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M E ET TH E AUT H O R

Critical
Components of
Successful CPR:
The RECOVER Guidelines, Kenichiro Yagi, BS, RVT,
VTS (ECC, SAIM)

Preparedness, and Team Adobe Animal Hospital

Los Altos, California

Ken practices at Adobe

Animal Hospital as an ICU and
In 2011, a trainer for an obedience class faced the dire situation of Blood Bank Manager. He is
a dog collapsing and seemingly going into cardiac and respiratory an active educator, lecturing
arrest. As the owner laid over her best friend crying in horror, the internationally, providing
trainer began performing cardiopulmonary resuscitation (CPR) practical instruction, and
authoring texts, chapters, and
to the best of his knowledge, providing chest compressions and
articles on transfusion medicine,
mouth-to-snout breaths. Several moments into CPR, the dog respiratory care, and critical
took an agonal breath; the trainer continued CPR. After several care nursing. He serves on
more moments, much to the owner’s, trainer’s, and classmates’ the boards of the Veterinary
relief, the dog regained consciousness and, although disoriented, Emergency and Critical Care
tried to get up. The outcome was that the dog and owner were Society and the Academy of
Veterinary Emergency and
able to go home, seemingly recovered from the event.1
Critical Care Technicians, on
Reviewing the video footage of this incident, we can critique the the Veterinary Innovation
way CPR was performed and discuss its potential effectiveness in Council, and as the NAVTA State
light of evidence-based CPR guidelines established in 2012 by the Representative Chairperson.
Reassessment Campaign on Veterinary Resuscitation (RECOVER) He is a graduate student
Initiative. The RECOVER guidelines were produced through a series of in veterinary medicine and
surgery through the University
systematic reviews conducted by more than 100 specialists in the field
of Missouri. Ken invites all
of emergency and critical care and allied specialties. The RECOVER veterinary technicians to ask
initiative also identified a series of knowledge gaps toward which the “Why?” to understand the
veterinary community can direct its investigative efforts to continue “What” and “How” of our field
to improve the effectiveness of CPR. The guidelines are accessible at and to constantly pursue new
no cost (veccs.org/recover-cpr), and veterinary professionals can use limits as veterinary professionals.
them to develop CPR training standards for veterinary teams today.

FIGURE 1. A properly organized and equipped

crash cart located in a central emergency
area is critical for swift intervention.

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 Critical Components of Successful CPR: The RECOVER Guidelines, Preparedness, and Team
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THE RECOVER GUIDELINES ON CPR of CPR; refresher training is recommended

The guidelines address 5 aspects
surrounding cardiopulmonary arrest (CPA):
preparedness and prevention, basic life
support (BLS), advanced life support (ALS),
monitoring, and post–cardiac arrest care.
Preparedness and Prevention
With the documented rate of successful
resuscitation by CPR and survival to
discharge being approximately 6%,2 the
veterinary team must be prepared for CPA
to maximize chances of resuscitation.
Preparedness begins with obtaining the
knowledge behind CPR as well as psychomotor
(physical) training for performing it. Initial
training should introduce all key concepts
at least every 6 months to keep the
knowledge current and reinforced.
A designated emergency area should be
centrally located and fully stocked for performing
CPR. The staff should be familiar with an
organized crash cart containing necessary
supplies, drugs, equipment, and documents,
and the cart should be routinely checked (either
on a schedule or a per-use basis) to ensure it is
properly stocked and that everything is in-date
and functional (FIGURE 1). Crucial items include
equipment for securing the airway and venous
access, emergency medications, monitoring
equipment, and other supplies to facilitate CPR
and emergency surgical procedures (BOX 1). The
emergency area should also contain visual aids,

BOX 1 Crash Cart or Emergency Area Supplies

Airway  Additional
 Endotracheal tubes  Vasopressin
 Tube ties  Dopamine
 Laryngoscope  Dobutamine
 Syringe for cuff inflation  Norepinephrine
 Diazepam/midazolam
Venous
 Furosemide
 IV catheters (24- to 16-gauge)
 Calcium gluconate
 Tape
 Sodium bicarbonate
 Saline flush
 Preassembled crystalloid Respiratory
fluid bag and IV sets  Suction machine and tubing
 T-ports and male adapter plugs  Suction catheters or red rubber tubes
 Scalpel blade and suture (for  Manual resuscitator (eg, Ambu bag)
venous cutdowns)  Thoracocentesis kit
 Syringes (1–6 mL)
 Needles (25- to 18-gauge) Surgical
 Intraosseous (IO) catheter setup (IO drill,  Tracheostomy tubes
bone biopsy needles, or large needles)  Sterile gloves
 Emergency surgical packs
Medication
 Sterile gauze
 Standard
 Scalpel blade and handle
 Epinephrine
 Atropine Equipment
 Reversal agents: atipamezole,  Electrocardiograph
flumazenil, naloxone  Capnometer
 Anti-arrhythmic agents:  Defibrillator
amiodarone, lidocaine

