3. Definitions
• Respiratory arrest
– Cessation of breathing
• Cardiopulmonary arrest
– Cessation of effective and spontaneous perfusion and
breathing (no palpable pulse, no heart sounds)
• CPR vs CPCR
– Cardiopulmonary resuscitation
– Cardiopulmonary cerebral resuscitation
4. Outcomes
• Overall poor prognosis
– Survival to discharge 6-7%
• Re-arrest rates
– 68% dogs and 37% cats Survival to discharge
5. • Large prospective observational study that
investigated many aspects of CPR
• Survival to discharge: 6% dogs and 3% cats
• Simple anesthetic arrest (only 3 cases)
– 33% survived to discharge
6. Dogs
With
CPA
ROSC
58%
No ROSC
23%
ROSC < 20 min: 23%
Euth: 10%
Repeat CPA:13%
ROSC > 20 min: 35%
No longer alive at 24 hr.
Euth: 21%
Repeat CPA: 4%
Alive at 24 hr.
10% Euth: 4%
Repeat
CPA:
0Survive to Discharge
6%
7. Outcome
• We often cannot change what happened to the
patient prior to arrest
• We can change staff and equipment variables that
affect outcome
• Successful outcomes are dependent on
– Staff preparedness
– Stocked crash area
– Working and available equipment
– TEAM WORK
8. Outcome: Staff Preparedness
• Recognize patients at risk
• Didactic training and hands on practice
– Refresher every 6 months
• Centrally located crash cart
– Routinely checked
• Algorithm and dosing charts
9. Outcome: Staff Preparedness
• Standardized CPR guidelines in human
medicine improved outcome after in hospital
CPA:
– 2000: 13.7%
– 2009: 22.3%
10. Who is at risk?
• Trauma
• Respiratory system disease
• Septicemia
• Prolonged seizures
• Cardiac disease
• Vagal stimulation
• Anesthetic agents
• Severe metabolic disease
11. Goals of CPCR
• Provide artificial respiration and
cardiovascular support until Return of
Spontaneous Circulation (ROSC)
– Coronary perfusion pressure
– Cerebral perfusion pressure
• Identify cause and treat immediately
14. CPR/CPCR
• Be prepared
– Determine if a pet is breathing or if it has a
heartbeat
– Training, supplies, cognitive aids
• Don’t panic!
– Try to remain calm but efficient
• Call for help
– CPCR is labor intensive and is more likely to be
successful with a team rather than an individual
15. CPR/CPCR
• First, follow your ABC’s (basic life support)
– Airway
– Breathing
– Circulation/chest compressions
• Then, think about your DEF’s (advanced life support)
– Drugs
– Electrical defibrillation/ECG/End tidal CO2
– Fluid therapy
16. CPR/CPCR
• First, follow your ABC’s (basic life support)
– Circulation/chest compressions
– Airway
– Breathing
• Then, think about your DEF’s (advanced life support)
– Drugs
– Electrical defibrillation/ECG/End tidal CO2
– Fluid therapy
19. Basic Life Support
• CIRCULATION
– Check for heart beat/pulse
– Do not assume there is no heart beat or pulse just
because they are not breathing
– Place patient in lateral recumbancy
• Preferably right
– If no heart beat or pulse begin chest compressions
20. Basic Life Support
• CIRCULATION/CHEST COMPRESSIONS
– Goal
• Maximize blood to the heart and brain
• Restore pulmonary CO2 elimination and O2 uptake by
providing pulmonary blood flow
– Small patients
• One hand thumb and forefingers
Cardiac pump theory
Recover: JVECC 22 (S1) 2012, S102-S131
21. Basic Life Support
• CIRCULATION/CHEST COMPRESSIONS
– Large patients
• Hands on top of one another at a 90 angle
• Widest part of chest
• Elbows straight
• Bend at the waist
Thoracic pump theory
Recover: JVECC 22 (S1) 2012, S102-S131
22. Basic Life Support
• CIRCULATION
– Chest compressions – where
• Cardiac Pump - patients <15kg (<33 pounds)
– Compress directly over the heart
– Point of the elbow
• Thoracic Pump- patients >15 kg or barrel chested
breeds
– Compress at the widest part of thorax (usually further
back/caudal)
23. Basic Life Support
• CIRCULATION/CHEST COMPRESSIONS
• Minimize interruptions to <10 seconds and switch out
every 2 minutes or upon checking vitals
• Including for intubation, blood draws, drug
administration
24. Basic Life Support
• Circulation/Chest compressions
– How hard
• Compress thoracic wall by ~1/3-1/2
– What rate
• At least 100 compressions/minutes
• “Stayin’ Alive” vs. “Another One Bites the Dust”
– What rhythm
• 1:1 cycle (equal time spent compressing as allowing
chest to expand)
25. Basic Life Support
