2/3/2014
CPR Update
RECOVER
REassessment
Campaign
On
VEterinary
Resuscitation.
CPR Update
RECOVER
•
Series of 7 articles in Journal of Veterinary Emergency and Critical Care
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evaluate the scientific evidence relevant to small animal CPR
compose consensus-based clinical CPR guidelines for dogs and cats
GOALS
CPR Update
RECOVER – 7 Parts
1
ABOUT “RECOVER” – Materials & Methods
2
Domain 1 - PREPAREDNESS AND PREVENTION
3
Domain 2 - BASIC LIFE SUPPORT (BLS)
4
Domain 3 - ADVANCED LIFE SUPPORT (ALS)
5
Domain 4 - MONITORING
6
Domain 5 - POST ARREST CARE
7
CPR GUIDELINES – All 5 domains
Part 1
RECOVER Materials
& Methods
CPR Update
RECOVER
• Systematic evaluation of 74 questions having to do with
small animal CPR
• Generated 101 CPR Guidelines
• Completed by more than 80 specialists in academia (48%)
and private practice (52%)
– mostly Anesthesia and Critical Care
• Modeled after International Liaison Committee On
Resuscitation (ILCOR)
– evidence analysis for in human CPR since 1992
• Endorsed by ACVECC and VECCS
• Many knowledge gaps identified – may guide research
• Will reconvene every 5 years
RECOVER
Introduction
CPA = Cardiopulmonary Arrest
CPR = Cardiopulmonary Resuscitation
PCA = Post Cardiac Arrest
PICO = Population-Intervention-Comparison-Outcome (Q format)
•<6% of dogs and cats that experience CPA in the hospital survive to discharge.
•20% of people who suffer in-hospital CPA are discharged
•CPA outcomes could be considerably improved in veterinary patients
•Current veterinary CPR recommendations have been derived from guidelines
for humans
•Disagreement about how to best perform CPR even among boarded
emergency and critical care veterinary specialists
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PrePre-Stocked Arrest Areas
Crash Carts
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Domain 1
Preparedness and
Prevention
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Preparedness
Prevention
Crash Carts
Retrospective study on cardiac arrest in human hospital:
– Delay in CPR due to equipment failure 18% of the time
– 9% of carts had significant deficiencies
• Inaccessible location
• Infrequent assessment of cart content
• Too much variation in carts when there are more than one
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•
What is the crash cart deficiency rate in vet medicine?
SOLUTIONS:
– Checklists and dated log sheet for restocking
– Regular re-training of staff
– Cognitive Aids improve outcome
• flow charts
• check lists
• Dose charts or calculators
Arrest Etiology & Outcome
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•
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anesthesia-related CPAs are associated with increased survival compared to
anesthesiaarrests from other causes.
Survival rate of dogs and cats for CPA is between 4 and 9.6%
Survival rate in human hospitals for CPA is 10-20%
Veterinary studies
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36-55% of CPAs occurring under anesthesia survive to discharge
0-3% of other CPAs survive to discharge
Survive to discharge is much more important than successful CPA resuscitation
Drug reactions resulting in CPA also have a relatively favorable outcome
Preparedness
Prevention
Arrest Etiology & Outcome
•
Human studies – operating room CPAs
– Death rate 34.9-65.5% for all etiologies
– Death rate 5.5% for anesthesia related CPAs
– Human error is noted in 91% of anesthesia related deaths
•
missing equipment due to lack of return to the cart
incomplete stocking
Inability to identify or locate needed medications
Failure to have drugs and syringes in a quick, usable form
– Deficiencies and defects in resuscitation equipment
PrePre-Stocked Arrest Areas
•
use of both pre-stocked arrest stations and cognitive aids
improves compliance with CPR protocols
80% of GPs and 98% of specialists in VECC & anesthesia have a
regularly maintained crash cart
Most problematic are:
Post resuscitation debriefing soon after the episode detects and corrects
human error.
Preparedness & Prevention
CPR Training
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CPR skills begin to decay within weeks of training, no matter
the learning method used
By 1-2 years after training, skills return to re-training level
Annual CPR training is crucial
Semi-annual CPR training is even better.
