Elsevier

Resuscitation

Volume 80, Issue 9, September 2009, Pages 1025-1028
Resuscitation

Simulation and education
Tuition of emergency medical dispatchers in the recognition of agonal respiration increases the use of telephone assisted CPR

https://doi.org/10.1016/j.resuscitation.2009.06.004Get rights and content

Abstract

Objectives

Bystanders cardiopulmonary resuscitation (CPR) increases survival in out-of-hospital cardiac arrest (OHCA). Emergency medical dispatchers (EMDs) can provide even totally inexperienced bystanders with instructions by telephone on how to resuscitate victims (T-CPR) until the emergency medical services (EMS) arrive. Agonal respiration makes it difficult for EMDs to identify cardiac arrests (CAs) which will prevent or delay initiation of T-CPR. The aim of this investigation was to study if tuition of EMDs can improve their ability to identify agonal respiration in OHCA to allow for more frequent offers of T-CPR.

Methods

An observational study was made in 2004 and subsequently, a repeat study was made in 2006. All OHCA (n = 315 in 2004, n = 255 in 2006) in the Stockholm region reported to the Swedish Cardiac Arrest Register were included and all corresponding EMS reports were reviewed. Emergency calls were recorded during the event. Witnessed cases of OHCA (n = 76 in both 2004 and 2006) were analyzed using a structured data collection tool.

Results

The frequency of offered T-CPR to all bystanders of OHCA in 2004 was 47%. After special tuition on agonal respiration in OHCA it rose to 68% in 2006 (p = 0.01). An even more marked rise was observed in OHCA cases with agonal respiration. In 2004 T-CPR was offered in 23% of these situations whereas the corresponding figures in 2006 had risen to 56% (p = 0.006).

Conclusions

Teaching EMDs to understand and recognize bystander descriptions of agonal respiration in patients with OHCA has resulted in a significant increase in offers of T-CPR in these situations.

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.

References (21)

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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.

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