• AIRWAY
– If agonal or not breathing obtain airway
– Check airway for any obstruction to flow
• Tilt head slightly back and extend the neck
• Carefully, pull tongue forward and down to better
visualize
• Use suction if needed
• Use manual palpation if needed
26. Basic Life Support
• AIRWAY
– Ensure proper tube placement
• Visualize placement
• Auscult for breath sounds
• Observe for chest excursions
• ETCO2
– Esophageal intubation-zero
27. Basic Life Support
• BREATHING
– Connect to a resuscitation/ambu bag
– Provide positive pressure ventilation up to 20 cm
H20
– 100% oxygen, 8-10 breaths/minute
– Inspiratory time 1 sec
– Tidal volume 10 ml/kg
– Avoid hyperventilation
28. Basic Life Support
• BREATHING
– Trouble shooting
• High pressure needed to generate breath
– Pleural space disease
– Pulmonary disease
– Tube obstruction
• No chest excursion
– Inappropriate endotracheal tube placement
– Cuff leaking
– See above
32. Advanced Life Support: Monitoring
• Attach ECG
– White lead – Right front
– Black lead – Left front
– Green lead – Right hind
– Red lead – Left hind
• Minimal alcohol or use conducting gel
• Rhythm diagnosis
– Administer appropriate drugs
33. Asystole
• No rhythm on ECG
• Survival rate in people nearly 0%
• Treatment options
– Atropine
– Epinephrine
– Vasopressin
36. Ventricular Fibrillation
• Course V Fib
– 30% response rate
– SVT or sinus rhythm common when converted
• Fine V Fib
– 5% conversion rate
– Asystole converted rhythm
• Predisposing causes
– Hypokalemia
– Hypomagenesemia
www.mauvila.com
www.resuscitationcentral.com
37. Advanced Life Support
• DRUG ADMINISTRATION
– Intravenous
• Ideal mode
• Central large bore catheter best
• Peripheral typically easier during arrest
• Consider venous cutdown early
• If peripheral catheter, flush with 5-50 ml flush to reach
the heart
38. Jugular Cut Down
• Quickly clip and prep area over jugular vein
• 1-2 cm incision made through skin (#10 or #11 blade) parallel
to the vessel
• Vessel dissected free from tissue
• Hemostats to lift/isolate vessel
• Catheter placed directly into vessel
• Secure in place by suturing
Advanced Monitoring and Procedures for Small Animal Emergency and Critical Care Fig 4.5
39. Intraosseous Catheter
• DRUG ADMINISTRATION
– Intraosseus
• For small patients and exotics
• All medications can be given
– Equipment
• Jamshidi bone marrow needle
• 18-30g hypodermic needles
• Spinal needle
– IO catheter sites
• Trochanteric fossa of femur
• Wing of the ilium
• Greater tubercle of the humerus
40. Advanced Life Support
• DRUG ADMINISTRATION
– Intratracheal
• Double dose
• Dilute with saline to 5-6 ml
• Flush to carina with red rubber catheter
• Give two deep breaths
• DO NOT GIVE SODIUM BICARBONATE via this route
– NAVEL
• Naloxone
• Atropine
• Vasopressin
• Epinephrine
• Lidocaine
41. Advanced Life Support
• Common drugs
– Epinephrine
– Atropine
– Vasopressin
– Dextrose
– Sodium bicarbonate
– Calcium gluconate,
insulin
– Reversal agents
• Naloxone, flumazenil,
antisedan
42. Vasopressors
• Increased vascular resistance to redirect blood
flow to core
– Epinephrine
• Low dose (0.01 mg/kg) recommended every 4-5 min
– Vasopressin
• 0.8 U/kg
• Can be used interchangeably or in combination with
epinephrine
48. Advanced Life Support
• Tricks or “short cuts” to remember doses
– Epinephrine: 0.1ml per 20 lbs
– Atropine: 1.0 ml per 20 lbs
– Naloxone: 1.0ml per 20 lbs
– Flumazenil: 1.0 ml per 20 lbs
49. Advanced Life Support
• ELECTRICAL DEFIBRILLATION
– Reserved for ventricular fibrillation
– 4-6 J/kg (40 J per 20 lbs)
50. Electrical Defibrillation
• ELECTRICAL DEFIBRILLATION
– Conducting gel for the paddles
– Rinse off alcohol if present
– Put patient in dorsal recumbancy
– Place paddles on either side of chest
– Charge paddles
– Yell “Clear” and make sure staff is clear
– Immediately resume CPR for 2 minutes before
assessing rhythm
51. Advanced Life Support: IV Fluids
• Fluid therapy
– Shock fluid therapy reserved for hypovolemic
patients only
– IVF contraindicated in euvolemic patients
• IVF therapy can decrease coronary perfusion
Coronary perfusion pressure = aortic diastolic pressure – right atrial pressure
52. Advanced Life Support
• Ideal additional monitoring
– ETCO2
