wks 8-11 Flashcards
CPR
Cardiopulmonary Resuscitation
RECOVER
Reassessment Campaign on Veterinary Resuscitation
new CPR guidelines: CABD
compressions
airway
breathing
defribillation
BLS
basic life support
1. chest compressions
2. ventilation
ALS
advanced life support
3. Monitoring
4. Vascular Access
5. Administer Reversals and/or Medications
ROSC
Return of Spontaneous Circulation
cardiac compressions
- Importance of high-quality chest compressions with minimal interruption
- uninterrupted cycles of 2 minutes
- rate of 100-120/min
- depth of 1/3-1/2 the width of the chest
chest compressions
Use in cardiopulmonary arrest (CPA) to restart the heart; Will depend on thoracic conformation
cardiac pump theory and thoracic pump theory
cardiac pump theory
Ventricles are directly compressed between sternum and spine in dorsal recumbency or between the ribs in lateral recumbency
thoracic pump theory
Chest compressions increase the intrathoracic pressure; compresses the aorta & collapses the vena cava leading to blood flow out of thorax
Artificial Respiration
Early ventilation is very beneficial
Increases chance of success
- ventilation rate of 10 breaths/minute
- Inspiratory time of 1 second
- Tidal volume of 10ml/kg
- Delivered simultaneously with compressions
4 methods of artificial respiration
- ET tube + Anesthetic machine
- ET tube + Ambu Bag
- Mask + Ambu Bag
- Mouth to Snout
rapid intubation
can be accomplished while the animal is in lateral recumbancy and undergoing chest compressions
Mouth-to-Nose Resuscitation
- Insure patient airway
- Hold mouth tightly closed
- Place your mouth over the animal’s nares and blow into the nares till you see the lungs expand
- 30 compressions: 2 breaths
Cardiac Compressions + Artificial Respirations: Alone
30 compressions: 2 rapid breaths in 2-minute cycles
Cardiac Compressions + Artificial Respirations: assistance
- Person performing compression should be rotated after each 2-minute cycle to prevent fatigue
- Minimize chest compression interruptions
2-minute cycles of CPR
allow brief pause to:
◦ Rotate compressors
◦ Evaluate patient
◦ Evaluate ECG
Patients with no pulse but electrical activity
- Treat with vasopressors and anticholinergic drugs
- Administer every other cycle
Patients in ventricular fibrillation or pulseless ventricular tachycardia
- Treat with electrical defibrillation
- Mechanically defibrillation with a “precordial thump”
- Blow to the chest with a clenched fist
- Immediately start another 2-minute cycle
Medium, Large or Giant Breeds chest compressions
- hands over widest portion of the chest
- 30 compressions: 2 breaths if alone
- 100-120/minute
Narrow, Deep-Chested Breeds chest compressions
- hands directly over heart
- 30 compressions: 2 breaths if alone
- 100-120/minute
Barrel-Chested Breeds chest compressions
- dorsal recumbency
- hands over sternum directly over heart
- 30 compressions: 2 breaths if alone
- 100-120/minute
Small dogs & cats <10 kg with compliant chests for compressions
- Use 1-handed technique with hand wrapped around sternum directly
over heart - same rate
Small dogs & cats >10 kg or lower chest compliance or a fatigued compressor
Use the 2-handed technique directly over heart (similar to narrow-chested)
if the heart stopped what is the preferred emergency drug
epinephrine
- stimulates heart
- higher dose if administering through ET tube
CPR summary
- Determine the animal is apneic and/or no heartbeat
- Shout for help
- Begin cardiac compressions-give 30
- Assess airway-check for obstructions-provide mouth to snout (Swipe mouth, If obstructed: Heimlich Maneuver, Give 2 breaths)
- Intubate if help arrives; provide artificial
respiration simultaneously as compressions- Ventilation rate of 10 breaths/minute
- Tidal volume of 10ml/kg
- Inspiratory time of 1 second
- 100-120 compressions per minute
- Monitor with ECG
- Place IV catheter
- Administer medications
- Assess patient every 2 minutes for spontaneous
breathing and heart rate
proper monitoring
key to preventing anesthetic emergencies and to a successful outcome when they occur
when to stop CPR
- The animal recovers
- You are relieved by someone else
- You are physically exhausted
- The DVM calls time of death
DNR
do not resuscitate
apnea
no breathing
respiratory arrest
cessation of respiratory effort
dyspnea
difficult breathing
tachypnea
rapid respirations
cardiac arrest
cessation of circulation due to failure of heart to contract; always includes respiratory arrest
causes of anesthetic problems and emergencies
- human error
- equipment failure
- adverse effects of anesthetic agents
- patient related factors
human errors
1.Failure to obtain adequate history & examination
2.Inadequate experience with anesthetic machine
3.Incorrect administration of drugs
4.Failure to monitor properly
5.Failure to recognize and respond promptly to earlysigns of patient difficulty
6.Errors caused by being in a hurry or fatigued
Hypercapnea
can lead to respiratory acidosis = decreased blood pH
