A Patient Fought Back During CPR

When a patient suffers a cardiac arrest, they aren’t usually cursing, opening their eyes, and putting up a fight during resuscitation.

But that’s what happened with a 52-year-old woman who became unresponsive as her partner was driving her to seek care for chest pain, according to Nick Wright, DO, now an emergency medicine resident at Virginia Tech Carilion School of Medicine in Roanoke, and colleagues.

As first responders began compressions, she moved her hands and arms, explained Wright, who was a paramedic at the time. They reported the case in the American Journal of Case Reports.

Startled, Wright said he paused to check for a pulse. The patient immediately went limp and became unresponsive again.

They started compressions again, but the woman “grunted, opened her eyes intermittently, and purposefully grabbed the compressor’s arms,” they wrote.

The team also tried to place a supraglottic airway but they couldn’t because of “significant trismus.” Instead, they opted for nasopharyngeal airway and bag-mask ventilation, which “prompted purposeful movement and eye opening.”

Compressions continued, and the patient continued to show awareness. Each time they would stop, however, she would become unresponsive and rhythm checks confirmed ventricular fibrillation.

After the fourth shock, the team started using a mechanical CPR device and secured the patient’s arms with straps. Nonetheless, she was still able to move and ultimately freed her hands to try to pull the piston off her chest.

“She was cussing us up one side and down the other,” Wright told MedPage Today.

To ensure they weren’t “missing something,” Wright and colleagues used a second cardiac monitor to make sure their other device was working. The second device also detected ventricular fibrillation.

Finally, spontaneous circulation returned after the sixth defibrillation attempt. The patient “pushed herself upright in the mechanical CPR device and expressed significant distress, stating, ‘you’re all trying to kill me’ and ‘you’re kidnapping me.'”

When she arrived at the ED, she was taken directly to the cardiac catheterization lab, which revealed a 100% occlusive in-stent thrombosis of the mid-left anterior descending artery. A balloon angioplasty restored blood flow.

Her hospital stay was “otherwise uncomplicated, and she was discharged neurologically intact,” the authors wrote. They noted that she did have a history of recreational cocaine use and high blood pressure.

Wright’s group said cardiopulmonary resuscitation-induced consciousness (CPRIC) is “a rare phenomenon in which patients in cardiac arrest demonstrate signs of consciousness while undergoing cardiopulmonary resuscitation.”

It’s estimated that 0.23% to 0.9% of all worldwide cardiac arrests present with signs of CPRIC. The authors pointed out that CPRIC cases seem to be on the rise, either due to greater emphasis on high-quality CPR — a potential risk factor — or to improved reporting.

CPRIC etiology is unclear but “increased cerebral blood flow during resuscitation may be the root cause,” the authors wrote.

Gaurav Jerripotula Rao, MD, of Northwell Health in Huntington, New York, who was not involved in the case report, told MedPage Today that “sometimes when you have very, very good chest compressions, you are causing enough blood flow to get to the brain, where patients are able to have some sort of consciousness.”

Rao said that he has seen one or two cases of CPRIC, and that benzodiazepine and fentanyl are his preferred first line-treatment “in order to target both analgesia and sedation.” Wright noted based on a handful of case studies, “everybody has a different thought on what appropriate management looks like,” but it frequently involves a sedative, such as benzodiazepines, fentanyl, propofol, and ketamine.

“No matter what the patient is doing or saying at that time, if there is true cardiac arrest, your main focus should be to continue running your algorithm and maintaining high-quality chest compression, because that is what is going to give the patient the best prognosis in the long run,” Rao said.

There has been some debate over whether it’s ethical to sedate these patients. Wright’s group came close to using midazolam, but the patient’s circulation returned before they could administer it. He said they were in favor of doing so given that the “long-term psychological effects on patients [of resuscitation] are unknown.”

“We are breaking ribs and putting needles in bones and putting tubes in airways, and none of it is comfortable. … It would be a perfect trigger for somebody to have PTSD [post-traumatic stress disorder],” Wright said.

“Sedating these people will let you perform better resuscitations, but it will also keep these patients from remembering these events,” he added, noting that the case-study patient later said she remembered almost everything that happened.