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Dispatcher recognition of cardiac arrest

Question Type:
Diagnostic
Full Question:
Among adults and children who are in cardiac arrest outside of a hospital (P), does the description of any specific symptoms to the dispatcher (I), compared with the absence of any specific description (C), change increase the likelihood of cardiac arrest recognition (O)?
Consensus on Science:
For the critical outcome of cardiac arrest recognition, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 cluster RCT,(Weiser 2013, 883) as well as very-low-quality evidence from 26 non-RCTs comprising 8 before-after observational studies,(Eisenberg 1985, 47; Heward 2004, 115; Bohm 2007, 256; Vaillancourt 2007, 877; Clawson 2008, 257; Roppolo 2009, 769; Tanaka 2012, 1235; Stipulante 2014, 177) 9 prospective single-arm observational studies,(Clark 1994, 1022; Bang 1999, 175; Castren 2001, 265; Bang 2003, 25; Hallstrom 2003, 123; Nurmi 2006, 463; Bohm 2007, 256; Cairns 2008, 349; Dami 2010, 848) 8 retrospective single-arm observational studies,(Garza 2003, 955; Hauff 2003, 731; Kuisma 2005, 89; Flynn 2006, 72; Ma 2007, 236; Deakin 2010, 853; Clawson 2012, 375; Lewis 2013, 1522) and 1 case-control study.(Berdowski 2009, 2096) A total of 17 420 patients were included in these 27 studies.“Cardiac arrest recognition” was reported heterogeneously across the included studies, precluding meta-analysis. Seven observational studies reported the sensitivity of dispatch protocols to recognize cardiac arrest,(Eisenberg 1985, 47; Garza 2003, 955; Flynn 2006, 72; Ma 2007, 236; Vaillancourt 2007, 877; Cairns 2008, 349; Deakin 2010, 853) with results that ranged from 38% to 96.9% and specificity that exceeded 99% in the 2 studies that reported this outcome.(Flynn 2006, 72; Deakin 2010, 853) Recognition rates of cardiac arrest ranged from 18% to 83% where reported.(Bang 2003, 25; Nurmi 2006, 463)The majority of the study dispatch centers used scripted dispatch protocols with questions to identify patients who are unconscious and not breathing or not breathing normally. Four before-after studies(Eisenberg 1985, 47; Heward 2004, 115; Vaillancourt 2007, 877; Stipulante 2014, 177) suggested that introducing scripted dispatch protocols or modifying existing protocols can help increase cardiac arrest recognition. One study reported an increase in cardiac arrest recognition(Heward 2004, 115) while 3 reported an increase in the rates of telephone-assisted CPR after the introduction of scripted dispatch protocols.(Eisenberg 1985, 47; Vaillancourt 2007, 877; Stipulante 2014, 177) One study also reported an increase in “high-acuity” calls after a modification to the seizure protocol.(Clawson 2008, 257)Recognition of unconsciousness with abnormal breathing is central to dispatcher recognition of cardiac arrest. Many terms may be used by callers to describe abnormal breathing: difficulty breathing, poorly breathing, gasping breathing, wheezing breathing, impaired breathing,(Bang 2003, 25) occasional breathing, barely/hardly breathing, heavy breathing, labored or noisy breathing, sighing, and strange breathing.(Berdowski 2009, 2096) Agonal breaths were reported in approximately 30% of cases in 1 study,(Bohm 2007, 256) which can make obtaining an accurate description of the patient’s breathing pattern challenging for dispatchers. The presence of agonal breaths were mentioned as a factor negatively affecting cardiac arrest recognition in 10 studies,(Bang 2003, 25; Hauff 2003, 731; Nurmi 2006, 463; Bohm 2007, 256; Vaillancourt 2007, 877; Bohm 2009, 1025; Roppolo 2009, 769; Dami 2010, 848; Tanaka 2012, 1235; Lewis 2013, 1522) with 1 study reporting that agonal breaths were present in 50% of nonidentified cardiac arrest calls.(Vaillancourt 2007, 877) Other terms reported in the studies that may help identify possible cardiac arrest cases include “dead,” “is dead,” “cold and stiff,” “blue,” “gray,” or “pale.”(Bang 1999, 175) The aforementioned descriptions, however, may be limited, owing to cultural influences and language translation limitations.Three before-after studies suggested that offering dispatchers additional education that specifically addresses agonal breaths can increase the rates of telephone-assisted CPR(Roppolo 2009, 769; Tanaka 2012, 1235) and decrease the number of missed cases.(Bohm 2009, 1025)There is evidence from 3 studies that failure to recognize cardiac arrest may be associated with failure to follow scripted protocols by omitting specified questions about consciousness and breathing.(Castren 2001, 265; Hallstrom 2003, 123; Dami 2010, 848)
Treatment Recommendation:
We recommend that dispatchers determine if a patient is unconscious with abnormal breathing. If the victim is unconscious with abnormal or absent breathing, it is reasonable to assume that the patient is in cardiac arrest at the time of the call (strong recommendation, very-low-quality evidence).We recommend that dispatchers be educated to identify unconsciousness with abnormal breathing. This education should include recognition and significance of agonal breaths across a range of clinical presentations and descriptions (strong recommendation, very-low-quality evidence).Values, Preferences, and Task Force InsightsIn making these recommendations, we placed a higher value on the recognition of cardiac arrest by dispatchers, and we placed a lower value on the potential harms arising from inappropriate CPR and the potential need for increased resources. In this situation, we believe that the benefits associated with increased numbers of cardiac arrest patients receiving timely and appropriate interventions outweigh the undesirable effects (potential for patients not in cardiac arrest to inappropriately receive chest compressions, potential need for increased resources).We recognize that the evidence in support of these recommendations comes from mainly observational studies of very low quality. Large, high-quality RCTs addressing this question are unlikely to be conducted. We believe that the available evidence shows consistent results favoring scripted dispatch protocols and that education including a description of the presenting signs of cardiac arrest and populations at risk (eg, patients presenting with seizures) enables dispatchers to identify cardiac arrest. We recognize that dispatch protocols for a range of conditions (including but not limited to “seizures,” “breathing problems,” “chest pains,” “falls,” and “unknown problem”) optimized to identify potential cardiac arrest without undue delay may further improve early recognition of cardiac arrest.
CoSTR Attachments:
BLS 740 - Dispatcher recognition of cardiac arrest Bias assessment summary (Final 05 Dec 2014)_n.xlsx    
BLS 740 - Dispatcher recognition of cardiac arrest CoSTR (04-02-2015)_n.docx    
BLS 740 - Dispatcher recognition of cardiac arrest GRADE grid (27-01-2015)_n.docx    
BLS 740 -Dispatcher recognition of cardiac arrest Summary of Evidence Table (27-01-2015)_n.docx    

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