New in EM 011: How often does consciousness occur during CPR?

Originally Published on RCEM Learning Podcast October 2017

As part of the RCEM Learning Podcast I record reviews of recent literature with Dave McCreary. We’ve been doing this for about a year now and you can hear them all on the RCEM Learning Podcast each month. I’d like to have them here and searchable on this site too so I’ll be posting the ones I find most relevant here. You can hear the newest ones by subscribing to the free RCEM Learning Podcast. 

Audio:

Title: Consciousness induced during cardiopulmonary resuscitation: An observational study

Author: Olaussen, Jan 2017, Resuscitation

Background:

– There was the fascinating study a few years ago – the AWARE study that looked into the out of body experience where survivors picture themselves rising above their body and watching their resuscitation. They actually studied this and put pictures on shelves that would be out of sight when supine but easily seen if you were able to float above your bed during resus and then asked the survivors if they saw them. Most people didn’t remember anything and the two patients who had the floating experience both had it in areas where they didn’t have the shelf with the picture but for one of them they were able to identify quite a few verifiable details about his resuscitation despite being in VF.

Anyhow… People may be more awake than we think even when they’re dead…

I think most of us have been involved with a cardiac arrest case where the patient kept moving their arms causing all kinds of disruptions while we check the pulse and the monitor to confirm that yes they’re still in VF and now that we’ve stopped CPR they’ve stopped moving. We turn on the LUCAS again and they start moving their arms. In the couple of cases I’ve been involved with they’ve both been the younger acute STEMI patients who have gone on to do quite well.

Methods:

– retrospective review of the victorian cardiac arrest registry (this is Steve Bernard’s baby so it’s fairly high quality data set)

– the main weakness here of course is that they have no systematic means of documenting consciousness and could only identify it if someone happened to write it down

– they actually had a primary outcome of survival to hospital discharge – in other words is movement during CPR a good prognostic factor and something that suggests we should keep going or go for ECPR

Results

– out of 17000 cardiac arrest patients they found 112 (0.7%) relevant patients with possible CPR consciousness

– these people fulfilled all the other good prognostic features (down time, age, rhythm, witness, bystander…)

– 20% of them were described as being combative (can’t blame them)

– 44% survival to discharge here.

– they did look at meds given and found that if patients with CPR induced consciousness got sedation (typically midazolam) then they did substantially worse than those who didn’t. They note in their discussion that this might be due to depressed vasomotor tone and that several regions have developed SOPs that involve a slug of Ketamine if consciousness occurs during CPR.

– only a small number had mechanical CPR (though it’s my very limited experience that you see this more with mechanical CPR)

Bottom Line

– consciousness (or at least purposeful movements) during CPR is a thing albeit quite rare

– if it does happen it’s probably a good prognostic sign

– it can make CPR difficult and sedation is probably needed and benzos might be a bad way to do it

– Kudos to our buddies Justin and Casey on their lit review podcast for highlighting this paper

Foundations 2018 Programme now live

We’ve talked about this before but we now have the programme together and speakers confirmed.

Check out that line up!

Download the PDF file .

This conference is designed to help students and doctors at the beginnings of their careers get the technical and non technical skills needed to really succeed and flourish from the start. Target demographic is final year med students and interns but it’s clear from the registration list that there’s a much wider appeal for this stuff and we have all years of students and doctors registered along with nurses and paramedics.

The vision was always that there’s a generic skill set that all specialties in the hospital need to cover and it’s no surprise that these skills are equally relevant to non doctor providers.

We’ll hopefully have some time to socialise over drinks and food in a local venue after the conference so check in for more soon.

We have a few tickets left and would be great to sell out so please share this as wide as possible to anyone it might be relevant to.

There’s 6 CPD point for the day and lunch/coffee etc all included so head over to foundations.education to get registered and see you all there.

New in EM 010: Can we predict poor outcomes with syncope?

Originally Published on RCEM Learning Podcast October 2017

As part of the RCEM Learning Podcast I record reviews of recent literature with Dave McCreary. We’ve been doing this for about a year now and you can hear them all on the RCEM Learning Podcast each month. I’d like to have them here and searchable on this site too so I’ll be posting the ones I find most relevant here. You can hear the newest ones by subscribing to the free RCEM Learning Podcast. 

Audio:


TitlePredicting Short-Term Risk of Arrhythmia among Patients with Syncope: The Canadian Syncope Arrhythmia Risk Score

Author: Vankatesh Thiruganasambandamoorthy. Academic Emergency Medicine. August 2017.

Background

Syncope accounts for 1-3% of ED visits (really? I’ve definitely had days where it feels like closer to 30%) and up to 3% of hospital admissions from the ED. It’s common, and on the surface it’s a pretty straightforward assessment process. But there are pitfalls and serious underlying conditions that we are considering during that process. The Canadian’s love a good prediction tool, and they’re recently turned their sights on syncope and trying to give us an objective tool to identify patients at risk of nastiness at 30 days from discharge. This paper is a furthering of that work to refine the tool to identify patients at risk of death or arrhythmia requiring intervention at 30-days – so those who would benefit from ECG monitoring.

Methods

  • Prospective, multi-centre cohort study
  • Population: Patients 16 years with syncope presenting within 24 hours of the event
  • Exclusion: Prolonged LOC >5 minutes, change from baseline mental status, witnessed seizure, or LOC following head injury.
  • Trained ED staff identified patients for inclusion and a raft of data variables was collected both at the time and through chart review. ECGs were all assessed by a cardiologist and abnormalities reviewed by a second cardiologist.
  • Primary outcome: Composite of death (due to arrhythmia or unknown cause), arrhythmia, or procedural interventions to treat arrhythmia within 30 days.
  • Apply fancy statistical analysis, allow to simmer, and serve up a tasty decision tool.

Results

  • 5,010 patients analysed
  • 106 patients (2.1%; 95% CI 1.7-2.5) met primary outcome
    • 45 (0.9%) of these occurred outside the hospital
    • 22 (0.45) patients died (15 from unknown cause), 13 of these were outside of the hospital
  • Final 8 independent predictors:
    • Vasovagal predisposition (warm crowded place, prolonged standing, fear, emotion, pain)
      • -1 point
    • History of heart disease (coronary, valvular, myopathy, CCF, non-sinus rhythm)
      • +1 point
    • Any SBP <90 or >180 mmHg in the ED
      • +1 point
    • ED Dx of vasovagal syncope or cardiogenic syncope
      • -1 point for vasovagal
      • +2 points for cardiogenic
    • Elevated trop (>99%ile)
      • +1 point
    • QRS Duration >130ms
      • +2 points
    • QTc >480ms
      • +1 point
    • Scoring 0 had sensitivity of 97.1% and specificity 53.45 for primary outcome

Bottom Line

Bad outcomes from syncope evaluated in the ED are rare but do happen. Like all of these decision aids, this is just putting an objective number to what most of us already do with clinical gestalt. But this sort of score would be easy to use to provide an objective risk assessment and aid decisions re admission or discharge, and on whom to arrange outpatient ambulatory ECG measurement.

Links

The San Francisco Syncope Rule has 96% sensitivity and 62% specificity for “death, myocardial infarction, arrhythmia, PE, stroke, SAH, significant haemorrhage, or any other condition causing a return to ED and hospitalisation for related event”.