BLS 2001 Potential Harms to Rescuers: TF Scoping Review

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: N/A

The following Task Force members and other authors declared an intellectual conflict of interest, and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: N/A

Task Force Synthesis Citation

Lagina AT, Dicker B, Dassanayake V, Dainty K, Morrison LJ, Bray J, on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force. Potential Harms to Rescuers: a Scoping Review. [Internet] International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force BLS 2001: Potential Harms to Rescuers – New Scoping Review 2025. Available from: http://ilcor.org ;

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a scoping review of harms to rescuers conducted by the ILCOR BLS Task Force Scoping Review team. The Basic Life Support Adult Task Force group sought and considered evidence from the adult and pediatric literature.

Scoping Review

Webmaster to insert the Scoping Review citation and link to PubMed using this format when/if it is available.

Lagina AT, Dicker B, Dassanayake V, Dainty K, Morrison LJ, Bray J, on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force. Potential Harms to Rescuers: a Scoping Review. [Internet] in development.

PICOST

Search Strategies

Articles for review were obtained by searching EMBASE, OVID-Medline (ALL), and Cochrane, for all entries from 01 January 1966 to 6 November 2025 (last searched on November 6, 2025).

Articles are using key terms Rescuer, "Single rescuer", "single-rescuer", saviour*, savior*, deliverer, heart arrest, "cardiac arrest*", "cardiovascular arrest*", "cardiopulmonary arrest*", "cardio-pulmonary arrest*", out-of-hospital cardiac arrest, OHCA, "out-of-hospital cardiac arrest*", "outside-of-hospital cardiac arrest", heart massage, "cardiopulmonary resuscitation", "cardio-pulmonary resuscitation", "cardio pulmonary resuscitation", CPR, "basic life support", "cardiorespiratory resuscitation", "heart massage*", "cardiac massage*", "chest compression*", "cardiac compression*", ventilation, defibrillation, "Electric countershock", "Electric Defibrillation", "Automated External Defibrillator*", AED, harm, harms, danger*, injur*, trauma, damage, hurt, "adverse effects", safety, hazard, "disease transmission", infection, infection*, "patient-to-professional", stress, psychological, exhaustion, fatigue, collapse, burnout." including their MESH terms and Embase exploded terms. 

Inclusion and Exclusion criteria

Inclusion Criteria:

• Studies meeting the PEOST published between 01 January 1966 and 6 November 2025 were eligible.

• All languages, as long as there was an English abstract.

• Data from defibrillation and cardioversion on patients who are either presumed to be in cardiac arrest but not confirmed, or confirmed not to be in cardiac arrest, will be used as indirect evidence.

Excluded:

• Unpublished studies (e.g., conference abstracts, trial protocols) and animal studies.

• This review excluded studies that evaluated the use of personal protective equipment (PPE) in minimizing infection because this intervention was systematically reviewed in the ILCOR 2020 systematic review (https://doi.org/10.1016/j.resuscitation.2020.04.022).

• This review excludes fatigue, although fatigue is significant; the duration and level of discomfort do not meet the definition of harm.

• This review excludes psychological harm because the methodology of much of the literature is qualitative or survey-based, and the task force has initiated a specific stand-alone mixed-methods review on this topic.

• This review also excludes all harm and injuries sustained during training and transport.

• This review also excludes all harm and injuries sustained in responding and attempted resuscitation in extreme environments, such as mountainous or high-altitude areas, low-gravity environments, and military deployments

EtD Table: BLS 2001 Rescuer Safety Et D v5 0 SAC approved

Data Table: BLS 2001 Rescuer Safety Data Table v5 0 SAC approved

Task Force Insights

1. Why this topic was reviewed.

BLS Task Force prioritized this topic for review because it had not been reviewed by ILCOR since 2020, and that review only addressed harm to rescuers during CPR.1 The 2020 scoping review identified 5 experimental studies and 1 case report. This 2025 review expands the previous review to identify potential harms involved in responding to a cardiac arrest, including removing the person from water.

