JENNIFER KYES DVM, DACVECC

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1 JENNIFER KYES DVM, DACVECC

2 In dogs and cats that undergo CPA in a hospital have a survival rate to discharge of 4% for dogs and <9.5% for cats.

3 Until recently there were no universal guidelines CPCR in veterinary medicine In 2012, the RECOVER study was published by JVECCS. JVECCS 22(S1) 2012

4 Reassessment Campaign on Veterinary Resuscitation Analyzing: Preparedness & prevention Basic life support Advanced life support Monitoring Post cardiac arrest care Large animal

5 IMPENDING Obtundation Hypothermia Bradycardia Hypotension Dilated- unresponsive pupils Changes in respiratory rate, depth, rhythm, or agonal DEFINITIVE. Loss of consciousness Absence breathing Absent heart sounds Absent pulses DO NOT USE MM color CRT

6 Acute disease Anesthetic/drug reaction Hypovolema Hyperkalemia Metabolic acidosis Hypoxia Vagal arrests Examples Pericardial effusions GDVs UO s

7 Chronic disease Sepsis Neoplasia Severe trauma Any organ failure Cardiac disease Pulmonary disease Cirrhosis Renal disease

8 Circulation Airway Breathing NEW

9 Chest compressions MUST be Initiated immediately NEW Continuous Uninterrupted Interruptions should be < 10 seconds Right lateral recumbency

10 1 full cycle =2 minutes of uninterrupted compressions compressions/minute

11 Medium to large dogs >15kg Each chest compression the volume and thus intrathoracic pressure Indirectly moves blood forward Compress over the widest aspect of the chest

12 Small dogs/cats < 15kg Direct compression of ventricles Directly moves blood forward Can maintain a systolic BP of mmhg 25-50% of normal cardiac output Compress over 4 th - 6 th costrocondral junction (CCJ)

13 Mouth to snout ventilation is acceptable should intubation be unavailable ie) newborns 30 compressions and 2 rapid breaths Rotate every 2 minutes

14 Place endotracheal tube ETCO 2 >0 can confirm correct placement but during CPA ETCO 2 levels are very low Watch chest rise and fall with breath Watch for abdominal disten;on = esophageal intuba;on

15 NEW 10 breaths/minute Tidal volume 10ml/kg* Airway pressure <20 cmh 2 0 Use manometer Breath is 1 second in duration 100% oxygen Doxapram

16 Adult (Large bag) Over 30 kg TV 500 ml Child (medium bag) 7-30 kg TV 250 ml Infant (small bag) <7 kg TV40 ml

17

18 Pharmacological Intervention Advanced monitoring

19 MEDICATIONS Epinephrine* Vasopressin* Atropine* Glycopyrrolate Lidocaine Xylocaine endotracheal spray * MINIMUM *

20 Epinephrine Lidocaine Sodium Bicarbonate Atropine Glycopyrrolate Diazepam Furosemide Calcium gluconate Esmolol Propanolol Dopamine Norepinephrine Isoproterenol Dobutamine

21 SYRINGES Various sizes (1, 3, 6, 12cc) NEEDLES 18,20, 22, 25 g FLUSH Heparinized saline Saline only ET tubes & Laryngoscope Including ties and syringe for cuff

22 #10 scalpel blade Small curved hemostats Spay hook Various catheters 18g x 1.88 cath 18g x 1.16 cath 20g x 1.88 cath 20g x 1.16 cath PRN adapter Needle driver with scissors 3-0 ethilon suture material 2x2 sterile gauze

23 It take a minimum of 3 people to run a code but the code will run better if you have 5. DVM - runs the code, client communication RVT ventilation, compressions, or pharmacy ACA scribe, runner, time keeper

24 C Circulation 100 compressions per minute A Airway Intubate and monitor ETCO2 B Breathing 1 breath every 6 seconds, max 20 cmh20 Upon recognition of CPR : Start chest compressions immediately. Rotate compressor every 2 minutes. Record start time. Intubate and manually ventilate at 1 breath every 6 seconds. Record ETCO2. Administer Epinephrine 0.01mL/kg IV. Time mls Continue compressions for 5 minutes. Check for heart beat and elevated ETCO2. Record ETCO2 Administer 0.8u/kg Vasopressin (20u/ml) IV. Time mls Continue compressions for 5 minutes. Check for heart beat and elevated ETCO2. Record ETCO2 Administer Epinephrine 0.1mL/kg IV. Time mls Continue compressions for 5 minutes. Discontinue CPR after 20minutes of unsuccessful resuscitation. Record time. Additional medications: Lidocaine Fentanyl Hydromorphone Sodium bicarb Naloxone Dexdomitor Calcium gluconate Acepromazine Dextrose Flumazenil Diazepam Other Additional diagnostics: I stat BG X- ray U/S (brief) PCV/TS CBC Chem Defibrillator Additional notes: Doctor on duty: RVT on duty: Date: Primary doctor: Primary department:

25 Dilute all IT drugs with 5-10ml sterile water All IT doses should be x the IV dose Epinephrine should be 6-10 x the IV dose DO NOT GIVE bicarbonate or calcium gluconate IT! Bicarbonate dilutes surfactant Calcium is irritating to the mucosa

