2.1 Protocol 9: Cardiac or Respiratory Arrest / Death

Protocol 9: Cardiac or Respiratory Arrest / Death

Quick Answer: Protocol 9 governs dispatch management for pulseless, non-breathing patients. Emergency Medical Dispatchers (EMDs) must treat any unconscious patient who is not breathing or breathing abnormally (including agonal gasping) as an immediate sudden cardiac arrest. This triggers a maximum ECHO or DELTA response and immediate Fast-Track Telephone CPR (T-CPR). Resuscitation may only be withheld under the strict, non-discretionary MPDS OBVIOUS DEATH criteria (cold and stiff in a warm environment, decapitation, decomposition, incineration, non-recent death, injuries obviously incompatible with life, or submersion longer than 6 hours) or an in-hand, undisputed Do Not Resuscitate (DNR) / POLST order. When in doubt, start CPR.

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Introduction: The EMD as the First Link in the Chain of Survival

Out-of-hospital cardiac arrest (OHCA) claims hundreds of thousands of lives annually. In the modern Chain of Survival, the Emergency Medical Dispatcher is the true first, first responder. Brain death begins within four to six minutes of circulatory cessation, and the probability of neurologically intact survival decreases by approximately 7% to 10% for every minute that passes without effective cardiopulmonary resuscitation (CPR). Because the median EMS response time in urban and suburban systems ranges between six and ten minutes, a victim who receives no bystander CPR before professional arrival faces a survival rate below 5%.

Protocol 9 of the Medical Priority Dispatch System (MPDS) is engineered to eliminate systemic delay. It operates on a non-discretionary, rules-based triage architecture that immediately bifurcates calls into three mutually exclusive categories:

1. Sudden Unexpected Cardiac Arrest — Immediate maximum response and instant coaching of Dispatch Life Support (Telephone CPR).
2. Obvious Death — Irreversible physical cessation of life incompatible with survival, where resuscitation is withheld to preserve dignity and conserve emergency resources.
3. Expected Death (Terminal / Hospice Care) — Foreseen death resulting from terminal illness under documented palliative directives (DNR/POLST).

+-------------------------------------------------------------------------+
|                        CHAIN OF SURVIVAL METRIC                         |
|                                                                         |
|   No CPR Administered:      ~7-10% drop in survival per minute          |
|   Immediate Dispatcher CPR: Doubles or triples chances of survival      |
|   Agonal Breath Window:     40-60% of OHCA victims gasp initially       |
+-------------------------------------------------------------------------+

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Core Identification Criteria: Unconscious and Not Breathing Normally

In the Case Entry phase of every emergency call, the EMD must obtain the patient's exact location, callback telephone number, chief complaint, age, status of consciousness, and status of breathing. The cardinal rule of dispatch medicine states:

$\text{Unconscious} + \text{Not Breathing Normally} = \text{Cardiac Arrest}$

If the caller states that an adult patient is unconscious and not breathing, or that their breathing is questionable, ineffective, or agonal, the EMD must not proceed to interrogate secondary Key Questions. Instead, the dispatcher must immediately declare a cardiac arrest situation, send the emergency response, and initiate Telephone CPR.

The Agonal Breathing Phenomenon

The single greatest obstacle to bystander resuscitation is the failure of lay callers to recognize agonal respirations. Following sudden ventricular fibrillation, the dying brainstem continues to discharge primitive, reflexive neural impulses to the respiratory muscles for several minutes. This produces intermittent, bizarre respiratory efforts characterized as:

• Gasping, snorting, or snoring
• Groaning, sighing, or grunting
• Occasional irregular twitches or "fish-out-of-water" mouth movements
• Chest wall heave without genuine air exchange

Lay callers routinely misinterpret these dying gasps as evidence of life, telling the 9-1-1 dispatcher: "He's breathing, but he's making funny snoring noises," or "She just took a big deep breath every ten seconds."

                    AGONAL BREATHING DISPATCH RULE:
      "Gasping, snorting, or occasional groans are NOT breathing.
           Treat all irregular gasps as CARDIAC ARREST!"

