1. 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

2. 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

3. 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

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

5. 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).

6. A Little Math
424,000/365 = /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.

7. 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

8. 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
Nagao Current Opinion in Critical Care 2009

9. 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 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.

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

12. The OR for Bystander CPR in this metaanalysis was 2.44.

13. T-CPR and OHCA Survival

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

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

16. 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

17. 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”

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

19. 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.

20. 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 % CI 2.2, 5.2)
Bobrow Circ 2008

21. 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

22. PHASE 2: Barriers and Tactics

23. 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

24. Justification

25. PHASE 3: Continuous Coaching

26. 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

27. Sample Script: CPR Instructions

28. Focus: Creating & Maintaining CPR Quality
“Continuous Coaching”

29. CPR Quality Matters!

30. 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.

31. 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

32. 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