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 Critical Components of Successful CPR: The RECOVER Guidelines, Preparedness, and Team
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such as the CPR algorithm and CPR drug dosage dioxide from the pulmonary circulation. An
chart (available from veccs.org), which will unresponsive patient should be assessed for
improve efficiency during the event3 (FIGURE 2). possible arrest through auscultation of the
heart, palpation for pulses, and observation
Resuscitation Orders for breathing.4 The assessment should take no
Every animal admitted to the practice should longer than 10 to 15 seconds, and BLS should
have a designated resuscitation order be initiated as soon as possible once CPA is
established via a thorough conversation identified.5 It can be argued that BLS should
between the veterinary team and the owner be commenced as soon as possible even when
to prevent delays in implementing CPR if CPA cannot be confirmed: research shows that
needed. Color-coding housing labels, patient
charts, or patient tags to indicate the patient’s
A
resuscitation order can reduce confusion.
Patients with a chronic disease that has
progressed to the point of causing CPA
are less likely to respond to CPR. CPA as a
consequence of an acute condition is more
likely to have a successful outcome. Otherwise
healthy patients that arrest because of an
anesthetic event have a much higher chance
of survival, reported to be 47% in one study.2
B
Every effort should be made to ensure the
resuscitation order is appropriate for the patient
by accurately assessing its chances of survival.

Basic Life Support

BLS is the attempt to sustain life by artificially
maintaining blood flow and oxygenation of
the blood. Blood flow is created through chest
compressions while positive-pressure ventilation
(PPV) provides oxygen and removes carbon C

FIGURE 3. (A) For round-chested dogs (chest as wide as it

FIGURE 2. Large cognitive aids posted in the
emergency area can improve the efficiency of and
consistent adherence to guidelines by the CPR team.
is deep), compressions are focused on the widest point of
the chest. (B) For narrow-chested dogs (chest deeper than
it is wide), compressions are focused over the heart.
(C) Some dogs might be considered to be flat-chested by
typical breed conformation, but each individual should
have its conformation assessed for the optimal compression
point. This dog would benefit from compressions on the
widest point of the chest in lateral recumbency. If the
patient is truly wider than it is deep, then compression
over the sternum (red arrow) is reasonable.

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  T E C HP O I NT 
The RECOVER
guidelines establish
a standard and
benchmark against
which veterinary
professionals can
evaluate their CPR
methods and training.
rescuers can be unreliable in accurately assessing
presence of pulses; there is no evidence
that initiating compressions when an animal
is not in arrest causes significant harm; and
commencing CPR with as little delay as possible
improves outcome.6 When CPR is initiated, the
algorithm of CAB (circulation, airway, breathing)
is followed instead of ABC (airway, breathing,
circulation) as blood flow is most important
and chest compressions provide ventilation
even before intubation and provision of PPV.5
Circulation
Chest compressions are performed to create as
much blood flow as possible to the pulmonary
tissues for gas exchange and to deliver oxygen
to tissues to support metabolism and restore
organ function, ideally achieving return of
spontaneous circulation (ROSC). Even the
most effectively administered compressions
provide only 30% of normal cardiac output,
making consistent application of best
practices during CPR compressions critical.5
Chest compressions are recommended
to be performed at a rate of 100 to 120/min
regardless of species and size and forceful
enough to compress the chest one-third to
one-half of normal width. Compressions should
be performed in 2-minute cycles without
interruption; this is because 60 seconds of
consistent compression is required for myocardial
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perfusion pressure (MPP) to reach its maximum
potential, and every second of interruption
leads to significant decreases. Thus, any patient
assessment (eg, electrocardiography [ECG], pulse
palpation, auscultation) should be limited to
several seconds between the 2-minute cycles to
prevent complete loss of accumulated MPP. Two
minutes of uninterrupted chest compressions is
physically taxing, and switching the compression
provider for each cycle is recommended.
Physical aspects of chest compressions include
the provider superimposing his or her palms (ie,
stacking the hands flat, with the palm of one on
the back of the other) and creating downward
motion onto the patient through a “compression
point” (as opposed to an “area”). The
compression point depends on the conformation
and size of the patient, which should be
evaluated individually, even though breeds
are associated with each type (FIGURE 3).
Round-chested dogs (chest as wide as it
is deep) benefit from compressions focused
on the widest part of the chest cavity with the
patient in lateral recumbency, with the goal of
creating intrathoracic pressure and thus using
the thoracic pump theory. In this model, the
increased intrathoracic pressure applied to the
vasculature within the thoracic cavity creates
forward blood flow. Release of pressure allows
the rib cage to recoil open, creating negative
pressure to pull blood from the abdomen into
the thoracic cavity, which is then pushed forward
again with the subsequent compression.
FIGURE 4. Small dogs and cats can have compressions
focused over the heart with one hand.
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 Critical Components of Successful CPR: The RECOVER Guidelines, Preparedness, and Team
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In dogs with a narrow or keeled chest

