Sponsored by News Letter to the editor
Gareth Benson, Resuscitation Officer at the Betsi Cadwaladr University Health board in North Wales, has written to CSJ to share awareness of a new protocol, aimed at helping to improve the management of unintended consciousness during CPR. In this letter, Gareth outlines easy-to-
follow guidance with the aim of encouraging best practice and discussion across other UK Trusts. What are your thoughts on the protocol? How are you managing management of unintended consciousness during CPR at your organisation? Are you doing anything differently? What do you think
needs to happen to drive improvement? Write to the editor at:
louiseframpton@stepcomms.com to start a discussion. If you have an example of best practice, or news
of a successful improvement initiative, please get in touch and help start a debate!
Dear Editor,
I write to inform you of a development in our management of unintended consciousness during CPR at Betsi Cadwaladr University Health board in North Wales. With the 2025 RCUK guidelines acknowledging this phenomenon, we believe our existing protocol which has been part our resus policy since 2020 may be of use to other areas. Several studies and anecdotal evidence have shown that external chest compression coupled with adequate high oxygen ventilation can, in certain circumstances, cause a situation where adequate brain perfusion is achieved to engage consciousness, while still in a non-perfusing cardiac rhythm. This phenomenon of “consciousness in the absence of a return of spontaneous circulation (ROSC)” is becoming more frequently reported with the increased use of automated external compression devices such as LUCAS. Several studies have shown an increase in cerebral blood flow with the use of LUCAS, some to the levels required to engage consciousness; a
literary search, however, also shows examples of this phenomenon with standard manual CPR, although with more rarity. Awareness can range from eye opening to physically pushing the cardiac arrest team away, all in the absence of a beating heart and has obvious mental trauma implications to both the patient and staff involved. Following this phenomenon being witnessed first-hand during a cardiac arrest by members of BCUHB resuscitation department, guidance was sought as to a management strategy in anticipation of its recurrence. The search resulted in two pieces of guidance, both from other countries. The first was from Nebraska and indicated sedation with ketamine. The second from Holland indicated sedation with midazolam / fentanyl. No UK policy or guidance in this area could be found; enquiries to RC(UK) were likewise fruitless. Consultant grade representatives from both
cardiology and anaesthetics across the health board were approached and asked to give their professional input to their preferred choice of sedative, should they be in a position where this phenomenon occurred. The consensus was agreed that all were in favour of midazolam, due to its wide usage within both cardiology and anaesthetics and also its wider availability as a non-controlled drug. Fig 1 has been agreed by the resus committee with multi-professional input and adopted as an annex to the health board Resuscitation policy. We believe this to be the first protocol of its kind in the UK, (but stand to be corrected). We advocate that other health providers and the RC(UK) give consideration to the possibility of this phenomenon occurring and its management, as little evidence exists to guide intervention.
IV/IO Midazolam 1-2mg slow injection, then titrate in 1mg increments up to a maximum of 7.5mg
If available consider co-administration of IV / IO Fentanyl 50mcg, then 25mcg increments guided by results
*note reversal agents (Naloxone & Flumazenil) drug dosages relate to adult patients and must be appropriately prescribed. Kind Regards
Gareth Benson Dip(HE)ODP, VR Resuscitation Officer Glan Clwyd Hospital, Bodelwyddan, Wales Tel No: 01745 583910 ext: 7958
References 1. Pound J, Verbeek R, Cheskes S. CPR Induced Consciousness During Out Of Hospital Cardiac Arrest: A case report of an emerging phenomenon. Journal of Pre Hospital Emergency Care. 2016;10:1-5
14
www.clinicalservicesjournal.com I January 2026 Fig 1
Management of awareness without ROSC during ongoing CPR
2. Olausen A et al. Return of consciousness during ongoing cardiopulmonary resuscitation: A systemic review. Resuscitation Journal. 2015;86:44-48
3. Nebraska Board of Emergency Medical
Services, approved EMS Model Protocols 2012 Edition. Page 38 4. Landelijk Protocol Ambulancezorg [translate – Intl Veld Dutch National Guidelines] 2014;8;38 – Chapter 5.2
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