http://www.medscape.com/viewarticle/470874



911 Dispatchers to Revise CPR Instructions

Sid Kirchheimer

March 2, 2004 — Well-meaning bystanders attempting to save the life of an adult heart attack victim with cardiopulmonary resuscitation (CPR) are getting new instructions from 911 dispatchers until help arrives: Do chest compressions, and do not administer mouth-to-mouth resuscitation.

Already a trend among a growing number of 911 departments who were advising 911 callers to do chest compressions without mouth-to-mouth breathing, this new policy becomes official later this month for the National Academics of Emergency Dispatch (NAED), which provides medical instructions and is the accreditation and certifying organization for 911 operators in nearly 3,000 communities worldwide.

This means that in most cases, bystanders who try to perform CPR will be instructed by 911 dispatchers to continuously pump the patient's chest up to 400 times before they provide any mouth-to-mouth resuscitation. Under long-practiced guidelines, CPR formerly entailed clearing the airway and giving two "rescue" breaths before chest compressions began. Mouth-to-mouth ventilation was then resumed after every 15 or so compressions.

But there's mounting evidence that trying to convey telephone instructions to lay volunteers on how to perform mouth-to-mouth resuscitation during emergencies wastes valuable time and fuels their reluctance to help those suffering from sudden cardiac arrest. And some research indicates that rescue breathing does not increase a patient's chances of survival compared with doing chest compressions alone.

"Under the new procedures, rescue efforts by volunteers could be compression-only, but in instances where there's a long response time, some ventilation needs to take place," NAED spokeswoman Carlynn Page told Medscape. "But whether or not they are trained in CPR, the instructions that operators will initially give these volunteers will be compression-first."

Ms. Page said the new policy, which takes effect March 15, stems from updated recommendations by the American Heart Association and other experts on the best way for citizens to help those stricken with a heart attack until emergency personnel arrive at the scene. Within two weeks, these new instructions will be given to 911 dispatchers in at least 38 cities that serve some 10 million Americans.

"It's not that the American Heart Association or other experts are recommending that people not do mouth-to-mouth ventilation if they are properly trained, but in a limited setting where a bystander has not been trained in how to do CPR or is unsure of the procedure, it's better that they do chest compressions alone than do nothing," said John Billi, MD, chairman of the American Heart Association's emergency cardiovascular care committee.

"Chest compressions alone are much easier to teach over the telephone than the whole sequence of breathing and chest compressions," Dr. Billi told Medscape. "And we know that many people are reluctant to give mouth-to-mouth resuscitation, even though most of the time, a bystander is giving CPR to a loved one — a spouse, parent, or an elderly person living in their home. What's really important is that bystanders react quickly by immediately calling 911 and doing CPR to the best of their abilities, and giving them instructions on chest compressions is more simple than trying to teach them on how to properly do mouth-to-mouth ventilation."

As a general rule, CPR must be performed within four minutes of the heart's stoppage in order to save that person's life, Dr. Billi said.

Mouth-to-mouth breathing helps provide oxygen to blood, but chest compressions may be more important for ensuring survival of adult heart attack victims because it helps move blood throughout the body, primarily to the brain, said Dr. Billi, professor of internal medicine and medical education at the University of Michigan Medical School in Ann Arbor.

"The problem is, when bystanders stop compressions to perform mouth-to-mouth ventilation, too much time may be spent checking the airway and properly positioning the mouth," Dr. Billi said. "The victim may not be getting enough compressions to better ensure survival." A study in the May 25, 2000, issue of the New England Journal of Medicine found no difference in survival rates between cardiac arrest victims on whom bystanders performed dispatcher-assisted, compressions-only CPR and those treated with dispatcher-assisted CPR using a combination of chest compressions and rescue breathing. "That study is one among an evolving group of studies showing that in some circumstances, compressions-alone was as good as also using mouth-to-mouth ventilation," said Dr. Billi.

The new NAED policy doesn't change how emergency personnel will treat heart attack patients, or how first-aid and CPR training is taught to volunteers. Both the American Heart Association and the American Red Cross will continue to teach mouth-to-mouth rescue breathing to those taking certified CPR courses.

And this new compression-first policy applies only to adult patients, not to children whose hearts have stopped beating.

"With children, we always recommend mouth-to-mouth ventilation because their heart usually stops beating because of a breathing problem, and not because of a heart attack," said Dr. Billi. "The real recommendation here is that everyone should take a CPR class. It's easy to learn, easy to perform, and easy to be trained in."

Reviewed by Gary D. Vogin, MD

Sid Kirchheimer is a freelance writer for WebMD.