CPR.Anaphylaxis.Articles

Question 1

What is BLS goals?

Answer 1

Restore oxygenation, ventilation and blood flow via chest compression and positive pressure ventilation

Question 2

Describe the assessment of an unresponsive patient

Answer 2

ABC: Airway- open mouth if not responsive sweep.
Breathing- watch for breaths not just agonal
Circulation— pulse assessment high rate of false positives
Unresponsive apneic patients should have CPR initiated

Question 3

Describe BLS

Answer 3

Chest compressions initiated at 100-120 beats per minute. If airway is obtained positive pressure ventilation at 10 breaths per minute.

If mouth to snout rate of 30 compression to two breaths

Question 4

What is the cardiac pump theory

Answer 4

Direct compression of the ventricles increases ventricular pressure opening the pulmonic and aortic valves alowing blood flow
Elastic recoil of chest between compressions creates subatmospheric intrathoracic pressure draws venous blood into vessels.

Question 5

What is the thoracic pump theory

Answer 5

Increase in overall intrathoracic pressure during chest compressions forcing blood from the thorax into the systemic circulation. The heart does not pump rather is it a conduit for flow

Question 6

What are the correct placement of hands and what theory does it represent in CPR.

Answer 6

Round chest- highest point/ thoracic pump
Keel chest- over heart/ cardiac pump
flat chest- dorsal recumbency/ cardiac
small animal- over heart/ cardiac pump— one hand method

Question 7

Define ALS

Answer 7

advanced life support: initiate monitoring, vascular access and reversal agents

Question 8

What are the shockable rhythms in CPR

Answer 8

Ventricular fibrilation and pulseles ventricular tachardia (HR > 200).
Max 10 J/kg

Question 9

How do you treat refractory VF in CPR

Answer 9

amiodarone 2.5-5 mg/kg IV/IO
Lidocaine if this does not work— sown to increase energy required in shock for monophasic. Does not appear to be an issue with biphasic

Question 10

Describe how to perform open chest CPR

Answer 10

Patient is in right lateral recumbency for a left lateral thorocatomy. A quick clip of the 3-6th rib spaces and a splash of cholorexadine scrub removed with saline. Sterile gloves
Incision between the 4-5 intercostal space. Finnechito retractors are used to expand space. Incise/remove peridardium. Use two hands to compress apex to base

Question 11

Describe why bicarb is administered in CPR

Answer 11

In prolonged CPA ( > 10-15 min) Sodium bicarb consided at 1 mEq/Kg once.
Only when a metabolic acidosis < 7.0 is noted. Patient likely to have acidosis with CPA

Question 12

What are the objectives once ROSC is achieved

Answer 12

Avoid hyperoxemia/hypoxemia 
SaO2 94-98%, PaO2 80-100 mmHg
MAP > 80 mmHg
ScvO2 > 70%
Lactate < 2.5 mmol/L

Question 13

What are the 4 areas of Post cardiac arrest syndrome

Answer 13

Systemic ischemia/reprofusion responses
PCA brain injury
PCA myocardial dysfunction
Persitant precipitating pathology

Question 14

What are the optimization of ischemia/reperfusion injury for ROSC?

Answer 14

Glycemic control- less than 180 mg/dl Worse outcome when higher
CVP >0 <10 mmHg
Steroids if vasopressor dependent shock at hydrocortisone 1 mg/kg IV q 6 hrs

Question 15

How is the brain exposed to injury with a CPA?

Answer 15

Injury sustained during reperfusion
cytosolic and mitochondrial calcium overload leads to activation of proteases that lead to neuronal cell death and ROS
Burst of ROS occurs during reprofusion, oxidative alterations of lipids, proteins, nucleic acids
Mild theraputic hypothermia decreases cerebral dysfunction

Question 16

What is therapeutic hypothermia ROSC and when is it considered?

Answer 16

32-34C (89.6-93.2F) for 24-48 hours for dogs that are comatose and need mechanical ventilation.
Rewarm at 0.25C-0.5C per hour
Watch for shivering, increase muscle tone which increases O2 demand.
Decreased brain metabolism therefore it can tolerate longer ischemia— not shown helpful in recent human trials

Question 17

How long will neurological signs persist post ROSC

Answer 17

Neuro status not good predictor of outcome until 72 hours. EEG can improve this earlier

Question 18

Should anti-epileptics be initiated post cardiac arrest

Answer 18

Seizures and non convulsive seizrues in people have worse outcomes. Seizures increase O2 demand.
Tx with antiepileptics— pheno, keppra
Increased ICP not common in people but okay to tx with hypertonic agents

Question 19

What is PCA myocardial dysfunction and how long does it last

Answer 19

Increased CVP and PCWP
Reduced L/R sided systolic diastolic ventricular function with increased end diastolic and systolic volume
Reduced left ventricular ejection fraction and cardiac output

Question 20

Is hypotension necessary for a diagnosis of shock according the 2007 consensus statement on monitoring shock?

