Cardiopulmonary Cerebral Resuscitation (CPCR)
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Cardiopulmonary Cerebral Resuscitation (CPCR)--Veterinarian Presentation
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Cardiopulmonary Cerebral Resuscitation (CPCR)
- 1. Cardiopulmonary Cerebral Resuscitation (CPCR) Danielle Berube DVM, DACVECC Upstate Veterinary Specialties September 17, 2016
- 2. Outline • Introduction – Definitions – Outcome – Who is at risk • Basic Life Support • Advanced Life Support • RECOVER Initiative • Summary and updates
- 3. 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
- 4. Outcomes • Overall poor prognosis – Survival to discharge 6-7% • Re-arrest rates – 68% dogs and 37% cats Survival to discharge
- 5. • 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
- 6. Dogs With CPA ROSC 58% No ROSC 23% ROSC < 20 min: 23% Euth: 10% Repeat CPA:13% ROSC > 20 min: 35% No longer alive at 24 hr. Euth: 21% Repeat CPA: 4% Alive at 24 hr. 10% Euth: 4% Repeat CPA: 0Survive to Discharge 6%
- 7. 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
- 8. 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
- 9. Outcome: Staff Preparedness • Standardized CPR guidelines in human medicine improved outcome after in hospital CPA: – 2000: 13.7% – 2009: 22.3%
- 10. Who is at risk? • Trauma • Respiratory system disease • Septicemia • Prolonged seizures • Cardiac disease • Vagal stimulation • Anesthetic agents • Severe metabolic disease
- 11. 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
- 12. Goals: Coronary Perfusion Pressure • = Aortic diastolic pressure – right atrial pressure
- 13. Goals: Cerebral Perfusion Pressure • = mean arterial pressure – intracranial pressure
- 14. 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
- 15. 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
- 16. 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
- 17. Recover: JVECC 22 (S1) 2012, S102-S131
- 18. Basic Life Support Recover: JVECC 22 (S1) 2012, S102-S131
- 19. 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
- 20. 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
- 21. 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
- 22. 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)
- 23. 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
- 24. 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)
- 25. 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
- 26. Basic Life Support • AIRWAY – Ensure proper tube placement • Visualize placement • Auscult for breath sounds • Observe for chest excursions • ETCO2 – Esophageal intubation-zero
- 27. 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
- 28. 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
- 29. Recover: JVECC 22 (S1) 2012, S102-S131
- 30. Advanced Life Support Recover: JVECC 22 (S1) 2012, S102-S131
- 31. 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
- 32. 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
- 33. Asystole • No rhythm on ECG • Survival rate in people nearly 0% • Treatment options – Atropine – Epinephrine – Vasopressin
- 34. Pulseless Electrical Activity (PEA) • Aka electromechanical dissociation • Human survival 1-4% • Treatment options: – Epineprhine – Atropine – Vasopressin – Treat underlying cause
- 35. Sinus Bradycardia • Sinus rate < 60 dog/ <160 cat with palpable pulses • Treatment – Atropine – Reverse offending sedatives – Treat suspected underlying cause
- 36. 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 – Hypomagenesemia www.mauvila.com www.resuscitationcentral.com
- 37. 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
- 38. 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
- 39. 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
- 40. 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
- 41. Advanced Life Support • Common drugs – Epinephrine – Atropine – Vasopressin – Dextrose – Sodium bicarbonate – Calcium gluconate, insulin – Reversal agents • Naloxone, flumazenil, antisedan
- 42. 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
- 43. Parasympatholytics • Atropine – Extensively studied in CPR – 0.04 mg/kg every 4-5 minutes
- 44. 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
- 45. 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
- 46. Advanced Life Support: Alkalinizing Agents • Sodium bicarbonate • Indications – Prolonged CPA ( >10-15 min) with severe metabolic acidosis ( pH <7) • 1mEq/kg dilute IV
- 48. 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
- 49. Advanced Life Support • ELECTRICAL DEFIBRILLATION – Reserved for ventricular fibrillation – 4-6 J/kg (40 J per 20 lbs)
- 50. 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
- 51. 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
- 52. 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
- 53. • ETCO2 </= 10 mmHg after 20 minutes of CPCR accurately predicts death • “Cardiopulmonary resuscitation may reasonably be terminated in such patients”
- 54. 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
- 55. 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
- 56. 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
- 57. 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
- 58. 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
- 59. 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
- 60. 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
- 61. 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
- 62. 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)
- 63. RECOVER Initiative • Post Cardiac Arrest Care
- 64. Updates Since RECOVER INITIATIVE • Metabolic acidosis and hyperlactatemia (100%) • Respiratory acidosis: – 88% during CPR – 61% following ROSC • Hyperkalemia 65% • Decreased iCa 18% • Hypoglycemia 21% • Hyperglycemia 62% Take away message: Point of care testing may be important during CPR
- 65. 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
- 66. 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
- 67. 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.
