Dr Isak Kasuto - CPR: The ABCs of Getting Them Back

Question 1

What was the purpose of the RECOVER initiative?

Answer 1

The RECOVER initiative was designed to systematically evaluate the evidence on the clinical practice of veterinary CPR, namely:

• Creation of veterinary clinical guidelines
• Identification of important knowledge gaps in Veterinary CPR

Question 2

What are some reasons why CPR performed?

Answer 2

~To support a patient through a reversible disease process

~To support a patient until the owner arrives or can reach a decision

Question 3

Under what situation would CPR not be performed on an arresting animal?

Answer 3

If DNR orders have been given.

Question 4

When is CPR performed?

Answer 4

~In a case of cardiopulmonary arrest (CPA)

~In a case of recent arrest

Question 5

What is essential to perform in an unresponsive patient?

Answer 5

Rapid assessment of the patient - Primary assessment (ABCs)

Question 6

How long should a primary assessment (ABCs) take?

Answer 6

No more than 15 seconds

Question 7

Should we delay CPR when there is a suspicion of CPA?

Answer 7

NO! Benefits of starting CPR immediately with CPA outweighs the risks of performing CPR on an unresponsive patient not in CPA.

Question 8

How do we increase the chance of success with CPR?

Answer 8

By knowing the patients code status and early recognition of symptoms of CPA.

Question 9

What are some symptoms of CPA (or imminent CPA)?

Answer 9

Obtundation (non-responsiveness)
Hypothermia
Bradycardia
Weak Pulses
Hypotension
Dilated/Unresponsive Pupils
Pale/Cyanotic MM

Question 10

What is CPR?

Answer 10

Artificial maintenance of tissue oxygenation and circulatory support.

Question 11

What is the goal of CPR?

Answer 11

To provide artificial maintenance of tissue oxygenation and circulatory support until spontaneous return of patients own respiratory and circulatory systems (ROSC)

Question 12

What is the ROSC percent of animals in hospital?

Answer 12

35-45% ROSC (Ca better than Fe)

Question 13

What percent of animals survive to discharge from the hospital?

Answer 13

6-7% chance of survival to discharge from hospital (but a range of 2-10%)
(Statistics retrieved from JAVMA 1992, 2009 and JVECC 1992)

Question 14

What is the % chance of survival (to discharge) after anesthesia related arrest?

Answer 14

42% in felines to 47% in canines

Question 15

What are the basics of CPR?

Answer 15

~Airway
~Breathing
~Chest Compressions
~Monitoring
~Drugs/Fluids - IV Access
~Defibrillation 
~A-B-Cs or C-A-Bs

Question 16

What is considered Basic Life Support(BLS)?

Answer 16

~Airway
~Breathing
~Chest Compressions

Question 17

What is considered Advanced Life Support (ALS)?

Answer 17

~Monitoring
~Drugs/fluids - IV Access
~Defibrillation
~A-B-Cs or C-A-Bs

Question 18

When should chest compressions be initiated?

Answer 18

Rapidly if there is a suspicion of CPA

Question 19

What is the key thing to remember with chest compressions?

Answer 19

Continuous, uninterrupted chest compressions is key. Human studies show that interruptions (airway, defib, cath IV, drug administration, ECG etc) were associated with increased mortality

Question 20

How many seconds of chest compressions is needed before coronary perfusion pressure (CoPP) reaches maximum?

Answer 20

60 seconds of uninterrupted compressions

Question 21

What is the required rate for CPR?

Answer 21

Needs to be rate of 100-120 beats/minute

Question 22

How much of the thoracic wall should be depressed with each compression?

Answer 22

A depression of 1/3-1/2 width of thoracic wall is necessary

Question 23

What should occur every 2 minutes (cycles) during Compressions?

Answer 23

“Compressors” should be changed every 2 minutes

Question 24

What amount of time should interruptions be minimized to at each cycle change?

Answer 24

Interruptions should be minimized to less than 10 seconds at each cycle change

Question 25

Is a precordial thump recommended?

Answer 25

No, it is no longer recommended UNLESS you do not have a defibrillator and (VF/Pulseless VT) -Ventricular Fibrillation and Pulseless Ventricular Tachycardia is present

Question 26

How is chest compression type determined?

Answer 26

Type is dependant on patient size/type or presenting condition

Question 27

If an animal is < 10kg and keel chested (narrow, deep chested) what type of compressions would be recommended?

Answer 27

Cardiac Pump Compressions

Question 28

If an animal is > 10kg, what type of compressions would be recommended?

Answer 28

Thoracic Pump Compressions

Question 29

If an animal is very large or has a chest injury, what type of compressions are recommended?

Answer 29

Internal massage compressions

Question 30

If an animal is barrel chested (such as an english bulldog), what type of compressions are recommended?

Answer 30

Sternal compressions in dorsal recumbency

Question 31

Describe the cardiac pump compression (for animals <10kg):

Answer 31

Compress over the heart with thumb and fingers while the animal is in right lateral recumbency
*** Note: avoid excessive force to prevent intrathoracic trauma

Question 32

Describe the compression procedure for keel chested animals:

Answer 32

Compress directly over the heart (same technique as thoracic pump) while the animal is right lateral recumbency

Question 33

Describe the thoracic pump compression procedure (for animals >10kg OR keel chested animals):

Answer 33

~Place the animal in right lateral recumbency
~Get ABOVE the patient, arms extended (lock elbows), palms to the chest of the dog.
~Make a “quick” cough motion, depressing the thorax approximately 1/3-1/2 width

• • Compressions are made to the widest area of the thorax
• ** A 1:1 compression/relaxation cycle is desired, allowing full chest wall recoil

Question 34

Describe the compression procedure for Barrel-chested dogs (like English Bulldog)

Answer 34

~Similar technique to the thoracic pump compression procedure but the animal is in DORSAL recumbency
~ Efficiency appears to be similar to thoracic pump mechanism

Question 35

What situations require internal cardiac massage?

Answer 35

~ With large dogs > 20kg
~ Animals in Surgery
~ Pleural Space Disease, Pericardial Effusion, Diaphragmatic Hernia and Thoracic Defects

Question 36

What are some examples of pleural space disease that require internal cardiac massage?

Answer 36

Pleural effusion

Pneumothorax

Question 37

What are some examples of thoracic defects that would require internal cardiac massage?

Answer 37

Flail chest

Rib Fractures

Question 38

What is flail chest? What is the result of flail chest? What recumbency position will help stabilize the chest wall to allow for better ventilation?

Answer 38

Defined as at least two continuous ribs fractured, each at two locations. Flail chest results in a portion of the thoracic wall that will move in a paradoxical motion during inspiration and expiration. More common in dogs than cats. Lateral recumbency on the side of the flail chest will help stabilize the chest wall and allow better ventilation.

Question 39

What are the disadvantages to internal cardiac massage?

Answer 39

~Potential infection
~Higher costs and care requirements
~Client’s “perception”

Question 40

What is the purpose of abdominal compressions?

Answer 40

To facilitate abdominal venous return and improve cardiac output.

Question 41

Is there a high risk of trauma to the animal if abdominal compressions are performed?

Answer 41

No, there is minimal evidence of trauma if the performer is trained in the technique

Question 42

When is administering abdominal compressions considered reasonable?

Answer 42

It is a reasonable option when sufficient personnel who are trained in its use are available.