Teresa M. Rieser, VMD, DACVECC Veterinary...
Transcript of Teresa M. Rieser, VMD, DACVECC Veterinary...
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Teresa M. Rieser, VMD, DACVECC
Veterinary Specialist
Emergency/Critical Care
VCA West Los Angeles Animal Hospital
1900 S. Sepulveda Boulevard
Los Angeles, CA 90025
P 310-473-2951 | F 310-979-5400
VCAWLAspecialty.com
Cardiopulmonary resuscitation (CPR)
in veterinary medicine has largely
been modeled on human CPR
practices. Until recently, no evidence
based guidelines for the performance
of CPR have existed in veterinary
medicine. The Reassessment
Campaign on Veterinary
Resuscitation (RECOVER) had the
goal of creating evidence based
guidelines for CPR in cats and dogs.
In 2012 the RECOVER guidelines were published in the Journal of Veterinary Emergency
and Critical Care. The new CPR guidelines for dogs and cats are available by visiting here
to access the free special issue of the Journal of Veterinary Emergency and Critical Care.
RECOVER puts forth the following recommendations for CPR in small animals:
Preparedness
Be Prepared. Make sure that your crash cart is appropriately stocked and that all
staff members are aware of the location of the crash cart and their role in the
event of a cardiopulmonary arrest (CPA).
Checklists, algorithm charts (fig 1, fig 2) and drug dosing charts (fig 3) have all
been shown to be beneficial in adhering to CPR guidelines. Formal training in the
use of these aids also improves compliance. Finally, these charts should be
prominently placed in locations where CPA may occur.
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Emergency/Critical Care
VCA West Los Angeles Animal Hospital
1900 S. Sepulveda Boulevard
Los Angeles, CA 90025
P 310-473-2951 | F 310-979-5400
CPR training is important! This involves not only didactic training but also hands-
on training and high quality feedback.
Immediately following an arrest is an excellent time to review how the team
performed during the resuscitation, what was done well and what could be
improved.
Basic Life Support (BLS)
BLS refers to the recognition of CPA, administration of chest compressions
(fig 4, fig 5), air management and delivery of ventilations.
For the purpose of organization BLS, Advanced Life Support (ALS) and
monitoring are divided in the RECOVER guidelines but it should be understood
that in the clinical setting they occur simultaneously.
High quality chest compressions with minimal interruption are essential.
Chest compressions should be performed in lateral recumbancy in both dogs and
cats. Either left or right lateral recumbancy is acceptable.
High quality chest compressions should be started immediately upon recognition
of CPA.
The rate of compressions should be 100-120 compressions/minute with a
compression depth of 1/3-1/2 the width of the chest. Full elastic recoil of the
chest should be allowed between each compression.
Chest compressions should be performed for a full two minutes before
re-assessing the patient’s response to resuscitative efforts.
Fatigue can very negatively impact CPR efforts. Compressors should rotate in
delivery of compressions to avoid fatigue.
Early intubation and ventilations are also valuable.
Animals should be intubated in lateral recumbancy so as to not interrupt chest
compressions. Ventilations should be delivered at the same time as chest
compressions are performed.
A tidal volume or 10ml/kg should be used with a ventilation rate of 10 breaths/
minute. The inspiratory time should be 1 second. Higher rates of ventilations
have been associated with worsening outcomes in humans.
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Emergency/Critical Care
VCA West Los Angeles Animal Hospital
1900 S. Sepulveda Boulevard
Los Angeles, CA 90025
P 310-473-2951 | F 310-979-5400
In the event that intubation supplies are not available, mouth to snout ventilations
(fig 6) can be performed at a rate of 2 rapid breaths for every 30 chest
compressions.
Advanced Life Support (ALS)
ALS refers to the interventions that are started in veterinary CPR after BLS is
begun and until the return of spontaneous circulation (ROSC) occurs.