most serious and most preventable
empty o2 tank
patient related factors
- Geriatric patients
- Pediatric patients
- Brachycephalic dogs
- Sighthounds
- Obese animals
- C-section
- Trauma patients
- Patients with organ disease
anesthetic problems and emergencies
- animals that will not stay anesthetized
- animals that are too deeply anesthetized
animals that are too deeply anesthetized
- Respiratory rate of 6 bpm or less
- Shallow respirations
- Dyspneic
- Pale or cyanotic mucous membranes
- CRT > 2 seconds
- Bradycardia
- Weak pulse
- Cold extremities
- Absent reflexes
- Flaccid muscle tone
- Dilated pupils
temporary apnea
no breathing
anesthetic duties
- Set up & check out the anesthetic machine
- You can do this by yourself, but you will be expected to also go through the 7 steps for the instructor
- Place a mayo stand by the front of the surgery table to place the supplies
- Choose 2 ET tubes and gather all the supplies needed for induction & intubation (see anesthetic supplies check list)
- Administer all medications
- Intubate the patient
- Help with monitoring and adjusting anesthesia
- Bagging the patient
- Extubate
- Return patient to cage
- Bleed out machine
monitor duties
- Set up the monitor (including alarms, hi and low
parameters) and gather any supplies associated with
monitor - Start the white anesthesia record
- Assist circulator with physical exam
- Set up monitoring equipment prior to induction
- Measure blood pressure cuff
- Apply blood pressure cuff when patient is sedated – if able
- Hook up the patient to the monitoring equipment
- Monitor the patient throughout anesthesia
- 5 – 10 minute vital checks
circulator
- Perform the Set up hot water blanket & towel
- Pre-surgical examination
- Restrain patient for induction/intubation
- Patient record
- The circulator should gather the patient record and is
responsible for making sure all the paperwork is filled out (including the SOAP) record. - The circulator must work closely with the anesthetist to obtain the drug dosages given
- Enter controlled substance log info
- Enter stick log info
- Clean table after anesthesia
- Clean & return hot water blanket to cabinet
- Dispose of trash
no circulator
- Monitor should do the patient SOAP record
- Anesthetist should set up the hot water blanket and towel
- Monitor should perform the physical examination
- Monitor should enter the controlled substance log
- Monitor should enter the stick log info
- Anesthetist should clean table
- Anesthetist should clean & return hot water blanket
- Anesthetist should dispose of trash
subjective
- evaluation of animal
- Mentation/Status of animal: BAR, QAR, bright, alert, responsive; depressed, improving, getting worse
- Description/history: Fluffy has a 3 day history of diarrhea. He is known to eat things he is not supposed to. Has also vomited twice with toy stuffing in vomit.
- Presenting complaint/reason for visit
objective
- measurable data
- Physical exam findings
- Diagnostics test findings: Bloodwork, Fecal, etc
assessment
*analysis of S and O
- differential diagnosis: vet responsible
plan
- treatments
- client communication
- prognosis
- procedures
day before anesthesia
- animal weighed
- no food for 12 hours
night before anesthesia
- remove food
- cats in individual cage
- NPO tags
- water bowls can be left in cages
morning of anesthesia
- water removed
- double check for correct animals
- complete physical exam before
sutures removed
7-14 days
-tome
cutting instrument
-otomy
to cut into
incise
-ectomy
to cut out
excise
-ostomy
to form a new opening
surgical
reproductive surgery
Ovariohysterectomy (OHE, OVH): Spay
Cesarean section (C-section)
Mastectomy (mammary glands)
Orchiectomy: Neuter or Castration
Penrose Drain
Soft rubber tubing placed in a wound to prevent
build up of fluid
testicular implants
neuticles
abdominal surgery
Exploratory Laparotomy
Gastrotomy
Enterotomy
Intestinal Anastomosis (remove part of intestinal tract)
Splenectomy
Anal Sac Ablation (removal of anal glands)
Pre-Operative Preparation
Patient History at Check in
Client Communication at Check in
Physical Examination
Patient Preparation
surgical prep
- surgical clipping
- surgical scrub
antiseptics
iodophor scrubs
chlorohexidine scrub
alcohol
pattern of surgical scrub
centered and moved in a circular motion outward from initial site - remove sponge and begin rinse in same motion
positioning on surgery table with ropes
front legs - one loop above carpus and one below
hind legs - both loops below he hock
other tasks before surgery
Position surgery table for height of surgeon, tilt table depending on position
Direct lights at incision site
Regulate intravenous fluids
Open surgical packs, hand suture materials to surgical team
Monitor anesthesia
endotracheal intubation
flexible tube is placed inside the trachea of an
anesthetized patient; anesthetic gases are delivered directly from anesthetic machine into patients lung
why ET tube is used
- maintain airway
- prevent aspiration pneumonia