American Hospital Association (AHA)
– Cognitive performance
• completing steps of CPR in an orderly and rapid fashion
– Psychomotor skills for BLS
• Proper hand position, adequate rate and depth, adequate
recoil for chest compressions
• Minimizing interruptions
• Avoiding excessive ventilation in rate and volume
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Preparedness
Prevention
Preparedness
Prevention
CPR Team Leadership
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Presence of physician at human CPR does not necessarily improve outcome
Some studies show improved outcome, some no difference and a few worse
outcome when a doctor is present for CPR
The flaw might be in assuming that physicians are actually more experienced
(skilled) than nurses or paramedics at CPR
Survival rates not affected by experience of the first responder
No veterinary studies comparing outcomes of vets vs. techs for CPR
CPR Leadership Training definitely improves outcome of human CPR
CPR Team Leadership
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Rapid intervention of the first responder and application of ALS is crucial
to improving survival for human CPR
Leadership instruction coordinates the group CPR effort
Technical instruction teaches the mechanics of CPR
CPR Leadership Training improves:
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Time to initiate CPR
Percentage of defibrillation within the recommended time window
“hands on time” maximizing CPR time during the emergency
Chest compression rate
Improves cognitive skills
Does not necessarily improve all psychomotor skills
Preparedness
Prevention
CPR Team Leadership
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Preparedness & Prevention
Team Size
•
– 1 kennel attendant or tech to ventilate
– 1 kennel attendant or tech to do chest compressions
– 1 technician to be directed by the leader – intubate, establish IV
line, help with cut downs, get supplies and special need items,
clean up, etc.
– Leader keeps the records and coordinates, doesn’t do anything
that takes more than a few seconds
– Clear the room of other people, leave the door open, and have
others stand by if needed
CPR Leaders are more effective if they do not participate in the
resuscitation
CPA simulation is the ideal tool for teaching CPR Leadership
High fidelity manikins with immediate feedback are the best equipment for
teaching CPR Leadership skills
Preparedness
Prevention
Standardized Training
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Many studies show improved outcome in CPA after standardized training for
BLS and/or ALS are implemented
Not widely available in Veterinary Medicine
Case based learning tends to be more effective than text-book training alone
TAMU does provide a first responder paramedical course for veterinary
professionals and staff
CPR Guidelines put forth by VECC July 2012
Veterinary CPR – Leader (vet or tech) plus three
Preparedness & Prevention
Debriefing
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When high fidelity immediate feedback manikins are not
available, post episode debriefing is the next best thing for
learning psychomotor skills
Debrief after each real time CPR
Drill, debrief, drill, debrief, drill, debrief
significant improvement in survival in human pediatric patients (33–
50%) over time with the use of mock codes and debriefing integrated
into a resident teaching program
Patient survival in simulations increased from 0% to 89% during a retraining for ALS certified health care workers, using mock codes and
debriefing
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Preparedness
Prevention
Preparedness & Prevention
Debriefing
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Debriefing is more effective in learning CPR than any other
teaching modality used alone
Debriefing can take many forms:
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Verbal debriefing
Audio-visual playback and discussion
Review of immediate feedback devices that can record
Computer interactive audio-visual learning modules
Post--Training Assessment
Post
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A test at the end of the CPR training session improves learning retention weeks
to months later
Reviewing test results can be a learning tool as well.
CPR Update
RECOVER
Preparedness & Prevention
Conclusions
•
In light of the higher survival in dogs and cats following CPA
while under anesthesia, consideration should be given to
placement of arrest and algorithms in areas where animals are
routinely anesthetized
– anesthesia induction/prep areas
– Surgical suites
– Anesthetic recovery areas
•
At our HQHVSN Clinic, we have 2 surgery tables and one prep
table
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One table is always open
That table is the arrest station
Crash box is mobile
Emergency drugs are the only drugs not kept in the lock box
Anesthetic arrests most often occur during recovery
Key Preparedness and Prevention
recommendations for canine and feline CPR
• Organized, pre-stocked arrest stations
• improve performance
• Located where animals are routinely anesthetized
• Post-CPR debriefing improves future performance.
• Standardized training programs should be developed.
• have improved adherence to guidelines in human medicine
• are needed in veterinary medicine.
• High fidelity manikins are effective in human medicine.
• Leadership and team communication training increase
effectiveness.
