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

Summary

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 [1]. 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) [7]. 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 [8]. 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? [3].  
 
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 [4]. 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 [4]. 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 [2]. 

Evidence

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. 

Organizational Scan

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 [17]. 

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 [18]. 

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	Methods: searched MEDLINE, Embase, Cochrane and the World Health Organization COVID-19 database on March 24th, 2020. Studies were assessed for risk of bias and used the GRADE process to assess evidence certainty.   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
COVID-19: guidance for first responders — Government of the United Kingdom	National Guidance	If one performs mouth-to-mouth ventilation, no additional actions need to be taken other than monitoring yourself for symptoms of possible COVID-19 over the following 14 days, unless the individual had been confirmed to be positive for SARS-CoV-2 in the last 10 days.  In this scenario of direct mouth-to-mouth contact with a known case, advice on self-isolation should be followed.  Last Updated: September 21, 2020
Providing CPR or Rescue Breathing During a Pandemic: Ethical Considerations for Shelter Workers and Volunteers — Alberta Health Services	Provincial Guidance	During the pandemic, there is an elevated level of risk from providing CPR.  In making a decision, it may be helpful to ask the following questions: 1) Do the expected benefits justify the risks?; 2) Am I willing to assume the risks to myself and others around me?; and 3) Does my decision treat people fairly?  Last Updated: July 15, 2020
European Resuscitation Council COVID-19 Guidelines — European Resuscitation Council	Professional Organization Guidance	Lay bystanders should protect themselves and avoid actions with a high risk of transmission.   Consider placing a cloth/towel over the person’s mouth and nose before performing chest compressions and defibrillation.   Wash or disinfect hands after CPR.   Recommendations for children include placing a surgical mask over the child’s mouth and nose, providing compression-only CPR.   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	Recognize cardiac arrest only 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).  Last Updated: May 12, 2020
Cardiopulmonary Resuscitation During COVID-19 Pandemic A View From Trainees on the Front Line — DeFilippis et al.	Single Study	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 (i.e., first responders when a patient is in cardiopulmonary arrest) 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 (i.e., those on the phone instructing a bystander how to start chest compressions before responders arrive) 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
CPR in the Covid-19 Era – An Ethical Framework — Kramer et al.	Perspective Piece	General principles can be translated into three specific recommendations for crisis standards for CPR: 1) acknowledging resource constraints when discussing goals of care and DNR (do not resuscitate) status; 2) forgoing CPR in certain circumstances; and 3) ensuring the safety of healthcare personnel justifies constraints on resuscitation.  Last Updated: July 8, 2020
COVID-19: Aerosol Generating Medical Procedures (AGMPs) — Public Health Ontario	Organizational Scan	Last Updated: May 12, 2020
Adult CPR Protocol for Suspect and Confirmed Cases of COVID-19 — British Columbia Center for Disease Control	Organizational Scan	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.