- Perfusion

      - Cerebral

      - Myocardial

- Life support

      - Basic (ABC's)

      - Advanced (DEF)

- Airway

- Breathing

- Circulation

- Drugs

- Electrocardiogram

- Defibrillation

- tube selection

     - size - grab 3; size depends on animal

     - cuffed tubes

- laryngoscope (for insertion of endotracheal tube)

- suction - in cases of pulmonary edema

- patient positioning - so you can visualize before placing the tube

- emergency tracheostomy

- verification of tube placement

- secure tube (ambu bag is heavy...)

- inflate cuff

CPCR: Airway:

How do you verify the tube placement

- direct visualization

- palpation - hard from the outside of dog; can palpate in mouth to make sure it went down the right tube (caution: potential bite injury)

- chest wall movement

- auscultation - listen for good lung sounds

- end-tidal CO2 - can use end-tidal or capnography

CPCR: Breathing:

What rate

- 10-24 breaths/min (normal rate) (\/ in large dogs, /\ in small dogs)

      - too fast can HARM patient

- normal chest wall motion

- airway pressure should not exceed 20 cmH2O

CPCR: Circulation:

Why, random info

- Perfusion: heart & brain

- rapid institution of circulatory support (compressions)

- minimize interruptions (<30 sec, even between swapping compression people)

- cardiac massage

      - external: closed chest

      - internal: open chest

CPCR: Circulation:

Chest compressions:

rate, 2 kinds of compressions

- Rate: 120 cpm

      - higher perfusion pressures

      - greater ROSC and survival

            - Return of Spontanious Circulation

- Closed chest

- Open chest (through diaphragm or opening up chest)

CPCR: Circulation: Chest compresions:

Closed chest:

Positioning, pump theories, technique

- Lateral or dorsal recumbency (hard bc they roll)

- Pump theories

      - Cardiac pump - compressing heart (smaller animals)

      - Thoracic pump - compressing the whole chest (lareger dogs in lateral recumbency)

- Technique

      - compress chest by at least 25%

      - allow recoil of chest

      - a compression is 50% of 'duty cycle' (should be 1:1 ratio of time compressed and time relaxing w/ chest up)

      - this results in less than 20% normal cardiac output

- Alternative techniques

       - Simultaneous ventilation/compression (SVD)

       - Active compression/decompression (ACD)

Intravenous - central & peripheral

Intratracheal

Intraosseus

Intracardiac

- not recommended for closed-chest

- complications: hemopericardium, hemothorax, pneumothorax, intractable arrhythmias

- Pediatrics & exotics

- Location:

      - trochanteric fossa

      - tibal crest

      - proximal humerus

- rapid absorption!

- drugs OR fluids

- Drugs: Atropine, epinephrine, vasopressin, lidocaine

- Red-rubber catheter into ET tube or just inject meds into tube

- Double dose

- Dilute to 5-6 mls

- Give 2 full breths

- Fast

Central

- Jugular; blood sampling and fluids

- fastest circulation time

- Percutaneous (needle) or Cut-down (scalpel to visualize vessle)

- Requires greater technical expertise

Peripheral

- may already be present (ex anesthesia)

- less technical expertese

- slower to central circulation - flush drugs into central circ w/ 5-50 ml of a crystalloid solution

- percutaneous or cut-down (if vessel's collapsed or severly dehydrated)

- use gel, NOT alcohol (could spark)

- ensure good contact (to detect asystole, pulseless electrical activity, V-fib)

     - Asystole?  Check your ECG leads!

     - V-fib: ventricles tremor, no cardiac output

     - Pulseless electrical activity (PEA)/ electrical mechanical disociation - you can have a normal ECG ~20-30 min after a horse is dead :-o

- VERY common reason for animals to arrest

- Iatrogenic - we give large amt of K, stops heart

- Feline urethral obstruction can cause this

- What rate? shock doses, no fluids..it depends

- Hypovolemia - aggressive fluid resuscitation

     - isotonic crystalloids

     - hypertonic saline

- euvolemia (normal volume)

     - may decrease myocardia and cerebral perfusion

CPCR: Anesthesia-related arrest

4 steps

1. turn OFF inhalant, ON 100% oxygen

2. Check airway

3. CALL FOR HELP

4. Start CPCR, consider reversal agents

CPCR: Defibrillation:

Define

Types

- conversion of Vfib to a perfusing rhythm

- electrical (generally used but chemical and mechanical also available)

- External

- Internal

Sidenote: 5.5% decline in survival with each min elapsed from time of collapse until delivery of shocks

- Hand-held defib paddles

- NEED good contact - saline soaked sponges, defib gel, +/- clipped hair

- NO ALCOHOL

- 3-5 J/kg

- 3 successive shocks across chest wall, increase energy in 2nd and 3 shocks

- pause ONLY to evaluate ECG and charge defibrillator

- Treat underlying cause of CPA (cardiopulmonary arrest)