Basic Life Support
ABC
• Establish airway
• Ventilation (breathing)
Domain 2
BLS – Basic Life
Support
– 8-10 breaths per minute if intubated
– Up to 20 mm H20 on the manometer
– C:V ratio of 30:2 if not intubated (compression:ventilation
ratio)
• Chest compressions (circulation)
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100 per minute or faster
1/3 to ½ the width of the chest
Full recoil between compressions (press hard and fast)
Minimize interruptions (no more than 1 every 2 minutes)
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Basic Life Support
Basic Life Support
ABC
Training
• Numerous studies have shown that the quality
of BLS performed is associated with return of
spontaneous circulation (ROSC) and survival in
arrest victims.
• Minimal equipment
• Can be started immediately at onset of CPA
• Every staff member should be trained in BLS
1.
2.
3.
4.
Rapid recognition of CPA
Rapid initiation of CPR
Immediate chest compressions
Begin intubation and ventilation simultaneously
– At least chest compressions and breathing
– All may not be able to intubate
Basic Life Support
Basic Life Support
Training
Training
Rapid recognition of CPA
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Incidence of CPA during anesthesia
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1.
2.
3.
4.
ECG Confirms lack of effective circulation
0.17% in dogs, 0.24% in cats
Patient is unresponsive
Absence of breathing (agonal does not count)
Absence of palpable pulses or auscultable heart sounds
ECG confirms lack of effective circulation
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Asystole
Pulseless ventricular tachycardia
Other pulseless electrical activity
Ventricular fibrillation
If in doubt, do chest compressions
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<2% adverse effects when done when not in CPA
Rib fracture, tracheal bleeding, soreness
Basic Life Support
Basic Life Support
Training
Training
Rapid initiation of CPR
Ventilation
1. One person is the CPR Leader & record keeper
2. One person does chest compressions unless directed to
stop by the Leader
3. One person establishes the airway and ventilates unless
directed to stop by the leader
4. One person begins ALS, attaches monitors and carries
out other tasks as instructed by the CPR Leader
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Hypoxia and hypercapnea reduce likelihood or ROSC
Establishing oxygenation may prevent respiratory arrest
from progressing to cardiac arrest
When intubation is not available, rescue breathing 30:2
V:C is indicated
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Mouth to snout
AmbuBag and snug fitting anesthetic mask
Or anesthetic mask attached to oxygen tank
MAKE SURE VAPORIZER IS OFF
Watch for gastric distension and relieve with manual pressure
Take the manometer to 20 cm H20
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2/3/2014
Basic Life Support
Basic Life Support
Training
Training
Ventilation – Ambu Bags
Ventilation – Ambu Bags
Basic Life Support
Basic Life Support
Training
Training
Ventilation – Ambu Bags
Ventilation – Masks
Basic Life Support
Basic Life Support
Training
Training
Ventilation – Choosing Reservoir Bag Size (6xTV)
Ventilation – Choosing ET Tube Size (handout)
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2/3/2014
Basic Life Support
Basic Life Support
Training
Training
Ventilation – Tips for endotracheal intubation
Ventilation – Tips for endotracheal intubation
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Visualize the arytenoid cartilages
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Visualize the arytenoid cartilages
If you didn’t see it go in, assume it’s not in
Use polypropylene catheter stylet for cats (biggest that
moves freely in the ET tube – 5Fr, 8Fr, 10Fr)
Use the biggest tube that passes without too much
resistance
Fill the cuff, but do not overfill it
Tie the tube in place
Set oxygen flow rate at 1 L/min for circle system (>15
lbs) and 1.5 L/min for non-rebreathing circuits (<15 lbs)
Basic Life Support
Basic Life Support
Training
Training
Ventilation – Tips for endotracheal intubation
Ventilation – Tips for endotracheal intubation
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Trinity Trach Tube Ties – http://trachtubeties.com
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Fiberoptic Laryngoscopes are much superior to bulb
laryngoscopes (Miller blades preferred)
Green plastic base on blade, green stripe on handle
Different size attachment than standard laryngoscopes
Basic Life Support
Basic Life Support
Training
Training
Chest Compressions
Chest Compressions
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Achieve cardiac output of 25-30% normal
If they generate a pulse, technique is good
circumferential compression vests are not superior to
manual compressions at the sternum
Hand placement over the heart for lateral compressions
No evidence that dorsal recumbency is superior to
lateral recumbency
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“Given the lack of high-quality evidence, no evidence based
recommendation regarding the best body position for chest
compressions in dogs and cats can be made at this time.”
