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ANESTHESIA - 2 > 30 – CPR > Flashcards

30 – CPR Flashcards

1
Q

Anesthesia and drug related CPA survival

A
  • Highest: 35-48%
    o Already on life support (IV catheter and on O2)
    o Witnessed events in controlled circumstances
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2
Q

What are 3 categories of CPA?

A
  1. Anesthesia and drug related
  2. Underlying disease
  3. Reversible disease/injury (ex. tennis ball in throat)
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3
Q

What is the overall survival rate for patients following Cardio Pulmonary Arrest (CPA)?

A
  • 4-9.6%
  • POOR
  • *human error is a factor in 90% of cases
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4
Q

Underlying disease CPA survival

A
  • 2% chance of recovery to leave hospital
  • GRAVE prognosis
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5
Q

Reversible disease/injury CPA survival

A
  • 5% will leave hospital
  • Quick resolution of underlying disease allows chance of recovery
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6
Q

What are the 5 steps/domains to perform effective CPR?

A
  1. Readiness and preparation
  2. Basic life support
  3. Advanced life support
  4. Monitoring
  5. Postcardiac arrest care
    *need to be good in ALL OF THEM
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7
Q

Readiness and preparation

A
  • People NEED training and specific jobs during CPR
  • ‘ready area’
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8
Q

‘ready area’ for CPR

A
  • Table: sturdy, adjustable, accessible from all sides
  • Equipment: ET tubes, laryngoscopes, catheters
  • Oxygen
  • Ventilation
  • Monitoring equipment
  • Crash cart: drugs, dose chart
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9
Q

What the 5 roles, 1 for each person when doing CPR?

A
  • Compression
  • Ventilation
  • Administers drugs
  • Leader that calls out the shoots
  • Documentation
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10
Q

What are the clinical signs of CPA?

A
  • Unresponsive (loss of consciousness, collapse)
  • Lack of spontaneous ventilation (respiratory arrest)
  • Lack of heart beat (no pulse=can take to long to ID)
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11
Q

Pulse palpation as a technique to confirm CPA

A
  • UNRELIABLE
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12
Q

Unresponsive patient (5-10s)

A
  • STIMULATE!
    o No response=call for help!
  • A: airway
  • B: breathing
  • C: circulation (pulse)
  • *delays in initiation of CPR associated with worse outcome
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13
Q

Basic life support

A
  • Delays in initiation of CPR=worse outcome
  • Benefits of early CPR outweigh RISKS
  • Know resuscitation status
  • *call for help (need at least 3 people)
  • NOTE TIME
  • ‘3 minute emergency’
  • If under anesthesia: turn off anesthetic
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13
Q

‘3 minute emergency’

A
  • Brain damage after 3 minutes without O2 and glucose
  • Brain exhausts supply of ATP muscles
  • Na/K cell pump fails: cell edema
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14
Q

Basic life support

A
  • Hands-only CPR in humans
  • *EARLY VENTILATION is important in dogs and cates
  • Single rescuer BLS: 30 compressions:2breaths
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15
Q

Goal is to restore blood flow to provide O2 delivery

A
  • Compressions should start as SOON as there is a suspicion
  • Confirm a heartbeat later
  • Patient positioning
    o LATERAL RECUMBENCY
    o Barrel chested dogs can be in dorsal
  • *Good EXTERNAL COMPRESSION=25-30% of pre-arresting CO
  • Essential to provide highest possible quality of compressions
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16
Q

How to be effective at compressions

A
  • Rate: 100-120 bpm
  • *depth: 25% of depth/width of chest
  • LOCK your elbows (gravity vs. muscle strength)
  • Duration: rescuer fatigue!: perform uninterrupted cycles of 2 mins
  • Relaxation: 1:1 compression to relaxation ratio (allow full recoil of lungs)
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17
Q

Rescuer fatigue: length of compressions

A
  • Takes 60s to achieve coronary perfusion
  • *Minimize interruptions: 2-5 seconds
    o Intubation, ECG check, switching people
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18
Q

Why is full recoil so important during CPR?

A
  • *represents diastole
  • NO LEANING ON CHEST
    o Increased intrapleural pressure
    o Reduced venous return
    o Suboptimal ventricular filling
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19
Q

Systole (alive) or compressions (CPA)

A
  • Coronary blood flow negligible OR even retrograde
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20
Q

Diastole (alive) or decompression (CPA)

A
  • Majority of coronary blood flow
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21
Q

For animals <10kg or dogs with narrow, keel-chest conformation (CARDIAC PUMP)

A
  • DIRECT compressions of heart (3rd to 6th IC space)
    o Pushes blood out into circulation
  • Cup hand around sternum to squeeze with one hand
  • Avoid using fingertips (no pinching)
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22
Q

