Crash Carts & CPR Flashcards
What things are found in the 8 drawers of a crash cart?
- emergency drugs - alphabetical order, CPR (atropine, epinephrine, vasopressin), reversals (atipamezole, flumazenil, naloxone)
- airway supplies - ET tubes, laryngoscopes, batteries, bulbs
- IV access supplies - catheters, tubes, venipuncture, tourniquet
- fluids - 1 of each type, solution sets
- chest tube
- surgical supplies - gloves, equipment for simple procedures
- tracheostomy supplies
- open-chest CPR supplies
What is found on top and on the side of a crash cart?
TOP = defibrillator, calculator, measuring tape, flush
SIDE = paperwork (flow sheet, stock list), ambu-bag, pressure bag
What typically causes differences in organization of crash carts?
- size of items (bottles of emergency drugs)
- hospital needs/supplies
- hospital layout
What 4 aspects of routine maintenance is recommended for crash carts?
- use stocking list to fill each drawer appropriately
- routinely clean up and reorganize
- check all expiration dates
- label each drawer as stocked
What 3 things should be done every time a crash cart is used?
- restock what was used
- clean, reorganize
- label each drawer as stocked
What is CPR? CPA? ROSC? CPCR?
cardiopulmonary resuscitation
cardiopulmonary arrest
return of spontaneous circulation
cardiopulmonary-cerebral resuscitation
When are manikins useful for CPR training?
usually beneficial for early training —> long-term benefit questionable
- no high fidelity minikins in veterinary CPR
What call and response is required for CPR?
- call = “3 mL atropine”
- response = “3 mL atropine going in”
be specific and give orders
- Erin, give 1 L LRS bolus
- Sarah, connect the EKG leads
- Katie, give 3 mL atropine IV
How is arrest identified?
- Is the patient breathing?
- Is the patient’s heart beating?
- Does the patient need CPR? Does the owner want it?
- unconscious =/= dead!
How is CPA identified?
- pulse search
- agonal breathing
- electrical activity without perfusion
What are the ABC’s of basic life support identified by the American Heart Association? How does this relate to veterinary patients?
Airway, Breathing, Circulation
respiratory arrest > cardiac arrest —> ventricular fibrillation is less common and asystole/pulseless electrical activity is more common
How is airway/breathing maintained in an arrested patient? How can it be confirmed?
intubation
- visualization
- EtCO2 monitor —> stomach and esophagus will have low to absent CO2
How are breaths mechanically given to arrested patients? Why does hyperventilation still need to be avoided?
- breath size = 10 mL/kg
- breath timing = 1 second inspiration
- breath rate = 10 bpm
hypocapnia can result in cerebral vasoconstriction and cerebral hypoxia
How is circulation given to arrested patients?
chest compressions to stimulate normal cardiac function (systole and diastole)
What are 3 aspects of high quality chest compressions?
- PUSH HARD - 1/3-1/2 chest depth using core strength (not just leaning!) and allow for chest recoil
- PUSH FAST - 100-120 compressions per minute, higher in cats and small dogs (Stayin’ Alive)
- DON’T STOP = 2 minute cycles, switch out rapidly
What are the 2 places used for chest compressions?
- CARDIAC pump - hands at the level of the heart allowing for direct cardiac compression in small dogs and cats
- THORACIC pump - hands at the widest part of the chest transmitting intrathoracic pressure to the heart most commonly used in large dogs
What medical and electrical interventions are recommended for advanced life support?
- IV fluids
- vasopressors
- anticholinergics
- positive inotropes
- anti-arrhythmics
- defibrillation
- open chest CPR
What is the shortcut does of IV fluid boluses for arrested patients? What are the 2 relative contraindications?
200 mL per 20 lbs (1/4th shock dose of 20 mL/kg)
- arrest due to heart failure
- euvolemia (usually already hospitalized and on IVF) - can give smaller boluses for delivery of medications
What administration of emergency drugs is avoided?
IM or SQ
- use IV, IO, intratracheal
How is the intra-tracheal dose of emergency drugs different? How are they delivered?
3-10x IV dose
- Atropine = 10 mL/20 lbs
- Epinephrine = 1.0 mL/20 lbs
long catheter followed by sterile water
How are emergency drugs delivered IV?
- bolus through IVC
- flush!
What kind of drug is Atropine? What 2 affects does it have? In what patients is it especially helpful?
vagolytic
- abolishes parasympathetic input = fight or flight takes over
- increases HR
brachycephalic arrests, respiratory failure, and GI diseae
What dose is used for emergency Atropine? What is the shortcut?
0.04 mg/kg every 3-5 mins
1 mL/20 lbs
What kind of drug is epinephrine? What 2 effects does it have? How can it be detrimental?
catecholamine = fight or flight
- increased HR and strength of contractions
- arterial vasconstriction
can cause sustained tachycardia
What dose is used for emergency epinephrine? What is the shortcut?
