Zombie Attack! Combating Combative Cardiac Arrest

An interesting conversation erupted last night on Twitter (which resulted in me being awake way past my bedtime, i.e. 8pm) regarding the management of a specific issue in resuscitation from cardiac arrest: the combative dead person.

In recent times, following the emphasis that has been placed on good quality CPR both bystander and rescuer, many of us have been noticing this somewhat spooky phenomenon more often.  Trying on Twitter to nut out how to manage these patients was tough, so I would love some feedback: have you seen this happening and what do you do about it?

In patients who have arrested in public where bystander CPR is commenced immediately, it is increasingly common for us to see patients who present in a non-perfusing rhythm (usually VF it seems) but who, thanks to excellent CPR, still have cerebral perfusion.  This results in patients who start doing rather unexpected and unwelcome things whilst we jump up and down on their chest.  I personally have seen patients reaching for the hands of the person doing compressions, reaching towards their head as I tried to manipulate their airway, and looking around, seemingly aware of what is happening.  Many other paramedics and medical practitioners have reported the same issues, although there is scant mention in the literature.  Nevertheless, anecdote or not, this misbehaving is common enough now that my protocols, and the protocols of colleagues in New Zealand, specifically mention the phenomenon.

There are a few issues that this raises.  First of all is the difficulties that come with having the patient moving around during resuscitation.  Usually it is easy to physically restrain the arms, which will at least stop them from grabbing your hands while you do CPR.  It does make life tricky when trying to place an IV however, and if the IV is placed in the cubital fossa it is then prone to kinking off unless hands are tied down.  However the bigger issue that I have noted in several cases is difficulty managing the airway and ventilating.  These patients often seem to have strong jaw tone which makes placement of an airway impossible, and their respiratory effort, whilst inadequate on it’s own, interferes with ventilation.

The other issue that is a bit trickier to get to grips with, is the possibility of these patients having awareness during their arrest.  It is very spooky to have a patient looking around whilst in VF and many providers find it more than a little disconcerting.  I do not know if this represents true awareness, but I would certainly rather they definitely had no awareness!

So what do we do about it?  There seems to be two different approaches in the EMS protocols that I am aware of, with many of us prefering a third option.  I have no firm answers as I’m still exploring the various issues myself.

The approach favoured in my protocols is to give small boluses (1-2mg) of midazolam during the arrest if gag reflexes prevent intubation, but they don’t address these patients who are localising to pain and have strong jaw tone.  Using a NMBA is strongly frowned upon.  The rationale for this approach is not given.  The polar opposite of this is the New Zealand approach which calls for the administration of rocuronium only, with the rationale that the patient is not aware, so does not need sedation, and sedation “carries some risk in this setting”

I am trying to wrap my head around both of these concepts, so excuse me while I think out loud for a bit.

Sedation only:  In my experience sedation alone has not been enough to allow me to successfully manage the patient, in particular to allow me to place an airway and ventilate.  As noted above, there is some opposition to using sedation due the risk it carries, and further to this there was the line of thought that these patients don’t remember their arrest, are not truely aware, and therefore sedation is unecessary.

Whilst I don’t think sedation alone is enough, I’m not sure how I feel about either of these objections to using sedation.  First of all, the risk:  typically when we use sedation (especially something like midazolam) we are worried about negatively impacting on perfusion, primarily through vasodilation.  Obviously the patient in cardiac arrest has about as poor perfusion as you can possibly have, and CPR only restores a small fraction of that.  So perhaps concern over negatively impacting haemodynamics is warranted.  On the other hand, we are pouring large (excessive?) doses of adrenaline into these patients at the same time specifically to cause vasoconstriction.  So would a little bit of midazolam really matter?  I suspect it wouldn’t, but I don’t really know.  Perhaps (as in most things) ketamine would be a better option, but I don’t think that there is any reason to avoid midazolam.

