11/20/15

RECOVER: Standardizing
Veterinary CPR

JOSEPH M. DEFULIO, LVT

SAINT FRANCIS VETERINARY CENTER
WOOLWICH TOWNSHIP, NEW JERSEY

RECOVER Overview

u RECOVER
u Reassessment Campaign on Veterinary Resuscitation

u Published in 2012, reevaluating in 2017

u Main goal
u Develop a set of clinical consensus guidelines for the
practice of CPR in dogs and cats based upon an
extensive, systematic review of the literature in the
context of our target species

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Clinical Guideline Class

Descriptors

Class Risk:benefit ratio Clinical recommendation

I Benefit >>> Risk Should be performed

IIa Benefit >> Risk Reasonable to perform

IIb Benefit ≥ Risk May be considered

III Risk > Benefit Should not be performed

Clinical Guidelines Level

Descriptors

Level Populations studied Criteria for recommendation

A Multiple populations Multiple high quality and/or high
level of evidence studies

B Limited populations Few to no high quality and/or

high level of evidence studies

C Very limited Consensus opinion, expert

populations opinion, guideline based on
physiologic/anatomic principles,
standard of care

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Clinical Guideline Class &

Level Examples

u Crash cart – standardization and regular audit of the

location, storage, and content of resuscitation
equipment is recommended – I-A

u Supplemental Oxygen Administration – during CPR in

dogs and cats, the use of an FiO2 of 100% is
reasonable – IIa-B

u Corticosteroids – the routine use of corticosteroids

during CPR is not recommended – III-C

Emergency Preparedness

u Staff cardiopulmonary resuscitation (CPR) training

(didactic components & hands-on skills), at a
minimum, every six months

u Organized and frequently audited crash cart

u Review contents and drug expiration dates at the end of
each shift
u Apply a piece of tape across all of the drawers with the
date and your initials once it has been audited

u Presence of cognitive aids

u Emergency drugs and doses chart (cage cards too)
u CPR algorithm

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CPR Status

u Ensure that a CPR status is obtained on all patients,

especially those that are being admitted to the
hospital and/or undergoing anesthesia

u SFVC
u CPR
u DNR (do not resuscitate)

u Other method
u Green: open or closed chest CPR
u Yellow: closed chest CPR only
u Red: DNR

Team Dynamics

u Leader
u Distributing tasks, enforcing rules and procedures
u Does not need to be a doctor; does not change during code
u Compressor(s) (thoracic +/- abdominal)
u Performing external cardiac compressions
u Changes every two minutes

u Ventilator
u Adequately ventilating the patient
u Advanced Life Support (ALS)
u Monitoring equipment, vascular access, drug administration
u Recorder
u Document all details of CPR

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Closed Loop Communication

u Closed loop communication is imperative

u The leader will give a request, whomever is performing

the task should repeat it to verify accuracy, and then
perform it

u Results in a reduction of medical errors

Critical Care Monitoring Sheet

“CPR Flow Sheet”

u Recommended to use whenever working with a

critical patient, but required for use during CPR

u Aids in tracking crucial information, including, but not

limited to:
u CPR start and end times
u Drug administration quantities and times

u Become familiar with the form so that it is not your first

time seeing it during a code

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Crash Cart – Exterior & Drawer 1

u Exterior
u Monophasic
defibrillator
u Multi-
parameter
monitor
u 5 fully stock
drawers u Drawer 1
u Tape u Emergency drugs
indicating
recent audit u Defibrillator gel
u Venipuncture supplies
u Vascular access supplies

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Crash Cart – Drawers 2 & 3

u Drawer 2
u Endotracheal intubation supplies
u Airway suction supplies

u Drawer 3
u Pericardiocentesis kits
u Thoracocentesis kits
u Trochar catheters

Crash Cart – Drawers 4 & 5

u Drawer 4
u Fluid therapy supplies (crystalloids
and colloids)
u Aerokat (albuterol sulfate)

u Drawer 5
u Ventilation supplies
u Stomach pump
u Gastric decompression/lavage
tubes

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CPR Algorithm

u Step-by-step approach to
initiating CPR in a patient that is in
cardiopulmonary arrest (CPA)

u Intended to be used as a quick

reference

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Basic Life Support (BLS)

u BLS includes
u Recognition of CPA
u Chest compressions
u Airway management
u Ventilation

u When thinking of BLS, remember the mnemonic “CAB”

u C: circulation
u A: airway
u B: breathing

u BLS cycles last 2 minutes

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Cardiopulmonary Arrest

u Cessation of cardiac output and respirations

u Respiratory arrest first, cardiac shortly thereafter

u CPA should be detected within 5-10 seconds

u Evaluate airway, breathing, circulation (ABC)
u In humans, pulse palpation is a poor indicator of CPA
u Auscult your patient
u Agonal breath indicate that CPR should be started

u If there is uncertainty in CPA detection, initiate CPR

u Starting CPR on a patient not in CPA carries minimal risks

Cardiopulmonary Resuscitation

u Goal of CPR is return of spontaneous circulation

(ROSC)

u ROSC is achieved 35-45% of the time in canine and

feline patients

u Survival to discharge rates range between 2-10% in

canine and feline patients

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Patient Positioning

u Lateral recumbency u Dorsal recumbency

(left or right is (barrel-chested dogs)
acceptable; most
dogs and cats)

