Elsevier

Resuscitation

Volume 80, Issue 7, July 2009, Pages 769-772
Resuscitation

Clinical paper
Dispatcher assessments for agonal breathing improve detection of cardiac arrest

https://doi.org/10.1016/j.resuscitation.2009.04.013Get rights and content

Abstract

Aim of study

To determine if a new protocol can increase the detection of agonal respirations by emergency medical dispatchers and thus the presence of cardiac arrest.

Methods

This is a prospective before and after study performed in a large metropolitan city. Cases were identified by review of all cardiac arrests called into a central medical control office. Data were collected through review of tapes and documentation obtained from routine quality assurance audits of these cardiac arrests at the dispatch office as well as reports written by paramedics at the scene of each case. Data were collected for 8 months prior to and 4 months after the implementation of a new dispatcher protocol designed to identify the presence of agonal breathing which included counting the respiratory rate, holding the phone next to the patient, and identifiers used to describe this type of breathing.

Results

During the 8 months prior to implementation of the new protocol, no patient had agonal respirations detected compared with 22 patients detected in the 4 months after implementation. The percentage of patients who did not have EMD criteria for cardiac arrest, but actually were in cardiac arrest decreased from 28.0% (168/599) to 18.8% (68/362; p = 0.0012). Survival to ED admission was similar between the two groups. Bystanders started CPR significantly more frequently after the new protocol was instituted (60.9% before vs. 71.5% afterward, p = 0.006).

Conclusion

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.

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.

References (24)

Cited by (75)

  • Unrecognized cardiac arrests: A one-year review of audio from emergency medical dispatch calls

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    Previous studies have identified the breathing assessment as a major source of missed OHCAs [5,6]. Multiple studies have seen increases in OHCA detection when EMD-level training and protocols are specifically modified to address recognition of agonal breathing [7,8,9]. Given the importance of recognizing OHCA at the EMD-level, we aimed to identify common descriptions of cardiac arrest during emergency calls in a moderate-sized city in the southeastern United States that, if recognized early, may accelerate EMD recognition of OHCA, thereby increasing early T-CPR and improving OHCA outcomes.

  • 2020 recommendations on basic cardiopulmonary resuscitation: Main points

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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.

1

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