The second objection is a bit more complex and perhaps bothersome, not from a practical management point of view, but rather an ethical standpoint.  It seems to me that these patients are aware during CPR.  I don’t know if they are or not, but it certainly seems that way as they localise to pain and look around.  This makes me uncomfortable.
However the argument runs that if the patient does not remember the event, then there is no problem. 
But I don’t know if it is as simple as that.  I don’t think that not remembering suffering is the same as not suffering in the first place, but it is a tricky ethical conundrum.  In palliative care for example, relief of pain and suffering is of paramount importance, and clearly those patients are not going to recall anything at the end of their treatment! 
Of course there is also the distinct possibility that provision of sedation is actually for the benefit of the paramedic; some pyschological first aid for us to make us feel as though we are doing something good for a patient.

Paralysis only:  I’m pretty sure I don’t like this idea much at all.  Obviously in terms of stopping movement and allowing best intubating conditions, paralysis is king.  I have no problem with this at all, but I do feel uncomfortable in providing long term paralysis without sedation in any patient.  It may be that they will not remember anything, but again, I don’t think that is the same as not suffering in the first place.  I could perhaps be comfortable with short term paralysis with suxamethonium only in this situation (sux and an apology) but then there may be issues with using sux in the first place.  If the arrest was caused by hyperkalaemia then there is perhaps potential to exacerbate this by using sux.  With that said, we really have no way of knowing whether this is the case in the field.  We may take a guess if the patient is a dialysis patient for example, but we won’t really know.  Again, we also come back to the issue of whether it will really make a difference anyway? 
If the patient has hyper-k severe enough to have caused arrest, will the rise in K+ from sux be enough to be clinically significant?  I don’t know, so if someone does, please tell me!

So.  Heaps of writing, nothing decided.

I think where I stand at the moment is:  Sedation only hasn’t seemed adequate to me in the past, but I don’t think there are harms associated with using it.  I don’t know which agent is best; it’s probably ketamine, but at the moment I’m ok with cautious use of midazolam.
Paralysis only seems to be inhumane, especially if long term paralysis (rocuronium, pancuronium or vecuronium) is used.  Short term (suxamethonium) paralysis without sedation may be ok to secure an airway, but it doesn’t deal with any ongoing movement/biting etc and there may theoretically be issues with potassium.

Which leaves me at the option I have used with success in the past:  RSI with low doses of sedation and sux (as I don’t have roc yet), then ongoing sedation with whatever is authorised (midazolam for me) if required.  Although this approach is not officially sanctioned by the powers that be, I have never run into issues when using it.  I take care with my paperwork to explain the circumstances and my decision making and (as ever) this is enough.

Right!  Please let me know if you have seen this phenomenon yourself and what you do to address the issues.  Do you have protocol or is it up to the individual to problem solve? 

Things I still don’t know are:  Is sedation bad in these patients?  Is suxamethonium bad in these patients?  And most importantly, is not remembering bad things happening the same as bad things not happening?

Please get in touch with your thoughts.

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26 Responses to Zombie Attack! Combating Combative Cardiac Arrest

  1. Spoke to “concious” VF pt in CCU 4 days after event. He was aware enough that he recognised me as the guy who had been bagging/ inserted an LMA. He stated he didn’t have much memory of the incident but was able to recognise the team by the sense of deja vu. He knew who had done CPR and that I had done airway. Didn’t get to follow up with 2nd case.

  2. R says:

    Would BLS airways, well lubricated nasal trumpets in particular, be a reasonable initial approach? Either passive oxygenation (both nasal cannula and a non-rebreateher mask) or a BVM might be less invasive than intubation or a superglottic airway. Such measures might also allow more efforts to be applied to addressing their cardiac status. If ROSC isn’t achieved sedation might be deferred until additional ALS personnel arrive.

  3. Matt shepherd says:

    Would love to hear details of any cases @mattyshep71.

  4. rfdsdoc says:

    Reblogged this on PHARM.

  5. Damian P says:

    Always tough situations to be in. I have had a patient like this before, luckily we had a tube and recieve ROSC prior to it being a true issue. My pt arrested and bystander CPR was in progress. Shocked twice in vfib and had him back. He started showing purposeful movement prior to the second shock. Shortly after we had ROSC he became very combative. I’m talking about throwing around a medic who was restraining his legs combative. His vital were BP 150/P and hr 130. And we didn’t give him any vasopressors we got him back that fast. After two doses of 2.5 versed he ha still fighting hard. He called the receiving hospital to get them on board with our treatment plan and we paralysed him with vec and another 2.5 versed. He walked out of the hospital with no critical findings two days later. I know the discussion is on if they are still arrested and in that case I would have done the exact same. If you have justification for your treatment to how it’s benificial for the patient and the care needed to save his life I would elect for the highest level of care and RSI him.
    Also in the debate for BLS airway, I don’t think I could justify that an arrested pt can maintain and protect their airway without intubation. In my experience (even eith king airways or lma’s) with a combative pt you can provide adequate ventilation and would create too much gastric inflation by bag assisting.

