Sedation for Conscious Cardiac Arrest Patients

NPO

NPO

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Who has protocols for sedation of patients who gain conscious during CPR?

This is only something I've read about briefly, but last night it happened.

We had a patient in torsades, and became semiconscious during CPR, enough to grunt when the Lucas did compressions.

I called for an order, and requested and gave Versed. We do carry Ketamine, but I didn't think about it because it's honestly a new medication for me and I'm not super familiar with it. Retrospectively, it seems like it might be a safer choice, but the patient did surprisingly well with the versed.
 
I have only seen consciousness during chest compressions once 21 years ago on a cardiac tamponade patient. Every since then all of my cardiac arrests have been pretty much dead.
 
MSDeltaFlt said:
I have only seen consciousness during chest compressions once 21 years ago on a cardiac tamponade patient. Every since then all of my cardiac arrests have been pretty much dead.
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My understanding is this is a growing phenomenon due to high quality mechanical CPR devices.
 
I'd give somebody's left kidney for a mechanical CPR device. Not mine. I'm attached to mine. But I'd give somebody else's.
 
You actually did good to not give ketamine to this patient. Ketamine increases cardiac workload and often demonstrates tachycardia and hypertension. Obviously this isn't what we want for someone in a periarrest situation because we have pressors that are a lot more appropriate for this situation, controllable and reliable. If you're trying to sedate someone in a periarrest scenario or conscious during an arrest the best choice would probably be versed. With that being said, it's not necessarily terrible for someone to be semi-conscious in an arrest because that shows you're at least getting some blood flow to the brain. I don't know if I'd be super quick to sedate someone in the absence of a perfusing rhythm. If it ain't broke don't fix it. Compressions, get a stable perfusing rhythm, then start mucking about with comfort measures.
 
Since its such a rare phenomena that I'd doubt protocols exist. Besides, a grunt doesn't mean that they are conscious, it could be some sort of reflex. I'd say the risks of pushing sedatives during a code is too great and offers little to no benefit in a patient that 'could' be semi-councious.

However, it is a little different if the patient starts screaming "stop". If that is the case, I'd doubt the ED would care less if you used versed.

What was the outcome of the patient?
 
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LanceCorpsman said:
Since its such a rare phenomena that I'd doubt protocols exist. Besides, a grunt doesn't mean that they are conscious, it could be some sort of reflex. I'd say the risks of pushing sedatives during a code is too great and offers little to no benefit in a patient that 'could' be semi-councious.

However, it is a little different if the patient starts screaming "stop". If that is the case, I'd doubt the ED would care less if you used versed.

What was the outcome of the patient?
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I know of several agencies with protocols for it. I just don't know what the protocols (or literature) says about it.

The grunt was much more than a refex. Her eyes were opened spontaneously and she had purposeful movement.

The patient eventually went into refractory VFIB which was broken by dual sequential defibrilation. She was taken to Cath Lab where it was determined she had too many blockages to do anything there. She was put on a balloon pump and I transferred her to another facility for a CABG. For whatever reason the facility never started a sedation maintenance drip, so we redosed Versed every 5-10 minutes otherwise she'd start gagging on the tube and reaching for it.
 
My protocol:

Sedation for CPR induced consciousness (Confirm continued pulseless-ness):
• IV/IO Ketamine: 1-2 mg/kg for CPR induced consciousness. May repeat if needed in 5-10
minutes.
 
See I'm not a really huge fan of ketamine here if the cause of the arrest is AMI,
 
RocketMedic said:
Increases cardiac workload in a not-super-predictable fashion. I'd use versed instead.
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Time for some Google-fu... I don't remember an increase in cardiac workload. Learn something new every day!
 
Anything that increases SVR, like Ketamine has the potential to do, will decrease cardiac output especially with cardiac dysfunction. I prefer Versed as well. I really hate when people give IABP patients Ketamine...
 
Are we really worried about increasing cardiac workload in patients we just gave epi to? Giving ketamine on top of epi is like throwing a match into a bonfire. Epi aside, unless you are using a large dose of ketamine, the catecholamine discharge caused by it is moderate at best. The reason to avoid ketamine for this purpose is that it isn’t a reliable amnestic in smaller doses.

Midazolam, on the other hand, can absolutely crash a fragile, older patient whose heart is sick. At least if if they don’t have exogenous epi circulating.
 
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Consciousness during CPR is a real rarity, although certainly quite possible (I've seen it once). Sedating a critically unstable patient for any reason is just plain stupid. Ignore all the physiologic/pharmacologic reasoning. Common sense should tell you it's not appropriate. IF your patient survives, they'll be more than grateful, and will care less that they have some recall of events. The same happens in the OR and anesthesia. Some patients are just TOO unstable to get much, if any, anesthetic. Once they stabilize somewhat, THEN we can think about sedation and recall. Until that time, it's not a consideration, and could potentially be harmful.
 
The only agent i'd consider is ketamine. But, by and large I agree with jwk. If the patient is in cardiac arrest, there are much bigger fish to fry. They are unlikely getting enough perfusion to have any recall. Even in the case of survival, the anoxia that occured prior to CPR is likely enough to cause an encephalopathy that will hinder their perception and recall even if they have a neurointact survival. IF they have recall, oh well, there's much worse that could happen.
 
NPO said:
Who has protocols for sedation of patients who gain conscious during CPR?

This is only something I've read about briefly, but last night it happened.

We had a patient in torsades, and became semiconscious during CPR, enough to grunt when the Lucas did compressions.

I called for an order, and requested and gave Versed. We do carry Ketamine, but I didn't think about it because it's honestly a new medication for me and I'm not super familiar with it. Retrospectively, it seems like it might be a safer choice, but the patient did surprisingly well with the versed.
Click to expand...

We added Versed.
 

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With all due respect, I disagree. If the patient is conscious and saying "ow" that's plenty conscious. Too conscious.
 
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