- 68. Questions • Thank You! • References available upon request
Notes de l'éditeur
- CPR: used to treat animal that is not breathing and has no heart beat or pulse, consists of rescue breathing and chest compressions
- Previously reported wide range with published survival rates of 3-4% in dogs and 2-10% in cats
- Large study that reported many aspects/results of CPR in a university teaching hospital Patients undergoing simple anesthetic arrest: Very small number of cases No systemic disease and undergoing elective procedure Higher percentage of patients survived to discharge
- CPA: Cardiopulmonary Arrest
- Some of this data is what helped to spur the Recover initiative
- * If increase right atrial pressure can decrease coronary perfusion pressure
- * If increased intracranial pressure or decreased mean arterial pressure will decrease blood flow to brain
- * Determining if patient is breathing or has heartbeat should only take a few seconds
- Based on studies in people it is now recommended to start compressions first In veterinary patients respiratory arrest is often seen first so intubation is more important especially if patient still has heartbeat If true CPA start compressions first but should be immediately followed by or have simultaneous intubation
- Based on studies in people it is now recommended to start compressions first In veterinary patients respiratory arrest is often seen first so intubation is more important especially if patient still has heartbeat If true CPA start compressions first but should be immediately followed by or have simultaneous intubation
- * Start as soon as possible or at same time as chest compressions
- (inspiratory time/tidal vol): Positive pressure ventilation increased intrathoracic pressure decreased venous return Hyperventilation results in decreased arterial CO2 cerebral vasoconstriction
- Waldrop, et al JVECC 14 (1)2004 22-29 Rush JE, Wingfield WE. JVAMA 1992;200(12)1932-3. Hofmeister et al JAVMA 2009
- Electrical activity with no mechanical activity electromechanical dissociation Group of dysrhythmias unaccompanied by a detectable pulse or auscultable heart rhythm
- Can also do cut down on other vessels
- * Every other rotation
- 2-5 J/kg external; 0.3-0.5 J/kg internal
- If ETCO2< 10mm Hg attempt to improve CPR quality; if sudden and sustained increase in ETCO2 return of spontaneous circulation
- When a 20-minute end-tidal carbon dioxide value of 10 mm Hg or less was used as a screening test to predict death, the sensitivity, specificity, positive predictive value, and negative predictive value were all 100 percent.
- Due to limited time I will not go into details (could be an entire talk) and requires intensive post arrest care Left thoracotomy in 4th or 5th rib space Rib retractors Remove pericardium
- More than 80 veterinary professionals worked with advice from co chaire of the international laison committee on resuscitation
- 5 domains Preparedness and Prevention Basic Life Support Advanced Life Support Monitoring Post Cardiac Arrest Care
- Brief summary, this can be an entire talk
- JVECC 2014 Point of care testing may help determine cause of arrest as well as treatment recommendations Future studies may determine information about predicting outcome etc.
- JVECC 2015 out of the UK Shows increased training and following RECOVER recommendations Hopefully will promote more training guidelines Hopefully will allow more uniform data to be collected for future CPR recommendations
- JVECC 2016 Drs Boller, Fletcher, Brainard et al: Variables were defined and categorized as hospital, animal, event and outcome variables Core elements: suspected cause and location of arrest, first rhythm identified, occurrence of return of spontaneous circulation of more than 30 sec or more than 20 min, survival to discharge, functional capacity at discharge Report if CPR is discontinued or the patient is euthanized by owner request This will allow for us to gather further recommendations/results in the future