In the previous ILCOR 2020 Scoping review on harm to rescuers, the Task Force provided an ungraded treatment recommendation : Evidence supporting rescuer safety during CPR is limited. The few isolated reports of adverse effects resulting from the widespread and frequent use of CPR suggest that performing CPR is relatively safe. Delivery of a defibrillator shock with an AED during BLS is also safe. The incidence and morbidity of defibrillator-related injuries in the rescuers are low.1

The objective of this updated review is to understand potential unintentional harms to the rescuers responding to a cardiac arrest and performing resuscitation (chest compression and mouth-to-mouth ventilation), and with the use of a manual defibrillator and an automated external defibrillator. Also, the act of rescue, such as responding to a cardiac arrest and providing resuscitation in dangerous circumstances such as aquatic environments or other austere locations, is considered.

2. Narrative summary of evidence identified

A total of 20 studies were identified (Data table 1):2-21 11 studies investigated intra-arrest harm to rescuers, including nine reporting on the infection transmission3-7,10,12,14,18 and six reporting on defibrillator-related harms8,15,17,19-21; one study investigated the potential for harm enroute to the patient2 and another during the retrieval of an AED16; and three studied the reported harms during water rescue.9,11,13

Infection

One of the questions investigated by Couper et al. in the 2020 COVID-19​ ​systematic review was to identify transmission of infection associated with chest compression and defibrillation, and they concluded that "It is uncertain whether chest compressions or defibrillation cause aerosol generation or transmission of COVID-19 to rescuers. There is minimal evidence and a rapid need for further studies."22

Nine studies examined infection transmission to rescuers during cardiac arrest response, 3-7,10,12,14,18 including seven with calculable infection rates (N=428 exposed rescuers, 110 infections). 3-5,7,12,18 Studies examined the transmission of various pathogens: COVID-19 (n=3), Severe Fever with Thrombocytopenia Syndrome (SFTS, n=2), SARS-CoV (n=1), Crimean-Congo Hemorrhagic Fever (CCHF, n=1), and Clostridioides difficile contamination (n=1). While significant infection transmission was reported during CPR in most of these studies (Data table 2), there was substantial heterogeneity across pathogens, settings, methods used to estimate transmission rates, and the use of protective measures. In addition, the sample sizes were small, and the confidence intervals were too wide to be confident in the reported infection rates.

Defibrillator-related harm

Six studies reported on potential harms associated with defibrillators 8,15,19-21. Four of these studies reported on the voltage leakage through measurement devices placed on the patient's chest during elective cardioversion, one using insulating gloves 8, one with polyethylene medical gloves 15, and two with polyethylene drapes 20,21. Across all studies, 140 shocks were delivered. Regardless of insulation measures or energy levels (100J, 200J, or 360J), voltage leakage consistently remained below safe thresholds (5mA), indicating minimal risk of harm. Of the 140 shocks, no shocks were perceptible by a rescuer, and three measurements assessing current passing through a rescuer's arms had a detectable current. However, these findings may not reflect real-world conditions, where lay rescuers may use nitrile or latex gloves or go bare-handed, making it uncertain how this translates into practice

One study 17 investigated potential harm from CPR performed near implantable cardioverter defibrillators (ICD). This study indicated potential for voltage leakage above safe thresholds (5mA), indicating risk of harm., which was reduced when chest compressions were performed on the opposite side of the ICD. There was also a single case report 19 of a rescuer performing CPR on the same side as an ICD who experienced a shock that left the rescuer with transient paresthesia lasting approximately 60 minutes in fingers, followed by peripheral symptoms (small sensory nerve action potentials) in fingers that persisted for 6 months. There were no other reports of ICD or other defibrillator harm in real-world settings or large trials.

