What are the key recommendations for emergency medical dispatch situations?

Emergency Medical Dispatch: Key Recommendations

Emergency medical dispatch centers must implement standardized protocols to immediately identify cardiac arrest through a systematic two-question approach assessing unconsciousness and abnormal breathing, followed by immediate provision of hands-only CPR instructions with minimal delay. 1

Rapid Cardiac Arrest Recognition

Core Identification Protocol

Dispatchers should use a streamlined two-question approach at the beginning of every call to efficiently identify cardiac arrest: 1

• First question: Is the patient unconscious/unresponsive? 1
• Second question: Is the patient breathing normally? 1
• If the patient is unresponsive AND not breathing or not breathing normally, presume cardiac arrest and immediately initiate CPR instructions 1

Critical Recognition Points

Dispatchers must be specifically trained to recognize agonal breathing, which occurs in up to 50% of cardiac arrests and is the most common reason for missed recognition: 1

• Agonal gasps may be described by callers as "gasping," "deep snoring," "slow breathing," or other abnormal respiratory patterns 1
• Any form of abnormal breathing in an unresponsive patient should be treated as cardiac arrest 1
• Brief seizure-like activity immediately after collapse can mask cardiac arrest and should not delay presumptive diagnosis 1

Three before-after studies demonstrate that dispatcher education specifically addressing agonal breathing increases telephone-assisted CPR rates and decreases missed cardiac arrests: 1

Standardized Protocols Are Essential

Implementation of scripted dispatch protocols increases cardiac arrest recognition rates from as low as 18% to as high as 83%, with sensitivity ranging from 38% to 96.9%: 1

• Four before-after studies show that introducing or modifying scripted protocols increases cardiac arrest recognition 1
• Protocol adherence is critical—failure to follow scripted protocols by omitting questions about consciousness and breathing is associated with missed cardiac arrests 1
• Standardized algorithms should be implemented immediately upon call receipt, before asking about medical history or acute symptoms 1

A critical pitfall: Asking questions about the patient's medical history or acute condition before assessing consciousness and breathing delays bystander CPR by precious minutes and significantly reduces resuscitation success. 1

Dispatcher-Assisted CPR Instructions

Immediate Provision of Instructions

Emergency medical dispatch centers must have systems in place to provide CPR instructions, as this intervention significantly increases bystander CPR rates and survival from cardiac arrest: 1

• CPR instructions should be provided by designated dispatch personnel with minimal delay 1
• The initial call receiver should provide instructions whenever possible or immediately transfer to personnel trained in CPR instruction 1
• Dispatchers should stay on the line throughout the resuscitation attempt 1

Hands-Only CPR Protocol for Adults

For adult sudden collapse of presumed cardiac origin, dispatchers should provide chest compression-only CPR instructions (strong recommendation from the 2020 International Consensus): 1

The specific instruction sequence should be: 1

1. "Bring the phone and get NEXT to the person if you can"
2. "Listen carefully. I'll tell you what to do"
3. "Place the person FLAT on his back on the floor"
4. "KNEEL by the person's side"
5. "Put the HEEL of your HAND on the CENTER of the person's CHEST"
6. "Put your OTHER HAND ON TOP of THAT hand"
7. "PUSH DOWN FIRMLY, ONLY on the HEELS of your hands, at least 2 inches"
8. "Do this 50 times, just like you're PUMPING the chest. Count OUT LOUD: 1-2-3...50"
9. "KEEP DOING IT: KEEP PUMPING the CHEST UNTIL HELP TAKES OVER. I'll stay on the line"

Three randomized clinical trials support compression-only instructions over conventional CPR with breaths for adult cardiac arrest, showing at least comparable survival and potentially superior outcomes for witnessed arrests of cardiac origin: 1

• Hands-only CPR enables rescuers to start chest compressions on average one minute sooner than conventional CPR 1
• This approach substantially simplifies instructions and bystander action 1

When to Add Rescue Breaths

Ventilation instructions should be added for suspected asphyxial arrests (drowning, pediatric arrests, respiratory arrest): 1

After 30 compressions, provide these ventilation instructions: 1

• "PINCH the NOSE; with your other hand, LIFT the CHIN so that the head TILTS BACK"
• "Completely COVER the person's MOUTH with your MOUTH"
• "GIVE 2 BREATHS (come back to the phone)"
• Then return to 30 compressions, continuing cycles of 30:2 until EMS arrives

Engaging Hesitant Bystanders

Overcoming Caller Reluctance

Dispatchers must use assertive, confident communication to overcome bystander hesitation: 1

• Instead of asking "Would you like to try CPR?" state firmly: "We need to start CPR. I will help you" 1
• Convey leadership, teamwork, and assurance through calm, confident tone 1
• Reassure callers that CPR can only help and will not cause harm 1

The benefit-risk ratio strongly favors aggressive CPR initiation: 1

• Serious injury from bystander CPR in patients not actually in cardiac arrest is uncommon (1-2%) 1
• In nearly half of cases receiving dispatcher CPR instructions, the patient will not be in cardiac arrest, but this is acceptable 1
• Failure to provide CPR to true cardiac arrest victims is lethal 1
• Bystanders and dispatchers should be assured that the balance of benefit versus risk greatly favors beginning CPR whenever a patient is unresponsive and not breathing normally 1

System Performance and Quality

Dispatcher Training Requirements

Formal emergency medical dispatch training must include: 1

• Recurrent medical and practical training 1
• Interrogation skills development 1
• Protocol compliance monitoring 1
• Provision of pre-arrival instructions 1
• Certification with requirements for continuing education and recertification 1

Optimizing Recognition Accuracy

One cluster randomized controlled trial and six observational studies evaluated machine learning and various system interventions for cardiac arrest recognition: 1

• Machine learning-assisted dispatch recognized cardiac arrest in 93.1% versus 90.5% in control groups (though not statistically significant, p=0.15) 1
• Dispatch optimization is likely one of the most cost-effective solutions to improving cardiac arrest outcomes 1
• Cases of cardiac arrest missed at initial telephone triage have dramatically worse outcomes (5% survival versus 14% when correctly identified) 1

Three-Phase Call Management

The dispatch process should follow this structured approach: 1

1. Phase 1 - Identification: Determine if help is necessary by identifying symptoms at the symptom level, not requiring a diagnosis 1
2. Phase 2 - Priority: Assess urgency and level of ambulance response needed based on symptom description 1
3. Phase 3 - Activity: Dispatch appropriate resources while simultaneously providing pre-arrival instructions 1

Common Pitfalls to Avoid

Critical errors that reduce survival: 1

• Delaying cardiac arrest assessment by asking about medical history first 1
• Failing to recognize agonal breathing as a sign of cardiac arrest 1
• Omitting scripted protocol questions about consciousness and breathing 1
• Using tentative language that fails to engage hesitant bystanders 1
• Providing complex conventional CPR instructions when hands-only CPR is more appropriate 1
• Allowing caller uncertainty about cardiac arrest diagnosis to delay CPR instructions 1

When caller information is inconsistent (e.g., stating patient is conscious but not breathing), dispatchers should continue to consider cardiac arrest as the working diagnosis until an alternative condition is clearly identified. 1