C2005 Evidence Evaluation Template - Oct.14,...

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WORKSHEET for PROPOSED Evidence-Based GUIDELINE RECOMMENDATIONSNOTE: Save worksheet using the following filename format: Taskforce.Topic.Author.Date.Doc where Taskforce is a=ACLS, b=BLS, p=Pediatric, n=neonatal and i=Interdisciplinary. Use 2 or 3 letter abbreviation for author’s name and 30Jul03 as sample date format.Worksheet Author:

Franklin HG BRIDGEWATER

Taskforce/Subcommittee:

X BLS Author’s Home Resuscitation Council: Other: Australian Resuscitation Council

Date Submitted to Subcommittee: 18 July 2004 Revised 9 August 2004; 27 November 2004

STEP 1: STATE THE PROPOSAL. State if this is a proposed new guideline; revision to current guideline; or deletion of current guideline.Existing guideline, practice or training activity, or new guideline: International Guidelines 2000 for CPR and ECC – A Consensus on Science [Anonymous, 2000 #203] addresses Rescuer Safety during both CPR Training and CPR Performance (Resuscitation 2000;46 (1-3):59-61) . It focuses solely on infectious complications and maintains that adherence to recommendations from authoritative bodies and manufacturers will minimize an already extremely low risk of disease transmission during CPR. It acknowledges “CPR; The Human Dimension” but offers no references on this latter matter relating to the rescuer. This worksheet will address the question “What are the adverse effects for the responder who performs cardiopulmonary resuscitation (including infection control)?” It will review both the data leading up to Guidelines 2000 and also evidence available from that time until April 2004 for both the training and performance of CPR. Step 1A: Refine the question; state the question as a positive (or negative) hypothesis. State proposed guideline recommendation as a specific, positive hypothesis. Use single sentence if possible. Include type of patients; setting (in- /out-of-hospital); specific interventions (dose, route); specific outcomes (ROSC vs. hospital discharge).Adverse effects associated both with the training for and the practice of cardiopulmonary resuscitation are very uncommon and the implementation of conventional precautions will generally allow cardiopulmonary resuscitation to be safely taught and performed in all circumstances.

Step 1B: Gather the Evidence; define your search strategy. Describe search results; describe best sources for evidence.The primary search was conducted by perusing the following recognized electronic data bases

AHA Endnote 7 Master Library (April 2004) [http://ecc.heart.org/],Cochrane Database for Systematic Reviews [http://www.cochrane.org/ and Cochrane Central Register of Controlled TrialsMEDLINE : 1966- April 2004 [http://www.ncbi.nlm.nih.gov/PubMed/) Embase: 1988-2004

Articles deemed of relevance were retained in an EndNote 7 Library. The references included in the material retained in this Library were scanned and, if relevant articles were found that were not already within the library, they were added to the data base.

Search Strategy

The following terms were recognized as MeSH headings: adverse effect, cardiopulmonary resuscitation, disease transmission (including disease transmission, patient-to-professional), Emergency Medical Technician (EMT), hazards (including bio-hazards), infection control, injuries, manikin (mannequin), risk, and stress (including stress, psychological).

The following terms were used as text words:Bystander, first aider, first responder, physical stress, rescuer, resuscitator and training.

Using EndNote 7 to access PubMed (NLM), EMBASE (OVID) and Medline (OVID) Search 1: Cardiopulmonary resuscitation or CPR was used in “Title” for first option and the other MeSH headings and text words used in “Any field” for second option. Search 2: Risk, Disease transmission or Adverse effect was used in “Title” and Cardiopulmonary resuscitation or CPR in “Any field”

Using OVIDSearches were carried out using the above MeSH headings and text words. “Author” was utilized for locating secondary reference articles.

It was difficult isolating and identifying papers relating to risks in the performer of CPR with the overwhelming emphasis of reported articles being on the receiver of CPR.

• State major criteria you used to limit your search; state inclusion or exclusion criteria (e.g., only human studies with control group? no animal studies? N subjects > minimal number? type of methodology? peer-reviewed manuscripts only? no abstract-only studies?)

Only adverse effects related to the training for / performance of cardiopulmonary resuscitation were considered. The use of ancillary airway devices, with intubation as an adjunct were included as part of CPR – although technically the latter may be regarded as beyond the scope of BLS. Defibrillation was considered an element of BLS. One case of animal resuscitation by CPR highlights a potential hazard. Hazards associated with allied procedures such as cannulation were not considered. Papers relating to attitudes towards / the perception of the risks and hazards, with the allied consequences, and the medico-legal aspects of CPR were excluded.

• Number of articles/sources meeting criteria for further review:

One hundred and eleven articles were identified ( EndNote 7 Library: ILCORCPR United.enl). Six could not be located [Anonymous, 1984 #200] [Anonymous, 1992 #152] [Davis, 1978 #160] [Mannis, 1984 #212] [Perras, 1980 #218] [Zaeslin, 1966 #206] and 10 were considered not relevant [Anonymous, 1990 #149]

http://www.ncbi.nlm.nih.gov/PubMed/

http://www.cochrane.org/

http://ecc.heart.org/

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[Duffy, 1974 #161] [Dunlap, 1994 #162] [Fenner, 1998 #50] [Handley, 1998 #177] [Hodgin, 1992 #164] [Jevon, 2002 #18] [Lufkin, 1993 #169] [Rossi, 1993 #186] [Simmons, 1995 #187]. Two were considered of poor quality [Neiman, 1982 #171] [Nicklin, 1980 #172]. Ninety three articles (or abstracts thereof) were available for final consideration.

STEP 2: ASSESS THE QUALITY OF EACH STUDYStep 2A: Determine the Level of Evidence. For each article/source from step 1, assign a level of evidence—based on study design and methodology.

Level of Evidence

Definitions(See manuscript for full details)

Level 1 Randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effectsLevel 2 Randomized clinical trials with smaller or less significant treatment effectsLevel 3 Prospective, controlled, non-randomized, cohort studiesLevel 4 Historic, non-randomized, cohort or case-control studiesLevel 5 Case series: patients compiled in serial fashion, lacking a control groupLevel 6 Animal studies or mechanical model studiesLevel 7 Extrapolations from existing data collected for other purposes, theoretical analysesLevel 8 Rational conjecture (common sense); common practices accepted before evidence-based guidelines

Step 2B: Critically assess each article/source in terms of research design and methods. Was the study well executed? Suggested criteria appear in the table below. Assess design and methods and provide an overall rating. Ratings apply within each Level; a Level 1 study can be excellent or poor as a clinical trial, just as a Level 6 study could be excellent or poor as an animal study. Where applicable, please use a superscripted code (shown below) to categorize the primary endpoint of each study. For more detailed explanations please see attached assessment form.

Component of Study and Rating Excellent Good Fair Poor UnsatisfactoryDesign &

Methods

Highly appropriate sample or model, randomized, proper controls ANDOutstanding accuracy, precision, and data collection in its class

Highly appropriate sample or model, randomized, proper controlsOROutstanding accuracy, precision, and data collection in its class

Adequate, design, but possibly biased

ORAdequate under the circumstances

Small or clearly biased population or model

ORWeakly defensible in its class, limited data or measures

Anecdotal, no controls, off target end-points

ORNot defensible in its class, insufficient data or measures

Step 2C: Determine the direction of the results and the statistics: supportive? neutral? opposed?

DIRECTION of study by results & statistics: SUPPORT the proposal NEUTRAL OPPOSE the proposal

ResultsOutcome of proposed guideline superior, to a clinically important degree, to current approaches

Outcome of proposed guideline no different from current approach

Outcome of proposed guideline inferior to current approach

Step 2D: Cross-tabulate assessed studies by a) level, b) quality and c) direction (ie, supporting or neutral/ opposing); combine and summarize. Exclude the Poor and Unsatisfactory studies. Sort the Excellent, Good, and Fair quality studies by both Level and Quality of evidence, and Direction of support in the summary grids below. Use citation marker (e.g. author/ date/source). In the Neutral or Opposing grid use bold font for Opposing studies to distinguish them from merely neutral studies. Where applicable, please use a superscripted code (shown below) to categorize the primary endpoint of each study.

Supporting EvidenceAdverse effects associated both with the training for and the practice of cardiopulmonary resuscitation are very uncommon and the implementation of conventional precautions will generally allow cardiopulmonary resuscitation to be safely taught and performed in all circumstances.

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Good [Clements, 2003 QRH]

1

Fair

Dracup 1997 PSH

[Moser, 1999 PSH]

2

[McLauchlan, 1992 PSH]

1

[Anonymous, 1978 PTH]

[Axelsson, 1996 QL] [Axelsson, 1998 QL] [Emergency Cardiac Care Committee and

Subcommittees, 1992 TJ] [Glaser, 1985 PYH] [Marcus, 1988 TH] [McCray, 1986 TH] [Mejicano, 1998 TG(Evb)] [Miller, 1982 PRL] [Sepkowitz, 1996

TG(Evb)] [Sepkowitz, 1996 TG(Evb)]

11

[Blenkharn, 1990 TI] [Blenkharn, 1992

QTN] [Cavagnolo, 1985 PTI][Corless, 1992 PTI] [Cydulka, 1991 QTI]

[Hudson, 1983 PTI] [Lyster, 2003 QRI]

7

[Achong, 1980 TG(Narr)] [Ahmad, 1990 QEH][Anonymous, 1979 PTJ] [Anonymous, 1986 TJ] [Anonymous, 1987 TJ] [Anonymous, 1989 J] [Anonymous, 2000 J] [Anonymous, 2000 J] [Arend, 2000 TG(Evb)] [Becker, 1997 TG(Narr)][Bierens, 1996 QTG] [Cummins, 1989 GK] [Feldman, 1972 G(Narr)] [Hudson, 1984 PTI] [Jafari, 1997 J J] [Lambrew, 1979 PTN] [Montgomery, 1986 O] [Nickalls, 1986 QTN] [Ornato, 1989 TG(Narr)] [Osterholm, 1979 PTH] [Sande, 1986 #192] [Saviteer, 1985 QTHN] [Sun, 1995 PTG(Narr)] [Swanson, 1993

QSG(Narr)] [Wenzel, 2001 TG(Narr)][West, 1990 TN]

26

[Anonymous,

1989 J] [Anonymous,

1990 J] [Anonymous,

1998 K] [Anonymous,

1998 J] [Baker, 1999

RG(Narr)] [Baskett, 1993

TG(Narr)] [Cohen, 1985

PTN] [Cutler, 1979

QN] [Rinker, 2001

G(Narr)] [Stern, 1994 M]

10

58

1 2 3 4 5 6 7 8Level of Evidence

F = Other effect G(Narr) = Review (Narrative) G(Evb) = Review (Evidence-based) H = Clinical report I = Laboratory report J = Guidelines K= News report L = Survey M = Educational material N = Correspondence O = Position StatementP = CPR Training Q = CPR Performance R = Adverse physical effect S = Adverse psychological effect T = Disease transmission

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Neutral or Opposing EvidenceAdverse effects associated both with the training for and the practice of cardiopulmonary resuscitation are very uncommon and the implementation of conventional precautions will generally allow cardiopulmonary resuscitation to be safely taught and performed in all circumstances.

Fair

[Christian, 2004 TH] [Edwards, 2001 L] [Genest, 1990 QSH] [Laws, 2001 QSH] [Mannis, 1984 PTH] [Shimokawa, 2001 QRH] [Stacey, 2004 QRH] [Steinhoff, 2001 QTH] [Sullivan, 2000 PRH] [Thierbach, 2003 RI] [Walker, 2001 RI]

11

[Khan, 1979 PTI] [Lonergan, 1981 RI]

2

[Anonymous, 1990 J] [Ballard, 1986

QTL] [Bass, 1994 TG(Narr)] [Berumen, 1983 QSN] [Deetz, 1979

PTN] [Figura, 1996 QTH] [Finkelhor,

1980 QTH] [Gamble, 2001 QSG(Narr)]

[Genest, 1991 QSH] [Greenberg, 1983

PHN] [Heilman, 1965 QTH] [Hendricks, 1980 QTH] [Jacobson,

1976 TM] [McCabe, 1997 G(Narr)] [Memon, 1982 PRH] [Salzer, 1983 PN]

[Todd, 1980 QTH] [Valenzuela, 1991 QTH]

18

[Achong, 1979 NB] [Davies, 1979 QN] [Gilston, 1979 QN] [Prosser, 1990 PTN]

4

35

1 2 3 4 5 6 7 8Level of Evidence

F = Other effect G(Narr) = Review (Narrative) G(Evb) = Review (Evidence-based) H = Clinical report I = Laboratory report J = Guidelines K= News report L = Survey M = Educational material N = Correspondence O = Position StatementP = CPR Training Q = CPR Performance R = Adverse physical effect S = Adverse psychological effect T = Disease transmission

STEP 3. DETERMINE THE CLASS OF RECOMMENDATION. Select from these summary definitions.CLASS CLINICAL DEFINITION REQUIRED LEVEL OF EVIDENCE

Class IDefinitely recommended. Definitive, excellent evidence provides support.

• Always acceptable, safe• Definitely useful • Proven in both efficacy & effectiveness• Must be used in the intended manner for proper clinical indications.

• One or more Level 1 studies are present (with rare exceptions) • Study results consistently positive and compelling

Class II:Acceptable and useful

• Safe, acceptable• Clinically useful• Not yet confirmed definitively

• Most evidence is positive• Level 1 studies are absent, or inconsistent, or lack power • No evidence of harm

• Class IIa : Acceptable and usefulGood evidence provides support

• Safe, acceptable• Clinically useful • Considered treatments of choice

• Generally higher levels of evidence• Results are consistently positive

• Class IIb: Acceptable and usefulFair evidence provides support

• Safe, acceptable • Clinically useful• Considered optional or alternative treatments

• Generally lower or intermediate levels of evidence• Generally, but not consistently, positive results

Class III: Not acceptable, not useful, may be harmful

• Unacceptable• Not useful clinically• May be harmful.

