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Review of: Dias JA, Brown TB, Saini RC, et al: "Simplified dispatch-assisted CPR instructions outperform standard protocol." Resuscitation. 72(1):108-114, 2007.
The Science
The 2005 AHA guidelines have impressed all of us with the importance of effective chest compressions. In the past, 9-1-1 emergency medical dispatchers (EMDs) were instructed to provide callers with instructions in providing CPR. Several studies have demonstrated how cumbersome and difficult it is to get the caller to perform both chest compression and mouth-to-mouth ventilations. Recent 9-1-1 protocols have advocated chest compression only instructions. This study examined the Medical Priority Dispatch System instructions with what the authors referred to as "simplified" instructions.
The primary difference between the two instruction sets is the degree of detail given to the caller, regarding where to place their hands and how deep to compress the chest. The simplified instructions state, "Pump the chest rapidly, in the center of the chest between the nipple, at a rate of about 100 per minute, as hard as you can. Keep doing this until the paramedics arrive. I ll stay on the line." These instructions took less than half the time to recite the MPDS instructions.
The researchers provided these instructions to volunteer callers who then performed chest compressions on a manikin, and the times and quality of compressions were measured. They found that the time to initiate CPR was significantly shorter with the simplified instructions. The simplified instructions also resulted in a greater proportion of chest compression depth.
The Street
I commend the authors for attempting to measure the effectiveness of pre-arrival advanced life support instructions. It is vital that we attempt to determine the best way to get 9-1-1 callers to provide quality CPR with minimal interruption and with instructions that are understandable and easy to follow.
The clear goal of pre-arrival ALS instructions is to get chest compressions started quickly and not stop until EMS arrives. While this study demonstrated that simplified instructions resulted in significantly improved chest compressions, there are some serious limitations to it.
The simulated callers were young, with an average age of about 25. The average cardiac arrest caller is significantly older. Following 9-1-1 CPR instructions without someone at the scene to help is physically difficult. The elderly caller is unlikely to be able to hold the phone to their ear and compress the chest, and therefore the instructions may need to be more detailed before chest compressions are begun.
While I agree that simplified instructions result in shorter time to chest compression, the next logical step is to perform this study using elderly callers. Another suggestion is to ask the caller if their phone has a speaker phone capability, which would allow the dispatcher to continue coaching the caller without interruption.
