Simulation and educationTuition of emergency medical dispatchers in the recognition of agonal respiration increases the use of telephone assisted CPR☆
Introduction
Individuals suffering out-of-hospital cardiac arrest (OHCA) who receive immediate basic cardiopulmonary resuscitation (CPR) from bystanders increase their chances of survival.1, 2, 3 However, the reported prevalence of bystander CPR is low and only about 30% of patients receive treatment before the emergency medical service (EMS) arrives.4, 5, 6 One strategy to increase bystander CPR has been to train emergency medical dispatch (EMD) personnel to provide protocol based CPR instructions over the telephone (T-CPR) until the arrival of the EMS. An increase in bystander CPR following the introduction of T-CPR has been reported by Culley et al.7 and Vaillancourt et al.8
Agonal respiration or gasping is reported to be present in about 40% of OHCA.9, 10, 11 Clark et al. furthermore reported that 27% of OHCA patients with agonal respiration were discharged alive compared with 9% of patients without.9 However, agonal respiration is probably one of the most common obstacles for T-CPR to be performed. It is described heterogeneously by the callers and, it is often mistaken for spontaneous respiration, thereby often confusing the EMDs in their attempts to identify cardiac arrest (CA). Initiation of T-CPR is thereby delayed or prevented.10, 12, 13, 14, 15 This is illustrated by a survey of OHCA in Stockholm in 2004 according to which callers who described that the patient had some sort of (agonal) respiration were offered T-CPR in 23% of instances compared to 92% of those who described that the patient showed no respiration.16
A significant increase in CPR was obtained in a simulation study with medical students in recognising agonal respiration as a sign of CA.15 Whether specific training of EMDs can improve their recognition of caller descriptions of abnormal respiration as a sign of OHCA and thereby increase the likelihood of offering T-CPR has, however, not been tested so far.
The aim of this study was therefore to ascertain whether tuition regarding the recognition of agonal respiration will improve the capability of EMDs’ to identify OHCA and offer T-CPR.
Section snippets
Methods
Consecutive events of OHCA in the Stockholm area between 20th of January to 3rd of May 2004, i.e. before EMD tuition, were included and compared with consecutive OHCAs from 1st of June to 20th of August 2006, i.e. after EMD tuition. The study area has a population of 2.2 million and is composed of urban, suburban and rural regions. A total of 36 EMS stations with 71 ambulances are located in the area. Included were witnessed OHCAs of a presumed cardiac origin aged ≥9 years. Crew-witnessed cases
Study population
In all, 315 OHCA cases were reviewed from 2004 (before intervention) and 255 from 2006 (after intervention). Excluded patients are accounted for in Table 1 with unwitnessed CA and obviously deceased patients being the most common exclusion criteria. Set criteria were fulfilled by 76 cases of OHCA in both groups (Fig. 1). Audio recordings of these 76 calls from both periods were reviewed. There was a high willingness to receive CPR instructions among the bystanders, 97% in 2004 and 100% in 2006.
Discussion
The purpose of this study was to explore the effect of specific respiratory tutorials for EMD personnel when responding to callers in cases of OHCA. A significantly higher proportion of bystanders were offered T-CPR after the tutorial. This is in line with Perkins et al. who in a simulation study improved the diagnostic accuracy among CPR providers after specific tuition in agonal respiration as a sign of CA.15 In the present study, significantly more offers of T-CPR were also made to callers
Conclusion
The occurrence of agonal respiration in association with CA is a common hindrance to offering T-CPR. In this study a significantly higher proportion of patients were offered T-CPR after a specific 1-day tutorial concerning agonal respiration for EMDs. We therefore conclude that a brief tutorial comprising the signs and implications of agonal respiration has great impact on the likelihood of EMDs to offer T-CPR.
Conflict of interest
Katarina Bohm has an unrestricted grant from SOS Alarm Sverige AB. The other authors report no conflicts.
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Cited by (67)
2020 recommendations on basic cardiopulmonary resuscitation: Main points
2021, Journal Europeen des Urgences et de ReanimationEuropean Resuscitation Council Guidelines 2021: Basic Life Support
2021, ResuscitationCitation Excerpt :ILCOR performed systematic reviews of compression-only versus standard CPR in both lay rescuer and professional or EMS settings.85,87 In the lay rescuer setting, six very-low-certainty observational studies compared chest compression-only with standard CPR using a CV ratio of 15:2 or 30:2.18,88–92 In a meta-analysis of two studies, there was no significant difference in favourable neurological outcome in patients who received compression-only CPR compared with patients who received CPR at a CV ratio of 15:2 (RR, 1.34 [95% CI, 0.82–2.20]; RD, 0.51 percentage points [95% CI, −2.16 to 3.18]).18,90
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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.2009.06.004.