• No positive high level data• Some studies suggest or confirm harm.

Indeterminate• Research just getting started.• Continuing area of research• No recommendations until further research

• Minimal evidence is available• Higher studies in progress • Results inconsistent, contradictory• Results not compelling

Adverse effects associated both with the training for and the practice of cardiopulmonary resuscitation are very uncommon and the implementation of conventional precautions will generally allow cardiopulmonary resuscitation to be safely taught and performed in all circumstances.

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STEP 3: DETERMINE THE CLASS OF RECOMMENDATION. State a Class of Recommendation for the Guideline Proposal. State either a) the intervention, and then the conditions under which the intervention is either Class I, Class IIA, IIB, etc.; or b) the condition, and then whether the intervention is Class I, Class IIA, IIB, etc.Intervention:

Adverse effects associated both with the training for and the practice of cardiopulmonary resuscitation are very uncommon and the implementation of conventional precautions will generally allow cardiopulmonary resuscitation to be safely taught and performed in all circumstances. (LOE 5 – 8)

Final Class of recommendation:

Class I-Definitely Recommended

REVIEWER’S PERSPECTIVE AND POTENTIAL CONFLICTS OF INTEREST: Briefly summarize your professional background, clinical specialty, research training, AHA experience, or other relevant personal background that define your perspective on the guideline proposal. List any potential conflicts of interest involving consulting, compensation, or equity positions related to drugs, devices, or entities impacted by the guideline proposal. Disclose any research funding from involved companies or interest groups. State any relevant philosophical, religious, or cultural beliefs or longstanding disagreements with an individual.

I am a specialist in general surgery with particular interest in trauma and pre-hospital care. This has been reinforced by a long association with the provision of an ambulance service to the South Australian community and the delivery of first aid through an organization having trained a large group of volunteers responding through a para-military structure at both the state and national level. More recently, service in the Australian Army reserve has seen experience gained in warlike conditions, non-warlike conditions and a peace keeping role. Research into first aid aspects has included an assessment of the physiological responses of first responders while performing CPR, latex allergy in a unique group of first responders and the development of a predictive model for casualties in the mass gathering setting. I have been associated with the Australian Resuscitation Council over a number of years representing St John at State level and The Royal Australasian College of Surgeons at National level. I have participated in research projects financially supported by St John Ambulance Australia and Emergency Management Australia. I will probably be seeking further financial support from such bodies for research projects. I have submitted a COI statement to ILCOR and AHA.

REVIEWER’S FINAL COMMENTS AND ASSESSMENT OF BENEFIT / RISK: Summarize your final evidence integration and the rationale for the class of recommendation. Describe any mismatches between the evidence and your final Class of Recommendation. “Mismatches” refer to selection of a class of recommendation that is heavily influenced by other factors than just the evidence. For example, the evidence is strong, but implementation is difficult or expensive; evidence weak, but future definitive evidence is unlikely to be obtained. Comment on contribution of animal or mechanical model studies to your final recommendation. Are results within animal studies homogeneous? Are animal results consistent with results from human studies? What is the frequency of adverse events? What is the possibility of harm? Describe any value or utility judgments you may have made, separate from the evidence. For example, you believe evidence-supported interventions should be limited to in-hospital use because you think proper use is too difficult for pre-hospital providers. Please include relevant key figures or tables to support your assessment.“Adverse effects associated both with the training for and the practice of cardiopulmonary resuscitation are very uncommon and the implementation of conventional precautions will generally allow cardiopulmonary resuscitation to be safely taught and performed in all circumstances.

Reported adverse physical effects have included myocardial infarction [Memon, 1982 #144], pneumothorax [Sullivan, 2000 #143], interosseous nerve palsy [Shimokawa, 2001 #139], poisoning [Berumen, 1983 #210] [Zaeslin, 1966 #206], hyperventilation [Thierbach, 2003 #30] and hypocarbia [Walker, 2001 #3]. Some data suggest that suggest that CPR might elicit ischemic symptoms in a rescuer with coronary artery disease [Lonergan, 1981 #29]. A puncture wound from a sternotomy wire [Steinhoff, 2001 #182] highlighted the risk of disease transmission but the patient was seronegative for HIV, HepB and HepC. Accepting defibrillation as part of BLS, there are reports of resuscitators receiving minor shocks but no reports of clinically significant shocks. Clements describes one incident associated with an implanted defibrillator [Clements, 2003 #37] and Miller reports a series of incidents with external defibrillation affecting rescuers, a bystander and a helicopter pilot [Miller, 1982 #72]. Simulation of defibrillation in a wet environment did not show significant risk [Lyster, 2003 #26]. Less specific events have been noted [Greenberg, 1983 #188].

CPR training had no adverse psychological effects for family members of patients with cardiac disease [Dracup, 1997 #216] [McLauchlan, 1992 #223] [Moser, 1999 #439] but such adverse effects of performing CPR have been noted. These have included negative feelings [Axelsson, 1996 #121] [Axelsson, 1998 #83], psychological stress [Gamble, 2001 #141], and critical incident stress [Laws, 2001 #10]. Swanson refers to “serious consequences for emergency personnel who respond to a crisis” but accepts that “the paucity of data currently available prevents firm conclusions about the effects on emergency personnel and may not be relevant to more routine CPR attempts” [Swanson, 1993 #138]. One study [Genest, 1990 #197] dealt with volunteer workers in unsuccessful attempts at CPR. Recognition of probable failure was not protective in itself and there was evidence of persisting psychological aftermaths with no respondent being entirely free from unbidden recollections of the experience.

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Isolated cases of confirmed disease transmission to the resuscitator exist. These include salmonella infantis [Ahmad, 1990 #100], SARS-CoV [Christian, 2004 #32], four of meningococcal disease [Feldman, 1972 #130], herpes simplex [Finkelhor, 1980 #123] [Hendricks, 1980 #132]], mycobacterium tuberculosis [Heilman, 1965 #129], shigella [Todd, 1980 #131] and streptococcus pyogenes [Valenzuela, 1991 #14] while performing CPR and herpes simplex while training [Mannis, 1984 #213]. Mejicano mentions a case of helicobacter pylori transmission [Mejicano, 1998 #181] but this is an example of resuscitator-to-patient transmission [Figura, 1996 #97] while two cases [Neiman, 1982 #171] [Nicklin, 1980 #172] are dubious. In the absence of high risk activities such as cannulation, there has been no reported case of transmission of HepB, HepC, HIV or cytomegalovirus during either the performance of or training for CPR. In circumstances conducive to disease transmission, it has not occurred [Anonymous, 1978 #204] [Glaser, 1985 #146] [Osterholm, 1979 #199; Perras, 1980 #218] [Saviteer, 1985 #175]. Over a 22 year period, the New York City Fire Department had no record of disease transmission through rescue breathing but there are no details provided of the number resuscitated in this period [Cutler, 1979 #126]. A critical examination of the data assigning risks to mouth-to-mouth resuscitation is important [Deetz, 1979 #209]. There is a continuing need for accurate reporting of such adverse effects. Bierens presenting the rational approach for the risk of transmission of the AIDS virus concludes that the risk of sero-conversion due to CPR is about one per million resuscitations in the highest risk group and less than one per billion resuscitations in the group most often resuscitated. He states that volunteer life-savers “should know that if there is no blood visible, or if there is no open wound in the mouth of the rescuer, no blood-blood contact and thus no sero-conversion is possible even when the victim is seropositive. [Bierens, 1996 #12]

There is no strong evidence to support the screening of intended participants in training as has been suggested for those with risk factors for ischaemic heart disease [Memon, 1982 #144] and for those who are asthmatic, diabetic, hypertensive, heavy smokers, obese, over the age of 45 or with pulmonary or cardiac disease [Salzer, 1983 #207]. Vaccination against hepatitis B is proposed for those with an occupational risk of exposure and disease transmission [Anonymous, 1990 #150] but it must be noted that, in this context, CPR has not been implicated in the transmission of this disease.

As early as 1965 [Heilman, 1965 #129] as a result of a case of TB transmission, it was suggested that some form of protection was needed to avoid the need for mouth-to-mouth contact when performing CPR. This concern remained in 1985 [Cohen, 1985 #147] and subsequently various guidelines and authors advocated their use [Nickalls, 1986 #201] [Anonymous, 1987 #190] [Anonymous, 1989 #191] [Baskett, 1993 #59] [Bierens, 1996 #12] [Hendricks, 1980 #132] accepting that their efficacy had not been demonstrated conclusively [Anonymous, 1990 #151]. Some data suggested that certain devices possibly afforded protection against bacterial transmission [Blenkharn, 1990 #122 ] [Cydulka, 1991 #159]. Both Sun [Sun, 1995 #54] and Mejicano [Mejicano, 1998 #181] reiterate the advice that such devices should be used despite no additional evidence of their efficacy in reducing disease transmission; there continues to be no data showing that these devices reduce disease transmission risk.

Early assessment of the efficacy of the technique of manikin disinfection focused on bacteria [Hudson, 1983 #165] and later assessments on viruses [Mannis, 1984 #213] [Hudson, 1984 #145] [Cavagnolo, 1985 #156] [Corless, 1992 #158]. While these data show that the techniques of disinfection assessed are effective, there is no data confirming a consequent reduction in disease transmission.

The Centers for Disease Control Cooperative Needle-stick Surveillance Groups abandoned follow-up on health care workers exposed to saliva and other non-blood fluids from patients with HIV because none of 106 workers followed up for more than one year sero-converted. [Cummins, 1989 #13] [Marcus, 1988 #194]. Post exposure prophylaxis for Hepatitis B is only advocated for accidental percutaneous or per-mucosal exposure to HBsAg-positive blood [Anonymous, 1990 #150]. For Neisseria meningitidis, antimicrobial prophylaxis is recommended for anyone directly exposed to the patient’s oral secretions (eg through mouth-to-mouth resuscitation, endotracheal intubation, or endotracheal tube management). Rifampicin has been the drug of choice but ciprofloxacin or ceftriaxone are reasonable alternatives [Jacobson, 1976 #167] [Achong, 1979 #76] [Jafari, 1997 #153]. A rescuer who has given mouth-to-mouth ventilation to a patient with pulmonary tuberculosis should have serial tuberculin skin testing and should be offered prophylaxis if conversion occurs[Bass, 1994 #155] [Mejicano, 1998 #181].”

Preliminary draft/outline/bullet points of Guidelines revision: Include points you think are important for inclusion by the person assigned to write this section. Use extra pages if necessary.

Publication: Chapter: Pages: Adverse effects associated both with the training for and the practice of cardiopulmonary resuscitation are very uncommon and the implementation of conventional precautions will generally allow cardiopulmonary resuscitation to be safely taught and performed in all circumstances.(Class 1, LOE =5-8)The recommendation is supported on the basis of the relative absence of reported adverse effects in the context of a large number of resuscitations combined with limited data demonstrating the safety of certain training concepts and techniques. There is a dearth of higher level evidence.

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A rational appraisal of anticipated personal and environmental hazards while performing CPR will effectively remove the possibility of physical harm to the resuscitator (Class IIb, LOE 7).

Training to perform CPR may be confidently encouraged but performing CPR does have a psychological impact that deserves consideration (Class IIb, LOE 5).

Disease transmission during CPR is a rare event and this concern should not discourage resuscitation attempts.(Class IIb LOE 7).

Use of Standard Precautions and appropriate barrier devices may reduce the likelihood of bacterial transmission (Class IIb,LOE 6). Health care workers should be appropriately vaccinated but post-exposure follow-up is only needed in cases of accidental

percutaneous or per-mucosal inoculation and after direct exposure to either meningococcal or tuberculous disease. Exposure to other respiratory diseases should be discussed with a physician (Class IIb LOE 7).

The Class 1 status of the final recommendation in the presence of lower class recommendations for the components of the discussion reflects the potentially life saving nature of CPR in contrast to the rarity of an adverse effect upon the resuscitator rather than a high level of evidence.

Topic and subheading: “Adverse effects associated both with the training for and the practice of cardiopulmonary resuscitation are very uncommon and the implementation of conventional precautions will generally allow cardiopulmonary resuscitation to be safely taught and performed in all circumstances.”

Attachments: Bibliography in electronic form using the Endnote Master Library. It is recommended that the bibliography be provided in annotated

format. This will include the article abstract (if available) and any notes you would like to make providing specific comments on the quality, methodology and/or conclusions of the study.

Citation List“Adverse effects associated both with the training for and the practice of cardiopulmonary resuscitation are very uncommon and the implementation of conventional precautions will generally allow cardiopulmonary resuscitation to be safely taught and performed in all circumstances.”

Citation Marker Full Citation**[Achong, 1979 #76] Achong, M. R. (1979). "Hazards of mouth-to-mouth resuscitation." Lancet 2(8150).

NB

In response to [Davies, 1979 #136], he advocates an aggressive in hospital IV antibiotic regime for resuscitators exposed to N. meningitidis by mouth-to- mouth contact.

Level of Evidence: 8

Quality of Evidence: Fair

Nature of evidence: Neutral

*[Achong, 1980 #73] Achong, M. R. (1980). "Infectious Hazards Of Mouth-To-Mouth Resuscitation." American Heart Journal 100(5): 759-761.

TG(Narr)

Reports [Heilman, 1965 #129] [Feldman, 1972 #130] [Davis, 1978 #160] [Osterholm, 1979 #199] [Perras, 1980 #218] [Khan, 1979 #124] And Concludes That “The Seemingly Very Small Risk Of Transmission Of Infection From Patient To Operator During Mouth-To-Mouth Resuscitation Is No Reason To Abandon Mouth-To-Mouth Resuscitation. However, More Frequent Documentation Of The Outcome Of Such Contacts With Patients Harbouring Various Infections Would Allow A Better Appreciation Of The Risks Involved.”



Nature of evidence: Supportive

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*[Ahmad, 1990 #100] Ahmad, F., D. C. A. Senadhira, et al. (1990). "Transmission of salmonella via mouth-to-mouth resuscitation." Lancet 335(8692): 787-788.

