What are the differences in CPR (Cardiopulmonary Resuscitation) protocols for conscious versus unconscious patients?

CPR Protocols for Conscious vs. Unconscious Patients

CPR should never be performed on conscious patients, as it is exclusively indicated for patients in cardiac arrest who are unconscious, unresponsive, and without normal breathing or a definite pulse. 1

Assessment Protocol for Determining Need for CPR

Unconscious Patients

1. Initial Assessment:

   • Check responsiveness (tap and shout)
   • If unresponsive, assess breathing 1
   • For lay rescuers: Look for absent or abnormal breathing (gasping)
   • For healthcare providers: Check for a pulse for no more than 10 seconds 1

2. Criteria for Starting CPR:

   • Unconscious/unresponsive AND
   • Absent or abnormal breathing (agonal gasping) OR
   • No definite pulse felt within 10 seconds (healthcare providers) 1

3. CPR Components for Unconscious Patients:

   • High-quality chest compressions (5-6 cm depth, 100-120/minute)
   • Allow complete chest recoil between compressions
   • Minimize interruptions in compressions 2
   • For trained rescuers: 30 compressions to 2 ventilations
   • For untrained lay rescuers: compression-only CPR 1

Conscious Patients

1. Key Point: CPR is contraindicated in conscious patients 1

2. Special Circumstances - CPR-Induced Consciousness:

   • Rarely (0.7% of cases), patients may regain consciousness during high-quality CPR 1
   • Signs include: eye opening (20.5%), speech (29.5%), body movement (87.5%) 1
   • Management options:
     • Consider small doses of sedatives/analgesics to prevent pain and distress 1
     • Neuromuscular-blocking drugs alone should not be given 1
     • Regimens should be based on those used for critically ill patients 1

3. Alternative for Conscious Patients with Arrhythmias:

   • "Cough" CPR may be considered only in specific settings like cardiac catheterization labs
   • Only for conscious, monitored patients who can be instructed to cough forcefully every 1-3 seconds
   • Should not delay definitive treatment
   • Not useful for unresponsive patients and should not be taught to lay rescuers 1

Common Pitfalls and Caveats

1. Misdiagnosis of Cardiac Arrest:

   • Agonal breathing (present in 40-60% of cardiac arrest victims) is often misinterpreted as normal breathing 1
   • Healthcare providers often take too long to check for a pulse or have difficulty determining if a pulse is present 1
   • When in doubt, start CPR - the risk of harm from CPR in patients not in cardiac arrest is low 1

2. Delays in Starting CPR:

   • Protracted delays can occur when checking for a pulse 1
   • For healthcare providers: limit pulse checks to no more than 10 seconds 1
   • For lay rescuers: rely on unresponsiveness and abnormal/absent breathing only 1

3. Inappropriate CPR in Conscious Patients:

   • CPR should never be initiated on conscious patients as it can cause:
     • Pain in the area of chest compressions (8.7%)
     • Bone fractures (ribs and clavicle) (1.7%)
     • Rhabdomyolysis (0.3%) 1

4. Managing CPR-Induced Consciousness:

   • Failure to recognize this phenomenon can lead to inappropriate interruption of CPR
   • Healthcare professionals should be prepared with protocols for sedation when needed 1
   • Psychological effects of awareness during CPR may be significant 3

Evidence Quality and Recommendations

The 2020 American Heart Association guidelines provide strong recommendations (Class 1, Level C-LD) regarding assessment criteria for cardiac arrest and initiation of CPR 1. The evidence on CPR-induced consciousness is more limited, with good practice statements rather than formal recommendations due to insufficient evidence for a systematic review 1.

The distinction between conscious and unconscious patients is fundamental to CPR protocols, with clear evidence that CPR is only indicated for patients in cardiac arrest who are unconscious and unresponsive with absent or abnormal breathing 1.