Cardiopulmonary cerebral resuscitation: current guidelines and their application (Proceedings)
Cardiopulmonary cerebral resuscitation (CPCR) refers to the re-establishment of circulation and preservation of neurologic function following an arrest.1 Since its inception in the late 1800's, CPCR has saved the lives of countless human and veterinary patients. However, low overall survival rates following CPCR indicate that there is still much room for improvement in these practices. This session reviews current practices and updates on CPCR in the veterinary patient.
Basic life support
Basic life support refers to the process of establishing an airway, initiating positive pressure ventilation, and performing chest compressions. Because cardiopulmonary arrest (CPA) in veterinary patients is frequently initiated by respiratory arrest, an ABC approach is generally taken as described below.Airway
Orotracheal intubation is easily achieved in dogs, as the larynx can be directly visualized by retracting the tongue. The head and neck should be gently extended and a laryngoscope may be used to improve visualization of the larynx. In cases where hemorrhage, saliva, or gastric contents interfere with visualization, suction may be helpful. Alternately, the glottis may be palpated with one finger used to guide tube placement. Once tube placement is verified, the tube should be secured by tying to the nose or around the back of the head. The cuff should be inflated, and assisted ventilation provided. If chest wall excursion is not seen, lung sounds are absent, or abdominal distension is noted, tube placement should be reconfirmed by direct visualization and the cuff should be reinflated. Improper tube placement and tube dislodgement are common causes of CPCR failure.
Once an endotracheal tube is in place, breathing is initiated at a rate of 10-20 breaths per minute with 100% oxygen. An ambu bag with attached oxygen line is ideal for this purpose. If only one person is available to perform CPR, 2 breaths should be given for each 30 chest compressions. If several trained personnel are available, then breaths may be delivered independent of compressions. Chest wall excursion should be seen with each delivered breath. Airway pressures ideally should not exceed 20-30 cm H2O. High airway pressures or inadequate chest wall excursion should prompt a search for pleural space disease, tube malposition, or tube occlusion.
Chest compressions are initiated at a rate of 100-120 per minute, compressing the circumference of the chest by approximately 30%. The patient should be in lateral recumbency during compressions. In smaller dogs, where the cardiac pump theory is believed to predominate, hands should be placed over the ventral third of the chest just behind the point of the elbow, corresponding to a position directly over the heart. In larger dogs, the thoracic pump theory is believed to be most important in generating blood flow, and hands should therefore be placed over the widest part of the thorax to create a maximal rise in intrathoracic pressure.
A number of alternative techniques have been investigated that may help to augment blood flow during CPCR. Those that are directly applicable in veterinary patients include circumferential chest compression and interposed abdominal compressions. Circumferential chest compression is most commonly performed in cats and small dogs by encircling the chest with both hands to maximize the rise in intrathoracic pressure during chest compression. In larger animals, interposed abdominal compression may be implemented by having an additional person perform abdominal compressions during the relaxation phase between chest compressions. Interposed abdominal compressions increase venous return to the heart, leading to greater stroke volumes and cardiac output, and have been associated with increased survival to discharge in human patients.
Advanced life support
Advanced life support consists of drug administration, determination of cardiac electrical activity, and application of electrical defibrillation if indicated. These techniques build upon basic life support to increase the likelihood of successful resuscitation.