Manya Charette

Part 3: Adult Basic Life Support and Automated External Defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms. Highlights in prevention indicate the rational and judicious deployment of search-and-rescue operations in drowning victims and the importance of education on opioid-associated emergencies. Other 2015 highlights in recognition and activation include the critical role of dispatcher recognition and dispatch-assisted chest compressions, which has been demonstrated in multiple international jurisdictions with consistent improvements in cardiac arrest survival. Similar to the 2010 ILCOR BLS treatment recommendations, the importance of high quality was reemphasized across all measures of CPR quality: rate, depth, recoil, and minimal chest compression pauses, with a universal understanding that we all should be providing chest compressions to all victims of cardiac arrest. This review continued to focus on the interface of BLS sequencing and ensuring high-quality CPR with other important BLS interventions, such as ventilation and defibrillation. In addition, this consensus statement highlights the importance of EMS systems, which employ bundles of care focusing on providing high-quality chest compressions while extricating the patient from the scene to the next level of care. Highlights in defibrillation indicate the global importance of increasing the number of sites with public-access defibrillation programs. Whereas the 2010 ILCOR Consensus on Science provided important direction for the “what” in resuscitation (ie, what to do), the 2015 consensus has begun with the GRADE methodology to provide direction for the quality of resuscitation. We hope that resuscitation councils and other stakeholders will be able to translate this body of knowledge of international consensus statements to build their own effective resuscitation guidelines.

Part 3: Adult Basic Life Support and Automated External Defibrillation

This Part of the 2015 International Consensus on Cardiopul monary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science With Treatment Recommendations (CoSTR) presents the consensus on science and treatment recommendations for adult basic life support (BLS) and automated external defibrillation (AED). After the publication of the 2010 CoSTR, the Adult BLS Task Force developed review questions in PICO (population, intervention, comparator, outcome) format.1 This resulted in the generation of 36 PICO questions for systematic reviews. The task force discussed the topics and then voted to prioritize the most important questions to be tackled in 2015. From the pool of 36 questions, 14 were rated low priority and were deferred from this round of evidence evaluation. Two new questions were submitted by task force members, and 1 was submitted via the public portal. Two of these (BLS 856 and BLS 891) were taken forward for evidence review. The third question (368: Foreign-Body Airway Obstruction) was deferred after a preliminary review of the evidence failed to identify compelling evidence that would alter the treatment recommendations made when the topic was last reviewed in 2005.2 Each task force performed a systematic review using detailed inclusion and exclusion criteria, based on the recommendations of the Institute of Medicine of the National Academies.3 With the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library). Reviewers were unable to identify any relevant evidence for 3 questions (BLS 811, BLS 373, and BLS 348), and the evidence review was not completed in time for a further question (BLS 370). A revised PICO question was developed for the opioid question (BLS 891). The task force reviewed 23 PICO questions for the …

In patients with out-of-hospital cardiac arrest, does the provision of dispatch cardiopulmonary resuscitation instructions as opposed to no instructions improve outcome: A systematic review of the literature ☆

CONTEXT Early bystander cardiopulmonary resuscitation (CPR) provides an essential bridge to successful defibrillation from sudden cardiac arrest (SCA) and there is a need to increase the prevalence and quality of bystander CPR. Emergency medical dispatchers can give CPR instructions to a bystander calling for an ambulance enabling even an inexperienced bystander to start CPR. The impact of these instructions has not been evaluated. OBJECTIVES To determine if, in adult and pediatric patients with out-of-hospital cardiac arrest, the provision of dispatch CPR instructions as opposed to no instructions improves outcome. METHODS Two independent reviewers used standardized forms and procedures to review papers published between January, 1985 and December, 2009. Findings were peer-reviewed by the International Liaison Committee on Resuscitation. DATA SYNTHESIS We identified 665 citations; five met the inclusion criteria. One retrospective cohort study reported improved survival with dispatch CPR instructions than without it. Three studies, two observational and one with retrospective controls showed trends toward increased survival after dispatcher-assisted CPR was implemented and one showed trend toward decreased survival. There were no randomised studies addressing the topic. No studies addressing dispatch CPR instructions in the pediatric population were found. CONCLUSION There is limited evidence supporting the survival benefit of dispatch-assisted CPR instructions. All studies comparing survival outcomes when CPR is provided with or without the assistance of dispatch-assisted CPR instructions lack the statistical power to draw significant conclusions. Since it has been demonstrated that such instructions can improve bystander CPR rates, it is reasonable to recommend they should be provided to all callers reporting a victim in cardiac arrest.