QEH

Case report of transmission of salmonella infantis by mouth-to-mouth resuscitation.

Level of evidence: 7

Quality of evidence: Fair

Nature of evidence : Supportive

*[Anonymous, 1978 #204] Anonymous. Lack of transmission of hepatitis B after oral exposure to hepatitis B surface antigen-positive saliva. MMWR - Morbidity & Mortality Weekly Report 1978(27):247-8.

PTH

Recounts two incidents with exposure of 34 people in which transmission of Hepatitis B did not occur. It concludes “the risk of transmission of hepatitis B as a result of indirect oral contact with HBsAg-positive saliva appears to be small.”




*[Anonymous, 1979 #148] Anonymous (1979). "Disinfection of C.P.R. training manikins." Australian Nurses' Journal 8(10): 14-5.

PTJ

A statement of recommendations from the Australian Resuscitation Council Newsletter.




[Anonymous, 1984 #200] Anonymous, editor. Guidelines for the prevention of disease transmission in the use of CPR. Washington DC: National Research Council; 1984.

NOT AVAILABLE

*[Anonymous, 1986 #193] Anonymous. Standards and Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC). National Academy of Sciences - National Research Council.[erratum appears in JAMA 1986 Oct 3;256(13):1727]. JAMA 1986;255(21):2905-89.

TJ

Pages 2926-2928 cover “Safety in training for and providing CPR”. It addresses in detail the matter of disease transmission but maintains a supportive stance for CPR. There is no mention of other hazards.




*[Anonymous, 1987 #190] Anonymous. Recommendations for prevention of HIV transmission in health-care settings. MMWR - Morbidity & Mortality Weekly Report 1987;36 Suppl 2:1S-18S.

TJ

This document is the basis for Universal Precautions. It states “Although saliva has not been implicated in HIV transmission, to minimize the need for emergency mouth-to-mouth resuscitation, mouth pieces, resuscitation bags, or other ventilation devices should be available for use in area in which the need for resuscitation is predictable.”




*[Anonymous, 1989 #7] Anonymous (1989). "Risk of infection during CPR training and rescue: supplemental guidelines. The

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Emergency Cardiac Care Committee of the American Heart Association." JAMA 262(19): 2714-5.

J

Abstract: The American Heart Association and the American Red Cross used the findings from the 1985 National Conference on Standards and Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care to establish their policy on the risk of infection during cardiopulmonary resuscitation (CPR) training and rescue. Findings that support the safety of CPR training and rescue and appropriate risk reduction strategies are presented as an update to the 1985 article. The Emergency Cardiac Care Committee of the American Heart Association incorporated recent advisories from the Centers for Disease Control as well as other information into guidelines that augment earlier recommendations.

Provides guidelines for

Rescuers with known or suspected infections

Rescuers with a duty to provide CPR

The layperson

CPR training for infected individuals

Individuals unable to complete a CPR course

Additional references [Anonymous, 1986 #193], [Sande, 1986 #192], [Anonymous, 1987 #190],

[anonymous, 1989 #191]




*[Anonymous, 1989 #191] Anonymous. Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus to health-care and public-safety workers.[erratum appears in MMWR Morb Mortal Wkly Rep 1989 Nov 3;38(43):746]. MMWR - Morbidity & Mortality Weekly Report 1989;38 Suppl 6:3-37.

J

Notes no transmission of HBV or HIV infection but the risk of other infectious diseases is stated. They advocate disposable resuscitation equipment and ancillary airway devices.




*[Anonymous, 1990 #149] Anonymous (1990). "CDC issues guidelines for protection against viral hepatitis." Clinical Pharmacy 9(9): 670.

Refers to [Anonymous, 1990 #150] below.

NOT RELEVANT

*[Anonymous, 1990 #150] Anonymous (1990). "Protection against viral hepatitis. Recommendations of the Immunization Practices Advisory Committee (ACIP)." Morbidity & Mortality Weekly Report. Recommendations & Reports 39(RR-2): 1-26.

J

In the context of HBV infection:

It is proposed that persons with occupational risk be vaccinated pre-exposure.

Post exposure prophylaxis is advocated for “accidental percutaneous or per-mucosal exposure to HBsAg-positive blood.”




*[Anonymous, 1990 #151] Anonymous (1990). "Disease transmission and cardiopulmonary resuscitation. Emergency Cardiac

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Care Committee, Heart and Stroke Foundation of Canada." CMAJ Canadian Medical Association Journal 143(10): 1007-8.

O

Refers to evidence for lack of transmissibility of HIV/AIDS and Hep B by saliva but notes spread of viral respiratory infections by M-M CPR. It accepts that “the value of CPR outweighs the small, theoretical risk of disease transmission.” It advocates ready access to mechanical ventilation or barrier devices accepting that their efficacy has not been demonstrated conclusively (in 1990).

Concludes that “the value of CPR outweighs the small, theoretical risk of disease transmission”.



Nature of evidence: supportive

[Anonymous, 1992 #152] Anonymous (1992). "Q & A: disinfecting Resusci Annes." Healthcare Hazardous Materials Management 5(9): 11.

NOT AVAILABLE

*[Anonymous, 1998 #154] Anonymous (1998). "AHA clarifies message on mouth-to-mouth component of CPR." Arteriosclerosis, Thrombosis & Vascular Biology 18(2): B3.

K

Report of [Becker, 1997 #184] "A reappraisal of mouth-to-mouth ventilation during bystander-initiated cardiopulmonary resuscitation. A statement for healthcare professionals from the Ventilation Working Group of the Basic Life Support and Pediatric Life Support Subcommittees, American Heart Association.[see comment]." Circulation 96(6): 2102-12.

Includes quotation from Cummins RO “Don’t worry about disease – worry about saving the person’s life”




*[Anonymous, 1998 #202] Anonymous (1998). "The 1998 European Resuscitation Council guidelines for adult single rescuer basic life support. Basic Life Support Working Group of the European Resuscitation Council.[see comment][erratum appears in BMJ 1998 Aug 22;317(7157):501]." BMJ 316(7148): 1870-6.

J

Reflects content of [Handley, 1998 #177]. "The 1998 European Resuscitation Council guidelines for adult single rescuer basic life support: A statement from the Working Group on Basic Life Support, and approved by the executive committee.[see comment][erratum appears in Resuscitation 1998 Aug;38(2):131-2]." Resuscitation 37(2): 67-80.

In contrast to [Handley, 1998 #177] the document describes general risks (traffic and other environmental factors) and the specific concerns about poisoning, the possible but rare event of disease transmission and the need for effective ancillary devices. It notes that “Resuscitation manikins have been shown not to be a source of infection.”




*[Anonymous, 2000 #2] Anonymous (2000). "Part 3: adult basic life support. European Resuscitation Council." Resuscitation 46(1-3): 29-71.

J

An extract from the major publication of “International Guidelines 2000 for CPR and ECC – A Consensus on Science”. [Anonymous, 2000 #203] listed above. Pages 59-61 focus on disease transmission during both training for and performance of CPR.

Note the comment on error concerning transmission of N. gonorrhoeae in [Anonymous, 2000 #203] below.

Can we use G2000 to support G2005?

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*[Anonymous, 2000 #203] Anonymous (2000). "Guidelines 2000 for Cardiopulmonary resuscitation and emergency cardiovascular care - An international consensus on science." Resuscitation 46(1-3): 1-447.

J

The index reference for the work sheet.

The statement on page 60 referring to [Mejicano, 1998 #181] as a reference for transmission of Neisseria gonorrhoeae seems to be an error. Mejicano makes no reference to N. gonorrhoeae but only N. meningitidis.




*[Arend, 2000 #95] Arend, C. F. (2000). "Transmission of infectious diseases through mouth-to-mouth ventilation: Evidence-based or emotion-based medicine?" Arquivos Brasileiros de Cardiologia 74(1): 73-97.

TG(Evb)

Abstract: Cardiopulmonary arrest is the interruption of the heart's mechanical activity confirmed by unconsciousness, apnoea, and absence of central pulse'. The basic technical knowledge for management of this medical emergency by way of cardio-pulmonary resuscitation (CPR) should be part of the training curriculum for health care workers and is highly recommended for the general public. However, concern about the transmission of diseases appears to have created substantial barriers for the use of CPR, both in and out of the hospital setting. The idea that the intention of saving a person's life could result in the death of the rescuer is intimidating and reduces peoples' desire and availability to help cardiopulmonary arrest victims. The outcome of reduced use of CPR is reflected in the increase in the morbidity and mortality of the event 6'1.

Studies carried out by Brenner report that about 50% of physicians would refuse to carry out mouth-to-mouth ventilation in strangers and 714% would not perform mouth-to-mouth ventilation on victims with AIDS-". Another study reports that, although 68°/n of the interviewees would perform chest compressions on an unknown victim of cardiopulmonary arrest, only 15"/o would perform mouth-to-mouth ventilation. A number of other papers report similar findings. In the great majority of cases, the reason for the reluctance to immediately start CPR is the fear of catching transmissible diseases, especially HIV,

The objective of this article is to review the literature on infectious diseases transmitted through mouth-to-mouth ventilation. The search for available scientific evidence for pre- and post-exposure prophylaxis has been made through searching the Medline: database of articles published between 1990-1999. In addition to this, all the articles published between 1966-1999 in journals indexed to Index Medicus with the key word mouth-to-mouth ventilation or mouth-to-mouth ventilation, and cardiopulmonary resuscitation were reviewed. Conclusions were also based on a personal collection of articles, posters and relevant notes collected over the last few years.

This review adds no new data or material for the interval since that of [Mejicano, 1998 #181]




*[Axelsson, 1996 #121] Axelsson, A., J. Herlitz, et al. (1996). "Bystander-initiated cardiopulmonary resuscitation out-of-hospital. A first description of the bystanders and their experiences." Resuscitation 33(1): 3-11.

QL

Abstract: At present there are about 1 million trained cardiopulmonary resuscitation (CPR) rescuers in Sweden. CPR out-of-hospital is initiated about 2000 times a year in Sweden. However, very little is known about the bystanders' experiences and reactions. The aim of this study was to describe bystander-initiated CPR, the circumstances, the bystander and his experiences. All CPR bystanders

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in Sweden who reported their resuscitation attempts between 1990 and 1994 were approached with a phone interview and a postal questionnaire, resulting in 742 questionnaires. Bystander-initiated CPR most frequently took place in public places such as the street. The rescuer most frequently had problems with mouth-to-mouth ventilation (20%) and vomiting (18%). More than half (53%) of the rescuers experienced CPR without problems. Ninety-two percent of the bystanders had no hesitation because of fear of contracting the acquired immunodeficiency syndrome (AIDS) virus. Ninety-three percent of the rescuers regarded their intervention as a mainly positive experience. Of 425 interviewed rescuers, 99.5% were prepared to start CPR again.

In considering the psychological reactions, 7% of the respondents indicated some negative feelings about the CPR process but only 0.5% were uncertain about starting CPR again.




*[Axelsson, 1998 #83] Axelsson, A., J. Herlitz, et al. (1998). “Factors surrounding cardiopulmonary resuscitation influencing bystanders’ psychological reactions.”

QL

Abstract: The incidence of Sweden’s out-of-hospital cardiac arrests averages 10,000 annually. Each year bystanders initiate cardiopulmonary resuscitation (CPR) approximately 2000 times prior to arrival of emergency medical service (EMS). The aim of this study was to identify factors influencing the bystanders psychological reactions to performing CPR. We mailed a questionnaire to all bystanders who reported performing CPR to the CPR Centre of Sweden from autumn 1992 to 1995. The study included 544 bystander reports. Nine factors were found to be associated with bystanders experience in a univariate analysis. Among these were victim outcome (p < 0.0001), CPR duration (p = 0.0009) and their experience of the attitude of the EMS personnel (p = 0.004). In a multivariate logistic regression model, lack of debriefing following the intervention (p = 0.0001) and fatal victim outcome (p = 0.03) were independent predictors of a negative bystander psychological reaction. The importance of having someone to talk to following an intervention and the EMS personnel concern for the rescuer should be emphasised. The goal should be that critical incident debriefing is available to every bystander following his or her CPR attempt.

This survey includes some of the cases from [Axelsson, 1996 #121] 1990-1994. The results of the two surveys were similar with this providing some insight concerning this negative psychological reaction.




*[Baker, 1999 #44] Baker, D. J. (1999). "The pre-hospital management of injury following mass toxic release; a comparison of military and civil approaches." Resuscitation 42(2): 155-159.

RG(Narr)

Abstract: Mass release of toxic substances may occur either accidentally or deliberately in both peace and war. Different approaches to the management of casualties from such an event have been developed by civil and military emergency medical teams, and reflect the different circumstances in which they operate. The nature and classification of toxic hazards is considered and the civil and military operational and medical responses compared. Both systems have different aspects that can contribute to early casualty management in a contaminated environment. Simple reference made to “the need for protection of emergency responders”




*[Ballard, 1986 #68] Ballard, J. L., M. J. Musial, et al. (1986). "Hazards of delivery room resuscitation using oral methods of endotracheal suctioning." Pediatric Infectious Disease 5(2): 198-200.

QTL

Abstract: Between 1978 and 1982 at least eight physicians at our institution were exposed to infectious secretions while performing mouth-to-tube resuscitation. A questionnaire revealed that 74% of responding paediatric physicians accidentally ingested secretions in 1982. The risk of cross-

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contamination between newborn patients and resuscitating physicians with the oral methods of oropharyngeal and endotracheal suctioning is considerable.

A documentation of practice and hazards in the late 1970s and early 1980s. May overstate the case when saying the risk is considerable.




*[Baskett, 1993 #59] Baskett, P. J. F. (1993). "Ethics in cardiopulmonary resuscitation." Resuscitation 25(1): 1-8.

