A Patient Fought Back During CPR

A woman in her fifties experienced a cardiac arrest while en route to the hospital due to chest pain, according to emergency physician Dr. Nick Wright and his colleagues. As first responders initiated CPR, the patient reacted by moving her hands and arms, a striking anomaly in a typical cardiac arrest scenario. Trained as a paramedic at the time, Wright paused to check for a pulse, only for the patient to go limp again.

The resuscitation efforts continued, but the patient grunted, intermittently opened her eyes, and managed to grab the compressor's arms.

Despite attempts to insert a supraglottic airway, trismus prevented it, leading to the use of a nasopharyngeal airway and bag-mask ventilation, which elicited purposeful movement and eye opening from the patient. The resuscitation persisted, and each pause was met with the patient's unresponsiveness. After the fourth shock, a mechanical CPR device was employed, but the patient's awareness remained undiminished, even managing to free her hands to attempt removing the piston from her chest.

The patient's verbal outbursts were notably profane, with statements like "you're all trying to kill me" and "you're kidnapping me." Resuscitation efforts culminated after the sixth defibrillation attempt, restoring spontaneous circulation. The patient's attempt to pull off the piston and her profanity indicated a high level of consciousness during CPR.

Upon arrival at the Emergency Department, she was immediately referred to the cardiac catheterization lab, where a severe occlusive in-stent thrombosis was discovered in her mid-left anterior descending artery. Subsequently, a balloon angioplasty reestablished blood flow.

The patient's hospital stay was uneventful, and she was discharged with no neurological deficits. The authors highlighted that CPR-Induced Consciousness (CPRIC) is an infrequent occurrence, estimated to account for 0.23% to 0.9% of all worldwide cardiac arrests. They suggested that an increase in CPRIC cases might be attributed to stricter adherence to high-quality CPR protocols or enhanced reporting practices.

The exact cause of CPRIC remains uncertain, but it may be linked to heightened cerebral blood flow during resuscitation attempts.

Dr. Gaurav Jerripotula Rao, a colleague not involved in the case, proposed that excellent chest compressions could enhance cerebral blood flow, potentially leading to temporary consciousness. He has witnessed a few similar cases and advocated for the use of sedatives like benzodiazepines, fentanyl, propofol, or ketamine in managing such instances. However, the optimal management strategy remains a subject of debate.

The authors acknowledged the ethical dilemma surrounding sedation in such cases, noting the lack of long-term data on the psychological impact of resuscitation on patients. They were poised to administer midazolam but opted to wait as the patient's circulation returned before the administration. The case study patient expressed significant distress upon recovery, recounting her ordeal with remarkable clarity.