Harm from CPR to Victims Not in Cardiac Arrest (BLS #353): Systematic Review

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This CoSTR is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final COSTR will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

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: (none applicable)

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: (none applicable)

CoSTR Citation

Svavarsdottir H, Olasveengen TM, Mancini MB, Avis S, Brooks S, Castren M, Chung S, Considine J, Kudenchuk P, Perkins G, Ristagno G, Semeraro F, Smith C, Smyth M , Morley PT, -on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force.

Harm from CPR to Victims Not in Cardiac Arrest Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 2019 Dec 28th. Available from:

Methodological Preamble

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of basic life support conducted by Hildigunnur Svavarsdottir and Theresa M. Olasveengen with involvement of clinical content experts. Evidence for adult literature was sought and considered by the Basic Life Support Adult Task Force. These data were taken into account when formulating the Treatment Recommendations.


The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Among adults and children who are not in cardiac arrest (CA) out-side of a hospital (OHCA)

Intervention: Does provision of chest compressions from lay rescuers

Comparators: Compared with no use of chest compressions.

Outcomes: Change survival with favorable neurological / functional outcome at discharge, 30 days, 60 days, 180 days, and/or 1 year; harm (e.g. rib fracture); complications; major bleeding; risk of complications (e.g. aspiration); survival only at discharge, 30 days, 60 days, 180 days and/or 1 year; survival to admission

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded. It is anticipated that there will be insufficient studies from which to draw a conclusion; case series and case reports will also be included in the initial search.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to October 13th 2019.

Consensus on Science

For the important outcome of “harm” we identified very low certainty evidence (downgraded for risk of bias and imprecision) from 4 observational studies enrolling 762 patients who were not in cardiac arrest and received CPR by lay rescuers outside the hospital. Three of the studies (White 2010, 91; Haley 2011, 282; and Moriwaki 2012, 3) reviewed the medical records to identify harm, and 1 included follow-up telephone interviews (White 2010, 91). Pooled data from the first 3 studies, encompassing 345 patients, found an incidence of rhabdomyolysis of 0.3% (one case), bone fracture (ribs and clavicle) of 1.7% (95% CI, 0.4–3.1%), pain in the area of chest compression of 8.7% (95% CI, 5.7–11.7%), and no clinically relevant visceral injury. The fourth study (Tanaka 2014, 1751) relied on fire department observations at the scene, and there were no reported injuries in 417 patients.

Treatment Recommendations

We recommend that lay persons initiate CPR for presumed cardiac arrest without concerns of harm to patients not in cardiac arrest (strong recommendation, very low certainty evidence).

Justification and Evidence to Decision Framework Highlights

In making this discordant recommendation (strong recommendation based on very low certainty evidence), the BLS Task Force placed a much higher value on the potential survival benefits of CPR initiated by lay persons for patients in cardiac arrest, and a lower value on the low risk of injury in patients not in cardiac arrest. The intention of this recommendation is to strongly encourage and support lay rescuers who are willing to initiate CPR in any setting when they believe someone to have suffered from a cardiac arrest. The intention is also to support emergency medical dispatchers or telecommunicators in their efforts to provide telephone assisted CPR instructions in suspected cardiac arrest calls.

Knowledge Gaps

Current knowledge gaps include but are not limited to:

  • Studies to identify harm and provide follow-up after hospital discharge. Many of the conditions prompting initiation of CPR for persons not in cardiac arrest are associated with reduced responsiveness and have poor prognosis. Whether chest compressions and rescue breaths could accentuate these conditions independent of physical injury, though unlikely, is not known at the present time.
  • The incidence of chest wall bone fractures was substantially lower than the incidence reported after CPR in patients who were in cardiac arrest. This is likely the result of shorter duration of CPR (approximately 6 min) initiated by laypersons but stopped by professional rescuers, and younger patient age in the studies reviewed. However, the possibility of under reporting due to non-systematic diagnostic studies cannot be excluded, and further research is warranted.
  • Could the accuracy of dispatcher-assisted protocol be enhanced to reduce the frequency of CPR performed on patients not in cardiac arrest without compromising the initiation of CPR on patients in cardiac arrest?


Evidence-to-Decision Table: BLS-353 Harm from CPR to victims not in arrest


Haley KB, Lerner EB, Pirrallo RG, Croft H, Johnson A, Uihlein M. The frequency and consequences of cardiopulmonary resuscitation performed by bystanders on patients who are not in cardiac arrest. Prehosp Emerg Care. 2011;15(2):282-7.

Moriwaki Y, Sugiyama M, Tahara Y, Iwashita M, Kosuge T, Harunari N, Arata S, Suzuki N.

Complications of bystander cardiopulmonary resuscitation for unconscious patients without cardiopulmonary arrest. J Emerg Trauma Shock. 2012;5(1):3-6.

Tanaka Y, Nishi T, Takase K, Yoshita Y, Wato Y, Taniguchi J, Hamada Y, Inaba H. Survey of a protocol to increase appropriate implementation of dispatcher-assisted cardiopulmonary resuscitation for out-of-hospital cardiac arrest. Circulation. 2014;129(17):1751-60

White L, Rogers J, Bloomingdale M, Fahrenbruch C, Culley L, Subido C, Eisenberg M, Rea T. Dispatcher-assisted cardiopulmonary resuscitation: risks for patients not in cardiac arrest. Circulation. 2010;121(1):91-7.

Systematic Review


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