Sedation after ROSC

[NomadicMedic]

Mechanical CPR devices often provide sufficient perfusion that a high quality CPR recipient will awaken enough to answer questions with blinks and track the team around the room.

"A patient making purposeful movements, even being awake and alert while in cardiac arrest, can have profound emotional and psychological implications on the patient as well as the paramedic providers caring for them."

I believe not sedating these patients is cruel, akin to a paralytic with no concurrent sedation and analgesic.


Rice DT, et al. CPR induced consciousness: It’s time for sedation protocols for this growing population. Resuscitation (2016), http://dx.doi.org/10.1016/j.resuscitation.2016.02.013

 

[harold1981]

I have never seen it in nine years, and only once did I do an interfacility transfer in which the attending physician instructed us (on a writen statement) that a carotid blowout was imminent and that sedation was going to be the only course of action. Our protocols cover 17million people at a national level, so I can imagine that it happens quite a few times a year. We have three criteria: there must be a individual treatment plan in place, which is signed by the attending physician. People with terminal cancer in the lungs, head and neck, who have a high risk for CBS or lungbleeds tend to have these documents with them, which also include a DNR/NTBR-order and a statement that the prognosis is infaust. Second, based on our assessement we must establish that the patient is asfyxiated and will die as a result of this. Third, we must establish that the patient is suffering unbearably. If all three criteria are satisfied we can proceed and provide acute palliative care by sedating the patient while he dies.

Emergency care is provided by us (EMS). Primary health care is provided primarily by GP´s, 24/7. GP´s on duty have emergency vehicles too. In the unlikely event that that we arrive at an emergency situation requiring palliative sedation, and no individual treatment plan is in place, we may call in the help of a GP, while we push 5mg midazolam based on our agitation-protocol, and repeat with a 2,5mg dose every five minutes untill a GP arrives. In every case, the call will be evaluated by our medical director.

 

[RRTMedic]

How do you feel about sedating a patient who is waking up post-CPR with 2,5 to 5mg Versed?

The rational behind this would be to reduce anxiety, reduce oxygen consumption, reduce awareness and prevent memories from the resuscitation setting.
I know that there are a few contraindications, eg hypotension, shock, brain injury, drugs/alcohol intox and muscular weakness.
I have had different medics disagree with the suggestion of sedating the awakening patient after ROSC, stating that I don´t want to knock down their respiratory drive. However, if respiratory depression or apnea reoccurs, we are there to resume ventilations with a BVM immediately (besided the patient is often still intubated).
Also, if need arises, the effect of the midazolam can be antagonized in the ED. And...we are giving a small dose, I believe they use 25mg in the OR as an anesthetic induction.

Please share your thoughts on this matter. Also, how do you feel about Midazolam in combination with IV fentanyl post-ROSC for the purpose of reducing the pain and discomfort of an AMI and chest compessions?

Sedate the patient if they are combative with altered mental status or not sedating them would potentially result in an extubation. Had a situation like this....post cardiac arrest after 30 minutes of V-fib... patient started sitting up and swinging his arms and was obviously out of his mind... My partner gave him 5 mg of versed and that put him down nicely.... then he coded again 5 mins later. Then again he was having a huge anterior-septal STEMI.

 

[Carlos Danger]

Mechanical CPR devices often provide sufficient perfusion that a high quality CPR recipient will awaken enough to answer questions with blinks and track the team around the room.

"A patient making purposeful movements, even being awake and alert while in cardiac arrest, can have profound emotional and psychological implications on the patient as well as the paramedic providers caring for them."

I believe not sedating these patients is cruel, akin to a paralytic with no concurrent sedation and analgesic.


Rice DT, et al. CPR induced consciousness: It’s time for sedation protocols for this growing population. Resuscitation (2016), http://dx.doi.org/10.1016/j.resuscitation.2016.02.013

Whether or not it is "cruel" depends on the specifics of the situation. Of course we should try to make folks comfortable where possible, but it isn't always the top priority, especially when you are talking about brittle patients in true life-and-death scenarios. Even in elective anesthesia there are times when the patient just has to endure some discomfort. Verbal reassurance actually tends to go a long way. Also, just because someone has some awareness doesn't mean they are necessarily even distressed by it.

 

[Summit]

If we sedate people during resuscitation, it complicates post ROSC neuro assessment so we could end up cooling people who don't need to be cooled, or delaying cooling.

I've had times where I swear the patient was looking at me during compression... not sure if it was really so. It's weird, like that scene in Bringing Out the Dead.

Hard to figure where to draw the line for comfort. It is easy to draw it at protecting interventions and care. I'd err towards that because a bad memory is something worth living with so you don't lose brain function d/t delayed cooling in order to allow proper neuro assessment, or the complications of unnecessary cooling.

 

[TomB]

It's unnecessary and confounds the neuro exam at a very important time. If there is a return of airway reflexes, extubate.

 

[Summit]

It's unnecessary and confounds the neuro exam at a very important time. If there is a return of airway reflexes, extubate.

I'd include purposeful movement (which would mean no cooling) and put a caveat for the etiology of the arrest (likely to lose airway again?).

 

[TomB]

We use "obeying commands" rather than "purposeful movement". Too much gray area for the latter. Is grabbing for a tube purposeful? Perhaps, but it's primitive. We've withheld cooling for these patients and they ended up trying to shave with the TV remote (borderline CPC 3 -- long term care arranged at discharged).

 

[Summit]

It depends on who the ICU team is... I've seen this point debated and don't have a solid answer... but now we have TTM at 36C which is easier, has fewer complications, and fewer patients excluded without being inferior to 33C so it is a lot easier to lean towards cooling the neurologically borderline.

 

[SpecialK]

Agreed. Ideally to avoid neuromuscular blockade in patients who are post-ROSC however if the balance of risk is in favour of doing it, then do it. A single dose of rocuronium only lasts about 40 minutes and the time you get the patient off the floor, onto the bed, into the ambulance, drive to hospital, unload, get them inside and everything set up that's 20 to 30 minutes used right there. A single dose can be reversed in ED too, although I am not a fan of the "it can be undone or wear off" motto but in this case, it's not so bad.