Clinical paperDispatcher assessments for agonal breathing improve detection of cardiac arrest☆
Introduction
Persons collapsing with out-of-hospital cardiac arrest who receive immediate cardiopulmonary resuscitation (CPR) by bystanders have much better rates of survival and even better chances of full neurological recovery.1, 2, 3 Despite widespread attempts to train the public at large, bystander CPR is not performed in the majority of such cases.4, 5 Therefore, over the past two decades, in an effort to increase the number of cases in which early CPR is performed, instructions for CPR have been given over the telephone by emergency medical dispatchers (EMDs) to on-scene bystanders who have never learned CPR or who are having trouble recalling the actions to take.2, 6, 7, 8, 9, 10, 11 Such dispatcher-assisted CPR instructions have been confirmed not only to be provided effectively, but also to increase survival.2, 6, 12 Traditionally, these instructions have included techniques for airway maintenance, ventilation, and chest compressions. However, recently there has been a focus on chest compressions alone in the first few minutes of dispatcher-assisted CPR.13, 14
Although dispatcher-assisted CPR has been effective in providing CPR instructions appropriately to bystanders, EMDs may not identify a significant number of cases of cardiac arrest during the emergency telephone call. As a result, EMDs may not instruct bystanders to initiate CPR for a large number of cases for which dispatcher-assisted CPR would have been most appropriate.15 One potential reason for this inability of dispatchers to identify cardiac arrest over the phone may be the presence of intermittent spontaneous agonal respirations, also known as gasps.15, 16, 17, 18 Agonal respirations are a brainstem reflex and the last respiratory pattern that occurs during the early stages of cardiac arrest.19, 20 This type of respiratory activity can create confusion in the telephone interrogatory between bystanders and EMDs when the EMDs are attempting to determine whether or not the victim is breathing or breathing “normally”.
In an effort to improve cardiac arrest detection by EMDs, a new protocol was implemented at the 9-1-1 dispatch center in the city of Dallas, TX (USA). The specific aim of this study was to determine whether the new protocol increased the detection of agonal respirations by EMDs and thus the presence of cardiac arrest.
Section snippets
Institutional Review Board approval
The study was approved by the Institutional Review Board at the University of Texas Southwestern Medical Center at Dallas (UT Southwestern) as well as the Dallas Fire Chief and Director of Medical Services for the City of Dallas. Patient data were analyzed individually and in aggregate using incident numbers and other procedures to ensure that patient confidentiality was maintained at all times.
Setting
The study was a prospective investigation conducted in a large metropolitan municipality with a
Results
During the 12 months of study, 962 patients were identified as having out-of-hospital cardiac arrest in the jurisdiction of the city of Dallas with 57% male, 43% female, with a mean age of 63 ± 17 years (SD) and range 17–106 years. There were no significant differences in age and sex before or after the protocol implementation (Table 1).
During the 8 months prior to implementation of the new protocol dispatchers did not actively seek signs of agonal breathing and no patients with agonal
Discussion
This study demonstrated that implementation of an EMD protocol to improve the detection of agonal respirations significantly increased cardiac arrest detection by dispatchers and subsequent performance of bystander CPR. During the 4-month follow-up period after protocol implementation, 100 more patients were found to meet criteria for not breathing normally compared to the prior 8 months.
In previous investigations evaluating the factors that impeded dispatcher-assisted CPR, investigators found
Conclusion
When callers to emergency medical dispatchers are interrogated about whether or not the patient is breathing, the presence of agonal respirations may confound the detection of cardiac arrest. Introduction of a new 9-1-1 dispatcher assessment protocol to assess for the presence of agonal respirations can significantly increase the detection cardiac arrest over the telephone, thus increasing the opportunity for dispatchers to appropriately provide CPR instructions to those patients who should
Conflict of interest
None.
Acknowledgments
We would like to thank all of the emergency medical dispatchers in the city of Dallas for their kind support and hard work in the implementation of this investigation.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.04.013.
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