2. Cardiopulmonary Arrest Cardiopulmonary Cerebral Resuscitation
Emergency Nursing:
Cardiopulmonary Arrest
and
Cardiopulmonary Cerebral Resuscitation
Pgs CTVT

3. Emergency Care Area ***
Requirements
Central location
Easy access
Dedicated “crash table”
Basic necessary equipment
Oxygen source
Suction unit
Surgical lighting
Multiple electrical outlets
Other useful equipment ECG and defibrillator, blood pressure machines.
Reference Fig. 33-8: Emergency procedures and supplies needed.
Other important items include various size oxygen masks, reservoir bags, and asthmatic inhaler as indicated in PP picture.

5. Crash Cart *** Organize and prioritize drawers according to the ABC’s
A=airway
B=breathing
Thoracocentesis materials for emergency respiratory patient
Venous access (C=circulation)
Venous access drawer
Various size and length catheters
Reference crash cart contents (pages 6-11) and check list.
Emphasize checking drawers per shift.
Check endotracheal cuffs prior to placement in the drawer.
Ensure tie gauze, suction, etc., is in airway drawer.
Discuss keeping drug drawer neat, well-labeled, and organized.

7. Laboratory Equipment ***
Minimum database “QATS” (quick assessment test)
Lactate testing
Additional point of care testing
Blood gases
Coagulation testing
Commercial test kits
Ethylene glycol
Reference laboratory equipment required for emergency response.
Review suggested minimum database required: PCV, total protein, blood glucose, azostick.
Additional point of care: testing such as arterial blood gases, and other useful emergency commercial test kits, such as ethylene glycol test kits.
Discuss usefulness of monitoring blood lactate; elevated values (>2.5g/dl) indicates tissue hypoxia, or poor perfusion.

8. Principles of Triage ***
Set protocols for a consistent, thorough response
A CRASH PLAN
Be well-organized
Expect the unexpected
Set protocols are necessary for consistent, thorough evaluations.
Use systematic “check-offs” in triage to evaluate the most life-threatening problem first—usually the respiratory system.
Mnemonic devices such as a CRASH PLAN (Box 33-1) in stressful situations help to avoid a chaotic, unorganized response when time may not be a luxury.

9. Definitions *** Cardiopulmonary arrest
Cessation of breathing and effective blood circulation

10. Definitions *** Cardiopulmonary Resuscitation (CPR)
Providing ventilation and assisted circulation
Cardiopulmonary Cerebral Resuscitation (CPCR)
Acronym emphasizes the importance of maintaining perfusion and oxygen delivery to the central nervous system during and after an arrest

11. Definitions *** Vagal arrest:
Caused by heightened vagus nerve stimulation or vagal tone
Common diseases associated with vagal arrests
Gastrointestinal disease
Respiratory disease
Neurological disease
Ophthalmic disease
The vagal arrest from vomiting occurs by a reflex slowing of the heart, mediated by the vagus nerve.
In weak and debilitated animals, bradycardia can be severe and lead to cardiac arrest.
Severe straining associated with urination or defecation can produce similar, and detrimental, results.
Most common source of vagus-mediated arrest is weak and vomiting animals.

13. Cardiopulmonary Arrest ***
Cardiopulmonary arrest is a potential complication in:
any critical illness
healthy patients undergoing anesthesia

14. Patients at Risk For an Arrest ***
Respiratory difficulty
Heart disease
Severe hypothermia
Multi-organ failure
Trauma
Shock
Any critical patient is at risk for an arrest.
Good communication between the veterinarian and technician is paramount to providing good care.
Monitor patients closely for any signs of deterioration or changes in mentation.

15. Patients at Risk for an Arrest
Anesthetized patients
Monitor for unexplained changes in anesthetic depth
Frequently monitor vital signs during entire procedure
Monitor closely after anesthesia
Support perfusion with fluids, heating pads
Prevention of an arrest begins with the technician’s attitude.
Be cautious even if the procedure is routine; monitor the patient as if it were your own pet.
Take your time and do not rush through an examination, procedure, or anesthetic recovery.
Re-evaluate critical patients frequently, as well as any patient during triage.

