Past Continuing Education Events
Past CE Events
Past CE Events:
Continuing Education: Current CPR Techniques
Cardiopulmonary cerebral resuscitation represents one of the most challenging tasks for the veterinarian. When the patient does not respond it is an emotional drain on the veterinarian and the staff. On the other hand, when executed well and with success, it can be one of the most rewarding experiences. The staff feels a sense of accomplishment and unity. There are cases with chronic, terminal illness where this may not be appropriate. However, it is my opinion that the majority of our cases CPR should be approached with determination, intensity, organization and skill.
Cardiac arrest is defined as cessation of effective circulating blood flow and ventilation. Cardiopulmonary arrest is typically associated with loss of consciousness, collapse, lack of a palpable pulse, pale or cyanotic mucous membranes, lack of effective respirations, and lack of measurable blood pressure. Successful resuscitation involves cardiopulmonary and cerebral resuscitation (CPCR). In order to accomplish this goal we must strive for early recognition, fast and effective action by our staff members, early CPR with an emphasis on compressions, and intensive post-cardiac arrest care.
Preparedness: Preparedness is essential for effective CPR. Resources should include a hard surfaced table, crash cart with supplies & medications (see the links at the end of the article for my list of these), hair clippers, oxygen accessibility, endotracheal tubes, ECG with defibrillation, monitoring equipment including Doppler blood pressure and pulse oximetry, suction, capnography, a CPR worksheet for record keeping, chest tap set-up and drug dose charts. The maintenance of this equipment should be assigned to one specific staff member and checked daily to ensure it is always ready to go. Routine practice drills can be very helpful and will help prepare your staff for the real thing. CPR canine or feline models can be purchased and you can find reasonably priced ones for under $200.
Early recognition: Impending cardio-pulmonary arrest often gives us clues before it actually occurs. It is critical that our staff is able to recognize these warning signs. Common signs seen in the pre-arrest setting may include altered mentation, cyanosis, prolonged CRT, changes in respiratory rate, depth or pattern including agonal respirations, bradycardia or high risk tachyarrhythmia, hypotension, hypothermia, cold extremities, changes in pupil size (dilated pupils usually occur within 45 seconds of the arrest) , agitation and vocalization, and staring into space. A well-trained team from assistants to the technicians can help recognize these signs and alert the veterinarian. Early recognition gives these patients a much better chance at survival.
Every patient should have CPR directives planned in advance. Clients should be asked this question prior to their pets being admitted to the hospital. We have them check a box at the end of their estimate that says I approve CPR or I decline CPR. We then place a cage card stating the owner’s wishes thereby avoiding delay when the pet needs immediate intervention.
Team set into action: Teamwork is essential in any emergent situation. By pre-assigning roles and practicing responses to CPR, valuable time is saved, and patient morbidity is decreased. It takes at least 6 people to efficiently perform CPCR:
#1 – Leader/compressions #2 - Ventilation #3 - Get drugs, fluids (runner), pulse oximetry, heating pad #4 - Place EKG leads (use gel not alcohol in case you need the defibrillator), rear limb doppler blood pressure (listening to your compressions with the Doppler is a good measurement of your compressions) #5 - IV catheter #6 - Record all drugs or interventions
Every CPR needs a leader which should be the doctor. The doctor needs to be directing each staff member to the most urgent task at which should be the doctor. For example, a technician or the doctor should do compressions while a technician intubates, inflates the cuff and starts
ventilating using the ambu bag.
A dose of epinephrine can be placed down the endotracheal tube using a polypropylene or long red rubber catheter if an IV catheter is not in place. A technician should then be placing an IV catheter. Assistants should be tasked with setting up fluids, EKG, obtaining blood pressure, pulse oximetry and placing a heating pad on the patient.
Compressions: Start every CPR with compressions. Compressions will provide some gas exchange by passively moving air into and out of the larger conducting airways. Additionally, the pulmonary blood that has just participated in gas exchange and is maximally saturated will be circulated via chest compressions. It is ok to begin compressions on an apneic patient ( do not wait until the heart has stopped completely).
Technique: The animal should be placed in right lateral recumbency. Animals less than 10kg should have compressions performed over the 4th–6th intercostal space at the costochondral junction and dogs greater than 10kg should have compressions performed over the widest diameter of the thoracic cage, just dorsal to the costochondral junction. Compression should displace thorax by 30% and should be a ratio of 1:1 to allow for ventricular filling. If the compressions are too fast then there will not be enough time for ventricular filling and the compressions will not be as effective. Compressions must be continuous and uninterrupted for 2 minutes. (Switch the person doing the compressions every two minutes if possible) however, if compressions must be interrupted avoid a delay greater than 10 seconds. Perform approximately 60-70 compressions per minute and assistant can begin nterposed. abdominal compressions.
Airway: It is important to have your technicians trained in performing endotracheal intubation with the patient’s in lateral recumbency. Elevating the head may cause a precipitous decline in blood flow to the brain and can actually initiate cardiac arrest.