- Cardiovascular support

- Respiratory support

- Neurological support

1. Pain - /\ analgesia

2. Awareness - /\ anesthesia

3. Atropine/Ketamine - be aware of it

4. hypercapnia - hyperventilate

5. hypoxia - /\ oxygen

6. hypotension - /\ fluids

7. hypovolemia - /\ fluids

8. tachyarrhythmias

1. drugs: opioids, alpha2 agonists - give reversal

2. excessive vagal tone: eye, viscera, too light - give anticholinergic

3. hypothermia - warm up

4. hyperkalemia (K is stored in cells and released when HBC) - we correct it

5. sick sinus syndrome, conduction block, etc (slow arrhythmias)

- 60 bpm is the "magic" number

- weak pulse, low blood pressure

- pale mucus membranes

- prolonged CRT

- low urine output

- pre-existing organ disease

- Too light/too deep - panting will make too lite - you can hear valves clicking

- hypoxemia

- hypercapnia - eventually gets to brain stem and lows it down

- hyperthermia - rare cause

- pain

- awareness

- drug induced

- drugs: thiobarbiturates/propofol

- overventilated

- too deep

- closed pop-off valve

- occluded airway - happens in cats with asthsma (mucus plugs tube) and kinked tubes

- cardiac arrest

- hypoventilation

- pneumothorax

- decreased inspired oxygen - diagnose with pulse ox or arterial blood gas - fix: O2, intubate, ventilate

- hypoventilation: too deep, intracranial or cervical disease, drugs

- restriction of resp movement: pneumothorax, surgeon's hands on chest

- exhausted soda-sorb, inspiratory valve stuck open, too long ET tube (rebreathing)

- excess CO2 production (rare b/c they are not exercising)

What to do if:

Patient is not breathing

- treat underlying problem (drugs, too deep, open popoff)

- mechanical or manual ventilation

- doxapram respiratory effect is very short

What to do if:

Patiet wakes up

- Use inhalant (if caught early)

- Inject more anesthetic (10-20% of induction dose)

What to do if:

MAP is too low

- check anesthetic depth and decrease inhalant

- administer fluids (if possible)

- administer drugs to increase MAP

What to do if:

Patient regurges

- protect airway

- protect esophagus (if really acidic, rinse w/ sterile water)

- remove esophageal stethescope

- suction oral pharynx & esophagus

- consider extubating w/ cuff inflated

protection

teaching

essential for survival!

Nociceptor

2 types

specialized sensory receptors; small unmyelinated nerves

A fiber mechanoheat- first pain - localized

  - ex: hit shin, it hurts immediately

C fiber mechanoheat - "second" or "slow pain"

  - diffuse & persistent

  - ex: wake up the next morning and it's throbbing and achey

Visceral

  - thoracic and abdominal viscera (organs)

  - poorly localized (hurts all over)

  - cramping/gnawing

Somtatic

  - peripheral (skin, joints, muscle, skeletal)

  - easily localized (it hurts here)

  - aching, stabbing, or throbbing

Acute

 - soft tissue trauma

 - inflammation (a little is good, too much retards healing)

 - facilitates tissue healing

 - post-op pain

Chronic

 - persists beyond expected healing time (>3-6 months)

 - MUCH more difficult to treat

Nociception

 - transduction

 - transmission

 - modulation

Perception - MUST be conscious

Response (behavior chagne)

- Transduction - noxious stimuli at nociceptor (what hurts)

- Transmission - nerve impulse (signal goes to brain)

- Modulation - modify nociceptive transmission (can be upregulated or downregulated)

- corticosteroids = poor wound healing, delayed recovery

- weight loss, negative energy balance

- /\ incidence of post-op complication

- \/ efficiency of ventilation

- self mutilation/biting wound

- may become chronic and difficult to treat

- observe without interacting

      - respond favorably to extra attention

      - vocalization stops when comforted

- buarding behavior, hunched posture

- unwillingness to move

- shivering or panting

- staring eyes

- physiologic sympathetic signs

- turn away from humans, hide at back of cage

- refuse to change body position

- vocalization rare

- lack grooming

- aggressive when moved/touched

- squinted eyes

- physiologic sympathetic signs

Preemptive analgesia - easier to prevent than treat

 - limit "wind up"

 - preop analgesics reduce anesthetic requirements

Multimoda analgesia (balanced)

- treatment must match pain level

- source/type of pain (visceral, somatic, pathologic, mixed)

- duration of pain

- species specific issues

- everyone is different

Undulations in capnogram that are synchronous with cardiac contractions (bumps with each heart beat b/c heart beat pumps out a little CO2 with each beat)

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