Triage, shock, and CPR

What is critical thinking?

Critical thinking- ability to rationally make a decision regarding the patient on the basis of thorough consideration of data discovered through investigation, analysis and evaluation

What does the word “Triage” mean?

To sort or to choose.

Triage is accomplished by determining a patient’s acuity level by observing, taking a history, and obtaining vital signs

What are some ways we are “assessing” our patients?

Is pet alert?

Difficulty breathing?

Abnormal posture?

Presence of blood?

Get brief history from owner

Some owners can be very emotional during emergencies

Obtain vital signs

Non urgent vs urgent vs emergency/life threatening

Non urgent: Get full history, client and patient info, inform of wait times, get tpr, vet does exam

Urgent: Get concern, perform tpr in room, get some details on history, vet performs exam and decides treatment. discuss CPR, have owner sign consent.

Emergency/life threatening: Client must give verbal consent for treatment, and for CPR, pet is brought to treatment for immediate stabilization, owner asked for consent forms by staff/front desk, full history obtained while patient is being stabilized.

What are the different levels of CPR code?

Red - No CPR, DNR

Yellow - Closed-chest CPR

Green - Open-chest CPR - surgical CPR

What should be included in a crash cart?

Needs to be very organized and fully stocked at all times

Emergency Drug Dose Table

Monitoring equipment

Suction unit

Defibrillator

Organize drawers according to ABC

Airway

Breathing

Circulation

Extra items: Stethoscope

Surgery pack

Suture

Scalpel blade

Rib retractor

Sterile gloves

Airway items in a crash cart

Endotracheal tubes

Tie

Inflation syringe

Stylets

Laryngoscope

Variety of blade sizes

Mouth gag

Gauze

Breathing items in a crash cart

O2 source

Direct line

Anesthesia machine

Ambu Bag

Circulation items in a crash cart

IV CatheterWhat are s

Tape

Syringes

Needles

Tourniquet

IV fluids and drip set

What are some drugs in a crash cart?

Atropine

Epinephrine

Vasopressin

Lidocaine

Sodium Bicarbonate

Possibly other drugs depending on hospital type and size

What is the definition of shock?

Defined as inadequate cellular energy production

Most commonly occurs secondary to poor perfusion or uneven blood flow resulting in critical decreases in oxygen delivery

What are the different kinds of shock?

Classifications:

Cardiogenic

Hypoxic

Metabolic

Distributive

Obstructive

Hypovolemic – most common

What is the most common kind of shock?

hypovolemic shock

What is hypovolemic shock?

Most common form of shock

Primary perfusion failure

Results from a reduction in circulating blood volume

Bleeding

Dehydration

Effusive fluid loss (third spacing)

What is cardiogenic shock?

Associated with decreased cardiac output

Can occur from heart failure

Cardiomyopathy

Valvular disease

Cardiac arrhythmias

What is hypoxic shock?

Reduction of oxygen in arterial blood

Anemia

Lack or hemoglobin

What is metabolic shock?

Inadequate nutrients available for cellular energy production

Hypoglycemia

What is distributive shock?

Maldistribution of blood flow associated with vasodilation

Consequent decrease in effective blood volume

Regardless of intravascular volume or cardiac output

Common causes

Trauma

Heatstroke

Envenomation

Anaphylaxis

Sepsis

What is obstructive shock?

Blockage in blood flow

Examples: GDV, pericardial effusion, caval syndrome

What are the stages of shock?

Stage 1: Compensatory shock

Stage 2: Decompensatory shock

Stage 1: Compensatory shock

Earliest phase of shock

Clinical signs

Increased heart rate and respiratory rate

Rapid capillary refill time

Brick red mucous membranes

Bounding pulses

Stage 2: Decompensatory shock

Second phase of shock

Clinical signs

Weak pulses

Rapid heart rate

Increased capillary refill time

Pale mucous membranes

Hypothermia

Dull mentation

How do we assess shock?