16. Reassessment Campaign On Veterinary Resuscitation
RECOVER GUIDELINES ADDRESS:
Preparedness and prevention
Basic Life support and Advanced Life Support
Monitoring
Post-resuscitative care

17. RECOVER: Preparedness and Prevention
At best we should try to prevent CPA
Prepared facilities
Necessary equipment and supplies (in a central location)
Check frequently for inventory content and function
Provide dosing charts and algorithms
Staff prepared team members
Standardize training
Have practice drills
Debriefing session after every CPR event

18. CPCR Protocols: BASIC LIFE SUPPORT
First step
Once a diagnosis of CPA is made, CALL FOR HELP!
BLS is best performed with a minimum of 2-3 people

19. CPCR Protocols
Basic Life Support creates artificial circulation to supply oxygenated blood to the body
the organs of most concern are the heart, lungs, and brain
Airway Circulation
Breathing OR Airway
Circulation Breathing
Current protocols may advocate the “CABs” to reflect the importance of restoring perfusion during the resuscitation efforts.

20. CPCR Protocols A = Airway
If respirations are absent or weak, the mouth should be opened and examined for possible obstruction
Common obstructions to airway include mucus secretions, vomitus, blood, ingested foreign material, or extraneous tissue or masses.
Airway should be cleared if possible to facilitate intubation.
Suction or tissue forceps and gauze can be used to remove obstructions.

21. CPCR Protocols B = Breathing
Visualize airway with laryngoscope
Pull tongue forward with dry gauze to facilitate tube passage
Suction readily available
Stylets readily available
Ventilate at a rate of 10 breaths/min or a breath every 6 seconds
Inspiratory time: 1 sec
Suction and stylets should be readily available if intubation is difficult.
Lidocaine spray can also be used for arytenoid spasms.
If intubation is not possible, a narrow orotracheal catheter or transtracheal cannulae can be used.

22. CPCR Protocols B = Breathing
First two breaths administered should be long breaths lasting a full 2 seconds followed by patient assessment
If voluntary breathing is not immediate, manually ventilate
Follow initial ventilation by assessing patient; spontaneous ventilation may be possible.
If the patient does not begin to take breaths on its own, manual ventilation must begin immediately.
If the patient was undergoing anesthesia, immediately turn off inhalant gas, leaving the patient to breathe 100% oxygen.

23. CPCR Protocols Ventilation
Goal: expand the chest by 30% with a slightly longer expiration than inspiration
Inspiratory Pressures
20 cm H2O dog
15 cm H2O cat
All personnel involved with resuscitation efforts need to be able to work the pop-off valve, and ensure that the proper size tubing and reservoir bag are appropriate size for the patient.
Monitor pressure by watching needle on gauge; most Ambu-bags do not have a pressure dial.

24. An endotracheal tube connected to an Ambu bag and oxygen source provides an ideal means to supply 100% oxygen and manual assisted ventilation.

25. CPCR Protocols B = Breathing
If intubation is not available, and/or the situation is single person CPR, mouth-to- snout ventilation should be considered
Mouth-to-nose resuscitation may be performed by sealing the lip margins and blowing into the animal’s nose
2 breaths every 30 compressions for single person CPR
Neonates may be intubated with a small red rubber catheter; oxygen can be delivered carefully by blowing through the tube
Mouth-to-nose ventilation is inadequate and should be only temporary until more oxygen can be provided; this type of resuscitation does carry some risk of exposure to potentially zoonotic diseases.

26. CPCR Protocols
Failed respiratory resuscitation may respond to acupuncture to labial fulcrum
Insert 25 g needle 1.0 mm and twist
The acupuncture point is Governor Vessel 26 (VG 26) of Jen Chung.
This point is located at the nasal philtrum at the level of the ventral edge of the nares (refer to Fig ).