(deeper than it is wide), the cardiac pump theory is
applied by focusing compressions over the heart
while the patient is in lateral recumbency. Each
compression physically pushes blood out of the
heart, while each recoil allows blood to flow in.
For flat-chested dogs (ie, the chest is truly
wider than it is deep), compressions should be
focused over the sternum with the dog in dorsal
recumbency, to employ the cardiac pump theory.
In small dogs and cats, compressions can be
performed directly over the heart while in lateral
recumbency, using a single- or two-handed
method (FIGURE 4).
In animals with conformation requiring lateral
recumbency, there is no evidence indicating
whether right or left lateral recumbency is
more effective.5
Key aspects of the physical positioning
of the compression provider include (1)
superimposed palms, (2) locked elbows, and
(3) standing at a sufficient height to place
the shoulders directly above the patient. This
height can be achieved by standing on a step
stool or by kneeling safely on the same surface
as the patient (whether it be the table or the
floor). The downward force should be created
by the core muscles of the abdomen rather
than the arms, allowing stronger exertion of
force and longer sustainability (FIGURE 5).
The use of such aids as a metronome can
help maintain specified compression rates;
BOX 2 Songs With a Beat of
Approximately 100/minute
 “Stayin’ Alive,” Bee Gees
 “Paradise City,” Guns N’ Roses
 “Rock Your Body,” Justin Timberlake
 “Suddenly I See,” KT Tunstall
 “Back To Life,” Soul II Soul
training to perform compressions to familiar
songs of the appropriate beat can be helpful
as well (BOX 2). More recently, devices
designed to provide audio cues for timing
compressions, ventilations, and 2-minute
cycles have become available (FIGURE 6).
Ventilation
Ventilation should be started as soon as possible
once compression is initiated. Endotracheal
intubation is performed with the patient in
lateral recumbency without interruption of
compressions, and the cuff is inflated so
that PPV is directed into the lungs instead of
into the stomach or out the mouth. Breaths
are provided 10/minute at a tidal volume of
10 mL/kg over a 1-second inspiration time
through the reservoir bag of an anesthetic

A B

FIGURE 5. Positioning for chest compressions. (A)

Forward view demonstrating superimposed palms and
locked elbows. (B) Side view demonstrating the
shoulders positioned directly over the patient in a
perpendicular manner. FIGURE 6. An auditory timing aid device for veterinary CPR.

