Cardiopulmonary Cerebral

Resuscitation (CPCR)
Danielle Berube DVM, DACVECC
Upstate Veterinary Specialties
September 17, 2016
 Outline
• Introduction
– Definitions
– Outcome
– Who is at risk
• Basic Life Support
• Advanced Life Support
• RECOVER Initiative
• Summary and updates
 Definitions
• Respiratory arrest
– Cessation of breathing
• Cardiopulmonary arrest
– Cessation of effective and spontaneous perfusion and
breathing (no palpable pulse, no heart sounds)
• CPR vs CPCR
– Cardiopulmonary resuscitation
– Cardiopulmonary cerebral resuscitation
 Outcomes
• Overall poor prognosis
– Survival to discharge 6-7%
• Re-arrest rates
– 68% dogs and 37% cats Survival to discharge
• Large prospective observational study that
investigated many aspects of CPR
• Survival to discharge: 6% dogs and 3% cats
• Simple anesthetic arrest (only 3 cases)
– 33% survived to discharge
 ROSC < 20 min: 23%
ROSC Euth: 10%
Repeat CPA:13%
58% No longer alive at 24 hr.
Dogs Euth: 21%
With ROSC > 20 min: 35% Repeat CPA: 4%
CPA
No ROSC Alive at 24 hr.
23% 10% Euth: 4%

Repeat
CPA:
Survive to Discharge 0
6%
 Outcome
• We often cannot change what happened to the
patient prior to arrest
• We can change staff and equipment variables that
affect outcome
• Successful outcomes are dependent on
– Staff preparedness
– Stocked crash area
– Working and available equipment
– TEAM WORK
 Outcome: Staff Preparedness
• Recognize patients at risk
• Didactic training and hands on practice
– Refresher every 6 months
• Centrally located crash cart
– Routinely checked
• Algorithm and dosing charts
 Outcome: Staff Preparedness
• Standardized CPR guidelines in human
medicine improved outcome after in hospital
CPA:
– 2000: 13.7%
– 2009: 22.3%
 Who is at risk?
• Trauma
• Respiratory system disease
• Septicemia
• Prolonged seizures
• Cardiac disease
• Vagal stimulation
• Anesthetic agents
• Severe metabolic disease
 Goals of CPCR
• Provide artificial respiration and
cardiovascular support until Return of
Spontaneous Circulation (ROSC)
– Coronary perfusion pressure
– Cerebral perfusion pressure
• Identify cause and treat immediately
Goals: Coronary Perfusion Pressure
• = Aortic diastolic pressure – right atrial
pressure
Goals: Cerebral Perfusion Pressure
• = mean arterial pressure – intracranial
pressure
 CPR/CPCR
• Be prepared
– Determine if a pet is breathing or if it has a
heartbeat
– Training, supplies, cognitive aids
• Don’t panic!
– Try to remain calm but efficient
• Call for help
– CPCR is labor intensive and is more likely to be
successful with a team rather than an individual
 CPR/CPCR
• First, follow your ABC’s (basic life support)
– Airway
– Breathing
– Circulation/chest compressions
• Then, think about your DEF’s (advanced life support)
– Drugs
– Electrical defibrillation/ECG/End tidal CO2
– Fluid therapy
 CPR/CPCR
• First, follow your ABC’s (basic life support)
– Circulation/chest compressions
– Airway
– Breathing
• Then, think about your DEF’s (advanced life support)
– Drugs
– Electrical defibrillation/ECG/End tidal CO2
– Fluid therapy
Recover: JVECC 22 (S1) 2012, S102-S131
Basic Life Support

Recover: JVECC 22 (S1) 2012, S102-S131

 Basic Life Support
• CIRCULATION
– Check for heart beat/pulse
– Do not assume there is no heart beat or pulse just
because they are not breathing
– Place patient in lateral recumbancy
• Preferably right
– If no heart beat or pulse begin chest compressions
 Basic Life Support
• CIRCULATION/CHEST COMPRESSIONS
– Goal
• Maximize blood to the heart and brain
• Restore pulmonary CO2 elimination and O2 uptake by
providing pulmonary blood flow
– Small patients
• One hand thumb and forefingers