27. CPCR Protocols C = Circulation
Once the airway is established and ventilation provided, assess circulation
Palpation of pulses (or apex heart beat)
Auscultation of the heart
Some animals suffer respiratory arrest without cardiac arrest.
In addition, peripheral pulses are typically not palpable when the mean blood pressure is <60 mm Hg.
An apex heartbeat may be indistinguishable when the pressure is <40 mm Hg.

28. CPCR Protocols Initiate chest compressions Positioning of animal
Depends on the animal’s size
Shape of the chest (barrel chest vs. deep and narrow chest)
The caregiver’s ability to deliver adequate compressions
A stepstool or a crash table that can be moved up or down can facilitate chest compressions.

29. CPCR Protocols
Cardiac pump method – manual pressure is applied directly to the heart which causes blood to flow out of the chambers
Animal is in rt. or lft. lateral recumbency
Place palm over heart; hand-over-hand
Compress chest to 1/3-1/2 its width
Place stack of towels under patient’s heart if necessary
Small dogs or cats may place sternal and compress ventrally
“Tennis-ball” technique
To optimize the cardiac and thoracic pumps, animals <15 lb (7 kg) should be placed in lateral recumbency.
Smaller patients may be propped sternal and compressed ventrally with one hand (like a tennis ball) for cardiac contractions.

31. CPCR Protocols
Thoracic pump method – compressing the chest wall causes a decrease in the volume of the chest cavity and an increase in intra-thoracic pressure, forcing blood out of the thorax
Hands are placed at the widest part of the chest
Upon release of the compression, a negative pressure gradient is created by the normal recoil of the chest
This promotes flow back into the thoracic cavity and the heart
Recommended for most large and giant breed dogs

32. CPCR Protocols KEYS TO SUCCESSFUL CARDIAC COMPRESSION
Allow time between compressions for adequate ventricular filling
Improved CPR outcomes are associated with uninterrupted chest compressions
Cycles of 2 min
Alternate person providing compressions
Rate of bpm
Interposed abdominal contractions
Alternate with external chest compression
Interposed abdominal and thoracic compressions may increase resuscitation statistics by theoretically increasing venous return.
Compression rates are typically 120/min for animals <15 lb and /min for animals >15 lb.
Administering ventilations and chest compressions simultaneously enhances the thoracic pump by increasing intrathoracic pressure during the compression (systole) and increasing venous return and atrial filling during relaxation (diastole).

33. CPCR Protocols
Interposed abdominal compressions

34. Open-Chest CPCR Indicated in animals with chest trauma
Open-chest CPCR is only beneficial if initiated early in the resuscitation effort
Open-chest CPCR should be initiated within 2 minutes of cardiopulmonary arrest
This is the purest example of cardiac pump method
The role of the technician in open chest CPCR is to assist the veterinarian with sterile instruments, suction, and continued ventilation.
Sterile emergency packs, sterile surgical gloves, adequate lighting, and sterile suction must be readily available.
Record all events and drug administration into the medical record or on a standardized CPCR form.

35. Advanced Life Support
Advanced Life Support is the addition of ECG and vital sign monitoring to support drug administration and other therapies such as fluid therapy, and defibrillation techniques
Administration of drugs
Drug choices based on cardiac output, blood pressure, and presence of arrhythmias
Evaluate need for fluid or colloid therapy
ECG monitoring
Defibrillation techniques

36. CPCR Protocols Administration of drugs Common drugs used in CPCR
Atropine – treats asystole, promotes/increases heart rate
Epinephrine – vasopressor, positive inotrope, chronotrope
Naloxone – reversal agent for opioids
Lidocaine – anti-arrhythmic agent for ventricular arrhythmias
Vasopressin - vasopressor
Magnesium chloride or sulfate – used for chemical defibrillation

37. CPCR Protocols Drug administration
May be ineffective due to poor perfusion
A central vein catheter is the CPCR drug administration route of preference during closed- chest CPCR
Although drug delivery is most effective through a central line, this is not necessarily the easiest or fastest means to obtain vascular access if the critical patient does not yet have an intravenous catheter.
The fastest route in this situation would be intratracheal; attempt a peripheral IV catheter placement for rapid fluid delivery.