Technique: Orotracheal intubation consists of placing endotracheal tube and inflating the cuff. Visual conformation with a laryngoscope is recommended. Suction should be available in case it is necessary to suction secretions/blood from the oropharynx to facilitate placement. Surgical placement of a tracheostomy tube may be warranted. Attach to oxygen and ventilate with an ambu bag. The respiratory rate should be 8-10 breaths per minute and should not exceed 20cm H20 airway pressure. Be careful not to overinflate the lungs or prolong inspiration time as this will impair venous return and cardiac output. End tidal expired carbon dioxide (ETCO2) can be used as a marker of CPCR effectiveness. End tidal expired carbon dioxide concentrations have been correlated to survival in canine and human studies with values exceeding 10-15 mm Hg. If ETCO2 is less than 10–15 mm Hg the patient is unlikely to be resuscitated. Doxapram is NOT recommended to stimulate respiration, as it has been shown to decrease cerebral blood flow
and increase cerebral oxygen demand.
Drugs: Routes—Intravenous, Intratracheally and Interosseously. Intratracheal medications such as naloxone, atropine, vasopressin, epinephrine and lidocaine can all be given via this route. Generally double the dose and dilute with 5-10mls of sterile water except for epinephrine. Epinephrine should be increased by 3-10 times the dose) Steroids are not recommended in CPR.
Naloxone: Dose 0.04mg/kg (or the same dose in mls as the drug you want to reverse). This should be one of the first drugs you grab for if the patient has been treated with an opiod.
Epinephrine: Dose-0.01-0.02mg/kg—repeat the dose every 3 minutes. Epinephrine is one of the most effective adrenergic drugs used during CPCR. Epinephrine can induce fibrillation, thus a defibrillator may be useful.
Atropine: Dose-0.04mg/kg for asystole and 0.01mg/kg for sinus bradycardia.
Lidocaine: Dose-2mg/kg IV— used to treat V-tach and ventricular flutter.
Amiodarone: is recommended for refractory ventricular arrhythmias.
Vasopressin: (anti-diuretic hormone) Dose – 0.8 U/kg IV- Improves myocardial and cerebral perfusion by increasing peripheral vasoconstriction. Vasopressin does not have direct cardiac effects. However, unlike other drugs used in CPR, vasopressin maintains its effectiveness in hypoxemic and acidemic states, making it a reasonable option for prolonged CPR.
Fluid therapy is only appropriate if your patient is suffering from hypovolemic shock or dehydration. It is not recommended to administer large doses of fluids if the patient is hydrated.
Defibrillation: Only effective when patient is in ventricular fibrillation. Continuous, uninterrupted chest compressions should be performed while the defibrillator is being charged and prepared. As a reminder, never use alcohol or ultrasound gel around the unit. One shock, immediately followed by chest compressions for a minimum of 2 minutes prior to reassessing the EKG is recommended. This will increase myocardial perfusion. Dose: 2-4 joules/kg for a monophasic defibrillator and 1-2 joules/kg for a biphasic. Animals are rarely in v-fib prior to arrest.
Troubleshooting: If the CPR is initially unsuccessful then change the position of the animal, change the person doing the compressions and ventilate more frequently.
Post resuscitation care: In the post-cardiac arrest phase, the chance of re-arrest is high (68% dogs, 37% cats). Post-resuscitation requires intensive monitoring and aggressive supportive care. It is recommended to monitor post arrest CBC/Chem/Lytes/BG/lactate and base deficit. Serial lactates should be under 2. Oxygen saturation target should post CPR should be 93% (higher will exacerbate reperfusion injury and worsen the prognosis. Hypotension is treated with IV boluses of the appropriate fluid choices and vasopressors. Treatment for cerebral edema using mannitol is often necessary as oxygen depletion occurs within 10 seconds and ATP depletion occurs within 2-4 minutes. The mannitol dose-1g/kg IV slowly over 15-20 minutes. The use of mannitol is recommended only in hydrated patients. Neurological improvement and recovery can occur up to 48 hours post arrest, even in patients that appear obtunded.
This unique CE Opportunity Will be held at the Crest Hollow Country Club On Thursday, July 19th, 2012 from 6pm to 10pm. This program has been submitted, but not yet approved, for 4 hours of continuing education credit in jurisdictions which recognize AAVSB RACE approval. Additionally, this program has been submitted, but not yet approved for 4 hours of NY State CE credit through the NY State Education Department. Limited seating. Please RSVP by 7-15-12.
Crest Hollow Country Club
8325 Jericho Turnpike
Woodbury, New York 11797
From New York City:
make left. Take Round Swamp Road
to the end (2.6 miles). Make left at
light onto NY 25 - Jericho Turnpike.
Proceed west for 1 mile (on the right)
From Eastern Long Island:
Exit 48, Round Swamp Road. At light
make right. Take Round Swamp Road
to the end (2.6 miles). Make left at
light onto NY 25 - Jericho Turnpike.
Proceed west for 1 mile (on the right)
This unique CE Opportunity will be held at the Huntington Hilton On Thursday, July 14th, 2011, from 6pm-10pm. This program has been approved for 4 hours of continuing education credit in jurisdictions which recognize AAVSB RACE approval.
Dr. Noelle La Croix, Diplomate ACVO Will be discussing New Advances in Ophthalmology And Dr. Judy Seltzer, Diplomate ACVD Will be discussing A Diagnostic Approach to Atopy.
For more information on this cruise, you can visit Lady Liberty Cruises.
The Veterinary Medical Center of Long Island is offering an opportunity for veterinarians to come to our facility and discuss case management issues and recommendations.
Round Table Dates:
Wednesday, May 20th, 2010
Thursday, July 30th, 2010