Risk for Contracting COVID-19 Via Bystander CPR for Out-of-Hospital Cardiac Arrest is Low

Individuals providing bystander cardiopulmonary resuscitation (CPR) for somebody experiencing out-of-hospital cardiac arrest have a low risk for COVID-19 infection, a new paper suggests.

“The first US case of COVID-19 was documented locally on January 20, 2020, with unrecognized viral transmission until the first death on February 26,” the authors wrote. “Resuscitation of patients in out-of-hospital cardiac arrest, which depends on rapid, coordinated efforts involving laypersons, telecommunicators, prehospital professionals, and hospital providers, may be adversely affected by COVID-19 concerns.”

To evaluate the risk to bystanders administering CPR to these patients, the researchers conducted a cohort analysis of out-of-hospital cardiac arrest attended by EMS services in Seattle and King County, WA, between January and April 2020. They included data where EMS services provided attempted resuscitation (EMS treated) and also when EMS responded but provided no attempted resuscitation due to outward signs of irreversible death. The study included data on 1,067 out-of-hospital cardiac arrests, 478 (44.8%) of which were treated by EMS. Twenty-three patients (2.2%) had lab-confirmed COVID-19 and another 13 patients (1.2%) had COVID-like illness.

According to the analysis, during the active period of COVID-19, there were 537 (50.3%) out-of-hospital cardiac arrests responded to by EMS, and 230 (48.1%) of them were treated. COVID-19 was diagnosed in 3.7% of dead-on-EMS-arrival patients and in 6.5% of cases treated by EMS. After February 26, 26.5% of out-of-hospital cardiac arrests in homes and 11% in nursing homes involved patients with COVID-19 (none in public places). Bystander CPR was provided in 57% of those cases.

“Our results have implications when considering the balance of risks and benefits of changes in out-of-hospital cardiac arrest resuscitation guidelines for bystander CPR,” they continued. “The balance depends on risk of COVID-19 transmission from infected patients and the disease’s prevalence among all out-of-hospital cardiac arrests. Experts question whether chest compressions are a high-risk aerosolizing procedure, especially given bystander CPR is typically provided in only a few minutes. Less than 5% of 121 exposed health care workers without PPE developed symptomatic COVID-19 following intensive care for an infected patient.”

Study limitations included incomplete potential COVID-19 testing and missing patient identifiers.

“As of April 15, our community had 15 deaths per 100,000 population from COVID-19, higher than 42 other states at that time,” the researchers wrote.”COVID-19 was diagnosed in less than 10% of out-of-hospital cardiac arrests. Assuming risk transmission to bystanders performing hands-only CPR without PPE is 10%, treating 100 patients could result in 1 bystander infection. Given a 1% mortality for COVID-19, approximately 1 rescuer might die in 10,000 bystander CPR events. By comparison, bystander CPR saves more than 300 additional lives among 10,000 patients with out-of-hospital cardiac arrest.”

The study was published in Circulation.