Higher compression rates (100-120/min) are associated
with better outcome than 60/minute
Do not “lean” on the chest between compressions, to
allow full recoil between compressions
Compressions should be fast, as should the release
If you have an extra person, interposed abdominal
compressions do improve circulatory resuscitation
Interruptions to check ECG should happen no more
often than every 2 minutes
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2/3/2014
Basic Life Support
Training
(CPR Flow Sheet Form)
Domain 3
ALS – Advanced
Life Support
Advanced Life Support
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Defibrillation (BLS in CPR for people)
IV fluid therapy to correct metabolic disturbances
Drug therapy, including anesthetic reversal drugs
Open chest CPR
Strong support for epinephrine at 0.01 mg/kg
Strong support for early defibrillation of Vfib or
pulseless Vtach
• IF BLS and ALS performed promptly, ROSC can be
as high as 50%
Advanced Life Support
ALS Steps
1. Apply and respond to Monitors & Vital Signs
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HR, RR, temp, ECG, BP, spO2, ETCO2
2. IV fluid bolus 10 ml/lb over 10-15 minutes
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Contraindicated for congestive heart failure or oliguria/anuria
Reassess and repeat as necessary
Add colloids or hypertonic fluids PRN
3. Collect blood samples for Quick Assessment Tests
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Glucose, BUN, creat, PCV/TS
4. Run CBC, panel, electrolytes if life can be prolonged
5. Respond to abnormalities, reassess and respond again
Advanced Life Support
Advanced Life Support
Drugs
Drugs
Epinephrine – (0.01 mg/kg IV or IT)
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vasopressors
vagolytics
antiarrhythmics
Glucocorticoids
pH buffers
Reversal agents
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Raise blood pressure (pressor)
Improve myocardial perfusion
Increase tissue perfusion
Increase cardiac output (increase SV, increase HR)
This dose is preferred to higher doses
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2/3/2014
Advanced Life Support
Advanced Life Support
Drugs
Drugs
Is Vasopressin preferred to epinephrine?
Atropine 1:20
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Dose – 0.8 U/kg IV or IT
Vasopressin causes no additional harm
No studies in dogs and cats to show that vasopressin is
better than epinephrine
Vasopressin has an advantage for resuscitation of
certain categories of people who suffer CPA
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Dose – 0.4 mg/kg IV or IT
Data using atropine without a pressor are lacking
Reasonable to use when bradycardia or brief asystole
occurs due to increased vagal tone
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Asystole
Prolonged CPA
Hypovolemia as a cause of CPA
brachycephalics
Ileus, vomiting or other severe GI disease
Respiratory distress
Traumatic intubation
Increased CSF pressure
Advanced Life Support
Advanced Life Support
Drugs
Drugs
Atropine 1:20
Antiarrhythmics
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Unclear role for prolonged asystole
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Take care giving atropine when alpha agonists are on
board (xylazine, dexdomitor)
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These need a shock as a last resort
Pulmonary hypertension and pulmonary edema
Atropine is not indicated for tachyarrhythmias:
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Lidocaine**
Procainamide
Amiodarone
Bretylium
Magnesium
Ventricular fibrillation
Ventricular tachycardia
Advanced Life Support
Advanced Life Support
Drugs
Drugs
Antiarrhythmics
Antiarrhythmics
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No compelling evidence for routine use
Use only if arrhythmia of increased automaticity is
present
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Ventricular tachycardia
Ventricular fibrillation – after defibrillation fails
Pulseless vtach – after defibrillation fails
Contraindicated for lack of electrical activity
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Amioderonemight be the most effective antiarrhythmic
for shock resistant vfib and pulseless vtach I dogs
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Anaphylaxis has been reported
Lidocaine is the next best choice
Bretylium and magnesium play no role in treating these
shock resistant arrythmias
Amioderone has not been evaluated in cats
Asystole
bradyarrhythmias
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2/3/2014
Advanced Life Support
Advanced Life Support
Drugs
Drugs
Lidocaine Cheat Sheet
Lidocaine CRI Recipe (40-80 ug/kg/min IV)
1. 3 IV boluses over 10 minutes
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2 mg/kg (1cc/10lbs) IV over 1 minute x 2
4 mg/kg (2cc/10lbs) IV over 1 minute
If using an IV pump (36-72 ug/kg/min IV)
1.