TG(Narr)

Abstract: There is a minority of patients in whom resuscitation is inappropriate. It is important to identify such patients beforehand and communicate the decision not to attempt resuscitation to the would-be first responders. In the absence of the patient's expressed wishes, any decision not to attempt resuscitation must be made by the senior doctor in charge. This doctor will take into account a number of factors and, when appropriate, consult with medical and nursing colleagues relatives, etc. before making such a decision. There are many factors influencing the decision to terminate resuscitation once it has been started. These are listed and discussed. Legal aspects are addressed and indications are made of the expected performance of lay and professional rescuers working under a variety of circumstances. The various definitions of death are described in the light of modern medical practice and the possibility of organ transplantation. There is an increasing fear of infection hazards to the rescuer during mouth to mouth ventilation. The risks are discussed and the use of protective devices is encouraged if they are immediately available. Finally, guidelines for hospital ethical CPR policy are outlined in the hope that they will be considered for adoption on a national and international scale.

The discussion on risks of disease transmission refers to the known reported incidents and the lack of transmission of HBV and HIV/AIDS and the need for good cleaning techniques and practice in training sessions.




*[Bass, 1994 #155] Bass, J. B., Jr., L. S. Farer, et al. (1994). "Treatment of tuberculosis and tuberculosis infection in adults and children. American Thoracic Society and The Centers for Disease Control and Prevention.[see comment]." American Journal of Respiratory & Critical Care Medicine 149(5): 1359-74.

TG(Narr)

A detailed document with no direct reference to CPR or the associated risks. Some value may be found by extrapolation in the section “Persons for whom preventive therapy is recommended.” [Mejicano, 1998 #181] uses this reference to support his statement “ a rescuer who has given mouth-to-mouth ventilation to a patient with pulmonary tuberculosis should have serial tuberculin skin testing and should be offered prophylaxis if conversion occurs.”




*[Becker, 1997 #184] Becker, L. B., R. A. Berg, et al. (1997). "A reappraisal of mouth-to-mouth ventilation during bystander-initiated cardiopulmonary resuscitation. A statement for healthcare professionals from the Ventilation Working Group of the Basic Life Support and Pediatric Life Support Subcommittees, American Heart Association.[see comment]." Circulation 96(6): 2102-12.

TG(Narr)

This review considers disease transmission within the question “Does mouth-to-mouth ventilation inhibit performance of bystander cardiopulmonary resuscitation?” It states ”The actual risks of disease transmission during mouth-to-mouth ventilation are quite small,” and refers to [Ahmad, 1990 #100] [Feldman, 1972 #130] [Figura, 1996 #97] [Finkelhor, 1980 #123 [Heilman, 1965 #129]] [Hendricks, 1980 #132] [Mannis, 1984 #170] [Todd, 1980 #131] [Valenzuela, 1991 #14]


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*[Berumen, 1983 #210] Berumen U. Dog Poisons Man. JAMA 1983;249:253.

QSN

A 23-Year-old medical student saw his dog (a puppy) suddenly collapse. He started External Car-diac Massage and a Mouth-To-Nose ventilation effort. Moments later, the dog died, and the student felt nauseated, vomited, and lost consciousness. On the patient's arrival at the hospital, an alert medical officer detected a bitter almonds odor on the patient's breath and administered the accepted treatment for cyanide poisoning, after which he recovered. It turned out that the dog had accidentally swallowed cyanide, and the poison eliminated through the lungs had been inhaled by his master during the Mouth-To-Nose artificial respiration. I know of another case of similar nature, bizarre as It may be, involving a man and a dog.

An almost unique case; since animal resuscitation was not excluded in the evidence review, the case highlights the environmental risks of exposure.




*[Bierens, 1996 #12] Bierens, J. J. and H. J. Berden (1996). "Basic-CPR and AIDS: are volunteer life-savers prepared for a storm?" Resuscitation 32(3): 185-91.

QTG

Abstract: Professional health care workers have access to guidelines, equipment and techniques to reduce the exposure to infectious material in case of resuscitation. The current official content of national courses for volunteer life-savers do not address this issue, as far as we know. Concern about the risks of infection due to resuscitation is increasing in this group. This article describes a rational approach of the problem, that includes data on the infection risk of basic-CPR, and an approach that accepts that the concern can not be controlled by objective data. In such an emotional approach, direct contact has to be minimised by using devices. Requirements for resuscitation devices with a barrier function are listed. Although both approaches will reduce the fear of infection, we advice a rational approach.

Provides a rational approach to justify the statement that the risks of transmission of HIV is low ie “about one per million resuscitations in the highest risk group”.




*[Blenkharn, 1990 #122] Blenkharn, J. I., S. E. Buckingham, et al. (1990). "Prevention of transmission of infection during mouth-to-mouth resuscitation.[see comment]." Resuscitation 19(2): 151-7.

TI

Abstract: The risk of infection transmitted during mouth-to-mouth or mouth-to-nose resuscitation procedures is difficult to define but is possibly quite low. However, the perceived risk is sufficient to cause serious concern for many individuals, including trained hospital personnel as well as the general public, and may preclude prompt and effective action. A novel airway device was evaluated for the retention of infective droplets and fluid permeability under simulated resuscitation conditions using a cardiopulmonary resuscitation training manikin. Retention of a 0.5-5.0 micron aerosol of Staphylococcus aureus cells was greater than 80% at flow rates of 6 l/min while under simulated resuscitation conditions the trapping of bacteria, originating predominantly from saliva, was over 90%. These data suggest that this device may afford significant protection against transmission of infection during exhaled air resuscitation manoeuvres.

An early assessment of the Resusci Face Shield (Laerdal Medical Limited).




*[Blenkharn, 1992 #137] Blenkharn, J. I. and D. A. Zideman (1992). "Preventing transmission of infection during mouth-to-

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mouth resuscitation.[comment]." Journal of Emergency Medicine 10(5): 624-5.

QTN

The author disputes one aspect of the findings of [Cydulka, 1991 #159] but remains supportive of the concept that a face shield will “satisfy the concern of the general public and of health care personnel relating to possible infection risks during exhaled air resuscitation and afford protection against the transmission of saliva, blood, and respiratory droplets during mouth-to-mouth ventilation.” Refers to [Blenkharn, 1990 #122]




*[Cavagnolo, 1985 #156] Cavagnolo, R. Z. (1985). "Inactivation of herpes virus on CPR manikins utilizing a currently recommended disinfecting procedure." Infection Control 6(11): 456-8.

PTI

Abstract: The adequacy of a currently recommended protocol for disinfecting CPR manikins was investigated. Known quantities of Herpes simplex type 1 virus were applied to various sites on both adult and infant manikin heads, exposed to disinfectant under simulated classroom conditions, and then assayed for infectious virus. Results indicate that the disinfecting protocol and disinfectant are adequate for inactivating herpes virus on CPR manikins, but that care must be exercised to ensure thorough cleaning.

Supportive of current (1985) disinfection procedures for manikins.




*[Christian, 2004 #32] Christian, M. D., M. Loutfy, et al. (2004). "Possible SARS Coronavirus Transmission during Cardiopulmonary Resuscitation." Emerging Infectious Diseases 10(2): 287-293.

TH

Abstract: Infection of healthcare workers with the severe acute respiratory syndrome-associated coronavirus (SARS-CoV) is thought to occur primarily by either contact or large respiratory droplet transmission. However, infrequent healthcare worker infections occurred despite the use of contact and droplet precautions, particularly during certain aerosol-generating medical procedures. We investigated a possible cluster of SARS-CoV infections in healthcare workers who used contact and droplet precautions during attempted cardiopulmonary resuscitation of a SARS patient. Unlike previously reported instances of transmission during aerosol-generating procedures, the index case-patient was unresponsive, and the intubation procedure was performed quickly and without difficulty. However, before intubation, the patient was ventilated with a bag-valve-mask that may have contributed to aerosolization of SARS-CoV. On the basis of the results of this investigation and previous reports of SARS transmission during aerosol-generating procedures, a systematic approach to the problem is outlined, including the use of the following: 1) administrative controls, 2) environmental engineering controls, 3) personal protective equipment, and 4) quality control.

Only one of nine workers involved met WHO criteria for SARS. The principle espoused to generate policy change is the chance that a SARS patient will suffer unwitnessed cardiopulmonary arrest or require emergency intubation and resuscitation-associated risks must be minimised.




*[Clements, 2003 #37] Clements, P. A. D. (2003). "Hazards of performing chest compressions in collapsed patients with internal cardioverter defibrillators." Emergency Medicine Journal 20(4): 379-380.

QRH

Abstract: The potential dangers to the rescuer performing chest compressions on a patient with an internal cardioverter defibrillator (ICD) are described. Simple measures to avoid these are discussed.

Three paramedics and one doctor performed external cardiac massage on an arrested patient with an internal cardioverter defibrillator (ICD). During the process the ICD discharged five times. The

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paramedic not wearing latex gloves when the ICD discharged received a shock and “had to rest for over half an hour before being able to resume work”.


Quality of Evidence: Good


*[Cohen, 1985 #147] Cohen, H. J. and W. Minkin (1985). "Transmission of infection during training for cardiopulmonary resuscitation." Annals of Internal Medicine 102(1): 136-7.

PTN

The correspondents highlight the NRC 1984 Guidelines, express concern about transmission of viral diseases during training and the potential inadequacies of disinfection procedures, and advocate the use of an overlay mask.




*[Corless, 1992 #158] Corless, I. B., A. Lisker, et al. (1992). "Decontamination of an HIV-contaminated CPR manikin." American Journal of Public Health 82(11): 1542-3.

PTI

Abstract: There has been a concern that the number of persons engaging in cardiopulmonary resuscitation (CPR) training could decline because of questions about human immunodeficiency virus (HIV-1) transmission. We investigated the theoretical possibility that a CPR manikin might serve as a fomite for HIV-1 transmission. Decontamination protocols were tested by using elevated levels of virus and decreasing decontamination times. Even under these compromising conditions, however, decontamination was effective.

“Our data suggest that one should not refrain from CPR training out of fear of contracting HIV infection”.



Nature of evidence: Support

*[Cummins, 1989 #13] Cummins, R. D. (1989). "Infection control guidelines for CPR providers." JAMA 262(19): 2732-3.

GK

Editorial comment on [Anonymous, 1989 #7]. Notes that “CDC Cooperative Needlestick Surveillance Group has abandoned follow-up on health care workers exposed to saliva and other nonblood fluids from patients with HIV because none of 106 workers followed up for more than one year sero-converted.” [McCray, 1986 #195] [Marcus, 1988 #194] and that a patient infected with HBV remains the greatest infectious threat to CPR providers. [anonymous, 1989 #191] This should be considered with [Glaser, 1985 #146]




*[Cutler, 1979 #126] Cutler, S. S. (1979). "Safety of mouth-to-mouth resuscitation." Lancet 2(8151): 1074.

QN

Documents the 22 year record of the New York City Fire Department of no disease transmission through rescue breathing. No details of number resuscitated in this period. Response to [Davies, 1979 #136] and [Gilston, 1979 #135]




*[Cydulka, 1991 #159] Cydulka, R. K., P. J. Connor, et al. (1991). "Prevention of oral bacterial flora transmission by using mouth-to-mask ventilation during CPR.[see comment]." Journal of Emergency Medicine 9(5): 317-21.

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QTI

Abstract: The Emergency Cardiac Care Committee of the American Heart Association has recently recommended utilizing protective barrier precautions during CPR (1,2). We assessed 17 mask and faceshield resuscitation devices for adequacy of barrier protection. Eight of the devices were faceshields (CPR Microshield, Hygenic, MedCare Mask, Resusci, Samaritan, Sealeasy, Portex); 8 were mask devices (Laerdal, Dyna Med, MTM Emergency Lung Ventilator, MTM Emergency Resuscitator, Res-Q-Flo, Rightway Mouth-to-Mask Resuscitation, Trufit), and one of the devices did not meet the criteria for either faceshield or mask (Lifesaver). All masks were disinfected, applied to the investigator's face as directed by the manufacturers' instructions, and then cultured for oral aerobic bacterial flora on the rescuer side. No mask devices cultured positive for oral aerobic bacterial flora, while 6 of 8 faceshield devices cultured positive for oral aerobic bacterial flora (P less than 0.007). The CPR Microshield and the Portex faceshield were the only devices that did not develop a positive culture. We conclude that all ventilation devices with a one-way valve, except the Sealeasy device, provide adequate barrier type protection from oral aerobic bacterial flora when simulating mouth-to-barrier type protection when performing mouth-to-mouth ventilation.

A technical assessment of ancillary equipment with one adverse finding being challenged by [Blenkharn, 1992 #137]




*[Davies, 1979 #136] Davies, J. N. (1979). "Operator risk in mouth-to-mouth resuscitation." Lancet 2(8142): 593.

QN

Raises the question of disease transmission and refers to [Osterholm, 1979 #199] but makes no contribution to the worksheet hypothesis




[Davis, 1978 #160] Davis, G. E. (1978). "Promiscuous resusannies--a public health problem? A plastic typhoid Mary." Journal of the Maine Medical Association 69(8): 214.

NOT AVAILABLE

*[Deetz, 1979 #209] Deetz TR. Operator risk in mouth-to-mouth resuscitation. Lancet 1979;2(8148):912.

PTN

Text: The letters from Professor Davies (Sept. 15, p. 593) and Dr Gilston (Sept. 29, p. 694) underscore the need for more information on risks of transmission of infectious diseases in persons who perform mouth-to-mouth resuscitation. I recently saw a nurse with fever, headache, chills, and pharyngitis. Twenty-four hours previously she had attempted mouth-to-mouth resuscitation on a 7-year-old child who had had a cardiopulmonary arrest. The child died, and culture of blood obtained post mortem grew group A P-haemolytic streptococci. Examination of the nurse was remarkable only for an acute exudative pharyngitis. A gram-stain of pharyngeal secretions was consistent with a streptococcal pharyngitis,' and group-A streptococci grew abundantly from a throat culture. The strep-tococcal isolates were sent to the State laboratory for typing. The child's streptococcus was typed as M-3, T-3/13, whereas the streptococcus isolated from the pharynx of the nurse was non-typable for both antigens. Since health personnel are exposed to infectious agents from many sources, a critical examination of the data assigning risks of mouth-to-mouth resuscitation is important before this potentially life-saving procedure is indicted. Many health-care personnel may even feel that the risk of contracting a treatable infectious disease is small compared with the possibility of a successful resuscitation.

