How to prepare for cardiopulmonary resuscitation
Medical patients often present to us significantly unwell and require anaesthesia or sedation for diagnostics and investigations. The risk of a ‘crash’ (aka cardiopulmonary arrest) can be higher in these patients, and the veterinary team need to be able to intervene immediately in the case of an arrest. Successful CPR begins with being prepared - and today we’re looking at what that means in practice.
The REassessment Campaign On Veterinary Resuscitation (RECOVER) initiative was established in 2010, to examine the evidence available on veterinary CPR, and develop new evidence-based guidelines for performing CPR in practice (their guidelines are available to read, open access, here). They highlighted that preparedness and prevention were key areas of successful CPR.
In order to be prepared for CPR, we need 2 things - an appropriately-stocked crash station, and a team who have regular CPR training and debriefing.
The ‘Crash Station’
Delays in the onset of CPR are associated with poorer patient outcomes, and so having a well-stocked, ready-to-go crash station is vital when performing CPR. In larger hospitals, there may be a dedicated station or area where all CPR is performed; in smaller clinics, this is likely to be a central area with access to monitoring equipment, oxygen and space for a team to work, such as the prep room.
The crash station should include a crash box or trolley containing airway supplies, equipment for intravenous access, emergency medications and respiratory support. Monitoring equipment (ECG and capnograph), emergency surgical supplies and suction should also be available within the crash station; all equipment should be clearly labelled so that it remains ready for use at all times.
In addition to the equipment listed above, quick-use dosage charts and a copy of the RECOVER CPR algorithm should be clearly visible within the crash station.
The crash station and crash trolley. The station has a multi parameter monitor with capnograph and ECG, and piped oxygen supply. The crash trolley is opposite the station and contains medications, airway supplies, an ambu bag, emergency surgical kit, IV access, thoracocentesis equipment and much more as well as an electrical defibrillator and conducting gel.
Crash Trolley Checks
The crash trolley and station should be checked daily-to-weekly depending on the size of your hospital, and immediately after any arrest. The trolley should be kept sealed when not in use; some purpose-made trolleys can be locked and tagged so that when the trolley is opened and the tag is broken, the team can clearly see the trolley has been broached and needs to be checked. In most cases, sticking a piece of micropore or durapore-style tape over the trolley drawers/lid of the crash box is sufficient. The date the trolley was checked should be written on the tape; when the tape has been torn or removed, the team know the trolley needs to be checked and re-stocked.
Resuscitation Orders
Another important part of CPR preparedness is knowing the resuscitation status of your patient. When a patient is admitted to the hospital, a CPR code should be obtained via discussion between the veterinary team and client. This CPR code should be clearly visible throughout the patient’s stay (e.g. through kennel labelling and/or included on the patient’s hospital sheets and anaesthetic record charts), so that if an arrest does occur, the team can intervene quickly whilst following the client’s wishes.
Training
CPR training is a vital part of being prepared. Both cognitive and psychomotor skills are required during basic life support, and so CPR training should include both the underpinning theory behind CPR (covered in our next few blog posts), as well as physical training on how to perform it.
Training should be standardised across the whole practice team, as this has been shown to improve success rates, and refreshed regularly (at least every 6 months). CPR training and emergency procedures should also be included within the induction of new staff members wherever possible.
The best way to provide standardised, whole-team physical training is through the use of CPR simulations and mannequins, which have been shown to improve psychomotor skills in human medicine. There are veterinary CPR models, though they can be quite costly. If you don’t have access to a CPR mannequin, a sturdy large toy dog with quite a rigid chest works well (you need something that you can press against during compressions, which will spring back up again).
You can run a CPR simulation with anywhere from 2-3 to 5-6 people. The team should be divided into the following roles:
Team Leader (this does not have to be a vet, having a vet as the team leader vs a nurse has not had any significant effect on CPR outcomes - so ideally have vets and nurses perform this role!)
Compressor (this role will rotate)
Ventilator
Assistant to attach monitoring and administer medications (this can be 1-2 people depending on the size of your hospital)
Scribe and timekeeper
The team should practice identifying a patient in cardiopulmonary arrest, performing 2-minute cycles of chest compressions and ventilation, attaching and assessing monitoring equipment, and drawing up and administering medications, and rotating between roles. After each drill, the team should have a quick de-brief to discuss what they feel went well, what could be improved, and any action steps that need to be taken.
Here is a good example of a CPR drill performed in practice. This video demonstrates great team leading and communication skills, the correct compression speed and technique, and gives you an idea of how to implement similar drills in practice. However, there are a couple of things I would do differently. I would not attach an SPO2 monitor during CPR, and I would not apply alcohol to a patient during CPR. The reason for this is that if electrical defibrillation is required and a patient has alcohol on them, this is a significant fire risk and so is contraindicated.
As you can see, this CPR drill lasted only a few minutes and so they are very quick to perform, and can be slotted into a few spare minutes throughout the day, or at the start or end of shift.
Do you perform CPR drills in practice? If so, how do you run them? I’d love to know your thoughts below! Our next few posts will dive deep into CPR, looking at basic and advanced life support techniques.
References and Further Reading
Mathis, A. 2019. Preparing and training for CPR in small animal practice. In Practice, 41(2), pp. 50-56.
McMichael, M. et al. 2012. RECOVER evidence and knowledge gap analysis on veterinary CPR part 2: preparedness and prevention. Journal of Veterinary Emergency and Critical Care, 22 (S1), S13-S25.
Yagi, K. 2017. Critical Components to Successful CPR. Today’s Veterinary Nurse, available from: https://todaysveterinarynurse.com/articles/critical-components-to-successful-cpr-the-recover-guidelines-preparedness-and-team/
