When a 911 Dispatcher Asks "Is the Patient Cold and Clammy?"
The dispatcher is trying to identify possible cardiac arrest by asking about descriptors that callers may use to describe an unconscious patient, as "cold and stiff," "blue," "gray," or "pale" are recognized terms that help identify cardiac arrest cases. 1
Primary Purpose: Cardiac Arrest Recognition
The question about a patient being "cold and clammy" serves as part of the dispatcher's systematic approach to identify cardiac arrest, which is the most critical time-sensitive emergency requiring immediate intervention. 1
Key Descriptive Terms for Cardiac Arrest Identification
Dispatchers are trained to recognize specific caller descriptions that may indicate cardiac arrest, including: 1
- "Dead" or "is dead" 1
- "Cold and stiff" 1
- "Blue," "gray," or "pale" 1
- "Cold and clammy" (related to the above descriptors)
These descriptive terms help dispatchers overcome the primary challenge of cardiac arrest recognition: determining unconsciousness with abnormal or absent breathing over the phone. 1
The Core Diagnostic Algorithm
Dispatchers should use a streamlined 2-question approach to efficiently identify cardiac arrest: 1
If the answer is unresponsive with absent or abnormal breathing, the presumptive diagnosis is cardiac arrest and CPR instructions should begin immediately. 1
Why Additional Descriptors Matter
The "cold and clammy" question serves as a supplementary descriptor because: 1
- Callers may not accurately assess consciousness or breathing initially 1
- Information from callers can be inconsistent (e.g., stating the patient is conscious but later saying they're not breathing) 1
- Physical appearance descriptors provide additional clues when the caller is uncertain about responsiveness or breathing 1
Critical Context: Shock vs. Cardiac Arrest
Important caveat: While "cold and clammy" skin is classically described as a late sign of shock 2, in the dispatch context, this descriptor is being used to help identify cardiac arrest, not to diagnose shock states. 1
The distinction matters because:
- In shock states: Cold, clammy skin indicates peripheral vasoconstriction and represents late-stage shock with systolic hypotension 2
- In cardiac arrest recognition: "Cold" descriptors help dispatchers identify patients who may already be in arrest and need immediate CPR 1
Common Pitfalls in Cardiac Arrest Recognition
The Agonal Breathing Problem
The single most important pitfall is misinterpreting agonal breaths as normal breathing, which occurs in 40-60% of cardiac arrest cases and leads to failure to recognize cardiac arrest. 1
- Agonal breaths appear as slow, irregular gasping respirations 3
- May be described by callers as "difficulty breathing," "gasping," "wheezing," "impaired breathing," "occasional breathing," "barely breathing," "heavy breathing," "labored or noisy breathing," "sighing," or "strange breathing" 1
- Agonal breaths were present in 50% of non-identified cardiac arrest calls in one study 1
Why This Matters for Outcomes
- Early cardiac arrest recognition with immediate CPR improves survival by 2- to 3-fold 3
- Missed cardiac arrests at telephone triage have dramatically worse outcomes: 5% survival versus 14% when properly identified 1
- The risk of injury from CPR in patients not actually in cardiac arrest is only 1-2%, far outweighed by the lethal consequences of missing true cardiac arrest 1, 3
The Dispatcher's Decision Framework
When a dispatcher asks about "cold and clammy" appearance, they are: 1
- Gathering supplementary information to support or refute cardiac arrest diagnosis
- Overcoming caller uncertainty about consciousness and breathing assessment
- Looking for physical descriptors that correlate with cardiac arrest when standard questions yield unclear answers
- Preparing to initiate telephone CPR instructions if cardiac arrest is suspected
The balance of benefit versus risk greatly favors an assertive approach to beginning CPR whenever a patient is unresponsive with abnormal breathing, even if there is uncertainty. 1