Evaluation of the safety of C-spine clearance by paramedics: design and methodology

BackgroundCanadian Emergency Medical Services annually transport 1.3 million patients with potential neck injuries to local emergency departments. Less than 1% of those patients have a c-spine fracture and even less (0.5%) have a spinal cord injury. Most injuries occur before the arrival of paramedics, not during transport to the hospital, yet most patients are transported in ambulances immobilized. They stay fully immobilized until a bed is available, or until physician assessment and/or X-rays are complete. The prolonged immobilization is often unnecessary and adds to the burden of already overtaxed emergency medical services systems and crowded emergency departments.Methods/DesignThe goal of this study is to evaluate the safety and potential impact of an active strategy that allows paramedics to assess very low-risk trauma patients using a validated clinical decision rule, the Canadian C-Spine Rule, in order to determine the need for immobilization during transport to the emergency department.This cohort study will be conducted in Ottawa, Canada with one emergency medical service. Paramedics with this service participated in an earlier validation study of the Canadian C-Spine Rule. Three thousand consecutive, alert, stable adult trauma patients with a potential c-spine injury will be enrolled in the study and evaluated using the Canadian C-Spine Rule to determine the need for immobilization. The outcomes that will be assessed include measures of safety (numbers of missed fractures and serious adverse outcomes), measures of clinical impact (proportion of patients transported without immobilization, key time intervals) and performance of the Rule.DiscussionApproximately 40% of all very low-risk trauma patients could be transported safely, without c-spine immobilization, if paramedics were empowered to make clinical decisions using the Canadian C-Spine Rule. This safety study is an essential step before allowing all paramedics across Canada to selectively immobilize trauma victims before transport. Once safety and potential impact are established, we intend to implement a multi-centre study to study actual impact.Trial RegistrationClinicalTrials.gov NCT01188447

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.

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.

An evaluation of 9-1-1 calls to assess the effectiveness of dispatch-assisted cardiopulmonary resuscitation (CPR) instructions: design and methodology

BackgroundCardiac arrest is the leading cause of mortality in Canada, and the overall survival rate for out-of-hospital cardiac arrest rarely exceeds 5%. Bystander cardiopulmonary resuscitation (CPR) has been shown to increase survival for cardiac arrest victims. However, bystander CPR rates remain low in Canada, rarely exceeding 15%, despite various attempts to improve them. Dispatch-assisted CPR instructions have the potential to improve rates of bystander CPR and many Canadian urban communities now offer instructions to callers reporting a victim in cardiac arrest. Dispatch-assisted CPR instructions are recommended by the International Guidelines on Emergency Cardiovascular Care, but their ability to improve cardiac arrest survival remains unclear.Methods/DesignThe overall goal of this study is to better understand the factors leading to successful dispatch-assisted CPR instructions and to ultimately save the lives of more cardiac arrest patients. The study will utilize a before-after, prospective cohort design to specifically: 1) Determine the ability of 9-1-1 dispatchers to correctly diagnose cardiac arrest; 2) Quantify the frequency and impact of perceived agonal breathing on cardiac arrest diagnosis; 3) Measure the frequency with which dispatch-assisted CPR instructions can be successfully completed; and 4) Measure the impact of dispatch-assisted CPR instructions on bystander CPR and survival rates.The study will be conducted in 19 urban communities in Ontario, Canada. All 9-1-1 calls occurring in the study communities reporting out-of-hospital cardiac arrest in victims 16 years of age or older for which resuscitation was attempted will be eligible. Information will be obtained from 9-1-1 call recordings, paramedic patient care reports, base hospital records, fire medical records and hospital medical records. Victim, caller and system characteristics will be measured in the study communities before the introduction of dispatch-assisted CPR instructions (before group), during the introduction (run-in phase), and following the introduction (after group).DiscussionThe study will obtain information essential to the development of clinical trials that will test a variety of educational approaches and delivery methods for telephone cardiopulmonary resuscitation instructions. This will be the first study in the world to clearly quantify the impact of dispatch-assisted CPR instructions on survival to hospital discharge for out-of-hospital cardiac arrest victims.Trial RegistrationClinicalTrials.gov NCT00664443

Cardiac arrest diagnostic accuracy of 9-1-1 dispatchers: A prospective multi-center study

INTRODUCTION We sought to determine the ability of 9-1-1 dispatchers to accurately determine the presence of out-of-hospital cardiac arrest (OOHCA) over the telephone, and to determine the frequency with which CPR instructions are initiated and chest compressions delivered in patients not in cardiac arrest. METHODS We conducted a multi-center, prospective cohort study of adult OOHCA patients not witnessed by EMS for which resuscitation was attempted. Dispatchers were not health care professionals and received 6 weeks of training followed by a 6-month preceptorship. We reviewed 9-1-1 call digital recordings for all unconscious patients for which the possibility of cardiac arrest was considered using a piloted standardized data collection sheet. RESULTS We reviewed 2260 recordings occurring between January 2008 and October 2009. Among those, 1536 were confirmed OOHCA, and 724 were not. Among the 1536 confirmed OOHCA cases, 1012 were recognized by dispatchers and 524 were not. Among the 724 cases not in cardiac arrest, dispatchers suspected cardiac arrest was present in 490 and absent in 234. OOHCA diagnostic accuracy characteristics were: sensitivity 65.9% (95% CI 63.5-68.2%), specificity 32.3% (95% CI 29.0-35.9%), PPV 67.4%, and NPV 30.9%. Dispatchers believed that OOHCA was present in 490/2260 (21.7%) cases when it was not, resulting in 54/490 (11.0%) patients inappropriately receiving chest compressions, or 54/2260 (2.4%) of the whole cohort. CONCLUSIONS Dispatchers had a fair sensitivity and modest specificity for the recognition of OOHCA. We found a very small number of patients receiving CPR when not in cardiac arrest, supporting the current use of dispatch-assisted CPR instructions.