Perfusion parameters of physical exam

Mentation- Quiet, Obtunded, Stupor or Coma

MM color- white, pale, brick red

CRT- slow or fast

HR- varies

Pulse quality- vasoconstriction=thready. Vasodilation=bounding

Extremity temperature- cool

How do we treat shock?

How do we monitor shock?

What are some important things for preparation for CPR

ideally 3-5 staff members - all staff should be trained

Clean facility with plenty of space.

Equipment ready - the crash cart fully stocked and organized.

To be calm and know that the patient is already dead so it can only go up from there…

48-50% chance of ROSC

What does ROSC stand for?

Return Of Spontaneous Circulation

Recognition of CPA - Cardiopulmonary Arrest

Often done by a vet tech. 10-15 sec.

Observing for changes in all patient. - mentation, R depth, pattern, HR, rhythm, quality.

Preventing is easier than treating!

CPA should be suspected in any patient with no obvious signs of breathing or heartbeat.

Starting CPR right after CPA is key to recovery!!

What are Agonal breaths?

Agonal breaths – gasping for air before dying, not considered adequate breathing; initiate CPR

What are the goals of CPR?

Return of spontaneous circulation (ROSC)

Return of respiration

Prevention of permanent CNS dysfunction.

What is basic life support? BLS

Just chest compression, airway and breathing. To temporarily support patients circulation, ventilation, and airway.

What are the ABC’s?

Airway, breathing, circulation.

What should the proper order of the ABC’s be?

CAB - Circulation is priority!!! chest compressions. Airway should only be first if only respiratory arrest and no witnessed CPA.

CPR initial assessment algorithm?

Find patient unresponsive - call for help: Shake and shout!!! quick look and the mouth and swipe for anything that may be obstructing. Any breathing?

Depending on number of rescuers -

1- Is the airway clear? yes - start single rescue BLS. no - clear airway and then start single-rescuer BLS. 30 compressions and then 2 breaths!! back and forth.

2+ - First person starts chest compressions 100-120 a minute. Second person checks airway while intubating. Ventilating every 6 seconds.

External chest compressions

2 handed - thoracic pump (compressing the peak of the whole chest which is then compressing the heart) : round chested medium and large dogs. Cardiac pump (lower where the heart actually is and compressing the chest right over the heart): keel chested (greyhounds), thinner, medium to large dogs

1 handed chest compression - cardiac pump: small dogs and cats. 2 handed method can over compress the heart in small pets.

Better for dogs like bulldogs, frenchies, pugs etc to be in dorsal recumbency.

How to perform compressions properly

Push hard and fast. Straight arms, no leaning, bend at waist. The patients ribs may break!

100-120 compressions a minute. 1:1 ; compressions : relaxation.

Compress 1/3 - ½ chest depth

Allow full recoil of the chest.

How long should you do compressions for?

Change persons doing compressions every 2 minutes. 2 minutes is considered one CPR cycle. It gets tiring super fast. communicate - someone should be timing. There should be ten seconds or less between switching out compressors. Minimize interruptions -Remember circulation takes priority over everything.

What should happen between switching compressors?

Should be fast - quickly asses patient, check for pulse, ECG, check for ROSC.

Internal chest compressions

This is a direct cardiac massage - a hand in the chest squeezing the heart. This is more effective than external compressions.

May require a thoracotomy - do not attempt if clinic/staff is not equipped for the aftercare!!

Lateral - hair is clipped but not complete sterile prep.

Could be done after 5 minutes of external compressions with no results.

When can external compressions not be done and internal chest compressions done instead?

• Rib fractures

• Penetrating chest wounds

• Pneumothorax

• Pericardial effusion

• Pleural effusion

• Diaphragmatic hernia

• Intraoperative cardiac arrest

How should you intubate during CPR?

With an e-tube and always try to intubate laterally!! so blood doesn’t leave the brain. If you can’t get tube in you can use a tight fitting mask.