0.01 mg/kg every 3-5 mins
0.1 mL/20 lbs
What kind of drug is vasopressin? What main action does it have?
vasopressor
vasoconstriction
What are 2 advantages of vasopressin over epinephrine?
- no increase in myocardial O2 demand
- not affected by acidosis
What dose is used for emergency vasopressin? What is the shortcut?
- 0.8 U/kg every 3-5 mins
- can alternate with epinephrine every 3-5 mins
0.5 mL/20 lbs
What is a good example of the first 3 rounds of medical advanced life support?
- ASAP - Atropine and low-dose Epinephrine
- 3-5 mins later - Atropine and Vasopressin
- 3-5 mins later - Atropine and high-dose Epinephrine
When are reversal agents commonly used when a patient is arresting?
- anesthetic-related
- sedation-related
- hepatic encephalopathy = increased BZD, typically caused by portosystemic shunts, hepatic lipidosis, or hepatic failure
What are the 3 most common reversal agents used when a patient is arresting? What do they do? What is their shortcut dose?
- Naloxone (Narcan) - reverses opioids at 1 mL/20 lbs
- Atipamezole (Antisedan) - reverses alpha-2 agonists at 0.2 mL/20 lbs
- Flumazenil - reverses BZD at 1 mL/20 lbs
How are reversal agents given?
ALWAYS IV
When is calcium gluconate indicated for arresting patients?
- ionized hypocalcemia
- calcium channel blocker toxicosis
2 mL/20 lbs
When is 50% dextrose indicated for arresting patients?
- documented hypoglycemia
- prolonged CPR > 15 mins
5 mL/20 lbs
When is mannitol indicated for arresting patients?
head trauma resulting in cerebellar herniation or refractory seizures
20 mL/20 lbs
When is sodium bicarbonate indicated for arresting patients?
after prolonged CPR >15 mins
10 mL/20 lbs over 2-3 mins diluted 1:1 with sterile saline
When are corticosteroids indicated for arresting patients?
- Addisonian crisis
- brachycephalic airway disease
- tracheal collapse
0.5 mL/20 lbs Dexamethasone SP
What monitoring is recommended during CPR?
everything you have!
- EKG
- SpO2
- EtCO2
- BP
- temperature
- U/S
- stethoscope
- eyes and ears
What 2 things need to be considered when reading an EKG in an arrested patient?
- interference from movement
- electrical activity =/= cardiac contraction
(don’t rely heavily on EKG)
What measurement of EtCO2 predicts failure to achieve ROSC? What does a slow decline in CO2 lead to?
EtCO2 < 10 mmHg
decreased lung perfusion —> circulatory failure —> death
What is the most critical time for arrested patients?
post-arrest —> only 5-6% of veterinary patients that achieve ROSC survive to discharge
What are the most common causes of death post-arrest?
- post-arrest syndrome
- cardiogenic shock
- hypoxic/anoxic brain injury
- multi-organ failure
- underlying disease progression and comorbidities
- seizure prophylaxis, arrhythmias
- fluid imbalance, decreased organ perfusion
- mechanical ventilation
Why is electrical defibrillation not commonly performed? What type is done?
ventricular fibrillation or pulseless ventricular tachycardia is not as common in veterinary patients
biphasic - lower energy (2-4 J/kg) = less tissue damage
How are veterinary patients electrically defibrillated?
- basic life support first - CAB
- defibrillation after starting CPR if ventricular fibrillation or pulseless ventricular tachycardia is present
ensure firm contact with chest and use gel (NOT alcohol) —> CLEAR!
What are 2 advantages to open chest CPR? Disadvantage?
- more effective at restoring ROSC
- better neurologic outcomes
requires more skill and equipment
What are 4 indications for open chest CPR?
- tension pneumothorax
- pericardiac effusion
- large volume of pleural effusion
- large patients
What are the 2 positions used for open chest CPR? How is this performed?
- right lateral recumbency - clip at 3rd-5th ICS
- left lateral recumbency - clip at 4th-5th ICS
- place Finochietto retractors
- sharply excise pericardium at the ventral aspect, avoiding phrenic nerves
- compress from apex to base
What are the 2 techniques for open chest CPR?
- one-hand - fingers of the right hand wrap around the LV and compress against the sternum
- two-hand - RV in left hand and LV in right hand
How is defibrillation performed during open chest CPR?
- wrap internal paddles in saline-soaked lap sponges or gauze
- place on either side of the heart
- reduce dose by 1/2 —> 2 J/kg
What happens following open chest CPR?