26 NEW Hypovolemic - administer shock doses Dogs 90ml/kg Cats 45ml/kg Voluven Dogs 5 ml/kg Cats 2-3 ml/kg Euvolemic - no IV fluids or maintenance

27 OPTION 1 1. Epinephrine mg/kg (=ml/kg) 2. Vasopressin- 0.8u/kg 3. Epinephrine - 0.1mg/kg (=ml/kg) New EPI dose

28 20 kg dog. Move the decimal place to the left twice for low dose and once for high dose. Low dose Epi 0.2ml High dose Epi- 2.0ml

29 OPTION 2 1. Vasopressin - 0.8u/kg 2. Epinephrine mg/kg 3. Vasopressin - 0.8u/kg New drug

30 CAB AVP 0.8 u/kg Epi 0.01mg/kg Epi 0.01mg/kg AVP 0.8 u/kg AVP 0.8u/kg Epi 0.1mg/kg

31 Definition: Nerves that when stimulated slow heart rate and cause vasodilation. This can cause bradycardia and hypotension resulting in fainting and cardiac arrest. Commonly seen with vomiting or diarrhea in our veterinary patients. In a vagal arrest, Atropine is your first drug of choice Dose: 0.04mg/kg IV

32 NO lidocaine.. except for sustained VT. Less common now with low dose Epinephrine recommendations. NO sodium bicarbonate.except for CPR>10min or ph<7.0 NO calcium gluconate.except for hypocalcemia or hyperkalemia NO dextrose..except for hypoglycemia NO STEROIDS!

33 Drugs Dosage Route Indicated Epinephrine 1st 0.01mg/kg (1:1000) 2 nd 0.1mg/kg IV, IT, IO PEA, Asystole Vasopressin 0.8u/kg IV, IT, IO PEA, Asystole Atropine 0.04mg/kg IV, IT, IO Vagal arrest Lidocaine 2-4mg/kg IV, IT, IO Ventricular arrhythmias after resuscitation Never use in cats! Sodium bicarbonate 0.5mEq/kg IV, IO Not for IT use Calcium gluconate ml/kg IV, IO Not for IT use Tricyclic antidepressant overdose Severe pre- existing metabolic acidosis Ca- channel blocker toxicity Hyperkalemia Hypocalcemia Dextrose 1ml/kg IV, PO, IO Hypoglycemia Hyperkalemia

34 Vasopressin AKA antidiuretic hormone Synthesized in the hypothalamus and released from the pituitary Release in response to Change in total body sodium BP Blood volume

35 Multiple receptors V1R: vascular smooth muscle*** Vasoconstriction at high doses Vasodilation (brain, kidney, pulmonary and mesenteric vessels) at low doses V2R: renal collection duct & platelets Increased water absorption Stimulate platelet aggregation V3R: pituitary ACTH release Diabetes insipidus

36 Cardiopulmonary resuscitation Improved cerebral O2 delivery, increased successful resuscitation, improved neurological outcome, improved vital organ blood flow Vasodilatory shock Vasoplegia no response to fluids or other pressors Central diabetes insipidus Deficiency of AVP hence the use of DDAVP Von Willebrand disease Treated with DDAVP

37 NEW AVP equivalent to Epi in survivability after cardiac arrest in humans studies. Indicated for asystole or PEA Dose units/ kg IV or IT administration. CRI units/kg/min

38

39 Animals are not people Most common arrhythmia in dogs and cats Asystole Pulseless electrical activity (PEA) Previously known as electrical mechanical dissociation or EMD Normal HR on ECG but absent contractility & pulses No PROVEN treatment for PEA or asystole

40 Only in patients with ventricular fibrillation Dose 4 6 j/kg 1 shock dose à 5 minutes compressions à check ECG à increase J by 50% and repeat shock dose Precordial thumps NEW

41 DO S NEW ETCO 2 ROSC if 10-15mmHg DONT S Feel for pulses Arterial blood gases Pulse oximetry Pupil size/plrs

42

43 Keep the following as close to normal SpO2 (>95%) PaO2 ( mmhg ) Lactate ( mmol/l) Blood pressure (100mmHg) PaCO2 (32-43 mmhg) Note: keep all other things normal too!

44 Hypothermia and rewarming Mild hypothermia (32-34) improves neurological outcome DO NOT USE STEROIDS Hyperosmolar solutions (HSS 5%, mannitol) is recommended if cerebral edema is suspected Dull, comatose, blind, seizures Seizure prophylaxis may be considered

45 Serial neurological exams Modified Glasgow Coma Scale May take hours post arrest to accurately assess prognosis Poor prognostic indicators after CPCR (24hr) Absent corneal reflex Absent PLRs Absent withdrawal reflex to pain Absent motor response

46 1. Myocardial and cerebral dysfunction Cellular damage Ischemia- reperfusion injury Inflammatory mediators 2. Effects of anoxia Bacterial translocation Coagulopathies 3. Multiple organ failure, sepsis, septic shock 4. DEATH

47 NEW Start with continuous, uninterrupted chest compressions Avoid excessive ventilation rates Keep between breaths/min After defibrillation immediate return to chest compressions for 5 minutes after single shock Permissive hypothermia post resuscitation Vasopressin = epinephrine as first line of treatment

48

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