3 techniques for CPR in small animals

A
  • One-handed thumb-to-fingers
  • Circumferential
  • One-handed palm
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23
Q

For animals >10kg (THOARACIC PUMP)

A
  • Compression over WIDEST PART OF THORAX
  • Increases overall intra-thoracic pressure
    o Secondarily compress aorta
    o Leading blood flow out of thorax
  • During elastic recoil
    o Sub-atmospheric intra-thoracic pressure favours blood flow from the periphery back to thorax
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24
Q

Flat chested dogs: position

A
  • Between front legs
  • *when you put them in dorsal and they stay
    o If do not stay=do thoracic pump
25
Q

Ventilation with CPR

A
  • *INTUBATION is best
  • 100% O2
  • Use anesthesia machine or Ambu bag
  • *turn OFF vaporizer
  • Room air 21% O2
  • Own breath: 14% O2
26
Q

Securing airway for provision of ventilation is critical (‘next choices’)

A
  • Check for obstruction (blood, fluid): have suction ready
    1. MASK
    1. MOUTH-to-SNOUT
27
Q

Mask for ventilation

A
  • Not ideal, only if intubation is not available
  • Provides O2, extend head and neck to avoid aerophagia
  • Must STOP compressions to ventilate
  • Compression-to-ventilation ratio 30:2 recommended
28
Q

Mouth-to-snout for ventilation

A
  • Hold mouth tightly closed
  • Put own mouth over patients nares
  • Low fraction of inspired O2
  • *not ideal
29
Q

Intubate patients as soon as possible during CPR

A
  • LATERAL recumbency, neck extended
  • Use laryngoscope (no room for error)
    o Visualize what you are doing
    o Check proper placement
    o Avoid vagal stimulation
  • Inflate cuff
  • Secure/tie in place
  • Replace if necessary
  • *provide 100% O2
  • *can be performed SIMULTANEOUSLY WITH CHEST COMPRESSIONS
30
Q

Ventilation respiratory rate

A
  • 10 breaths per minute
  • Do NOT go too fast
  • Tidal volume: 10ml/kg
  • Inspiratory time: 1s
  • Airway pressure: sufficient to result in a visible chest rise
  • *airway pressure (IPPV): 30-40 cmH2O during chest compression
    o In between compressions, less than 20cmH20
31
Q

Advanced life support

A
  • Initiate monitoring:
    o ECG
    o Capnography
    o Femoral pulse
  • IV access
  • Reversals
32
Q

Monitoring with ECG

A
  • Diagnosis of arrest rhythm
  • Determine advanced life support
  • *do not interrupt 2 min cycle of compression
    o Inter-cycle pause; minimize time <10s
    o Check ECG and palpate pulse at same time
    o Do NOT delay resumption of chest compressions
  • *leader should call out arrest rhythm and ask if everyone agrees
33
Q

What are the most common arrest rhythms?

A
  • Non-shockable
    o Asystole
    o Pulseless electrical activity (PEA)
  • Shockable
    o Pulseless ventricular tachycardia
    o Ventricular fibrillation
  • Initial rhythm can change! (continue to check!)
34
Q

Asystole

A
  • Most common arrest rhythm in dogs and cats
  • Non-shockable
  • ‘flat-line’ (no electrical activity in heart)
35
Q

How do you treat asystole?

A
  • Continue basic life support: supplements heart action
  • Drugs
    o Epinephrine +/- vasopressin (every other cycle)
    o Atropine: ONLY once and early on
36
Q

Pulse electrical activity

A
  • See in overdose GA (barbiturates)
  • Non-shockable
  • Normal HR and rhythm, but NO myocardial contractility
  • Heart rate less than 200bpm
    o Continue basic life support
  • Drugs:
    o Epinephrine +/- vasopression (every other cycle)
    o Atropine: only once, early on
37
Q

Ventricular fibrillation (fine or coarse)

A
  • Unorganized electrical activity in heart
    o Poor myocardial contractions: loss of CO
  • Most common initial arrest rhythm in people
  • *uncommon in cats and dogs
  • May develop during course of resusication
    o Need to monitor ECG during compression pauses
38
Q

What is the treatment of ventricular fibrillation?

A
  • Electrical defibrillation
  • Precordial (‘hit chest’)
39
Q

What is the concept of electrical defibrillation

A
  • Electrical impulses depolarizes myocardial cells ‘reset button’
  • Electrical and uncoordinated mechanical activity stops
  • Allows regular pacemaker cells to regain control
    o Sinus rhythm
    o Asystole: if SA node doesn’t refire
  • *start basic life support at same time you charge the defibrillator
40
Q

Electrical defibrillation ‘steps’ or guidelines

A
  • Lubricate paddles with conductive gel
  • Do NOT use alcohol: combustible
  • DORSAL recumbency
  • Place paddles on opposite sides of thorax
    o Over heart at costo-chondral junction
  • *check that NO one is in contact with patient or table
    o Shout ‘clear’ when ready
41
Q

What do you do after defibrillation?

