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
Frances Williamson, Masashi Okubo, Pek Jen Heng, Abel Martinez Mejias, Wei-Tien Chang, Matthew Douma, Jestin Carlson, James Raitt and Therese Djärv on behalf of the International Liaison Committee on Resuscitation First Aid Task Force. Unintentional injury by laypersons chest compressions to patients who are not in cardiac arrest: A systematic review
Methodological Preamble and Link to Published Systematic Review
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 (Ashoor, 2017, 50300 – PROSPERO citation) conducted by the Knowledge Synthesis Unit at St Michael’s Hospital, Toronto, Canada with involvement of clinical content experts. Evidence for adult and pediatric literature was sought and considered by the Basic Life Support Adult Task Force and the Pediatric Task Force groups respectively. Additional scientific literature was published after the completion of the systematic review and identified by the Pediatric Task Force, and is described before the justifications and evidence to decision highlights section of this CoSTR. These data were taken into account when formulating the Treatment Recommendations. In 2020, the International Liaison Committee on Resuscitation (ILCOR) published a consensus on science with treatment recommendations (CoSTR), for the important outcome of “harm,” identified very-low-certainty evidence and concluded with a strong recommendation that laypersons initiate CPR for presumed cardiac arrest without concerns of harm to patients not in cardiac arrest. It was noted, under justifications, by the Task Force, that they 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 the recommendation was 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. Further, the intention was also to support emergency medical dispatchers or telecommunicators in their efforts to provide telephone assisted CPR instructions in suspected cardiac arrest calls. Knowing the harm of CPR in patients not in cardiac arrest is of great importance in making recommendations for lay persons. This systematic review was performed on behalf of the ILCOR First Aid Task Force. The term harm was changed to unintentional injury since harm is more related to intentional than unintentional.
Systematic Review
Williamson Frances HPJ, Okubo Masashi, Martinez Mejias Abel, Chang Wei-Tien, Douma Matthew, Carlson Jestin, Raitt James, Djärv Therese. Does delivering chest compressions to patients who are not in cardiac arrest cause unintentional injury? A systematic review. Resuscitation Plus. 2024;20.
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PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Adults and children who are not in cardiac arrest (CA) out-side of a hospital
Intervention: Provision of chest compressions from lay persons
Comparators: No use of chest compressions
Outcomes: Survival with favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days, and/or 1 year; unintentional physical injury (previous ‘harm’) (e.g. rib fracture, bleeding); risk of injury (e.g. aspiration)
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
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 was done October 6 2023 and updated to September 17 2024.
PROSPERO Registration CRD42023476764.
Consensus on Science
One study (Ng 2022, 266) compared patients not in cardiac arrest who had chest compressions with patients who did not have chest compressions. This study (Ng 2022, 266) reported no complications from CPR in the 173 patients with layperson-CPR when compared to the 130 patients who did not have CPR. Additionally, they identified a non-statistically significant higher percentage of admittance to hospital from ED as well as more deaths in-hospital for those with chest compressions compared to those without. The remaining four studies (White 2010, 91; Haley 2011, 282; Tanaka 2014, 1751 and Moriwaki 2012, 3) reported outcomes in patients not in cardiac arrest given layperson-CPR without any control group. In pooled data from the five studies encompassing 1031 patients, 9 (<1%) had either an unintentional injury or risk of injury and a further 24 (2%) had symptoms such as chest pain or discomfort. According to the authors, no deaths due to CPR were reported, but 61 (6%) died before discharge from hospital.
For the outcome of “unintentional physical injury” we identified low certainty evidence (downgraded for risk of bias and imprecision) from four observational studies (White 2010, 91; Moriwaki 2012, 3; Tanaka 2014, 1751 and Ng 2022, 266) enrolling 954 patients who were not in cardiac arrest and received CPR by lay rescuers outside the hospital. Pooled data found that <1% (n=4) of the patients had a reported fracture (ribs and clavicle) and an incidence of internal bleeding of <1% (one case), asymptomatic tracheal bleeding <1% (one case) and a chest hematoma <1% (one case).