• With ROSC see a steady increase in value
• Humans with ETCO2 not reaching above 12mmHg
during arrest did not have ROSC
– Obtain blood for stat labs
• PCV/TS, BG, electrolytes and pH
Fig 9: Capnography in dogs: Compendium October 2004
53. • ETCO2 </= 10 mmHg after 20 minutes of CPCR
accurately predicts death
• “Cardiopulmonary resuscitation may
reasonably be terminated in such patients”
54. Additionally…
• Things to anticipate
– Large dogs or patients with intrathoracic disease may
require open chest CPR
– If no venous access
• Get red rubber ready for intratracheal administration
• Be prepared for cut down
55. Open Chest CPR
• Indications
– Pleural space disease
– Pericardial effusion
– Penetrating chest wounds/chest wall trauma
– Heavy patient/large breeds/incompressible thorax
– Intra –operative arrests
– No ROSC after 2-5 minutes of closed chest CPR
– Post cardiothoracic surgery, chest/abdomen is already
open
56. RECOVER Initiative
• Reassessment Campaign on Veterinary Resuscitation
• VECCS and ACVECC worked together to evaluate
resuscitation and how it is applied clinically
• Adapted the approach taken by the American Heart
Association (AHA) and the International Liaison
Committee on Resuscitation (ILCOR)
• Results published in JVECC as supplemental volume
in June 2012
57. RECOVER Initiative
• Divided into 7 parts focusing on evidence and
knowledge gap analysis
– Part I: Evidence analysis and consensus process:
collaborative path toward small animal CPR guidelines
– Part II: Preparedness and prevention
– Part III: Basic Live support
– Part IV: Advanced life support
– Part V: Monitoring
– Part VI: Post cardiac arrest care
– Part VII: Clinical guidelines
58. RECOVER Initiative
• Divided into 7 parts focusing on evidence and
knowledge gap analysis
– Part I: Evidence analysis and consensus process:
collaborative path toward small animal CPR guidelines
– Part II: Preparedness and prevention
– Part III: Basic Live support
– Part IV: Advanced life support
– Part V: Monitoring
– Part VI: Post cardiac arrest care
– Part VII: Clinical guidelines
59. RECOVER Initiative
• Preparedness and Prevention
– Equipment and supply delays or failure resulted in
delay of CPCR in 18% of cases
– Routine training and review
– Use of flow charts/dosing charts
– Team leader during arrest
– De-brief following successful or unsuccessful
CPCR
60. RECOVER Initiative
• Basic Life Support
– Chest compressions
• Large dogs: hands over widest part of chest
• Small dogs: hands directly over heart
• Very small dogs/cats: circumferential
• 100-120 compressions per minute
– Ventilation
• Continuous compression and ventilation
• 10 breaths per minute
– Cycles
• Rotate compressors every 2 minutes
61. RECOVER Initiative
• Advanced Life Support
– Epinephrine: low dose every 3-5 minutes
– Atropine
– Vasopressin: 0.8 units/kg as a substitute or in
combination with epinephrine
– Defibrillation: in cases of V-fib
– 100% O2
– IVF: not recommended if euvolemic
62. RECOVER Initiative
• Monitoring
– ETCO2: use for monitoring of ROSC
– Additional monitoring can be considered but
should NOT interrupt compressions
• ECG
• Doppler
• Electrolytes
– Use along with auscultation of heart and lungs (do
not use as sole device)
64. Updates Since RECOVER INITIATIVE
• Metabolic acidosis and
hyperlactatemia (100%)
• Respiratory acidosis:
– 88% during CPR
– 61% following ROSC
• Hyperkalemia 65%
• Decreased iCa 18%
• Hypoglycemia 21%
• Hyperglycemia 62%
Take away message: Point of care testing may be important during CPR
65. Updates Since RECOVER INITIATIVE
• Since RECOVER initiative this hospital showed:
– Increased use of capnography
– Increased use of suction to aid in intubation
• RECOVER guidelines altered CPR teaching
66. Updates Since RECOVER INITIATIVE
• To provide recommendations for reviewing
and reporting CPR events in dogs and cats
• Template for standardized reporting
• Will allow high quality veterinary CPR
research, improve data comparison and serve
as the foundation for veterinary CPR registries
67. Summary
• Be Prepared
– All staff know what to look for
– All staff know where supplies are
• Check for breathing and pulses
• Follow your ABC’s (or BACs) and then the
DEF’s
• Record what was done and when.