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 Critical Components of Successful CPR: The RECOVER Guidelines, Preparedness, and Team
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machine or a manual resuscitator (FIGURE 7). If a
spirometer is not available, a manometer reading
of 20 cm H2O indicates consistent breaths. The
reduced respiratory rate of 10 breaths/minute
and subsequently low per-minute ventilation
(approximately 100 mL/kg/min versus the normal
200 mL/kg/min) are tolerable because of the
reduced pulmonary blood flow during arrest.
Keeping the breath size and frequency consistent
also helps prevent eliminating too much carbon
dioxide and thereby causing hypocapnia through
hyperventilation, which would cause cerebral
vasoconstriction and impair blood flow to the brain.
If endotracheal tubes are unavailable, mouth-
to-snout ventilation can be used, although its
efficacy in providing adequate ventilation and
oxygenation is currently unknown.4 Mouth-to-
snout ventilation is performed by closing the
animal’s mouth and keeping the neck in alignment
with the spine while the rescuer blows through
his/her mouth into the nares of the patient.
The recommended compression:ventilation
ratio is 30:2, with the breaths delivered and chest
excursion observed briskly—each inspiration
should last no longer than 1 second—to avoid
further interruption of chest compressions.5
Keeping the inspiration time consistently short
also mitigates the reduction of venous return
that can be caused by increased intrathoracic
pressure from PPV coinciding with compressions.5
FIGURE 7. Positive-pressure ventilation can be performed
with a reservoir bag on the anesthetic machine.
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Advanced Life Support
ALS includes measures (eg, drugs, defibrillation)
beyond those to sustain basic life (compression
and ventilation) that provide additional support
for the patient. However, all ALS interventions
are unlikely to lead to ROSC without effective
BLS measures and thus should be instituted
without interruption of appropriate BLS.5
Medications During CPR
A variety of drugs are used during CPR to
maximize chances of ROSC. Administration
through the IV or intraosseous (IO) route is
appropriate. While venous access might already
be established in hospitalized animals, swift
establishment of venous access is necessary
for patients brought into the emergency room
in CPA. Procedures such as venous cutdown or
IO catheter placement can minimize the time
required to establish venous access but should
not interrupt BLS interventions. In larger patients
arriving in arrest, the use of an IO drill stored
in a designated location can reduce the time
required to establish venous access to 30 to
60 seconds (FIGURE 8). Drugs used in CPR
include vasopressors, parasympatholytics,
reversal agents, antiarrhythmics, IV fluids,
and alkalinizing agents (TABLE 1).
FIGURE 8. An intraosseous catheter driver can facilitate
venous access in emergency cases. The photo
demonstrates tibial placement with an electric
intraosseous driver. The femur and humerus may be
used for manual placement as needed and able.
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Vasopressors the endotracheal tube5; however, this route

Epinephrine is the most commonly used
vasopressor during CPR, serving to cause
vasoconstriction through its action on the α1, β1,
and β2 receptors to redirect the blood flow from
the periphery to the body core and vital organs.5
Two epinephrine dosages are specified by the
RECOVER guidelines. The low dose (0.01 mg/kg
IV or IO) is associated with a higher rate of survival
to discharge, while the high dose (0.1 mg/kg IV or
IO) is associated with a higher rate of ROSC. Note
that although the high dose may be more likely to
induce ROSC, the chance of survival to discharge
is lower, possibly related to reduced perfusion
to vital organs due to severe vasoconstriction.7
Epinephrine is dosed once every 3 to 5 minutes,
making every other compression cycle an ideal
time for administration. Epinephrine can be
administered via the intratracheal route at
twice the IV/IO dose; a long catheter is used
to administer the drug diluted 1:1 with saline
or sterile water into the lower airway through
should be used only when venous access is not
possible as the effect of the drugs remaining in
the airway upon ROSC is difficult to predict.
Vasopressin, which acts on vascular
smooth muscles through the V1 receptor to
cause vasoconstriction, can be used in lieu
of or in conjunction with epinephrine for the
same effects. No additional harm caused
by the use of vasopressin over epinephrine
has been observed, and there might be
potential benefits such as responsiveness in
acidic environments and a lack of inotropic
and chronotropic effects that can add to
myocardial ischemia when ROSC is achieved.5,7
The suggested dosage for vasopressin is
0.8 U/kg IV or IO, and it can be administered
intratracheally as described for epinephrine.
Parasympatholytics
Atropine is a parasympatholytic commonly
used in CPR at 0.04 mg/kg IV or IO every

TABLE 1 Medications Used During CPR5

TYPE NAME DOSE USAGE
Arrest Epinephrine (low dose) 0.01 mg/kg IV or IO Every other compression cycle
0.02-0.1 mg/kg IT

Epinephrine (high dose) 0.1 mg/kg IV, IO, or IT In prolonged CPR (>10 min)

Vasopressin 0.8 U/kg IV or IO Every other compression cycle, in lieu of or in

1.2 U/kg IT conjunction with epinephrine

Atropine 0.04 mg/kg IV or IO Beneficial in bradycardic arrest or high vagal

0.15-0.2 mg/kg IT tone

Bicarbonate 1 mEq/kg IV or IO Prolonged CPR, pH <7.0

Antiarrhythmic Amiodarone 5 mg/kg IV or IO Refractory VF, pulseless VT

May cause hypotension/anaphylaxis

Lidocaine 2 mg/kg IV or IO slow Alternative to amiodarone

(1-2 min)

