or clothing over the person’s mouth; 4) providing hands-only CPR; and 5) using an automated external defibrillator, if available.
@HeartCPR (January 2021) 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.
As per Public Health Ontario (May 2020), cardiopulmonary resuscitation is an aerosol generating medical procedure (AGMP). 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 British Columbia Centre for Disease Control (September 2020) has provided a new protocol for adult CPR with regards to COVID-19. This is largely applicable for clinical settings but can still be useful information for first responders .
Review of Evidence
|Type/Source of Evidence
COVID-19 in cardiac arrest and infection risk to rescuers: A systematic review
— Couper et al.
COVID-19: guidance for first responders
— Government of the United Kingdom
Providing CPR or Rescue Breathing During a Pandemic: Ethical Considerations for Shelter Workers and Volunteers
— Alberta Health Services
European Resuscitation Council COVID-19 Guidelines
— European Resuscitation Council
|Professional Organization Guidance
Resuscitation Council UK Statement on COVID-19 in relation to CPR and resuscitation in first aid and community settings
— Resuscitation Council United Kingdom
Cardiopulmonary Resuscitation During COVID-19 Pandemic A View From Trainees on the Front Line
— DeFilippis et al.
Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR
— Sayre et al.
CPR in the Covid-19 Era – An Ethical Framework
— Kramer et al.
COVID-19: Aerosol Generating Medical Procedures (AGMPs)
— Public Health Ontario
|Last Updated: May 12, 2020
Adult CPR Protocol for Suspect and Confirmed Cases of COVID-19
— British Columbia Center for Disease Control
|Last Updated: September 3, 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.