CPCR: Improving resuscitation statistics (Proceedings)

Definitions:

Cardiopulmonary arrest (CPA): abrupt and unexpected cessation of spontaneous effective ventilation and circulation

Cardiopulmonary resuscitation (CPR): provides artificial ventilation and assists circulation until advanced life support is provided or spontaneous cardiopulmonary function is restored.

CPCR: cardiopulmonary cerebral resuscitation

Anesthetic arrests and patients with reversible conditions should be resuscitated aggressively.

Reasons for such a poor success rate include severity of underlying disease, delay in the recognition of CPA, and delay in delivery of appropriate therapy.

Readiness

Training (practice sessions), calculated drug chart, crash cart supplies

Recognition of potential CPA patients, physical and laboratory monitoring

A B C's:           Airway           Breathing           Circulation

Assess the effectiveness of each.

     A: Open jaws and examine airway for patency, obstruction, secretions. You'll need assistance; always use a laryngoscope. A suction system is very helpful. Quickly pre-measure tube. Intubate; tie tube in immediately. Visual marker to prevent tube migration. Tracheostomy may be needed for upper airway obstruction

     B: Take a few seconds and see if chest wall is rising, feel and listen for airflow. If not, attach 100% oxygen. Start with 2 or 3 full breaths and reassess spontaneous breathing. If not present, continue to ventilate the patient 15 to 25 breaths per minute. General inspiratory pressures for a dog is 20cm H20, 15 cm H20 for the cat. Breather should communicate with code leader as to how much pressure is needed to expand the chest. Thoracocentesis may be warranted, particularly in the trauma or chronic disease patient. Monitor airway tube for pulmonary fluid; suction PRN.

     C: Feel for a pulse. If none present, begin cardiac compressions. 80 - 120 compressions per minute with animal in lateral recumbency. Lower table or stand on step stool; Compress directly over the heart to compress the thorax 25-30% by leaning into patient with elbows bent. Increase ventilations and apply simultaneously with compressions. Assess retinal blood flow via Doppler.

Alternative modes of chest compression:

In larger dogs (>7 kg) can try dorsal recumbency with compressions over distal 1/3 of sternum.

Abdominal counterpressure

Vascular access:

Central venous is best for drug delivery, peripheral catheter for rapid fluid administration, intra-tracheal drug delivery may be utilized (one-fourth regular IV dose) intraosseous catheter if pediatric emergency and intravenous access is not possible

EKG:

Recognize asystole, ventricular arrhythmia, ventricular fibrillation, sinus rhythm, electromechanical dissociation

Drugs: (Refer to table below)

          Atropine:           bradycardia

          Epinephrine:       asystole, electromechanical dissociation

          lidocaine:           ventricular arrhythmias

          naloxone:           electromechanical dissociation, narcotic overdose

Drug administration: central venous is best, intratracheal is second best, peripheral venous is third choice. Intracardiac as a last resort.

Open chest CPR:

     √ Provides better circulatory effects vs closed chest

     √ Probably not valuable after 10 minutes, therefore, if it's to be done, do it quick!

     √ Think about underlying disease, prognosis, aggressive CPCR to the anesthetic arrest; consider owner's wishes before opening chest.

Drug Therapy for Cardiopulmonary Resuscitation

(Drug dosages provided by Dr. Douglass Macintire, DVM, MS, Diplomate ACVIM and ACVECC)

I. Drugs to increase blood pressure or cardiac output

II. Drugs to Increase Contractility

III. Anti-arrhythmic drugs

IV. Drugs for supportive care.