Cardiopulmonary Cerebral Resuscitation (CPCR) for Veterinary Technicians

Cardiopulmonary Cerebral Resuscitation (CPCR)

Danielle Berube DVM, DACVECCUpstate Veterinary Specialties

September 17, 2016

Outline

• What is it• Outcomes• Who is at risk• Basic Life Support• Advanced Life Support• RECOVER Initiative

What is it?• 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

CPR/CPCR

• Used to treat animal that is not breathing and has no heart beat or pulse

• Consists of rescue breathing and chest compressions

Outcomes

• Overall poor prognosis– Survival to discharge 6-7%

• Re-arrest rates– 68% dogs and 37% cats Survival to discharge

Outcomes• 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

Outcomes: Prepardness

• Staff preparedeness– Recognize at risk patients– Know where everything is– Know what to do– Anticipate clinician requests– Communicate

Who is at risk?• Trauma• Respiratory system disease• Septicemia• Prolonged seizures• Cardiac disease• Vagal stimulation• Anesthetic agents• Severe metabolic disease

Know where everything is:A dedicated “crash” area

• Crash cart with ready to use endotracheal tubes, Laryngoscope and assorted blades

• Drugs for resuscitation


• Oxygen administration– Oxygen source– Anesthesia machine/ambu bag– Cone masks


• Fluid resuscitation– IV catheter placement supplies– Infusion pumps– Lactated ringer’s solution, normal saline,

plasmalye or normosol R


• Monitoring supplies– ECG– Doppler and blood pressure cuffs– Suction unit– Warming device– ETCO2

Know what to do

• Chest compressions• Intubation/breathing• Hooking up monitoring equipment• IV catheter placement• Drawn up requested drugs• Recorder

Anticipate clinician requests

• Training/practice sessions• Dosing chart• Emergency drugs pre calculated for

patients

Communicate

• One person in charge, “running the code”• This is a tense situation, try not to take

things personally

www.cvknowhow.com

Goals of CPCR

• To provide artificial respiration and cardiovascular support until spontaneous perfusion and ventilation is restored

• Identify arrhythmias and/or inciting cause and treat immediately

CPR/CPCR• Be prepared

– Know how to determine if a pet is breathing or if it has a heartbeat or pulse rate and act quickly

• Don’t panic!– Try to remain calm but efficient

• Call for help– CPR is labor intensive and is more likely to be

successful with a team rather than an individual

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

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

RECOVER: JVECC 22 (S1) 2012, S102-S131

Basic Life Support

Recover: JVECC 22 (S1) 2012, S102-S131

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

Basic Life Support• CIRCULATION/CHEST COMPRESSIONS

– Goal• Maximize blood to the heart and brain

– Small patients• One hand thumb and forefingers


Cardiac pump theory

Basic Life Support

• CIRCULATION/CHEST COMPRESSIONS– Large patients

• Hands on top of one another at a 90 angle• Elbows straight• Bend at the waist


Thoracic pump theory

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)

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

Basic Life Support• Circulation/Chest compressions

– How hard• Compress thoracic wall by ~1/3

– 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)

Basic Life Support• AIRWAY

– Check the patient for ventilation– If agonal or not breathing obtain airway– Check airway for any obstruction to flow

• Lay animal down• Tilt head slightly back and extend the neck• Carefully, pull tongue forward and down to better

visualize (if patient not actually in respiratory arrest, this is when it will bite)

• Use tongue depressor to check for and remove any foreign objects or vomit

Basic Life Support• AIRWAY

– If airway is patent• Intubate with endotracheal tube• Suction if needed to visualize

– If cannot visualize within a few seconds of suctioning, attempt to manually guide endotracheal tube into airway

• Secure endotracheal tube• Inflate cuff

Intubation

Advanced Moitoring and Procedures for Small Animal Emergency and Critical Care Pg 300 Fig 23.9

Basic Life Support

• AIRWAY– Ensure proper tube placement

• Auscult for breath sounds• Observe for chest excursions• ETCO2

– Esophageal intubation-zero– Tracheal intubation 5 prior to ROSC

www.medwow.com

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

https://mail.google.com/mail/?ui=2&ik=f4978dbbf5&view=att&th=138ba09b55882a07&attid=0.5&disp=inline&safe=1&zw

Anesthetic Arrest

• Turn off gas anesthetic• Flush the anesthetic line

– Disconnect patient– Press O2 flush valve– Empty reservoir bag– Reconnect patient

• Give patient positive pressure breaths; “bagging” the patient

Anesthetic Arrest:“Bagging” the patient

• Close pop off valve• Give positive pressure breath by

squeezing the reservoir bag– No greater than 20 cm H2O

• Open pop off valve• 8-10 breaths/min

Basic Life Support • Early recognition and preparedness is key for

patient survival• Chest compressions over heart if <15 kg, over

widest part of the thorax if >15kg at 100-120 compressions /minute

• Intubate/Obtain airway• 100% oxygen at approximately 10

breaths/minute


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

Advanced Life Support• DRUG ADMINISTRATION

– Intraosseus• For small patients and exotics• All medications can be given

– 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


• Common drugs – Epinephrine– Atropine– Vasopressin– Amiodarone– Dextrose

– Calcium gluconate, insulin– Reversal agents

• Naloxone, butorphanol, flumazenil, antisedan


• 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

Rhythm Diagnosis: Identifying the Arrhythmia

• Asystole– “flat line”– 22.8-72%


• Pulseless electrical activity– Electrical activity without mechanical activity– 11-23.3%


• Sinus bradycardia– Normal sinus beats but slower rate– 19-23%


• Ventricular fibrillation– 2-19.8%


• Ventricular tachycardia– Not commonly seen during an arrest but can

lead up to CPA


• ELECTRICAL DEFIBRILLATION– Reserved for ventricular fibrillation

– What the doctor needs• Conducting gel for the paddles• Put patient in dorsal recumbancy• When doctor says clear – let go of the patient and

anything connected to the patient• After discharged immediately resume CPR for 2

minutes before assessing rhythm

www.resuscitationcentral.com


• Fluid therapy– Shock fluid therapy reserved for hypovolemic

patients only– IVF contraindicated in euvolemic patients


• 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• Blood pressure if able

www.medwow.com

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

RECOVER Initiative• Reassessment Campaign on Veterinary

Resuscitation• VECCS and ACVECC worked together to

evaluate resuscitation and how it is applied clinically

• Results published in JVECC as supplemental volume in June 2012

RECOVER Initiative

• 5 domains– Preparedness and Prevention– Basic Life Support– Advanced Life Support– Monitoring– Post Cardiac Arrest Care

RECOVER

• 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

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

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

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)

RECOVER Initiative

• Post Cardiac Arrest Care

Summary

• Be Prepared• Check for breathing and pulses prior to

starting• Never do CPR on a conscious animal• Follow your ABC’s and then remember the

DEF’s

Finally…• Listen, see what needs to be done and if

qualified get to it, if not qualified take over for someone who can.

• Jump in and help with intubation, vascular access, compressions, instrumentation.

• Find and draw up equipment and drugs.• Record what was done and when.• Remember, this is a TEAM effort. • EVERYONE can contribute.

Thank you!

Questions?

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Cardiopulmonary Cerebral Resuscitation (CPCR) for Veterinary Technicians