CPD article

CPR: basic life support

The most common cause of CPA in humans is
Abstract ventricular fibrillation either due to heart disease or
Cardiopulmonary arrest is an emergency situation which can present to any veteri- secondary to severe systemic disease. McIntyre et al
nary clinic at any time. The RECOVER guidelines (2012) are an evidence-based (2014) published common causes of CPA in veteri-
consensus for current cardiopulmonary resuscitation recommendations for veteri- nary patients which included: cardiac-related issues
nary patients. Being prepared is the key to dealing with the situation in a quick (hypotension, haemorrhage or anaemia), respira-
and efficient manner. Preparedness consists of having a ‘ready area’, stocked tory failure, neurological disorders or metabolic de-
crash trolley and team training. All members of the team should be trained and rangements. Anaesthetic-related CPA carries the best
confident in delivering basic life support measures which include chest compres- prognosis for survival (Maton and Smarick 2012).
sions, endotracheal intubation and manually ventilating the patient. This may be because the patient is already intubated
(therefore the airway is protected), is receiving sup-
Key words: emergency, preparedness, CPA, CPR, airway, circulation, breathing plemental oxygen and is being closely monitored
which enables rapid CPA diagnosis and subsequent
commencement of CPR. McIntyre et al (2014) pub-

C
ardiopulmonary resuscitation (CPR) was lished success rates of CPR to hospital discharge in
first documented in the 1700s in Amsterdam animals of only 2–16%. If patients develop CPA as a
where many people worked and travelled on result of irreversible disease the outcome of CPR is
canals. There was a high rate of drownings because likely to be unsuccessful.
people fell into the water, so the Society for Recovery
of Drowned Persons dedicated their work to saving Preparedness
victims. In 1891 Dr Friedrich Maass documented the The likelihood of a survival is increased when the
performance of chest compressions and by 1903 Dr team is prepared. Research from human literature
George Crile reported a successful resuscitation. suggests that either equipment failure or poor sup-
There has been a lot of dispute over the best way plies result in delay of CPR efforts in up to 18% of
to perform CPR and there remain large gaps in cases (McMicheal et al, 2012). There are several areas
evidence. Historically in the veterinary field ideals that need to be considered in terms of preparedness:
have been extrapolated from human research, but the team; crash area; and crash trolley.
in 2011 an evidence-based consensus was designed
specifically for veterinary patients. The Reassess- The team
ment Campaign on Veterinary Resuscitation (RE- There is no recommendation for the optimal team
COVER) guidelines were published in 2012 and can size (McMicheal et al, 2012). From personal experi-
be reviewed in full in The Journal of Emergency ence it is beneficial to have 3+ persons: a chest com-
and Critical Care 22(S1): S102–S131 (Fletcher et al, pressor; a ventilator; and a drug administrator/timer.
2012). Team members can rotate tasks in order to switch
chest compressors after 2 minute intervals. There is
Causes of CPA little evidence to support a more experienced team
Cardiopulmonary arrest (CPA) is defined as a failure member (e.g. clinician) having a more successful
of effective circulation and ventilation. This leads to outcome (McIntyre et al, 2014). The most important
reduced tissue oxygenation and organ damage and component of a successful resuscitation is that some-
emergency intervention can be life saving. Patients body takes the role of leader and directs the team by
fall into two categories; those with reversible causes; distributing tasks. Communication must be clear and
those with irreversible causes. concise. Closed loop communication is practised in
some settings where the leader gives an instruction
and the team member repeats the instruction back
Eleanor Haskey BSc(hons) RVN VTS(ECC) to the leader. This can help to reduce mistakes due
VPAC A1, Head ECC nurse, Royal Veterinary to orders not being clear or an instruction not being
College, Hawkshead Lane, North Mymms, heard due to the chaotic nature of the situation.
Hertfordshire, AL9 7TA Training is another important factor. Personnel
should receive effective and standardised training

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 CPD article

with the option of refresher sessions every 6 months

(McMicheal et al, 2012). These should be practical ses-
sions, using a mannequin, to ensure all team mem-
bers are able to effectively carry out all tasks such as
ventilation and chest compressions. Feedback should
be given and technique critiqued so the team opti-
mises their CPR efforts.

Crash area
Many busy emergency veterinary departments will
have a dedicated crash area where the animal is tak-
en in a crash situation. This may not be possible in
smaller settings and so it may be more appropriate to
resuscitate the animal where they are, e.g. ward area.
Ideally a crash area should have enough space for
the team to be able to access the patient from all
sides, good lighting and an oxygen supply. A suction
unit should be kept plugged in and ready to use. If
a specific crash area is utilised then a table with al-
tering height is beneficial to maximise chest com-
pression technique. If a static table is used then a
foot stool should be supplied for shorter members
of the team. A continuous electrocardiogram (ECG)
Figure 1. All crash carts within the practice
machine and capnograph are the monitoring equip-
should contain the same items in the same
ment of choice. A defibrillator can be a useful addi-
places to minimise wasted time looking for
tion if working in an emergency setting. resources.

