Last month’s Heart Beats article “Beyond 911” highlighted how a tiered response system contributed to improving the survival in Out of Hospital Cardiac Arrests (OHCA). The most important keys to survival were found to be early CPR and early defibrillation(shocking). This article will take a closer look at CPR in OHCA and the effect that COVID has had on CPR.

Throughout the world the importance of improving survival in OHCA was recognized and in 1992 the International Liaison Committee of Resuscitation (ILCOR) was founded. It meets every 5 years to update resuscitation standards with most recent standards released in 2020. (

One of the first standardized tools developed was the “Chain of Survival” to help the public provide the most efficient care for someone collapsing from a cardiac arrest.

Ambulance response times have been optimized but it can take 6 to 8 minutes for an ambulance to arrive thus a “tiered response” system was developed with fire services that improved response times by about 3 minutes. Further advancement for the initiation of CPR was needed and Dispatcher CPR was introduced, decreasing the time for initiation of CPR even further by the 911 operator giving instructions on how to perform CPR.

With the time from collapse to the start of compressions being one of the two cornerstones for survival, public or “bystander” CPR has been promoted extensively. Despite the push for CPR training the highest incidence of bystander CPR is only 42%.

But, and a big but, what has happened to bystander CPR since COVID? Fire services and EMS must put on Personal Protective Equipment (PPE) which has increased their time to get to the patients’ side making bystander CPR even more important. However, an international study in 2020, with a prominence of Canadian data, indicated a significant decrease in the willingness to provide CPR during the pandemic. This is not surprising especially if the patient is a stranger.

With the pandemic related decrease in bystander CPR, a study was undertaken in King County Washington to look at the risk of dying from CPR related COVID and compared it to the missed opportunities of a patient surviving a cardiac arrest. They estimated that 1 rescuer might die from COVID in 10,000 bystander CPR events. By comparison, if 10,000 bystanders provided CPR more than 300 additional lives would be saved.  A 300 fold difference. Depending on one’s personal situation, this may be an insignificant number especially if it is a family member but, on the other hand it may be a significant number if you are a stranger or have COVID risk factors.

COVID, by its nature, has increased the hesitancy for bystanders to provide the rescue breathing component of CPR. Fortunately, recent studies have shown that compression only CPR with an adequate rate (105-120) and compression depth (2 inches) may be as good as compressions and breathing. This may allay the concerns some bystanders have in providing CPR.

With all of these factors in mind, ILCOR has modified its bystander CPR recommendations for COVID as follows:

Lay Rescuers

Bystander CPR has consistently been shown to improve the likelihood of survival from out-of-hospital cardiac arrest, which decreases with every minute that CPR and defibrillation are delayed. Rescuers in the community are unlikely to have access to adequate PPE and therefore may be at increased risk of exposure to COVID-19 during CPR compared with healthcare providers with adequate PPE. Rescuers with increasing age and the presence of comorbid conditions such as heart disease, diabetes mellitus, hypertension, and chronic lung disease4 are at increased risk of becoming critically ill if infected with severe acute respiratory syndrome coronavirus. However, when the cardiac arrest occurs at home (as has been reported in 70% of out-of-hospital cardiac arrests before the recent widespread shelter-at-home ordinances), lay rescuers are likely to have already been exposed to COVID-19(

Chest Compressions
  • For adults: Lay rescuers should perform at least hands-only CPR after recognition of a cardiac arrest event, if willing and able, especially if they are household members who have been exposed to the patient at home. A face mask or cloth covering the mouth and nose of the rescuer and/or patient may reduce the risk of transmission to a nonhousehold bystander.
  • For children: Lay rescuers should perform chest compressions and consider mouth-to-mouth ventilation, if willing and able, given the higher incidence of respiratory arrest in children, especially if they are household members who have been exposed to the patient at home. A face mask or cloth covering the mouth and nose of the rescuer and/or patient may reduce the risk of transmission to a nonhousehold bystander if unable or unwilling to perform mouth-to-mouth ventilation.

We are living in a very unique time and for this, unique solutions will be needed.


 Dr. Andrew Affleck CCFP(EM) FIFEM
Board Member, Northern Hearts