• Remember, this is a TEAM effort.
CPR: used to treat animal that is not breathing and has no heart beat or pulse, consists of rescue breathing and chest compressions
Previously reported wide range with published survival rates of 3-4% in dogs and 2-10% in cats
Large study that reported many aspects/results of CPR in a university teaching hospital
Patients undergoing simple anesthetic arrest:
Very small number of cases
No systemic disease and undergoing elective procedure
Higher percentage of patients survived to discharge
CPA: Cardiopulmonary Arrest
Some of this data is what helped to spur the Recover initiative
* If increase right atrial pressure can decrease coronary perfusion pressure
* If increased intracranial pressure or decreased mean arterial pressure will decrease blood flow to brain
* Determining if patient is breathing or has heartbeat should only take a few seconds
Based on studies in people it is now recommended to start compressions first
In veterinary patients respiratory arrest is often seen first so intubation is more important especially if patient still has heartbeat
If true CPA start compressions first but should be immediately followed by or have simultaneous intubation
Based on studies in people it is now recommended to start compressions first
In veterinary patients respiratory arrest is often seen first so intubation is more important especially if patient still has heartbeat
If true CPA start compressions first but should be immediately followed by or have simultaneous intubation
* Start as soon as possible or at same time as chest compressions
Waldrop, et al JVECC 14 (1)2004 22-29
Rush JE, Wingfield WE. JVAMA 1992;200(12)1932-3.
Hofmeister et al JAVMA 2009
Electrical activity with no mechanical activity
electromechanical dissociation
Group of dysrhythmias unaccompanied by a detectable pulse or auscultable heart rhythm
Can also do cut down on other vessels
* Every other rotation
2-5 J/kg external; 0.3-0.5 J/kg internal
If ETCO2< 10mm Hg attempt to improve CPR quality; if sudden and sustained increase in ETCO2 return of spontaneous circulation
When a 20-minute end-tidal carbon dioxide value of 10 mm Hg or less was used as a screening test to predict death, the sensitivity, specificity, positive predictive value, and negative predictive value were all 100 percent.
Due to limited time I will not go into details (could be an entire talk) and requires intensive post arrest care
Left thoracotomy in 4th or 5th rib space
Rib retractors
Remove pericardium
More than 80 veterinary professionals worked with advice from co chaire of the international laison committee on resuscitation
5 domains
Preparedness and Prevention
Basic Life Support
Advanced Life Support
Monitoring
Post Cardiac Arrest Care
Brief summary, this can be an entire talk
JVECC 2014
Point of care testing may help determine cause of arrest as well as treatment recommendations
Future studies may determine information about predicting outcome etc.
JVECC 2015 out of the UK
Shows increased training and following RECOVER recommendations
Hopefully will promote more training guidelines
Hopefully will allow more uniform data to be collected for future CPR recommendations
JVECC 2016 Drs Boller, Fletcher, Brainard et al:
Variables were defined and categorized as hospital, animal, event and outcome variables
Core elements: suspected cause and location of arrest, first rhythm identified, occurrence of return of spontaneous circulation of more than 30 sec or more than 20 min, survival to discharge, functional capacity at discharge
Report if CPR is discontinued or the patient is euthanized by owner request
This will allow for us to gather further recommendations/results in the future