Compression Techniques

u Small dogs and cats (<10 kg)

u 1-handed technique, hand circumferentially around the
sternum, directly over the heart

u Alternate technique (“larger” small dogs and cats,

lower thoracic compliance)
u 2-handed technique directly over the heart

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Compression Techniques

u Small dogs and cats u “Larger” small dogs

(<10 kg); compliant and cats, lower
chests
thoracic compliance

Compression Techniques

u Medium, large, and giant breed dogs

u Point of maximum intensity (widest portion) of the chest

u Keel-chested (i.e. greyhounds)

u Directly over the heart

u Barrel-chested (i.e. English bulldogs)

u Sternal compressions directly over the heart

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Compression Techniques

u Medium, large, and u Keel-chested (i.e. u Barrel-chested (i.e.

giant breed dogs greyhounds) English bulldogs)

Technique Critique

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Cardiac Pump Theory

u Dorsal recumbency: cardiac

ventricles are directly compressed
between the sternum and spine

u Lateral recumbency: cardiac

ventricles are directly compressed
between the ribs

u Most cats and small dogs (with

thoracic wall compliance), barrel-
chested and keel-chested dogs

Thoracic Pump Theory

u Chest compressions
increase the overall
intrathoracic pressure, which
in turn compresses the aorta
and collapses the vena
cava; this process causes
blood flow out of the chest

u Most medium, large, and

giant breed dogs

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Chest Compressions

u Don’t delay compressions for ET intubation

u Compressions rate: 100-120 per minute (cats & dogs)

u Compression depth: 1/3 to 1/2 width of the chest

u Allow full elastic recoil between compressions

u Reduced coronary and cerebral perfusion in pigs if full
elastic recoil is not allowed
u High prevalence of leaning in human CPR

u Switch compressors every 2 minutes to avoid fatigue

Interposed Abdominal
Compressions

u Perform abdominal compressions

opposite of chest compressions

u Facilitates venous return from the

abdomen, thus increasing cardiac
output

u Minimal evidence of abdominal

trauma

u Reasonable when there are enough

team members

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Open-Chest CPR

u More effective than u Disadvantages

closed-chest CPR in
restoring ROSC u Financial endeavor
u Need experienced
team
u Direct cardiac massage
u Need surgical back-up
u Risk of infection
u Indications
u Hemoabdomens
u Intra-operative arrests
u Large dogs
u Pneumothorax
u Pericardial effusion

Airway & Ventilation

u Rapid endotracheal intubation (lateral or dorsal)

u Suction available, if needed

u Intubate while compressions are being performed

u The use of a laryngoscope is strongly advised

u Secure the ETT and inflate the cuff

u Mouth-to-snout ventilation if performing CPR alone (30:2)

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Airway & Ventilation

u Ventilation rate: 10 breaths per minutes

u Tidal volume: 10 mL/kg

u Inspiratory time: 1 second

u FiO2: 100% (unless ABG dictates otherwise)

u If patient is hooked up to an anesthesia circuit, turn off

the inhalant, flush the circuit and begin ventilation; not
required to switch to an ambu bag

Advanced Life Support

u Should ideally be occurring while BLS is underway

u If BLS and ALS are performed promptly, initial ROSC

rates can be as high as 50% in canine & feline patients

u ALS
u Monitoring equipment
u Vascular access
u Drug administration
u Defibrillation
u Precordial thump

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Monitoring Equipment

u Electrocardiogram (ECG)
u Subject to artifact during CPR
u Quickly evaluate during intercycle pauses

u End-tidal carbon dioxide (ETCO2)

u Early indicator of ROSC
u Sudden increases in ETCO2 can indicate ROSC
u Dogs: ETCO2 > 15 mmHg – increased rate of ROSC
u Cats: ETCO2 >20 mmHg – increased rate of ROSC

Vascular Access

u Intravenous (IV)
u Cephalic
u Saphenous (lateral, medial)
u +/- jugular
u +/- cut down

u Intraosseous (IO)
u Often times easier and quicker than IV access in
neonatal & pediatric patients

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Drug Administration

u Routes of administration
u IV/IO (preferred)
u Intratracheal (IT) if unable to obtain IV/IO access
u Intracardiac (IC) is not recommended

u IT administration
u NAVEL (naloxone, atropine*, vasopressin*, epinephrine*, lidocaine); no
sodium bicarbonate
u Increased doses (insufficient data – up to 10x for epinephrine)
u Dilute with 0.9% NaCl and administer via a red rubber catheter (RRC)
down the ETT (RRC should be longer than ETT)

