Elsevier

Resuscitation

Volume 80, Issue 10, October 2009, Pages 1108-1113
Resuscitation

Clinical paper
Perceptions of collapse and assessment of cardiac arrest by bystanders of out-of-hospital cardiac arrest (OOHCA)

https://doi.org/10.1016/j.resuscitation.2009.06.028Get rights and content

Abstract

Background

An important predictor of outcomes from out-of-hospital cardiac arrest (OOHCA) is bystander resuscitation, but in industrialised nations this is undertaken only in 15–50%. To explore reasons for this low response rate we analysed bystander perceptions during the victim's collapse, and methods used to assess cardiac arrest.

Methods

Over a 12-month period we prospectively investigated all dispatches for witnessed cardiac arrest of two physician-staffed emergency medical service (EMS) units within a western European metropolitan area (Berlin, Germany). On scene the bystander was identified by the EMS physician and approached to have a semi-structured interview in the following days.

Results

Out of 201 eligible responses, 138 bystanders could be interviewed (68.7%). 63 (45.3%) of these bystanders did not detect cardiac arrest. 36 bystanders (25.9%) spontaneously reported a “bluish colour” of the patient's head or body which occurred “unexpectedly”. 39 persons (28.1%) reported abnormal breathing. Assessment of breathing was not undertaken in 27.0%, nor of circulation in 29.0%. If circulation was assessed pulse check was performed in 93.4%.

Conclusion

In this sample of interviewed bystanders of OOHCA, almost half of the arrests were not detected. This might be a reason for the low rate of bystander resuscitation. Common bystander perceptions of arrest presence included “bluish skin colour” and abnormal breathing of the victim. These findings indicate that improvement of perception capabilities should be incorporated as a major learning objective into lay basic life support training. In addition, information regarding skin colour may be of value in dispatch protocols.

Section snippets

Background

Out-of-hospital cardiac arrest (OOHCA) is a major cause of death in industrialised nations, accounting for some 400,000 cases per year in the U.S. and Europe.1, 2 There is sound evidence that bystander CPR is one of the most important predictors of favourable outcome following OOHCA.3, 4, 5, 6, 7 One could characterise this crucial time interval between the victim's collapse and start of professional BLS as “bystander's window” (Fig. 1). In spite of various efforts to improve aspects of the

Methods

From August 15th 2006 to August 14th 2007, we prospectively analysed all witnessed CA cases of the mobile intensive care unit (MICU) and the helicopter emergency medical system (HEMS) based at our hospital. The MICU serves mixed suburban and inner-city regions, and the HEMS operates evenly distributed over the whole city area. Berlin EMS serves a metropolitan area of 3.5 Million inhabitants and is organised as a two-tired system. ALS units (15 MICU and 1 HEMS) are physician-staffed, while BLS

Patient's data

From 277 screened cases 76 were excluded, specific reasons are given in Fig. 2.

Discussion

The “bystander's window” is a crucial part of the chain of survival and might at present be the most effective measure to improve survival in OOHCA. The obligatory step before initiating BLS is perception of arrest, so our study aimed to analyse the bystander's perspective under reality conditions. This was performed systematically for the first time, highlighting severe deficits in perception of arrest, and on the other hand giving valuable information on features which are detectable by lay

Conclusion

Only half of the interviewed bystanders in this study were able to detect arrest while witnessing OOHCA. Bystanders frequently reported bluish skin colour and abnormal breathing. Agonal breathing often hindered the detection of CA. If assessment of circulation was undertaken pulse check was performed by almost all interviewees. Poor detection skills might be an important reason of low bystander resuscitation rates. For detection of arrest we could demonstrate a significant dependence on

Conflict of interest

All authors declare that they have no competing interests concerning all issues connected to this paper. This study was carried out by an academic institution and there was no external funding.

JB designed the study and is responsible for the intellectual content, SS developed the protocol and conducted all interviews including statistics, HRA was involved in the study design and gave important intellectual input discussing the content.

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“A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.06.028”.

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