Emphasizes the need for careful analysis of reported cases of disease transmission.




*[Dracup, 1997 #216] Dracup K, Moser DK, Taylor SE, Guzy PM. The psychological consequences of cardiopulmonary resuscitation training for family members of patients at risk for sudden death. Am. J. Public Health

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1997;87(9):1434-9.

PSH

Abstract: OBJECTIVES: The purpose of this study was to determine psychological consequences of teaching cardiopulmonary resuscitation (CPR) to family members of patients at risk for sudden death. METHODS: Patient-family pairs (n = 337) were randomized into one of four groups: control, CPR only, CPR with cardiac risk factor education, and CPR with a social support intervention. Only family members received CPR training. Data on emotional state and psychosocial adjustment to illness were collected at baseline, 2 weeks, and 3 and 6 months following CPR training. RESULTS: There were no significant differences in the emotional states of family members across the four groups. However, significant differences in psychosocial adjustment and emotional states occurred in patients across treatment groups following CPR training. Patients whose family members learned CPR with the social support intervention reported better psychosocial adjustment and less anxiety and hostility than patients in the other groups. Control patients reported better psychosocial adjustment and less emotional distress than patients in the CPR-only and CPR-education groups. CONCLUSIONS: These findings support tailoring family CPR training so that instruction does not result in negative psychological states in patients. The findings also illustrate the efficacy of a simple intervention that combines CPR training with social support.

The relevant component of this trial states “There were no significant differences in the emotional states of family members across the four groups.”




*[Duffy, 1974 #161] Duffy, P., J. Wolf, et al. (1974). "Letter: Possible person-to-person transmission of Creutzfeldt-Jakob disease." New England Journal of Medicine 290(12): 692-3.

TH

Relates to disease transmission by corneal transplantation.

NOT RELEVANT

*[Dunlap, 1994 #162] Dunlap, N. E., W. C. Bailey, et al. (1994). "Occupational exposure to tuberculosis: risk and consequences." Chest 106(3): 658-9.

G(Narr)

Relates to occupational exposure to tuberculosis and the arguable need for the use of high efficiency particulate air (HEPA) respirators. No mention of CPR.

NOT RELEVANT

*[Edwards, 2001 #42] Edwards, S. M., J. C. Williams, et al. (2001). "Universal precautions at cardiac arrests." Anaesthesia 56(4): 378-379.

L

Short article focuses on the provision of equipment for cardiac arrests and proposes that resuscitation is a high risk situation and that the anaesthetist is particularly at risk. It claims to identify a potential hazard where facilities are provided on a selective rather than universal approach.




*[Emergency Cardiac Care Committee and Subcommittees, 1992 #185]

Emergency Cardiac Care Committee and Subcommittees, A. H. A. (1992). "Guidelines for cardiopulmonary resuscitation and emergency cardiac care, II; Adult basic life support." JAMA 268: 2195-7.

TJ

Provides recommendations for control of disease transmission during CPR training and outlines practices espoused for the performance of CPR.



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*[Feldman, 1972 #130] Feldman, H. A. (1972). "Some recollections of the meningococcal diseases. The first Harry F. Dowling lecture." JAMA 220(8): 1107-12.

G(Narr)

Reports “at least four cases (of meningococcal disease) have followed mouth-to-mouth resuscitation”.




*[Fenner, 1998 #50] Fenner, P. (1998). "Management of marine envenomation. Part 2: Other marine animals." Modern Medicine of Australia 41(2): 90-95.

M

Abstract; In the previous issue, Part 1 of this article discussed jellyfish envenomation and its treatment. This part covers the effects of envenomation by other marine animals, and summarises the first aid and medical treatment to be used. With travel becoming commonplace, general practitioners and travel medicine specialists, then they are first consulted, should routinely advise their patients about the hazards of marine envenomation, both in Australia and overseas.

NOT RELEVANT

*[Figura, 1996 #97] Figura, N. (1996). "Mouth-to-mouth resuscitation and helicobacter pylori infection [25]." Lancet 347(9011).

QTH

Case report of possible transmission of Helicobacter pylori infection - Professional provided mouth-to-mouth resuscitation on patient whose “mouth was full of vomit”. Actually a case of Disease transmission, Professional-to-patient.




*[Finkelhor, 1980 #123] Finkelhor, R. S. and J. H. Lampman (1980). "Herpes simplex infection following cardiopulmonary resuscitation." JAMA 243(7): 650.

QTH

Case report of resuscitator developing herpetic stomatitis and paronychia after performing CPR on a patient with mouth ulcers from which herpes simplex virus was isolated.




*[Gamble, 2001 #141] Gamble, M. (2001). "A debriefing approach to dealing with the stress of CPR attempts." Professional Nurse 17(3): 157-60.

QSG(Narr)

Abstract : Nurses may suffer physiological and psychological stress following a cardiopulmonary resuscitation attempt. Implementation of debriefing sessions following the care of a patient experiencing a cardiac arrest can reduce staff stress. Using a debriefing process enables learning opportunities to be identified and acted on by resuscitation teams.

Suggests that CPR is highly stressful for the nursing staff and that this can be detrimental.




*[Genest, 1990 #197] Genest M, Levine J, Ramsden V, al. e. The impact of providing help: Emergency workers and cardiopulmonary resuscitation attempts. J. Trauma. Stress 1990;3:305-9.

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QSH

Abstract: Although anecdotes suggest that emergency medical technicians often themselves have to cope with severe trauma as a result of their work, almost all empirical work has been concerned with the aftermath of disaster. Fourteen volunteer ambulance attendants were asked about resuscitation attempts in which they had been involved. It was found that many of these evidenced a persistent psychological aftermath. Some of these individuals experienced vivid, involuntary, and uncontrollable thoughts, feelings, and/or mental images concerning their attempt. Perceived control and coping responses were examined, and found to be related to the impact of the resuscitation attempt upon the ambulance personnel. Data from this preliminary investigation indicate the need for further work in the area, and with related populations, such as nonprofessionals who attempt cardiopulmonary resuscitation.

It is notable that the study dealt with volunteer workers in unsuccessful attempts at CPR. Recognition of probable failure is not protective in itself. There was evidence of persisting psychological aftermaths with no respondent being entirely free from unbidden recollections of the experience.




*[Genest, 1991 #198] Genest M, Genest S, Swanson RW, al. e. Emergency workers and CPR attempts. In: International Society for Traumatic Stress Studies; 1991; Washington, DC; 1991.

QSH

Abstracts: A growing body of literature has assessed the long-term physical and psychological impact of disasters on rescuers but there have been no previous investigations to assess the impact of small-scale rescues. Pilot work that we carried out with rural ambulance personnel in 1988 indicated that they suffered significant distress as a result of their work.

Currently, assessment is being carried out on all the ambulance personnel, fire fighters and police officers in two cities, and will eventually include emergency room physicians and nurses.

The focus is the impact of cardiopulmonary resuscitation (CPR) attempts. Most CPR attempts are unsuccessful. Following CPR attempts, rescuers will be interviewed and asked to complete a package of questionnaires. They will be followed and re-assessed at intervals for an extended period of time. Comparison subjects in the same positions but who have not carried out CPR attempts will be assessed.

Data concerning general psychological adjustment, post-traumatic symptoms, and coping strategies will be presented from baseline assessments, as well as from initial post-CPR-attempt assessments. Data from some assessments carried out 3 months and 6 months after the CPR attempts will also be available.

No conclusions can be made from this abstract. Attempt to pursue through University of Saskatchewan. [email protected] Reply indicates authors cannot be traced.




*[Gilston, 1979 #135] Gilston, A. (1979). "Operator risk in mouth-to-mouth resuscitation." Lancet 2(8144): 694.

QN

Refers to [Heilman, 1965 #129] and [Zaeslin, 1966 #206] and introduces the argument for ECM before EAR (in 1979!)




*[Glaser, 1985 #146] Glaser, J. B. and J. P. Nadler (1985). "Hepatitis B virus in a cardiopulmonary resuscitation training course. Risk of transmission from a surface antigen-positive participant." Archives of Internal Medicine 145(9): 1653-5.

PTH

mailto:[email protected]

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Abstract: A group exposure to cardiopulmonary resuscitation training manikins contaminated by saliva from a participant during the immediate presymptomatic infectious stage of "e" antigen-positive hepatitis B recently occurred. None of the 18 susceptible participants developed serologic or clinical evidence of new hepatitis B infection during the six-month postexposure observation period. The risk of transmission in this setting appears to be low. Postexposure prophylaxis does not appear indicated.

This reinforces two other investigations suggesting that transmission under these circumstances is unlikely. [Osterholm, 1979 #199] [Anonymous, 1978 #204]




*[Greenberg, 1983 #188] Greenberg M. CPR: a report of observed medical complications during training. Ann. Emerg. Med. 1983;12(3):194-5.

PHN

In response to [Memon, 1982 #144], four specific incidents are noted.

Left chest pain and SOB with preceding MI in a 48 yo male

Recurrent mild anaphylaxis in a 28 yo female

Chest pain with preceding angina in a 60 yo male

Weakness, vertigo and altered mental state after 8 hr training course in a 25 yo female.

He notes students have periodically complained of symptoms characteristic of hyperventilation.




*[Handley, 1998 #177] Handley, A. J., J. Bahr, et al. (1998). "The 1998 European Resuscitation Council guidelines for adult single rescuer basic life support: A statement from the Working Group on Basic Life Support, and approved by the executive committee.[see comment][erratum appears in Resuscitation 1998 Aug;38(2):131-2]." Resuscitation 37(2): 67-80.

J

The only reference to hazards in this article is the recognition that “in some communities there is a reluctance to perform rescue breathing on a stranger due to a concern over disease transmission”. This matter has been excluded from this worksheet.

NOT RELEVANT

*[Heilman, 1965 #129] Heilman, K. M. and C. Muschenheim (1965). "Primary cutaneous tuberculosis resulting from mouth-to-mouth respiration." New England Journal of Medicine 273(19): 1035-6.

QTH

Early advocate for ancillary devices in CPR to avoid the need for mouth –to-mouth resuscitation.




*[Hendricks, 1980 #132] Hendricks, A. A. and E. P. Shapiro (1980). "Primary herpes simplex infection following mouth-to-mouth resuscitation." JAMA 243(3): 257-8.

QTH

Case report of disease transmission with reference to [Heilman, 1965 #129]. Advocates awareness of problem with use of protective devices and consideration of post resuscitation testing for syphilis, hepatitis and tuberculosis.



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*[Hodgin, 1992 #164] Hodgin, L. (1992). "New law in the Big Apple mandates CPR infection-control equipment." Occupational Health & Safety 61(3): 56, 58.

K

On the premise that trained personnel are reluctant to perform CPR because of fear of disease transmission, a city law was passed in January 2002 requiring all specified public places to have infection-control resuscitation equipment available.

NOT RELEVANT

*[Hudson, 1983 #165] Hudson, A. D. (1983). "A hypochlorite solution for removing bacteria from CPR manikins." Annals of Emergency Medicine 12(8): 485-8.

PTI

Abstract: To study the effectiveness of a dilute hypochlorite solution in removing bacteria from cardiopulmonary resuscitation (CPR) manikins, cultures from several areas of manikins disinfected with hypochlorite were compared with those from manikins disinfected with another protocol, and bacteria which grew were counted and identified. The use of dilute hypochlorite resulted in significant reduction of bacterial numbers (P less than .0005), without damaging manikin components or provoking unpleasant reaction from trainees. Dilute hypochlorite disinfection of CPR training manikins after each class session might greatly reduce the possibility of transmitting pathogenic bacteria or other micro-organisms between participants in resuscitation practice.




*[Hudson, 1984 #145] Hudson, A. D. (1984). "Herpes simplex virus and CPR training manikins: reducing the risk of cross-infection." Annals of Emergency Medicine 13(12): 1108-10.

PTI

Abstract: Two disinfecting solutions for removing herpes simplex virus (HSV) from CPR training manikin face skin were investigated. Both 70% ethanol and 70% ethanol plus 0.5% chlorhexidine solutions were effective in reducing recoverable virus at both 10(5) and 10(7) particles per milliliter inoculum concentrations (P less than .01 and P less than .005 versus no decontamination, respectively). The survival characteristics of HSV on manikin skin also were explored, demonstrating greater than four hours of viability.

Demonstrates efficacy of standard cleaning technique with reference to [Todd, 1980 #131] [Deetz, 1979 #209] [Heilman, 1965 #129] [Finkelhor, 1980 #123] [Hendricks, 1980 #132] [Achong, 1980 #73] [Davis, 1978 #160] [Khan, 1979 #124] [Nicklin, 1980 #172]




*[Jacobson, 1976 #167] Jacobson, J. A. and D. W. Fraser (1976). "A simplified approach to meningococcal disease prophylaxis." JAMA 236(9): 1053-4.

TM

Considers mouth-to-mouth a risk factor for transmission of meningococcal disease and therefore an indicator for prophylaxis.


Quality of Evidence: fair


*[Jafari, 1997 #153] Jafari, H. and B. Perkins (1997). "Control and prevention of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP)." Morbidity & Mortality Weekly Report. Recommendations & Reports 46(RR-5): 1-10.

J

Abstract: These recommendations update information regarding the polysaccharide vaccine

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licensed in the United States for use against disease caused by Neisseria meningitidis serogroups A, C, Y, and W-135, as well as antimicrobial agents for chemoprophylaxis against meningococcal disease (superseding MMWR 1985;34:255-9). This report provides additional information regarding meningococcal vaccines and the addition of ciprofloxacin and ceftriaxone as acceptable alternatives to rifampin for chemoprophylaxis in selected populations.

Antimicrobial prophylaxis is recommended for c) anyone directly exposed to the patient’s oral secretions (eg through.mouth-to-mouth resuscitation, endotracheal intubation, or endotracheal tube management). Rifampicin has been the drug of choice but ciprofloxacin or ceftriaxone are reasonable alternatives.