Reversal Atipamezole 50 mcg/kg IV or IO α2 agonist reversal

Flumazenil 0.01 mg/kg IV or IO Benzodiazepine reversal

Naloxone 0.04 mg/kg IV or IO Opioid reversal

Electrical defibrillation Monophasic 4-6 J/kg (external) For VF and pulseless VT
0.5-1 J/kg (internal) Administer immediately if within 4 minutes of
onset, otherwise after compression cycles

Biphasic 2-4 J/kg (external) Can increase dose by 50% each cycle up to a
0.2-0.4 J/kg (internal) maximum of 10 J/kg

IO, intraosseous; IT, intratracheal; IV, intravenous; VF, ventricular fibrillation; VT, ventricular tachycardia.

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 Critical Components of Successful CPR: The RECOVER Guidelines, Preparedness, and Team
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other compression cycle. While there are no
high-quality studies showing clear benefits
of its use in CPR, there is no evidence of
harm. Atropine is thought to be beneficial
in patients with asystole or PEA, especially
those suspected to be experiencing high
vagal tone (eg, vomiting, ileus, gastrointestinal
disease, respiratory disease).5,7 Intratracheal
administration is also possible at 0.08 mg/kg.
Reversal Agents
If patients in CPA were under the influence of
any reversible anesthetic agent or sedation,
reversal of said agent could improve the
chances of successful outcome. Atipamezole,
flumazenil, and naloxone are readily
available reversal agents for α2 agonists,
benzodiazepines, and opioids, respectively.
Antiarrhythmic Agents
While no evidence supports the routine use
of antiarrhythmics in CPR, administration of
amiodarone has been suggested for patients
with VF refractory to electrical defibrillation.
Hypotension and anaphylactic reactions have
been documented in dogs receiving amiodarone,
and careful monitoring is recommended
following ROSC.5,7 Lidocaine can be administered
to patients with refractory VF, although the
evidence regarding its benefits is mixed.7
Intravenous Fluids
The use of IV fluids during CPR largely depends
on the state of IV fluid balance in the patient.
IV fluids are beneficial for patients experiencing
hypovolemia as the increased intravascular
volume leads to better preload, improving
chances of creating effective blood flow
through chest compressions. Not every patient
benefits from IV fluids, however, as euvolemic
or hypervolemic individuals can become
overloaded with fluids, which leads to increased
central venous pressure that can in turn reduce
MPP and cerebral perfusion pressure.5 Electrolyte
disturbances can be a contributor to CPA or a
result of metabolic acidosis, drug therapy, and
other interventions. No evidence of benefit exists
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for correcting electrolyte disturbances other
than severe hyperkalemia or hypocalcemia.7
Alkalinizing Agents
Routine administration of alkalinizing agents, such
as sodium bicarbonate, as a buffer for metabolic
acidosis is not recommended, but these agents
can be considered for prolonged CPA because
severe acidemia can affect the vasculature’s ability
to respond to vasopressors and impair normal
enzymatic functions. Administration of sodium
bicarbonate is accompanied with a cautionary note
that it can lead to alkalemia and paradoxic cerebral
and metabolic acidosis.7 It is recommended
that sodium bicarbonate be reserved for severe
acidemia (pH <7.0) in prolonged CPR.5
Electrical Defibrillation
When a patient is experiencing VF, electrical
defibrillation is the appropriate therapy to convert
to normal rhythm. The approach to electrical
defibrillation depends on the phase of VF. In the
first phase, which lasts approximately 4 minutes,
the heart experiences minimal ischemia and has
enough energy reserves to carry on metabolic
processes. In the second phase (subsequent
6 minutes), the heart experiences reversible
ischemic damage as the energy reserves in the
form of ATP are depleted. In the third phase,
the heart experiences irreversible ischemic
damage as energy stores are exhausted.5
If the patient is in the first phase of VF, it
should be defibrillated as soon as the defibrillator
is charged, allowing for interruption of chest
compressions as the cellular energy reserves of the
heart makes successful defibrillation more likely.
If the patient is suspected to be in the second
phase or beyond, a full cycle of chest compressions
should be performed before defibrillation to allow
for replenishing of some cellular energy to improve
chances of success.5 Electrical defibrillation is also
warranted when the patient is experiencing pulseless
ventricular tachycardia. VF and pulseless ventricular
tachycardia are referred to as “shockable rhythms”
based on their responsiveness to defibrillation.
When a shockable rhythm is identified during
assessment between compression cycles, chest
  T E C HP OI N T 
Two minutes of
uninterrupted chest
compressions is
physically taxing,
and switching the
compression provider
for each cycle is
recommended.
compression should be resumed and a full 2-minute
cycle completed as the defibrillator is allowed
to charge. Defibrillation should be performed
after the completion of the compression cycle.
The dosing of electrical defibrillation depends
on the type of defibrillator. Monophasic
defibrillators are dosed at 4 to 6 J/kg and
biphasic defibrillators at 2 to 4 J/kg. Biphasic
defibrillators are preferred because of their
ability to defibrillate with lower energy output,
leading to less myocardial damage. Chest
compressions should be resumed immediately