38. CPCR Protocols 2nd option for Drug Delivery
Intratracheal
LEAN or NAVEL
Double the IV dose
Third option for Drug delivery
Peripheral
Intra-osseous (RECOVER guidelines says this is a first option)
Last option - Intracardiac as last resort
Difficult to hit a flaccid heart
More damage may occur
Use 1/10 of the IV dose
Acronym LEAN can be used to remember which drugs can be administered by the intratracheal route (lidocaine, epinephrine, atropine, and naloxone).
Intratracheal drugs are administered via a catheter passed through the endotracheal tube (Fig ).
Insertion of drug into the intratracheal catheter must be followed by a flush of air or saline to ensure drug deposition into the airways; a deep breath administered via manual ventilation helps to further distribute the drug.
Drug doses administered by the intratracheal route may be rapidly estimated by doubling the IV dose; small drug volumes may require dilution for effective administration.
Presence of pulmonary edema may hinder absorption.
Third best route of drug delivery in CPCR is via a peripheral catheter; fluid administration is superior by this route, since it is typically a shorter, larger bore catheter that will facilitate rapid fluid boluses.
Intracardiac option is the last resort since it is difficult to hit a flaccid heart, and for the risk of damaging the heart.
However in open-chest CPCR, intracardiac drug administration is preferred; usually, one-tenth of the intravenous dose is injected directly into the left ventricle.

39. A polypropylene catheter passed through an endotracheal tube can be used for the intratracheal administration of some drugs during CPCR.

40. CPCR Protocols
ECG
Allows recognition of specific arrhythmias so that appropriate drugs are administered
Evaluate at the end of every 2 minute cycle
Allows for response to therapy to be assessed

41. Three Arrhythmias Seen During an Arrest
Asystole (“flat-line”)
Treated with atropine and/or epinephrine; repeated doses if no response is observed
Electromechanical dissociation (EMD)
Treated with naloxone, megadose atropine, or epinephrine
Asystole (Fig )
EMD or pulseless electrical activity (Fig )
Ventricular fibrillation (Fig )
Bradycardia is also a common sequela to poor perfusion and hypoxia; treatment is small increments of atropine.
EMD can have the presence of ECG complexes with no cardiac contractions to generate a pulse (which is why this arrhythmia is also called pulseless electrical activity or PEA).

42. Three Arrhythmias Seen During an Arrest
Ventricular fibrillation
Treatment is by electrical defibrillation using an electrical defibrillator
Chemical defibrillation may be attempted using drugs such as magnesium chloride
A strong precordial thump is potentially effective as a last resort
Ventricular tachycardia (on the left of the ECG) suddenly degenerates into ventricular fibrillation (on the right side of the ECG).

43. An electrical defibrillator and ECG should be located on top of the crash cart for treatment of ventricular fibrillation during cardiac arrest.

44. Three Factors to Consider in Defibrillation
Paddle surface should be as large as will fit on the surface of the chest wall or cardiac muscle
Should be placed parallel on the sides of the chest, at the level of the heart.
Be aware that the current may “jump” and be dangerous for team members and not treat the patient effectively
Use electrode gel/lube NOT ultrasound gel
Paddles should be as close as possible
*Defibrillators are dangerous! It is imperative that the individual operating the defibrillator announce “ALL CLEAR” before discharging.*

45. Prolonged Life Support
Post-resuscitation goals
Correct underlying cause of arrest
Correct problems caused by the arrest and the trauma of the resuscitation

46. Central Nervous System Support
Avoid hypothermia
Avoid hypoglycemia or hyperglycemia
Perform serial neurological exams: PLR, corneal, palpebral, response to stimuli
Neurologic examinations should be done hourly.
Pupillary light response, responsiveness to stimulation, respiratory pattern, motor responses, and motor postures should be noted.
Normal pupil size and pupillary light responses (PLR) are positive signs.
Slow PLRs, anisocoria, and pinpoint pupils that are nonresponsive to light are progressively guarded neurological indicators.
Nonresponsive bilaterally dilated pupils indicate severe brain damage and a poor prognosis; recent administration of atropine during the arrest should be ruled out as a cause of dilated nonresponsive pupils.
Breathing patterns also reflect brainstem function; abnormal breathing patterns or periods of apnea (breathlessness) are poor prognostic indicators.