Barriers and facilitators to CPR knowledge transfer in an older population most likely to witness cardiac arrest: a theory-informed interview approach

Background We sought to identify perceived barriers and facilitators to cardiopulmonary resuscitation (CPR) training and performing CPR among people above the age of 55 years. Methods We conducted semistructured qualitative interviews with a purposive sample of independent-living individuals aged 55 years and older from urban and rural settings. We developed an interview guide based on the constructs of the Theory of Planned Behaviour, which elicits salient attitudes, social influences and control beliefs potentially influencing CPR training and performance. Interviews were recorded, transcribed verbatim and analysed until achieving data saturation. Two independent reviewers performed inductive analyses to identify emerging themes, and ranked them by way of consensus. Results Demographics for the 24 interviewees: mean age 71.4 years, women 58.3%, urban location 75.0%, single dwelling 58.3%, CPR training 79.2% and prior CPR on real victim 8.3%. Facilitators of CPR training included: (1) classes in a convenient location; (2) more advertisements; and (3) having a spouse. Barriers to taking CPR training included: (1) perception of physical limitations; (2) time commitment; and (3) cost. Facilitators of providing CPR included: (1) 9-1-1 CPR instructions; (2) reminders/pocket cards; and (3) frequent but brief updates. Barriers to providing CPR included: (1) physical limitations; (2) lack of confidence; and (3) ambivalence of duty to act in a large group. Conclusions We identified key facilitators and barriers for CPR training and performance in a purposive sample of individuals aged 55 years and older.

Factors Associated with the Successful Recognition of Abnormal Breathing and Cardiac Arrest by Ambulance Communications Officers: A Qualitative Iterative Survey

Abstract Objectives. We sought to identify barriers and facilitators to ambulance communications officers’ (ACOs’) recognition of abnormal breathing and administration of cardiopulmonary resuscitation (CPR) instructions. Methods. We conducted semistructured qualitative interviews based on the constructs of the Theory of Planned Behavior to elicit salient attitudes, social influences, and behavioral controls potentially influencing ACOs’ intent to recognize abnormal breathing as a symptom of cardiac arrest and administer CPR instructions over the phone. We conducted interviews until achieving data saturation. We recorded interviews and transcribed them verbatim. Two independent reviewers performed inductive analyses to identify emerging themes. Results. We interviewed 24 ACOs from four Canadian provinces (67% female, median 9.5 years of experience, 33% with paramedic training). We identified eight behavioral, 14 subjective normative, and 22 control beliefs. Important attitudes were as follows: 1) CPR instructions may help the patient and are likely to be beneficial for the caller; 2) abnormal breathing is an early sign of cardiac arrest; and 3) dispatch-assisted CPR instructions can improve survival. The leading social influence was management/quality assurance staff. Behavioral control was the construct most associated with ACOs’ ability to recognize abnormal breathing, including 1) adherence to mandatory scripted protocol, 2) poor caller description of breathing pattern, and 3) ACO training on abnormal breathing. Conclusions. This qualitative study found that control beliefs are most influential on ACOs’ intention to recognize abnormal breathing and provide CPR instructions over the phone. Training and policy changes should target these beliefs to increase the frequency of ACO-administered CPR instructions to callers reporting a patient in cardiac arrest.

Factors influencing the intentions of nurses and respiratory therapists to use automated external defibrillators during in-hospital cardiac arrest: a qualitative interview study.

OBJECTIVES Nurses and respiratory therapists are seldom allowed to use automated external defibrillators (AED) during in-hospital cardiac arrest. This can result in significant time delays before defibrillation occurs and lower survival for cardiac arrest victims. We sought to identify barriers and facilitators to AED use by nurses and respiratory therapists. METHODS We conducted semi-structured qualitative interviews with a purposeful sample of nurses and respiratory therapists. We developed the interview guide based on the constructs of the theory of planned behaviour, which elicits salient attitudes, social influences, and control beliefs potentially influencing the intent to use an AED. Interviews were recorded, transcribed verbatim, and analysed until achieving data saturation. Two independent reviewers performed inductive analyses to identify emerging categories and themes, and ranked them by frequency of the number of participants stating the topic. RESULTS Demographics for the 24 interviewees include mean age 40.5, 79.2% female, 87.5% performed cardiopulmonary resuscitation (CPR), 29.2% defibrillated a patient. Identified attitudes pertained to the timeliness of defibrillation, patient survival, simplicity of AED use, accuracy of rhythm recognition, and harm to self or others. Social influences consisted of physician and hospital administration support of AED use. Control beliefs included training on AED use, policy allowing AED use, familiarity with AED, and task burden during resuscitation. CONCLUSIONS Most nurses and respiratory therapists intended to use an AED if permitted to do so by a medical directive. Successful implementation would require educational initiatives focusing on safety and efficacy of AEDs, support from physicians and hospital administrators, and additional training on AED use.