Answer 20

Hypotension is not necessar as is circulatory and cellular dysfnuction.
Markers lactate >2.5 mmol/L and ScvO2 <70%

Question 21

In JVECC 2016 what were characistics of dogs found to have fluid on AFAST/TFAST in ECC?

Answer 21

More unstable patients had fluid
Free fluid patients had higher lactate
shock index higher in dogs with free fluid

Question 22

What are the benefits and risks of a inspiratory impedance threshold device?

Answer 22

Device that generates a momentary resistance in inspiration (break) which augments negative intrathoracic pressure and improves venous return.
Good for hemodynamic values, but increases airway resistance and decreases respiratory compliance

Question 23

Describe how to measure CO by ultrasound velocity dilution

Answer 23

An extracoporeal circuit is created from an arterial cath (metatarsal) to a central venous cath with a pump. Transonic ultrasound velocity tranducers are placed before the venous side and after the arterial side. A known volume of body temp isotonic saline (0.5-2 ml/kg) bolus is given prior to the transducer in the circuit. It senses the velocity change due to dilution.
Compares well to LiDCO even with hypovolemia hemorrhage

Question 24

Are abdominal compressions recommend in recover guidelines?

Answer 24

Abdominal compressions cause minimal trauma when performed correctly. Improves venous return and should be performed if staffing is available.

Question 25

How is vasopressin recommended in the recover guidelines

Answer 25

Mediated through V1 in smooth muscle. Receptors are active despite acidemia.
May be used in conjuction with or as subsitute for Epi
0.8U/kg

Question 26

Describe monophasic vs biphasic defibrillation

Answer 26

Monophasic: one way
Biphasic: initally goes one way then travels back to initial
Compression continue after shock for 2 minute cycle.

Question 27

In a JVECC 2017 study what was the fastest method for achieving vascular acess

Answer 27

IO was faster for one person in which the jugular IV access was also as fast. Used rotary device in the humerus

Question 28

In Paramedic 2 was epinephrine a benefit

Answer 28

Epinephrine given out of hospital did improve 30 day survival but did not improve neurological status

Question 29

In THAPAC was hypothermia a benefit

Answer 29

Hypothermia in childern at 33C for in hospital CPA did not improve functional outcome or survival at 1 year.

Question 30

In a CCM 2018 study what was noted regarding right ventricular dilation during CPR

Answer 30

Right ventricular dilation as determined via ultrasound during CPR was larger for PE compared to hypoxia or arrhythmia however detection accuracy was not good with users

Question 31

Define hypersensitivity

Answer 31

reproducible signs that occur with exposure to stimulus at a dose tolerated by normal people.
all encompassing term

Question 32

Define anaphylaxis

Answer 32

Serious life threatening genralized or systemic hypersensitivity reaction. Generally considered IgE mediated

Question 33

Describe how anaphylaxis occurs- pathophys

Answer 33

Type 1 immediate reaction.
Mast cell has IgE antibiotidy at the Fc portion will cross link when rexposure occurs.
Mast cell degranulation: Histamine, tryptase, heparin, cytokines
Platelet activating factor leads to bronchoconstriction

Question 34

What are the common anaphylaxis organs in dogs vs cats

Answer 34

Dogs: Liver GI Hepatic venous congestion leading to necrosis
Cats: Pulmonary and GI Bronchoconstriction, laryngeal edema and mucous production

Question 35

How do antihistamines and steroids aid in anaphalxitic reactions

Answer 35

Won’t help with cardiovascular but may be helpful with cutaneous signs. Good for mild to moderate, only if ocular/nasal/cutaneous in severe
Steroids not good evidence either way

Question 36

How does epinephrine help in anaphalcitc reactions

Answer 36

Alpha 1 adrengic stimulation vasoconstriciton on small arterioles (can help with edema)
B2: bronchodilation, decrease histamine release
B1: increase cardiac contractility
0.01 mg/kg IM Max 0.3 mg

Question 37

What are the three types of anaphylactic reactions

Answer 37

Immunologic IgE
Immunologic non IgE
Non- Immunologic

Question 38

How to treat anaphylaxis refractory to epinephrine

Answer 38

Vasopressors: Dopamine, norepi, vasopression
Glucagon- may help with patients on a beta blocker. can cause emesis, protect airway. Bolus then CRI
Atropine- for resitant bradycardia
Ipratropium inhaled for resistant bronchospasms