CPR Induced Consciousness
Question# 790
My question is regarding sedation strategies for CPR induced consciousness (CPRIC)
CPRIC is quite rare, however there is currently no standing order from base hospital in regards to management. Patients who have experienced this event without adequate sedation report post traumatic symptoms and only 38% of responders who have seen this provided sedation(study: development of an international prehospital CPRIC guideline: a Delphi study) It would seem fentanyl/midazolam or ketamine are most used. Could these patients be considered under the "combative patient" directive? In the case they are intubated they can fall under "procedural sedation", but what if an IGEL or OPA/NPA are being used? Would this be considered as a standalone medical directive in the future given the laundry list of tasks to be done on these calls and to avoid overwhelming providers?
CPRIC is quite rare, however there is currently no standing order from base hospital in regards to management. Patients who have experienced this event without adequate sedation report post traumatic symptoms and only 38% of responders who have seen this provided sedation(study: development of an international prehospital CPRIC guideline: a Delphi study) It would seem fentanyl/midazolam or ketamine are most used. Could these patients be considered under the "combative patient" directive? In the case they are intubated they can fall under "procedural sedation", but what if an IGEL or OPA/NPA are being used? Would this be considered as a standalone medical directive in the future given the laundry list of tasks to be done on these calls and to avoid overwhelming providers?
Answer:
Unfortunately, it is impractical to draft medical directives that speak to each clinical scenario paramedics may face in the field, especially those circumstances that are rare.
Fortunately, paramedics are experts at navigating complex scenarios with minimal resources. When it comes to the prehospital management of CPR induced consciousness (CPRIC), there is scant research, but a scoping review of the few existing guidelines suggest that the main pharmacologic agents used are midazolam, ketamine, and fentanyl.
These are all medications within ACP scope, and there is already a standing order to use midazolam/fentanyl for procedural sedation in the intubated patient. The doses in the combative patient medical directive would be high for this indication, given their hemodynamics. Given that SGAs or airway adjuncts are not definitive airways, we shy away from procedurally sedating these patients.
At this stage, there are more impactful proposals to modifying/creating medical directives that can have a broader, more global, and more positive influence on patient care in the region, impacting more patients.
Keep in mind, most patients with this phenomenon have no recollection of the event: it is more distressing for family members and providers. That said, if there is a cohort of patients who are traumatized by these events and their awareness/recollection of them, it could be important to treat.
For these rare and complex patients, we highly recommend a patch to the BHP to further discuss the management of these patients.
Patients with CPRIC have a much more favourable prognosis with resuscitation, and it’s important to remember that CPRIC is not ROSC (though it may be confused as such). This confusion may in turn lead to inappropriate and frequent pulse checks, resulting in too many CPR interruptions. It's thus important that these events don't negatively impact the resuscitation (high quality CPR, defibrillation, and resuscitation meds that are indicated).
Fortunately, paramedics are experts at navigating complex scenarios with minimal resources. When it comes to the prehospital management of CPR induced consciousness (CPRIC), there is scant research, but a scoping review of the few existing guidelines suggest that the main pharmacologic agents used are midazolam, ketamine, and fentanyl.
These are all medications within ACP scope, and there is already a standing order to use midazolam/fentanyl for procedural sedation in the intubated patient. The doses in the combative patient medical directive would be high for this indication, given their hemodynamics. Given that SGAs or airway adjuncts are not definitive airways, we shy away from procedurally sedating these patients.
At this stage, there are more impactful proposals to modifying/creating medical directives that can have a broader, more global, and more positive influence on patient care in the region, impacting more patients.
Keep in mind, most patients with this phenomenon have no recollection of the event: it is more distressing for family members and providers. That said, if there is a cohort of patients who are traumatized by these events and their awareness/recollection of them, it could be important to treat.
For these rare and complex patients, we highly recommend a patch to the BHP to further discuss the management of these patients.
Patients with CPRIC have a much more favourable prognosis with resuscitation, and it’s important to remember that CPRIC is not ROSC (though it may be confused as such). This confusion may in turn lead to inappropriate and frequent pulse checks, resulting in too many CPR interruptions. It's thus important that these events don't negatively impact the resuscitation (high quality CPR, defibrillation, and resuscitation meds that are indicated).
References
Howard J, Lipscombe C, Beovich B, Shepherd M, Grusd E, Nudell NG, Rice D, Olaussen A. Pre-hospital guidelines for CPR-Induced Consciousness (CPRIC): A scoping review. Resusc Plus. 2022 Nov 28;12:100335. doi: 10.1016/j.resplu.2022.100335. PMID: 36465817; PMCID: PMC9713363.