Sustained and targeted public education and CPR training campaigns are very important, but training each and every citizen in your community to perform CPR is incredibly difficult, if not impossible. So the best strategy to increase overall bystander involvement is to combine frequent, brief and targeted public training with “just-in-time” dispatcher CPR instructions.
Pre-arrival telephone CPR instructions vary from place to place, and few 9-1-1 centers measure their performance to ensure quality. What we want is the same measured, guideline-compliant approach that ensures each and every 9-1-1 caller will receive lifesaving instructions as quickly as possible.
Let’s look at some of the key issues surrounding pre-arrival telephone CPR instructions.
Early recognition of SCA is essential to improving rates of bystander CPR; lack of recognition remains a major obstacle to getting CPR started. We need to recognize that SCA can present itself in ways that confuse both lay and trained rescuers, delaying the start of CPR for precious minutes.
Patten exhibited one such presentation—the “deep, long agonal breaths” that Ian Winterstein witnessed as his friend lay on the ground behind the car. “I’ve worked a lot of codes,” says Winterstein, who performed the compressions. “But I’ve never seen agonal respirations like this.”
Agonal breathing—an abnormal breathing pattern often described as gasping, snoring, snorting, gurgling, moaning, breathing every once in a while, or labored or noisy or heavy breathing—can last for several minutes and occur in up to half of all documented SCAs.12,13 It represents a brain stem reflex to ischemia and reduced blood flow to the brain.
Not surprisingly, then, survival appears to be higher if EMTs observe it when starting resuscitation attempts. One study found that victims were almost three-and-a-half times more likely to live to hospital discharge when EMTs noted gasping.14 Despite these observations, agonal breathing can delay the recognition of SCA and thus the start of CPR15–18—bystanders often mistake agonal breaths for signs of life and don’t realize they stem from cardiac arrest.
SCA victims will often demonstrate agonal breathing after CPR is started, as the compressions provide some blood and oxygen to the brain. Many lay rescuers are inclined to stop CPR when this occurs, but in fact they should continue rapid, forceful chest compressions unless the victim wakes up, demonstrates purposeful movement or trained rescuers arrive. We must train our dispatchers to identify and understand the significance of gasping over the telephone, and to start and maintain bystander CPR when it occurs.18
We also need to make it clear that brief “seizure-like” symptoms can also accompany SCA. Victims often twitch or shake immediately after collapse. These movements, while usually brief, can lead bystanders to mistake the event for a seizure and, again, delay the start of CPR.19, 20 This is especially true when the victim is young and a cardiac arrest seems unlikely.
Barriers to Bystander CPR
Increasing bystander CPR requires that we tackle the physical, psychological and communication barriers which keep bystanders from taking action when they witness or encounter a possible cardiac arrest. Population-based surveys and interviews with lay rescuers cite several obstacles, including inability to recognize cardiac arrest, panic, lack of confidence, fear of causing harm, fear of medical-legal ramifications, concerns about disease transmission and lack of physical ability to perform CPR.3–9 In real life events, these barriers often combine and vary among populations, settings and situations.
Dispatch-assisted CPR is our opportunity to overcome these barriers. If properly trained, our dispatchers can quickly calm panic-stricken callers, help them identify cardiac arrest, give them confidence and instruct them in CPR.
Formal Dispatch-Assisted CPR Programs
Given the importance and potential of bystander CPR in the Chain of Survival, we must build formal dispatch-assisted CPR programs at our 9-1-1 centers. Such programs can be built on any scale, from the smallest 9-1-1 center to county and statewide efforts. Whatever the size, there are three essential pillars: protocol development, dispatcher training and quality assurance (QA) systems that shed light on performance.