Elsevier

Resuscitation

Volume 82, Issue 12, December 2011, Pages 1483-1489
Resuscitation

Review article
In out-of-hospital cardiac arrest patients, does the description of any specific symptoms to the emergency medical dispatcher improve the accuracy of the diagnosis of cardiac arrest: A systematic review of the literature

https://doi.org/10.1016/j.resuscitation.2011.05.020Get rights and content

Abstract

Aim

We sought to determine if, in patients with out-of-hospital cardiac arrest (OHCA), the description of any specific symptoms to the emergency medical dispatcher (EMD) improved the accuracy of the diagnosis of cardiac arrest.

Methods

For this systematic review, we searched MEDLINE, EMBASE and the Cochrane Library with no restrictions, and hand-searched the gray literature. Eligible studies included dispatcher interaction with callers reporting OHCA, and reported diagnosis of cardiac arrest. Two independent reviewers used standardized forms and procedures to review papers for inclusion, quality, and to extract data from eligible studies. Findings were peer-reviewed by the International Liaison Committee on Resuscitation.

Results

We identified 494 citations; 74 were selected for full evaluation (kappa = 0.70) and 23 were included (kappa = 0.68), including six before–after, two case-control, and 15 descriptive studies. One before–after study and ten descriptive studies report that inquiring about consciousness and breathing status can help dispatchers recognize cardiac arrest with moderate sensitivity [ranging from 38% to 97%], and high specificity [ranging from 95% to 99%]. One case-control study, three before–after studies, and four observational studies report that abnormal breathing is a significant barrier to cardiac arrest recognition. One before–after study and two descriptive studies report that seizure activity can be a manifestation of cardiac arrest.

Conclusion

Dispatchers should recognize cardiac arrest when a victim is described as unconscious and not breathing or not breathing normally, and consider cardiac arrest when generalized seizure is described. They should receive specific instructions on how to best recognize the presence of abnormal breathing.

Introduction

Bystander cardiopulmonary resuscitation (CPR) can significantly improve the likelihood of survival for out-of-hospital cardiac arrest victims (OHCA).1 Unfortunately, bystander CPR rates remain low and vary significantly from one region to another.2,3 Sixty-five percent of all cardiac arrests occur outside the hospital setting,4 where the overall rate of survival to hospital discharge rarely exceeds 8%.2,5 Various attempts have been made to improve bystander CPR rates on a large scale, including the organization of large group CPR training events, promotional CPR videos, and CPR training of high school students.5 Unfortunately, none of these initiatives have succeeded in significantly improving bystander CPR or survival rates for cardiac arrest thus far. Other experts have proposed targeting CPR training for family members of patients suffering from heart disease, but more than 40% of all deaths from heart disease occur suddenly and often constitute the victim's first manifestation of heart disease.6

Emergency medical dispatcher-assisted CPR instructions have been shown to significantly improve community bystander CPR rates.7, 8, 9, 10, 11 This intervention combines the benefits of training a large number of citizens with the highly targeted approach of providing CPR teaching or reminders to callers reporting a victim in cardiac arrest. In order to recognize cardiac arrest over the phone, most emergency medical dispatchers (EMDs) ask a number of standardized questions including information on the victims’ consciousness, absence of breathing, or presence of abnormal breathing. Using this strategy, their ability to recognize cardiac arrest over the telephone ranges from 70% to 90%.12,13 Agonal or abnormal breathing is often seen in the initial minutes of cardiac arrest, and may be misinterpreted as a sign of life.7 In addition to abnormal breathing, other factors may be involved and limit the ability of EMDs to make a diagnosis of cardiac arrest.14, 15, 16, 17, 18, 19 The correct identification of cardiac arrest has been associated with increased survival.19,20

For adult and pediatric patients with OHCA, we sought to determine if the description of any specific symptoms to the EMD by the caller (compared with the absence of any specific description) improves the accuracy of the diagnosis of cardiac arrest.

Section snippets

Methods

This systematic review was completed as part of the C2010 Consensus on Science and Treatment Recommendations process, managed by the International Liaison Committee on Resuscitation (ILCOR).21

Literature search results

Our systematic review of the literature identified 714 potentially relevant citations. After manually removing duplicates, there remained 494 unique citations to review. Using standardized pre-determined selection criteria, we excluded 420 citations based on manuscript title and abstract (kappa = 0.70; 95% confidence interval 0.59–0.80). We used the same criteria to review full-text copies of the remaining 74 manuscripts. Characteristics of the 51 papers rejected at this stage are presented in

Discussion

Findings from this systematic review of the literature can be summarized in the following manner: (1) dispatchers should assume that cardiac arrest is present when a caller describes the victim as unconscious, not breathing, or not breathing normally; (2) additional instructions on the significance of abnormal breathing should be provided to EMDs in order to improve their ability to recognize cardiac arrest over the phone; (3) in addition, dispatch protocols could be modified to include tools

Conclusions

Emergency medical dispatchers should assume that cardiac arrest is present when a caller describes the victim as unconscious, not breathing, or not breathing normally. They should be educated about the significance of abnormal breathing in the context of cardiac arrest, and they should consider the introduction of focused questions when victims present with seizure activity. The quality of most studies included in this systematic review was classified as “Fair”.

Conflicts of interest

Dr. Christian Vaillancourt received funding from the Canadian Institutes of Health Research (CIHR) and the Heart and Stroke Foundation of Ontario (HSFO) to study dispatch-assisted CPR instructions.

Manya Charette has no conflicts of interest to declare.

Katarina Bohm has no conflicts of interest to declare.

Dr. James Dunford has no conflicts of interest to declare.

Dr. Maaret Castrén received funding from the Laerdal Foundation to study dispatch-assisted CPR instructions.

Funding sources

Academic practice plan of the Department of Emergency Medicine, University of Ottawa.

Acknowledgements

Disclaimer: This review includes information on resuscitation questions developed through the C2010 Consensus on Science and Treatment Recommendations process, managed by the International Liaison Committee on Resuscitation (http://www.americanheart.org/ILCOR). The questions were developed by ILCOR Task Forces, using strict conflict of interest guidelines. In general, each question was assigned to two experts to complete a detailed structured review of the literature, and complete a detailed

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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.2011.05.020.

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