Skip to main content

Main menu

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums

User menu

  • My alerts

Search

  • Advanced search
The College of Family Physicians of Canada
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums
  • My alerts
The College of Family Physicians of Canada

Advanced Search

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • RSS feeds
  • Follow cfp Template on Twitter
  • LinkedIn
  • Instagram
Case ReportPractice

Consciousness with cardiopulmonary resuscitation

Roger Gray
Canadian Family Physician July 2018; 64 (7) 514-517;
Roger Gray
Family physician practising in Chisasibi, Que, and a part-time Clinical Faculty Lecturer in the Department of Family Medicine at McGill University in Montreal, Que.
MD CM CCFP
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: roger.gray@mcgill.ca
  • Article
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF
Loading

Cardiopulmonary resuscitation–induced consciousness (CPRIC) is a phenomenon that is receiving increasing attention, and of which family physicians and all care providers with advanced cardiac life support skills should be aware. It has been hypothesized that owing to a variety of physiologic variables, such as autoregulation, comorbidities, and cerebral ischemic thresholds, it is possible for patients receiving high-quality cardiopulmonary resuscitation (CPR) to maintain consciousness.1–3 The case presented here is of a younger man who appeared to regain consciousness several times during CPR.

Case

A 38-year-old man presented to the emergency department in a remote regional hospital staffed by family physicians. He had a 4-hour history of retrosternal chest pain radiating into his neck. In the hour before presentation the patient had also developed lightheadedness and diaphoresis. The patient had type 2 diabetes, for which he took no medications, and he smoked approximately 10 cigarettes daily. He also had a relevant family history of coronary artery disease and early myocardial infarction.

On presentation the patient was alert, pale, diaphoretic, and visibly ill. Vital signs were taken at triage and the patient was found to have a blood pressure of 83/50 mm Hg and a heart rate of 34 beats/min. He was transferred to the resuscitation room and a 12-lead electrocardiogram was obtained, which showed an inferior ST-segment elevation myocardial infarction (Figure 1). The patient was immediately administered 320 mg of acetylsalicylic acid to chew, 300 mg of clopidogrel by mouth, and a litre bolus of normal saline intravenously for a suspected right ventricular infarct. After receiving fluid resuscitation the patient’s blood pressure and heart rate were 158/107 mm Hg and 77 beats/min, respectively. The anticipated transfer time for percutaneous coronary intervention for this patient was approximately 5 hours, and the patient had no contraindications to thrombolysis; therefore, the decision was made to attempt coronary thrombolysis with tenecteplase.

Approximately 7 minutes after receiving tenecteplase the patient became unresponsive, with no pulse, and polymorphic ventricular tachycardia (VT) was identified on the cardiac monitor. Chest compressions were immediately started and the patient was defibrillated 1 minute after cardiac arrest with 200 J. Table 1 provides a summary of the resuscitation, including likely episodes of consciousness. The patient had return of spontaneous circulation (ROSC) at 8 minutes but this was not sustained. The rhythm on the cardiac monitor varied from polymorphic VT to ventricular fibrillation to VT (Figure 2). The patient was ultimately defibrillated 6 times and received 3 mg of epinephrine, 2 g of magnesium sulfate (for suspected torsades de pointes), and 300 mg of amiodarone.

At several points during the resuscitation the patient regained some consciousness. He made purposeful movements to push CPR providers away and verbalized with defibrillations. When signs of consciousness were recognized, CPR was immediately stopped and pulse checks were performed. During pulse checks there was no palpable pulse and the patient lost consciousness shortly after cessation of CPR. The decision was therefore made to continue CPR and defibrillation attempts, and a 4-point restraint was applied to prevent interruptions to CPR. Return of spontaneous circulation was ultimately reobtained 17 minutes after the patient initially went into cardiac arrest. He eventually became fully conscious and was able to speak with family members before being intubated in preparation for transfer to a tertiary care facility. The patient was transferred, received rescue percutaneous coronary intervention for acute occlusion of the circumflex branch of the left coronary artery, and was ultimately discharged from hospital 4 days after cardiac arrest. He had complete neurologic recovery at the time of discharge. When interviewed 3 months later about his recollection of his resuscitation, he recalled experiencing discomfort in his chest and neck, and that he felt 2 “shocks” that made his muscles tense. He had no recollection of CPR specifically and denied any recollection of pain.

Although the patient’s outcome in this case was positive, several care providers who participated in this patient’s resuscitation reported feeling personal distress during the resuscitation. None of the care providers had ever experienced a patient regaining consciousness with CPR, nor were they aware that it was possible. They were therefore uncertain whether the case had been appropriately managed and whether the patient should have been sedated rather than restrained.

Figure 1.
  • Download figure
  • Open in new tab
Figure 1.