2.
3.
2. If not effective, then start IV CRI (40-80 ug/kg/min)
•
Add 50cc 2% lidocaine to 1L fluids to make a 1 mg/ml solution
Set IV pump at Body Weight in pounds per hour for low end
Double fluid rate for upper end of dose range
If using drip rate (40-80 ug/kg/min IV)
1.
2.
(CPR Drug Dose Chart)
Mix as above if >30 lbs in body weight
Make stronger solution if <30 lbs
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3.
4.
5.
If <5 lbs - 20cc 2% lidocaine in 100c fluid in the Buretrol (4 mg/ml)
If 5-30 lbs - 10cc 2% lidocaine in 100c fluid in the Buretrol (2 mg/ml)
Use 60 drop/ml IV set (use 15-20 drops/ml for 15-30 lb pets)
Count seconds per drop if <30 lbs
Count drops/sec if >30 lbs
(drip rate chart)
Advanced Life Support
Advanced Life Support
Drugs
Drugs
Buretol
Corticosteroids
Dial-A-Flow
•
No evidence that it helps, unless indicated for
underlying process
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Septic shock
Anaphylaxis
Addisonian crisis
No evidence that it causes harm
Not currently recommended
Advanced Life Support
Advanced Life Support
Drugs
Drugs
Reversal agents
Lipid therapy
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Naloxone (0.04 mg/kg IV)
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Reverses opiates on board
Effects on endogenous endorphins
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Reverses dexdomitor or amitraz no board
Yohimbine (0.125 mg/kg IV)
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Reverses benzodiazepines on board
Atimepazole (0.1 mg/kg IV)
Reverses xylazine or amitraz no board
Reversing other sedatives exacerbates ketamine dysphoria
Lipophilic drugs
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Flumazenil (0.01 mg/kg IV)
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Positive inotrope, antiarrhythmic
More studies need to recommend for routine use
If CPA during anesthesia is resuscitated, lipid therapy to clear
lipophilic anesthetic drugs faster should be considered
•
Propofol, diazepam, ketamine, opiates
beta blockers, calcium channel blockers
parasiticides, herbicides
psychotropic agents
Intralipid® (Baxter) 20% lipid emulsion
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1.5 mL/kg over 5–15 min then 0.25 mL/kg/min over 1–2 hrs
repeated in several hours if clinical signs of toxicity return, and
there is no lipemia
Use aseptic technique
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Advanced Life Support
Advanced Life Support
Drugs
Drugs
Buffers - bicarbonate
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Preponderance of evidence recommends against routine
use of bicarbonate without confirming severe acidosis
Could be considered in prolonged CPA
Fewer harmful effects in dogs as compared to other
species
Indicated for confirmed metabolic acidosis
Calcium
• Routine use is not warranted or recommended
• Indicated for:
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Hypocalcemia
calcium channel blocker overdose
Severe hyperkalemia
(Bicarbonate administration handout)
Advanced Life Support
Advanced Life Support
Drugs
Drugs
Correcting Electrolyte/Metabolic Disturbances
IV vs. IT drug administration
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Hyperkalemia – see section 5 Case Study “Tom”
Hypokalemia (Potassium Supplementation Handout)
Hypocalcemia
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Calcium gluconate 10% 1.5-2.5cc IV slowly
Recheck calcium in 15 minutes, re-dose PRN
Hypoglycemia
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Dilute 1-3cc 50% Dextrose, qs to 10cc
Administer IV over 1-3 minutes
Serial reassessment of blood glucose and re-treat PRN
Can use glucagon for insulin overdose
Atropine, epinephrine, vasopressin
Use high dose (10x) for IT epinephrine (Drug Dose Chart)
Technique
1.
2.
3.
4.
5.
6.
7.
