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Prehospital practitioner awareness and experience of CPR-induced consciousness

Niall Carty, Military Advanced Paramedic, Central Medical Unit, Dublin, Ireland; Gerard Bury, Professor of General Practice, University College Dublin (UCD) School of Medicine, and Director, UCD Centre for Emergency Medical Science, UCD Health Sciences Centre, Belfield, Dublin, Ireland. Email:


Background: Cardiopulmonary resuscitation-induced consciousness (CPRIC) is an important but under-researched area. CPRIC in Irish emergency services has never been examined and this study aimed to explore the experiences of prehospital practitioners. Methods: This study includes qualitative and quantitative elements, using an online anonymous survey followed by a confidential, one-to-one, semi-structured interview with emergency medical technicians, paramedics and advanced paramedics. Results: Of the respondents surveyed, 93% had been involved in the care of at least one case of out-ofhospital cardiac arrest (OHCA); 36% had managed 6–10 OHCAs within the previous 12 months. Three-quarters (75%) were aware of CPRIC and 57% reported that they had witnessed at least one episode of this. CPRIC incidents were characterised by a range of clinical features, which sometimes interrupted care provision and were managed using wide-ranging and non-standardised responses including drug therapy. Both high-quality manual and mechanical CPR were linked to CPRIC. The rate of reported return of spontaneous circulation (63%) was significantly higher than that in Irish national data for OHCA. Seven volunteers participated in confidential sem-istructured interviews. Themes identified included the impact on resuscitation, unfamiliarity with CPRIC manifestations, how CPRIC affected practitioners and educational needs. Practitioners experienced distress because of this phenomenon. All highlighted their desire to have CPRIC addressed by clinical practice guidelines. Key words l Cardiopulmonary resuscitation l Prehospital CPR-induced consciousness l In-hospital CPR induced consciousness l Consciousness during CPR l Awareness during CPR l Awake during CPR

Accepted for publication:31 July 2022

Cardiopulmonary resuscitation-induced consciousness (CPRIC) is being increasingly recognised as an issue in out-of-hospital cardiac arrest (OHCA) (Pourmand et al, 2019; Chin et al, 2020; Doan et al, 2020; Singh et al, 2020).

Olaussen et al’s (2017) Australian registry study showed a 0.7% incidence, with an increase from 0.3% in 2008 to 0.9% in 2014 (Olaussen et al, 2017). Gregory et al’s (2021) UK membership survey showed that 57% of UK paramedics reported at least one incident of CPRIC and multiple effects on resuscitation.

No agreed definition of CPRIC exists. However, most clinicians identify CPRIC as consciousness regained to a variable extent while CPR is being performed. Signs range from purposeful movements to more subtle signs such as eye opening or agonal breathing. CPRIC may obstruct CPR, is potentially detrimental to the patient and distracting to practitioners and can be distressing for the patient, practitioners and bystanders.

Identifying CPRIC may allow relevant interventions and optimum CPR to be carried out.

The increasing incidence of CPRIC may be as a result of more effective CPR because of minimum ‘hands-off time’, the introduction of mechanical CPR devices and earlier identification of cardiac arrest (Gräsner et al, 2020).

CPRIC issues can be clinical (e.g. managing an agitated patient, decisions to stop resuscitation) and professional (e.g. the impact on practitioners).

In Ireland, advanced paramedics (APs) are the most senior grade of ambulance service practitioners, and they have comprehensive advanced life support roles and respond to all OHCAs. Paramedics commonly attend OHCAs but do not administer drugs. Emergency medical technicians (EMTs) do not routinely attend OHCAs.

The Pre-Hospital Emergency Care Council (PHECC) is the statutory regulator for prehospital practitioners and publishes all relevant clinical practice guidelines (CPGs) (PHECC, 2017). Medical lthcare Ltd






Vol 14 No 9 • Journal of Paramedic Practice

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