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COVID-19 in Cardiac Arrest and Infection Risk to Rescuers: A Systematic Review

Leads: Dr Amy Grove (Public Health), Prof Gavin Perkins, Dr Keith Couper (Acute Care Interfaces)

Rapid response research.

Dates: March 2020 - April 2020


There may be a risk of COVID-19 transmission to rescuers delivering treatment for cardiac arrest. Current resuscitation guidelines highlight the importance of rescuer safety. Delaying the delivery of chest compressions and defibrillation for up to several minutes for healthcare workers to don personal protective equipment (PPE) will reduce the likelihood of patient survival. In contrast, the delivery of aerosol generating procedures to a patient infected with COVID-19 may place healthcare workers at risk. Driven by concern amongst the clinical community as to the optimum approach in cardiac arrest, the International Liaison Committee on Resuscitation (ILCOR) identified the urgent need for a review of current evidence to inform international resuscitation treatment recommendations in patients where there is a risk that they have COVID-19.

Policy and Practice Partners:

The review was undertaken on behalf of the International Liaison Committee on Resuscitation, Consensus on Science with Treatment Recommendations.

Co-Funding Partners:

NHS England.

Aims and Objectives:

The aim of this review was to identify the potential risk of transmission associated with key interventions (chest compressions, defibrillation, cardiopulmonary resuscitation) to inform international treatment recommendations.


We undertook a systematic review comprising three questions: (1) aerosol generation associated with key interventions; (2) risk of airborne infection transmission associated with key interventions; and (3) the effect of different personal protective equipment strategies. We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and the World Health Organization COVID-19 database on 24th March 2020. Eligibility criteria were developed individually for each question. We assessed risk of bias for individual studies, and used the GRADE process to assess evidence certainty by outcome.

Main Results:

We included eleven studies: two cohort studies, one case control study, five case reports, and three manikin randomised controlled trials. We did not find any direct evidence that chest compressions or defibrillation either are or are not associated with aerosol generation or transmission of infection. Data from manikin studies indicates that donning of personal protective equipment delays treatment delivery. Studies provided only indirect evidence, with no study describing patients with COVID-19. Evidence certainty was low or very low for all outcomes.


It is uncertain whether chest compressions or defibrillation cause aerosol generation or transmission of COVID-19 to rescuers. There is very limited evidence and a rapid need for further studies.

Implications for Implementation:

The recommendations are published on the Consensus on Science with Treatment Recommendations website. Available at:

Protocol registration:

PROSPERO CRD42020175594.


Taylor-Phillips S, Couper K, Grove A, Freeman K, Osokogu O, Court R, Mehrabian A, Morley P, Nolan JP, Soar J, Perkins GD. COVID-19 in cardiac arrest and infection risk to rescuers: a systematic review. Resus. 2020; 151:59-66.

Associated clinical guidance from the International Liaison Committee on Resuscitation.

Couper K, Taylor-Phillips S, Grove A, Freeman K, Osokogu O, Court R, Mehrabian A, Morley P, Nolan JP, Soar J, Berg K, Olasveengen T, Wychoff M, Greif, R, Singletary N, Castren M, de Caen A, Wang T, Escalante R, Merchant R, Hazinski M, Kloeck D, Heriot G, Neumar R, Perkins GD; on behalf of the International Liaison Committee on Resuscitation. COVID-19 infection risk to rescuers from patients in cardiac arrest. 2020.