A
  • Restart chest compression immediately (full 2-min cycle)
  • Desired outcome
    o Normal ECG rhythm
    o Asystole: all electrical activity is stopped and hopefully starts again
    *Compressions should be performed for 2mins prior to next shock
42
Q

If a shockable rhythm persists after first defibrillation attempt, what do you do?

A
  • Double energy dose for next shock
  • Stay at dose for subsequent doses
  • LOW DOSE epinephrine
43
Q

Monitoring end tidal CO2

A
  • Info about CO and pulmonary perfusion
  • Measure efficacy of chest compressions
    o EtCO2 <18mmHg=POOR perfusion
    o Normal: 35-45 mmHg
  • *MOST predictive prognostic indicator
44
Q

End tidal CO2 most predicative prognostic indicator

A
  • Higher EtCO2 values (>15mmHg) during CPR associated with increased rate of return of spontaneous circulation
  • *Fast indicator of return of spontaneous circulation: sudden increase in EtCO2
45
Q

What are the 2 types of CV drugs?

A
  • Vasopressive agents
  • Vagolytic drugs
  • Anti-arrythmic drugs
46
Q

What are some reversal drugs of anesthetic agents?

A
  • Opioids
  • Alpha-2 agonists
  • Benzodiazepines
47
Q

Routes of drug administration

A
  • IV
  • Intraosseous (IO)
  • Intratracheal
  • Intracardiac=NOT recommended
48
Q

IV drug administration

A
  • *preferred route of drug administration
  • Cutdown in necessary
  • Flush with large volumes after drug administration
  • Decreased CO means poor distribution in dogs
49
Q

Intraosseous (IO) drug administration

A
  • If can’t achieve IV within 2 mins
  • Handheld electrical IO drills
  • Circulating time do drugs comparable to IV
50
Q

Intratracheal drug administration

A
  • Simple, rapid but NOT recommended as primary route
  • ONLY if IV or IO not possible
  • Lower airways have large absorptive capacity
  • Drugs absorbed into pulmonary circulation
  • Ex. atropine, epinephrine, vasopressin, lidocaine, naloxe
51
Q

Technique for intratracheal drug administration

A
  • Pass feeding tube down ET tube to level of carina
  • Flush catheter with air and give a few good breaths
  • *Drug dose is DOUBLED
  • Epinephrine uses ‘high dose’
  • Drugs diluted in 0.9% NaCl
52
Q

Epinephrine

A
  • Catecholamine with NONSPECIFIC alpha and beta adrenergic effects
  • *alpha mediated vasoconstriction: key for CPR
  • Blood volume: central circulation
  • Beta effects may be harmful
  • *do NOT work well in hypoxemic, hypothermic and academic environment
53
Q

Epinephrine doses

A
  • *LOW dose IV
  • High dose=NO longer recommended
  • Repeat every 3-5mins of arrest (every other 2 min cycle)
54
Q

Vasopressin

A
  • Non-catecholamine vasopressor
  • Acts on V1 receptors of vascular smooth muscle
  • Profound peripheral vasoconstriction
    o Not in coronary or renal arteries
    o Mild cerebral vasodilation
  • More effective in hypoxemic, hypothermic, academic environment
  • Double does for intratracheal
  • *as a substitute or in combo with E every 3-5 mins
    o Usually more expensive
55
Q

Atropine

A
  • Patients arrested due to HIGH VAGAL TONE
  • Vagolytic drugs inhibit PS tone
    o Increases HR
    o Increases AV nodal conduction
  • *as early as possible and ONLY ONCE
  • Lack of sufficient evidence for effectiveness duing CPR in people
56
Q

Monitoring effectiveness of CPR

A
  • After 30-60s
    o Palpable femoral pulse
    o Capnogram (EtCO2>15mmHg)
  • if ineffective, change technique
    o person, position, augmentation
    o (consider open chest: lots of after care)
57
Q

What is the initial return of spontaneous circulation and how many survive hospital discharge?

A
  • Initial ROSC: 35-40% of animals
  • 2-10% survive hospital discharge
  • *optimizing post cardiac arrest care is ESSENTIAL for successful CPR
58
Q

What makes being back from the dead tricky?

A
  • Ischemia-reperfusion injury
  • Brain injury
  • Myocardial dysfunction
  • Something killed you originally
    o Persistent precipitating pathology
59
Q

Ischemia-reperfusion injury

A
  • Sepsis likes syndrome
  • Hemodynamic optimization, glycemic control, adrenal function
60
Q

Brain injury

A
  • Injury occurs during reperfusion
  • Mannitol, hypothermia, seizure prophylaxis

ANESTHESIA - 2 (15 decks)

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