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Background & Aim • Anecdotal occurrence • Latest CPR guidelines: “Harder & Faster”

– ↑ CPP 1 → ↑ brain oxygenation.2

• No ILCOR guidelines on the management – Some local emerging guidelines

• Among patients with CA, we aimed to identify cases of CPR-induced consciousness, perceivable by the rescuer, in the literature and management strategies.

1Nolan et al. ERC Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation. 2010;81:1219-76. 2 Imberti et al. CPP and cerebral tissue oxygen tension in a patient during cardiopulmonary resuscitation. Intensive Care Med. 2003;29:1016-9.

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Methods Search strategy and information sources: PRISMA. Medline, PubMed, EMBASE, Cinahl and The Cochrane Library Grey literature: Google and Google scholar Commencement to the 8th of July 2014. Eligibility criteria: Patients: Patients of any age receiving CPR within any arrest setting Exposure: CPR-induced consciousness detectable by the rescuer Comparison: Unconscious in the same study Outcome: Any reported outcome Study types: All study types Exclusion: Only reported on consciousness before or after CPR. Bispectral index (BIS) monitoring as the only measure of awareness Cough-CPR Subjective near-death experiences. Study selection: Duplicates removed. Two author appraisal. Reference lists of relevant articles were searched.

Consciousness/ or

Awareness/ or Perception/ or Pain

perception/ or Movement/ or

Wakefulness/ or “combative” or

“alert” or “awake”)

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Results 2274 records identified through database searching: Medline (136), PubMed (522), Embase

(1273), Cinahl (212), Cochrane (131)

9 studies included in this review (10 patients)

1997 non-duplicated titles screened

41 records excluded Not awareness during, but after (n=11) Ambiguous title → not awareness (n=4)

Not patient awareness, but others (e.g. family) (n=3) Ventilated, not CPR (n=1)

Irrelevant opinion piece (n=3) Animal models (n=3)

Cough-CPR (n=6) Near-death experience (n=6)

BIS monitoring (n=4)

1947 records excluded

50 abstracts appraised

2 records identified through

grey literature search

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Results 2

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Results 3

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Discussion • Infrequent & varied management • Cause?

– Early CPR: Majority was in-hospital or early out-of-hospital. – Pressure: Two cases (Bihari 2008, Tobin 2009) observed

MAP > 50mmHg. – Brain oxygenation: individual factors

• eg Autoregulation,3 ischaemic threshold,4 and co-morbidities.5

– Mechanical devices • ↑ CPP 6 and

• ↓ interruptions.7 – Δ CPP → Δ brain oxygenation approx 2min later 8

3. Moppett et al. Anesth Analg. 2007 4. Bandera et al. Stroke. 2006 5. Jespersen et al. J Cereb Blood Flow Metab. 2012 6. Metzger et al. Crit Care Med. 2012 7. Ong et al. Scand J Trauma Resusc Emerg Med. 2012. 8. Imberti et al. Intensive Care Med. 2003.

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Discussion • Implications

– Extend CPR efforts? – Varied:

• Stopping at patient’s wish • Yu et al. 2hrs of asystole (total of 280min resuscitation time) → full recovery.

• Survival? – CPR-induced consciousness: Unclear – BIS: No 9, 10 – Non-invasive infrared cerebral oximetry: Yes 11, 12

• Guidelines forward – Clear definition of CPR-induced consciousness signs – Sedation: Balance efficacy, humane and adverse effects – Some guidelines exist

9. Chollet-Xemard et al. Bispectral index monitoring is useless during cardiac arrest patients' resuscitation. Resuscitation. 2009 10. Garcia et al. Bispectral index recorded during prehospital cardiopulmonary resuscitation as a predictor of survival. Emergencias. 2012 11. Singer et al. Cerebral oximetry levels during CPR are associated with return of spontaneous circulation following cardiac arrest: an observational study. Emerg Med J. 2014. doi: 10.1136/emermed-2013-203467. [Epub ahead of print] 12. Ahn et al. A pilot study examining the role of regional cerebral oxygen saturation monitoring as a marker of return of spontaneous circulation in shockable (VF/VT) and non-shockable (PEA/Asystole) causes of cardiac arrest. Resuscitation. 2013

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“The patient indicated that he did not wish to continue and agreed to cease resuscitative efforts. After approximately 2 h, chest compressions were stopped and the patient died.”

Good neurological outcome?

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“Agitation and/or pain during (mechanical) chest compressions can be treated with 2 µg/kg of Fentanyl IV (which can be titrated to 4 µg/kg), and 2.5mg of Midazolam IV (which can be titrated to 5mg).”

St John NZ

AV

Dutch

“Very rarely, the movement is significant enough to interfere with resuscitation. Rocuronium may be administered in this setting, provided ETT position has been confirmed”

“If during CPR Pt gag reflex prevents ETT, a small dose of Midazolam (1-2 mg IV) may be administrated to facilitate intubation”

Survey

• Prelim results are here

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CPR-non-interfering

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CPR-interfering

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Conclusion

• CPR-induced consciousness may occur, but is infrequently reported

• The incidence, implications and prognostic value of CPR-induced consciousness remains unknown

• Treatment strategies varies and lack evidence/guidelines

• Required: Increased awareness by rescuers & development of consensus-based guidelines

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Questions?

Thanks! Acknowledgement:

Alfred E&TC and Trauma Services for ongoing support and funding to

attend.

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