Anesthesia for CPR

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During CPR, some patients "achieve some level of consciousness or alertness without a spontaneous heartbeat."

In Nebraska:

EMS protocols direct paramedics to administer a ketamine bolus if a patient has any signs of consciousness — spontaneous eye opening, purposeful movement or verbal response to include moaning. Those medics should also consider a midazolam bolus and repeat ketamine boluses or infusion for continued patient sedation.

Any comments on that protocol?

I know of an elderly patient who was admitted to the hospital after passing out and being resuscitated at home. At the time it was believed to be from choking. At the hospital he said he wanted to be resuscitated, if necessary, so there was no DNR order. He needed resuscitation about 24 hours after admission. He was clearly awake during chest compressions (he said "stop" at one point). In your opinion, should the Nebraska protocol have been used to sedate the patient? As far as I know, the only drug given for the patients discomfort, at some point, was morphine.

I've heard stories about nurses speaking to conscious patients during resuscitation and telling them when they're about to be shocked. Is it ever acceptable for a patient to go through that unsedated?

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Specializes in Nurse Anesthesiology.

If a patient is pulseless and requiring CPR and chest compressions giving them sedatives in any form can cause further cardiac suppression. Anesthetic/amnestic drugs like versed and morphine can and will suppress the CNS. Sorry but I would take an awake pt to make it through a code than a comfortable one who doesn't.

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Not that common for this to happen and to have a "protocol" for something like that seems dicey to me. I'd be more concerned that the concern would be more getting the patient sedated than being sure they didn't have a pulse and needed compressions.

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Specializes in Emergency.

As a field paramedic we seldom see any movement/signs of awareness during CPR but it does happen! We have used versed (midazolam) in the past and just put ketamine in our toolbox. Again, during CPR it is quite rare, but not unheard of. Now post CPR with ROSC (return of spontaneous circulation) we ALWAYS "snow" the patient. We have no idea what level of awareness this person may have even if that person cannot respond to us.

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Specializes in Critical care.
If a patient is pulseless and requiring CPR and chest compressions giving them sedatives in any form can cause further cardiac suppression. Anesthetic/amnestic drugs like versed and morphine can and will suppress the CNS. Sorry but I would take an awake pt to make it through a code than a comfortable one who doesn't.

This is stuff you anesthetists know very well, but if the providers avoid the Versed recommendation and stick to only Ketamine, ( I'm not advocating this BTW, just giving a 'for instance' scenario) they most likely will avoid suppressing cardiac output. However, I too feel that the scenario they are trying to avoid is rare enough and the fix (Ketamine mono-therapy) has enough downsides that it's a poor solution. Perhaps waiting 20 mins for the emergence reaction from Ketamine-only sedation (probably now in the ED, mind you) to then give the benzos, right? I think that's a bad choice. too.

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Only a few times have I seen patients have a return of consciousness during CPR without ROSC.

First of all, pat yourself on the back for doing damn good CPR.

Second, it's almost always in patients who have very low EFs who arrest.

Ketamine makes sense because it increases SNS stimulation on the heart (increase HR, CO) and for that matter cerebral blood flow, and doesn't tend to depress respirations once you do get the pulse back.

Also, many people don't realize that besides ketamine dissociative sedation, it also provides analgesia and amnesia.

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Also, many people don't realize that besides ketamine dissociative sedation, it also provides analgesia and amnesia.

Be careful about that. Ketamine doesn't give predictable amnesia and even when it does, the dose is higher than just doses for sedation. Giving ketamine without reliable amnesia (versed) is asking for trouble. Small doses of ketamine (10mg) are not as likely to cause dysphoria as larger doses (50 mg) but they do not give reliable amnesia.

That said, for patients in an arrest situation, they are easier to induce amnesia in because of a hypoperfused brain.

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