Breathing - B in ABC

After clearing airway and intubating or placing mask, attach to 100% oxygen source and start breathing with bag. Breath every 6 seconds or if it is just you, two breaths after every 30 compressions

Why do we avoid hyperventilating our patients during CPR?

• Increases intrathoracic pressure thus decreasing venous return to heart

• Lowers coronary perfusion

• Decreases CO

• Cerebral vasoconstriction

• Decreased cerebral blood flow

How do we asses how effective our CPR is?

By feeling a palpable pulse, which can be difficult because of compressions.

Capnometer can help see if it is effective to asses Cardiac output NOT ventilation!!

In CP arrest EtCo2 drops significantly. - IF compressions are sufficient the ETCo2 will be OVER 18mmHg

What is advanced life support?

This is the use of things like drugs, catheters, etc. vasopressors, antiarrhythmic, reversals, vagolytics, etc,

What are a few ways to administer drugs in advanced life support?

Central line - a catheter that ends in the vena cava. This is ideal

peripheral IVC - can take 1-2 minutes for them to circulate

IO catheter - femur, humerus, or tibial crest

Intratracheal (IT) - can be used when unable to get IV access. Navel can be a route. The dose should be increased 2-2.5x their IV dose.

Intracardiac (IC) - Last resort! Only to be used during internal compressions.

What are some drugs used in advanced life support?

Vagolytics: Atropine

Vasopressors: Epinephrine, Vasopressin

Antiarrhythmics: Lidocaine, Amiodarone

Buffer therapy: Sodium Bicarbonate

Electrolyte therapy: Calcium Gluconate

Reversal agents: Naloxone, Yohimbine, Atipamezole, Flumazenil (all the pams - benzodiazepines).

Atropine

Anticholinergic parasympatholytic effects. Another is Glycopyrrolate - don’t use because it takes too long.

^^ heart rate

Decrease GI secretions

No benefit or detrimental effect of its use at standard dosing

Most effect in treatment of vagal-induced asystole.

Vasopressors? What are they? What do they do?

They constrict the veins and arteries

Epinephrine - catecholamine that causes peripheral vasoconstriction. - optimal dose is not known. Low dose is 0.01 mg/kg every 3-5 minutes. Works by

Vasopressin - Causes peripheral, coronary, and renal vasoconstriction

• 0.8 u/kg IV every other cycle

• Can be used in place of or with epinephrine

Antiarrhythmics? What are they? What do they do?

Lidocaine - Treatment of ventricular tachycardia - 2mg/kg IV sloowwlly.

Not useful for patients in ventricular fibrillation - raises the threshold

Amiodarone - Only drug that can benefit patient in ventricular fibrillation

• Not commonly stocked in veterinary hospital

Sodium Bicarbonate Buffer therapy - what is it used for?

• Use is less common

  • Once thought to correct metabolic acidosis

• Ideally only given if venous blood gas results confirm acidosis

• Can be given in prolonged duration CPA (>10-15 min)

Calcium Gluconate - electrolyte therapy

• No longer recommended for routine CPA

• Was thought to aid in cardiac contractility but actually causes “stone heart”

• Indicated for patients with hyperkalemia or mod-severe hypocalcemia

Cardiac rhythms in CPA

• Asystole – flatline

  • Most common arrest rhythm

  • Initiate BLS, consider drug therapy

  • Not shockable

• Pulseless electrical activity (PEA)

  • Normal ECG to widened/bizarre waveform but no myocardial contraction

  • Initiate BLS, consider drug and fluid therapy

  • Not shockable??

• Ventricular fibrillation (VF)

  • Chaotic electrical activity – no identifiable waveform, heart quivering

  • Shockable!!

Defibrillation

• Treatment of choice for VF and pulseless V-tach

• Pass electrical current through heart cells to depolarize them and hopefully they repolarize together and resume normal function

• Clear!

• Precordial thump- hard punch right over the chest - method can be used when defibrillator is unavailable

Post-arrest care.

The likelihood of re-arrest is very high!

Patients must be monitored closely