TITLE: Pediatric CPR resuscitation maneuver from a bystander thanks to pre-arrival guidance by a dispatcher: a case report
Authors: Daniele Celin, critical area nurse CO118 Emilia Est.
Elisa Nava, Juliette Masina: critical area nurse, IPA 118 Regional group for CO118 Emilia Est
CASE REPORT: December 2020, Bologna.
Event: complete airway obstruction from food.
Patient: Male, two years old, unconscious, gasping.
The working group that deals with the drafting and revising of the Pre-arrival Instructions in the 118 Emilia Est Operations Center has decided to publish this article that deals with an event that occurred in December 2020 as it fully expresses the entire activity of the headquarters nurse.
Professional skill comes from the ability to be able to combine mainly three aspects:
- Nursing skills in the emergency-urgency setting
- Relational skills in high-stress situations
- Expertise in the use of advanced technological systems provided by CO118 Emilia-Romagna region
All nurses at the operations center also have experience working on emergency vehicles (ambulance, medical car, and helicopter). When a nurse performs the function of central operator, they have to perform a care setting in a “blind” way, and in the same way, in the case of administration of pre-arrival instructions, there is the limitation of the lack of visual feedback.
In order to properly size the event, it is therefore essential to ask precise questions to the caller and, based on the information received, provide pre-arrival instructions, simple and coded to reduce the free time from therapy and implement any life-saving maneuvers.
Pre-arrival instructions contained in Operational Instruction 55-2021- CO118AOEE, which refer to international guidelines, are updated with each new publication and constructed so that non-healthcare personnel (bystanders) can understand them.
The working group started by asking how the user-perceived the information given by telephone and conducted an experimental study on non-medical personnel by simulating calls to the 118 centers in which pre-arrival instructions were provided.
The dispatcher provided Pre-Arrival Instructions (PAIs) without coded support based on their own experience. However, the data collected showed that the instructions were not correctly understood and applied.
Subsequently, a document containing instructions duly explicitly simplified for use by non-healthcare personnel was introduced for use by all operators, both in paper and digital format, after which the experience was repeated with other non-medical personnel.
The new data produced were processed, and it was found that:
- Having an unambiguous tool in which the operations to be performed by the user are described makes it possible to avoid personalism and to maintain the correct sequence.
- The subjects have shown to perform more correctly the indicated maneuvers
In a second step, high fidelity simulations were carried out through workshops aimed at newly hired staff at the Operations Center to reinforce the importance of the correct communication strategy in giving pre-arrival instructions.
Every year, in Italy, about 450 children have an obstruction of the airways (in 65% of cases, the cause is food), and about 30 of these die in the absence of timely disobstruction maneuvers.
The 118-control center represents a fundamental link in the rescue chain: the nurse locates the place where it is necessary to send rescue, through a health interview, they stratify the event and assign a color code that defines its presumed criticality, sends the appropriate means of rescue for the type of request and if necessary give Pre-arrival Instructions.
The minutes that separate the call for help from the arrival of health personnel at the scene of the event can be decisive for the patient’s survival, and it is precisely in these cases that the nurse operator can make the difference.
The operators of the 118 Operations Centers of the Emilia-Romagna region can benefit from technological support:
- Management software
- Numerical alpha database containing data for the entire region
- Health interview with an algorithm of proposed criticality concerning selected items
- Recognition of at-risk patients (Sla – hospitalized at home, etc.)
- Districts database for proposing means of rescue closest to the event
- Geolocation tools and support of care response by the operations center nurse
The latest tool introduced in May 2020 is the Flagmii platform that allows dynamic geolocation of the caller, video call, and chat function.
By sending an internet link through an SMS, the operator will receive the geolocation (if the user has GPS active) and can ask to activate the video call.
The introduction of the video call, through an exceptionally easy-to-use platform, has made it possible to “enter the event” while being at a distance, applying essential corrections to the actions of lay personnel and thus improving the quality of the maneuvers performed.
On 23 December 2020, at 6:44 pm, the parents of P, a two-year-old boy, called 118 because the little boy had lost consciousness following the ingestion of a small piece of mozzarella cheese.
