Jeff Clawson, M.D.

Jeff Clawson, M.D.

Brett Patterson

Brett Patterson

Ask Doc
By Jeff Clawson, M.D., & Brett Patterson

We have been hearing through the grapevine that MPDS v13.0 will have some very important changes that should significantly improve the time to start PAI chest compressions in cases of sudden cardiac arrest. Versions 12.1 and 12.2 contained some specific revisions in this regard, but we are not aware of what the next changes might be, especially given the more recent emphasis on this part of modified CPR mechanics often called “compressions only”.

Eric Fayad, Lead Communications Trainer, IAEMD Instructor, SUNSTAR EMS, Pinellas County, FL

This is absolutely correct, and very important to the future of improving CPR applied by EMDs. I can provide some specific details into these changes. First, there is a basic misnomer that needs to be clarified. There is a very important distinction between what is sometimes incorrectly called “compressions only,” and the other process first pioneered by the Academy 10 years ago that we called “compressions first.” The commonly heard term in EMS is compressions only, which is more understandable clinically if we call it compressions “forever,” since pre-arrival breaths are never advised, regardless of the response time. For example, if a delay in responder arrival occurs due to unit unavailability, extended distance, or any other factor, whether in rural, suburban, or even urban locations, no breaths are ever provided, no matter how long the response.

From what the Academy can determine from the available scientific literature, or from recommendations provided by the American Heart Association (AHA) or other Resuscitation Councils, there is no specific evidence that in extended resuscitation attempts (even 10 minutes or longer), giving any breaths helps or hurts the outcome. It can be argued that by this time, the patient’s “oxygen tank” (whether blood, or more importantly, tissue oxygen levels) should be replenished. But another argument has some credible substantiation (although not at these extended time periods). This being that any gap in compressions results in lost cardiac vessel and/or brain blood pressure and may, in and of itself, be the final blow ensuring the patient’s non-resuscitatability. Additionally, there is a strong argument that artificial ventilations not precisely provided by advanced technologies (mouth-to-mouth) causes an increase in intrathoracic pressure that is detrimental to the resuscitation effort, and that these risks associated with artificial ventilations may actually outweigh any benefit, regardless of the response time.

In our ongoing efforts to reduce the time it takes to get hands-on-chest and minimize compression interruptions, we made several changes in v12.2, in anticipation of the 2010 AHA guidelines, and several more changes are now being beta tested in v13.0, in anticipation of the 2015 guidelines. As you may know, v12.2 contains a new “DLS Link” section in the Case Entry Protocol so that Protocol 9 can be completely bypassed in the cardset when ineffective breathing is discovered at Case Entry (this is done automatically in the software). Additionally, several other enhancements were made to reduce the time necessary to start CPR, including a direct link to compressions instructions for INEFFECTIVE BREATHING patients (airway maneuver and mouth check removed), and new instructions for multiple rescuers were added so that compressions can be started while instructions are continued with the second rescuer. Also, the patient age group 8 to18 years was moved from the Ventilations 1stPathway (30 compressions to 2 breaths) to the Compressions 1st Pathway (600 initial compressions) due to the disturbing prevalence of sudden cardiac arrest among young athletes.

In addition to changes aimed at reducing the time to compressions, the use of the AGONAL BREATHING Detector was mandated in three places where research revealed that some patients were reported to be breathing effectively but actually were not. One of these situations is on the Chief Complaint of Unconsciousness (Protocol 31), where the patient is reported to be breathing at Case Entry. This was implemented as a safety net to ensure that these high-risk patients (about 1.5 percent of the total volume), were “double checked” before a dispatch code was assigned.

Version13.0 of the MPDS is currently being tested and is slated for release in the next few months. This version features comprehensive changes, most notably to the recognition of agonal respirations and the use of the AGONAL BREATHING Detector. The changes include:

  • A new DLS definition for UNCERTAIN BREATHING:
  • “A situation where a 2nd party caller is uncertain, unsure, indefinite, or ambiguous when asked if an unconscious patient is breathing.”
  • A new Axiom for UNCERTAIN BREATHING: “UNCERTAIN BREATHING status indicates a 2nd party caller who has seen the patient and is still unsure. This is considered NOT BREATHING until proven otherwise.”
  • A new Axiom regarding the recognition of AGONAL BREATHING:
  • “Prompt recognition of AGONAL BREATHING is critical to the treatment of cardiac arrest because it reduces time to compressions. PAIs should be instituted immediately after ECHO coding when an unconscious patient’s breathing status is INEFFECTIVE or UNCERTAIN (AGONAL BREATHING Detector use is not necessary).”
  • And a new Rule regarding AGONAL BREATHING Detector use:
  • “Use of the AGONAL BREATHING Detector is not necessary when UNCERTAIN BREATHING or INEFFECTIVE BREATHING is associated with unconsciousness.
  • The AGONAL BREATHING Detector Tool has also been modified to make interpretation of its results more clear and applicable to protocol navigation.
Specific to your question, v13.0 also contains a new option for a “Compressions Only” pathway that must be authorized by local medical control. This will provide agencies a choice between the current Compressions 1st pathway and the new Compressions Only pathway. We suspect that rural systems with longer response times may elect to continue with the Compressions 1st pathway that provides ventilations at approximately 10 minutes and beyond after arrest, while urban systems with shorter response times may elect to eliminate ventilations altogether and use the new Compressions Only pathway. As mentioned previously, the evidence is still inconclusive with regard to the benefit of ventilations late in the cardiac arrest scenario.

Perhaps the single most impactful change to v13.0 is the addition of a new “Fast Track” for patients who are initially and obviously described as being in cardiac arrest early in the Case Entry sequence. In many situations, callers report what appears to be someone who is obviously not breathing. The IAED has created a special fast track feature that requires simply typing in an “o” (for “obvious”) in the “Tell me exactly…” field that bypasses ALL remaining Case Entry questions and immediately recommends a 9-ECHO-1 response requiring a single click to activate. This is then followed by one question regarding availability of an AED (automatic external defibrillator), making sure he is flat on his back, followed by chest compressions.

This new fast track has been called the “CPR Blitzkrieg” by one of our Beta test comm centers and its very rapid process is clearly demonstrated in the v13.0 sequence specific audio case file on the Academy website: http://www.emergencydispatch.org/hands-on-chest-case-mpds-v13

The ProQA time to getting hands-on-chest is 20 seconds. It simply cannot get shorter than this, unless the EMD is clairvoyant.

In addition to these protocol changes, a concerted effort has been launched by the Academy to educate Emergency Medical Dispatchers (EMDs) with regard to prompt recognition of agonal breathing and the impact of prompt and uninterrupted chest compressions. We have incorporated elements of this education into the initial and continuing education curriculums, trained all of our instructors during their mandated updates, and are publishing related articles in our Journal. This effort will continue. Additionally, we are actively researching protocol outcomes between versions in accredited communication centers so that we can measure the impact of these changes and further our improvement efforts.

You can help in this effort by educating your EMDs with regard to the importance of identifying cardiac arrest early, most importantly through the recognition of agonal respirations, and getting hands-on-chest as soon as possible. It is important that EMDs not be hesitant to start CPR when the status of breathing is questionable at all; it is much better to start CPR and find out it is not needed than not to start CPR and find out it was needed. This is a cultural change that needs to take place in communication centers worldwide and the Academy relies on people like you who are patient care oriented and interested in the evolution of the MPDS to “spread the word.”

Thank you so much for your insightful inquiry and for providing us with the opportunity to respond in this forum.

Doc and Brett