Is your unconscious patient in cardiac arrest? A New protocol for telephonic diagnosis by emergency medical call-takers: A national study

Potential to enhance telephone cardiopulmonary resuscitation with improved instructions - findings from a simulation-based manikin study with lay rescuers

BACKGROUND

Telephone-Cardiopulmonary Resuscitation (T-CPR) significantly increases rate of bystander resuscitation and improves patient outcomes after out-of-hospital cardiac arrest (OHCA). Nevertheless, securing correct execution of instructions remains a difficulty. ERC Guidelines 2021 recommend standardised instructions with continuous evaluation. Yet, there are no explicit recommendations on a standardised wording of T-CPR in the German language. We investigated, whether a modified wording regarding check for breathing in a German T-CPR protocol improved performance of T-CPR.

METHODS

A simulation study with 48 OHCA scenarios was conducted. In a non-randomised trial study lay rescuers were instructed using the real-life-CPR protocol of the regional dispatch centre and as the intervention a modified T-CPR protocol, including specific check for breathing (head tilt-chin lift instructions). Resuscitation parameters were assessed with a manikin and video recordings.

RESULTS

Check for breathing was performed by 64.3% (n = 14) of the lay rescuers with original wording and by 92.6% (n = 27) in the group with modified wording (p = 0.035). In the original wording group the head tilt-chin manoeuvre was executed by 0.0% of the lay rescuers compared to 70.3% in the group with modified wording (p < 0.001). The average duration of check for breathing was 1 ± 1 s in the original wording group and 4 ± 2 s in the group with modified wording (p < 0.001). Other instructions (e.g. check for consciousness and removal of clothing) were well performed and did not differ significantly between groups. Quality of chest compression did not differ significantly between groups, with the exception of mean chest compression depth, which was slightly deeper in the modified wording group.

CONCLUSION

Correct check for breathing seems to be a problem for lay rescuers, which can be decreased by describing the assessment in more detail. Hence, T-CPR protocols should provide standardised explicit instructions on how to perform airway assessment. Each protocol should be evaluated for practicability.

Features of Emergency Medical System calls that facilitate or inhibit Emergency Medical Dispatcher recognition that a patient is in, or at imminent risk of, cardiac arrest: A systematic mixed studies review

Aim

To identify and appraise evidence relating to the features of an Emergency Medicine System call interaction that enable, or inhibit, an Emergency Medical Dispatcher’s recognition that a patient is in out-of-hospital cardiac arrest, or at imminent risk of out-of-hospital cardiac arrest.

Methods

All study designs were eligible for inclusion. Data sources included Medline, BNI, CINAHL, EMBASE, PubMed, Cochrane Database of Systematic Reviews, AMED and OpenGrey. Stakeholder resources were screened and experts in resuscitation were asked to review the studies identified. Studies were appraised using the Mixed Methods Appraisal Tool. Synthesis was completed using a segregated mixed research synthesis approach.

Results

Thirty-two studies were included in the review. Three main themes were identified: Key features of the Emergency Medical Service call interaction; Managing the Emergency Medical Service call; Emotional distress.

Conclusion

A dominant finding is the difficulty in recognising abnormal/agonal breathing during the Emergency Medical Service call. The interaction between the caller and the Emergency Medical Dispatcher is critical in the recognition of patients who suffer an out-of-hospital cardiac arrest. Emergency Medical Dispatchers adapt their approach to the Emergency Medical Service call, and regular training for Emergency Medical Dispatchers is recommended to optimise out-of-hospital cardiac arrest recognition. Further research is required with a focus on the Emergency Medical Service call interaction of patients who are alive at the time of the Emergency Medical Service call and who later deteriorate into OHCA.

PROSPERO registration: CRD42019155458.

Incidence, characteristics and complications of dispatcher-assisted cardiopulmonary resuscitation initiated in patients not in cardiac arrest

AIM

Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) can increase bystander CPR rates and improve outcomes in out-of-hospital cardiac arrest (OHCA). Despite the use of protocols, dispatchers may falsely recognise some cases to be in cardiac arrest. Hence, this study aimed to find the incidence of DA-CPR initiated for non-OHCA cases, its characteristics and clinical outcomes in the Singapore population.

METHODS

This was a multi-centre, observational study of all dispatcher-recognised cardiac arrests cases between January to December 2017 involving three tertiary hospitals in Singapore. Data was obtained from the Pan-Asian Resuscitation Outcomes Study cohort. Audio review of dispatch calls from the national emergency ambulance service were conducted and information about patients' clinical outcomes were prospectively collected from health records. Univariate analysis was performed to determine factors associated with in-hospital mortality among non-OHCA patients who received DA-CPR.

RESULTS

Of the 821 patients recognised as having OHCA 328 (40.0%) were not in cardiac arrest and 173 (52.7%) of these received DA-CPR. No complications from chest compressions were found from hospital records. The top diagnoses of non-OHCA patients were cerebrovascular accidents (CVA), syncope and infection. Only final diagnoses of CVA (aOR 20.68), infection (aOR 17.34) and myocardial infarction (aOR 32.19) were significantly associated with in-hospital mortality.

CONCLUSION

In this study, chest compressions initiated on patients not in cardiac arrest by dispatchers did not result in any reported complications and was not associated with in-hospital mortality. This provides reassurance for the continued implementation of DA-CPR.

Singapore Paediatric Resuscitation Guidelines 2021

We present the 2021 Singapore Paediatric Resuscitation Guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, which was published in October 2020, and the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council, were reviewed and discussed by the committee. These recommendations were derived after deliberation of peer-reviewed evidence updates on paediatric resuscitation and took into consideration the local setting and clinical practice.

Singapore Basic Cardiac Life Support and Automated External Defibrillation Guidelines 2021

Basic Cardiac Life Support and Automated External Defibrillation (BCLS+AED) refers to the skills required in resuscitating cardiac arrest casualties. On recognising cardiac arrest, the rescuer should call for '995' for Emergency Ambulance and immediately initiate chest compressions. Good-quality chest compressions are performed with arms extended, elbows locked, shoulders directly perpendicular over the casualty's chest, and the heel of the palm placed on the lower half of the sternum. The rescuer compresses hard and fast at 4-6 cm depth for adults at a compression rate of 100-120 per minute, with complete chest recoil after each compression. Two quick ventilations of 400-600 mL each can be delivered via a bag-valve-mask after every 30 chest compressions. Alternatively, a trained, able and willing rescuer can provide mouth-to-mouth ventilation. Cardiopulmonary resuscitation should be stopped only when the casualty wakes up, the emergency team takes over care, or when an automated external defibrillator prompts for heart rhythm analysis or delivery of a shock.