- once ROSC is established, patient likely needs to be kept sedated with BZD or fentanyl and put on mechanical ventilation
- cover the thoracotomy with sterile drapes
- clip the surrounding hair and sterile prep
- change gloves and instruments
- lavage the thorax
- place a thoracostomy tube and close the incision
What is the main indication for pericardiocentesis? 2 contraindications?
pericardial effusion causing tamponade, arrhythmias, or significant CV compromise
- cats - effusion due to CHF may not need to be tapped
- coagulopathy
What complications are associated with pericardiocentesis?
- cardiac laceration
- arrhythmias
- infection
- pneumothorax
What are 2 indications for thoracocentesis? When is it contraindicated?
pleural effusion and pneumothorax
coagulopathy
What complications are associated with thoracocentesis?
- cardiac laceration
- pulmonary lacteration
- iatrogenic pneumothorax
- infections
What are the major indications for chest tube placement? When is it contraindicated?
pneumothorax and pleural effusion
coagulopathy
What complications are associated with chest tube placement?
- infection
- pneumothorax
- lung laceration
- tube migration
What are the major pros and cons to traditional thoracostomy tube placement?
PROS:
- larger bore good for thick effusions
- less risk of kinking
- continuous suction
CONS:
- larger bore causes more pain
- requires anesthesia
- SQ leakage possible
What are the major pros and cons to Mila thoracostomy tube placement?
PROS:
- rapid placement requires only sedation
- smaller bore for comfort
- less invasive and less risk for trauma
CONS:
- smaller bore does not work well with thick effusion
- flexibility makes migration easier
What are the 4 major indications for temporary thoracostomy tube placement?
- upper airway obstruction - FB, mass
- severe laryngeal collapse/paralysis
- severe upper airway swelling
- inability to open mouth
What are 3 contraindications for placing temporary thoracostomy tubes?
- coagulopathy
- tracheal collapse
- owner non-compliance - $$$
What complications are associated with temporary tracheostomy tube placement?
- hemorrhage
- esophageal laceration
- tracheal trauma
- SQ emphysema
- airway obstruction post-placement
- pnuemonia
What are the 3 most common causes of cardiac arrest in dogs/cats?
- asphyxiation
- asystole, pulseless electrical activity, ventricular fibrillation
- anesthesia-related
What anti-arrhythmic is commonly found in the crash cart?
Lidocaine
What electrolyte administration is not recommended during CPR?
potassium
Which of the following is the most appropriate first step that should be taken in any arrest situation?
a. Give atropine IV at the shortcut dose of 1ml per 20 pounds.
b. Calling the owners to be sure they want CPR to be performed.
c. Setting up the defibrillator to deliver a shock.
d. Initiate chest compressions.
D
What is the expected ETCO2 measurement after esophageal intubation?
a. 0-10 mmHg
b. 35-40 mmHg
c. > 50 mmHg
d. The ETCO2 monitor will not function if the patient is not properly intubated.
A
Which is the following is true regarding the cardiac pump theory of chest compressions?
a. The cardiac pump theory should be applied for CPR of any patient over 15kg.
b. Compression of the heart causes the mitral valve to close and blood from the left atrium to be expelled into the aorta.
c. Hand placement for compressions using the cardiac pump theory should be directly over the heart.
d. When applying the cardiac pump theory of compressions it is only necessary to release the chest half-way after each compression.
C
What is the recommended chest compression rate for veterinary CPR?
a. Matching the rate of chest compressions
b. 10 breaths per minute
c. Any rate needed to maintain ETCO2 < 10 mmHg
d. 30-40 breaths per minute, to match the animal’s normal respiratory rate
B
What is the recommended chest compression rate for veterinary CPR?
a. Matching the respiratory rate
b. About 1 compression per second
c. 100-120 compressions per minute
d. As fast as possible
C
If venous access cannot be rapidly obtained, what is the most appropriate route of administration of emergency medications?
a. Subcutaneous injection
b. Intramuscular injection
c. Delivery through the endotracheal tube
d. Squirted in the mouth
C
During advanced life support, emergency medications like atropine and epinephrine should be delivered in which of the following manners?
a. Every 3-5 minutes.
b. Just once.
c. Every 2 minutes for at least 15 minutes.
d. Set up as a CRI for the duration of the CPR attempt.
A
What is the main effect of the drug epinephrine?
a. Slows the heart rate and prevents arrhythmias.
b. Causes the blood vessels to dilate so that blood can get to the heart and brain more efficiently.
c. Causes an increased heart rate and stronger heart contractions.
d. Reverses the effects of opioids like fentanyl and hydromorphone.
C
Name the EKG pattern that starts at the red arrow in this picture.
a. Ventricular fibrillation
b. Sinus tachycardia
c. Atrial fibrillation
d. Sinus arrhythmia
A
True or False? The EKG tracing shown here means that the patient’s heart is beating.
FALSE - electrical activity =/= heart contraction
What does the acronym ROSC stand for?
return of spontaneous circulation