47. Central Nervous System Support
Mannitol
An osmotic diuretic
Sometimes used in the management of cerebral edema and acute renal failure
The mannitol molecule resides in the vascular space and draws water from the interstitial spaces between cells, thereby decreasing edema and expanding the vascular volume.
As mannitol is excreted by the kidneys, its osmotic effects “pull” water with it into the urine.
Mannitol is also a free radical scavenger, which may aid in the treatment of reperfusion injury.

48. Cardiovascular System Support
Monitor heart rate
Bradycardia—atropine or glycopyrrolate
Sinus tachycardia—may result from fear, anxiety, pain, hypotension, hypoxia
Ventricular arrhythmias—check for pulse/heart beat asynchronicity

49. Cardiovascular System Support
Monitor blood pressure
Monitor urine production
Keep patient on oxygen
Acute renal failure is a common complication in the post-arrest patient.
Urine production should be closely monitored through a closed urinary catheter if possible.
Normal urine output is 1-2 ml/kg/hr.
Monitoring central venous pressure, PCV/TP, and body weights can also be an indicator of volume status.

50. Respiratory System Support
Common respiratory complications
Pulmonary edema due to congestive heart failure
Noncardiogenic edema associated with hypoxia

51. Respiratory System Support
Vigorous chest compressions from CPCR
May result in pulmonary contusions, rib fractures, atelectasis, and/or edema
Respiratory Therapy
Oxygen supplementation
Ventilation support
Monitoring of arterial blood gases
Pulse oximetry and/or capnography
Capnography measures ETCO2 – rising values indicate improved pulmonary blood flow and improved perfusion

53. CPCR Protocols Laboratory markers to monitor(“QATS”) Blood glucose
Lactate
Packed cell volume
Total protein
Electrolytes
Blood glucose concentrations should be monitored frequently, because many patients who arrest develop hypoglycemia.
Patients are typically supplemented with dextrose through IV fluids.
Hyperglycemia should be avoided.

54. Prolonged Life Support
Commonly used drugs
Furosemide (Lasix)
Treats pulmonary edema and acute kidney failure
Glucocorticosteroids
Controversial
May be beneficial in stabilizing cellular membranes
Capable of rapid action against the oxygen-free radicals created during reperfusion injury
The diuretic effects of furosemide cause an increase in urine output and may enhance the effects of mannitol when given simultaneously.
In cases of pulmonary edema, furosemide causes volume contraction, which decreases edema formation.
Glucocorticoid examples include dexamethasone sodium phosphate, prednisolone sodium succinate.

55. Prolonged Life Support
Commonly used drugs
Dobutamine
Positive inotropic drug
Improves the contractility of heart muscle
Dopamine
Increases renal perfusion in canine patients at low doses
Increases systemic blood pressure at higher dosages
Dobutamine may also be administered to maintain mean arterial pressure.
Higher doses are associated with tachycardia; monitor heart rate closely during use.
Use of dopamine in feline patients is controversial.

56. Prolonged Life Support
Commonly used drugs
Sodium bicarbonate
Treatment for severe life-threatening acidosis
Adverse effect can outweigh benefits
Restore circulation and perfusion before supplementation with fluid therapy
Caution is warranted because overzealous bicarbonate therapy is both harmful and easy to accomplish.
Unpredictable acid–base disturbances and other problems can be attributed to overdoses.
Blood pH must be monitored via serial venous or arterial blood gas analyses.

57. Prolonged Life Support
Commonly used drugs
Lidocaine
Treatment of ventricular arrhythmias
Short acting
Contraindicated in ventricular escape and isolated premature ventricular complexes
Monitor ECG closely

58. Prognosis
UC Davis study: survival rate at 1 wk for cardiac resuscitation patients:
Dogs: 3.8%
Cats: 2.3%