  6. I’ve seen it happen once and a swift dose of midazolam solved the problem.

  7. craig says:

    As one of the people responsible for the NZ protocol I thought I should comment.
    We spent a long time trying to decide what the right thing to do here was. We are seeing more and more of these patients – presumably due to better CPR and we have had a number of patients moving and vocalising – it isn’t that rare.
    I agree it is conventional teaching that we don’t give neuromuscular blockers without adequate sedation but our goal here hasn’t been to facilitate a balanced anaesthetic its to stop the patient interfering with their own resuscitation. But we don’t want to be inhumane.
    I think the incidence of awareness in this group of patients is vanishingly low and we couldn’t find one – although someone here has posted a personal report – I think it is very uncommon. We just want the patient to stop moving and with the obvious limitation of a very slow peripheral-central-periperal circulation time, roc does this.
    There is also evidence that an agent like midazolam in patients who are peri-arrest can precipitate them into arrest. There is an argument you cannot make an arrest any worse – but i think you can and we don’t know the implication of giving an agent like midazolam so we chose to avoid it. Ketamine probably would take away this risk so is an option and we did consider this, but we also didn’t want to further complicate the management of cardiac arrest so we opted for a single agent – a dose of rocuronium. Do we want to superimpose an RSI on traditional cardiac arrest management?
    Obviously we welcome feedback and our guidelines are open for comment and we do respond to it (well most of it ). We don’t think in this group of patients this approach is being inhumane – but we are open to debate.

    • Hi Craig, thanks so much for reading and posting, I really appreciate it. It is great to see the process behind coming to decisions regarding protocols as much of this is usually opaque to the boots on the ground.

      Please don’t take any of my comments as criticism, they are merely the ramblings of an ambo trying to get his head around a novel situation in a largely evidence free zone. The New Zealand protocols are the only others I am aware of that have specifically mentioned the issue, hence referring to them. (As an aside: I greatly admire the straightforward pragmatism embodied in your protocols, and am very envious of the analgesia options you give your medics)

      With regards to NMBAs, do you think there is further risk involved in using suxamethonium in these patients? At this stage (and possibly forever) road paramedics here do not have rocuronium as an alternative, although we do have pancuronium for long term paralysis. If the initial goal is securing of an airway do you think a dose of sux without sedation would be adequate, or is the risk of hyperkalaemia too great? Obviously this doesn’t help much if the patient is still wriggling around of course.
      In the case of the patient who has received roc getting ROSC, I presume that standard practice of including sedation kicks back in?

      You raise a valid point regarding the complication of an arrest by throwing RSI into the mix. We are fortunate to typically have at least two advanced providers at an arrest, but even then there can be enough to keep everyone busy without adding further stuff into the mix.

      I guess this brings us to the philosophical question that has been nagging at me: what are your thoughts on whether the lack of memory of suffering is the same as not suffering in the first place? I admit that one of the reasons I lean towards giving sedation is that I haven’t resolved this in my own mind yet, so I cleave to my standard practice from other patient groups. There is probably also an element of psychological first aid for me involved in giving sedation.

      Thanks again for commenting.

  8. Maxwell says:

    Locally a 46 year old who presented to ED with chest pain and immediately arrested was given roc only during multiple shocks for repeated VF. I was called post arrest to inform me they were going to scan her head as couldn’t understand why wasn’t waking post return of circulation, as loss of output had always been very brief. I went to look. Her BP was high and pupillary reflexes super-reactive some twenty minutes after the rocuronium. I gave some propofol and reassured would be off to sleep. When patient woke clear and v distressed recall of receiving multiple shocks while unable to move. A terrifying and deeply traumatic event.

