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
Know where everything is:A dedicated “crash” area
• Oxygen administration– Oxygen source– Anesthesia machine/ambu bag– Cone masks
Know where everything is:A dedicated “crash” area
• Fluid resuscitation– IV catheter placement supplies– Infusion pumps– Lactated ringer’s solution, normal saline,
plasmalye or normosol R
Know where everything is:A dedicated “crash” area
• 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
RECOVER: JVECC 22 (S1) 2012, S102-S131
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
RECOVER: JVECC 22 (S1) 2012, S102-S131
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
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
Recover: JVECC 22 (S1) 2012, S102-S131
Advanced Life Support
Recover: JVECC 22 (S1) 2012, S102-S131
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
Advanced Life Support
• Common drugs – Epinephrine– Atropine– Vasopressin– Amiodarone– Dextrose
– Calcium gluconate, insulin– Reversal agents
• Naloxone, butorphanol, flumazenil, antisedan
Advanced Life Support
• 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%
Rhythm Diagnosis: Identifying the Arrhythmia
• Pulseless electrical activity– Electrical activity without mechanical activity– 11-23.3%
Rhythm Diagnosis: Identifying the Arrhythmia
• Sinus bradycardia– Normal sinus beats but slower rate– 19-23%
Rhythm Diagnosis: Identifying the Arrhythmia
• Ventricular fibrillation– 2-19.8%
Rhythm Diagnosis: Identifying the Arrhythmia
• Ventricular tachycardia– Not commonly seen during an arrest but can
lead up to CPA
Advanced Life Support
• 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
Advanced Life Support
• Fluid therapy– Shock fluid therapy reserved for hypovolemic
patients only– IVF contraindicated in euvolemic patients
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• 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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