Opportunities and Challenges in Telecommunicator CPR (T-CPR) Paris Hotel and Casino  Las Vegas, Nevada Opportunities and Challenges in Telecommunicator CPR (T-CPR) Presented by: Dr. Bentley Bobrow Dr. Thomas Rea Micah Panczyk

Presenter Disclosure Information Ben Bobrow, MD Opportunities and Challenges in Telecommunicator CPR FINANCIAL DISCLOSURE: Heart Rescue Project Grant from Medtronic Foundation involving community-based translation of resuscitation science UNLABELED/UNAPPROVED USES DISCLOSURE: None

Presenter Disclosure Information Thomas Rea, MD Opportunities and Challenges in Telecommunicator CPR FINANCIAL DISCLOSURE: Heart Rescue Project Grant from Medtronic Foundation involving community-based translation of resuscitation science. Medical Director for Association of Public Safety Communication Officials. UNLABELED/UNAPPROVED USES DISCLOSURE: None

Presenter Disclosure Information Micah Panczyk Opportunities and Challenges in Telecommunicator CPR FINANCIAL DISCLOSURE: No disclosures to report UNLABELED/UNAPPROVED USES DISCLOSURE: None

Presentation Slide Title Stare at the cube for a moment. See how it flips back and forth, front to back and back to front. It is a demonstration of how you can see the same thing in different ways. We want dispatchers to “see” incoming calls in a different way. Right now, dispatchers assume the call is not an out-of-hospital cardiac arrest (OHCA) until the call proves otherwise. We want them to assume the next call IS a cardiac arrest until proven otherwise. This shift in the “burden of proof” is a different way of seeing the next call and will help cultivate the assertive approach to call-taking recommended in the latest guidelines for Telephone CPR (T-CPR).

A Little Math 424,000/365 = 1162 1162/24 = 48 There are 1162 OHCAs every day in the U.S. That means there are 48 OHCAs every hour in the U.S. There are about 15 OHCAs in Arizona every day. That means there is a 63% chance of a cardiac arrest in Arizona in any given hour.

Signs of Cardiac Arrest Sudden, unexpected collapse Unconsciousness, NO sign of life Abnormal breathing (gasping) common Brief seizure - lack of oxygen to brain Signs of OHCA

Chances of survival decrease 7-10% for every minute without CPR The Race is On … Chances of survival decrease 7-10% for every minute without CPR Survivall Signs of OHCA 5 10 15 20 Nagao Current Opinion in Critical Care 2009

Urban Response Timeline – Arizona 2012 0:00:30 0:02:17 0:03:44   PSAP Handling Turnout 0:01:47 0:01:27 0:9:16-0:11:16 0:11:16-0:13:16 0:09:16 Travel To patient First shock 0:01:00-0:02:00 0:01:00-0:02:00 0:05:32 The top row of numbers indicate cumulative elapsed time since the start of a call. The bottom row of numbers represent the time elapsed in a defined interval (for example, “PSAP” and “Handling” and “Turnout” are all different intervals). A call is received at the Primary Safety Answering Point (PSAP) at time 0. The 9-1-1 operator there determines if the call is a public safety or fire/medical call. If it’s a fire/medical call, it is sent to the secondary answering point and received there 30 seconds later. The call is handled (or “processed” – the nature of the call is identified, units are dispatched and pre-arrival instructions are started if necessary) for 1:47 seconds and EMS units prepare to leave for the incident for 1:27 seconds. By the time EMS units leave the station (“Turnout”), 3:44 has elapsed since the start of the call. When travel to the scene, time to reach the patient, and time to assess the patient are taken into account, it can take up to 13:16 from the start of the call for EMS units to deliver the first shock with an AED. Considering how rapidly the chance of survival falls per minute, this slide demonstrates the importance of bystander CPR before EMS units arrive and take over.

On average, only 8% of cardiac arrest patients survive in the United States.

The OR for Bystander CPR in this metaanalysis was 2.44.

T-CPR and OHCA Survival

Expanding and Improving T-CPR: The Three-Phase Model

Identifying OHCA Over the Phone PHASE 1: Identifying OHCA Over the Phone

Taking the Lead: Controlling the Call Active Listening: The First Seconds - Caller often volunteers 2/3 of critical information Callers are often frantic - Be ASSERTIVE 4 - Be CALM5 Tell them help is on the way Get and use caller’s name

AHA’s Two Question Model Is the patient conscious? If necessary, ask if “responsive” or “awake” If necessary, ask to speak to patient Is the patient breathing NORMALLY? Allows you to catch Agonal Breathing If “no” to both, start CPR instructions1,2 Be assertive: Don’t ask – TELL “You need to do CPR, I will help you”

What to Avoid Extra questions which delay the identification of cardiac arrest and initiation of CPR

What is agonal breathing? Agonal breathing is an abnormal pattern of breathing characterized by shallow, slow (3-4 per minute), irregular respirations followed by irregular pauses. They may also be characterized as gasping, labored breathing, accompanied by strange vocalizations. The cause for agonal breathing is a lack of oxygen to the brain stem.

Survival 28% vs 8% (adjusted OR 3.4 95% CI 2.2, 5.2) The presence of agonal breathing indicates a more favorable prognosis than in cases of cardiac arrest without agonal breathing: 27% of patients with agonal breathing were discharged alive compared with 9% without them (p<.001) Clark Ann Emerg Med 1992 28% vs 8% (adjusted OR 3.4 95% CI 2.2, 5.2) Bobrow Circ 2008

How do bystanders describe agonal breathing? Audible: sounds like snoring Description: ”he’s making noises” ... ”humming” ... like a humming sound” Description: ”he’s gasping for air” Description: ”he’s soring like he’s in a deep sleep” Descriptor: ”she’s moaning” Descriptor: ”she’s groaning

PHASE 2: Barriers and Tactics

Assertiveness is Key! BARRIER TACTIC 1 Bystander panicked, making CPR instruction problematic Use confidence and assertiveness to take control of the situation 2 Bystander squeamish about M-T- M contact Provide compression-only instructions 3 Bystander fears legal ramification Assure bystander of Good Samaritan laws safeguarding citizen action 4 Bystander fearful of hurting the patient in getting them to a the floor. TELL bystander he MUST. Engage help if multiple rescuers present. Use pillows. 5 Bystander fears CPR will hurt patient Assure bystander that CPR is safe and won’t hurt patient

Justification

PHASE 3: Continuous Coaching

The Right Instructions AHA recommends Compression-Only CPR … For adults with non-respiratory cause of arrest Easier to perform Compression-Only CPR associated with better long-term survival than CPR with rescue breathing2 AHA recommends CPR with Rescue Breathing … For children 8 years old and younger For adults with respiratory cause of arrest Drowning Choking 1. Svenson et al N Engl J Med 2010 2. Dumas et al Circulation 2012

Sample Script: CPR Instructions

Focus: Creating & Maintaining CPR Quality “Continuous Coaching”

CPR Quality Matters!

Recommendation on AEDs Ask if an AED is available only if the event is in a public place with more than one rescuer present. If using an AED, instruct the rescuers to bare the patient’s chest.

Continuous Coaching: Tactics & Tips Count out rate at 100 beats/minute The beat to the disco classic “Stayin’ Alive” Let caller take over counting Allows you to monitor and speed rate if needed Remind rescuer to press “hard and fast” Shhhhh! Don’t talk too much! Let rescuers focus on what they’re doing! Tell them to switch if tired & multiple rescuers Stay with caller until EMS takes over

Review OHCA frequency and survival rate T-CPR is associated with improved survival The Three Phases of T-CPR 2 question identification Overcoming barriers Continuous coaching