Research demonstrates that agonal respirations are present in 40% to 60% of adult patients during the first two to four minutes of cardiac arrest. Ironically, victims exhibiting agonal respirations have the highest potential for neurologically intact resuscitation because their arrest is recent and their coronary perfusion pressure has not fully degraded. If the EMD accepts the caller's assertion that the patient is "breathing," the call is misclassified under Protocol 6 (Breathing Problems) or Protocol 31 (Unconscious/Fainting), delaying CPR by critical minutes and drastically increasing mortality.

The IAED Agonal Breathing Detector (ABD)

To standardize agonal breath recognition, the MPDS incorporates the Agonal Breathing Detector (ABD) tool within computer-aided dispatch (ProQA) software. When a caller is uncertain whether an unresponsive person is breathing normally, the EMD instructs:

"Say 'now' every time their chest rises or they take a breath."

The software measures the elapsed time between caller keystrokes. If the calculated respiratory rate is below 8 breaths per minute, or if the inter-breath interval exceeds 8 to 10 seconds, the ABD automatically triggers a cardiac arrest alert, forcing an immediate transition to T-CPR instructions.

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Triaging Protocol 9: Unexpected Arrest vs. Obvious Death vs. Expected Death

The EMD must systematically differentiate between sudden reversible arrest and cases where resuscitation is medically futile or legally prohibited.

                                  CASE ENTRY
                                      |
                     Is patient unconscious & not breathing?
                                      |
         +----------------------------+---------------------------+
         |                                                        |
       YES                                                        NO
         |                                                        |
   Any signs of                                             Protocol 6, 10,
   Obvious Death?                                           19, or other CC
         |
    +----+----+--------------------------------+
    |         |                                |
   YES        NO                              DNR?
    |         |                                |
  Obvious   SUDDEN CARDIAC ARREST         Valid & In-Hand?
  Death     (ECHO 9-E-1 / 9-E-2)          +----+----+
  (9-B-1)     |                           |         |
  Withhold  Fast-Track to Telephone CPR  YES        NO
  CPR       (100-120 bpm Compressions)    |         |
                                       Expected  Start CPR
                                        Death    Immediately
                                       (9-O-1)   (9-E-1)

1. Unexpected Cardiac Arrest (ECHO & DELTA Pathways)

• ECHO Level (9-E-1 Not breathing at all; 9-E-2 Uncertain breathing; 9-E-3 Hanging; 9-E-4 Strangulation; 9-E-5 Suffocation): Activated during Case Entry the instant the dispatcher identifies cardiac arrest (e.g., patient is non-breathing, breathing status uncertain, or hanging). ECHO responses initiate an instantaneous, parallel turnout of all available emergency resources (ALS, BLS, and first responders with AEDs) prior to completing interrogation. The EMD immediately initiates Fast-Track T-CPR.
• DELTA Level (9-D-1 Ineffective breathing; 9-D-2 OBVIOUS or EXPECTED DEATH — questionable): Used when breathing is reported as ineffective, or when the caller describes a death situation but cannot confirm one of the unquestionable OBVIOUS/EXPECTED DEATH conditions. Note that Protocol 9 has no ALPHA or CHARLIE level — its only non-ECHO/DELTA codes are 9-B-1 and 9-Ω-1.

2. Obvious Death Criteria (Strict Non-Discretionary Signs)

Withholding CPR is a profound clinical decision. The EMD is legally and ethically barred from exercising subjective clinical judgment. Resuscitation may only be withheld if the caller explicitly describes at least one of the non-discretionary OBVIOUS DEATH conditions. In the MPDS these are carried as Protocol 9 suffix letters appended to the determinant code:

Note that cold skin alone, stiffness alone, fixed pupils, cyanosis, or dependent lividity (blood pooling) are NOT MPDS OBVIOUS DEATH criteria. Only the conditions above allow resuscitation to be withheld.