Harm enroute to the patient or while collecting an AED

A Danish study based on an online survey of 7,000 volunteer responders reported a very low risk of harm (<0.7%) while enroute to cardiac arrest patients, with only one hospitalization for an ankle fracture and 25 minor injuries not requiring medical care. 2 A survey of volunteer community responders showed a high rate (53% of 45 rescuers) of minor injuries (e.g. cuts) mainly from breaking the glass in locked cabinets while attempting to retrieve the AED. 16

Harms in attempting a rescue in aquatic settings

Three studies reported on fatal drownings in attempted rescue in aquatic environments by bystanders. 9,11,13 Two studies (from Turkey and Australia, respectively) reported annual rescue-related fatality rates between 0.02 and 0.08 per 100,000 population 11,13. All three studies reported that most rescue-related fatal drownings occurred while attempting to rescue the rescuer's family members and during the rescue of young people under the age of 44 who were predominantly male 9,11,13.

3. ​​Narrative Reporting of the task force discussions

Only 20 studies were identified that reported on harms, and these were grouped into transmission of infection, electrical injury during defibrillation, injury occurring while attempting to resuscitate or acquire an AED, and injuries associated with attempted rescue in water.

During this scoping review the authors retrieved two studies which were excluded but future reviews may want to expand the inclusion criteria to allow the use of this data to inform on rescuer harm. The study by Gibson et al. (2021) suggests that perhaps future reviews should consider including equipment contamination as an indirect measure for risk of infection to the rescuer. In this observational study they reported widespread contamination of EMS equipment with Clostridioides difficile: 75% of blood pressure cuffs, 95% of pulse oximeters, and 100% of ECG leads were contaminated. While this study did not measure direct infection transmission, it demonstrates the potential for transmission and underscores the importance of equipment decontamination protocols. 23 A second study by Wampler et al (2016) was excluded by definition as it was a simulation study; however, it was a randomized, blinded simulation study that evaluated whether rescuers could detect defibrillation shocks while performing manual chest compressions using various protective barriers on a cadaver. The results showed that nitrile gloves and a neoprene pad prevented perceived detection of defibrillation in 99% of shocks. 24

The task force considered the limited observational data suggesting rescue-related risks are rare with the large number of resuscitations performed globally. The current evidence is insufficient to merit a systematic review. However, the evidence does highlight some areas that the task force felt could be included in a good practice statement, particularly given that identified risks are avoidable. The ungraded treatment recommendation published in 2020 is withdrawn.

​​​Good practice statement

The risk of harm to rescuers during CPR, including defibrillation, may be very low, based on limited available evidence. Documented harmful events are rare and may be associated with removing patients from bodies of water, breaking glass while removing AEDs from cabinets, hands on CPR with an ICD in place, performing CPR on patients with infectious diseases without personal protective equipment and incurring minor injuries while responding to a cardiac arrest (Good Practice Statement).

Knowledge Gaps

Large, well-designed studies evaluating the transmission of infectious agents during resuscitation procedures are needed.

Appropriately powered RCTs comparing the safety of hands-on defibrillation including bare hands, and various gloves in use at the bedside are needed.

The routine collection of rescuer resuscitation-related injuries in OHCA and IHCA registries are needed to provide assurance for the potential rescuer and the system of care.

References

1. Olasveengen TM, Mancini ME, Perkins GD, et al. Adult basic life support: 2020 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2020;142:S41-S91.

2. Andelius L, Hansen CM, Tofte Gregers MC, et al. Risk of physical injury for dispatched citizen responders to out-of-hospital cardiac arrest. Journal of the American Heart Association. 2021;10.

3. Bae S, Chang H-H, Kim S-W, et al. Nosocomial outbreak of severe fever with thrombocytopenia syndrome among healthcare workers in a single hospital in Daegu, Korea. International Journal of Infectious Diseases. 2022;119:95-101.

4. Botan E, Uyar E, Ozturk Z, et al. COVID-19 Transmission and Clinical Features in Pediatric Intensive Care Health Care Workers. Turkish archives of pediatrics. 2022;57:93-98.

