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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
Flat chested dogs: position
- Between front legs - *when you put them in dorsal and they stay o If do not stay=do thoracic pump
25
Ventilation with CPR
- *INTUBATION is best - 100% O2 - Use anesthesia machine or Ambu bag - *turn OFF vaporizer - Room air 21% O2 - Own breath: 14% O2
26
Securing airway for provision of ventilation is critical (‘next choices’)
- Check for obstruction (blood, fluid): have suction ready - 1. MASK - 2. MOUTH-to-SNOUT
27
Mask for ventilation
- 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
Mouth-to-snout for ventilation
- Hold mouth tightly closed - Put own mouth over patients nares - Low fraction of inspired O2 - *not ideal
29
Intubate patients as soon as possible during CPR
- 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
Ventilation respiratory rate
- 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
Advanced life support
- Initiate monitoring: o ECG o Capnography o Femoral pulse - IV access - Reversals
32
Monitoring with ECG
- 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
What are the most common arrest rhythms?
- 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
Asystole
- Most common arrest rhythm in dogs and cats - Non-shockable - ‘flat-line’ (no electrical activity in heart)
35
How do you treat asystole?
- Continue basic life support: supplements heart action - Drugs o Epinephrine +/- vasopressin (every other cycle) o Atropine: ONLY once and early on
36
Pulse electrical activity
- 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
Ventricular fibrillation (fine or coarse)
- 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
What is the treatment of ventricular fibrillation?
- Electrical defibrillation - Precordial (‘hit chest’)
39
What is the concept of electrical defibrillation
- 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
Electrical defibrillation ‘steps’ or guidelines
- 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
What do you do after defibrillation?
- 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
If a shockable rhythm persists after first defibrillation attempt, what do you do?
- Double energy dose for next shock - Stay at dose for subsequent doses - LOW DOSE epinephrine
43
Monitoring end tidal CO2
- 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
End tidal CO2 most predicative prognostic indicator
- 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
What are the 2 types of CV drugs?
- Vasopressive agents - Vagolytic drugs - Anti-arrythmic drugs
46
What are some reversal drugs of anesthetic agents?
- Opioids - Alpha-2 agonists - Benzodiazepines
47
Routes of drug administration
- IV - Intraosseous (IO) - Intratracheal - Intracardiac=NOT recommended
48
IV drug administration
- *preferred route of drug administration - Cutdown in necessary - Flush with large volumes after drug administration - Decreased CO means poor distribution in dogs
49
Intraosseous (IO) drug administration
- If can’t achieve IV within 2 mins - Handheld electrical IO drills - Circulating time do drugs comparable to IV
50
Intratracheal drug administration
- 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
Technique for intratracheal drug administration
- 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
Epinephrine
- 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
Epinephrine doses
- *LOW dose IV - High dose=NO longer recommended - Repeat every 3-5mins of arrest (every other 2 min cycle)
54
Vasopressin
- 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
Atropine
- 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
Monitoring effectiveness of CPR
- 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
What is the initial return of spontaneous circulation and how many survive hospital discharge?
- Initial ROSC: 35-40% of animals - 2-10% survive hospital discharge - *optimizing post cardiac arrest care is ESSENTIAL for successful CPR
58
What makes being back from the dead tricky?
- Ischemia-reperfusion injury - Brain injury - Myocardial dysfunction - Something killed you originally o Persistent precipitating pathology
59
Ischemia-reperfusion injury
- Sepsis likes syndrome - Hemodynamic optimization, glycemic control, adrenal function
60
Brain injury
- Injury occurs during reperfusion - Mannitol, hypothermia, seizure prophylaxis

ANESTHESIA - 2 (17 decks)

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