An article, published online March 31, 2008, in the American Heart Association’s journal Circulation, entitled Hands-Only (Compression-Only) Cardiopulmonary Resuscitation: A Call to Action for Bystander Response to Adults Who Experience Out-of-Hospital Sudden Cardiac Arrest. A Science Advisory for the Public From the American Heart Association Emergency Cardiovascular Care Committee, has raised many questions regarding the provision of CPR instructions in the dispatch environment. Specifically, does this recommendation warrant an immediate change to the CPR pre arrival instructions contained in the Academy approved Medical Priority Dispatch System™ (MPDS)?
Current, MPDS protocol is based on the recommendations of the Academy’s Special Resuscitation Council, which was formed to consider the proposed 2005 ILCOR/AHA resuscitation guidelines. This special resuscitation council published their DLS-specific recommendations in May of 2005, in the journal Resuscitation.
The Academy’s Special Resuscitation Council considered many aspects of the available research while composing the dispatch CPR protocol including arrest etiology, time of collapse to instruction and arrival of responders, the availability of professionally delivered instructions versus layperson recall and performance, and defibrillation intervention. These factors are very important considering they are intricate to the recommendations produced by ILCOR and the AHA for laypersons, BLS and ALS responders, and hospital staff. While the 2005 AHA guidelines were very specific for these providers, they included only three, short paragraphs specific to dispatch CPR, and a third of that was devoted to recognizing agonal respirations. With the DLS standard unclear, it was up to the Academy’s council to consider the evidence and create one.
This latest science advisory from the AHA has been published to “…amend and clarify the “2005 American Heart Association
(AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)” for bystanders who witness an adult out-of-hospital sudden cardiac arrest.” These new guidelines are not DLS specific in that they do not consider the availability of professionally delivered pre-arrival instructions and they emphasize layperson confidence, recall, and ability. The new guidelines summary for adult victims of witnessed cardiac arrest is as follows:
When an adult suddenly collapses, trained or untrained
bystanders should—at a minimum—activate their community
emergency medical response system (eg, call 911) and
provide high-quality chest compressions by pushing hard and
fast in the center of the chest, minimizing interruptions (Class I).
● If a bystander is not trained in CPR, then the bystander should provide hands-only CPR (Class IIa). The rescuer should continue hands-only CPR until an automated external defibrillator arrives and is ready for use or EMS providers take over care of the victim.
● If a bystander was previously trained in CPR and is confident in his or her ability to provide rescue breaths with minimal interruptions in chest compressions, then the bystander should provide either conventional CPR using a 30:2 compression-to-ventilation ratio (Class IIa) or hands-only CPR (Class IIa). The rescuer should continue CPR until an automated external defibrillator arrives and is ready for use or EMS providers take over care of the victim.
● If the bystander was previously trained in CPR but is not confident in his or her ability to provide conventional CPR
including high-quality chest compressions (ie, compressions of adequate rate and depth with minimal interruptions) with rescue breaths, then the bystander should give hands-only CPR (Class IIa). The rescuer should continue hands-only CPR until an automated external defibrillator arrives and is ready for use or EMS providers take over the care of the victim.
When considering these new recommendations it should be noted that the AHA Committee “…has concluded that adult victims of out-of-hospital cardiac arrest who receive bystander hands-only
(compression-only) CPR or conventional CPR have a similar chance of survival.”
It is very important to note that a primary motivation of the new recommendations is the recall ability and motivation of bystanders in the cardiac arrest situation and these considerations are clearly affected when instructions are provided by a trained EMD.
The current version of the MPDS is in line with the new recommendations in that a continuous sequence of 400 uninterrupted compressions are provided for adult victims of presumed cardiac arrest. The protocol considers the limitations stated in the new guidelines including the limited performance and recall variations of laypersons and the fact that “…there may be an interval after cardiac arrest when ventilations become absolutely critical for survival.” As is emphasized in the new guidelines, the protocol is designed to evaluate the cardiac arrest patient and institute uninterrupted chest compressions as soon as possible.
The question that remains, even after considering these new recommendations, is when in the CPR sequence do ventilations become necessary for survival and, should this endpoint be included in the dispatch protocol or be left to the responders? Options include extending the initial 400 compressions to another finite number or simply providing compressions-only until responders arrive.
The Academy’s Special Resuscitation Council is charged with evaluating these new recommendations to determine what, if any, changes to the MPDS are prudent. In the meantime, protocol users can be assured that current protocol meets the latest DLS standard, and is constantly being evaluated and refined in consideration of the most recent research. If changes are deemed necessary, they will likely be incorporated into version 12.0 of the MPDS, currently undergoing beta testing.