CPR Flashcards
1
Q
Goal - CPR
A
support body, restart circulatory and respiratory systems
2
Q
Success rate - animal CPR
A
low, about 10% (animals under GA have a better success rate as this is a reversible cause of CV or respiratory arrest vs terminal diseases and close monitoring allows prompt detection of arrest)
3
Q
When is CPR most likely to be effective?
A
before major organs have undergone a prolonged period without blood supply
4
Q
Define respiratory arrest
A
cessation of effective breathing
5
Q
Define CPA
A
Cardiopulmonary arrest = cessation of effective CO and respiration
6
Q
Define ROSC
A
Return of spontaneous circulation = re-establishment of sustained CO without assistance
7
Q
Define BLS
A
= basic life support
- chest compressions and assisted ventilation
8
Q
What is ACLS?
A
- Advanced cardiac life support
- BLS + medical + electrical interventions
9
Q
What is CPR?
A
= resuscitative efforts (BLS and/or ACLS) required to elicit ROSC and emphasising the importance of neurological outcome
10
Q
Factors to consider performing CPR
A
- owner’s wishes
- nature of underlying dz
- QoL should resuscitation be succesful
- availability of ongoing intensive care
- finances
11
Q
What happens if CPR is initially succesful?
A
= result in restarting heart beat, detectable circulation (i.e. ROSC) and spontaneous ventilation
- ongoing management (24-48hrs, depends on patient health status) can be highly intensive, demand continuous nursing, monitoring, expensive
- many cases, high risk of a crash recurring (>80% animals rearrest within 24 hours)
12
Q
Long-term survival of patients undergoing cardiopulmonary arrest
A
poor to grave (people - poor)
13
Q
What % animals are discharged after CPR?
A
-
14
Q
Name different resuscitation statuses
A
- DNR
- Closed-chest CPR
- Open-chest CPR
- establish before CPA
15
Q
When is a DNR order appropriate?
A
- hopeless prognoses (metastatic neoplasia, end-stage CRF, end-stage CHF, end-stage hepatic failure, profound neurological dysfunction, DIC, overt coagulopathies, owner’s wishes, inability to provide adequate post-resuscitation care and finances)
16
Q
How do you recognise CPA?
A
- can be harder than you think!
- ABC triage (airway patent, breathing efforts, circulation - audible heart sounds, palpable pulses)
- often preceded by hypoventilation and bradycardia
- don’t rely on MM alone (respiratory distress may be cyanotic or grey but some patients have a normal CRT minutes following death)
17
Q
Impending signs of CPA
A
- certain arrhythmias –> degenerate into potentially fatal arrhythmias (VT, ventricular flutter, 3rd degree AV block)
- other ECG changes (atrial standstill, ST depression, R on T phenomenon)
- sustained tachycardia that doesn’t respond to appropriate fluids
- patients where dyspnoea cannot be alleviated
- patients with refractory hypotension despite adequate therapy
- severe metabolic acidosis (pH 9mmol/L)
- high vagal tone (patient population at risk, sometimes in these individuals, stimulating vagu nerve –> life-threatening bradycardia aka vasovagal syncope and vagal arrest)
18
Q
When can vagal stimulation occur?
A
- V
- defecation
- respiratory/abdominal dz (esp splenic diseases)
- ocular or neck sx
19
Q
Action - when a vasovagal arrest is recognised
A
- provide O2
- give atropine (refer to emergency dosage chart)
20
Q
What is needed to provide CPR in CPA cases?
A
- provide O2
- perform CPR
- crash cart/box
- monitoring equipment (at least an ECG)
21
Q
What should a crash box include?