Cardiac pump theory

Recover: JVECC 22 (S1) 2012, S102-S131

 Basic Life Support
• CIRCULATION/CHEST COMPRESSIONS
– Large patients
• Hands on top of one another at a 90 angle
• Widest part of chest
• Elbows straight
• Bend at the waist

Thoracic pump theory

Recover: JVECC 22 (S1) 2012, S102-S131

 Basic Life Support
• CIRCULATION
– Chest compressions – where
• Cardiac Pump - patients <15kg (<33 pounds)
– Compress directly over the heart
– Point of the elbow
• Thoracic Pump- patients >15 kg or barrel chested
breeds
– Compress at the widest part of thorax (usually further
back/caudal)
 Basic Life Support
• CIRCULATION/CHEST COMPRESSIONS
• Minimize interruptions to <10 seconds and switch out
every 2 minutes or upon checking vitals
• Including for intubation, blood draws, drug
administration
 Basic Life Support
• Circulation/Chest compressions
– How hard
• Compress thoracic wall by ~1/3-1/2
– What rate
• At least 100 compressions/minutes
• “Stayin’ Alive” vs. “Another One Bites the Dust”
– What rhythm
• 1:1 cycle (equal time spent compressing as allowing
chest to expand)
 Basic Life Support
• AIRWAY
– If agonal or not breathing obtain airway
– Check airway for any obstruction to flow
• Tilt head slightly back and extend the neck
• Carefully, pull tongue forward and down to better
visualize
• Use suction if needed
• Use manual palpation if needed
 Basic Life Support
• AIRWAY
– Ensure proper tube placement
• Visualize placement
• Auscult for breath sounds
• Observe for chest excursions
• ETCO2
– Esophageal intubation-zero
 Basic Life Support
• BREATHING
– Connect to a resuscitation/ambu bag
– Provide positive pressure ventilation up to 20 cm
H20
– 100% oxygen, 8-10 breaths/minute
– Inspiratory time 1 sec
– Tidal volume 10 ml/kg
– Avoid hyperventilation
 Basic Life Support
• BREATHING
– Trouble shooting
• High pressure needed to generate breath
– Pleural space disease
– Pulmonary disease
– Tube obstruction
• No chest excursion
– Inappropriate endotracheal tube placement
– Cuff leaking
– See above
Recover: JVECC 22 (S1) 2012, S102-S131
Advanced Life Support

Recover: JVECC 22 (S1) 2012, S102-S131

Advanced Life Support: Monitoring
• Monitoring
– ECG
• Asystole (22.8 – 72%)
• Pulseless electrical activity (11 - 23.3%)
• Sinus bradycardia (19 - 23% )
• Ventricular fibrillation (2 – 19.8%)
– ETCO2
• Proportional to pulmonary blood flow
• Low: poor prognosis
Advanced Life Support: Monitoring
• Attach ECG
– White lead – Right front
– Black lead – Left front
– Green lead – Right hind
– Red lead – Left hind
• Minimal alcohol or use conducting gel
• Rhythm diagnosis
– Administer appropriate drugs
 Asystole
• No rhythm on ECG
• Survival rate in people nearly 0%
• Treatment options
– Atropine
– Epinephrine
– Vasopressin
 Pulseless Electrical Activity (PEA)
• Aka electromechanical dissociation
• Human survival 1-4%
• Treatment options:
– Epineprhine
– Atropine
– Vasopressin
– Treat underlying cause
 Sinus Bradycardia
• Sinus rate < 60 dog/ <160 cat with palpable pulses
• Treatment
– Atropine
– Reverse offending sedatives
– Treat suspected underlying cause
 Ventricular Fibrillation
• Course V Fib
– 30% response rate
– SVT or sinus rhythm common when converted
• Fine V Fib
– 5% conversion rate
– Asystole converted rhythm
• Predisposing causes
– Hypokalemia www.mauvila.com

