18) cardiopulmonary rescucitation. basics of fluid therapy and parenteral feeding Flashcards
indication?
- Cardiopulmonary arrest CPA
- Clinical signs:
➢ Gasping/ agonal breathing
➢ Lack of spontaneous breathing
➢ Lack of palpable pulse
➢ Lack of cardiac sounds
considerations before performing cpr
- Underlying disease
- Owners will
- Timing, must be within 3-5 minutes after CPA
- Equipment
- Trained staff (3 + n)
basic cardiac life support is done with?
ABCDEF method!
airways breathing circulation drugs ECG fluid therapy
airways?
➢ Clean the airways
➢ Endotracheal intubation
➢ Mouth-to-nose resuscitation until intubation and positive pressure ventilation with 100% oxygen can be performed
breathing?
➢ With AMBU-balloon
➢ Ventilation: 10 breaths/min, volume of 10mL/kg and inspiration time of 1sec, ideally with portable bag-valve-mask apparatus
➢ Acupuncture of Jen chung point
circulation?
➢ Thoracic compression
➢ Right lateral recumbency
➢ Medium-large breed: both hands on the widest points of the thorax
➢ Medium breeds: one hand over the heart (4th to 6th IC space)
➢ Small breeds and cats: 1 hand over the cardiac area, thumb on the other side of the chest
➢ Rhythm 80-100/ min (staying alive!), compression to ventilation rate 30:2
➢ in animals without any abdominal disease → can do interposed abdominal compression to also improve the venous return
➢ Open-Chest Cardiopulmonary Resuscitation (Emergency thoracotomy)
drugs?
➢ Intravenous application → lift the limb over the heart, 2-3 min!
➢ Intratracheal application
o Safe with: atropine, epinephrine/adrenalin, lidocaine, naloxone, vasopressin
o Use 2-2.5 x dose (epinephrine/ adrenalin even 3-10x)
o Drug must be solved in 5-10 ml sterile water or saline
o CAVE: severe pulmonary disease (edema)
o Adrenalin (tonogen inj) → alpa2 adrenergic stimulating effect → peripheral arteriolar vasoconstriction → cerebral and coronarial perfusion increased
0.01 mg/kg IV → repeated dosage (max 0.1mg/kg)
o Atropine (atropine inj. → heart rate incr., vascular resistance incr., blood pressure incr. → most effective in case of vagotonia induced asystole
0.04 mg/kg IV → repeated (max 3 times)
ECG? check for:
◼ Sinus bradycardia
◼ Asystole
◼ Ventricular fibrillation, flutter
◼ Pulse-less electrical activity
fluid therapy if the animal is hypovolemic?
◼ → isotonic balanced crystalloid solutions should be rapidly administered, shock dose: dog 90ml/kg, cat 45ml/kg
◼ synthetic colloids (hatastarch HAES, hydroxyethyl, starch, dextran 70, stroma-free hemoglobin) will rapidly expand intravascular volume with less infusion volumes required (don’t give infusion to euvolemic animals!), shock dose: dog 5ml/kg, cat 2-3ml/kg
◼ hypertonic saline (NaCl 3%
if animal is euvolemic:
◼ crystalloids in bolus with max speed, dog 2ml/kg bolus, cat 10ml/kg bolus
Monitoring of critically ill patients
- Temp, pulse, respiratory rate, capillary refill time, blood glucose
- Critically ill patients:
➢ SIRS
➢ Septicemia
➢ CHF
➢ Severe respiratory disease
➢ Cerebral diseases (seizures)
➢ Multiplex trauma
➢ Coagulopathies, toxicosis, anesthesia
➢ Ill puppies < 2kg
monitoring after CPR
- end-tidal CO2 during CPR
o <10 mmHg indicates esophageal intubation
o 12-18 mmHg indicates return to spontaneous circulation (ROSC)
o >45 mmHG indicates hypoventilation of increased CO2 delivery to lungs after ROSC - Routine ECG during CPR
- monitor closely after CPA: ECG, blood pressure (dopamine, dobutamine or other pressor agents as blood pressure support), neurologic status, pulse oximetry, ETCO2, venous blood gases
- anaerobic metabolism occurs during shock and CPA → blood lactate levels rise → needs treatment
postresection care?
- efforts to normalize venous oxygen content, lactate, blood pressure, central venous pressure, PCV and oxygen saturation
- mannitol or furosemide often indicated to reduce cerebral edema
- mechanical ventilation in hypercapnic or hypoxic animals
- when needle vasopressors and positive inotropes
- postoperative care after open-chest CPR
- recurrence very likely → treatment of underlying cause crucial
Where can the fluid deficit be? + why
- Intravascular → Hypovolemia ➢ Subsequent to severe dehydration ➢ Acute hemorrhage ➢ Maldistribution (e.g. shock, GDV) ➢ Anaphylaxis - Interstitial and intracellular → Dehydration ➢ Lack of fluid/food intake ➢ Excessive loss of fluid (but not from vascular like bleeding!) → vomitus, diarrhea, PU
evaluation of the hydration status/level of dehydration:
history physical exam ➢ Skin turgor ➢ Position of the eyes (enophthalmos) ➢ Perfusion parameters: ◼ Color of mm (also shiny or dry?) ◼ CRT ◼ Heart rate ◼ Pulse quality ◼ Vena jugularis distention - Measuring the body weight - Easy and quick laboratory assays (PCV, TP, USG, lactate) - Measurement of the total body water (multifrequencial bioelectric impedance analysis
Estimating the degree of dehydration according to physical exam
- 5% → cannot be detected
- 5-6% → slightly dry mucous membranes
- 6-8 % → dry mm, loss of skin turgor
- 8-10% → -“- + enophthalmos
- 10-2% → tented skinfold, dull corneas, hypovolemia
- > 12% → hypovolemic shock and death
stages of shock?