A 12-lead electrocardiogram showing an inferior ST-segment elevation myocardial infarction

View this table:
  • View inline
  • View popup
Table 1.

Summary of cardiac arrest events and actions

Figure 2.
  • Download figure
  • Open in new tab
Figure 2.

Rhythm on the cardiac monitor varying from polymorphic VT to VT to ventricular fibrillation

VT—ventricular tachycardia.

Discussion

A 2015 systematic review of case reports of CPRIC by Olaussen et al identified 10 cases of CPRIC in the literature.1 Reported levels of consciousness included eye opening, agonal breathing, localizing painful stimuli, purposeful arm movements, verbal and nonverbal communication with the resuscitation team, and following instructions. This systematic review also found that in half of the identified cases patients were alert enough to interfere with the resuscitation by “pushing and grabbing the rescuer, withdrawing from the compressions, and pulling on endotracheal tubes and mechanical devices.”1 Patient consciousness also led to CPR being interrupted more frequently for pulse checks. Several care providers commented on their uncertainty about how to appropriately manage CPRIC.1,4–6 Management strategies included sedation, physical restraint, instructions to the patient, and reassurance. Medications that have been used for sedation in CPRIC include ketamine, midazolam, propofol, etomidate, and fentanyl.1,4,6,7 Of note, a prospective study of awareness in CPR found that only 2% of patients recalled visual or auditory awareness of their resuscitation and no patients remembered experiencing pain.8

An observational study of CPRIC in 112 patients with out-of-hospital cardiac arrest in Australia provides some guidance on how to best manage CPRIC.7 In this study, the frequency of CPRIC in all cardiac arrests increased from 0.3% in 2008 to 0.9% in 2014. Patients who experienced CPRIC were more likely to be younger, male, have an initial rhythm of ventricular fibrillation or VT, and have a shorter interval between cardiac arrest and provision of emergency medical services care. The most common manifestations of CPRIC in this study were body movement (87.5%), speech (29.5%), eye opening (20.5%), jaw tone (20.5%), and being combative (19.6%). The study described 2 clinically relevant associations with CPRIC and survival, although both must be taken in the context of small sample size and retrospective analysis. First, CPRIC was independently associated with ROSC and survival to hospital discharge. Additionally, patients with CPRIC who were administered opiates, benzodiazepines, or muscle relaxants took longer to obtain ROSC and were less likely to survive to discharge. The use of ketamine and other dissociative agents was not described in this study; however, ketamine might be safer than other medications in CPRIC owing to its lower risk of inducing hypotension.4,6,7

Conclusion

Cardiopulmonary resuscitation–induced consciousness is a newly identified phenomenon of increasing incidence and might be related to early high-quality CPR in younger, healthier patients.5 Care providers should be aware that CPRIC can occur and that although it can be distressing to care providers, CPRIC is associated with improved survival. Once identified, the priority in the management of CPRIC should be the continuation of high-quality CPR with minimal interruptions. Physical restraints and patient reassurance might be required to minimize interruptions to CPR and continue effective resuscitation, as was done in this case. Few survivors have any recollection of their resuscitation. If needed, ketamine might also be used to sedate the patient to minimize CPR interruption, but further research is needed to confirm its safety and appropriate dosing in CPRIC.4 Hypotension-inducing medications should be avoided. Further research is required to determine the frequency of CPRIC in Canada and to develop guidelines on how to best manage this condition.

Notes

Editor’s key points

  • ▸ Advanced cardiac life support providers should be aware that cardiopulmonary resuscitation–induced consciousness (CPRIC) can occur and is being reported with increasing frequency.

  • ▸ Although it can be distressing to the care providers, few survivors of cardiac arrest with CPRIC have any recollection of their resuscitation. In fact, CPRIC is associated with positive patient outcomes.

  • ▸ Physical restraints and patient reassurance might be required to minimize interruptions to CPR in patients with CPRIC. Medications for sedation can also be administered, but those that can induce hypotension should be avoided.

Points de repère du rédacteur

  • ▸ Les prestataires de soins spécialisés de réanimation cardiorespiratoire (RCR) devraient être au fait de la possibilité qu’une reprise de conscience provoquée par la réanimation cardiorespiratoire (RCRCR) puisse survenir, et que de telles situations sont de plus en plus souvent signalées.

  • ▸ Même si ce phénomène peut être bouleversant pour les prestataires de soins, il y a lieu de mentionner que peu de survivants à un arrêt cardiaque ayant repris connaissance durant la RCR se souviennent de leur réanimation. En réalité, la RCRCR est associée à des résultats favorables chez les patients.

  • ▸ Il peut être nécessaire de recourir à des mesures de contention physique et de rassurer le patient pour minimiser les interruptions de la RCR chez les patients qui reprennent connaissance. Des sédatifs peuvent aussi être administrés, mais il faut éviter ceux qui peuvent induire une hypotension.

