Cardiopulmonary Cerebral Resuscitation


Table 157-3 THERAPEUTIC MANAGEMENT OF PROBLEMS ASSOCIATED WITH CARDIAC ARREST

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Chapter 157 Cardiopulmonary Cerebral Resuscitation



William W. Muir, III


Resuscitation is the restoration of life after apparent death. Cardiopulmonary resuscitation (CPR) includes therapy to restore heart and lung function to normal. Most resuscitative techniques incorporate methods to maximize and maintain cerebral blood flow and clinicians have redefined CPR as cardiopulmonary cerebral resuscitation (CPCR). Preparedness and early recognition of the signs of sudden death are the major factors that determine long-term outcome (Tables 157-1 and 157-2).


Table 157-1 SIGNS OF CARDIOPULMONARY ARREST























































Evaluations Clinical Signs and Observations
Effort, rate, and rhythm of breathing Dyspnea (abdominal breathing)
Gasps (gurgling sounds)
Tachypnea
Bradypnea
Altered patterns of breathing:
  Cheyne-Stokes
Agonal
Heart rate and rhythm Tachycardia
Bradycardia
Irregular rhythm
Pulse Peripheral arterial pulse is difficult orimpossible to palpate at systolic BPs < 40–50 mm Hg
Heart sounds Heart sounds are inaudible at BPs < 40–50 mm Hg
Bleeding Absence of bleeding
Change in color of blood from red to blue during surgical procedure
Peripheral perfusion Change in mucous membrane color:
Pale or white
Blue or cyanotic—5 g/dl of reduced Hb imparts bluish discoloration to mucous membranes; anemic animals (<5 g/dlHb) do not demonstrate cyanosis
Pupils Pupils dilate within 1–2 min after cardiac arrest
Mental state Altered consciousness
Coma

BPs = arterial blood pressures; Hb = hemoglobin.



Table 157-2 ESSENTIAL EQUIPMENT TO PERFORM CPCR*



1. Assortment of cuffed endotracheal tubes with inside diameter of 2–15 mm

2. Oxygen supply source
a. Ambu bag and oxygen source

b. Small animal anesthetic machine

c. Demand valve

d. Oxygen hose to deliver nasal oxygen

e. Respirator (pressure or volume cycled)

f. Oxygen chamber

3. Fluid and drug administration equipment
a. Assortment of intravenous needles and catheters
(1) Needles—18–25 gauge

(2) Over-the-needle or through-the-needle catheters—17–22 gauge

b. Assortment of syringes—1, 3, 6, 12, and 60 ml

c. Solution administration sets
(1) Standard solution administration sets (10 drops/ml) for animals over 5 kg

(2) Mini-drop solution administration sets (60 drops/ml) for animals <5 kg and to deliver drugs that must be administered by infusion

d. Venous extension tubing to prolong the time until drug effect, by increasing distance between fluids and patient

e. Three-way stopcocks and catheter injection plugs

4. Fluids
a. Balanced electrolyte solutions to be administered IV in most emergency situations; rate of fluid administration is determined by circumstances (see text for dosages):
(1) 20 ml/kg/hr during hypotension

(2) 40 ml/kg/hr following acute cardiac arrest

(3) 90 ml/kg/hr following circulatory collapse due to hemorrhage

b. Other solutions
(1) 5% dextrose in water to supply volume and additional calories and dilute plasma potassium concentration

(2) Normal saline (0.9% NaCl) to supply volume and dilute plasma potassium concentration

(3) Colloid solutions (6% dextran 70; hetastarch) to supply volume and oncotic value

(4) Mannitol (20% Osmotrol) to be used as an osmotic diuretic and as an oxygen free radical scavenger

c. Special solutions

(1) Hypertonic saline solutions (usually 3 or 7%) to restore vascular volume; the appropriate quantity of NaCl may be mixed in 6% dextran 70; 7% NaCl in 6% dextran 70 can be administered IV, 4 ml/kg, over 1–2 min

(2) Blood substitute (Oxyglobin, Biopure), 10–30 ml/kg/hr IV, to maintain tissue oxygenation following acute hemorrhage or in severe anemia

5. Drugs (see text for dosages)
a. Anticholinergics (atropine or glycopyrrolate)

b. Epinephrine (1 : 1000 and 1 : 10,000)

c. Dopamine or dobutamine

d. Calcium chloride

e. Lidocaine (2%)

f. Injectable procainamide

g. Glucocorticosteroids (dexamethasone, prednisolone sodium succinate)

h. Furosemide

i. Mannitol

j. Diazepam, thiobarbiturate (thiopental), phenytoin

k. Oxymorphone, other opioids

l. Doxapram

6. Surgical instruments
a. Scalpel and several #10 blades

b. Mosquito and Kelly hemostats

c. Rib retractors

d. Thumb forceps

e. Metzenbaum and Mayo scissors, needle holders

7. Bandage material (1, 2, and 4 inch)
a. Sterile 4-inch × 4-inch gauze sponges

b. Cotton bandage

c. Elastic bandage

d. Tape

8. Other equipment
a. Clippers

b. Leg splints (tongue depressors can be used in animals under 10 kg)

c. Water circulating heating pad

d. Electrocardiographic machine

e. Electrical defibrillator

f. Aspiration or suction device and tubing

g. Assortment of suture material


* This material should be kept in one place, preferably on an emergency cart or in a large tool chest.