Arrest Drugs

u Epinephrine (1 mg/mL) u Vasopressin (20 U/mL) u Atropine (0.54 mg/mL)

u Can cause u Works well in acidic u Parasympatholytic
myocardial ischemia environments
u Most likely useful for
and arrhythmias
u Decreased risk of dogs and cats with
u Low dose: 0.01 mg/ myocardial asystole or PEA
kg every other BLS ischemia associated with high
cycle vagal tone
u Can use in
u High dose: 0.1 mg/kg conjunction with or u Dose: 0.04 mg/kg
(consider for in place of
prolonged CPR) epinephrine
u Increased rate of u Dose: 0.8 U/kg
ROSC but not
survival to u Dose every 3-5
discharge minutes (every other
round of BLS)

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Antiarrhythmic Drugs

u Amiodarone (50 mg/mL)

u Ventricular fibrillation (VF)/pulseless ventricular
tachycardia (pulseless VT) resistant to defibrillation
u Dose: 5 mg/kg

u Lidocaine (20 mg/mL)

u Refractory VF/pulseless VT, +/- increased J/kg with
monophasic defibrillator
u Dose: 2 mg/kg

Reversal Drugs

u Naloxone (0.4 mg/mL)

u Opioid reversal
u Dose: 0.04 mg/kg

u Flumazenil (0.1 mg/mL)

u Benzodiazepine reversal
u Dose: 0.01 mg/kg

u Atipamezole (5 mg/mL)
u α-2 reversal
u Dose: 100 μg/kg

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Electrolyte Therapy

u Hypocalcemia often develops with prolonged CPA,

however, calcium should not be administered during
CPR (no effect or worse outcome)

u Hyperkalemia often develops with prolonged CPA; in

the event of hyperkalemia, treatment can be
considered (minimal supporting evidence)

Corticosteroids

u Lack of evidence to prove

corticosteroids beneficial

u Potential for side effects,

especially with poor perfusion

u Not recommended

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Fluid Therapy

u Fluid therapy is not recommended in

patients that are euvolemic or
hypervolemic

u Hypovolemic patients should be treated

with IV fluids

u NOTE: Never administer a full shock bolus;

administer in increments with
reevaluations of the patient in between

Defibrillation

u Delivery of an electrical shock that depolarizes all myocardial

cells

u Monophasic defibrillation: unidirectional current flows from one

electrode to another

u Biphasic: current initially flows in one direction, then reverses and

flows in the other direction

u Guidelines
u No isopropyl alcohol on patient
u Patient can not touch metal surfaces
u No one should be in direct contact with the patient

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Defibrillation

u Shockable rhythms
u Ventricular fibrillation
u Pulseless ventricular tachycardia

u Dose
u Monophasic (external): 4-6 J/kg
u Biphasic (external) 2-4 J/kg

u Always follow defibrillation with one full round of CPR

Shockable Rhythms

u Pulseless ventricular tachycardia

u Ventricular fibrillation

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Precordial Thump

u Strike the patient with the heel of your hand directly

over the heart

u Some efficacy for treatment of VF and pulseless VT

u Defibrillation is recommended (when available) over

precordial thump

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Post-Cardiac Arrest (PCA)

u Monitoring
u ECG
u ETCO2 (hypocapnia can lead to decreased cerebral blood flow)
u +/- ABG
u (N)IBP
u Glasgow-coma scale
u Mild therapeutic hypothermia (MTH)
u Organ protecting effects in PCA patients
u Initiate on patients that remain comatose ASAP after ROSC; maintain for
24-48 hours
u Need mechanical ventilator
u Avoid rapid warming

Post-Cardiac Arrest

u Corticosteroids
u Routine administration is not recommended
u Hydrocortisone can be considered in canine and feline
patients that remain hemodynamically unstable despite
fluids and pressors

u Hyperosmotic therapy
u Cerebral edema identified with people in the PCA period
u Consider hypertonic saline or mannitol (diuretic effects;
adjust fluids accordingly)

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Post-Cardiac Arrest

u Seizure prophylaxis
u Prognostic significance of seizure is uncertain in canine
and feline patients
u Can be considered with barbiturates (i.e. Phenobarbital)
during the PCA period

u PCA care should be sent to referral hospitals, as they

require intensive care and monitoring

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Post-CPR Debriefing

u Should occur after every code

u Review and critique your performance and skills, as

well as your team’s performance and skills

u Prevent focusing on blaming individuals

u Can lead to enhancement of CPR performance

Other Terminology

u CCR: cardiocerebral resuscitation

u CPCR: cardiopulmonary cerebral resuscitation

*CPR is the preferred terminology over CPCR

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Sources

u Fletcher, Daniel J., and Manuel Boller.

"Cardiopulmonary Resuscitation & Post-Cardiac Arrest
Care." Small Animal Critical Care Medicine. By
Deborah C. Silverstein and Kate Hopper. 2nd ed. St.
Louis: Elsevier Saunders, 2015. 11-25. Print.

u Fletcher, Daniel J., Manuel Boller, Benjamin M.

Brainard, Steven C. Haskins, Kate Hopper, Maureen A.
McMichael, Elizabeth A. Rozanski, John E. Rush, and
Sean D. Smarick. "RECOVER Evidence and Knowledge
Gap Analysis on Veterinary CPR. Part 7: Clinical
Guidelines." Journal of Veterinary Emergency and
Critical Care 22.S1 (2012): S102-131. Web.

Questions?

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