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Research 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: carty81@hotmail.com Abstract 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 Hea MA 2022 © 358 Vol 14 No 9 • Journal of Paramedic Practice
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Research Oversight (Medico) is a national 24-hour emergency telemedical support unit. Consultation, advice and permissions can be sought by practitioners on dynamic situations where treatment falls outside the PHECC guidelines. This study aims to explore the CPRIC experience of paramedic practitioners in Ireland as well as their awareness and views on educational and other support needed to deal with the phenomenon. Methodology This cross-sectional study included quantitative and qualitative elements with an online anonymous survey of practitioners and a follow-up, confidential, one-to-one semi-structured interview with practitioners who volunteered to take part. There was no patient or public involvement. An invitation to participate with an introductory letter was distributed to 358 EMTs, paramedics and APs (from the National Ambulance Service, Dublin Fire Brigade and Defence Forces in two regions). Recruitment occurred via work emails distributed by employers. Interested practitioners responded to a dedicated email address. The anonymous online survey, created using Google Forms, included: l Practitioner profile l CPRIC experience l Three case vignettes. The interviews were transcribed and analysed using thematic analysis, without reaching saturation. Data were analysed using Microsoft Excel. Research ethics approval was granted by the University College Dublic (UCD) Human Research Ethics Committee (LS-E-20-152-Carty-Bury). lthcare Ltd Hea MA 2022 © Results Survey results Out of the 358 practitioners invited, 232 replied (response rate 64.8%) including 136 APs, 78 paramedics and 18 EMTs from all three organisations. Most participants (81%) were male. Out of the 232 respondents, 224 (96.6%) reported management of an OHCA (eight EMTs had not been involved); 174/232 (75%) were aware of CPRIC (APs: 91.7%; paramedics: 53.8%; EMTs: 44.4%). Of the 224 with experience of OHCA care, 73% reported involvement in six or more incidents within the previous 12 months, indicating the cohort had significant recent experience. Of those with OHCA experience, 127/224 (56.7%) said they had witnessed some form of CPRIC, 79/224 (35.3%) said they had not and 18/224 (8%) were unsure. Of the 145 respondents who had or may have witnessed CPRIC, 76/145 (52.4%) had experienced CPRIC once and 47.6% reported more than one episode. Respondents were asked to comment on the most recent case they had experienced. The initial arrhythmia was predominantly ventricular fibrillation (VF) or pulseless ventricular tachycardia (Figure 1); 94/145 (65%) reported that CPR was interrupted at least once because CPRIC features appeared (Figure 2). Figure 3 shows reported CPRIC clinical features identified by practitioners. During CPR, 111/145 (76.6%) practitioners reported three or more movements. Mechanical CPR devices were in use in 59% of cases (Figure 4). CPRIC cases were managed by patient reassurance (29%), drug therapy (20%), other action (7%) or without any specific intervention (44%); 31/145 (21.4%) of respondents contacted Medico for advice. In 128/145 (88%) cases, the patient was transferred to hospital and in 92/145 (63%) return of spontaneous circulation (ROSC) occurred (Figure 5). In the three vignettes, practitioners with experience of OHCA were asked about possible 14% 68% 14% 4% Asystole Pulseless electrical activity Pulseless ventricular tachycardia Ventricular fibrillation Figure 1. Initial rhythm noted by respondents (n=145) 14% 65% 68% 35% 14% 4% Figure 2. CPR interrupted (n=145) No Yes Journal of Paramedic Practice • Vol 14 No 9 359

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Research

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: carty81@hotmail.com

Abstract

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

Hea

MA

2022

©

358

Vol 14 No 9 • Journal of Paramedic Practice

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