CPCR is divided into three phases:


• Phase 1, basic life support (BLS), consists of establishing an airway (A), breathing (B), and circulatory support (C).

• Phase 2, advanced life support (ALS), incorporates the use of drugs (D), electrocardiography (E), and methods to convert ventricular fibrillation or asystole (F) to sinus rhythm.

• Phase 3, prolonged life support (PLS), includes measures that focus on treating the causes of cardiac arrest and deciding whether to continue resuscitative efforts. Gauging (G) (monitoring of patient trends), hypnogenesis (H) (use of sedation, anesthesia, and pain control), utilization of methods to restore cerebral function, and intensive care (I) oriented toward preventing multiorgan failure are also elements of PLS.


BASIC LIFE SUPPORT: AIRWAY, BREATHING, AND CIRCULATORY SUPPORT



Airway




Key Point


Establishing a patent functional airway should be accomplished as soon as possible.



Establishing an Airway



Mouth to Endotracheal Tube


To pass a cuffed endotracheal tube of appropriate size place the patient on the sternum, open the mouth widely, and maximally extend the head and neck. Expose the larynx (using a laryngoscope if necessary) and proceed with intubation.



Tracheotomy


A tracheotomy may be necessary in animals with upper airway obstruction, brachycephalic animals, or in dogs and cats that are successfully resuscitated, regain consciousness, and object to oral-tracheal intubation. (Tracheotomy is described in Chapter 3.)



Mouth to Muzzle


Tightly cup hands around the muzzle of small dogs and cats, or place mouth directly over the patient’s muzzle. Blow exhaled air into the animal’s lungs.



Mouth to Mask


A variety of masks have been developed for use in dogs and cats for the delivery of oxygen or inhaled anesthetics.




Key Point


Mouth-to-muzzle and mouth-to-mask methods do not secure the airway but may be useful when equipment is limited. Distention of the stomach with air may limit lung expansion and predisposes to regurgitation.



Proper Endotracheal Tube Placement


Correct placement of the endotracheal tube can be verified by:


• Clearing and securing an airway.

• Direct observation of the tube positioned through the larynx (most reliable technique).

• Palpation of the endotracheal tube in the trachea.

• The appearance of water vapor on clear endotracheal tubes.

• The inability of the animal to vocalize.

• Gas exiting the endotracheal tube during exhalation. This sign, which frequently is used clinically, should not be the only method used to ensure proper endotracheal tube placement.


Air or Oxygen Delivery Systems (Fig. 157-1, top)



• Self-refilling bags connected to oxygen (Ambu bag) can be used to provide an air or oxygen source during controlled breathing.

• Demand valves, which are oxygen-powered, manually triggered ventilatory devices, permit both the initiation and termination of ventilation.

• Anesthetic machines are the most readily available source of oxygen in most hospitals.

• Automatic pressure- or volume-cycled ventilators can be used to assist (control volume) or control (control rate and volume) breathing. Most ventilators do not function properly during thoracic compression.

• In translaryngeal or tracheal insufflation (see Fig. 157-1, bottom), place an over-the-needle catheter (Surflo, Terumo Medical Corp.) (17-14 gauge) in the trachea and attach to a three-way stopcock, venous extension tubing, and oxygen supply.

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Figure 157-1 Methods of endotracheal oxygen administration (top); transtracheal oxygen administration (bottom) via catheter placement through the cricothyroid notch (1) or between tracheal rings (2).


(Modified from Sherding RG: Medical Emergencies. New York: Churchill Livingstone, 1985.)



Breathing


A ventilator, delivering 50% to 100% oxygen, can be used to assist or control breathing. The resuscitator’s exhaled air, which contains 16% to 18% oxygen, may be expelled into a properly placed endotracheal tube and is adequate for maintaining Pao2 if large tidal volumes are used.


• Detect and immediately treat:
• Tension pneumothorax

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Aug 27, 2016 | Posted by in SMALL ANIMAL | Comments Off on Cardiopulmonary Cerebral Resuscitation

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