The dispatcher quickly identified the target of the call and conducted the health interview.
From the mother’s information, the child appeared unconscious, with cyanotic lips and no respiratory activity.
The nurse recorded the event on the operating system as K3 Advanced Red Blue, i.e., a respiratory pathology in the home was identified, and the code of maximum severity was assigned, which requires the simultaneous dispatch of an ambulance and self-medication, so the nurse in charge at 18:47 sent a BLSD vehicle and the ALS vehicle of territorial competence.
The operator who recorded the distress call continued the call with the little one’s parents, providing them with pre-arrival instructions for pediatric disobstruction: given the condition, he had the father begin CPR.
The nurse asked the mother if she had a smartphone, and upon her affirmative response, she sent a text message that enabled the activation of the video call through the Flagmii platform: in less than three minutes from the beginning of the call, she was “on the scene” thanks to the video camera activated by the mother.
Immediately, the nurse confirmed the severity of the situation by validating the information previously received from the mother: the child with a GCS of 3, cyanotic, and no respiratory activity.
The father was performing chest compressions, but the nurse could see that the position of the hands was wrong and therefore corrected him by urging him to perform them according to the guidelines.
About twelve minutes after the call, the airway was unobstructed, and the child began to show signs of resumption of breathing and circulation: he made stentorian sounds and finalized his eye movements to the parent’s call.
From that moment, only a few seconds passed for the arrival of the BLSD vehicle that, once arrived at the house, was able to perform a first assessment of vital parameters (FR 50, SpO2 90%, HR 150) and administered oxygen with ventimask until the arrival of the ALS vehicle, which occurred about 10 minutes later.
Upon arrival, the doctor re-evaluated the child, noting a further improvement in the neurological picture (GCS 4+4+6), an SpO2 of 100% in oxygen, an FR of 40, and an HR of 120.
The child was then loaded on the ambulance and transported to the emergency room of the Maggiore Hospital of Bologna with a code of medium severity.
He was then transferred to the Pediatric Intensive Care Unit of Sant’Orsola Hospital, where he underwent bronchoscopy and was kept under observation for a few days.
The child was discharged home, with no outcomes, on 28 December 2020.
The nurse at the operations center has always given pre-arrival instructions, even though he has the objective limits of the laity of the users and of having to work at a distance since he cannot touch the patient.
Technological progress allows today to reduce this gap, providing tools such as the one mentioned in the case report.
The video call is undoubtedly a precious tool to allow the administration of pre-arrival instructions in the correct way.
The combination of video call and coded Pre-arrival Instructions, updated according to the latest guidelines and simplified in order to be administered to non-healthcare bystanders, represents today the best possible combination to obtain an increase in survival in case of time-dependent pathologies (cardiac arrest, airway obstruction), a good health education (in case of convulsions or epistaxis, for example) or help in potentially evolving situations (such as the recognition of a precipitous birth).
- Gavin D. Perkins, Antony J. Handley, Rudoldh W. Koster et al. European Resuscitation Council Guidelines for resuscitation 2015 Section 2. Adult basic life support and automated external defibrillation. Resuscitation 95 (2015) 81-99.
- Ian K. Maconochie, Robert Bingham, Christoph Eich et al. European Resuscitation Council Guidelines for Resuscitation 2015 Section 6. Paediatric life support. Resuscitation 95 (2015) 223-248.
- Jonathan Wyllie, Jos Bruinenberg, Charles Christoph roehr et al. European Resuscitation Council guidelines for Resuscitation2015. Section 7. Resuscitation and support of transition of babies at birth. Resuscitation 95 (2015) 249-263.
- Management of Burns and Scalds in Primary Care, June 2007, revision date 2010, www.evidencebasednursing.it .
- A. Apostoli, E. Lo Palo, “Le ustioni chimiche” 11 January 2014
- Raccomandazioni cliniche sulla gestione delle epistassi, ACTA, Official Journal of the Italian Society of Otorhinolaryngology, Volume IV- number 1- May 2010.
- Engineering Ingegneria informatica s.p.a., “Manuale utente 118 EMS”, April 2020. www.eng.it