Evidence : Supportive

*[Jevon, 2002 #18] Jevon, P. (2002). "Cardiopulmonary resuscitation. Mouth-to-mouth ventilation." Nursing Times 98(12): 43-4.

M

An educational short document making reference to [Mejicano, 1998 #181]. Offers no new data.

NOT RELEVANT

*[Khan, 1979 #124] Khan, A. H., F. P. Roland, et al. (1979). "Cardiopulmonary resuscitation--potential danger of cross-infection." JAMA 241(25): 2701-2.

PTI

The deposition of normal oral bacteria onto manikin surfaces during training was seen as indicative of potential disease transmission. Swapping roles for two-person CPR training was seen as particularly hazardous.




*[Lambrew, 1979 #168] Lambrew, C. T., N. Wynne, et al. (1979). "Training mannequins an important source of transmission of hepatitis." Journal of the Maine Medical Association 70(1): 44.

PTN

An editorial reflecting [Davis, 1978 #160] and referring to[Anonymous, 1978 #204]




*[Laws, 2001 #10] Laws, T. (2001). "Examining critical care nurses' critical incident stress after in hospital cardiopulmonary resuscitation (CPR)." Australian Critical Care 14(2): 76-81.

QSH

Abstract: The object of this study was to determine if critical care nurses' emotional responses to having performed cardiopulmonary resuscitation were indicative of critical incident stress. A descriptive approach was employed using a survey questionnaire of 31 critical care nurses, with supportive interview data from 18 of those participants. Analysis of the data generated from the questionnaire indicated that the respondents experienced thought intrusion and avoidance behaviour. A majority of those interviewed disclosed that they had experienced a wide range of emotional stressors and physical manifestations in response to having performed the procedure. The findings from both questionnaire and interview data were congruent with signs of critical incident stress, as described in the literature. This has been found to be detrimental to employees' mental health status and, for this reason, employers have a duty of care to minimise the risk of its occurrence and to manage problems as they arise.

Level of Evidence:5

Quality of Evidence Fair:


*[Lonergan, 1981 #29] Lonergan, J. H., J. Z. Youngberg, et al. (1981). "Cardiopulmonary resuscitation: physical stress on

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the rescuer." Critical Care Medicine 9(11): 793-5.

RI

Abstract: The physical stress on the rescuer performing cardiopulmonary resuscitation (CPR) was assessed utilizing the ECG, rate pressure product (RPP), and total body oxygen consumption (VO2). Six healthy physicians served as rescuers. Only a sub-maximal physical effort was required to perform good CPR, as demonstrated by the heart rate and VO2 changes. However, the effect was enough to generate a mean rescuer RPP approaching 20,000 with 2 of the rescuers well over 20,000. These data suggest that CPR might elicit ischemic symptoms in a rescuer with coronary artery disease.




*[Lufkin, 1993 #169] Lufkin, K. C. and E. Ruiz (1993). "Mouth-to-mouth ventilation of cardiac arrested humans using a barrier mask." Pre-hospital & Disaster Medicine 8(4): 333-5.

TI

Abstract: INTRODUCTION: Concern for possible disease transmission during mouth-to-mouth resuscitation has decreased the incidence of bystander cardiopulmonary resuscitation (CPR). Barrier masks have become available that may be effective in CPR as well as protective against cross-contamination. HYPOTHESIS: A silicone rubber barrier mask incorporating a one-way-valved airway (Kiss of Life [KOL]) designed to prevent contamination of the rescuer, permits satisfactory mouth-to-mouth ventilation of victims of cardiopulmonary arrest. METHODS: Ten adult patients who did not survive non-traumatic cardiac arrest were ventilated with exhaled room air using a KOL barrier mask while external cardiac massage continued. Arterial blood gases were obtained every two minutes for a maximum of 10 minutes. The operator was blinded to the results of these blood tests. RESULTS: Eight men and two women with ages from 55 to 99 years were studied. Four patients were edentulous and two of these had marked mandibular atrophy. The two patients with mandibular atrophy were poorly ventilated with the barrier mask. One other patient was not ventilated successfully. This patient had undergone multiple attempts at endotracheal intubation and had transtracheal needle ventilation performed prior to use of the barrier mask. One patient had elevated PaCO2 despite being well-ventilated clinically. Six patients were ventilated well clinically and had satisfactory PaCO2 and PaO2 values. CONCLUSION: The barrier mask studied appears to be an effective aid to ventilation in CPR. Patients without facial support, as in edentulous patients with mandibular atrophy, are not ventilated well with this device.

NOT RELEVANT

*[Lyster, 2003 #26] Lyster, T., D. Jorgenson, et al. (2003). "The safe use of automated external defibrillators in a wet environment." Prehospital Emergency Care 7(3): 307-11.

QRI

Abstract: There has been concern regarding potential shock hazards for rescuers or bystanders when a defibrillator is used in a wet environment and the recommended safety procedure, moving the patient to a dry area, is not followed. OBJECTIVE: To measure the electrical potentials associated with the use of an automated external defibrillator (AED) in a realistically modelled wet environment. METHODS: A raw processed turkey was used as a patient surrogate. The turkey was placed on a cement floor while pool water was applied to the surrounding area. To simulate a rescuer or bystander in the vicinity of a patient, a custom sense probe was constructed. Defibrillation shocks were delivered to the turkey and the probe was used to measure the voltage an operator/bystander would receive at different points surrounding the surrogate. The test was repeated with salt water. RESULTS: The maximum voltage occurred approximately 15 cm from the simulated patient and measured 14 V peak (current 14 mA peak) in the case of pool water, and 30 V peak (current 30 mA peak) in the case of salt water. CONCLUSIONS: Thirty volts may result in some minor sensation by the operator or bystander, but is considered unlikely to be hazardous under these circumstances. The maximum currents were lower than allowed by safety standards. Although defibrillation in a wet environment is not recommended practice, our simulation of a patient and a rescuer/bystander in a wet environment did not show significant risk should circumstances demand it.

Australian Resuscitation Council policy accepts defibrillation as an element of BLS [Handley, 1998 #177] describes BLS as not using other equipment but continues “The development of automated defibrillation (AED) has allows minimally trained persons to extend their BLS skills.”


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[Mannis, 1984 #170] Mannis, M. J. and R. T. Wendel (1984). "Transmission of herpes simplex during cardiopulmonary resuscitation training." Comprehensive Therapy 10(12): 15-7.

PTH

Abstract:

NOT AVAILABLE

*[Mannis, 1984 #213] Mannis MJ, Wendel RT. Transmission of herpes simplex during CPR training. Ann. Ophthalmol. 1984;16(1):64-6.

PTH

Abstract: Instruction in cardiopulmonary resuscitation (CPR) has become a standard part of training for medical personnel and is widely recommended for the lay public. We present a case report of two women, one of whom contracted herpes labialis and one of whom contracted ocular herpes simultaneously after participating as partners in a CPR training course. This case suggests that added precautions against the transmission of infectious disease should be taken by screening participants in CPR courses for signs of respiratory, oral, or facial cutaneous disease. In addition, this case underscores the crucial importance of adequately disinfecting mannequins between users and between training sessions. Specific recommendations are made.

A report of two cases of possible disease transmission from the same training setting. Not proven by any means.




*[Marcus, 1988 #194] Marcus R. Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus.[see comment]. N. Engl. J. Med. 1988;319(17):1118-23.

TH

Abstract: Since 1983, we have conducted national surveillance of health care workers exposed to blood or body fluids from persons infected with the human immunodeficiency virus (HIV), to assess the risk of HIV transmission by such exposures. As of July 31, 1988, 1201 health care workers with blood exposures had been examined, including 751 nurses (63 percent), 164 physicians and medical students (14 percent), 134 laboratory workers (11 percent), and 90 phlebotomists (7 percent). The exposures resulted from needle-stick injuries (80 percent), cuts with sharp objects (8 percent), open-wound contamination (7 percent), and mucous-membrane exposure (5 percent). We concluded that 37 percent of the exposures might have been prevented. Of 963 health care workers whose serum has been tested for HIV antibody at least 180 days after exposure, 4 were positive, yielding a seroprevalence rate of 0.42 percent (upper limit of 95 percent confidence interval, 0.95 percent). Three subjects experienced an acute retroviral syndrome associated with documented seroconversion; serum collected within 30 days of exposure was not available from the fourth person. Two exposures that resulted in seroconversion were caused by co-workers during resuscitation procedures. We conclude that the risk of HIV infection after exposure to the blood of a patient infected with HIV is low, but at least six months of follow-up is recommended. Many exposures can be prevented by careful adherence to existing infection-control precautions, even during emergencies.

A later report of the same project as [McCray, 1986 #195]. Sixty of 1201 workers were exposed to blood by mucous-membrane contact. There is no statement that CPR was involved – only “various other procedures “are mentioned.




*[McCabe, 1997 #183] McCabe, E. (1997). "Code team hazards." Nursing Management 28(3): 48K-48L.

G

Abstract: Hospitalised resuscitation code) team members face unique risks: physical, chemical,

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environmental, psychosocial/ psychosocial and/or infectious hazards. The everyday health and safety dangers code teams encounter are discussed.

Emphasises occupational health and safety aspects of resuscitation but specifically refers to electrical hazards of cardioversion. The comments on chemical and environmental hazards omit mention of the poisoned/contaminated casualty.




*[McCray, 1986 #195] McCray E. Occupational risk of the acquired immunodeficiency syndrome among health care workers. N. Engl. J. Med. 1986;314(17):1127-32.

TH

Abstract: In August 1983, we initiated nationwide prospective surveillance of health care workers with documented parenteral or mucous-membrane exposures to blood or other body fluids of patients with the acquired immunodeficiency syndrome (AIDS) or AIDS-related illnesses. The purpose of the surveillance project is to quantitate prospectively the risk to health care workers of acquiring the AIDS virus, human T-cell lymphotropic virus Type III/lymphadenopathy-associated virus (HTLV-III/LAV), as a result of occupational exposures. By December 31, 1985, 938 health care workers were being followed in the surveillance project. The mean length of follow-up was 15 months (range, 0 to 56) and 531 health care workers (57 percent) had been followed for more than one year. Needle-stick injuries and cuts with sharp instruments accounted for 76 percent of the exposures. Over 85 percent of all exposures were to blood or serum. None of the health care workers have acquired signs or symptoms of AIDS. Analyses of T-lymphocyte subsets were performed for 341 (36 percent) of the exposed health care workers, and tests for antibody to HTLV-III/LAV were performed for 451 (48 percent). Seven health care workers who had low helper/suppressor T-lymphocyte ratios on initial testing were retested; only three had persistently low ratios. Only two health care workers tested were seropositive for antibody to HTLV-III/LAV. The results of this surveillance project, thus far, suggest that the risk to health care workers of occupational transmission of HTLV-III/LAV is low (the upper bound of the 95 percent confidence interval for the seroprevalence rate among workers with greater than or equal to 3 months of follow-up with HTLV-III/LAV antibody testing is 1.65 percent) and appears to be related to parenteral exposure to blood

A 1986 report of the same project as [Marcus, 1988 #194]




[McLauchlan, 1992 #223] McLauchlan CAJ, Ward A, Murphy NM, Griffith MJ, Skinner DV, Camm AJ. Resuscitation training for cardiac patients and their relatives. Its effect on anxiety. Resuscitation 1992;24(1):7-11.

PSH

Abstract: It is feared by many doctors that teaching basic life support (BLS) to high risk cardiac patients or a member of the family increases their anxiety. We trained a group of patients with recurrent ventricular tachycardia in BLS together with a friend or family member. Measurement of anxiety before and three months after training demonstrated a reduction in anxiety in both groups. This suggests that basic life support training can be targeted to high risk groups without fear of increasing anxiety.




*[Mejicano, 1998 #181] Mejicano, G. C. and D. G. Maki (1998). "Infections acquired during cardiopulmonary resuscitation: estimating the risk and defining strategies for prevention." Annals of Internal Medicine 129(10): 813-28.

TG(Evb)

Abstract: PURPOSE: To estimate the risk for acquiring an infectious disease during cardiopulmonary resuscitation (CPR) or CPR training and to identify strategies to minimize that risk. DATA SOURCES: English-language articles published since 1965 were identified through a search

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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 needle-sticks 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. Postexposure 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. (My emboldening - FHB)

The conclusion may well be the proposal for this worksheet!




*[Memon, 1982 #144] Memon, A. M., J. E. Salzer, et al. (1982). "Fatal myocardial infarct following CPR training: the question of risk." Annals of Emergency Medicine 11(6): 322-3.

PRH

Single case report of fatal myocardial infarction occurring during CPR training. Advocates that any persons with known ischaemic heart disease should be excluded from CPR training and that persons with risk factors for IHD should be assessed by a physician before CPR training.

Reveals [Macauley, 1978 #208] - not found elsewhere.




*[Miller, 1982 #72] Miller, L. V. and R. Brennan (1982). "Cardiac defibrillator use in potentially hazardous situations." Biomedical Sciences Instrumentation 18(pp 87-90).

PRL

Abstract: Given the high voltages required for cardiac defibrillation and the now relatively common use of this emergency procedure in the pre-hospital environment, what is the potential and actual hazard to the health and safety of emergency paramedical personnel, bystanders, and patients when defibrillation is required in less than ideal field situations? As the first phase of a larger undertaking to define training needs and develop protocols to insure safe defibrillator use in potentially hazardous situations, we have conducted a survey of actual pre-hospital defibrillation experience. The survey findings demonstrate that a majority of paramedic personnel do experience the need to defibrillate in circumstances where environmental factors such as moisture, flammable liquids and gases, confining or precarious locations, emergency vehicle motion, and/or conductive surfaces or structures do have significance for the safe and successful performance of cardiac defibrillation. While many have experienced incidents involving difficulties in effecting successful defibrillation, or minor harm or discomfort to rescuers and bystanders, no incidents involving major injury or death directly attributable to such factors have been reported. Only one confirmed instance of defibrillator malfunction was reported. Also of significance is the wide variety of policies and procedures (some well-founded, others based on misconception) instituted in response to actual and perceived hazards. These policies reflect the varied, and often inadequate, training provided to emergency paramedical personnel to prepare them for evaluating defibrillator use hazards in the unpredictable pre-hospital environment. This training inadequacy appears to be, to a great extent, the result of an absence of pertinent information in the emergency medical and paramedical literature, a situation we intend to help rectify.

