18) cardiopulmonary rescucitation. basics of fluid therapy and parenteral feeding Flashcards

1
Q

indication?

A
  • Cardiopulmonary arrest CPA
  • Clinical signs:
    ➢ Gasping/ agonal breathing
    ➢ Lack of spontaneous breathing
    ➢ Lack of palpable pulse
    ➢ Lack of cardiac sounds
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2
Q

considerations before performing cpr

A
  • Underlying disease
  • Owners will
  • Timing, must be within 3-5 minutes after CPA
  • Equipment
  • Trained staff (3 + n)
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3
Q

basic cardiac life support is done with?

A

ABCDEF method!

airways
breathing
circulation
drugs
ECG
fluid therapy
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4
Q

airways?

A

➢ Clean the airways
➢ Endotracheal intubation
➢ Mouth-to-nose resuscitation until intubation and positive pressure ventilation with 100% oxygen can be performed

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5
Q

breathing?

A

➢ 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

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6
Q

circulation?

A

➢ 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)

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7
Q

drugs?

A

➢ 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)

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8
Q

ECG? check for:

A

◼ Sinus bradycardia
◼ Asystole
◼ Ventricular fibrillation, flutter
◼ Pulse-less electrical activity

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9
Q

fluid therapy if the animal is hypovolemic?

A

◼ → 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%

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10
Q

if animal is euvolemic:

A

◼ crystalloids in bolus with max speed, dog 2ml/kg bolus, cat 10ml/kg bolus

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11
Q

Monitoring of critically ill patients

A
  • 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
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12
Q

monitoring after CPR

A
  • 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
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13
Q

postresection care?

A
  • 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
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14
Q

Where can the fluid deficit be? + why

A
- 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
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15
Q

evaluation of the hydration status/level of dehydration:

A
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
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16
Q

Estimating the degree of dehydration according to physical exam

A
  • 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
17
Q

stages of shock?

A
  • 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!!!
18
Q

problems we are targetting during fluid therapy?

A
  • Dehydration
  • Electrolyte-& acid-base homeostasis
  • Tissue perfusion
  • Hypovolemia
  • Hypovolemic shock
19
Q

main types of infusions?

A

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)

20
Q

volumes for fluid therapies?

A
- 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
21
Q

We have to calculate a volume appropriate for

A
  • 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
22
Q

Subcutaneous rehydration

A
  • 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
23
Q

Possible complications of fluid therapy:

A
  • Tachycardia, coughing, tachypnoea dyspnea
  • Ascites, jelly-like subcutis, exophthalmos
  • Polyuria, vomitus/ diarrhea
  • Serous nasal discharge
  • Chemosis
  • Restlessness, tremor
24
Q

IV catheter problems/complications:

A
  • Paravenous infusion
  • Thrombophlebitis
  • Catheter-site infection (→ septicemia!)
25
Q

paranteral treatment

A

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

26
Q

subcutaneous injections

A

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)

27
Q

Intramuscular injections

A
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
28
Q

Intravenous injection

A

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)