[!CRITICAL] The Cardinal Dispatch Rule of Obvious Death: If there is any doubt, any ambiguity in the caller's description, or if the caller cannot verify one of the listed conditions, the EMD must assume viable cardiac arrest and instruct immediate CPR. When the situation is described but the caller is uncertain, the MPDS assigns 9-D-2 (OBVIOUS or EXPECTED DEATH — questionable), a DELTA code that still sends a response. Cold skin alone, cyanosis, fixed pupils, or dependent lividity do not constitute OBVIOUS DEATH.

3. Expected Death / Terminal Illness & DNR Orders

Patients enrolled in home hospice or palliative care often pass away as expected from end-stage terminal disease. When an emergency call is placed for an expected death, the EMD must verify whether an authorized Do Not Resuscitate (DNR), Physician Orders for Life-Sustaining Treatment (POLST), or Medical Orders for Life-Sustaining Treatment (MOLST) directive exists.

Under IAED standards, resuscitation may only be withheld under Protocol 9 EXPECTED DEATH — unquestionable (9-Ω-1) if all of the following conditions are met. Protocol 9 carries two suffixes for this pathway: x (terminal illness) and y (DNR).

• The caller states that the patient is in terminal palliative/hospice care.
• A signed, valid DNR or POLST document is physically present in the room and confirmed by the caller.
• There is no dispute among family members or caregivers at scene regarding withholding care.

If the document cannot be located, if its validity is contested, if the patient or legal surrogate recently revoked it, or if family members demand intervention, the EMD must immediately start CPR. Paramedics can review physical documents on arrival and terminate resuscitation under medical control.

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Caller Confirmation Requirements and Positioning for CPR

To conduct effective Telephone CPR, the EMD must establish physical control of the scene:

1. Caller Proximity Verification

The EMD must confirm: "Are you right by the patient now?" If the caller is on a second floor or across the street, coaching is impossible. The EMD must order the caller to the patient's immediate side with the phone or dispatch someone nearby.

2. Positioning Mechanics: Firm, Flat Surface

Chest compressions delivered on a soft mattress or couch dissipate mechanical force into the bedding, yielding inadequate coronary and cerebral perfusion pressures. The EMD must instruct:

"Listen carefully: We need to get them flat on their back on the floor. I will help you."

If the caller states they cannot lift or move the patient, the EMD must provide specific leverage techniques (e.g., pulling on clothing, sliding the patient off the bed onto a blanket on the floor) using repetitive persistence.

3. Managing Bystander Reluctance and the Hysterical Threshold

Callers encountering sudden death frequently exceed their hysterical threshold. When a caller screams, hyperventilates, or declares "I can't do CPR, I'm going to hurt them!", the EMD must employ Repetitive Persistence—repeating the exact phrase with identical wording and calm, firm inflection:

"Listen to me. It's okay, I am right here with you. We need to help them right now. Place your hand on the center of the chest."

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Comparative Triage Matrix: Protocol 9 Presentations

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Dispatch Dialogue: Rapid Identification of Agonal Breathing

EMD:        "9-1-1, what is the address of the emergency?"
CALLER:     "1442 Elm Street! Please hurry, my husband just collapsed!"
EMD:        "What is the phone number you're calling from?"
CALLER:     "555-0192!"
EMD:        "Okay, tell me exactly what happened."
CALLER:     "We were watching TV, and he made a loud noise and fell to the floor! He won't answer me!"
EMD:        "Is he awake?"
CALLER:     "No, he's completely out!"
EMD:        "Is he breathing normally?"
CALLER:     "Uh... yeah, well, he's breathing, but he's making this horrible snorting, snoring sound... like a big loud gasp every twenty seconds!"
EMD:        [IDENTIFIES AGONAL BREATHING -> CARDIAC ARREST]
            "Help is on the way right now. Do not hang up. We need to start CPR immediately—his gasping means his heart has stopped."
CALLER:     "Wait, but he's gasping, he's breathing!"
EMD:        "Listen to me carefully: that gasping is not real breathing. It is a sign of cardiac arrest. We must start chest compressions now. Are you right beside him on the floor?"
CALLER:     "Yes, I'm right here!"
EMD:        "Place the heel of your hand on the center of his chest, right between the nipples. Put your other hand on top. Pump the chest hard and fast: 1, 2, 3, 4..."