A
ESSENTIAL: - ETT - IV catheters - bandaging material - laryngoscope - syringes/ needles - drugs OPTIONAL (BUT IDEAL): - defibrilator - scalpel blades - suture material - IV fluids - pressure bag - ETCO2 monitor
22
Q
Personnel resources - CPR
A
- minimum 3 people
1. provide ventilation
2. compression
3. written record and/or get necessary equipment or other items
(4. another person to evaluate for effective pulse generation from compressions and monitor to TOSC) - a team leader must take responsibility for ‘running the crash’
23
Q
What is the first step of CPR?
A
- can start alone
- secure Airway, Breathe for the patient and get Circulation going by chest compressions (start compressions before intubating!!!)
24
Q
How do you secure the airway in CPR?
A
- ETT intubation
- verify correct placement (laryngoscope, palpate neck to ensure you feel ‘only 1 tube’ - that being an ETT within trachea)
- hold tube in place until securely tied and then inflate cuff
- right lateral recumbency
- continuous ECG (NOT spirit but coupling gel)
25
How do you provide positive pressure ventilation in CPR? How many breaths/minute?
- 100% O2 (via an Ambubag)
- connected to O2 supply or anaesthesia machine
- 12-15 breaths/minute (more breaths is detrimental)
- ensure assisted breathing leads to adequate thoracic expansion
26
Why is hyperventilation not desired in CPR?
--> increases in intrathoracic pressure which compromises CO and reduces cerebral and coronary perfusion
27
What to do if you encounter difficulty ventilating a CPR patient:
```
CHECK FOR:
- Displacement of tube
- Obstruction of tube
- Pneumothorax
- Equipment failure
(REMEMBER by the acronym 'DOPE')
```
28
How do you perform chest compressions? how does it vary for cats and small dogs vs. larger dogs?
- already under GA --> consider direct cardiac massage
- CLOSED-CHEST: either cardiac pump or thoracic pump theory are appropriate
- small dogs and cats: compressions should encompass heart from both sides (hands both sides of chest = cardiac pump theory)
- larger dogs (>7kg): compression should be focused on widest part of chest (thoracic pump theory)
- done forcefully but let thorax spring back completely
- switch after 2 minutes
- OPEN-CHEST CPR: for very large dogs (>40kg) thoracic compressions may be ineffective and open chest CPR should be performed
29
How many compressions should you aim to do?
approx 100/minute (v important)
30
Considerations for open-chest CPR
- significant pleural space dz
- pericardial effusion
- large dogs
- chest wall dz
- pericardial effusion
- penetrating chest wounds
- intra-operative arrests
- haemoabdomen
- unwitnessed arrests
- unsuccessful closed chest CPR (after 5-10 mins)
31
T/F: providing concurrent or interposed abdominal counterpressure is valuable during CPR
Actually this is unknown
- interposed abdominal compressure with each breath almost impossible so limited value
- continuous abdominal pressure (to limit back-flow of blood from heart) if sufficient personnel are present
32
Outline how to perform ACLS. How does this vary with different ECG findings?
- once BLS begins, the normal progression is to start ACLS
- administer drugs with hope of achieving ROSC
- must interpret ECG for this:
> some electrical activity on ECG + no detectable pulse this is Pulseless Electrical Activity (PEA) --> adrenaline
> absensce of any electrical activity (asytole) --> adrenaline
> ventricular fibrillation --> electrical defibrillation
> sinus bradycardia --> atropine
> sinus tachycardia --> lidocaine
33
Outline use of adrenaline
- adrenergic agonist
- used to 'restart' the heart in patients with asytole or PEA
- standard vasopressor for cardiac arrest
- alpha-mediated vasoconstriction
- increases aortic pressure
- increases myocardial perfusion
34
Outline use of atropine in CPR
- vagolytic drug
- increases HR once it has restarted or reverse a vasavagal event
- avoid inducing tachycardia as this will increase O2 demands of the heart
- for vagally mediated arrests and severe bradycardia
- parasympatholytic
- accelerates pacemakers
- increases AV conduction
- routine use may not improve outcome
- may potentiate sinus tachycardia
- may encourage VF if given with epinephrine
35
Outline use of lidocaine in CPR
- used to treat fast VT before they degenerate into fibrillation
- decreases automaticity
- suppresses ventricular arrhythmias
- less effective than amiodarone
36
How are drugs administered during CPR?