5. Brown A, Schwarcz L, Counts CR, et al. Risk for acquiring coronavirus disease illness among emergency medical service personnel exposed to aerosol-generating procedures. Emerging infectious diseases. 2021;27:2340.

6. Chalumeau M, Bidet P, Lina G, et al. Transmission of Panton-Valentine leukocidin-producing Staphylococcus aureus to a physician during resuscitation of a child. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2005;41:e29-30.

7. Christian MD, Loutfy M, McDonald LC, et al. Possible SARS coronavirus transmission during cardiopulmonary resuscitation. Emerging infectious diseases. 2004;10:287.

8. Deakin CD, Thomsen JE, Lofgren B, et al. Achieving safe hands-on defibrillation using electrical safety gloves--a clinical evaluation. Resuscitation. 2015;90:163-167.

9. Franklin RC, Peden AE, Brander RW, et al. Who rescues who? Understanding aquatic rescues in Australia using coronial data and a survey. Australian and New Zealand journal of public health. 2019;43:477-483.

10. Ghazali DA, Ouersighni A, Gay M, et al. Feedback to Prepare EMS Teams to Manage Infected Patients with COVID-19: A Case Series. Prehospital and disaster medicine. 2020;35:451-453.

11. Işın A, Turgut A, Peden AE. Descriptive epidemiology of Rescue-Related fatal drowning in turkey. International journal of environmental research and public health. 2021;18:6613.

12. Kim WY, Choi W, Park S-W, et al. Nosocomial transmission of severe fever with thrombocytopenia syndrome in Korea. Clinical Infectious Diseases. 2015;60:1681-1683.

13. Lawes JC, Rijksen EJ, Brander RW, et al. Dying to help: Fatal bystander rescues in Australian coastal environments. PLoS One. 2020;15:e0238317.

14. Liu W, Tang F, Fang LQ, et al. Risk factors for SARS infection among hospital healthcare workers in Beijing: a case control study. Tropical Medicine & International Health. 2009;14:52-59.

15. Lloyd MS, Heeke B, Walter PF, et al. Hands-on defibrillation: an analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation. 2008;117:2510-2514.

16. NG Jonathan Shen You , HO Reuben Jia Shun , YU Jae Yong, et al. Factors influencing success and safety of AED retrieval in out of hospital cardiac arrests in Singapore. The Korean Journal of Emergency Medical Services. 2022;26:97-111.

17. Petley GW, Albon B, Banks P, et al. Leakage current from transvenous and subcutaneous implantable cardioverter defibrillators (ICDs): A risk to the rescuer? Resuscitation. 2019;137:148-153.

18. Soni L, Maitra S, Ray BR, et al. Risk of sars-cov-2 infection among health-care providers involved in cardiopulmonary resuscitation in covid-19 patients. Indian J Crit Care Med. 2021;25:921-923.

19. Stockwell B, Bellis G, Morton G, et al. Electrical injury during "hands on" defibrillation-A potential risk of internal cardioverter defibrillators? Resuscitation. 2009;80:832-834.

20. Wight JA, Iravanian S, Haouzi AA, et al. Hands-on defibrillation with a safety barrier: An analysis of potential risk to rescuers. Resuscitation. 2019;138:110-113.

21. Wight JA, Bigham TE, Hanson PR, et al. Hands-on defibrillation with safety drapes: Analysis of compressions and an alternate current pathway. American Journal of Emergency Medicine. 2022;52:132-136.

22. Couper K, Taylor-Phillips S, Grove A, et al. COVID-19 in cardiac arrest and infection risk to rescuers: A systematic review. Resuscitation. 2020;151:59-66.

23. Gibson CV, Swindell JE, Collier GD. Assessment of prehospital monitor/defibrillators for Clostridioides difficile contamination. Prehospital and Disaster Medicine. 2021;36:412-413.

24. Wampler D, Kharod C, Bolleter S, et al. A randomized control hands-on defibrillation study—barrier use evaluation. Resuscitation. 2016;103:37-40.