For the outcome of “risk of injury” we identified low certainty evidence (downgraded for risk of bias and imprecision) from four observational studies (White 2010, 91; Haley 2011, 282; Moriwaki 2012, 3 and Ng 2022, 266) enrolling 614 patients who were not in cardiac arrest. Pooled data, found an incidence of rhabdomyolysis of <1% (one case).
We identified low certainty evidence (downgraded for risk of bias and imprecision) from three observational studies (White 2010, 91; Moriwaki 2012, 3 and Ng 2022, 266) enrolling 537 patients who were not in cardiac arrest regarding symptoms. Pooled data found 24 (4%) had chest pain or discomfort.
Treatment Recommendations
We recommend that laypersons initiate CPR for presumed cardiac arrest without concerns of causing unintentional injury (Strong recommendation, low certainty evidence).
We recommend that other rescuers (e.g., trained bystanders, health care professionals and those with a duty to respond) initiate CPR for presumed cardiac arrest without concerns of unintentional injury to patients not in cardiac arrest (Good practice statement).
Justification and Evidence to Decision Framework Highlights
Narrative Reporting of the Evidence to Decision Framework Incorporating Values and Preferences and other domains included in the framework, by Task Force Chairs. Technical Remarks refers to details that helps to provide specificity for the recommendation based on the current science i.e. dosing or timing.
In making this discordant recommendation, the FA Task Force placed a 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 persons who are willing to initiate CPR in any setting when they believe someone to have suffered a cardiac arrest.
The included studies focused on lay persons, i.e. not other persons such as health care professionals or those with a duty to response who might be fully or partly trained in first aid and CPR, but the TF believe that the benefit of starting CPR outweigh the harm and used the indirect evidence to make a good practice statement.
Three studies studies (White 2010, 91; Tanaka 2014, 1751; 3 and Ng 2022, 266) were on different dispatcher protocols for CPR and it might be possible to use these results to support emergency medical dispatchers or telecommunicators in their efforts to provide telephone assisted CPR instructions in suspected cardiac arrest calls, but the TF felt this to be beyond the scope of first aid.
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 (most often less than 5 min) initiated by laypersons but stopped by professional rescuers. However, the possibility of under reporting due to non-systematic diagnostic studies cannot be excluded.
Knowledge Gaps
Current knowledge gaps include but are not limited to:
- More studies are needed with robust methodology to identify unintentional injuries and provide follow-up after hospital discharge.
- There is a possibility of under reporting due to nonsystematic diagnostic studies. Further, as follow up was limited (i.e. many patients were discharged from the ED), it is possible that symptoms occur later.
- Only one (Haley 2011, 282) study included people under 18 years. Children might have a different pattern of both causes and injuries.
- The included studies were from the United States and Asia. Attitudes towards performing layperson CPR might differ between cultures.
- Few aspects of equity were reported in studies, the use of a structure such as Cochranes PROGRESS Plus might increase reporting.
Equity statement:
- Few aspects of equity were reported in studies. The use of a structure equity assessment, such as the Cochrane PROGRESS Plus tool, might increase reporting. The proportion of men and women were roughly equal in the studies. However, in three studies the layperson often had some kind of relationship to the victim, either as a family member or personnel at a nursing home. They might both fear causing an injury and prioritize survival.
ETD summary table: FA 7670 Et D Unintentional injury from CPR
References
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.
Ng JYX, Sim ZJ, Siddiqui FJ, Shahidah N, Leong BS, Tiah L, Ng YY, Blewer A, Arulanandam S, Lim SL, Ong MEH, Ho AFW: Incidence, characteristics and complications of dispatcher-assisted cardiopulmonary resuscitation initiated in patients not in cardiac arrest. Resuscitation. 2022, 170:266-273.
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.