- Compensatory stage: increased HR, red mm, CRT <1sec, bounding pulse
- Decompensatory stage: decreased HR, pale mm, CRT >2sec to absent, pulse weak to absent, hypothermia
Mild cases → PO fluids might be enough, severe dehydration → fluid therapy!!!
problems we are targetting during fluid therapy?
- Dehydration
- Electrolyte-& acid-base homeostasis
- Tissue perfusion
- Hypovolemia
- Hypovolemic shock
main types of infusions?
Crystalloids
- Small molecules (electrolytes, glucose)
- Based on Na content:
➢ Isotonic
◼ 0.9% NaCl (SalsolA), Ringer, Lactated ringer, Sterofundin Iso
➢ Hypotonic
◼ 5% glucose/dextrose, 0.45% NaCl (Salsol B), Balansol, Rindex
➢ Hypertonic
◼ NaCl 10% inj
Colloids
- Large molecular weight solutes (starch, proteins)
➢ Synthetic
◼ Starch (HAES), gelatin
➢ Natural
◼ Human albumin, blood products (plasma, blood)
volumes for fluid therapies?
- Isotonic ➢ 10-20 ml/kg bolus in 15 to 20min ➢ Max 60-90 ml/kg/dog and 45-60 ml/kg/cat - Colloid ➢ 2-5 ml/kg bolus ➢ Max 10-20 ml/kg/dog and 5-10 ml/kg/cat - Hypertonic ➢ Only allowed if the patient is not dehydrated!! ➢ 4-7 ml/kg/dog and 2-4 ml/kg/cat
We have to calculate a volume appropriate for
- Rehydration
- Maintenance
- Replacement of ongoing losses
➢ Vomitus (1-4ml/kg)
➢ Diarrhea 950-200 ml/occasion)
➢ Drained pleural or peritoneal fluid)
➢ Large exudative wounds
➢ Extreme panting
Subcutaneous rehydration
- Only for stable patients with mild dehydration
- Warmed up isotonic crystalloids
➢ K-content of max 40mmol/l
➢ Don’t give glucose or hypertonic solutions → high complication rate, can lead to necrosis - 18-22 G needle
- 15-200 ml/localization
- Dorsal part of the neck, thorax
- Complications: poo absorption, cellulitis, infections, tissue necrosis
- Daily Sc infusion therapy for CKD cats
Possible complications of fluid therapy:
- Tachycardia, coughing, tachypnoea dyspnea
- Ascites, jelly-like subcutis, exophthalmos
- Polyuria, vomitus/ diarrhea
- Serous nasal discharge
- Chemosis
- Restlessness, tremor
IV catheter problems/complications:
- Paravenous infusion
- Thrombophlebitis
- Catheter-site infection (→ septicemia!)
paranteral treatment
3 main application routes:
- Subcutaneous
- Intramuscular
- Intravenous
Rules for application:
- Always look for manufacturers recommendations
- Go with the most effective and safest way
- Rules of thumb:
➢ Only give IV if IM and SC not possible because of risk for tissue necrosis
➢ Never give suspensions IV
➢ Give oily injections always IM
subcutaneous injections
Possible complications:
- Bleeding at the injection site
- Hematoma
- Irritation of the nerves at the injection site
- Tissue necrosis, tissue irritation
- Injection at injection site (→ abscess) or seroma formation
- Allergic reaction
- IV application by mistake
Location and application:
- Neck caudal, thorax upper half (don’t give on the midline over the spine!)
- Give insulin at area with thinner skin
- Give FeLV and rabies vaccines in abdominal area (→ resection in case in injection site sarcoma easier here)
- Always point the needle cranially and aspirate before injection
- Rotate site in case of multiple injections
- In case of fluid therapy: max 10-20ml/kg/spot and warm up before application (only without necrotizing substances like glucose, and no hypertonic solution)
Intramuscular injections
Locations: - M. semitendinosus or semimembranosus (don’t sever ischiatic nerve!) - M. quadriceps femoris - M. triceps brachii - M. supraspinatus et infraspinatus - Lumbar paraspinal muscles ➔ Inject into relaxed muscle
Intravenous injection
Aim:
- Rapid onset of effect (e.g. anesthesia, reanimation, seizures, shock, hypoglycemia, pulmonary edema, effect of antibiotic)
- Tissue irritating medicine
Locations:
- V. cephalica antebrachii
- V. saphena lateralis (dog)
- V. femoralis (v. saphena medialis)
- Not: v. jugularis externa( (only okay if a catheter s placed)
Possible complications:
- Bleeding → compression
- Hematoma
- Thrombosis
- Phlebitis (thrombophlebitis)
- Infections (abscess, phlegmon, septicemia)
- Paravenous application → inflammation, necrosis
- Air embolism
- Allergic reaction (→anaphylaxis, urticaria) (e.g. penicillin, blood products)
- Drug side effects (apnea with anesthetics, arrhythmia cordis with calcium and potassium)
