CPCR

CPR

What does CPCR stand for?

Cardiopulmonary cerebral resuscitation

What does RECOVER stand for?

Reassessment Campaign on Veterinary Resuscitation

What is RECOVERs aim? (3)

• Improve outcomes for patients using evidence-based guidelines

• Improve training for vet professionals

• Improve return of spontaneous circulation (ROSC) and survival to discharge

% of ROSC using RECOVER

28-44

% of survive to discharge using RECOVER

3-10

When has cardiopulmonary arrest occurred? (8)

• Mentation (unresponsive patient)

• Changes in breathing

• Altered MM colour

• No pulse

• Changes in HR or rhythm

• Capnography (decreasing ETCO2)

• Absence of bleeding

• Pupillary dilation

How long should assess the unresponsive patient take?

Under 10 seconds

First steps if patient is unresponsive? (2)

• Shake and shout

• Call for help

Unresponsive patients and ABC exam

A - airway (obstruction?)

B - breathing (watch chest rise)

C - no longer check circulation as people misidentified pulse

What is basic life support (BLS)? (2)

• Chest compressions

• Ventilation

BLS - check compressions (3)

• 100-120 compressions per min

• 1:1 cycle

• Allow chest to fully recoil

BLS - Ventilation

1 breath/6 seconds

BLS - Ventilitation and no. rescuers

single - can’t intubate, use tight fitting mask

multiple - intubate

Why compressions for 2 minutes? (4)

Maximises blood flow

• takes one min for for compressions to reach best cariac output

• only 1/3 of normal cardiac output

Every break = losses blood flow and never reach peak

Chest compressions - standard round chest (3)

• Place hands over the highest point of the chest

• Utilises the thoracic pump mechanism 

• Compressions ½ to a 1/3 of chest width

Chest compressions - keel chested (greyhounds) (3)

• Place hands directly over the heart

• Utilises the cardiac pump mechanism 

• Compressions ½ to a 1/3 of chest width

Chest compressions - wide-chested (bulldogs) (3)

• Place hands over sternum

• Patient in dorsal

• Compressions ¼ chest depth

Chest compressions - small dog/cat (4)

• Directly over heart, hold sternum in palm, brace dorsum with non-dominant hand

• Use flat thumbs and fingers

• Utilises the cardiac pump approach

• Can use one hand over heart

Chest compressions - small dog/cats notes (3)

• 10-15kg

• Can use 2 thumb approach where you wrap hands around the whole animal

• Do not use 2 hands - overcompression can damage heart

Chest compressions - hand position (3)

• One over the other

• Heel over heel

• Hands interlocked

Chest compressions (3)

• Shoulders over hands

• Lock elbows

• Use core and abdominal muscle and bend at the waist

What if the table is too short? (4)

• Use stool

• Get on table

• Drop table height

• Put patient on floor

Why use interposed abdominal compressions? (2)

• Increases return from caudal vena cave

• Better blood flow and perfusion

When to use interposed abdominal compressions? (2)

• Larger dogs, where capnograph isn’t  reading well

• Seesaw with other compressions

How to place ventilation? (2)

• laryngoscope to ensure correct placement

• capnography best indicator of placement

Ventilation timing (2)

• 1 breath every 6 seconds, 1 second inspiratory time

• don’t over-ventilate

When would a tracheostomy be necessary?

If mouth/throat is blocked e.g. tennis ball

What does ALS stand for?

Advanced life support

When to start ASL?

Can be done same time as BLS if enough people

What does ALS consist of? (3)

• monitor

• IV access

• reversals

What is involved in ALS monitoring? (2)

• capnography

• ECG

ALS monitoring - capnography (3)

• monitors how effective chest compressions are

• aim for ETCO2 >18mmHg

• best indicator of ROSC

ALS monitoring - ECG (2)

• diagnose an arrest rhythm

• guides drug therapy

ALS IV Access (3)

• IV access best – superior to IO

• cephalic

• jugular

ALS Access options (3)

• intravenous

• intraosseous

• intra-tracheal

Drugs given through the trachea must be….

double the IV dose

What drugs are safe to give intra-tracheal? (5)

• naloxone

• atropine

• vasopressin

• epinephrine

• lidocaine

NAVEL

Patient is under anaesthetia when CPCR is needed. What do we do first? (2)

• turn of anaesthetic, flush oxygen, empty bag

• administer reversal agents

What reverses opioids?

naloxone

What reverses Alpha-2?

atipamezole

What reverses benzodiazepines?

flumazenil

How quickly should BLS and ALS be performed?