– Hypomagenesemia

www.resuscitationcentral.com
 Advanced Life Support
• DRUG ADMINISTRATION
– Intravenous
• Ideal mode
• Central large bore catheter best
• Peripheral typically easier during arrest
• Consider venous cutdown early
• If peripheral catheter, flush with 5-50 ml flush to reach
the heart
 Jugular Cut Down
• Quickly clip and prep area over jugular vein
• 1-2 cm incision made through skin (#10 or #11 blade) parallel
to the vessel
• Vessel dissected free from tissue
• Hemostats to lift/isolate vessel
• Catheter placed directly into vessel
• Secure in place by suturing

Advanced Monitoring and Procedures for Small Animal Emergency and Critical Care Fig 4.5
 Intraosseous Catheter
• DRUG ADMINISTRATION
– Intraosseus
• For small patients and exotics
• All medications can be given
– Equipment
• Jamshidi bone marrow needle
• 18-30g hypodermic needles
• Spinal needle
– IO catheter sites
• Trochanteric fossa of femur
• Wing of the ilium
• Greater tubercle of the humerus
 Advanced Life Support
• DRUG ADMINISTRATION
– Intratracheal
• Double dose
• Dilute with saline to 5-6 ml
• Flush to carina with red rubber catheter
• Give two deep breaths
• DO NOT GIVE SODIUM BICARBONATE via this route
– NAVEL
• Naloxone
• Atropine
• Vasopressin
• Epinephrine
• Lidocaine
 Advanced Life Support
• Common drugs – Calcium gluconate,
– Epinephrine insulin
– Atropine – Reversal agents
• Naloxone, flumazenil,
– Vasopressin antisedan
– Dextrose
– Sodium bicarbonate
 Vasopressors
• Increased vascular resistance to redirect blood
flow to core
– Epinephrine
• Low dose (0.01 mg/kg) recommended every 4-5 min
– Vasopressin
• 0.8 U/kg
• Can be used interchangeably or in combination with
epinephrine
 Parasympatholytics
• Atropine
– Extensively studied in CPR
– 0.04 mg/kg every 4-5 minutes
 Antiarrhythmic drugs
• Ventricular tachycardia
– Lidocaine 2mg/kg IV

• Ventricular fibrillation
– Electrical defibrillation
– If no response: amiodarone 2.5-5 mg/kg IV or IO
• Risk of allergic reaction
 Reversal Angents
• Naloxone (Reverses opioids)
– 0.04 mg/kg IV
• Flumazenil (Reverses Benzodiazepines)
– 0.01 mg/kg IV
• Atepamazole (Reverses alpha2 agonists)
– 0.05 mg/kg IV
 Advanced Life Support:
Alkalinizing Agents
• Sodium bicarbonate
• Indications
– Prolonged CPA ( >10-15 min) with severe
metabolic acidosis ( pH <7)
• 1mEq/kg dilute IV
Available at VECCS.org
 Advanced Life Support
• Tricks or “short cuts” to remember doses
– Epinephrine: 0.1ml per 20 lbs
– Atropine: 1.0 ml per 20 lbs
– Naloxone: 1.0ml per 20 lbs
– Flumazenil: 1.0 ml per 20 lbs
 Advanced Life Support
• ELECTRICAL DEFIBRILLATION
– Reserved for ventricular fibrillation

– 4-6 J/kg (40 J per 20 lbs)

 Electrical Defibrillation
• ELECTRICAL DEFIBRILLATION
– Conducting gel for the paddles
– Rinse off alcohol if present
– Put patient in dorsal recumbancy
– Place paddles on either side of chest
– Charge paddles
– Yell “Clear” and make sure staff is clear
– Immediately resume CPR for 2 minutes before
assessing rhythm
 Advanced Life Support: IV Fluids
• Fluid therapy
– Shock fluid therapy reserved for hypovolemic
patients only
– IVF contraindicated in euvolemic patients
• IVF therapy can decrease coronary perfusion
Coronary perfusion pressure = aortic diastolic pressure – right atrial pressure
 Advanced Life Support
• Ideal additional monitoring
– ETCO2
• With ROSC see a steady increase in value
• Humans with ETCO2 not reaching above 12mmHg
during arrest did not have ROSC
– Obtain blood for stat labs
• PCV/TS, BG, electrolytes and pH