- through existing catheters
- catheres placed via cut-downs
- via intra-osseous catheters
- intra-tracheal catheters
- last resort route = intra-cardiac injections
- through ETT (double dose and follow with 10 sterile water - a hypotonic solution to increase absorption, follow with big breath from Ambu bag or anaesthesia machine)
37
What other drugs may be useful during CPR?
- calcium gluconate (v slowly, IV, 3ml for cat, 5ml small dog, 10ml large dog) if severely hypocalcaemic or hyperkalaemic
- sodiumm bicarbonate (1 mEq/kg usually = 1ml/kg, IV over 20-30minutes) if pH
38
Outline fluid administration during CPR
- to help circulate drugs that are administered
- vital with hypovolaemia (one of commonest causes of arrest)
- give via pressure bags
+/- administer colloids or hypertonic saline
- only CI is when fluid overload caused the arrest
39
Outline defibrillation in CPR
- usually trained individual
- everyone must be alert and respond to 'CLEAR'
- only coupling gel should be used to improve skin contact (NEVER SPIRIT)
- voltage (joules) should be determined from crash cart chart: usually 100J for cats and small dogs, 200J larger dogs, 50J for internal defibrillation (open-chest CPR)
40
Ouline post-resuscitation challenges to overcome
- severe neurological dysfunction
- myocardial injury
- rib fractures
- renal failure
- 'shock gut'
- DIC
- respiratory failure
* monitor for these and tx appropriately
41
How long is a successful CPR patient in a critical state?
- at least next few hours (if healthy beforehand)
- if systemically ill before or were undergoing invasive sx (may remain critical for at least 2-48 hours). High risk of cardiac or respiratory arrest recurring. Thus close monitoring, appropriate support until CV and respiratory function return to normal.
42
Indications - CPR
patient that has arrested or is having an impending arrest
43
T/F: sometimes you have a heart beat but not CO
True - this is still a cardiac arrest
44
What is the 1st goal of CPR?
ECG rhythm + pulse
45
What happens in R on T phenomenon?
- this is an arrhythmia that is an impending sign of a CPA
| - electrical pulseline doesn't return to baseline
46
Behavioural signs - impending CPA in a cat
- lateral recumbency
- open mouth breathing
- thrashing
47
What type of arrest do animals/ humans usually have?
- ANIMALS: respiratory arrest (focus on compressions first)
| - HUMANS: cardiac arrest
48
What is the 50:50 duty cycle?
refers to time spent doing chest compressions versus time spent waiting for the chest to recoil.
49
T/F: time b/w VF onset and defibrillation is inversely correlated with survival.
True
50
What drugs can you administer by ETT?
- lipid soluble only
- acronym 'NAVEL':
= Naloxone, Atropine, Vasopressin, Epinephrine, Lidocaine
* never give Ca or bicarbonate through ETT.
51
Outline use of vasopressin in CPR
- vasopressor
- some thorectical advantages over epinephrine
- limited data
- inconsistent results
- only need to give once
52
Advantages - open chest CPR
- diastolic filling assessed
- pericardial tamponade avoided
- aorta can be cross-clamped
- VF visually diagnosed
- myocardial flaccidity assessed directly
53
Disadvantages - open-chest CPR
- experienced personnel
- more personnel
- significant step
- finances and sx
- risk of infection
54
Complications post-CPR
- blindness
- dysphoria (dissatisfaction with life)
- neuro dysfunction
55
Determinants - CPR termination
- time between CPA and starting CPR
- length of resuscitative efforts
- comorbidity
- senior staff consensus
- inform owner early
- VF survival decreases by 7-10%/min
- >12 mins survival is 2-5%
- ROSC >30 mins or >10 mins asystole