after electrical discharge while the defibrillator
is charged for another dose. ECG should
be assessed after the compression cycle is
completed to determine if the shockable rhythm
is still present and another dose is needed.5
Monitoring
Monitoring during CPR can be best accomplished
through the use of capnography and
electrocardiography (ECG).
Capnography
Monitoring end-tidal carbon dioxide (ETCO2)
values during CPR is the most useful method
to assess the effectiveness of compressions in
creating blood flow and lung perfusion. Because
minute ventilation is relatively consistent during
CPR, the measured ETCO2 value will increase
in proportion to the pulmonary blood flow
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created through compressions (FIGURE 9). In
addition, measurement of ETCO2 can be used
to confirm that the endotracheal tube is in the
trachea because significant CO2 is unlikely to
be measured from the esophagus. However,
a lack of measurement does not necessarily
indicate esophageal placement, as ineffective
compressions and poor pulmonary circulation
will not produce CO2. During CPR, maintenance
of ETCO2 above 10 to 15 mm Hg is favorable for
the patient in achieving ROSC, whereas chances
of ROSC were observed to be lower below
these values.5 Capnography can also serve
as an indicator for ROSC because the values
will increase significantly, likely to hypercapnic
values, upon re-establishment of pulmonary
circulation from spontaneous cardiac output.
Electrocardiography
ECG, which assesses the electrical activity of
the heart, is a valuable monitoring modality
during CPR. Between compression cycles, ECG
can be monitored to determine spontaneous
electrical activity (FIGURE 10). During the
compression cycle, mechanical action will
be detected, and it is difficult to distinguish
between mechanical and spontaneous activity
(FIGURE 9). Asystole is the most common
arrest rhythm, in which case compressions
should be resumed. The patient may exhibit
FIGURE 9. The screen of a multiparameter ECG monitor
during CPR. The ECG is registering mechanical action
exerted by the compressions (blue circle). The
capnography (yellow circle) is displaying a breath
(larger plateau) and compression-induced ventilation
(small spikes). The ETCO2 measurement (red circle) is
reading 6 mm Hg and 11 breaths/min.
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 Critical Components of Successful CPR: The RECOVER Guidelines, Preparedness, and Team
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electrical activity without any palpable pulse,
or pulseless electrical activity (PEA), in which
case compressions should be resumed. The
possibility of PEA also highlights the importance
of confirming actual pulses after visualizing
electrical activity on ECG. Ventricular fibrillation
(VF) is less common and is treated through
defibrillation if present. Multiple members of
the CPR team should be observing the ECG
readout during the assessment period between
compression cycles to clearly communicate
the rhythm and swiftly move to the next step.
Post–Cardiac Arrest Care
For patients that recover from CPA and achieve
ROSC, post–cardiac arrest care includes respiratory
status optimization, cardiovascular system
support and optimization, and neuroprotective
therapy. An algorithm for postarrest care is
provided in the RECOVER guidelines. Care
for a patient after achieving ROSC is an
A
B
C
D ROLE
FIGURE 10. Possible ECG tracings during CPR. (A) Asystole,
with no regular electrical activity. (B) PEA: no palpable
pulses are being produced even though electrical activity
is seen. (C) Another example of PEA. (D) Ventricular
fibrillation: nonorchestrated discharge of electrical activity
leading to ineffective cardiac output. Courtesy of Kristie
Garcia, LVT, VTS (Cardiology)
20 | TODAY’SVETERINARYTECHNICIAN | May/June 2017
intensive process, with ROSC being only the
first hurdle to overcome toward actual survival
to discharge; a patient that has arrested once
is likely to re-arrest during this period.
TEAM DYNAMICS
Team Structure
The presence of a CPR team leader significantly
improves the flow during CPR. The leader
is responsible for assigning roles to team
members (TABLE 2), enforcing protocol, and
facilitating communication. Intermittently
summarizing the current status of the CPR
attempt, soliciting input from team members,
and organizing changes in roles and next steps
are all important tasks performed by the CPR
leader. Specific training for those taking on
the role of a CPR leader is recommended.
At my place of employment, the role of CPR
team leader, usually a veterinary technician, is
intentionally assigned to someone other than the
attending veterinarian to allow the CPR team and
veterinarian to function independently. The CPR
leader focuses on organizing the CPR, assigning
roles, and directing the CPR flow. The veterinarian
makes medical decisions, fills no other roles,
focuses on patient diagnosis and treatment, and
communicates with the client. This veterinarian
and CPR team arrangement has greatly enhanced
our ability to manage the controllable factors
of CPR and prevent delays and mistakes from
splitting the veterinarian’s attention between
the patient, client, and CPR flow (FIGURE 11).
TABLE 2 Team Roles During CPR
TASKS
Compression Chest compressions (alternated)
Establish airway
Airway management
Ventilate
Establish venous access
Drug administration
Administer drugs
Document events
Recorder
Time events
CPR leader Organize CPR
Veterinarian Manage patient
 Peer Reviewed
CONTINUING
EDUCATION