Fig 9: Capnography in dogs: Compendium October 2004

• ETCO2 </= 10 mmHg after 20 minutes of CPCR
accurately predicts death
• “Cardiopulmonary resuscitation may
reasonably be terminated in such patients”
 Additionally…
• Things to anticipate
– Large dogs or patients with intrathoracic disease may
require open chest CPR
– If no venous access
• Get red rubber ready for intratracheal administration
• Be prepared for cut down
 Open Chest CPR
• Indications
– Pleural space disease
– Pericardial effusion
– Penetrating chest wounds/chest wall trauma
– Heavy patient/large breeds/incompressible thorax
– Intra –operative arrests
– No ROSC after 2-5 minutes of closed chest CPR
– Post cardiothoracic surgery, chest/abdomen is already
open
 RECOVER Initiative
• Reassessment Campaign on Veterinary Resuscitation
• VECCS and ACVECC worked together to evaluate
resuscitation and how it is applied clinically
• Adapted the approach taken by the American Heart
Association (AHA) and the International Liaison
Committee on Resuscitation (ILCOR)
• Results published in JVECC as supplemental volume
in June 2012
 RECOVER Initiative
• Divided into 7 parts focusing on evidence and
knowledge gap analysis
– Part I: Evidence analysis and consensus process:
collaborative path toward small animal CPR guidelines
– Part II: Preparedness and prevention
– Part III: Basic Live support
– Part IV: Advanced life support
– Part V: Monitoring
– Part VI: Post cardiac arrest care
– Part VII: Clinical guidelines
 RECOVER Initiative
• Divided into 7 parts focusing on evidence and
knowledge gap analysis
– Part I: Evidence analysis and consensus process:
collaborative path toward small animal CPR guidelines
– Part II: Preparedness and prevention
– Part III: Basic Live support
– Part IV: Advanced life support
– Part V: Monitoring
– Part VI: Post cardiac arrest care
– Part VII: Clinical guidelines
 RECOVER Initiative
• Preparedness and Prevention
– Equipment and supply delays or failure resulted in
delay of CPCR in 18% of cases
– Routine training and review
– Use of flow charts/dosing charts
– Team leader during arrest
– De-brief following successful or unsuccessful
CPCR
 RECOVER Initiative
• Basic Life Support
– Chest compressions
• Large dogs: hands over widest part of chest
• Small dogs: hands directly over heart
• Very small dogs/cats: circumferential
• 100-120 compressions per minute
– Ventilation
• Continuous compression and ventilation
• 10 breaths per minute
– Cycles
• Rotate compressors every 2 minutes
 RECOVER Initiative
• Advanced Life Support
– Epinephrine: low dose every 3-5 minutes
– Atropine
– Vasopressin: 0.8 units/kg as a substitute or in
combination with epinephrine
– Defibrillation: in cases of V-fib
– 100% O2
– IVF: not recommended if euvolemic
 RECOVER Initiative
• Monitoring
– ETCO2: use for monitoring of ROSC
– Additional monitoring can be considered but
should NOT interrupt compressions
• ECG
• Doppler
• Electrolytes
– Use along with auscultation of heart and lungs (do
not use as sole device)
 RECOVER Initiative
• Post Cardiac Arrest Care
 Updates Since RECOVER INITIATIVE

• Metabolic acidosis and • Decreased iCa 18%

hyperlactatemia (100%) • Hypoglycemia 21%
• Respiratory acidosis: • Hyperglycemia 62%
– 88% during CPR
– 61% following ROSC
• Hyperkalemia 65%
Take away message: Point of care testing may be important during CPR
 Updates Since RECOVER INITIATIVE

• Since RECOVER initiative this hospital showed:

– Increased use of capnography
– Increased use of suction to aid in intubation
• RECOVER guidelines altered CPR teaching
 Updates Since RECOVER INITIATIVE

• To provide recommendations for reviewing

and reporting CPR events in dogs and cats
• Template for standardized reporting
• Will allow high quality veterinary CPR
research, improve data comparison and serve
as the foundation for veterinary CPR registries
 Summary
• Be Prepared
– All staff know what to look for
– All staff know where supplies are
• Check for breathing and pulses
• Follow your ABC’s (or BACs) and then the
DEF’s
• Record what was done and when.
• Remember, this is a TEAM effort.
 Questions
• Thank You!
• References available upon request