Crash trolley
The crash trolley is likely to be stored in the crash
area. If there is no crash area then several smaller
crash boxes can be located in different areas such as
theatre, prep room and radiography.
All crash carts within the practice should be stand-
ardised (Figure 1). They should contain the same
items in the same places to minimise wasted time
looking for resources. All personnel who are likely to
be involved in CPR efforts should know where to lo-
cate the crash trolley/box and where items are kept
within it. It is useful to access these during training
refreshers so they act as a visual reminder.
Equipment should include airway equipment
(laryngoscope, a range of endotracheal (ET) tubes and
tracheostomy tubes, Intubeaze®, urinary catheter),
intravenous (IV) access (short peripheral catheters of
multiple sizes, intraosseous catheters, surgical blade
for cutdown), emergency drugs (adrenaline and atro-
pine — large settings may contain other drugs such
as drug antagonists, i.e naloxone, calcium gluconate, Figure 2. The RECOVER initiative have devised a CPR algorithm and
propofol), ventilation equipment (anaesthetic cir- drugs chart, and this can be included on the crash trolley.
cuits or Ambu bags), surgical kit for cut down or open
chest CPR, needles and syringes. crash. The RECOVER initiative have devised a CPR
The crash trolley should be sealed so people do not algorithm and drugs chart (Figure 2) that can be kept
‘borrow’ equipment that may be required urgently. It alongside the crash trolley as a quick reference guide.
should be audited monthly and restocked after each A standardised CPR recording form can be useful for

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 CPD article

then call for assistance and move the patient to the

crash area. Airway, breathing and circulation (ABC)
should be rapidly assessed and if there is concern re-
garding CPA then CPR should be commenced imme-
diately. The alarm should be raised for help by shouting
‘CRASH’. In large hospital settings it can be extremely
useful to have a crash alarm installed. If a patient ex-
periences CPA, the alarm can be sounded making staff
aware of an emergency in a certain area of the hospital
so help can be provided and CPR started. Time should
not be wasted trying to feel for a pulse or auscultating a
thorax as this will delay CPR efforts. There is some evi-
dence to suggest that the benefit of starting CPR in a
patient not in CPA outweighs the risks associated with
not starting CPR (Hopper et al, 2012).

Basic life support (BLS)

BLS consists of ABC — airway, breathing and circu-
lation. Rapid initiation and effective technique are
associated with return of spontaneous circulation
(ROSC) and survival. It may be more appropriate to
use the pneumonic CAB — circulation, airway and
Figure 3. Thoracic pump compression tech-
breathing as chest compressions should not be de-
nique.
layed until an airway is obtained.

Circulation
During CPA there is no cardiac output, therefore chest
compressions should be used to generate pulmonary
blood flow in order to eliminate CO2 and increase
oxygen uptake. Efficient compressions will increase
tissue perfusion and oxygen delivery. Establishing
blood flow can be done via external chest compres-
sions (closed chest) or cardiac massage (open chest)
with the latter being considered an advanced life sup-
port technique.
Technique for external chest compressions:
ll Cats and dogs should be put into lateral recumbency
ll Three types of chest compressions:
llThoracic pump (Figure 3) — patients >10 kg —
compressions are delivered over the highest part
of the thoracic wall to increase intrathoracic
pressure, therefore forcing blood from the major
vessels into the systemic circulation
llCardiac pump (Figure 4) — patients <10 kg —
Figure 4. Cardiac pump compression technique. compressions delivered over the heart either one
handed or two handed so the heart ventricles are
recording the times and events of actions during the directly compressed
CPR efforts. llBarrel chested dogs, e.g. Bulldogs — place in
dorsal recumbency and compress over the
Recognising a crash sternum
Identification of a CPA includes the unconscious/un- ll Compressions should be delivered by locking the
responsive patient with absent or agonal respiration. If elbows and placing one hand on top of the other
there is concern that a patient is rapidly deteriorating — ensure that the table height is adequate to max-
and it is felt that a crash situation may be imminent imise efforts

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 CPD article

The chest should be compressed between a third to

ll
a half of the resting diameter Key Points
There should be full recoil of the chest between
ll Cardiopulmonary arrest (CPA) is defined as a failure of effective circulation and ven-
ll
compressions which creates negative pressure tilation.
within the thorax and aids the filling of the ven- Being prepared for a crash situation greatly increases the chances of a positive out-
ll
tricles come.
Compressions should be delivered at a rate of 100–
ll Basic life support consists of circulation, airway and breathing.
ll
120 beats per minute (regardless of size of patient) Chest compressions should be delivered at a rate of 100–120 beats per minute.
ll
in 2 minute uninterrupted cycles Breaths should be delivered at a rate of 10 per minute.
ll
Compressors should be rotated with minimal in-
ll
terruption to compressions
There is no evidence to support trauma from coun-
ll
ter abdominal compressions so if there are enough
personnel that are trained then this can be consid-
ered as an adjunct to chest compressions.

Airway and breathing

Hypercapnia and hypoxia both increase the likelihood
of an unsuccessful outcome so it is essential to obtain
and secure an airway and provide adequate ventila-
tion. This should be performed with the patient in
lateral recumbency as chest compressions will have
already been initiated and should continue uninter-
rupted. The use of a laryngoscope can aid in ET tube
placement. A rigid urinary catheter can be used as a
stylet in difficult airways. Suction may be required if
there has been reflux from the stomach or fluid from
the lungs causing upper airway obstruction. ET tubes
should be tied in place as they are easily dislodged due
to movement during CPR. The cuff should be inflated
to improve ventilation and due to the risk of gastric
reflux during CPR. Breaths should be delivered to
the patient via an anaesthetic circuit (Ayres T–piece/ Figure 5. Breaths can be delivered to the pa-
Bain) or an Ambu bag (Figure 5) at a rate of 10 breaths/
tient via an Amby bag.
minute with a tidal volume of 10 ml/kg and an inspira- saving and if started immediately are more likely to
tory pressure of 15 cmH20. A common mistake is to be associated with a ROSC. Preparedness and train-
increase ventilation as chest compressions are hap- ing are key features that can be easily achieved by en-
pening so be careful to time ventilation efforts to avoid suring that the crash trolley/box is fully stocked and
decreasing oxygen delivery. that all staff members are familiar with how to de-
liver chest compressions and manually ventilate the
Conclusion patient.  VN
BLS is the steps taken in an emergency situation when
a patient is experiencing CPA. These steps can be life Conflict of interest: none.

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