The purpose of CPR is to reverse sudden unexpected death resulting from reversible disease processes or iatrogenic complications.
For years, in veterinary medicine, the term cardiopulmonary cerebrovascular resuscitation (CPCR) or cardiopulmonary cerebral resuscitation has been used. Recently the Reassessment Campaign on Veterinary Resuscitation (RECOVER) has recommended going back to the term cardiopulmonary resuscitation (CPR) stating that it is less confusing and more universal. No matter what it is termed, it is inevitable in emergency medicine that at some point you will be faced with an arrest. While cardiopulmonary resuscitation in veterinary medicine is fairly unsuccessful (reports less than 6% in dogs and cats, 22% in humans) the speed at which you initiate resuscitative measures is imperative to the overall chance of survival for the patient.
Decisions on whether to conduct CPR for patients should be discussed with the owners pre-emptively whenever possible.
Here’s some tips that will help cpr efforts go smoother in your clinic.
What are the owners wishes?
As CPR is a costly treatment, owners of patients who are likely to suffer from cardiopulmonary arrest should be informed of likely costs and outcomes.
Ensuring there is a section on your admission forms along with a cost estimate is a great way to ensure all clients are given the option prior any upsetting events.
If a client wishes you to try everything, or conversely to not go ahead with CPR should it become necessary, this should be clearly marked on the patient’s cage and followed by all staff.
Practice, Practice, Practice.
It is important to fully understand how to perform basic life support in order for the patient to have the best chance of survival. Practicing CPR drills and how to correctly perform chest compressions and ventilation will allow staff to be better prepared for the real thing.
Get your clinic to schedule regular CPR drills, even on a stuffed toy is better than no drills at all.
Poorly performed compressions generate even smaller stroke volumes.
Start with compressions first.
There are three phases to CPR: Basic, Advanced and Prolonged. Basic life support is limited to the ABCs (airway, breathing, circulation) of CPR. Advanced life support covers gaining intravenous access, drug administration, monitoring equipment and defibrillation. Prolonged only occurs after the patient has been successfully resuscitated.
Recently recommendations for basic life support have been changed from ABCs to CABs. This is because it has been shown that starting with cardiac compressions first offers a better chance of survival. The goal is to support ventilation, oxygenation and circulation by administering manual and external chest compressions and ventilation.
If a patient is in full cardiopulmonary arrest or cardiac arrest you will need to initiate chest compressions immediately. If the patient is in respiratory arrest only, the cardiac function should be closely monitored while ventilatory support is administered. Even if performed correctly, most people will only produce 30% of normal stroke volume when performing chest compressions.
Good technique should include:
- Not leaning on the patient because it decreases the recoil of the chest
- Working to compress the chest 1/3 to 1/2 the width of the chest
- Elevate your body above that of the pet so that you have good leverage
- Lock your elbows and hands and compress using your shoulders, not your arms
- Shoulders should be positioned above your hands in a direct line
Currently the recommendation is to give 100 to 120 compressions per minute.
Swap every 2 minutes.
Depending on the size of the patient, most people cannot effectively compress the chest for more than 2 minutes at a time; it is recommended to switch persons every 2 minutes. Once someone is already feeling tired, the technique of the compressions decreases dramatically, causing subsequent poor cardiac output for the patient. It takes 1 minute of compressions for aortic blood pressure to reach a steady state. When switching people it is important that the switch occurs quickly and smoothly. Ideally, the chest should continue to be compressed without any stoppage in between.
Position your patient
There has been much discussion about whether pets should be in right/left lateral recumbency or dorsal/ventral recumbency for compressions. While there is not a lot of evidence-based literature supporting better outcomes, it is recommended that flat chested animals (Bulldogs, Frenchies etc.) should have chest compressions performed in dorsal recumbency. This allows for the better recoil of the chest. Because it can be difficult to stabilise in dorsal recumbency, one should consider placing the pet in a trough.This may be time-consuming or not possible, and if chest compressions are not being performed with good technique because of movement of the animal, then lateral recumbency should occur.
For pets or cats that have flatter and triangle/pointed chests, chest compressions should occur in lateral recumbency. There is no evidence-based literature to support whether right versus left recumbency offers a better outcome.
Establish an Airway
Without question, chest compressions are the single most important aspect of CPR and should start first.There is much evidence-based literature in human medicine showing improved CPR statistics when chest compression-only CPR is performed and/or when chest compressions are started before airway and breathing. The airway is established second.
Methods for establishing an airway (in order of preference) include intubation, facemask and ambu-bag followed by mouth-to-snout.
Unlike human CPR, breaths are given simultaneously with compressions at a rate of 10 breaths per minute.If you are performing CPR by yourself, you should perform 30 compressions and then administer 2 breaths.If performed with at least one other person, it should be 1 breath every 6 seconds (10 breaths a minute).
To perform adequate breathing, the patient’s neck should be extended. Each breath should be for a full one second while someone watches to ensure the chest inflates for the first few breaths.
Breaths should be no longer than one second to ensure adequate ventilation.
In this short video, Dr Erica Tinson, senior resident in veterinary emergency and critical care at the U-Vet Animal Hospital in Werribee provides instructions aimed at pet owners on how to respond. This is still useful for you as a veterinary nurse. Credit:
want to learn more?
Learn more about CPR. In this short course the following are covered:
- Arrival at the Clinic
- The Emergency Crash Cart
- Cardiopulmonary Resuscitation (CPR)