By Brett Patterson
This question comes from a dispatcher who provided a bystander with PAIs to assist a trauma victim:
I recently provided PAIs that included mouth-to-mouth ventilations and compressions on a trauma patient. Such patients could be bleeding and potentially expose the bystander-rescuer to blood-borne pathogens. Should we be telling bystanders to do this? Isn’t there a risk to the bystander performing these instructions?
A call to 911 is considered by our courts as an implied call for help. As such, we offer help in the form of the standard of care in dispatch. Our baseline is the standard of care in emergency medicine. The current resuscitation standard for traumatic cardiac arrest is CPR with ventilations. I know of no standard that calls for withholding resuscitative efforts based on a concern about disease transmission. The Ethics section of the 2010 Guidelines for CPR and ECC (unchanged in the 2015 Guidelines) has only this on the subject:
- Withholding and Withdrawing CPR (Termination of Resuscitative Efforts) Related to Out-of-Hospital Cardiac Arrest (OHCA)—Criteria for Not Starting CPR in All OHCA
- Basic life support (BLS) training urges all potential rescuers to immediately begin CPR without seeking consent, because any delay in care dramatically decreases the chances of survival. While the general rule is to provide emergency treatment to a victim of cardiac arrest, there are a few exceptions where withholding CPR might be appropriate, as follows:
- Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril
- Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition)
- A valid, signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated DNAR (Do Not Attempt Resuscitation) order
Aside from standards, we need to consider the risk/benefit ratio. The MPDS has been advising and instructing resuscitation for over 35 years, and I am not aware of a single case where a rescuer has contracted a communicable disease related to a resuscitation effort. There is no data that I know of that shows significant risk to laypersons who render CPR, much less placing a rescuer “at risk of serious injury or mortal peril.”
A 1998 study looked at the risk and defining strategies for Infections acquired during cardiopulmonary resuscitation1:
PURPOSE: To estimate the risk for acquiring an infectious disease during cardiopulmonary resuscitation or CPR training and to identify strategies to minimize that risk.
DATA SOURCES: English-language articles published since 1965 were identified through a search of the MEDLINE database and selected bibliographies.
STUDY SELECTION: Studies that contained information about transmission of infectious organisms, particularly HIV and other blood-borne viruses that might be transmitted through mouth-to-mouth ventilation, contact exposures, and needlesticks during CPR.
DATA EXTRACTION: Descriptive and analytic data from each study.
DATA SYNTHESIS: Fear of acquiring infection, especially HIV infection, can delay prompt initiation of mouth-to-mouth ventilation. Although pathogens can be isolated from the saliva of infected persons, salivary transmission of blood-borne viruses is unusual, and transmission of infection has been rare: Only 15 documented cases have been reported. Most of these cases involved a bacterial pathogen, such as Neisseria meningitidis. Transmission of hepatitis B virus, hepatitis C virus, or cytomegalovirus during CPR has not been reported; all three reported cases of HIV infection acquired during resuscitation of an infected patient resulted from high-risk cutaneous exposures. There have been no reports of infection acquired during CPR training. Simple infection-control measures, including use of barrier devices, can reduce the risk for acquisition of an infectious disease during CPR and CPR training. Post-exposure protocols can further protect potential rescuers and trainees.
CONCLUSIONS: The benefit of initiating lifesaving resuscitation in a patient in cardiopulmonary arrest greatly outweighs the risk for secondary infection in the rescuer or the patient. Nevertheless, use of simple infection-control measures during CPR and CPR training can reduce a very low level of risk even further.
In summary, while fear of contracting an infectious disease is a significant factor in layperson reluctance to provide CPR, the chance of contracting an infectious disease while providing CPR is extremely low, and CPR is the current standard of care in the resuscitation literature.
Brett A. Patterson
Academics & Standards Associate
Medical Council of Standards Chair
Mejicano G, Maki D. “Infections acquired during cardiopulmonary resuscitation: estimating the risk and defining strategies for prevention.” Annals of Internal Medicine. 1998; 129(10):813-28.