Assuming defibrillation is part of BLS and CPR this paper is acceptable.

Sixty American Emergency Medical Services were surveyed by questionnaire. One hundred and twenty responses were obtained from 42 organisations. Thirteen reported one or more incidents of

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minor shocks to rescuers, a bystander and a helicopter pilot due to moisture, conductive structures or confining locations.




*[Montgomery, 1986 #189] Montgomery WH. The 1985 Conference on Standards and Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care. JAMA 1986;255(21):2990-1.

O

Editorial referring to [Anonymous, 1986 #193]




[Moser, 1999 #439] Moser DK, Dracup K, Doering LV. Effect of cardiopulmonary resuscitation training for parents of high- risk neonates on perceived anxiety, control, and burden. Heart & Lung: Journal of Acute & Critical Care 1999;28(5):326-333.

PSH

OBJECTIVES: Study objectives: (1) To compare the effects of 3 methods of cardiopulmonary resuscitation (CPR) training for parents of infants at risk for cardiac or respiratory arrest on anxiety, perception of control, and sense of burden; and (2) to identify parents' attitudes about CPR training and willingness to perform CPR if needed. METHODS: A longitudinal, controlled trial was conducted with parents and other caretakers of high-risk infants. Subjects were recruited from 5 level III neonatal intensive care units. We enrolled each of 578 subjects in 1 of 4 groups: (1) CPR-Video; (2) CPR- Didactic; (3) CPR-Social Support; or (4) control (no CPR training). Of these, 335 completed the entire study. Data were collected at baseline, and 2 weeks and 6 months after CPR training. The main outcomes measured were perceived anxiety, control, and burden related to caring for a high-risk infant and attitudes about responding to an emergency. RESULTS: Subjects reported moderately high anxiety, sense of burden, and feelings of loss of control before CPR training. Within groups, subjects in all 3 treatment groups reported improvement in perceptions of anxiety, control, and burden 2 weeks after CPR training, with continued improvement evident 6 months after CPR training (P = .001). In contrast, perceptions were unchanged in the control group. Among groups, at 2 weeks there were significant differences in means between control and CPR-Didactic groups (P = .01), and at 6 months there were significant differences in means between control and CPR-Didactic groups (P = .01) and between control and CPR-Social Support groups (P = .01). CONCLUSION: CPR training is an important intervention for promoting a sense of control and reducing the anxiety and sense of burden experienced by parents of neonates at risk for cardiopulmonary arrest.




*[Neiman, 1982 #171] Neiman, R. (1982). "Post manikin resuscitation stomatitis." Journal of the Kentucky Medical Association 80(12): 813-4.

PTH

Case report of single case of aphthous ulceration after a basic CPR course with a prediction of “voluminous literature of morbidity to practitioners of CPR on manikins”.


Quality of Evidence: Poor


*[Nickalls, 1986 #201] Nickalls RW, Thomson CW. Mouth to mask respiration. British Medical Journal Clinical Research Ed. 1986;292(6532):1350.

QTN

Strongly supports use of ancillary airway devices.

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*[Nicklin, 1980 #172] Nicklin, G. (1980). "Manikin tracheitis." JAMA 244(18): 2046-7.

PTN

Personal account of symptoms developing after a CPR training session


Quality of Evidence: Poor


*[Ornato, 1989 #196] Ornato JP. Providing CPR and emergency care during the AIDS epidemic. Emerg. Med. Serv. 1989;18(4):45-8.

TG(Narr)

Abstract: A 1987 Gallup poll showed that 70% of Americans surveyed believe AIDS is the must urgent health problem in the United States. Forty percent fear they themselves might get AIDS; 55% have taken some type of protective step to reduce the chances of contracting it. Although there has been much hysteria and overreaction, there is ample justification to take the public-health threat imposed by this potentially fatal disease seriously. There are now approximately five to 10 million people worldwide who are infected with the human immunodeficiency virus (HIV) that causes AIDS. More than 40,000 AIDS cases have been reported in the United States, more than 20,000 deaths have already occurred, and an additional 1-1.5 million Americans are infected with HIV I-3 By 1991, the United States Public Health Service projects there will be 270,000 AIDS cases and more than 140,000 AIDS deaths in this country. Like most other Americans, health-care providers are concerned about the risk of contracting AIDS, including possible exposure from their patients. In a recent survey of medical and pediatric residents working in hospitals with large AIDS-patient populations, 25% said they would not continue to care for AIDS patients if they were given a choice.'' Although there may be a potential threat of disease transmission from an AIDS patient to an emergency health-care provider, the risk is small and can be minimized by following procedures recommended by the Centers for Disease Control (CDC).

A statement of contemporaneous thought in 1989.




*[Osterholm, 1979 #173] Osterholm, M. T., E. R. Bravo, et al. (1979). "Lack of transmission of viral hepatitis type B after oral exposure to HBsAg-positive saliva." British Medical Journal 2(6200): 1263-4.

PTH

Assesses 21 hospital trainees who had taken part in CPR training with a person with HBsAg-positive saliva. Circumstances were highly suited to disease transmission if it was possible. It did not occur. Mandatory testing of all individuals for HBsAg before CPR training is thought unwarranted.


Quality of Evidence: Good


[Perras, 1980 #218] Perras ST, Poupard JA, Byrne EB, Nast PR. Lack of transmission of hepatitis non-A, non-B by CPR manikins. N. Engl. J. Med. 1980;302(2):118-9.

NOT AVAILABLE

*[Prosser, 1990 #174] Prosser, R. L., Jr. (1990). "Cardiopulmonary resuscitation training and risk of infection." JAMA 263(22): 3025.

PTN

On the basis that there is risk, albeit minuscule, of contracting a serious infection during training the author proposes that “the requirement that mouth-mask-mannequin practice and testing be a part of basic and advanced cardiac life support courses should be eliminated”.

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Nature of evidence: Opposing

*[Rinker, 2001 #25] Rinker, A. G., Jr. (2001). "Disease transmission by mouth-to-mouth resuscitation." Emergency Medical Services 30(1): 89-90.

G(Narr)

Adds no new information in texts or references




*[Rossi, 1993 #186] Rossi, R., K. H. Lindner, et al. (1993). "Devices for expired air resuscitation." Prehospital & Disaster Medicine 8(2): 123-6.

TI

Abstract: Objectives: Expired air resuscitation is an essential part of first-aid and cannot be replaced by other measures. Because of the risk of transmitting infectious diseases, the use of devices is recommended. Three types are available--masks, tubes, and foils. Participants: Six masks (Air-Vita Bi-Protect, Laerdal Pocketmask, Drager Hivita Mask E, Rescue-Med Device, Resuscitator, SealEasy Resuscitation Kit), five tube instruments (Dr. Brook Airway, Dual-Aid, Goettinger Tubus, Lifeway, Sussex Valve Airway), and two foils (Ambu Life-Key, Laerdal ResusciFace Shield) were studied. Measurements: Inspiratory and expiratory resistance, valve leakage, ability to protect against infection transmission, and practicability (e.g., possibility of training on standard mannequins, seal) were measured and tested in the laboratory. Results: Only a few of the mask and tube devices had low inspiratory and expiratory resistances. Some of the one-way valves failed. There were definite risks of provoking complications (vomiting, lacerations) when using tube instruments. Conclusions: Devices consisting of a foil have definite advantages, and seem to be more appropriate for the use by first-aiders [first responders].

Supportive of ancillary devices in airway management during CPR but mentions hazards of tubes.

NOT RELEVANT

*[Salzer, 1983 #207] Salzer J, Marshall C, Hillman EJ, Bullock J. CPR: A report of observed medical complications during training. Ann. Emerg. Med. 1983;12:195.

PN

Subsequent to [Memon, 1982 #144] and [Greenberg, 1983 #188]. All trainees who are asthmatic, diabetic, hypertensive, heavy smokers, obese, over the age of 45 or with pulmonary or cardiac disease are advised to have a medical assessment before undertaking the course.




*[Sande, 1986 #192] Sande MA. Transmission of AIDS. The case against casual contagion. N. Engl. J. Med. 1986;314(6):380-2.

TO

Maintains that the AIDS virus is transmitted sexually, by injection or by birth and that other modes are extremely rare. Mentions saliva but not CPR.




*[Saviteer, 1985 #175] Saviteer, S. M., G. C. White, et al. (1985). "HTLV-III exposure during cardiopulmonary resuscitation." New England Journal of Medicine 313(25): 1606-7.

QTHN

A correspondence report of two nurses with documented mucous-membrane exposure to potentially infective saliva from a patient with AIDS-related complex without disease transmission providing

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“further evidence that the risk of seroconversion after a point exposure to the oral secretions of an infected person is probably quite low.




*[Sepkowitz, 1996 #127] Sepkowitz, K. A. (1996). "Occupationally acquired infections in health care workers. Part II.[erratum appears in Ann Intern Med 1997 Apr 1;126(7):588]." Annals of Internal Medicine 125(11): 917-28.

TG(Evb)

Abstract: BACKGROUND: Health care workers are at occupational risk for a vast array of infections that cause substantial illness and occasional deaths. Despite this, few studies have examined the incidence, prevalence, or exposure-associated rates of infection or have considered infection-specific interventions recommended to maintain worker safety. OBJECTIVE: To characterize the type and frequency of infections, the recommended interventions, and the costs of protecting health care workers. Part II of this two-part review focuses on infections caused by blood-borne organisms, organisms spread through the oral-faecal route, and organisms spread through direct contact. It also reviews established interventions for controlling transmission. DATA SOURCES: A MEDLINE search and examination of infectious disease and infection control journals. DATA SELECTION: All English-language articles and meeting abstracts published from January 1983 to February 1996 related to occupationally acquired infections among health care workers were reviewed. Outbreak- and non-outbreak-associated incidence and prevalence rates were derived, as were costs to prevent, control, and treat infections in health care workers. DATA SYNTHESIS: Occupational transmission to health care workers was identified for numerous diseases, including infections caused by blood-borne organisms (human immunodeficiency virus, hepatitis B virus, hepatitis C virus, Ebola virus), organisms spread through the oral-fecal route (salmonella, hepatitis A virus), and organisms spread through direct contact (herpes simplex virus, Sarcoptes scabiei). Most outbreak-associated attack rates range from 15% to 40%. Occupational transmission is usually associated with violation of one or more of three basic principles of infection control: hand-washing, vaccination of health care workers, and prompt placement of infectious patients into appropriate isolation. CONCLUSIONS: The risk for occupationally acquired infections is an unavoidable part of daily patient care. Occupationally acquired infections cause substantial illness and occasional death among health care workers. Further studies are needed to enhance compliance with established infection control approaches. As health care is being reformed, the risk for and costs of occupationally acquired infection must be considered.

Excluding the item of blood-borne transmission, it is noted that there is no mention of disease transmission associated with CPR in the sections on Oral-Faecal Transmission or Direct Contact (pages 920-922).




*[Sepkowitz, 1996 #128] Sepkowitz, K. A. (1996). "Occupationally acquired infections in health care workers. Part I." Annals of Internal Medicine 125(10): 826-34.

TG(Evb)

Abstract: BACKGROUND: Health care workers are at occupational risk for a vast array of infections that cause substantial illness and occasional deaths. Despite this, few studies have examined the incidence, prevalence, or exposure-associated rates of infection or have considered infection-specific interventions recommended to maintain worker safety. OBJECTIVES: To review all recent reports of occupationally acquired infection in health care workers in order to characterize the type and frequency of infections, the recommended interventions, and the costs of protecting workers. Part I of this two-part review focuses on the historical and ethical aspects of the problem and reviews data on infections caused by specific airborne organisms. DATA SOURCES: A MEDLINE search and examination of infectious disease and infection control journals. DATA SELECTION: All English-language articles and meeting abstracts published between January 1983 and February 1996 related to occupationally acquired infections among health care workers were reviewed. Outbreak- and non-outbreak-associated incidence and prevalence rates were derived, as were costs to prevent, control, and treat infections in health care workers. DATA SYNTHESIS: More than 15 airborne infections have been transmitted to health care workers, including tuberculosis, varicella, measles, influenza, and respiratory syncytial virus infection. Outbreak-associated attack rates range from 15% to 40%. Most occupational transmission is associated with violation of one or more of three basic principles of infection control: hand-washing, vaccination of health care workers,

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and prompt placement of infectious patients into appropriate isolation. CONCLUSIONS: The risk for occupationally acquired infection is an unavoidable part of daily patient care. Infections that result from airborne transmission of organisms cause substantial illness and occasional deaths among health care workers. Further studies are needed to identify new infection control strategies to 1) improve protection of health care workers and 2) enhance compliance with established approaches. As health care is being reformed, the risk for and cost of occupationally acquired infection must be considered.

An extensive review, as required by the OBJECTIVE, fails to produce any reference to disease transmission during CPR.




*[Shimokawa, 2001 #139] Shimokawa, A., S. Tateyama, et al. (2001). "Anterior interosseous nerve palsy after cardiopulmonary resuscitation in a resuscitator with undiagnosed muscle anomaly." Anesthesia & Analgesia 93(2): 290-1.

QRH

Abstract: IMPLICATIONS: We present a case of nerve palsy after cardiopulmonary resuscitation in a resuscitator with undiagnosed muscle anomaly. Effort-related nerve palsy may occur after prolonged performance of CPR.

The palsy developed after 30 minutes of CPR. Spontaneous recovery did not occur. Exploration was necessary to determine the cause and provide relief.