Communication Surrounding CPR Debriefing

Closed-Loop Communication
During CPR, the closed-loop communication
method is recommended. This consists of
instructions being given clearly and directed at
one individual, who then repeats the instruction
to confirm accurate communication. Closed-
loop communication reduces the chances of
medical errors due to misunderstanding or
missing instructions and helps orient other
team members about the status of CPR flow.
CPR Flow Sheet
A well-designed sheet to record pertinent details
related to the CPR attempt is recommended
(FIGURE 12). A standard record sheet serves
as a checklist for tasks and roles required
during CPR, provides documentation of specific
events (eg, timing of last drug administration)
during CPR, and enables review after CPR.
A properly maintained database of details
regarding CPR and outcomes allows the practice
to track the effectiveness of CPR. The RECOVER
initiative has also published guidelines for
standardized reporting of in-hospital veterinary
cardiac arrest and CPR and is working on
establishing a global registry to gather more
 affix
 cage
After a CPR event, a debriefing session is
recommended to review and critique the
performance from both an individual and team
perspective. Debriefing sessions allow errors
to be identified and provide an opportunity to
develop plans for improvement by correcting
any issues. The session is designed to let team
members discuss the decisions made, actions
taken, and possible alternatives; identify any
need for training; and recognize each other for
successful actions.9 Adequate debriefing can be
conducted in 5 to 10 minutes by the team leader.
Questions should include “What went well with
this CPR session?”, “What could have been
done better?”, and “Are there any major issues
to report to the CPR committee?” Open and
transparent discussion in a safe environment is
vital to effective debriefing, which leads to both
individual and team improvement6 (FIGURE 13).
THE FUTURE OF VETERINARY CPR
The RECOVER guidelines establish a standard
and benchmark against which veterinary
Please
Date: ______________
Time Event Recognized: ______________

information surrounding CPR to address Event

☐ Witnessed
☐ Not Witnessed
☐ Cardiac Arrest
☐ Respiratory Arrest

unanswered questions and improve the guidelines.8

Breathing immediately prior to CPCR:
☐ Spontaneous
☐ Agonal
☐ Apneic
☐ Assisted
label  here  
Ventilation:
☐ Endotracheal Tube ☐ Mask / Valve / Bag Or  
☐ Tracheostomy ☐ Other: ____________
Intubation:
Time: ____________ Size: _______________ Patient  Name:  
By Whom: ______________________________
Placement confirmation via: Acct  Number:  
☐ Auscultation ☐ Exhaled CO2
☐ Other: ___________________
Compressions:
☐ Manual ☐ None
Start Time: ______________
Thoracotomy:
Time: ___________ By Whom: ________________________

