Harm to rescuers from CPR (BLS): Scoping Review

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This Review 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 Review 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)

Task Force Scoping Review Citation

Semeraro F, Svavarsdottir H, Mancini MB, Avis S, Brooks S, Castren M, Chung S, Considine J, Hung K, Kudenchuk P, Nishiyama C, Perkins GD, Ristagno G, Smith C, Smyth M, Morley PT, Olasveengen TM -on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force. Harm to rescuers from CPR - Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 2020 Jan 2nd. Available from: http://ilcor.org

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a scoping review of harm to rescuers from CPR by the ILCOR BLS Task Force Scoping Review team. Evidence for adult literature was sought and considered by the Basic Life Support Adult Task Force.

PICOST

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

Population: In rescuers

Intervention: does performing resuscitation (ventilations, compressions, defibrillation, etc) on adult and pediatric patients with cardiac arrest (out-of-hospital and in-hospital)

Comparators: as opposed to not performing resuscitation

Outcomes: increase the likelihood of harm (eg. Infection, exhaustion, stress, physical harm etc.)?

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion.

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 November 1st, 2019.

Search Strategies

Pubmed (153 records; Period 01/01/2007- 01/11/2019)

((Rescuer OR “Single rescuer” OR “single-rescuer” OR saviour* OR savior* OR deliverer) AND ("Heart Arrest"[Mesh] OR "heart arrest*"[TIAB] OR "cardiac arrest*"[TIAB] OR "cardiovascular arrest*"[TIAB] OR "cardiopulmonary arrest*"[TIAB] OR "cardio-pulmonary arrest*"[TIAB] OR "Out-of-Hospital Cardiac Arrest*"[Mesh] OR OHCA OR "Out of Hospital Cardiac Arrest*"[TIAB] OR "Out-of-Hospital Cardiac Arrest*"[TIAB] OR "Outside-of-Hospital Cardiac Arrest"[TIAB] OR resuscitation [Mesh] OR resuscitation* [TIAB] OR "cardiopulmonary resuscitation"[Mesh] OR "cardiopulmonary resuscitation"[TIAB] OR "Cardio-Pulmonary Resuscitation" OR "Cardio Pulmonary Resuscitation" OR CPR [TIAB] OR "Life Support Care"[Mesh] OR "Basic Cardiac Life Support" OR "basic life support" OR "Cardiac Life Support" [TIAB] OR "cardiorespiratory resuscitation"[TIAB] OR "Heart Massage*"[Mesh] OR “heart massage*”[TIAB] OR “cardiac massage*” [TIAB] OR “chest compression*”[TIAB] OR “cardiac compression*”[TIAB] OR ventilation OR defibrillation OR “Electric countershock” [MeSH Terms] OR “Electric Defibrillation” OR “Automated External Defibrillator*” OR AED)) AND (harm OR harms OR danger* OR injur* OR trauma OR damage OR hurt OR “adverse effects” OR safety OR hazard OR “disease transmission” OR infection [MeSH Terms] OR infection* OR “patient-to-professional” OR stress OR psychological OR exhaustion OR fatigue OR collapse OR burnout))

Embase (249 records; Period 2007- 2019)

(Rescuer OR “Single rescuer” OR “single-rescuer” OR saviour* OR savior* OR deliverer) AND ('heart arrest'/exp OR ('cardiac arrest*' OR 'cardiovascular arrest*' OR 'cardiopulmonary arrest*' OR 'cardio-pulmonary arrest'):ta,ab,kw OR 'out of hospital cardiac arrest'/exp OR (ohca OR 'out-of-hospital cardiac arrest*' OR 'outside-of-hospital cardiac arrest'):ta,ab,kw OR 'heart massage'/exp OR ('cardiopulmonary resuscitation' OR 'cardio-pulmonary resuscitation' OR 'cardio pulmonary resuscitation' OR cpr OR 'basic life support' OR 'cardiorespiratory resuscitation' OR 'heart massage*' OR 'cardiac massage*' OR 'chest compression*' OR 'cardiac compression*' OR ventilation OR defibrillation OR “Electric countershock” OR “Electric Defibrillation” OR “Automated External Defibrillator*” OR AED) :ta,ab,kw) AND (harm OR harms OR danger* OR injur* OR trauma OR damage OR hurt OR “adverse effects” OR safety OR hazard OR “disease transmission” OR infection OR infection* OR “patient-to-professional” OR stress OR psychological OR exhaustion OR fatigue OR collapse OR burnout))

Cochrane (267 records; Period 01/01/2007- 01/11/2019)