*[Simmons, 1995 #187] Simmons, M., D. Deao, et al. (1995). "Bench evaluation: three face-shield CPR barrier devices." Respiratory Care 40(6): 618-23.

TI

Abstract: Due to the fear of disease transmission, the practice of mouth-to-mouth (M-M) rescue breathing is rarely performed; to address this concern, many types of CPR barrier devices have been developed. These include bag-valve-mask devices, mouth-to-mask devices, and face shields (FS). The purpose of this study was to measure the volumes delivered during mouth-to-face shield (M-FS) breathing, to measure the back pressure and calculate the resistance to flow through their 1-way valves, and to test for backward leak of gas through the valves. METHODS: Three FS brands were evaluated: Kiss of Life (KOL), MicroSHIELD (Micro) and Res-Cue Key (RCK). Volume delivered during M-M and M-FS breathing was evaluated by 10 rescuers who used the devices while performing rescue breathing on a CPR mannequin. Back pressure was measured and resistance calculated by directing airflow through the 1-way valves. Backward leak was evaluated by measuring the O2 concentration at the rescuer side of the valve while 100% O2 was directed toward the patient side of the valve. Differences among the brands were evaluated using analysis of variance. RESULTS: The mean (SD) values for volumes in L were: M-M 1.00 (0.25), Micro 0.77 (0.20), RCK 0.64 (0.10), and KOL 0.24 (0.11). Mean values for back pressure in cm H2O at 50 L/min were Micro 16.7 (1.29), KOL 7.22 (0.13), and RCK 2.15 (0.16). Significant backward leak only occurred with RCK. CONCLUSION: Not one of the FSs tested met all of the requirements suggested by the American Heart Association and by the International Standards Organization.

Questions the efficacy of a selection of particular face-shields in CPR.

NOT RELEVANT

*[Stacey, 2004 #93] Stacey, R., D. Morfey, et al. (2004). "Secondary contamination in organophosphate poisoning: Analysis of an incident." Qjm: Monthly Journal of the Association of Physicians 97(2): 75-80.

QRH

Abstract: Background: Acute organophosphate poisoning is rare in the UK, and the risks to attending staff are seldom appreciated. Study design: Report of an incident. Results: In May 2001, a 45-year-old man attempted suicide by drinking organophosphate insecticide, and was brought to an urban general hospital in a collapsed state. Twenty-five hospital workers and paramedics sought medical advice after coming into contact with the poisoned patient, of whom ten complained of

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symptoms related to toxin exposure. Provision of emergency services by the hospital was compromised, and the emergency department was closed until the area was decontaminated and staffing levels could be restored. Discussion: Ingestion of OP compounds can present a significant risk to health professionals as well as patients. Problems with the management of this patient included late recognition of the need for decontamination, large numbers of non-essential staff coming into contact with the patient, and the difficulty of carrying out medical procedures while wearing protective equipment. Decontamination should always be considered early, and the possibility of an ingested poison being vomited and causing a chemical spill should not be overlooked.

Strictly not CPR but the patient needed airway management and cardiac support with the associated risks of exposure of personnel to an organophosphate compound.




*[Steinhoff, 2001 #182] Steinhoff, J. P., C. Pattavina, et al. (2001). "Puncture wound during CPR from sternotomy wires: case report and discussion of peri-resuscitation infection risks." Heart & Lung: Journal of Acute & Critical Care 30(2): 159-60.

QTH

Abstract: Performing resuscitations presents multiple infectious risks to critical care providers. Potential sources for infection include direct contact with blood and other bodily fluids and possible inoculation through needle-stick injuries. In this article, we present a case of a cardiac care unit nurse who, while providing cardiopulmonary resuscitation, suffered a puncture wound to her left hand from the patient's sternotomy wires from previous cardiac surgery. The patient died despite these resuscitation efforts. He was seronegative for human immuno-deficiency virus, hepatitis B, and hepatitis C, and the nurse's wound healed without complications. This is the first reported case of such an injury occurring during a resuscitation. It demonstrates how a subtle, invisible, and unrecognized physical risk could cause infection in critical care providers.




*[Stern, 1994 #176] Stern, A. and E. Dickinson (1994). "Don't be a dummy. Staying safe with mannequin training." Journal of Emergency Medical Services 19(5): 85-6.

M

Highlights issues about cross-contamination and the use of manikins




*[Sullivan, 2000 #143] Sullivan, F. and D. Avstreih (2000). "Pneumothorax during CPR training: case report and review of the CPR literature." Prehospital & Disaster Medicine 15(1): 64-9.

PRH

Abstract: Cardiopulmonary resuscitation is taught widely to both lay persons and health care workers. It is a challenging psychomotor skill. Concerns about its safety to the rescuer have centred around the risk of infectious disease exposure. A young nursing assistant developed a minimally symptomatic pneumothorax during CPR training. This case is the first reported example of this complication for a CPR trainee or provider. The literature is reviewed for complications for CPR provider and recipient and the relevant issues regarding the current status and future direction of this intervention.




*[Sun, 1995 #54] Sun, D., R. B. Bennett, et al. (1995). "Risk of acquiring AIDS from salivary exchange through cardiopulmonary resuscitation courses and mouth-to-mouth resuscitation." Seminars in Dermatology 14(3): 205-211.

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PTG(Narr)

Abstract: In summary, the risk of transmission of HIV and other infectious diseases by saliva during CPR training practice is extremely low because of low infectious virus titres and properties of saliva that inhibit HIV. However, it is necessary to perform decontaminations of mannequins, by application of a suitable disinfectant and by a mechanical wipe-down with a sponge, to cleanse the external buccal area of the mannequin after contact with each CPR trainee. For health care and public safety professionals training and performance of MTM ventilation during CPR should be carried out with barrier devices such as the bag-valve-mask or face shield. Guidelines and standards of the AHA, American Red Cross, and the CDC for prevention of infection during CPR and emergency cardiac care are more fully available elsewhere. If the recommended procedures are followed, the risk of acquiring HIV from saliva during MTM should be extremely low.

Advocates teaching mouth-to-mouth ventilation performed with some form of barrier-device.




*[Swanson, 1993 #138] Swanson, R. W. (1993). "Psychological issues in CPR." Annals of Emergency Medicine 22(2 Pt 2): 350-3.

QSG(Narr)

Abstract: CPR has been incorporated into emergency cardiac care with the evolution of both basic and advanced life support components. To date, however, the psychological issues associated with these skills have not been addressed. These issues include the psychological impact of failed resuscitation on the rescuer, the importance of breaking bad news is an empathetic and grief facilitating way to family members and the importance of emergency workers attending to their own feelings and health (critical incident debriefing). This paper describes ongoing research on the impact of CPR on the rescuer, discusses a method of talking to families after a loved one has suddenly died, and provides insights into the psychological dysfunctions that emergency personnel may be exposed to. The technique and importance of critical incident debriefing following an unsuccessful CPR attempt is discussed.

Swanson refers to “serious consequences for emergency personnel who respond to a crisis” but accepts that “the paucity of data currently available prevents firm conclusions about the effects on emergency personnel and may not be relevant to more routine CPR attempts.” References [Genest, 1991 #198] [Genest, 1990 #197] have not yet been seen.




*[Thierbach, 2003 #30] Thierbach, A. R., B. B. Wolcke, et al. (2003). "Artificial ventilation for basic life support leads to hyperventilation in first aid providers." Resuscitation 57(3): 269-77.

RI

Abstract: The 'Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - International Consensus on Science' recommend an artificial ventilation volume of 10 ml/kg bodyweight (equivalent to a tidal volume of 700-1000 ml) without the use of supplemental oxygen in adults with respiratory arrest. For first aid providers using the mouth-to-mouth or mouth-to-nose-ventilation technique, respectively, a ventilation volume of approximately 9.6 l/min results. Additionally, a deep breath is recommended before each ventilation to increase the end-expiratory oxygen concentration of the air exhaled by the first aid provider. To investigate the effects of these recommendations in healthy volunteers, test persons were asked to ventilate an artificial lung model for a period of up to 10 min. The tidal volume was set at 800 ml at a breathing rate of 12/min. End-tidal carbon dioxide, oxygen saturation (measured by pulse oximetry), and heart rate were measured continuously. Capillary blood gas samples were collected and non-invasive blood pressure readings were recorded prior to the start of ventilation and immediately after the end of the measuring period. The data reveal a statistically significant and clinically relevant decrease in end-tidal carbon dioxide pressure (P<0.001, median decrease 14 mmHg), and the occurrence of hyperventilation-associated symptoms such as paraesthesia, dizziness, and carpopedal spasms in more than 75% of the participants. Clinically and statistically significant hyperventilation results in first aid providers performing artificial ventilation according to the guidelines. This artificial ventilation is associated with a significant decrease in capillary and end-tidal carbon dioxide pressure as well as with multiple symptoms of an acute hyperventilation syndrome. Ventilation performed according

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to these guidelines may cause injury to the health of the first aid provider. Rescuers ventilating the victim should be replaced at regular intervals and the recommendation to take a deep breath before each ventilation should not be upheld in order to minimise the risk of hyperventilation.




*[Todd, 1980 #131] Todd, M. A. and J. S. Bell (1980). "Shigellosis from cardiopulmonary resuscitation." JAMA 243(4): 331.

QTH

The authors believe that the case confirms oral transmission of pathogenic bacteria during CPR in an emergency situation and refer to [Khan, 1979 #206].




*[Valenzuela, 1991 #14] Valenzuela, T. D., T. M. Hooton, et al. (1991). "Transmission of 'toxic strep' syndrome from an infected child to a fire-fighter during CPR." Annals of Emergency Medicine 20(1): 90-2.

QTH

Abstract: Several cases of a toxic shock-like syndrome have been reported in the United States during the past five years in association with Streptococcus pyogenes infection. We report a case of a fire-fighter exposed during attempted CPR to the secretions of an S pyogenes-infected child. The fire-fighter developed an infection of the hand and subsequent febrile illness with hypotension, erythematous rash, renal failure, and hypocalcemia. Bacterial isolates of blood and cerebrospinal fluid from the deceased child were identical in type and exotoxin production with isolates grown from the hand wound of the fire-fighter. This is the first reported case of documented transmission of S pyogenes, causing a toxic shock-like syndrome in an emergency medical technician.

The fire-fighter ventilated the child with a B-V-M apparatus but his hands became covered with the child’s sputum. He later injured his right hand causing an abrasion.




*[Walker, 2001 #3] Walker, G. M. and R. Liddle (2001). "Prolonged two-man basic life support may result in hypocarbia in the ventilating rescuer." Resuscitation 50(2): 179-83.

RI

Abstract: OBJECTIVES: To determine whether the quality of expired air given during mouth-to-mouth ventilation differs between one- and two-person basic life support. METHODS: 15 young fit volunteers performed 15-min simulated resuscitation on a manikin. The oxygen and carbon dioxide concentration of their expired breath and the total ventilation was continuously monitored. Compression:ventilation ratios of 15:2 for one-person and 5:1 for two-person resuscitation were used. RESULTS: In two-man resuscitation, where the rescuer who is ventilating the patient is not performing chest compressions, the oxygen content of the expired breath rises (P<0.01), and the carbon dioxide content falls (P<0.01). The carbon dioxide concentration declined gradually throughout the 15-min session. Most participants complained of light-headedness on completion of the two-man session. Total ventilation did not differ between the two methods (P=0.757, 95% CI=-0.329, 0.242). CONCLUSION: Trainees in basic life support should be informed that symptoms of hypocarbia may occur in prolonged mouth-to-mouth ventilation, when acting in a two-man team. We would advise rescuers using these protocols to change places every 5 min to avoid these symptoms. These findings add further weight to the recommendations that all resuscitation should be carried out using 15:2 compression:ventilation ratio.




*[Wenzel, 2001 #94] Wenzel, V., A. H. Idris, et al. (2001). "The respiratory system during resuscitation: A review of the history, risk of infection during assisted ventilation, respiratory mechanics, and ventilation strategies

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for patients with an unprotected airway." Resuscitation 49(2): 123-134.

TG(Narr)

Abstract: The fear of acquiring infectious diseases has resulted in reluctance among healthcare professionals and the lay public to perform mouth-to-mouth ventilation. However, the benefit of basic life support for a patient in cardiopulmonary or respiratory arrest greatly outweighs the risk for secondary infection in the rescuer or the patient. The distribution of ventilation volume between lungs and stomach in the unprotected airway depends on patient variables such as lower oesophageal sphincter pressure, airway resistance and respiratory system compliance, and the technique applied while performing basic or advanced airway support, such as head position, inflation flow rate and time, which determine upper airway pressure. The combination of these variables determines gas distribution between the lungs and the oesophagus and subsequently, the stomach. During bag-valve-mask ventilation of patients in respiratory or cardiac arrest with oxygen supplementation ( >= 40% oxygen), a tidal volume of 6-7 ml kg-1 ( ~ 500 ml) given over 1-2 s until the chest rises is recommended. For bag-valve-mask ventilation with room-air, a tidal volume of 10 ml kg-1 (700-1000 ml) in an adult given over 2 s until the chest rises clearly is recommended. During mouth-to-mouth ventilation, a breath over 2 s sufficient to make the chest rise clearly (a tidal volume of ~ 10 ml kg-1 ~ 700-1000 ml in an adult) is recommended.

In summary after considering mouth-to-mouth resuscitation and the fear of infectious diseases the conclusion is made that disease transmission (patient-to-professional) is more likely with tuberculosis than HIV and that “the benefit of basic life support for a patient in cardiopulmonary or respiratory arrest greatly outweighs the risk for secondary infection in the rescuer or the patient.”

No unrecognised references or evidence are provided.




*[West, 1990 #17] West, K. (1990). "CPR infection-control article unclear." Occupational Health & Safety 59(12): 28.

TN

The author is critical of a preceding article (not located) and refers to [Glaser, 1985 #146].




[Zaeslin, 1966 #206] Zaeslin C. Dangers of mouth to mouth resuscitation in some cases of poisoning (in German). Vjsehr Schweiz Sanit Off 1966;43:224.

NOT AVAILABLE

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