- provide pathway for gases
- decrease dead space
- provide an avenue for controlled respiration
- provide an avenue for resuscitative measures in an emergency
equipment needed for ET intubation
- appropriate tube size
- orange ties
- gauze sponge
- air syringe
- laryngoscope
- sterile lube
- stylet
- lidocaine for cats
murphy type
- most common
- beveled end and side hole
- diameter less than trachea
- cuff to seal trachea
Cole type
- no cuff or hole
- fitted to trachea
- more common in pediatric and exotics
types of ET tube material
polyvinyl chloride
red rubber
silicone
PVC
- stiffer
- can damage trachea
- cannot autoclave
red rubber
- more flexible and less traumatic
- kinks
- not transparent
silicone
- more expensive
- can be autoclaved and reused
- strength and flexibility
reinforced ET tubes
embedded with coil of metal to prevent kinking while also bends
how ET tubes are sized
sized by the internal diameter and length
how to choose proper diameter of ET tube
- adult cats: 3.0mm, 3.5mm, 4.0mm
- small dogs: 3.0mm-5.0 mm
- medium dogs: 5.0mm-7.0mm
- big dogs: 7.0mm+
- use largest tube that will fit the airway
how to measure proper length to insert ET tube
thoracic inlet to tip of nose
how to check and ET tube prior to use
- damage
- debris
- hold up to light to check for lumen obstruction
- cuff leaks (air or water)
laryngoscope
device used to increase visibility of larynx
- handle, blade, light source
arytenoids
two white, barlike cartilage structures located at opening to trachea
glottis
contains vocal chords
epiglottis
leaf shaped cartilage that covers the glottis during swallowing
how do dogs and cats differ in their larynx
cats tongue is more rough
positioning for ET intubation
sternal recumbency
6 steps to ET intubation
- visualize the et tube pass between the arytenoids
- confirm et tube is in the trachea
- advance tube to predetermined length
- tie the tube in
- inflate the cuff
- check for proper inflation of the cuff
laryngospasm
reflex closure of the glottis &
arytenoids
6 ways to confirm an ET tube is in the trachea
- see if go between arytenoids - best way to confirm
- cough
- fogging in the et tube
- watch flutter valve “flutter”
- feel air
- check capnograph……
**if you hear whining noises, it is in the esophagus
when should patient be extubated
after 2-3 good swallows
how to clean ET tube
- always clean the tube inside and out with a brush and disinfectant
- inflate the cuff when cleaning to be sure no secretions are caught in the folds
- soak in disinfectant (chlorhexidine) and rinse well
- hang to dry
what to also tell clients when discharging pet that has been intubated
it is not unusual for an animal to cough for several days after being intubated due to tracheal irritation; dry cough not a wet cough - wet cough is indication of something more serious
cuff not inflated or under inflated
- inability to create a seal between cuff & trachea
- difficulty or inability to keep the patient anesthetized
- aspiration of stomach contents
- aspiration of foreign material and fluid during dental cleaning
- pollution of work space with anesthetic gas
tube diameter too small
- inability to create a seal between cuff & trachea
- small tubes are more likely to block with mucus
- increased resistance to breathin
cuff overinflated or tube diameter too large
- necrosis of tracheal mucosa
- big concern in cats
- possibility of tracheal rupture
tube too long
if tube is too deep:
* intubation of one main bronchus = hypoxemia
* difficulty keeping patient anesthetized
if extends beyond mouth = increased mechanical
dead space, hypoventilation & hypoxemia
tube too short
- inability to intubate
- changes patients position and may dislodge tube
overzealous intubation
- tracheal irritation = tracheitis & postoperative cough
- trauma or tracheal rupture = pneumomediastinum and/or pneumothora
tube kinked or obstructed
- dyspnea & hypoxemia
- cyanosis!
- asphyxia = cardiac arrest if not corrected!
tube not removed before return to consciousness
- damage from chewing
- blockage of airway
- severed portion of tube and may be aspirated or swallowed
tube not cleaned and disinfected
- transmission of infectious agents
- blockage of tube with dried mucus or other foreign material
steps if patients vomits when intubated
- lower head
- can tilt table
- do not extubate!
- pull tongue anteriorly
- remove secretions/vomitus
- notify veterinarian
- monitor by ausculating lungs
- get in sternal recumbency asap
anesthetic masks
- cone shaped devices used to administer oxygen and anesthetic gases to non-intubated patients
- used for anesthetic induction and maintenance
main intubation procedure before
- premeds
- wait 15 minutes
- IV catheter to sedate
- induction IV to anesthetize
- then place tube to maintain anesthesia
size syringe for cats and dogs
cats: 3cc
dogs: 6cc
main extubation procedure
- shut of anesthetic gas but leave on o2 for 5 minutes
- deflate cuff
- untie at one good swallow
- wait till 2-3 good swallows to take out tube