((Rescuer OR “Single rescuer” OR “single-rescuer” OR saviour* OR savior* OR deliverer) AND (MeSH descriptor: [Heart Arrest] OR ("cardiac arrest" OR "cardiovascular arrest*" OR "cardiopulmonary arrest*" OR "cardio-pulmonary arrest*"):ti,ab,kw OR MeSH descriptor: [Out-of-Hospital Cardiac Arrest] OR ("cardiopulmonary resuscitation" OR "Cardio Pulmonary Resuscitation" OR CPR OR "Life Support Care" OR "Basic Cardiac Life Support" OR "basic life support" OR "Cardiac Life Support" OR "cardiorespiratory resuscitation"):ti,ab,kw OR MeSH descriptor: [Heart Massage] OR ("cardiac massage*" OR "chest compression*" OR "cardiac compression" OR ventilation OR defibrillation OR “Electric countershock” OR “Electric Defibrillation” OR “Automated External Defibrillator*” OR AED):ti,ab,kw) AND (harm OR harms OR danger* OR injur* OR trauma OR damage OR hurt OR “adverse effects” OR safety OR hazard OR “disease transmission” OR infection [MeSH Terms] OR infection* OR “patient-to-professional” OR stress OR psychological OR exhaustion OR fatigue OR collapse OR burnout))

Inclusion and Exclusion criteria

Inclusion Criteria: human studies.

Exclusion Criteria: animal studies or those that did not describe risk or adverse effects in CPR performers. Abstract only studies and studies not peer reviewed or not answer question.

Data tables

Reference

Methods

Participants

Intervention

Comparisons

Outcomes

Stockwell et al 2009

Case Report

51-year-old male patient

The rescuer, who was performing chest compressions at

the time felt a shock travel up his left arm causing him to cry out and withdraw his hands from the patient’s chest.

Sullivan et al 2012

Experimental studies

Gloves made of four commonly used polymers were tested

Few of the gloves tested limited the current to levels proven to

be safe. A lack of sensation during hands-on defibrillation does not

guarantee that a safety margin exists.

Lloyd et al 2008

Experimental studies

43 hand-on shock in 39 adult patients

Patients undergoing elective cardioversion

None of the 43 shocks were perceptible to the

rescuers.

Deakin et al 2015

Experimental studies

61 shock in 43 adult patients

Patients undergoing elective cardioversion

Rescuers were unable to perceive current flowing for any shocks, irrespective of energy.

Wigh et al 2019

Experimental studies

33 adult patients

Patients undergoing elective cardioversion

No instances of dielectric breakdown occurred, and no shocks were perceptible.

Petley et al 2019

Experimental studies

35 adult patients

Patients undergoing elective cardioversion

Surface voltages (median RMS) to which the rescuer is likely to be exposed are higher when performing chest compressions from the patient’s left side compared with the right (127 V vs 67 V respectively, 95% CI of difference

- 34 V to 67 V, P < 0.0001).

Task Force Insights

1. Why this topic was reviewed.

This topic was suggested by the European Resuscitation Council. The BLS taskforce was supportive of an updated evidence review as this topic had not been reviewed by ILCOR since 2010. The topic was reviewed focusing on any potential harm to the rescuers during CPR, but focusing on harm during chest compressions, mouth to mouth ventilations and with the use of defibrillators.

2. Narrative summary of evidence identified

There were insufficient studies identified to support a more specific systematic review.

Five experimental studies and one case report were identified that were published since 2008. The five experimental studies reported the perception of rescuers in an experimental setting during shock administration for elective cardioversion. During these studies the authors also measured current flow and the average leakage current in different experiments.

3. Narrative Reporting of the task force discussions

We identified many gaps in the published literature. The majority of the studies identified in this review were focused on experimental evaluation of perception of rescuers during shock administration for elective cardioversion and the measurement of energy delivered through the patient’s body. No Randomized Controlled Trials were identified that met our inclusion criteria. This scoping review demonstrated that the majority of studies focused on safety of defibrillation delivery with the use of gloves during chest compression.

Based on previous Worksheet published in 2009 by ILCOR (Author: Sung Oh Hwang) BLS Task Force agree with previous evaluation that the performance of CPR on individuals is generally safe for rescuers. Few reports demonstrate the possibility of disease transmission in the course of performing mouth-to-mouth resuscitation. 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 defibrillator shock with an AED during basic life support is also safe. The incidence and morbidity of defibrillator-related injuries in the rescuers is low.

The BLS Task Force considers the overall body of new evidence identified insufficient to warrant a full systematic review. There are few reports of harm to rescuers from performing CPR and defibrillation identified are supportive of current recommendations that lay rescuers may safely perform CPR and use an automated external defibrillator.

Knowledge Gaps

Very little evidence was identified addressing this question. Future research could explore the psychological and emotional effects lay rescuers experience after resuscitation events, and any potential benefit from providing follow-up to lay rescuers after resuscitation events.

References

Deakin CD, Thomsen JE, Løfgren B, Petley GW. Achieving safe hands-on defibrillation using electrical safety gloves--a clinical evaluation. Resuscitation. 2015 May;90:163-7.

Lloyd MS, Heeke B, Walter PF, Langberg JJ. Hands-on defibrillation: an analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation. 2008 May 13;117(19):2510-4.

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

Stockwell B, Bellis G, Morton G, Chung K, Merton WL, Andrews N, Smith GB. Electrical injury during "hands on" defibrillation-A potential risk of internal cardioverter defibrillators? Resuscitation. 2009 Jul;80(7):832-4.

Sullivan JL, Chapman FW. Will medical examination gloves protect rescuers from defibrillation voltages during hands-on defibrillation? Resuscitation. 2012 Dec;83(12):1467-72.

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


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