2 minutes

What are the two shockable rhythms?

• pulseless ventricular tachycardia (pulseless VT)

• ventricular fibrillation (VF)

Pulseless ventricular tachycardia (pulseless VT) (3)

• no pulse

• fast, rapid electrical activity

• generates a very high HR >200

Ventricular fibrillation (VF) (4)

• no pulse

• heart muscle ‘quivering’

• rapid, discordant electrical activity

• no significant mechanical function or normal looking waveform

What are the two non-shockable rhythms?

• asystole

• pulseless electrical activity (PEA)

Asystole (2)

• no pulse, electrical or mechanical activity

• flat line

Pulseless electrical activity (PEA) (3)

• no pulse or mechanical activity

• residual electrical activity

• will see something on the waveform

No pulse shockable rhythm response (2)

• defibrillator (electrical)

• precordial thump (mechanical)

Defibrillator (2)

• stops heart to ‘reset’ it

• stops myocytes to allow it to beat normally

Precordial thump (2)

• replacement for defibrillator

  poor prognosis

Defibrillation positioning (2)

• patient in dorsal

• paddles on opposite sides of heart

Defibrillation technique (2)

• don’t touch dog or table - shout ‘CLEAR’

• use electrode gel on paddle

If first defibrillator shock doesn’t work…

double dose for all future shocks

Option for non-shockable rhythm

drug therapy

Drug therapy options

• epinephrine (adrenaline)

• vasopressin

• atropine

Giving drug therapy…. (3)

• use vasopressors to cause potent vasoconstriction

• makes compressions more effective

• stimulate alpha-1

Aim of drug therapy (3)

• redirect blood flow from periphery to core

• maximise blood flow to brain & heart

• help BLS (excellent compressions only getting 30% normal CO)

Epinephrine (3)

• catecholamine

• non-specific

• high dose epinephrine no longer recommended

• may come back but don’t often make it to discharge

Epinephrine targets (3)

• Α1 receptors – peripheral vasoconstriction

• Β1 receptors – ↑ cardiac contractility and rate

• Β2 receptors – vasodilation & bronchodilation

Most beneficial target for CPR

A1 receptor

Vasopressin (2)

• antidiuretic hormone

• very expensive

Vasopressin targets (3)

• acts on the V1 receptor, so no beta effects

• causes peripheral vasoconstriction

• no effect on heart 

Atropine (4)

• anticholinergic

• no harm in giving, but there is no strong evidence that it benefits

• only give once

• ½ life 20-30mins

What does PCA stand for?

Post cardiac arrest algorithm

What is involved in PCA

• monitoring

• fluid therapy

• oxygen supplementation

PCA - fluid therapy (2)

• only if needed, only if reason for crash was hypokalaemia

• monitor while on fluids

PCA - oxygen supplementation

achieve normal saturation

Importance of the team (3)

• whole team approach

• someone needs to be team leader

• ideal world – 5-6 people

Team roles (6)

• chest compressions (priority)

• airway and IPPV

• monitoring

• IV access

• record keeping and timer

• runner (if enough people)

How to be prepared? (3)

• ASA score – highlight any at risk patients undergoing anaesthesia

• CPR Training & refreshers

• crash box

Importance of crash trolley (3)

• easy to access

• not out of date

• stocked and organised

Crash trolley contents (7)

• IV catheters, bungs/T-ports

• syringes & needles (some pre-prepared)

• drugs and dose charts

• ET tubes with tie + laryngoscope

• fluids + giving sets

• airway access, urinary catheter, suction

• defibrillator