Mark catheter at end of ET tube when end is at base of heart
Draw dose and dilute qs to 3-10cc with sterile water or saline
attach dose to 5-8F polypropylene catheter
Disconnect endotracheal tube from ventilation (oxygen tank
of ambu bag)
Pass catheter to mark, inject drug
Detach syringe, fill with air, and inject again to clear drug
Resume ventilation
Advanced Life Support
Advanced Life Support
Defibrillation
Defibrillation
• Electrical defibrillation is without question the most
effective therapy for sudden cardiac death due to VF
• Defibrillation should pre-empt CPR as soon as Vfib is
identified, if Vfib has been present for less than 4
minutes
• If Vfib more than 4 minutes, do 30 compressions and
ventilate prior to defibrillation
• Bipolar defibrillation is preferable to monophasic
• most evidence supports prompt resumption of cardiac
compressions, so single shock every 2 minutes is
preferable to several in immediate succession
• USE ECG cream rather than alcohol for lead contacts
Increasing Defibrillator Energy
• Excessively high defibrillation energy may be
associated with increased myocardial damage
• However, failure to successfully defibrillate is
inevitably associated with death.
• For monophasic defibrillators, increasing energy
• doses are associated with increased success
• For BP defibrillators, the evidence is less clear
• an escalating protocol could be considered for both
types defibrillators (increase by 50% each time)
(CPR Drug Dose Handout)
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Advanced Life Support
Advanced Life Support
Defibrillation
Defibrillation
Internal Cardiac Compressions
HP CodeMaster Defibrillator/ECG
• Open-chest CPR is more effective than closed-chest
CPR in restoring ROSC and promoting a good outcome
in canine models of VFib (can visualize efficacy)
• open-chest CPR requires significant resources, is a
procedure that requires a skillful veterinary team, and
demands advanced post-cardiac arrest supportive care.
• In cases of significant intrathoracic disease it may be
advisable to promptly perform open-chest CPR and
defibrillation.
– tension pneumothorax
– Pericardial effusion
Advanced Life Support
Advanced Life Support
Defibrillation
Defibrillation
Zoll Defibrillators
Philips HeartStart Defibrillator / Monitor
Advanced Life Support
Defibrillation
DRE VidaStat Biphasic Defibrillator & Monitor
Domain 4
Monitoring
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Monitoring
Monitoring
Monitoring recommendations - Summary
1. Confirming CPA and intubation
2. Assessing adequacy of CPR and detecting ROSC
3. Continued monitoring after ROSC
• Time spent verifying absent pulse may delay onset of
CPR; chest compressions should be initiated immediately
for apneic, unresponsive patients.
• ECG analysis of an unresponsive patient may help to rule
out CPA, or be used to evaluate for rhythms requiring
specific therapy
• End-tidal CO2 (EtCO2) should not be used as the sole
confirmation of endotracheal intubation
• Pauses in chest compressions to evaluate the ECG
rhythm should be minimized
Monitoring
Monitoring
Monitoring recommendations - Summary
BSL - Rapid recognition of CPA
• EtCO2 monitoring is useful to identify ROSC, and may be
prognostic for the likelihood of ROSC
• Patient monitoring following ROSC should be directed at
identifying abnormalities that may portend another CPA,
and should be tailored to each patient
1. Patient is unresponsive, pupils unresponsive
2. Absence of breathing (agonal does not count)
3. Absence of heart beat
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No palpable pulses
No auscultable heart sounds
No Doppler activity at pulse points or on the cornea
Doppler assessment takes time, and might be more
appropriate after CPR has been started, or ROSL
4. Start cardiac compressions here