Cycle Time Epinephrine Atropine Medication Medication ECG Comments

1 Dose/Route Dose/Route Dose/Route Dose/Route rhythm Initials of person administering meds,

2 Dose/Route Dose/Route Dose/Route Dose/Route at IV catheter, I/O catheter, person

3 Dose/Route Dose/Route Dose/Route Dose/Route end of administering chest compressions,

4 Dose/Route Dose/Route Dose/Route Dose/Route cycle etc.

5 Dose/Route Dose/Route Dose/Route Dose/Route

6 Dose/Route Dose/Route Dose/Route Dose/Route

7 Dose/Route Dose/Route Dose/Route Dose/Route

8 Dose/Route Dose/Route Dose/Route Dose/Route

9 Dose/Route Dose/Route Dose/Route Dose/Route

10 Dose/Route Dose/Route Dose/Route Dose/Route

Additional comments: _______________________________________________________________________________

_________________________________________________________________________________________________
_________________________________________________________________________________________________
Time Resuscitation Event Ended: ______________ Status: ☐ Alive ☐ Deceased
Reason Resuscitation Ended: ☐ Return of Circulation (ROSC) ☐ Efforts Terminated (No sustained ROSC)
☐ Medical Futility
Clinician: _______________________________ Team Leader: ______________________________
Ventilator: ______________________________ Drug Handler: ______________________________
Compressors: ____________________________________________________________________________

FIGURE 11. A structured CPR team. Separate roles Recorder: _________________________________

between CPR leader (pink scrubs) and veterinarians

(brown scrubs and red scrubs) allow for uninterrupted
CPR while the case is discussed. FIGURE 12. Sample CPR record form.

TODAY’SVETERINARYTECHNICIAN | May/June 2017 | 21

 Critical Components of Successful CPR: The RECOVER Guidelines, Preparedness, and Team
PEER
REVIEWED
professionals can evaluate their CPR methods
and training. The need for standardized
guidelines regarding veterinary CPR is well
recognized internationally, and to date, the
RECOVER guidelines have been translated
into Portuguese, Spanish, Japanese, and
Mandarin. All of RECOVER’s information will
be housed on a central Internet resource to be
available worldwide (recover-initiative.org).
The RECOVER initiative is being updated,
with publication planned in 2018. The 2012
RECOVER review process revealed knowledge
gaps that are intended to be filled through
ongoing research in the field, with the
RECOVER initiative directly contributing.
The establishment of the global registry and
a standardized record sheet will allow each
practice to contribute to the data collection,
and additional methods are planned. Through
the process, the RECOVER initiative has
pioneered a large-scale evidence-based
guideline creation process that is translatable
to a variety of topics in veterinary medicine.
Both online and physical CPR certification
courses have been created and approved
by the American College of Veterinary
Emergency Critical Care and the Veterinary
Emergency and Critical Care Society.
Certification for the psychomotor training is
being expanded through the establishment
of an official trainer network to significantly
increase global accessibility. For veterinary
FIGURE 13. A debriefing session enhances the team
dynamics and facilitates further improvement of CPR
through open and transparent communication.
22 | TODAY’SVETERINARYTECHNICIAN | May/June 2017
professionals, preparedness for CPA through
certificate training should be considered
a standard in practice. The training is
reaching other animal workers and the lay
public to improve chances of resuscitation
for out-of-hospital arrests as well.
CONCLUSION
Veterinary technicians play a critical role in
assessing patients at risk of experiencing CPA
and swiftly initiating CPR when necesssary.
While the current success rate and the rate
of survival to discharge are expectedly low,
establishment of organized training based on
an evidence-based protocol such as RECOVER
is a duty of the veterinary team to ensure the
best possible chance of a positive outcome. 
Acknowledgment
The author would like to thank Dr. Manuel Boller
and Dr. Dan Fletcher for providing the latest
information on the plans of the RECOVER Initiative.
References
1. Ellis S. Man uses CPR, saves dog’s life. Global Animal
[website]. March 29, 2011. globalanimal.org/2011/03/29/
man-uses-cpr-saves-dogs-life-video. Accessed March 2017.
2. Hofmeister EH, Brainard BM, Egger CM, et al. Prognostic
indicators for dogs and cats with cardiopulmonary arrest
treated by cardiopulmonary cerebral resuscitation at a
university teaching hospital. JAVMA 2009;235(1):50-57.
3. McMichael M, Herring J, Fletcher DJ, et al. RECOVER
evidence and knowledge gap analysis on veterinary CPR.
Part 2: Preparedness and prevention. J Vet Emerg Crit Care
2012;22(S1):S13-S25.
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evidence and knowledge gap analysis on veterinary
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Silverstein D, Hopper K (eds). Small Animal Critical Care
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