    • Gav says:

      At the time of nmb (without sedation) we don’t know if a patient is going to survive. We would not dream of leaving a patient in possible distress during end of life care, why should these scenarios be any different. I think the biggest difficulty to the resuscitation team is not the practicalities, but that we are inadvertently causing suffering and that is what we as human beings trying to help another human being struggle with. In my experience I went home wondering if I caused suffering, regardless of the outcome or airway management

    • Thanks Maxwell. That is exactly what I hope to avoid in giving some sedation to these patients (although this case is perhaps at the extreme end!) Certainly in the field we have no real way of knowing what, if anything, the patient will remember which makes life a little tricky as well.

  9. Gav says:

    Please note, patient and institution is anonymous. I’ve had several experiences of this in the last year, it’s a freaky experience to say the least, and difficult to manage. My first was a STEMI who I shocked 16 times, multiple, ROSC after each shock, was not tubed due to ROSC. He would try to stop us doing CPR. The real difficulty was shocking him in vf when he was awake and trying to say no and role off the trolly. We had to wait several times for his cerebral perfusion to drop off and loose consciousness several times. Difficult to justify sedation at the time because we kept getting him back with effective self ventilation. He survived and had no awareness. We were all pretty disturbed by the experience. I think 0.5mg/kg of ketamine would have been the most humane approach but maintain his ventilators drive. My most difficult experience was also a STEMI who had vomited had trismus and was trying to roll of the trolly in vf. Couldn’t BMV, likely soiled airway and unable to restrain her and shock her. In my hospital RSI drugs and ketamine are centralised so only immediately available. After about 10min of refractory vf fentanyl and sux. Difficult BMV (not impossible ) could not be intubated. 30mim refractory vf.
    Small dose of ketamine might be the way to go, but would the catecholamine production cause more problem with shockable rhythm?

    • Another hell of a case there Gav! I think in a situation like that I would perhaps be more inclined to treat it as a crash airway situation and be more ok with just some paralysis initially to secure an airway (with a scalpel and a bougie ready to go as well).
      Given the amount of adrenaline these patients are receiving (and probably producing!) I don’t think that ketamine would really be an issue, but I don’t know for sure. (See below)

      • Gav says:

        Not just an airway problem however, bloody difficult to shock a patient and minimise hands off time when they are trying to roll off the trolly and need restraint. Delivering a safe (ie staff safety) and timely shock is a big a problem as the airway.

  10. KIdocs.org says:

    ..Rob, can you tell them the ‘Santa Claus’ anecdote? Or is that too bad taste?

  11. craig says:

    Philosophically I agree with you. Just because you are probably going to die should your last 2-3 minutes of awareness be full of pain from CPR and defibrillation and the feeling that goes with paralysis. We know from anaesthetic awareness studies how hideous the experience is. I suppose another perspective is how do we know that the group that are not as responsive don’t have a similar experience and should we provide sedation to all cardiac arrest patients from a humanitarian perspective?
    There is actually quite a lot of data around quality of life in post-CA survivors and while there seems to be lot written around cognition and brain function there doesn’t seem to be anything meaningful about awareness post-cardiac arrest as a problem – so it doesn’t seem to be a major issue – but I’m not sure anyone has actually gone looking and not in the last couple of years with better CPR and devices like Lucas.
    An informal survey of some Medical director colleagues at a conference I’m currently at in the States suggested they are split 50:50 on whether to provide sedation. Most of those opposed were because of the haemodynamic profile of midazolam in a cardiac arrested patient or the lack of evidence of meaningful awareness in the population we are talking about – community arrest as opposed to health provider witnessed cardiac arrest. So perhaps that brings us back to Ketamine? I cannot see the small sympathomimetic effect of ketamine having a negative cardiovascular effect given the adrenaline we are filling them up with !!
    Craig

  12. You raise an interesting point Craig. Until recent times most of our patients in arrest were flat as pancakes with barely a flicker of brainstem activity giving them the odd gasp. Now that we are seeing many more with significantly better cerebral perfusion, do we owe it to all of them to provide sedation during the arrest? Certainly in the field it can be difficult to know who will survive or not, let alone who will remember the event. I’m not sure that I see our medical advisory committee going for that, but it is an interesting philosophical question.