5. ECG checks confirm lack of effective circulation
6. ETCO2 falls to near zero
Monitoring
Monitoring
BSL - Rapid recognition of CPA
BSL - How to Assess Breathing
•
•
•
•
•
Watch for chest excursions for at least 1 minute
One hand lightly on the costochondral junction
Fingers of the other hand in front of the nose at the
same time
Need to see chest movement more than once
There should be clocks on the walls in all areas that are high
risk for CPA
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Surgery prep
OR and areas for other anesthetic procedures
Anesthesia Recovery
ICU
Clock on the crash cart is good
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Monitoring
Monitoring
BSL – Pulse Palpation to Detect CPA
ECG to Detect CPA
• Femoral pulse is preferred
• lay rescuers and healthcare professionals are often
unable to accurately and swiftly determine the presence
or absence of a pulse
• Need corroborating evidence
• Pulseless electrical activity (PEA) can give a false negative
for CPA
• Relatively normal ECG must be corroborated by other
evidence of spontaneous circulation
• ECG does reliably identify arrhythmias
–
–
–
–
– Vfib – defibrillate
– Vtach making pulses – drugs
– Pulseless Vtach – consider defibrillation then drugs
Lack of apical beat
Apnea
agonal breathing
lack of an auscultable heartbeat
• Presence of dorsal pedal pulse (metatarsus) confirms
MAP >80mmHg
• ECG can confirm bradyarrhythmia and asystole –
atropine for both (defib not indicated for asystole)
• ALL CPA victims get epinephrine
Monitoring
Monitoring
ECG to Detect CPA
ETCO2 to Detect CPA
• ECG can identify collapse without CPA
• At constant ventilation, a rapid decline in ETCO2 value is
expected during the evolution of CPA
– Respiratory arrest
• Start IPPV and assess for impending CPA
– sudden decrease of ETCO2 to near zero is a strong indicator of CPA
– Vagal surge
• Atropine, ventilate, assess for impending CPA
– Hypoglycemia
• IV dextrose and reassess
– Anaphylaxis
• Epinephrine, corticosteroids, antihistamines, IV fluids
– Internal hemorrhage
• IV fluids, transfusion
– Severe hypokalemia or acidosis
• Supplement potassium first, then correct acidosis only if severe
• In nonintubated patients, asphyxial CPA may elevate ETCO2
immediately prior to CPA
– Subsequent ETCO2 will rapidly decrease after the first few
delivered breaths unmasking the presence of CPA
– Asphyxia without CPA might show improvement in ETCO2 after
intubation and oxygenation
• ETCO2 cannot be used alone to diagnose CPA
• Rising ETCO2 during resuscitation may indicate ROSC
Monitoring
Monitoring
Confirmation of Endotracheal Intubation
ECG Monitoring During CPR
• direct visualization of the ETT between the arytenoid
cartilages is important
• Palpate tube in the trachea
• auscultation of air movement in both hemithoraces rules
out bronchial intubation
• observation of chest wall motion, or ETT condensation
are supportive evidence
• high ETCO2 immediately following intubation means
endotracheal intubation is likely, due to the low amount
of CO2 in the stomach and esophagus
• low ETCO2 isn’t helpful
• ECG can identify arrhythmias amenable to defibrillation
(pulseless VT and VFib)
• primary VFib remains a rare cause of CPA in veterinary
patients
• Most animals have initial arrest rhythm of PEA or
asystole that may convert to VFib during CPR
• ECG monitoring should be weighed against the risk of
interrupting chest compressions for ECG rhythm check
• resume chest compressions as soon as possible after
defibrillation and rhythm check
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Monitoring
Monitoring
ETCO2 Monitoring During CPR
ETCO2 Monitoring During CPR
• EtCO2 serves as a noninvasive surrogate measurement of
CO and myocardial perfusion during CPR
• EtCO2 is frequently used as a reflection of quality of CPR
when comparing approaches or devices.