Footnotes

  • Competing interests

    None declared

  • This article has been peer reviewed.

  • Cet article a fait l’objet d’une révision par des pairs.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Olaussen A,
    2. Shepherd M,
    3. Nehme Z,
    4. Smith K,
    5. Bernard S,
    6. Mitra B
    . Return of consciousness during ongoing cardiopulmonary resuscitation: a systematic review. Resuscitation 2015;86(1):44-8. Epub 2014 Nov 4.
    OpenUrl
  2. 2.
    1. Jespersen SN,
    2. Østergaard L
    . The roles of cerebral blood flow, capillary transit time heterogeneity, and oxygen tension in brain oxygenation and metabolism. J Cereb Blood Flow Metab 2012;32(2):264-77. Epub 2011 Nov 2.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Bandera E,
    2. Botteri M,
    3. Minelli C,
    4. Sutton A,
    5. Abrams KR,
    6. Latronico N
    . Cerebral blood flow threshold of ischemic penumbra and infarct core in acute ischemic stroke: a systematic review. Stroke 2006;37(5):1334-9. Epub 2006 Mar 30.
    OpenUrlAbstract/FREE Full Text
  4. 4.↵
    1. Pound J,
    2. Verbeek PR,
    3. Cheskes S
    . CPR induced consciousness during out-of-hospital cardiac arrest: a case report on an emerging phenomenon. Prehosp Emerg Care 2017;21(2):252-6. Epub 2016 Oct 28.
    OpenUrl
  5. 5.↵
    1. Bihari S,
    2. Rajajee V
    . Prolonged retention of awareness during cardiopulmonary resuscitation for asystolic cardiac arrest. Neurocrit Care 2008;9(3):382-6.
    OpenUrlPubMed
  6. 6.↵
    1. Olaussen A,
    2. Shepherd M,
    3. Nehme Z,
    4. Smith K,
    5. Jennings PA,
    6. Bernard S,
    7. et al
    . CPR-induced consciousness: a cross-sectional study of healthcare practitioners’ experience. Australas Emerg Nurs J 2016;19(4):186-90. Epub 2016 Jul 29.
    OpenUrl
  7. 7.↵
    1. Olaussen A,
    2. Nehme Z,
    3. Shepherd M,
    4. Jennings PA,
    5. Bernard S,
    6. Mitra B,
    7. et al
    . Consciousness induced during cardiopulmonary resuscitation: an observational study. Resuscitation 2017;113(4):44-50. Epub 2017 Feb 1.
    OpenUrl
  8. 8.↵
    1. Parnia S,
    2. Spearpoint K,
    3. de Vos G,
    4. Fenwick P,
    5. Goldberg D,
    6. Yang J,
    7. et al
    . AWARE—AWAreness during REsuscitation—a prospective study. Resuscitation 2014;85(12):1799-805. Epub 2014 Oct 7.
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Canadian Family Physician: 64 (7)
Canadian Family Physician
Vol. 64, Issue 7
1 Jul 2018
  • Table of Contents
  • About the Cover
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on The College of Family Physicians of Canada.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Consciousness with cardiopulmonary resuscitation
(Your Name) has sent you a message from The College of Family Physicians of Canada
(Your Name) thought you would like to see the The College of Family Physicians of Canada web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Consciousness with cardiopulmonary resuscitation
Roger Gray
Canadian Family Physician Jul 2018, 64 (7) 514-517;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Respond to this article
Share
Consciousness with cardiopulmonary resuscitation
Roger Gray
Canadian Family Physician Jul 2018, 64 (7) 514-517;
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Case
    • Discussion
    • Conclusion
    • Notes
    • Footnotes
    • References
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

Practice

  • Is 45 the new 50 in colorectal cancer screening?
  • Approach to diagnosis and management of childhood attention deficit hyperactivity disorder
  • Determining if and how older patients can safely stay at home with additional services
Show more Practice

Case Report

  • Supporting young carers in Canada
  • Kounis syndrome case study
  • Trauma-informed palliative care
Show more Case Report

Similar Articles

Navigate

  • Home
  • Current Issue
  • Archive
  • Collections - English
  • Collections - Française

For Authors

  • Authors and Reviewers
  • Submit a Manuscript
  • Permissions
  • Terms of Use

General Information

  • About CFP
  • About the CFPC
  • Advertisers
  • Careers & Locums
  • Editorial Advisory Board
  • Subscribers

Journal Services

  • Email Alerts
  • Twitter
  • LinkedIn
  • Instagram
  • RSS Feeds

Copyright © 2025 by The College of Family Physicians of Canada

Powered by HighWire