The relatively small cardiac output that is generated in CPR necessitates a high
peripheral vascular resistance in order to provide adequate cerebral and
coronary perfusion pressures. For this reason, vasopressor therapy is valuable in
CPR.
Epinephrine has been shown to be of benefit in CPR. Both high dose (0.1 mg/kg
IV) and low-dose (0.01mg/kg) have been advocated over the years. The current
recommendation is to use low-dose initially. If CPR is prolonged, high-dose may
be considered.
In order to avoid overdosage, epinephrine should only be given during every
other 2 minute cycle of CPR.
Vasopressin can also be considered for its vasopressor effect which occurs by
stimulation of different receptors than are targeted by epinephrine. The
recommended dose is 0.8U/kg IV every 3-5 minutes.
Atropine is a parasympatholytic that has been widely used in CPR. Studies have
not shown a clear cut benefit to its use for different types of CPA. It does appear
to be of benefit in resuscitating patients who are identified as having pulseless
electrical activity (PEA) or asystole. Because if has not been shown to be
detrimental, it is still reasonable to use it routinely in CPA at a dose of 0.04mg/kg
IV. Higher doses are NOT appropriate and have been associated with worse
outcomes.
Electrical defibrillation (fig 7) is indicated for ventricular fibrillation of pulseless
ventricular tachycardia. If an electrical defibrillator is not available, a precordial
thump can be attempted.
Part 7 of the RECOVER guidelines discusses these interventions in depth as well as
additional drug therapies and monitoring.
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Emergency/Critical Care
VCA West Los Angeles Animal Hospital
1900 S. Sepulveda Boulevard
Los Angeles, CA 90025
P 310-473-2951 | F 310-979-5400
Figures
Figure 1
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Emergency/Critical Care
VCA West Los Angeles Animal Hospital
1900 S. Sepulveda Boulevard
Los Angeles, CA 90025
P 310-473-2951 | F 310-979-5400
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Figure 2
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Emergency/Critical Care
VCA West Los Angeles Animal Hospital
1900 S. Sepulveda Boulevard
Los Angeles, CA 90025
P 310-473-2951 | F 310-979-5400
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Figure 3
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Emergency/Critical Care
VCA West Los Angeles Animal Hospital
1900 S. Sepulveda Boulevard
Los Angeles, CA 90025
P 310-473-2951 | F 310-979-5400
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Figure 4
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Emergency/Critical Care
VCA West Los Angeles Animal Hospital
1900 S. Sepulveda Boulevard
Los Angeles, CA 90025
P 310-473-2951 | F 310-979-5400
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Figure 5
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Emergency/Critical Care
VCA West Los Angeles Animal Hospital
1900 S. Sepulveda Boulevard
Los Angeles, CA 90025
P 310-473-2951 | F 310-979-5400
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Figure 6
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Emergency/Critical Care
VCA West Los Angeles Animal Hospital
1900 S. Sepulveda Boulevard
Los Angeles, CA 90025
P 310-473-2951 | F 310-979-5400
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Figure 7
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Emergency/Critical Care
VCA West Los Angeles Animal Hospital
1900 S. Sepulveda Boulevard
Los Angeles, CA 90025
P 310-473-2951 | F 310-979-5400
Dr. Rieser earned her veterinary degree from the University of
Pennsylvania in 1995. She completed an internship at the University of
Georgia in 1996 and then returned to the University of Pennsylvania for a
residency is Small Animal Emergency and Critical Care. She became
board certified in Small Animal Emergency and Critical Care in 1999. She
remained at the University of Pennsylvania as a lecturer in Emergency
Medicine and Critical Care for one year and then joined VCA. She worked
at the VCA Newark Animal Hospital from 2000 until 2012. Dr. Rieser is
delighted to join the team at VCA West LA Animal Hospital. Her areas of
interest include renal hemodynamics and electrolyte disturbances.
Teresa M. Rieser, DVM, DACVECC
Veterinary Specialist
VCA West Los Angeles Animal Hospital