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Renal > CPR > Flashcards

CPR Flashcards

1
Q

Goal - CPR

A

support body, restart circulatory and respiratory systems

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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)

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3
Q

When is CPR most likely to be effective?

A

before major organs have undergone a prolonged period without blood supply

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4
Q

Define respiratory arrest

A

cessation of effective breathing

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5
Q

Define CPA

A

Cardiopulmonary arrest = cessation of effective CO and respiration

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6
Q

Define ROSC

A

Return of spontaneous circulation = re-establishment of sustained CO without assistance

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7
Q

Define BLS

A

= basic life support

- chest compressions and assisted ventilation

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8
Q

What is ACLS?

A
  • Advanced cardiac life support

- BLS + medical + electrical interventions

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9
Q

What is CPR?

A

= resuscitative efforts (BLS and/or ACLS) required to elicit ROSC and emphasising the importance of neurological outcome

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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
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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)
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12
Q

Long-term survival of patients undergoing cardiopulmonary arrest

A

poor to grave (people - poor)

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13
Q

What % animals are discharged after CPR?

A

-

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14
Q

Name different resuscitation statuses

A
  • DNR
  • Closed-chest CPR
  • Open-chest CPR
  • establish before CPA
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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)
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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)
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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)
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18
Q

When can vagal stimulation occur?

A
  • V
  • defecation
  • respiratory/abdominal dz (esp splenic diseases)
  • ocular or neck sx
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19
Q

Action - when a vasovagal arrest is recognised

A
  • provide O2

- give atropine (refer to emergency dosage chart)

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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)
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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
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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’
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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
Q

How do you provide positive pressure ventilation in CPR? How many breaths/minute?

A
  • 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
Q

Why is hyperventilation not desired in CPR?

A

–> increases in intrathoracic pressure which compromises CO and reduces cerebral and coronary perfusion

27
Q

What to do if you encounter difficulty ventilating a CPR patient:

A 
CHECK FOR:
- Displacement of tube
- Obstruction of tube
- Pneumothorax
- Equipment failure
(REMEMBER by the acronym 'DOPE')
28
Q

How do you perform chest compressions? how does it vary for cats and small dogs vs. larger dogs?

A
  • 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
Q

How many compressions should you aim to do?

A

approx 100/minute (v important)

30
Q

Considerations for open-chest CPR

A
  • 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
Q

T/F: providing concurrent or interposed abdominal counterpressure is valuable during CPR

A

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
Q

Outline how to perform ACLS. How does this vary with different ECG findings?

A
  • 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
Q

Outline use of adrenaline

A
  • 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
Q

Outline use of atropine in CPR

A
  • 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
Q

Outline use of lidocaine in CPR

A
  • used to treat fast VT before they degenerate into fibrillation
  • decreases automaticity
  • suppresses ventricular arrhythmias
  • less effective than amiodarone
36
Q

How are drugs administered during CPR?

A
  • 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
Q

What other drugs may be useful during CPR?

A
  • 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
Q

Outline fluid administration during CPR

A
  • 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
Q

Outline defibrillation in CPR

A
  • 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
Q

Ouline post-resuscitation challenges to overcome

A
  • severe neurological dysfunction
  • myocardial injury
  • rib fractures
  • renal failure
  • ‘shock gut’
  • DIC
  • respiratory failure
  • monitor for these and tx appropriately
41
Q

How long is a successful CPR patient in a critical state?

A
  • 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
Q

Indications - CPR

A

patient that has arrested or is having an impending arrest

43
Q

T/F: sometimes you have a heart beat but not CO

A

True - this is still a cardiac arrest

44
Q

What is the 1st goal of CPR?

A

ECG rhythm + pulse

45
Q

What happens in R on T phenomenon?

A
  • this is an arrhythmia that is an impending sign of a CPA

- electrical pulseline doesn’t return to baseline

46
Q

Behavioural signs - impending CPA in a cat

A
  • lateral recumbency
  • open mouth breathing
  • thrashing
47
Q

What type of arrest do animals/ humans usually have?

A
  • ANIMALS: respiratory arrest (focus on compressions first)

- HUMANS: cardiac arrest

48
Q

What is the 50:50 duty cycle?

A

refers to time spent doing chest compressions versus time spent waiting for the chest to recoil.

49
Q

T/F: time b/w VF onset and defibrillation is inversely correlated with survival.

A

True

50
Q

What drugs can you administer by ETT?

A
  • lipid soluble only
  • acronym ‘NAVEL’:
    = Naloxone, Atropine, Vasopressin, Epinephrine, Lidocaine
  • never give Ca or bicarbonate through ETT.
51
Q

Outline use of vasopressin in CPR

A
  • vasopressor
  • some thorectical advantages over epinephrine
  • limited data
  • inconsistent results
  • only need to give once
52
Q

Advantages - open chest CPR

A
  • diastolic filling assessed
  • pericardial tamponade avoided
  • aorta can be cross-clamped
  • VF visually diagnosed
  • myocardial flaccidity assessed directly
53
Q

Disadvantages - open-chest CPR

A
  • experienced personnel
  • more personnel
  • significant step
  • finances and sx
  • risk of infection
54
Q

Complications post-CPR

A
  • blindness
  • dysphoria (dissatisfaction with life)
  • neuro dysfunction
55
Q

Determinants - CPR termination

A
  • 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

Renal (30 decks)

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