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What is the end-point of successful CPR?
ROSC- return of spontaneous circulation
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What are predisposing factors for CPA (cardiopulmonary arrest)? (8)
- sepsis/ SIRS
- anesthesia/ medications
- toxicities
- respiratory disease
- cardiac/ pericardial disease
- trauma
- TBI (traumatic brain injury)
- neoplasia
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What are warning signs of impending CPA (cardiopulmonary arrest)? (7)
- rapidly declining mentation
- hypothermia
- bradycardia (cats)
- hypotension
- dilated, unresponsive pupils
- changes in respiratory pattern/ agonal
- pale/ cyanotic mucous membranes
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How do we recognize cardiopulmonary arrest (CPA)? (3)
- loss of consciousness
- absence of spontaneous ventilation
- absence of heart sounds on auscultation
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Describe the RECOVER initiative.
- Reassessment Campaign on Veterinary Resuscitation
- consensus based on clinical guidelines for veterinary CPR
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How is return of spontaneous circulation (ROSC) assessed? (4)
- audible heart sounds
- electrical activity coinciding with heart sounds
- palpable pulses
- spontaneous respiration
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The purpose of CPR is to maintain...
perfusion to the cerebrum and myocardium.
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What is the difference b/w basic life support and advanced life support?
- basic: maintenance of organ function by promoting perfusion of brain and heart; airway, breathing, circulation, compression (ABCs)
- advanced: utilize pharmacologic support, defibrillation, fluid therapy, and monitoring to restore function; airway, breathing, circulation, compression, drugs, ECG, electrical defib, fluids, futility (ABCs)
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When you recognize CPA,...
- IMMEDIATELY initiate chest compressions
- initiate ventilation
- then go through the steps of the ABCs
- 2 minute cycles
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Describe the AIRWAY step of the recover ABCs. (4)
- clear airway with suction
- laryngoscope to visualize airway
- ET intubation
- be prepared to perform a tracheostomy
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How can we verify that we have the ET tube in the proper location? (4)
- direct visualization
- palpation
- chest wall movement
- auscultation of lung sounds when given a breath
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Describe the BREATHING step of the recover ABCs. (5)
- goal of 100% FiO2 at a rate of 10-15 breaths/ minute
- tidal volume of 10mL/kg
- deliver a breath for 1 second
- peak airway pressure of no greater than 20cm H2O
- ambu bag or rebreathing bag on an anesthetic machine
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Why should hyperventilation be avoided when breathing for a patient? (5)
- increased RR--> increased intrathoracic pressure-->
- decreased coronary perfusion pressure
- decreased cardiac output
- decreased right ventricular function
- decreased venous return
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Describe the CIRCULATION step of the recover ABCs. (3)
- goal is to maximize perfusion to the brain and heart
- minimize interruptions (<10 seconds)
- chest compressions
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Describe closed chest resuscitation. (4)
- 100-120 compressions/ minute
- compress by 1/3 of the diameter of the chest
- 1:1 "duty cycle" (elastic recoil, venous fill)
- switch compressors every 2 minutes (studies show you are not as effective performing compression after 2 minutes)
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What are 2 techniques for closed chest compressions?
- cardiac pump: compression of the heart, stimulate direct forward flow of blood, small dogs and cats
- thoracic pump: compression over widest part of chest, forward flow dependent on changes in intra-thoracic pressure, large and medium dogs
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What are indications for open chest resuscitation? (6)
- penetrating chest wounds
- rib fractures
- pleural space disease
- pericardial effusion
- intra-operative cardiac arrest
- failure to achieve ROSC within 2-5 minutes of closed compressions
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Describe the DRUG step of the recover ABCs. (6)
- IV (central or peripheral catheter) preferred; intraosseous, intratracheal, intracardiac
- Vasopressors (Epi, Vasopressin)
- Parasympatholytics (Atropine)
- Positive inotropes
- Reversal drugs
- Antiarrhythmics
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What are pros and cons of using a peripheral catheter versus central catheter to deliver drugs?
- Peripheral: less expertise needed, drugs must be flushed to central circulation with saline, con is that its slower to central circulation (up to 2 minutes)
- Central: requires technical expertise, time consuming, but faster circulation time
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Which drugs can be given through an ET tube? (5)
- NAVEL: Naloxone, Atropine, Vasopressin, Epinephrine, Lidocaine
- [you must double the dose if giving these drugs by ET tube; give 2 full breaths after administering drugs]
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What are locations for administration of intraosseous drugs? (4)
- trochanteric fossa
- tibial crest
- proximal humerus
- ilial wing
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What are potential complications with giving intracardiac medications (which is why this method is never recommended, but is last ditch effort)? (4)
- coronary vessel laceration
- hemopericardium
- pneumothorax
- intractable arrhythmias
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What is the goal of vasopressor therapy? (2)
- augment cardiac output achieved with compressions
- increase peripheral vascular resistance
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What are the effects of epinephrine? (3)
- vasoconstriction (alpha-1 effect)
- positive chronotrope (inc HR, beta-1 effect)
- positive inotrope(beta-1 effect)
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What dose of Epi is used in an arrest situation?
- 0.01-0.02 mg/kg (~0.1mL/10kg)
- this is the recommended first drug for arrest
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What are the benefits of using vasopressin as an arrest drug? (3)
- does not increase myocardial oxygen demand, effect not blunted by acidemia, improved cerebral perfusion by dilation of cerebral vasculature
- this is recommended as a second-line drug after Epi
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Describe the ECG step of the recover ABCs. (2)
- monitoring is vital in CPR
- observe every 2 minute cycle
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What are the 3 major cardiac rhythms associated with cardiopulmonary arrest?
- asystole
- pulseless electrical activity
- ventricular fibrillation
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Describe the END-TIDAL CO2 step of the recover ABCs. (2)
- capnography ETCO2< 10-12mmHg--> go to chest compressions
- increased ETCO2 is strongly associated with ROSC (>15mmHg in dogs, >20mmHg in cats)
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Describe the ELECTRICAL DEFIBRILLATION step of the recover ABCs. (3)
- goal is to convert to a perfusing cardiac rhythm by driving abnormally firing myocardial cells into the refractory period and re-establish sinus
- only for treatment of "shockable" rhythm, ie. Vfib
- 1 shock, compressions for 2 minutes
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Describe the FLUIDS step of the recover ABCs. (2)
- use only with hypovolemia
- if a patient was euvolemic before arrest, fluids are not indicated
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When is CPR deemed unsuccessful, ie. futility? (3)
- after >20minutes of CPCR
- if underlying cause of arrest cannot be identified or reversed
- owner wishes
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What are post-CPR principals after successful CPR? (5)
- treat underlying cause of CPA
- cardiovascular support
- respiratory support
- neurological support
- serial, invasive monitoring
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What are possible sequela of CPR? (4)
- MODS (multi-organ dysfunction syndrome)
- anoxic brain injury
- myocardial dysfunction
- worsening of primary disease
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