    I agree that midazolam is not really the drug to be using in these situations, ketamine would probably be more appropriate if we felt sedation was required. I also think that the sympathomimetic effect is neither here nor there given the obscene amounts of adrenaline we pout into them. Unfortunately ketamine has still not made it’s way onto ground EMS here (it will “soon”) so I am stuck with midazolam in the meantime

  13. Ben says:

    Completely agree with your thoughts re sedation. I’ve yet to be faced with a patient that has presented as above, but picturing in the simulator that is my brain, my instinct says sedation is not only humane, but also in the interests of safety of patient and treating crew, as well as fitting with the expected clinical course of the patient, ie, if you get ROSC, they will quite possible be intubated/sedated.
    Similar sentiment regarding Midazolam in low-output CPR; I doubt it’s the agent of choice and hence Ketamine would be the next agent off the block for me (particularly as in my service and in a regional centre, I don’t have access to NMBA but do carry 2x 200mg Ketamine and lots of Midazolam). I would imagine that I would be expected to call our consult line to our MD for the OK to do this, esp as we typically have single advanced provider and two standard providers on scene.
    See you at SMACC!

  14. Rotovegas Paramedic says:

    Reblogged this on Rotovegas Paramedic and commented:
    This is a really interesting reflective commentary on a phenomenon that many of us in the prehospital have encountered since the advent of 30:2 CPR and greater emphasis on high quality chest compressions. Robbie eloquently highlights some of the management dilemmas.

  15. Tingles says:

    Great post Robbie, one which poses a number of prickly questions. My view is if you had a Pt who was peri-arrest and combative following TBI (either before or as a result of resuscitation) most of us with the capability wouldn’t think twice about performing RSI to secure airway and facilitate further resuscitation (including maintenance of analgesia, sedation +/- NMB) – so why is the post CA Pt any different?

    We know there are no “perfect” sedative / hypnotic / analgesics in this setting but nor are there in TBI. What we need to do is minimise adverse effects while rapidly gaining control in order to provide targetted resuscitation of O2, CO2 and perfusion (note I did not say BP). This is not possible with a hypoxic, combative Pt pushing your hands away!!

    Keep up the great blogging!!

  16. Northern Australia Para says:

    Hi amboFOAM. Great to see another paramedic out there getting into the FOAM movement. Fortunately found your blog via PHARM and look forward to more posts. Have heard of a case recently where someone was in a ?VF arrest witnessed by the paramedic crew and they were a bit freaked out by having the person verbalise and respond to them during CPR. I knew some people had a few seconds of consciousness after VF before their brain perfusion dropped off but have never heard of this phenomenon before this incident.
    Like you we don’t have any NMBA but carry plenty of midazolam and have a couple of ketamine. Think ketmaine would probably be the thing for us as our intensive care paramedics can only cold tube. In my time with the ambulance service up here (6.5 years) this is the only case I’ve heard of so I can’t see us being allowed to ketamine these types of patients.
    A really interesting topics and thoughts on it though. Something to keep an eye on later.

  17. Chris says:

    I had this happen last night and it really messed with my head to the point I stopped compressions at one point to do auscultation of heart sounds which were obviously absent. He pt was fighting my opa and turning his head and bit/ clenched on my thumb when I first attempted to place my king lt. Definitely the strangest arrest I’ve ever run he even moved his arms at one point. As for the correct solution I’m not sure but it’s definitely a weird feeling when you feel like your patient is watching you run a code. The good news we got a rosc and started hypothermia protocol and he’s in the ICU at least I did what I could.

  18. Sharon Wheat says:

    I woke up thinking I was being beaten up by a gang that were taking turns at me. But, hey, why did they keep counting to 10? I then remembered that I was at the University of Pittsburgh Hospital and figured out I was getting CPR. I kept trying to tell them that I was awake and they should stop. – but I couldn’t move anything except my right hand (slightly) and my tongue. I thought I couldn’t move because of weakness and the continuing assault on my chest – but now I wonder if I was given a paralytic. I most definitely remember the pain from the chest compressions (6 cracked ribs), remember what people were saying, remember the defibrillator being used twice. I’ve never felt more helpless – finally accepting the fact that I had no control and was probably going to die. I then blacked out – for quite some time since I ended up on ECMO. I wish I didn’t still remember – but I do.
    Txt

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