• alter circulatory support methods to optimize EtCO2
• EtCO2 rises steeply when ROSC occurs
• continued low EtCO2 predicts nonsurvival
• EtCO2 less than 10 mm Hg over several minutes during
CPR is a poor prognostic indicator for ROSC
• Use caution when interpreting a rise in EtCO2 after using
either sodium bicarbonate or epinephrine during CPR
• Increase in EtCO2 from <10 to >14 mm Hg should prompt
evaluation for return of a heartbeat
• Rise in EtCO2 an be used to distinguish PEA from ROSC
Monitoring
Monitoring
Ventilation Monitoring During CPR
Blood Gas and Electrolyte Assay During CPR
• High ventilation rates (>10–12 breaths/min) should be
avoided
• increased time of positive intrathoracic pressure has
negative effect on hemodynamics
• Excessive ventilation during CPR commonly occurs, even
with trained personnel
• Venous blood gas values have better predictive value for
ROSC than arterial blood gas values
• Venous blood gasses are directly related to cardiac
output and tissue perfusion
• When cause of CPA is due to electrolyte abnormalities,
electrolyte assay may allow directed therapy
• Ionized hypocalcemia may be prognostic for ROSC
• Identifying and correcting abnormalities may promote
ROSC
Monitoring
Monitoring
Vfib Waveform During CPR
Monitoring after ROSC
• coarse VF is more likely to respond with ROSC following
defibrillation than fine VF
• Asystole is unlikely to respond to defibrillation, despite
this being commonly portrayed in medical dramas
• On the other hand, little is lost by attempting to
defibrillate prolonged asystole
• To prevent re-arrest
– treat precipitating disease
– treat short term sequellae of CPA
• Treat longer term sequellae of CPA
– Brain hypoxia and ischemia
– Cardiac ischemia and dysfunction
– Reperfusion injury
• Two types of post ROSC monitoring
– Intensive continuous monitoring
– Intermittent monitoring
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Monitoring
Monitoring after ROSC
• Parameters monitored
– ECG - Myocardial hypoxia can result in post-resuscitation
arrhythmia
– BP - Episodes of hypotension following ROSC are associated with
a worse outcome
– Temperature – thermoregulation is a good prognostic indicator
– spO2, +ETCO2 – hypoxic injury to the lungs can result in
refractory pulmonary edema (ARDS)
– Glucose - severity of post ROSC hyperglycemia is correlated with
worse outcome
Domain 5
Post--Arrest Care
Post
• Post ROSC seizures worsen prognosis
Post Arrest Care
• In humans, 60-70% of sudden CPA victims do not
survive to hospital discharge despite having achieved
ROSC initially
• survival to discharge rates for dogs and cats range from
2-10%, despite initial ROSC of 35–45%
• these patients succumb to post-cardiac arrest (PCA)
syndrome
–
–
–
–
multiorgan failure
cardiogenic shock
anoxic brain injury
Sequellae of preexisting diseases
Post Arrest Care
Post-Arrest Recommendations – Summary
•
•
•
•
•
fluid therapy adjusted according to monitoring is reasonable
Monitor and establish normoxemia
neurologic benefit of gradual rewarming after hypothermia
Conservative fluid resuscitation until cats are rewarmed
no evidence to support routine administration of
corticosteroids, antiseizure meds, mannitol, or metabolic
protectants
• Low-dose corticosteroid treatment of patients with
persistent hypotension requiring sympathomimetic support
may be considered
Post Arrest Care
Post-Arrest Recommendations – Summary
• Hypertonic saline (HS) may be considered for cerebral
edema as evidenced by coma, obtundation or dysphoria
• Bundled therapy may have outcome benefit.
–
–
–
–
Hypothermia
Hypertension
Normocapnia (as opposed to hypocapnia)
Thiopental, methylprednisolone, phenytoin, antioxidants
• More comprehensive PCA care in a specialty with ICU may
have an outcome benefit
CPR Guidelines
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CPR Guidelines
CPR Guidelines
Placement of Hands for Chest Compressions
Small Animal Veterinary CPR Algorithm
Post CPR Alogrithm
CPR Guidelines
Placement of Hands for Chest Compressions
• For most dogs, do chest compressions over the widest
portion of the chest
• maximally employs the thoracic pump theory
• Either left or right lateral recumbency are acceptable
CPR Guidelines
Placement of Hands for Chest Compressions
• In keel-chested (i.e., deep, narrow chested) dogs like
greyhounds, do chest compressions with the hands directly
over the heart
• in either left or right lateral recumbency
CPR Guidelines
Placement of Hands for Chest Compressions
CPR Guidelines
Placement of Hands for Chest Compressions
• for barrel chested dogs like English Bulldogs, consider doing
sternal compressions directly over the heart
• patient in dorsal recumbency
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CPR Guidelines
Placement of Hands for Chest Compressions
CPR Guidelines
Placement of Hands for Chest Compressions
• for cats and small dogs (<10 kg) with compliant chests, a 1handed technique for circumferential chest compressions
• hand wrapped around the sternum directly over the heart
• An alternative is the 2-handed technique directly over the
heart to employ the cardiac pump mechanism
– This method may be considered in larger cats and small dogs with
lower thoracic compliance
– or in situations in which the compressor is becoming fatigued while
doing 1-handed compressions
CPR Guidelines
Placement of Hands for Chest Compressions
CPR Guidelines
Placement of Hands for Chest Compressions
CPR Guidelines
Complete CPR Guidelines
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